CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 72-year-old
gentleman status post fall off a horse which was unwitnessed.
He was found on the trail with his riding helmet beside him.
He was able to give his name but was otherwise disoriented.
He was transferred to [**Hospital **] Hospital.  By report his GCS
was 14, but he had no purposeful movement.  Head CT showed
traumatic subarachnoid hemorrhage with bifrontal contusions,
multiple convexity skull fractures with no significant
displacement, no more than thickness of the bone, one small
area of pneumocephalus on the base of the thalamus.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Closed fracture of orbital floor (blow-out),Unspecified essential hypertension,Other accidental fall from one level to another,Superficial injury of cornea
Cl skl base fx/menin hem,Fx orbital floor-closed,Hypertension NOS,Fall-1 level to oth NEC,Superficial inj cornea
Admission Date:  [**2185-10-28**]       Discharge Date:  [**2185-11-15**]

Date of Birth:   [**2113-2-2**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient is a 72-year-old
gentleman status post fall off a horse which was unwitnessed.
He was found on the trail with his riding helmet beside him.
He was able to give his name but was otherwise disoriented.
He was transferred to [**Hospital **] Hospital.  By report his GCS
was 14, but he had no purposeful movement.  Head CT showed
traumatic subarachnoid hemorrhage with bifrontal contusions,
multiple convexity skull fractures with no significant
displacement, no more than thickness of the bone, one small
area of pneumocephalus on the base of the thalamus.

The patient was seen by the Ophthalmology Service for the
left frontal skull fracture which extended into the left
orbital roof.  No surgical intervention was needed.  His
globes were intact, and there was no need for surgical repair
of the orbital roof.  The patient was also seen by CT Surgery
for question of an esophageal [**Hospital 1994**].

The patient was intubated and sedated in the OR on Propofol.
When lightened, he was restless, unable to focus, moving all
extremities, left greater than right.  He did not open his
eyes or follow commands.  He localized with his left upper
extremity.  He had withdraw in the bilateral lower
extremities.  In the right upper extremity, he lifted
against gravity but weaker than the left.  Right pupil was 4
mm and reactive, left is irregular and nonreactive, surgical.
 He did have cornuals, gag, and cough.

The patient had repeat head CT on [**2185-10-29**], which
was unchanged from the previous day CT.  On [**2185-10-31**], the patient was awakened and attentive.  Left pupil was
surgical, right was 4.5 down to 4.0 and reactive.  He had
purposeful movements of the left greater than right.  Smile
was symmetric.

The patient had MRA/MRV to rule out stroke as the cause for
right upper extremity weakness which was negative.  It was
unclear as to the cause of the decreased movement in the
right upper extremity.  We recommended weaning from the
ventilator and weaning sedation.

The patient had repeat chest CT.  Thoracic Surgery felt there
was a low probability of an esophageal [**Last Name (LF) 1994**], [**First Name3 (LF) **] prophylaxis
antibiotics were discontinued on [**10-31**].  On [**2185-11-4**], the patient opened his eyes and followed voice.  He
occasionally followed commands.  He continued with
right-sided weakness.  Ophthalmology was consulted again who
said that he showed evidence of healing corneal abrasions.
The patient will need follow-up with outpatient
ophthalmologist after discharge.

The patient was extubated on [**11-3**] and transferred to
the regular floor on [**11-4**].  He was seen by Physical
Therapy and Occupational Therapy and found to require acute
rehabilitation prior to discharge to home.

DISCHARGE MEDICATIONS:  Lopressor 50 mg p.o. b.i.d. hold for
systolic blood pressure less than 110, heart rate less than
55, Hydralazine 20 mg p.o. q.6 hours, hold for systolic blood
pressure less than 110, heart rate less than 55, Nystatin
ointment 1 application topically q.i.d. p.r.n. to affected
areas, Insulin sliding scale, Captopril 25 mg p.o. t.i.d.,
hold for systolic blood pressure less than 100, Erythromycin
ophthalmic ointment 0.5% O.U. at h.s., Nystatin oral
suspension 5 cc p.o. q.i.d., Heparin 5000 U subcue q.12
hours.

CONDITION ON DISCHARGE:  The patient's neurologic status
improved greatly.  He was awake and alert and oriented times
[**1-16**], moving all extremities, but continued with some
right-sided weakness.  He was following commands and was out
of bed ambulating with assistance.

FOLLOW-UP:  He will need to follow-up with Dr. [**Last Name (STitle) 1132**] on one
month with repeat head CT.  He was stable at the time of
discharge.






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.

Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36

D:  [**2185-11-15**]  09:54
T:  [**2185-11-15**]  09:53
JOB#:  [**Job Number 45458**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Closed fracture of orbital floor (blow-out),Unspecified essential hypertension,Other accidental fall from one level to another,Superficial injury of cornea'}


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: 

PRESENT ILLNESS: The patient is a 72-year-old
gentleman status post fall off a horse which was unwitnessed.
He was found on the trail with his riding helmet beside him.
He was able to give his name but was otherwise disoriented.
He was transferred to [**Hospital **] Hospital.  By report his GCS
was 14, but he had no purposeful movement.  Head CT showed
traumatic subarachnoid hemorrhage with bifrontal contusions,
multiple convexity skull fractures with no significant
displacement, no more than thickness of the bone, one small
area of pneumocephalus on the base of the thalamus.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Closed fracture of orbital floor (blow-out),Unspecified essential hypertension,Other accidental fall from one level to another,Superficial injury of cornea'}
