CHIEF COMPLAINT: s/p assault

PRESENT ILLNESS: 42M s/p assault, +EtOH, agitated on scene, transfer from
[**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] with multiple facial fractures. THere was
bright red blood that came out once intubated

MEDICAL HISTORY: PMH: HTN, scoliosis

MEDICATION ON ADMISSION: none

ALLERGIES: tramadol

PHYSICAL EXAM: On admission:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He is homeless and currently staying at the Emmaus Shelter in
[**Location (un) **] MA. He has been saving up money to try to make a trip
down to see his daughter. Of note, pt also has a 1 yo son in FL.
Closed fracture of malar and maxillary bones,Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Assault by unspecified means,Open wound of forehead, without mention of complication,Unspecified essential hypertension,Lack of housing
Fx malar/maxillary-close,Cl skul base fx-brf coma,Assault NOS,Open wound of forehead,Hypertension NOS,Lack of housing
Admission Date:  [**2123-8-7**]              Discharge Date:   [**2123-8-10**]

Date of Birth:  [**2081-4-2**]             Sex:   M

Service: SURGERY

Allergies:
tramadol

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
s/p assault

Major Surgical or Invasive Procedure:
None


History of Present Illness:
42M s/p assault, +EtOH, agitated on scene, transfer from
[**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] with multiple facial fractures. THere was
bright red blood that came out once intubated

Past Medical History:
PMH: HTN, scoliosis

PSH: umbo hernia repair


Social History:
He is homeless and currently staying at the Emmaus Shelter in
[**Location (un) **] MA. He has been saving up money to try to make a trip
down to see his daughter. Of note, pt also has a 1 yo son in FL.


Family History:
non-contributory

Physical Exam:
On admission:

Temp: 97.8 HR: 110 BP: 147/104 Resp: 28 O(2)Sat: 88% Low

Constitutional: Agitated
HEENT: Bilateral periorbital edema and ecchymosis, Pupils
equal, round and reactive to light, chemosis of the left eye
but no proptosis, able to see finger motion from left eye
Dried blood in bilateral nares
Chest: Clear to auscultation
Cardiovascular: Tachycardic, regular
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Laceration over forehead
Neuro: Slurred speech, moving all extremities

Psych: Intoxicated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae


Pertinent Results:
[**2123-8-7**] CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
1. Complex facial fractures as described above including the
frontal bone
(both anterior and posterior lamina), the cribriform plate,
bilateral lamina papyracea, bilateral orbital floors (left is
depressed by 8 mm, non-depressed on the right), the left
anterior and posterior maxillary sinus walls, the right anterior
maxillary sinus wall, and the nasal bones.
2. Bilateral preseptal periorbital hematomas, more on the left
than the right, and extending inferiorly into the left
premaxillary soft tissue region.

CT HEAD W/O CONTRAST Study Date of [**2123-8-7**] 7:36 PM
IMPRESSION:
1.  No acute intracranial hemorrhage.
2.  Multiple facial bone fractures as described above and better
assessed on the concurrent facial bone CT.

CT C-SPINE W/O CONTRAST Study Date of [**2123-8-7**] 7:37 PM
IMPRESSION:  No acute fracture or malalignment

[**2123-8-7**] 07:36PM   WBC-31.0* RBC-4.78 HGB-14.7 HCT-44.7 MCV-94
MCH-30.7 MCHC-32.8 RDW-13.1
[**2123-8-7**] 07:36PM   PLT COUNT-345
[**2123-8-7**] 07:36PM   PT-10.9 PTT-26.5 INR(PT)-1.0
[**2123-8-7**] 07:36PM   FIBRINOGE-352
[**2123-8-7**] 07:36PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2123-8-7**] 07:36PM URINE  RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2123-8-7**] 07:36PM URINE  MUCOUS-RARE
[**2123-8-7**] 07:36PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2123-8-7**] 07:36PM   ASA-NEG ETHANOL-87* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-8-7**] 07:36PM   LIPASE-33
[**2123-8-7**] 07:36PM   UREA N-5* CREAT-0.5
[**2123-8-7**] 07:45PM   freeCa-1.09*
[**2123-8-7**] 07:45PM   HGB-15.0 calcHCT-45 O2 SAT-92 CARBOXYHB-5 MET
HGB-0
[**2123-8-7**] 07:45PM   GLUCOSE-216* LACTATE-3.5* NA+-143 K+-3.7
CL--107 TCO2-20*
[**2123-8-7**] 07:45PM   PH-7.31* COMMENTS-GREEN TUBE
[**2123-8-7**] 09:50PM   O2 SAT-96
[**2123-8-7**] 09:50PM   TYPE-ART RATES-18/7 TIDAL VOL-550 PEEP-5
O2-100 PO2-126* PCO2-44 PH-7.26* TOTAL CO2-21 BASE XS--6
AADO2-547 REQ O2-90 INTUBATED-INTUBATED

Brief Hospital Course:
The patient was transferred to the ICU for close monitoring. He
was extubated in the morning and was responsive. His facial
lacerations were sutured by plastic surgery. He was placed on
sinus precautions with head of bed elevation and antibiotics.
Ophthalmology saw the patient given orbital fractures. The
patient reported no change in vision. Follow up was recommended
2-3 weeks after discharge. He was breathing well on room air and
his diet was advanced to regular. Tertiary survey did not reveal
further injuries. He was stable and transferred to the floor on
HD3.

On the floor he remained alert and oriented. His vital signs and
respiratory status remained stable. He was tolerating a regular
diet and voiding adequate amounts of urine without difficulty.

Occupational therapy was consulted for cognitive evaluation who
recommended outpatient follow up with cognitive neurology after
discharge.

Social work was consulted given the circumstances around the
accident and +ETOH use. He was provided provided  with victim's
compensation info and contact info for
[**Name (NI) 112150**]. He was discharged home with plans to stay with his sister
on [**2123-8-10**].


Medications on Admission:
none

Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. OxycoDONE (Immediate Release)  5-15 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-19**] tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
3. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*40 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID


Discharge Disposition:
Home

Discharge Diagnosis:
s/p assault: multiple facial fractures


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital after an assault. You
sustained multiple broken bones in your face. You were seen by
the plastic surgeons and ophthalmologists to evaluate your
injuries. Please follow up at the appointments scheduled for you
below.

It is recommended that you maintain sinus precautions because of
your injuries. Sinus precautions means:
1. Do not smoke for several days.
2. Do not use straws for several days.
3. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel ??????stuffy?????? or there may be some nasal
drainage.
4. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
5. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
6. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used.
7. Keep your head elevated at at least 30 degrees to decrease
the swelling and pressure in your face.

You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.


Followup Instructions:
Department: DIV OF PLASTIC SURGERY
When: FRIDAY [**2123-8-13**] at 2:45 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2123-9-1**] at 3:00 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please call the GREATER [**Hospital1 **] FAMILY HEALTH CENTER for
further medical assistance at:
[**Hospital1 112151**], [**Numeric Identifier 39146**]
Phone:([**Telephone/Fax (1) 112152**]

Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office in Behavioral
Neruology to schedule an appointment to be seen withinthe next
2-3 weeks. His office number is [**Telephone/Fax (1) 1690**], ask for his
administrative [**First Name9 (NamePattern2) 112153**] [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**] to assist you with booking
this appointment.



Completed by:[**2123-8-10**]
{'Closed fracture of malar and maxillary bones,Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Assault by unspecified means,Open wound of forehead, without mention of complication,Unspecified essential hypertension,Lack of housing'}


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: s/p assault

PRESENT ILLNESS: 42M s/p assault, +EtOH, agitated on scene, transfer from
[**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] with multiple facial fractures. THere was
bright red blood that came out once intubated

MEDICAL HISTORY: PMH: HTN, scoliosis

MEDICATION ON ADMISSION: none

ALLERGIES: tramadol

PHYSICAL EXAM: On admission:

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: He is homeless and currently staying at the Emmaus Shelter in
[**Location (un) **] MA. He has been saving up money to try to make a trip
down to see his daughter. Of note, pt also has a 1 yo son in FL. 

### Response:
{'Closed fracture of malar and maxillary bones,Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Assault by unspecified means,Open wound of forehead, without mention of complication,Unspecified essential hypertension,Lack of housing'}
