CHIEF COMPLAINT: Fall from 15 feet

PRESENT ILLNESS: 60 year old male s/p unwitnessed 15 ft. fall. Patient was
moving all extremities when he arrived at OSH but was confused.
He was intubated, sedated, and paralyzed at OSH and sent to
[**Hospital1 18**]
for transfer. In the ambulance his O2sats dropped but after
bagging, his oxygen returned to [**Location 213**]. He was given vecuronium
and versed upon arrival to the ER here.

MEDICAL HISTORY: HTN, Gout, s/p PTCA with stent

MEDICATION ON ADMISSION: Lisinopril
Allopurinol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: :99 BP:146/117 HR:92 RR: 16 O2Sats: 95%
Gen: intubated, sedated, in collar, on back board
HEENT: posterior scalp laceration approximately an inch long, no

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Married
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Closed fracture of lumbar vertebra without mention of spinal cord injury,Accidental fall from ladder,Accidents occurring in industrial places and premises,Unspecified essential hypertension,Gout, unspecified,Closed fracture of clavicle, unspecified part,Coronary atherosclerosis of native coronary artery,Closed fracture of three ribs
Cl skul base fx w/o coma,Retroperitoneum inj-cl,Fx lumbar vertebra-close,Fall from ladder,Acc on industr premises,Hypertension NOS,Gout NOS,Fx clavicle NOS-closed,Crnry athrscl natve vssl,Fracture three ribs-clos
Admission Date:  [**2179-12-9**]              Discharge Date:   [**2179-12-20**]

Date of Birth:  [**2119-8-21**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall from 15 feet

Major Surgical or Invasive Procedure:
None


History of Present Illness:
60 year old male s/p unwitnessed 15 ft. fall. Patient was
moving all extremities when he arrived at OSH but was confused.
He was intubated, sedated, and paralyzed at OSH and sent to
[**Hospital1 18**]
for transfer. In the ambulance his O2sats dropped but after
bagging, his oxygen returned to [**Location 213**]. He was given vecuronium
and versed upon arrival to the ER here.


Past Medical History:
HTN, Gout, s/p PTCA with stent

Social History:
Married

Family History:
Unknown

Physical Exam:
:99 BP:146/117 HR:92 RR: 16 O2Sats: 95%
Gen: intubated, sedated, in collar, on back board
HEENT: posterior scalp laceration approximately an inch long, no

depressions palpated on head
Ears: Small amount of dried blood in right external ear canal
Pupils: 2mm bilaterally
Neck: in cervical collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Patient intubated, sedated, and on paralytics during my exam.

Pupils 2mm. Patient not withdrawing to pain.

Re-evaluation:
Patient off sedation.
Eyes: PERRL
Patient moving all extremities to command. Full strenth
throughout.

Toes downgoing bilaterally.



Pertinent Results:
[**2179-12-16**] 07:20AM BLOOD WBC-9.1 RBC-3.42* Hgb-10.8* Hct-30.5*
MCV-89 MCH-31.6 MCHC-35.4* RDW-14.3 Plt Ct-253
[**2179-12-15**] 04:00PM BLOOD WBC-9.1 RBC-3.37* Hgb-11.1* Hct-30.3*
MCV-90 MCH-32.9* MCHC-36.5* RDW-14.2 Plt Ct-260
[**2179-12-15**] 06:20AM BLOOD WBC-8.9 RBC-3.17* Hgb-10.1* Hct-28.1*
MCV-89 MCH-31.9 MCHC-36.0* RDW-14.3 Plt Ct-249
[**2179-12-14**] 05:52AM BLOOD WBC-6.6 RBC-3.14* Hgb-9.9* Hct-28.0*
MCV-89 MCH-31.6 MCHC-35.5* RDW-14.5 Plt Ct-213
[**2179-12-10**] 03:36AM BLOOD Hypochr-OCCASIONAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2179-12-16**] 07:20AM BLOOD Plt Ct-253
[**2179-12-15**] 06:20AM BLOOD Glucose-123* UreaN-15 Creat-0.8 Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
[**2179-12-9**] 01:10PM BLOOD Amylase-72
[**2179-12-14**] 05:52AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.2
[**2179-12-11**] 09:58AM BLOOD Type-ART Temp-37.4 Rates-0/16 FiO2-50
pO2-88 pCO2-41 pH-7.42 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Vent-SPONTANEOU
[**2179-12-10**] 05:22PM BLOOD Lactate-1.6
[**2179-12-9**] 01:49PM BLOOD Hgb-12.5* calcHCT-38 O2 Sat-79
[**2179-12-11**] 05:59AM BLOOD freeCa-1.05*

CHEST AP:
Heart and mediastinum are normal. The lung fields are clear.
Costophrenic angles are sharp. There is no evidence of
pneumonia.
IMPRESSION: Chest clear.
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: WED [**2179-12-15**] 4:42 PM

BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and color
Doppler son[**Name (NI) 867**] of the right and left common femoral,
superficial femoral, and popliteal veins is performed. Normal
waveforms, compressibility, augmentation, and flow are
demonstrated. No intraluminal thrombus is identified.
IMPRESSION: No DVT.

TECHNIQUE: Noncontrast head CT scan [**2179-12-11**].
FINDINGS: Again seen is slight increase in surrounding
hypodensity of the left anterior temporal lobe parenchymal
hemorrhage, consistent with further evolution of bleed. Again
seen is evidence of bilateral subarachnoid hemorrhage, not
significantly changed in appearance compared to prior study.
Small subdural hemorrhage within the anterior middle cranial
fossa also appears relatively unchanged compared to prior study.
No new hemorrhage is identified. Ventricles appear stable. There
is no new shift of normally midline structures. The large right
occipital scalp hematoma with associated fracture again seen.
IMPRESSION: Continued evolution of left anterior temporal lobe
parenchymal hemorrhage. Otherwise, little change from prior
study.

C-SPINE WITH FLEXION AND EXTENSION ON [**12-11**].
HISTORY: Status post fall with ligament injury.
FINDINGS: The film in extension demonstrates normal alignment.
The film in flexion demonstrates straightening of the cervical
spine but overall limited flexion. This suggests ligamentous
spasm/injury.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SAT [**2179-12-11**] 8:44 PM

CT ABDOMEN: Bilateral pleural effusions are small with ajacent
lung consolidation could be due to atelectasis or aspiration.
Liver, spleen, kidneys and pancreas are unremarkable with no
evidence of traumatic injury. Multiple cortical cysts are in the
left kidney. Several nonobstructing stones are seen in the right
kidney, the largest one measuring 3.5 mm in the lower pole of
the kidney.
Right transverse process fractures of L1, L2, L3, L5 are noted
with a paravertebral and retroperitoneal hematoma involving the
right psoas muscle with straining of adjacent intraabdominal
fat. There is no evidence of intra- abdominal free air. The
small and large bowel wall are grossly unremarkable.
CT PELVIS. The bladder is catheterized. A small 2-mm stone is in
the bladder near the left UPJ. Small amount of pelvic fluid is
noted, measuring 33 Hounsfield units. Small presacral hematoma
is with no sacral fracturesindentified.
BONE WINDOW: Multiple fractures of the right ribs are noted as
well as of the transverse processes of the lumbar vertebra (as
mentioned above).
IMPRESSION:
1. Fractures of transverse process of the lumbar vertebra with
some paraspinal and retroperitoneal hematoma involving psoas
muscle. Soft tissue hematoma of the right flank in adjacent
area.
2. Small amount of hemorrhagic ascites, although no source of
bleeding indentified.
3. Multiple right rib fractures.
4. Presacral hematoma with no evidence of sacral fractures.
5. Right nephrolithiasis and intra bladder stone.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: SUN [**2179-12-12**] 10:02 AM


Brief Hospital Course:
Mr [**Known lastname 31**] was admitted to the Trauma service after being
transferred from [**Hospital 1474**] Hospital.  On initial survey he was
found to have small left anterior temporal lobe intraparenchymal
hemorrhage with a small amount of surrounding edema. There is
surrounding subarachnoid hemorrhage extending around the left
temporal lobe superiorly into the left frontoparietal lobe.
Within the anterior middle cranial fossa, there is a small
subdural hemorrhage which is also unchanged in size. There is no
significant shift of normally midline structures. There is no
evidence of hydrocephalus. There is a large scalp hematoma
overlying the right occiput with an underlying fracture again
seen extending across the right mastoid bone.
He also was found to have a fracture of the T11 spinous process
and L1/L3 process fracture, Right clavicle and right rib
fracture.  He was noted to have a presacral hematoma with a
small amount of acites and right flank hematoma
He was intubated at the outside hospital and remained intubated
for his first 3 hospital days.  His neurologic exam improved
daily from following commands and moving extremeties with full
strenght on hospital day one.  Follow up head CT's showed
evolving blood products.  He had a drop of crit on hospital day
#3 he had a crit drop to 22.4 which required a transfusion of 2
units of PRBC.  Follow up crits have been stable to 30.5 on
discharge.  He had a speech and swallow exam which recommended
soft solids and nectar thick liquids.

He was transferred to the Neuro Step down hospital day #5.
Where the mental status continued to improve on a daily basis
though continued with some intermittent agitation and impulsive
behavior.  He developed a fevers on [**12-14**] work up to this point
including urine and blood cultures, CXR, lower extremity
dopplers have all been negative. Neurologically he follows two
step commands, alert and orientated x2, moving all extremeties
with good movement.

He was transferred out of the neurostep down on hospital day #7,
improved mentation, orientated X3 but impulsive.  He awaits
insurance approval for rehab. Pt has continued to improve
neurologically and is less impulsive.  On HD#11 his insurance
cleared and pt was ready for transfer to rehab.


Medications on Admission:
Lisinopril
Allopurinol

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1)
Injection TID (3 times a day).
2. Acetaminophen 650 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Docusate Sodium 150 mg/15 mL Liquid [**Month/Day (4) **]: One (1)  PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for agitation.
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID
(2 times a day).
8. Levetiracetam 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Closed Head Injury, skull fractures, spin, rib and clavicle
fractures


Discharge Condition:
Neurologically stable


Discharge Instructions:
Call Dr[**Name (NI) 9034**] office if you develop worsening confusion,
agitation, memory problems, seizures or fevers.
Use TLSO when out of bed.

Followup Instructions:
Follow up with a head CT in 1 month with Dr [**Last Name (STitle) **], call
[**Telephone/Fax (1) 2731**] for an appointment, continue with Keppra until this
time.

Follow up with Dr [**Last Name (STitle) 363**] for spine issues, call for an
appointment [**Telephone/Fax (1) 3573**], need an appointment in 2 weeks.



Completed by:[**2179-12-20**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Closed fracture of lumbar vertebra without mention of spinal cord injury,Accidental fall from ladder,Accidents occurring in industrial places and premises,Unspecified essential hypertension,Gout, unspecified,Closed fracture of clavicle, unspecified part,Coronary atherosclerosis of native coronary artery,Closed fracture of three ribs'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Fall from 15 feet

PRESENT ILLNESS: 60 year old male s/p unwitnessed 15 ft. fall. Patient was
moving all extremities when he arrived at OSH but was confused.
He was intubated, sedated, and paralyzed at OSH and sent to
[**Hospital1 18**]
for transfer. In the ambulance his O2sats dropped but after
bagging, his oxygen returned to [**Location 213**]. He was given vecuronium
and versed upon arrival to the ER here.

MEDICAL HISTORY: HTN, Gout, s/p PTCA with stent

MEDICATION ON ADMISSION: Lisinopril
Allopurinol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: :99 BP:146/117 HR:92 RR: 16 O2Sats: 95%
Gen: intubated, sedated, in collar, on back board
HEENT: posterior scalp laceration approximately an inch long, no

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Married 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Injury to other intra-abdominal organs without mention of open wound into cavity, retroperitoneum,Closed fracture of lumbar vertebra without mention of spinal cord injury,Accidental fall from ladder,Accidents occurring in industrial places and premises,Unspecified essential hypertension,Gout, unspecified,Closed fracture of clavicle, unspecified part,Coronary atherosclerosis of native coronary artery,Closed fracture of three ribs'}
