CHIEF COMPLAINT: s/p fall from ladder

PRESENT ILLNESS: This is a 49 y/o male who was working in his basement on a
ladder, [**2-4**] steps when the ladder broke. He recalls the head
injury, no LOC. He now reports headache, diffuse, but no emesis,
nausea, dizziness, change in vision. He also denies neck pain as
well as extremity pain/paresthesias/numbness.

MEDICAL HISTORY: COPD OA, joint pain s/p multiple MVA's fx. Denies spine
fractures in past.

MEDICATION ON ADMISSION: Cymbalta, spiriva, ventolin, oxycontin, oxycodone

ALLERGIES: Amoxicillin

PHYSICAL EXAM: On Admission:
O: BP: 164/86 HR: 110   R 26      O2Sats 98%
Gen: WD/WN, comfortable, NAD. Obese. Wearing C-collar
Pupils: 3-2.5  EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-4**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: 1ppd x 30 years, does not drink daily
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Accidental fall from ladder,Obstructive sleep apnea (adult)(pediatric)
Brain lacer NEC w/o coma,Chr airway obstruct NEC,Fall from ladder,Obstructive sleep apnea
Admission Date:  [**2110-9-26**]              Discharge Date:   [**2110-9-29**]

Date of Birth:  [**2061-5-28**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Amoxicillin

Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
s/p fall from ladder

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 49 y/o male who was working in his basement on a
ladder, [**2-4**] steps when the ladder broke. He recalls the head
injury, no LOC. He now reports headache, diffuse, but no emesis,
nausea, dizziness, change in vision. He also denies neck pain as
well as extremity pain/paresthesias/numbness.


Past Medical History:
COPD OA, joint pain s/p multiple MVA's fx. Denies spine
fractures in past.


Social History:
1ppd x 30 years, does not drink daily


Family History:
non-contributory

Physical Exam:
On Admission:
O: BP: 164/86 HR: 110   R 26      O2Sats 98%
Gen: WD/WN, comfortable, NAD. Obese. Wearing C-collar
Pupils: 3-2.5  EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-4**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-6**] throughout. No pronator drift

Sensation: Intact to light touch.

Reflexes:  Pa Ac
Right      1   1
Left        1  1

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger

Exam on Discharge:
XXXXXXXXXXX

Pertinent Results:
Labs on Admission:
[**2110-9-26**] 07:45PM BLOOD WBC-14.0* RBC-5.31 Hgb-17.4 Hct-52.3*
MCV-99* MCH-32.8* MCHC-33.3 RDW-14.3 Plt Ct-181
[**2110-9-26**] 07:45PM BLOOD Neuts-78.8* Lymphs-14.9* Monos-5.4
Eos-0.2 Baso-0.6
[**2110-9-26**] 07:45PM BLOOD PT-13.5* PTT-29.9 INR(PT)-1.2*
[**2110-9-26**] 07:45PM BLOOD Glucose-108* UreaN-13 Creat-0.8 Na-141
K-4.3 Cl-101 HCO3-31 AnGap-13
[**2110-9-27**] 04:37AM BLOOD ALT-14 AST-13
[**2110-9-26**] 07:45PM BLOOD Calcium-9.5 Phos-4.0 Mg-1.8
[**2110-9-26**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Labs on Discharge:
XXXXXXXXXXXX

------------------
IMAGING:
------------------
CTA Head [**9-26**]:
FINDINGS: Subtle areas of subarachnoid hemorrhage are seen at
the convexity
sulci, unchanged from previous study. No new hemorrhage seen. CT
angiography of the head was obtained using departmental
protocol. Slightly
suboptimal opacification of the vascular structures is seen.
There is no
evidence of an aneurysm, vascular occlusion, or stenosis
identified. 3D
reformatted images appear normal.
IMPRESSION:
Unchanged appearance of subarachnoid hemorrhage at the convexity
sulci. Mild soft tissue swelling in the parietal soft tissues.
CT angiography demonstrate no evidence of vascular occlusion,
stenosis, or an aneurysm greater than 3 mm in size, although the
opacification of the vascular structures is somewhat suboptimal.

Head CT [**9-27**]:
NON-CONTRAST HEAD CT: Small foci of subarachnoid hemorrhage
along the
inferior right frontal lobe (2A:11) are not changed. Also there
is possible
tiny hyperdensity along the right superior convexity (2A: 24),
which could
just represent normal [**Doctor Last Name 352**] matter or could represent a tiny
additional focus of subarachnoid hemorrhage; the former is
favored as there is slight streak artifact in this region. High
density along the left parafalcine frontal region has a very
straight linear configuration and could be artifactual or could
represent a tiny additional focus of subarachnoid hemorrhage. No
definite new large intraparenchymal hemorrhage is seen, nor
shift of normally midline structures, effacement of the basal
cisterns, hydrocephalus, or large vascular territorial
infarction. Again note is made of subgaleal hematoma along the
left parietal scalp. Also, there may be non-displaced fracture
along the right frontal bone (2A:27). These are not changed from
prior. The orbits appear unremarkable. Opacification of the
right fronto- ethmoid recess, right anterior ethmoid air cell,
and near complete opacification of the left sphenoid sinus are
as before.
IMPRESSION: Inferior right frontal small foci of subarachnoid
hemorrhage are as before. Possible additional foci of
subarachnoid hemorrhage along the superior convexity bilaterally
are small and could be artifactual. No
definite substantial change.
ATTENDING NOTE: No change.

Brief Hospital Course:
Patient was transferred to [**Hospital1 18**] from OSH after sustaining a
closed head injury after falling from a ladder at home.  He was
admitted to the neurosurgery service for monitoring.  He had
repeated CT scans of the head, which did not reveal any new foci
of hemorrhage, and thereby determined to be stable.  On [**9-28**], he
was seen and evaluated by PT who was able to clear him for home
discharge.  Of note however, he was hypertense to 180(SBP), and
Lisinopril was started. After his blood pressure was adequately
controlled, his was discharged to home on [**9-29**] with appropriate
follow up instructions, and new prescription for lisinopril.

Medications on Admission:
Cymbalta, spiriva, ventolin, oxycontin, oxycodone


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain/T>100/HA.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
6. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
9. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for HTN.
Disp:*30 Tablet(s)* Refills:*0*
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
Disp:*60 Capsule(s)* Refills:*0*
12. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-3**]
Tablets PO Q6H (every 6 hours) as needed for headache: caution
not to exceed more than 4gm APAP in 24h.
Disp:*25 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Bilateral frontal contusions, Right sylvian fissure traumatic
SAH


Discharge Condition:
Neurologically Stable


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.

**You were also started on a new medication(Lisinopril) during
your hospitalization to treat your elevated blood pressure.
Please make sure to make an appointment with your PCP within the
next two days monitoring of this.



Completed by:[**2110-9-29**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Accidental fall from ladder,Obstructive sleep apnea (adult)(pediatric)'}


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 fall from ladder

PRESENT ILLNESS: This is a 49 y/o male who was working in his basement on a
ladder, [**2-4**] steps when the ladder broke. He recalls the head
injury, no LOC. He now reports headache, diffuse, but no emesis,
nausea, dizziness, change in vision. He also denies neck pain as
well as extremity pain/paresthesias/numbness.

MEDICAL HISTORY: COPD OA, joint pain s/p multiple MVA's fx. Denies spine
fractures in past.

MEDICATION ON ADMISSION: Cymbalta, spiriva, ventolin, oxycontin, oxycodone

ALLERGIES: Amoxicillin

PHYSICAL EXAM: On Admission:
O: BP: 164/86 HR: 110   R 26      O2Sats 98%
Gen: WD/WN, comfortable, NAD. Obese. Wearing C-collar
Pupils: 3-2.5  EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-4**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: 1ppd x 30 years, does not drink daily 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Accidental fall from ladder,Obstructive sleep apnea (adult)(pediatric)'}
