CHIEF COMPLAINT: fall

PRESENT ILLNESS: 41 y/o female, transferred from [**Hospital3 2783**] who fell
backwards off a 5foot stool while at work, striking her head.
+LOC at scene and was noted to be lethargic at [**Hospital1 **]. Patient has a known seizure disorder. At [**Hospital1 2436**], a
head CT was done showing a left occiptal fracture with a ? of an
adjacent small epidural bleed as well as right basilar skull
fractures. She was transferred to [**Hospital1 18**] for further
treatment/evaluation.

MEDICAL HISTORY: complex partial seizures--followed by Dr. [**Last Name (STitle) 16077**] @ [**Hospital1 336**].

MEDICATION ON ADMISSION: lamictal

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival in the trauma bay

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: married with 2 children
denies EtOH,/tobacco/IVDU
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of first cervical vertebra,Other convulsions,Open wound of scalp, without mention of complication,Accidental fall from chair
Cl skul base fx-brf coma,Fx c1 vertebra-closed,Convulsions NEC,Open wound of scalp,Fall from chair
Admission Date:  [**2142-4-17**]              Discharge Date:   [**2142-4-20**]

Date of Birth:  [**2100-6-2**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
41 y/o female, transferred from [**Hospital3 2783**] who fell
backwards off a 5foot stool while at work, striking her head.
+LOC at scene and was noted to be lethargic at [**Hospital1 **]. Patient has a known seizure disorder. At [**Hospital1 2436**], a
head CT was done showing a left occiptal fracture with a ? of an
adjacent small epidural bleed as well as right basilar skull
fractures. She was transferred to [**Hospital1 18**] for further
treatment/evaluation.

Past Medical History:
complex partial seizures--followed by Dr. [**Last Name (STitle) 16077**] @ [**Hospital1 336**].

Social History:
married with 2 children
denies EtOH,/tobacco/IVDU

last seizure [**2141-1-1**] while driving per Dr. [**Last Name (STitle) 16077**]

Family History:
non-contributory

Physical Exam:
on arrival in the trauma bay

Vitals: AF, 144/70 85, 19, 99% on RA
GEN: alert and oriented x 3, GCS 15, NAD, lying on board with
c-collar in place
HEENT: scalp laceration left posterior occiput, PERRL 3->2 mm,
EOMI, OP clear, midface stable, dentition intact
PULM: CTA bilaterally
CHEST: no crepitus
CV: regular, no murmurs
ABD: soft +BS, NTND, prior appendectomy scars
RECTAL: normal tone, guiac negative
PELVIS: stable to AP and lateral compression
BACK: NTTP, no stepoffs
BACK: right hip with ecchymosis, but NT
EXT: moving all 4, no signs of trauma
NEURO: CN II-XII intact, no focal motor or sensory deficits

Pertinent Results:
[**2142-4-17**] 08:00PM BLOOD WBC-14.0* RBC-4.37 Hgb-10.7* Hct-33.3*
MCV-76* MCH-24.4* MCHC-32.0 RDW-14.1 Plt Ct-189
[**2142-4-17**] 08:00PM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2142-4-19**] 07:15AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-136
K-3.2* Cl-103 HCO3-23 AnGap-13
[**2142-4-19**] 07:15AM BLOOD Calcium-8.3* Phos-2.0* Mg-1.9
[**2142-4-17**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

[**2142-4-17**] HEAD c-spine CT/CTA FINDINGS: There is no evidence of
intimal flap or intramural hematoma to suggest definite
dissection within both common carotid, internal carotid and
vertebral arteries.

There is a longitudinal fracture of the clivus extending from
the inferomedial clivus adjacent to the dens to the region of
the junction between the clivus and the petrous apex. This
fracture line may extend to foramen lacerum. The fracture line
passes immediately adjacent to the distal right vertebral artery
within the posterior fossa.

There is also a fracture of the right occipital condyle that
extends to the jugular foramen on the right. The fracture line
terminates in the right temporal bone in the region of the right
stylomastoid foramen.

There is also a fracture of the occipital bone that is
nondisplaced, running immediately to the left of midline.

No fractures are seen within the cervical spine vertebral
bodies, within the transverse foramina, and within the posterior
elements of the cervical spine.

CTA HEAD/CIRCLE OF [**Location (un) **]: Both anterior, middle and posterior
cerebral arteries are patent. There is again seen evidence of a
right frontal lobe contusion as well as probable
intraparenchymal hemorrhage within the left frontal lobe.

REFORMATTED IMAGING: Images reformatted in the coronal and
sagittal plane were essential in evaluating the patient's
cervical spine and show no evidence of fracture within the
cervical spine.

IMPRESSION:
1) No intramural hematomas or intimal flaps to suggest
dissection within both internal carotid and vertebral arteries.
Please note that additional reformatted imaging will be
performed at a separate date and an addendum will be issued.
2) Linear fractures of the clivus (with extension to the region
of foramen lacerum), the right occipital condyle, and the left
occipital bone, as described above.

[**2142-4-18**] T-L spine plain films
IMPRESSION: No thoracolumbar fracture identified.

[**2142-4-19**] MR CERVICAL SPINE  [**2142-4-19**] 11:42 PM
INTERPRETATION: No definite ligamentous injury identified. The
reliability of this technique for determining ligamentous
integrity is unknown.


Brief Hospital Course:
41 yo F s/p fall off 5 foot stool. After inital stabilization in
the trauma bay and obtaining CT scans the patient was
transferred to the TSICU for Q1h neuro checks and close
monitoring. The patient was stable overnight. A follow up head
CT showed a focal small left frontal contusion or extraaxial
hematoma, and right frontal contusion as well as a left
occipital bone and a fracture through the right side of the
clivus, which extends into the right medial occipital condyle, a
fracture across the right occipital skull base, and a fracture
of the right anterior arch of C1. The patient was kept in a hard
cervical collar and transferred to the step-down unit. The
patient was maintained on logroll precautions until TL spine
films were obtained and read as negative. Ortho spine with
consulted for the patient's C1 fracture. An MRI was obtained
that did not reveal any ligamentous instability. She will remain
in the hard collar for 12 weeks and follow up in 4 weeks with
spine.
ENT was consulted because of the patients temporal bone
fracture. The patient had no evidence of CN 7 involvement or
deficit. The patient will follow up in 3 to 4 weeks for a formal
audiogram.
The patient's outpatient neurologist was contact[**Name (NI) **] the morning
after admission. Dr. [**Last Name (STitle) 16077**] at [**Hospital1 336**] phone [**Telephone/Fax (1) 61877**], states
patient had been seizure free since [**2141-1-1**] when she had
seizure while driving. He described her seizures as partial
complex seizures with secondary generalization. As an outpatient
she was on Lamictal 300mg QAM and 200mg QHS. Initially the
patient was loaded with dilantin here because it was unclear
whether she had a seizure that prompted her fall. Dr. [**Last Name (STitle) 16077**]
advised to d/c dilantin and restart lamictal. She will follow up
with him at discharge.
The patient was evaluated by physical therapy and determined to
be safe for discharge on [**4-20**]. At the time of discharge the
patient was ambulating, eating PO, and using the bathroom
without difficulty.

Medications on Admission:
lamictal

Discharge Medications:
1. Lamotrigine 100 mg Tablet Sig: Three (3) Tablet PO QAM (once
a day (in the morning)).
Disp:*30 Tablet(s)* Refills:*0*
2. Lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO Q4PM ().
Disp:*20 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Occipital bone fractures
Temporal bone fracture
C1 fracture
Closed head trauma with contusion


Discharge Condition:
Good

Discharge Instructions:
[**Name8 (MD) **] MD or go to ER if temp >101, persistent pain, nausea or
vomiting, numbness or weakness in arms or legs, or any other
questions.  You must wear your neck collar at all times for the
next 12 weeks. You may shower normally despite the sutures in
your scalp.

Followup Instructions:
You should follow up with orthopaedic spine surgery in 4 weeks.
Until your follow up appointment you should keep your collar on
at all times. Call [**Telephone/Fax (1) 3573**] to schedule a follow up
appointment with Dr. [**Last Name (STitle) 363**].

You should follow up with your neurologist, Dr. [**Last Name (STitle) 16077**] at the
[**Hospital1 336**] on Monday. Call today after you are discharged to schedule
an appointment. You should continue taking your lamictal as he
prescribed before.

You should follow up in trauma clinic on Tuesday [**5-1**] to
have your scalp sutures removed. Call [**Telephone/Fax (1) 2359**] to schedule
an appointment.

Follow up with ENT for a hearing test in [**2-2**] weeks. Call the
[**Hospital **] clinic at [**Telephone/Fax (1) 41**] to schedule an
appointment.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
{'Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of first cervical vertebra,Other convulsions,Open wound of scalp, without mention of complication,Accidental fall from chair'}


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

PRESENT ILLNESS: 41 y/o female, transferred from [**Hospital3 2783**] who fell
backwards off a 5foot stool while at work, striking her head.
+LOC at scene and was noted to be lethargic at [**Hospital1 **]. Patient has a known seizure disorder. At [**Hospital1 2436**], a
head CT was done showing a left occiptal fracture with a ? of an
adjacent small epidural bleed as well as right basilar skull
fractures. She was transferred to [**Hospital1 18**] for further
treatment/evaluation.

MEDICAL HISTORY: complex partial seizures--followed by Dr. [**Last Name (STitle) 16077**] @ [**Hospital1 336**].

MEDICATION ON ADMISSION: lamictal

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival in the trauma bay

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: married with 2 children
denies EtOH,/tobacco/IVDU 

### Response:
{'Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with brief [less than one hour] loss of consciousness,Closed fracture of first cervical vertebra,Other convulsions,Open wound of scalp, without mention of complication,Accidental fall from chair'}
