CHIEF COMPLAINT: s/p MVC

PRESENT ILLNESS: This is a 47 year old female who was in a motor scooter accident
in [**Country 3594**] 2 days ago. She reportedly had loss of consciousness
and was admitted overnight in a hospital in [**Country 3594**]. Yesterday
she presented to [**Hospital6 2561**] complaining of a headache
and right elbow pain. A CT of the head there demonstrated right
skull fractures and a small left intraparenchymal hemorrhage.
The patient was transferred here in stable condition. Other than
her headache she is complaining of slight dizziness, but has no
focal neurologic complaints.

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: Zoloft 100 mg po qdaily
Oral contraceptives

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient is married. She occasionally drinks alcohol.
Closed fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration,Closed fracture of malar and maxillary bones,Other road vehicle accidents injuring other specified person
Cl skul base fx-coma NOS,Fx malar/maxillary-close,Oth rd veh acc-pers NEC
Admission Date:  [**2177-1-26**]              Discharge Date:   [**2177-2-2**]

Date of Birth:  [**2129-2-28**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p MVC

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 47 year old female who was in a motor scooter accident
in [**Country 3594**] 2 days ago. She reportedly had loss of consciousness
and was admitted overnight in a hospital in [**Country 3594**]. Yesterday
she presented to [**Hospital6 2561**] complaining of a headache
and right elbow pain. A CT of the head there demonstrated right
skull fractures and a small left intraparenchymal hemorrhage.
The patient was transferred here in stable condition. Other than
her headache she is complaining of slight dizziness, but has no
focal neurologic complaints.

Past Medical History:
Depression

Social History:
The patient is married. She occasionally drinks alcohol.

Family History:
Non-contributory

Physical Exam:
On admission:

Afebrile, stable vitals

Gen: pleasant, well-developed/well-nourished young female
Neuro: GCS 15, alert, oriented x 3, pupils 2-->3 bilaterally,
tongue midline, CN 2-12 grossly intact, Motor [**6-20**] throughout, no
drift, sensory intact to touch throughout, no babinski
HEENT: EOMI, hemotympanum in right ear, decreased hearing in
left
CV: RRR
Lungs: CTAB
Abd: soft, NT/ND
Spine: no tenderness or stepoffs
Extr: right elbow and left ankle abrasions


Pertinent Results:
[**2177-1-26**] 07:35PM   PHENYTOIN-15.2
[**2177-1-26**] 02:09PM   PT-12.1 PTT-19.4* INR(PT)-1.0
[**2177-1-26**] 01:15PM   GLUCOSE-114* LACTATE-1.3 NA+-144 K+-3.6
CL--104 TCO2-25
[**2177-1-26**] 01:05PM   UREA N-13 CREAT-0.8
[**2177-1-26**] 01:05PM   AMYLASE-38
[**2177-1-26**] 01:05PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2177-1-26**] 01:05PM   WBC-10.6 RBC-4.18* HGB-13.7 HCT-38.8 MCV-93
MCH-32.7* MCHC-35.3* RDW-12.4
[**2177-1-26**] 01:05PM   PLT COUNT-265

[**1-26**] Maxillofacial CT: There is a minimally displaced obliquely
oriented fracture extending along the right temporal bone which
extends into the right sphenoid bone, to involve the right
pterygomaxillary fossa. There is an associated nondisplaced
fracture involving the right zygomatic arch and right orbital
wall of the zygomatic bone. High-density material consistent
with hemorrhage is noted within the sphenoid sinus. There is a
subtle associated transversely oriented lucency most consistent
with a nondisplaced fracture along the roof of the sphenoid
sinus at the level of the orbital apex and optic canals. The
globes, extraocular eye muscles and optic nerves otherwise
appear intact. The paranasal sinuses are otherwise well
pneumatized aside from minor mucosal thickening within the right
maxillary antrum. There is again demonstrated a small amount of
pneumocephalus along the inner table of the squamous portion of
the left temporal bone. A definite fracture is not identified in
this location. Note is made of several opacified left mastoid
air cells without fracture appreciated in this location.

[**1-26**] CT Head: 1. Bilateral intraparenchymal hemorrhagic
contusions, most pronounced in the left inferior temporal lobe.
2. Small amount of likely subarachnoid hemorrhage in the
interpeduncular
cistern and high within the left frontal lobe.
3. Multiple fractures including the squamous portions of the
temporal bones bilaterally, roof of the sphenoid sinus, right
sphenoid, right lateral orbital wall and right zygomatic arch.
4. Pneumocephalus within the middle left cranial fossa which
raises possiblility of occult adjacent fracture.

[**1-26**] CT Neck: 1. No evidence for cervical spine fracture or
malalignment.
 2. For additional details regarding the skull base fractures
and intracranial hemorrhage, please refer to the accompanying CT
of the head and facial bones.


Brief Hospital Course:
This is 47 yo F who presented s/p fall from scooter while in
[**Country 3594**] on Friday [**2177-1-24**]. She flew back to U.S. on [**2177-1-25**]
and has been c/o headache and right elbow pain. By report she
had loss of consciousness from her accident +and awoke in  a
hospital in [**Country 3594**]. She was admitted to [**Hospital1 18**] trauma service
for managment of her injuries on [**2177-1-26**]. Her work-up revealed
right zymogatic and sphenoid fractures in the skull as well as a
a small subarachnoid hemorrhage. She was admitted to the
intensive care unit and monitored from a neurologic standpoint.
Neurosurgery was consulted and recommended starting the patient
on Dilantin for seizure prophylaxis. Plastic surgery service was
consulted and planned to repair her facial fractures on an
outpatient basis. She had a normal neurologic exam throughout
her hospitalization however was complaining of dizziness and
decreased hearing in her left ear. ENT service was consulted and
recommended the patient follow-up as an outpatient for an
audiogram. She was transferred out of the ICU on hospital day 2
and worked with physical therapy. She was deemed a good
candidate for outpatient physical therapy. She was discharged to
home with VNA on [**2177-2-2**]. All questions were answered to her
satisfaction upon discharge.




Medications on Admission:
Zoloft 100 mg po qdaily
Oral contraceptives

Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): to continue until neurosurgery follow-up
appointment.
Disp:*90 Capsule(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: for constipation as needed
.
Disp:*20 Capsule(s)* Refills:*2*
6. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: for severe pain only; otherwise take tylenol.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
s/p  MVC
Skull Fracture
Intracranial Hemorrhage
Zygomatic Fracture
Right Sphenoid Fracture


Discharge Condition:
Stable


Discharge Instructions:
You should continue to work on walking with outpatient physical
therapy and [**Hospital1 **] . You should call the trauma clinic
or come to the ER with any worsening headaches/dizziness/loss of
consciousness/ or new-onset numbness/weakness.

Follow up with the Trauma clinic, Neurosurgery, ENT and Plastic
Surgery after your discharge-- for an appointment.

[**Name8 (MD) **] M.D. for increase in severity of symptoms, fever, increase
in pain, numbness or tingling, pain or drainage from ear, nasal
drainage, questions or concerns.

Followup Instructions:
Call [**Telephone/Fax (1) 274**] for appointment in [**Hospital 3595**] Clinic

Call [**Telephone/Fax (1) 1669**] for appointment with Dr. [**Last Name (STitle) **] in
Neurosurgery in [**9-27**] weeks. Please obtain CT head without
contrast prior to follow-up appointment.

Call [**Telephone/Fax (1) 41**] for appointment in [**Hospital **] clinic for an audiogram
within 1-2 weeks.

You should follow-up in the [**Hospital1 18**] Trauma Surgery clinic within
2-3 weeks. Call for an appointment at [**Telephone/Fax (1) 2359**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2177-2-2**]
{'Closed fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration,Closed fracture of malar and maxillary bones,Other road vehicle accidents injuring other specified person'}


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 MVC

PRESENT ILLNESS: This is a 47 year old female who was in a motor scooter accident
in [**Country 3594**] 2 days ago. She reportedly had loss of consciousness
and was admitted overnight in a hospital in [**Country 3594**]. Yesterday
she presented to [**Hospital6 2561**] complaining of a headache
and right elbow pain. A CT of the head there demonstrated right
skull fractures and a small left intraparenchymal hemorrhage.
The patient was transferred here in stable condition. Other than
her headache she is complaining of slight dizziness, but has no
focal neurologic complaints.

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: Zoloft 100 mg po qdaily
Oral contraceptives

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: The patient is married. She occasionally drinks alcohol. 

### Response:
{'Closed fracture of base of skull with cerebral laceration and contusion, with loss of consciousness of unspecified duration,Closed fracture of malar and maxillary bones,Other road vehicle accidents injuring other specified person'}
