CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 59 yr old male who was found down in driveway unconscious. The
fall was unwittnessed and it was unknown how long the patient
was down on the ground. On presentation to the emergency
department, the patient could not recall the event. He was not
able to converse and his exam was limited related to
intoxication, ETOH level was 419. He was transported to [**Hospital1 18**]
for further care. Scalp laceration was stapled in the emergency
department.

MEDICAL HISTORY: EtOh Cirrhosis

MEDICATION ON ADMISSION: Aldactone
Lasix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
O: INR 1.2 PT 13.6, PTT 29.4.  NA 137
Gen: comfortable, NAD.
HEENT: Pupils: [**4-16**]        EOMs pt non compliant with exam
Neck: hard cervical collar on
Extrem: Warm and well-perfused.
Neuro:
Mental status:GCS=14 E=4, v=4, M=6 Awake and alert, able to
follow simple commands with repeated requests.
Orientation: Oriented to person only.
Recall: unable to recall objects
Language: Speech slow, one word answers after multiple
questions.
pt able to name "watch" slowly.

FAMILY HISTORY: 

SOCIAL HISTORY: Significant history of alcohol abuse.  Currently lives with
parents.
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Cerebral edema,Urinary tract infection, site not specified,Alcohol withdrawal,Other disorders of neurohypophysis,Closed fracture of one rib,Unspecified fall,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Open wound of scalp, without mention of complication,Alcoholic cirrhosis of liver,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified, recurrent,Cyst of kidney, acquired
Cl skul base fx-coma NOS,Cerebral edema,Urin tract infection NOS,Alcohol withdrawal,Neurohypophysis dis NEC,Fracture one rib-closed,Fall NOS,Enterococcus group d,Open wound of scalp,Alcohol cirrhosis liver,Recur unilat inguin hern,Cyst of kidney, acquired
Admission Date:  [**2148-5-5**]              Discharge Date:   [**2148-5-15**]

Date of Birth:  [**2088-10-8**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
[**2148-5-5**] Scalp stapled (Removed [**2148-5-14**])


History of Present Illness:
59 yr old male who was found down in driveway unconscious. The
fall was unwittnessed and it was unknown how long the patient
was down on the ground. On presentation to the emergency
department, the patient could not recall the event. He was not
able to converse and his exam was limited related to
intoxication, ETOH level was 419. He was transported to [**Hospital1 18**]
for further care. Scalp laceration was stapled in the emergency
department.

Past Medical History:
EtOh Cirrhosis



Social History:
Significant history of alcohol abuse.  Currently lives with
parents.

Physical Exam:
Upon admission:
O: INR 1.2 PT 13.6, PTT 29.4.  NA 137
Gen: comfortable, NAD.
HEENT: Pupils: [**4-16**]        EOMs pt non compliant with exam
Neck: hard cervical collar on
Extrem: Warm and well-perfused.
Neuro:
Mental status:GCS=14 E=4, v=4, M=6 Awake and alert, able to
follow simple commands with repeated requests.
Orientation: Oriented to person only.
Recall: unable to recall objects
Language: Speech slow, one word answers after multiple
questions.
pt able to name "watch" slowly.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields- pt non compliant with exam.
III, IV, VI: Extraocular movements- non compliant with exam.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength appears full and symmetric- patient does not
cooperate with full motor exam. No pronator drift

Sensation: Intact to light touch.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger


Pertinent Results:
[**2148-5-12**] 09:40AM BLOOD WBC-5.9 RBC-3.74* Hgb-12.9* Hct-35.9*
MCV-96 MCH-34.6* MCHC-36.1* RDW-12.9 Plt Ct-138*
[**2148-5-11**] 06:50AM BLOOD WBC-7.0 RBC-3.87* Hgb-12.9* Hct-37.9*
MCV-98 MCH-33.3* MCHC-34.0 RDW-13.0 Plt Ct-175
[**2148-5-10**] 06:17AM BLOOD Neuts-83.4* Lymphs-10.6* Monos-4.8
Eos-1.1 Baso-0.2
[**2148-5-11**] 06:50AM BLOOD PT-12.5 PTT-27.6 INR(PT)-1.1
[**2148-5-12**] 09:40AM BLOOD Plt Ct-138*
[**2148-5-14**] 06:15AM BLOOD Glucose-77 UreaN-12 Creat-0.8 Na-126*
K-4.1 Cl-91* HCO3-22 AnGap-17
[**2148-5-13**] 07:15AM BLOOD Glucose-86 UreaN-9 Creat-0.8 Na-127*
K-4.3 Cl-90* HCO3-26 AnGap-15
[**2148-5-12**] 09:40AM BLOOD Glucose-99 UreaN-10 Creat-0.7 Na-128*
K-4.1 Cl-92* HCO3-25 AnGap-15
[**2148-5-11**] 06:50AM BLOOD Glucose-105* UreaN-11 Creat-0.7 Na-128*
K-3.9 Cl-95* HCO3-22 AnGap-15
[**2148-5-10**] 03:55PM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-128*
K-4.9 Cl-96 HCO3-20* AnGap-17
[**2148-5-9**] 09:36PM BLOOD Glucose-113* UreaN-16 Creat-1.0 Na-130*
K-3.6 Cl-96 HCO3-23 AnGap-15
[**2148-5-9**] 04:40PM BLOOD Glucose-113* UreaN-17 Creat-0.9 Na-128*
K-3.8 Cl-95* HCO3-21* AnGap-16
[**2148-5-9**] 06:05AM BLOOD Glucose-98 UreaN-12 Creat-0.8 Na-130*
K-3.8 Cl-95* HCO3-20* AnGap-19
[**2148-5-8**] 01:40AM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-132*
K-3.9 Cl-99 HCO3-22 AnGap-15
[**2148-5-7**] 11:35AM BLOOD Glucose-135* UreaN-8 Creat-0.7 Na-132*
K-4.3 Cl-98 HCO3-23 AnGap-15
[**2148-5-7**] 02:28AM BLOOD Glucose-137* UreaN-8 Creat-0.8 Na-132*
K-4.1 Cl-96 HCO3-25 AnGap-15
[**2148-5-6**] 01:49AM BLOOD Glucose-135* UreaN-6 Creat-0.8 Na-134
K-5.4* Cl-100 HCO3-19* AnGap-20
[**2148-5-5**] 04:40PM BLOOD Glucose-129* UreaN-8 Creat-0.8 Na-137
K-4.5 Cl-101 HCO3-18* AnGap-23*
[**2148-5-11**] 06:50AM BLOOD ALT-9 AST-20 AlkPhos-64 Amylase-53
TotBili-0.7
[**2148-5-14**] 06:15AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.2
[**2148-5-13**] 07:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.1
[**2148-5-12**] 09:40AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
[**2148-5-11**] 06:50AM BLOOD Calcium-8.4 Phos-2.6* Mg-2.0
[**2148-5-10**] 03:55PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
[**2148-5-10**] 06:20AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.3
[**2148-5-5**] 04:40PM BLOOD ASA-NEG Ethanol-419* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Imaging:
[**5-6**] CT Head: Non displaced occipital fx into skull base, LSAH,
LSDH
[**5-6**] CT C-spine: No acute fx of C-spine. Right occipital fx
extends into R skull base/clivus, close proximity to right vert
artery. multi-level degnerative changes.
[**5-6**] CT Torso: Bilat dependent atelectasis. Nonspecific mildly
enlarged mediastinal LNs measure up to 1.1 cm in short axis.
gynecomastia. HH. incomplete fxs of right lateral 4th-7th ribs
of indetermin age. nondisplaced fx of lateral right 10th rib. no
ptx. no ev of acute visceral inj in abdomen or pelvis. Large fat
containing right inguinal hernia.
[**5-6**]: CTA Head/Neck: Intraparenchymal, subarachnoid and subdural
hemorrhage, in a distribution likely representing the sequela of
prior trauma. There is no evidence of an underlying vascular
malformation, aneurysm, dissection or hemodynamically
significant stenosis of either the CTA of the head or neck.
.
Stable skull base fracture, nondisplaced.
.
Approximately 50% stenosis of the right internal carotid artery
at its origin by NASCET criteria.
[**5-7**]: CT Head: Mildly increased edema surrounding the left
temporal and frontal hemorrhagic contusions. Stable extent of
subarachnoid, subdural and intraventricular hemorrhage.
.


Brief Hospital Course:
The patient was found to have a Subarachnoid hemorrhage
involving the left frontal, parietal, temporal, and right
frontal regions, left subdural hematoma, and areas of probable
intraparenchymal hemorrhage in bilateral temporal lobes. 2.5 mm
rightward
midline shift, a nondisplaced right occipital fracture extending
into the right skull base, and large right parietal soft tissue
hematoma and edema with overlying skin staples on CT scan. His
C-spine was cleared by CT scan. Several rib fractures were seen
on CT scan as well, however the age of the fractures was unable
to be determined. The patient was admitted from the emergency
department to the TSICU for closer monitoring.

The patients neurological status was monitored carefully by
trauma surgery as well as neurosurg while in the TSICU. Dilantin
therapy was initiated to prevent siezure. The patients
neurological status varied during his stay in the unit from
being cooperative with care to having difficulty answering
questions and combative. Given history of alcohol abuse, CIWA
scale was initiated. There was a concern for possible continued
intercranial bleeding and he was followed by CT scan which
showed no changes. These changes in mental status were
contributed to acute alcohol withdrawal at which time standing
valium was ordered. His mental status slightly improved, he was
able to take food and medications by mouth, and he was
transfered to the inpatient floor.

The patient was noted to have hyponitremia [**2148-5-9**] with a sodium
of 130. On admission the patients sodium level was 137 and over
time, continued to drop as low as 126. These values were treated
with intervals of normal saline IV, sodium tablets three times
daily, and fluid restriction. Urine chemistries from [**2148-5-9**]
showed normal urine sodium at 41. A mass insidentally found in
the lower pole of the right kidney was evaluated by ultrasound
and was found to be a simple cyst. [**2148-5-14**] endocrinology was
consulted and recommended strict I&O, continued fluid
restriction, and to monitor labs. The patients sodium level was
133 on day of discharge.

CIWA scale and standing valuim was continued on the floor, the
patients neuro status continued to improve. Social work and
nursing case managment were consulted and the patient's
disposition was complicated by lack of inurance. Physical
therapy was consulted and cleared the patient to return home.

Medications on Admission:
Aldactone
Lasix

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
5. Spironolactone 25 mg Tablet Sig: Three (3) Tablet PO Q 8H
(Every 8 Hours).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. Sodium Chloride 1 gram Tablet Sig: Four (4) Tablet PO TID (3
times a day).
Disp:*360 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Fall
Subarachnoid/Intraparenchymal/Subdural hemorrhages
Hyponatremia
Urinary tract infection


Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were admitted to the hospital after you were found down on
the ground unconscious. You were found to have mulitple areas of
bleeding in your brain. You were admitted to the Trauma ICU for
close monitoring; head CT scans were repeated and remained
stable. Because of your high blood alcohol level you experienced
withdrawal symptoms during your stay requiring medications to
help control these symptoms.

Your sodium was also very low in the hospital felt to be related
to an alteration in one of the body's regulatory hormones. To
treat this you were given salt tablets which you should continue
as prescribed. Your fulid intake was also restricted so that you
should be careful to not drink more than 1 liter of fluid in a
day. Your diuretic (Lasix) was also stopped as this can make the
condition of low sodium worse. The Endocrine doctors saw [**Name5 (PTitle) **]
[**Name5 (PTitle) 1028**] you were in the hospital and made these recommendations.

*IT IS IMPORTANT THAT YOU FOLLOW UP WITH YOUR PCP THIS WEEK TO
HAVE YOUR SODIUM LEVEL CHECKED*.

You were prescribed antibiotics for a urinary tract infection.
It is important to finish all of this medication as written on
the bottle until the bottle is empty.

IT IS VERY IMPORTANT THAT YOU DO NOT DRINK ALCOHOL OR TAKE
ILLICT DRUGS AS THIS PUTS YOU AT RISK FOR FURTHER TRAUMA.

Followup Instructions:
Follow up this Friday [**5-17**] with Dr. [**Last Name (STitle) 86480**] [**Telephone/Fax (1) 86481**], your
primary care doctor to have your Na (Sodium)level checked. It is
very important that you have this checked regularly.



Completed by:[**2148-5-20**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Cerebral edema,Urinary tract infection, site not specified,Alcohol withdrawal,Other disorders of neurohypophysis,Closed fracture of one rib,Unspecified fall,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Open wound of scalp, without mention of complication,Alcoholic cirrhosis of liver,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified, recurrent,Cyst of kidney, acquired'}


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

PRESENT ILLNESS: 59 yr old male who was found down in driveway unconscious. The
fall was unwittnessed and it was unknown how long the patient
was down on the ground. On presentation to the emergency
department, the patient could not recall the event. He was not
able to converse and his exam was limited related to
intoxication, ETOH level was 419. He was transported to [**Hospital1 18**]
for further care. Scalp laceration was stapled in the emergency
department.

MEDICAL HISTORY: EtOh Cirrhosis

MEDICATION ON ADMISSION: Aldactone
Lasix

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
O: INR 1.2 PT 13.6, PTT 29.4.  NA 137
Gen: comfortable, NAD.
HEENT: Pupils: [**4-16**]        EOMs pt non compliant with exam
Neck: hard cervical collar on
Extrem: Warm and well-perfused.
Neuro:
Mental status:GCS=14 E=4, v=4, M=6 Awake and alert, able to
follow simple commands with repeated requests.
Orientation: Oriented to person only.
Recall: unable to recall objects
Language: Speech slow, one word answers after multiple
questions.
pt able to name "watch" slowly.

FAMILY HISTORY: 

SOCIAL HISTORY: Significant history of alcohol abuse.  Currently lives with
parents. 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Cerebral edema,Urinary tract infection, site not specified,Alcohol withdrawal,Other disorders of neurohypophysis,Closed fracture of one rib,Unspecified fall,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Open wound of scalp, without mention of complication,Alcoholic cirrhosis of liver,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified, recurrent,Cyst of kidney, acquired'}
