CHIEF COMPLAINT: Trauma:  fall

PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year old right handed man who was transferred
from [**Hospital6 **] following a fall from standing with, per
report, generalized tonic clonic seizures.  According to OSH
records, pt was noted to have struck his head on the ground with
+ LOC.  CT head was obtained which showed a traumatic SAH.  A
CTA was subsequently performed which was noted to have poor
timing, and inconclusive for aneurysm. During this workup he was
also noted to have left orbit and sphenoid fractures. He was
transferred to [**Hospital1 18**] for further workup and mangement of these
injuries.

MEDICAL HISTORY: PMH: Seizures, ?right sided brachial plexus problem (unclear
details)

MEDICATION ON ADMISSION: keppra 500mg [**Hospital1 **]
Lisinopril 20mg daily
Celexa 40mg daily
Seroquel 50 mg hs

ALLERGIES: Penicillins

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**] ED:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Resides with girlfriend and his brother. [**Name (NI) **] 3 sons; +EtOH
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Alcohol withdrawal delirium,Closed fracture of surgical neck of humerus,Hemorrhage of gastrointestinal tract, unspecified,Closed fracture of malar and maxillary bones,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified alcohol dependence, unspecified,Unspecified essential hypertension,Laceration of skin of eyelid and periocular area
Cl skul base fx-coma NOS,Delirium tremens,Fx surg nck humerus-clos,Gastrointest hemorr NOS,Fx malar/maxillary-close,Fall from slipping NEC,Epilep NOS w/o intr epil,Alcoh dep NEC/NOS-unspec,Hypertension NOS,Lac eyelid skn/perioculr
Admission Date:  [**2170-5-12**]              Discharge Date:   [**2170-5-29**]

Date of Birth:  [**2114-1-15**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Trauma:  fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname **] is a 56 year old right handed man who was transferred
from [**Hospital6 **] following a fall from standing with, per
report, generalized tonic clonic seizures.  According to OSH
records, pt was noted to have struck his head on the ground with
+ LOC.  CT head was obtained which showed a traumatic SAH.  A
CTA was subsequently performed which was noted to have poor
timing, and inconclusive for aneurysm. During this workup he was
also noted to have left orbit and sphenoid fractures. He was
transferred to [**Hospital1 18**] for further workup and mangement of these
injuries.

Past Medical History:
PMH: Seizures, ?right sided brachial plexus problem (unclear
details)

PSH: Right ankle fx surgery, L shoulder surgery

[**Last Name (un) 1724**]: keppra 500'', ?Seroquel


Social History:
Resides with girlfriend and his brother. [**Name (NI) **] 3 sons; +EtOH

Family History:
Non-contributory

Physical Exam:
Upon presentation to [**Hospital1 18**] ED:

HR: 106 BP: 138/87 Resp: 16 O(2)Sat: 100

Constitutional: agitated, confused
HEENT: L periorbital swelling and edema, no underlying
proptosis, full EOM, PERRL
C-[**Last Name (un) **] in place, no midline tenderness
Chest: rhnochi BL
Cardiovascular: tachycardic
Abdominal: Soft, Nontender, Nondistended, no skin lesions
GU/Flank: No costovertebral angle tenderness
Neuro:
GCS 15, left facial trauma with left periorbital ecchymosis and
edema.  Pupils equally round and reactive to light, 6 to 2
mm bilaterally. Visual fields are full to confrontation. face
symmetric, Tongue midline without fasciculations.

Motor: [**4-7**] in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], LUE with weak deltoid secondary
to
pain.  Has baseline right hand grasp weakness
Sensation: Intact to light touch

Reflexes 2+ throughout
No clonus
Toes downgoing bilaterally
Handedness Right

Extr/Back: No cyanosis, clubbing or edema, no back
tenderness or step-offs
Skin: Warm and dry
Psych: agitated mood
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae


Pertinent Results:
[**2170-5-11**] 10:04 PM CTA Neck and Head:
CONCLUSION:
No evidence of aneurysm or other vascular abnormality causing
subarachnoid
hemorrhage.  No change in the subarachnoid and intraventricular
hemorrhage.
Probable left proximal humeral fracture.

SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Study Date of
[**2170-5-12**] 10:16 PM:
FINDINGS:
LEFT SHOULDER:  There is a fracture involving the surgical neck
of the left proximal humerus.  There is no dislocation.  The AC
joint demonstrates mild degenerative changes.  The visualized
left lung apex is grossly clear.
LEFT ELBOW:  There is no joint effusion.  There are no signs for
acute
fractures or dislocations.  There is minimal spurring involving
the olecranon at the distal attachment of triceps tendon.

[**2170-5-17**]:
Mild cardiomegaly and pulmonary vascular congestion are
unchanged since [**5-12**] following tracheal extubation.  There is
no appreciable pleural effusion or any focal pulmonary
consolidation.

[**2170-5-19**] 05:49AM BLOOD WBC-10.9 RBC-3.27* Hgb-11.3* Hct-33.5*
MCV-102* MCH-34.5* MCHC-33.7 RDW-14.7 Plt Ct-263
[**2170-5-17**] 06:06AM BLOOD WBC-10.9 RBC-3.37* Hgb-11.1* Hct-35.2*
MCV-105* MCH-32.8* MCHC-31.4 RDW-15.0 Plt Ct-242
[**2170-5-11**] 09:30PM BLOOD WBC-6.8 RBC-3.57* Hgb-12.2* Hct-36.0*
MCV-101* MCH-34.1* MCHC-33.8 RDW-14.8 Plt Ct-111*
[**2170-5-12**] 02:30AM BLOOD Neuts-81.6* Lymphs-12.0* Monos-5.6
Eos-0.4 Baso-0.4
[**2170-5-11**] 09:30PM BLOOD Neuts-78.4* Lymphs-13.3* Monos-7.2
Eos-0.3 Baso-0.8
[**2170-5-12**] 02:30AM BLOOD PT-13.2* PTT-28.9 INR(PT)-1.2*
[**2170-5-19**] 05:49AM BLOOD Glucose-88 UreaN-14 Creat-0.4* Na-131*
K-3.5 Cl-98 HCO3-20* AnGap-17
[**2170-5-18**] 05:58AM BLOOD Glucose-94 UreaN-17 Creat-0.5 Na-130*
K-3.6 Cl-99 HCO3-22 AnGap-13
[**2170-5-11**] 09:30PM BLOOD Glucose-108* UreaN-20 Creat-0.7 Na-143
K-4.0 Cl-109* HCO3-18* AnGap-20
[**2170-5-19**] 05:49AM BLOOD ALT-67* AST-118* AlkPhos-106 TotBili-2.3*
[**2170-5-13**] 02:06AM BLOOD ALT-62* AST-153* AlkPhos-86 TotBili-2.7*
[**2170-5-19**] 05:49AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0
[**2170-5-12**] 05:04AM BLOOD Type-ART pO2-186* pCO2-45 pH-7.34*
calTCO2-25 Base XS--1
[**2170-5-12**] 05:04AM BLOOD Lactate-1.1

[**2170-5-11**] 9:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2170-5-17**]**

   Blood Culture, Routine (Final [**2170-5-17**]):    NO GROWTH.

[**2170-5-19**] 05:49AM BLOOD WBC-10.9 RBC-3.27* Hgb-11.3* Hct-33.5*
MCV-102* MCH-34.5* MCHC-33.7 RDW-14.7 Plt Ct-263
[**2170-5-19**] 05:49AM BLOOD Plt Ct-263
[**2170-5-19**] 05:49AM BLOOD Glucose-88 UreaN-14 Creat-0.4* Na-131*
K-3.5 Cl-98 HCO3-20* AnGap-17
[**2170-5-19**] 05:49AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.0

Brief Hospital Course:
He was admitted to the trauma intensive care unit after falling
onto his left side and striking his head  sustaining loss of
consciousness.   He presented to the hospital with ETOH
intoxication. He was intubated in the emergency room for
reported agitation.  He was made NPO, given intravenous fluids,
and underwent imaging studies.  As a result of the fall he
sustained a bilateral subarachnoid hemorrhages, left sided
multiple facial fractures and a left humeral head fracture.

Regarding the subarachnoid hemorrhage neurosurgery was
consulted, followed and after stable exam and imaging, signed
off with recommendations that Mr. [**Known lastname **] should follow-up with
Dr. [**Last Name (STitle) **] in one month with a non-contrast head CT scan. His
neurological status was closely monitored and his blood pressure
parameters were tightly controlled.  His home dose Keppra was
continued and the dilantin was discontinued.  He was placed on a
CIWA scale for prevention of alcohol withdrawal and remained on
this protocol for approximately one week until resolution of
withdrawal symptoms.

Plastic surgery was consulted for his facial fractures as well
as OMFS for a maxillary fracture extending into the alveolar
process. His left eye-lid laceration was irrigated and sutured.
He was placed on sinus precautions with the possibility of
surgical intervention after the facial swelling subsides. OMFS
reviewed the imaging and reported that the fracture in question
was non-operative.  As part of the extensive evaluation,
ophthalmology was consulted and performed a dilated eye exam. It
was determined that no entrapment was identified.

After his vital signs stabilized,he was transferred from the ICU
to the surgical floor where his care was continued. His
remaining hospital course as follows:

Review of systems:

Neuro: His CIWA scale was continued and tapered until
discontinued. He improved symptomatically and his home
anti-psychotics were restarted.  He was started on Oxycodone and
Tylenol for pain relief. His mental status remained
intermittently disoriented. With the addition of his home
Seroquel he did improve over the course of his stay.

CV: He was tachycardic during this hospitalization to the
100s-120s.  This was believed to be due to his withdrawal from
alcohol and it was monitored closely and treated per the CIWA
protocol. Once off of CIWA he intermittently was in a sinus
tachycardia rhythm and low dose beta blockade was started. His
heart rate and blood pressures remained stable during the rest
of his hospital stay.

Resp: There were no acute issues and his oxygen saturations
remained stable.

GI: He was started on a soft (due to facial fractures) low
protein (due to liver dysfunction) diet.  He required assistance
with meals.  His appetite was initially diminished and he
required encouragement to eat.

GU: Foley catheter initially transitioned to condom catheter and
his urine output was adequate.

ID: No active issues.

Heme: No active issues. Prophylaxis: He was placed on boots for
prevention of deep vein thrombosis.

EXT:  His proximal humerus fracture was managed by Orthopedics
with a sling - he should not elevate his left arm on pillows at
all as this will hinder proper healing of his fracture.  He will
follow-up with Orthopedics for repeat x-rays in [**1-5**] weeks.

DISPO:  He was evaluated by physical and occupational therapy
and recommended for rehab after his acute hospital stay. Social
work was closely involved with patient and his family during his
stay - several family meetings took place to discuss progress
and disposition after discharge.

Medications on Admission:
keppra 500mg [**Hospital1 **]
Lisinopril 20mg daily
Celexa 40mg daily
Seroquel 50 mg hs

Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Citalopram 40 mg PO DAILY
3. LeVETiracetam 500 mg PO BID
4. Lisinopril 20 mg PO DAILY
hold for sbp<110
5. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Senna 1 TAB PO BID:PRN constipation
8. Bacitracin Ointment 1 Appl TP QID
9. Albuterol 0.083% Neb Soln 2 NEB IH Q6H:PRN sob/wheezing
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Heparin 5000 UNIT SC TID
12. Metoprolol Tartrate 12.5 mg PO BID
hold sbp <110, HR <60
13. Quetiapine Fumarate 50 mg PO HS


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
s/p Fall
Injuries:
1. Left humeral head fracture
2. Multiple left sided facial fractures include: minimally
displaced orbital floor and superior orbital fissure fractures,
nasal bone fractures, and maxillary fracture with alveolar
extension.
3. Traumatic subarachnoid hemorrhage
4. Acute alcohol withdrawal


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: intermittently lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Fall precautions


Discharge Instructions:
You were admitted to the hospital after a fall. You sustained an
injury to your head, facial fractures, and a left arm.

Your left arm was placed in a sling. You should remain
nonweightbearing on your left arm. The sling may be removed for
elbow ROM exercises and shoulder pendulum exercises. DO NOT
ELEVATE YOUR LEFT ARM AT ALL - IT WILL HEAL PROPERLY NOT
ELEVATED W/ THE SPECIAL SLING THAT WAS PROVIDED TO YOU.

It is recommended that you maintain sinus precautions given your
facial fractures. Sinus precautions include:
1. Do not forcefully spit for several days.
2. Do not smoke for several days.
3. Do not use straws for several days.
4. 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.
5. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.

You should resume taking all of your regular home medications
that your were taking prior to coming to the hospital.


Followup Instructions:
Department: ORTHOPEDICS
When: TUESDAY [**2170-6-12**] at 3:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2170-6-12**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: TUESDAY [**2170-7-3**] at 8:45 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROSURGERY
When: TUESDAY [**2170-7-3**] at 9:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: PLASTIC SURGERY
When: WEDNESDAY [**2170-6-20**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2170-6-7**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Alcohol withdrawal delirium,Closed fracture of surgical neck of humerus,Hemorrhage of gastrointestinal tract, unspecified,Closed fracture of malar and maxillary bones,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified alcohol dependence, unspecified,Unspecified essential hypertension,Laceration of skin of eyelid and periocular area'}


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: Trauma:  fall

PRESENT ILLNESS: Mr. [**Known lastname **] is a 56 year old right handed man who was transferred
from [**Hospital6 **] following a fall from standing with, per
report, generalized tonic clonic seizures.  According to OSH
records, pt was noted to have struck his head on the ground with
+ LOC.  CT head was obtained which showed a traumatic SAH.  A
CTA was subsequently performed which was noted to have poor
timing, and inconclusive for aneurysm. During this workup he was
also noted to have left orbit and sphenoid fractures. He was
transferred to [**Hospital1 18**] for further workup and mangement of these
injuries.

MEDICAL HISTORY: PMH: Seizures, ?right sided brachial plexus problem (unclear
details)

MEDICATION ON ADMISSION: keppra 500mg [**Hospital1 **]
Lisinopril 20mg daily
Celexa 40mg daily
Seroquel 50 mg hs

ALLERGIES: Penicillins

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**] ED:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Resides with girlfriend and his brother. [**Name (NI) **] 3 sons; +EtOH 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Alcohol withdrawal delirium,Closed fracture of surgical neck of humerus,Hemorrhage of gastrointestinal tract, unspecified,Closed fracture of malar and maxillary bones,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Other and unspecified alcohol dependence, unspecified,Unspecified essential hypertension,Laceration of skin of eyelid and periocular area'}
