CHIEF COMPLAINT: fall

PRESENT ILLNESS: Pt is a 73f who was found down for an unspecified period of time
and noted to be incoherent and smelling of alcohol at the scene.
Pt was taken to the ED via EMS and CT head obtained. CT scan
shows small chronic R frontal SDH 2mm in size and stable when
compared to previous scans. Also seen is a question
parafalcine SDH with no midline shift or hydrocephalus. Pt is
extremely hard of hearing and and unable to give an accurate
history secondary to her current mental status and ETOH
intoxication.

MEDICAL HISTORY: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
Depression, Alcohol abuse with falls
1 previous psych admission "for drinking" approx 20 years ago
no h/o sa's or sib
no h/o violence
therapist [**Doctor First Name 3548**] Mayburg [**Telephone/Fax (1) 11147**]

MEDICATION ON ADMISSION: Zoloft, Remeron

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 139/77 HR: 74 R 12 O2Sats
Pupils: R pupil 2-1.5 L pupil 2.5-2 EOMs Full
Neck: C collar in place. Pt grimmace to palpation of cervical
spine

FAMILY HISTORY: FAMILY PSYCHIATRIC HISTORY: mother had EtOH abuse/dependence.

SOCIAL HISTORY: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
h/o alcoholism x 50 years, previously attended AA not currently,
no h/o dt's or withdrawal seizures, unable to quantify current
consumption. numerous previous detoxs. denies other
illcits.smokes 1 ppd.
Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Subdural hemorrhage,Other and unspecified alcohol dependence, continuous,Esophageal reflux,Other cataract,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Unspecified hearing loss,History of fall,Unspecified fall
Subdural hemorr-coma NOS,Subdural hemorrhage,Alcoh dep NEC/NOS-contin,Esophageal reflux,Cataract NEC,Hypothyroidism NOS,Depressive disorder NEC,Thrombocytopenia NOS,Hypertension NOS,Hearing loss NOS,Personal history of fall,Fall NOS
Admission Date:  [**2182-7-25**]              Discharge Date:   [**2182-7-27**]

Date of Birth:  [**2108-11-8**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Pt is a 73f who was found down for an unspecified period of time
and noted to be incoherent and smelling of alcohol at the scene.
Pt was taken to the ED via EMS and CT head obtained. CT scan
shows small chronic R frontal SDH 2mm in size and stable when
compared to previous scans. Also seen is a question
parafalcine SDH with no midline shift or hydrocephalus. Pt is
extremely hard of hearing and and unable to give an accurate
history secondary to her current mental status and ETOH
intoxication.

Past Medical History:
PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
Depression, Alcohol abuse with falls
1 previous psych admission "for drinking" approx 20 years ago
no h/o sa's or sib
no h/o violence
therapist [**Doctor First Name 3548**] Mayburg [**Telephone/Fax (1) 11147**]

PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
seen via home visits
Thrombocytopenia
Hypertension
Hypothyroidism
Hearing loss
Subdural Hematoma [**10-24**] s/p R craniotomy for AonC SDH with
midline shift
Bilateral severe SNHL
GERD
Cataracts

Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
h/o alcoholism x 50 years, previously attended AA not currently,
no h/o dt's or withdrawal seizures, unable to quantify current
consumption. numerous previous detoxs. denies other
illcits.smokes 1 ppd.

SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Patient lives at [**Hospital3 11148**] [**Hospital3 **], primarily for help
with medications (otherwise independent). She has 6 children and
is divorced, no significant other.

Family History:
FAMILY PSYCHIATRIC HISTORY: mother had EtOH abuse/dependence.

Physical Exam:
BP: 139/77 HR: 74 R 12 O2Sats
Pupils: R pupil 2-1.5 L pupil 2.5-2 EOMs Full
Neck: C collar in place. Pt grimmace to palpation of cervical
spine

Neuro:
Mental status: Awake with eyes open. Will follow commands
intermintently. She is currently AOx3. Language: Speech slurred.


Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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: Decreased hearing bilaterally
[**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 full power [**5-22**] throughout. Unable to assess
pronator drift secondary to restraints.
Sensation: Intact to light touch

Pertinent Results:
CT head shows stable 2mm chronic R frontal SDH compared with
prior CT.
Parafalcine SDH noted with no evidence of midline shift or
hydrocephalus.

Labs:
BAC- 388
Na- 154 K 4.3 BUN 22 Creat 1.0 WBC- 6.8 HCT 35.5 PLT 204

[**2182-7-25**] repeat head CT: stable appearance



Brief Hospital Course:
Patient was admitted to ICU for close monitoring.  She remained
intact.  She had repeat CT which was stable.  She was
subsequently transferred to the floor where her exam was noted
to be at baseline.

Medications on Admission:
Zoloft, Remeron

Discharge Disposition:
Home with Service

Discharge Diagnosis:
Traumatic brain injury


Discharge Condition:
Good

Discharge 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.
??????	Do not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until seen in follow up.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, do not
resume taking it until you have followed up with Dr. [**Last Name (STitle) 548**].

Followup Instructions:
??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr.
[**Last Name (STitle) 548**] 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.
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Subdural hemorrhage,Other and unspecified alcohol dependence, continuous,Esophageal reflux,Other cataract,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Unspecified hearing loss,History of fall,Unspecified fall'}


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: fall

PRESENT ILLNESS: Pt is a 73f who was found down for an unspecified period of time
and noted to be incoherent and smelling of alcohol at the scene.
Pt was taken to the ED via EMS and CT head obtained. CT scan
shows small chronic R frontal SDH 2mm in size and stable when
compared to previous scans. Also seen is a question
parafalcine SDH with no midline shift or hydrocephalus. Pt is
extremely hard of hearing and and unable to give an accurate
history secondary to her current mental status and ETOH
intoxication.

MEDICAL HISTORY: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT
TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT,
HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR):
Depression, Alcohol abuse with falls
1 previous psych admission "for drinking" approx 20 years ago
no h/o sa's or sib
no h/o violence
therapist [**Doctor First Name 3548**] Mayburg [**Telephone/Fax (1) 11147**]

MEDICATION ON ADMISSION: Zoloft, Remeron

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: BP: 139/77 HR: 74 R 12 O2Sats
Pupils: R pupil 2-1.5 L pupil 2.5-2 EOMs Full
Neck: C collar in place. Pt grimmace to palpation of cervical
spine

FAMILY HISTORY: FAMILY PSYCHIATRIC HISTORY: mother had EtOH abuse/dependence.

SOCIAL HISTORY: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
h/o alcoholism x 50 years, previously attended AA not currently,
no h/o dt's or withdrawal seizures, unable to quantify current
consumption. numerous previous detoxs. denies other
illcits.smokes 1 ppd. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Subdural hemorrhage,Other and unspecified alcohol dependence, continuous,Esophageal reflux,Other cataract,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Unspecified hearing loss,History of fall,Unspecified fall'}
