CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: [**Age over 90 **]F who presented to [**Hospital1 18**] via ambulance after falling down 4
stairs while taking out her trash.  She underwent trauma
evaluation in the Emergency Department, and was admitted to the
Trauma ICU for further evaluation and management.

MEDICAL HISTORY: PMH: CHF, Afib on coumadin, MI, chronic back pain
PSH: right hip tfn, vertebroplasty (NWH)

MEDICATION ON ADMISSION: coumadin, lasix

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Gen: alert and oriented x3, nad
HEENT: normocephalic, atraumatic, PERRLA, EOMI, no evidence of
facial or neck trauma
CV: systolic ejection murmur, rrr
Resp: severe bilateral crackles
Abd: soft, NT, ND, +BS
Extr: no abrasions, ecchymoses, or deformity, 2+ pulses

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lived independently.  No EtOH or tobacco.
Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Old myocardial infarction,Accidental fall on or from other stairs or steps,Other household maintenance,Encounter for palliative care,Do not resuscitate status,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status
Fx dorsal vertebra-close,Ac on chr diast hrt fail,Crnry athrscl natve vssl,Aortic valve disorder,Atrial fibrillation,Old myocardial infarct,Fall on stair/step NEC,Househld maintenance NEC,Encountr palliative care,Do not resusctate status,Long-term use anticoagul,Status-post ptca
Admission Date:  [**2190-11-9**]              Discharge Date:   [**2190-11-11**]


Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
none

History of Present Illness:
[**Age over 90 **]F who presented to [**Hospital1 18**] via ambulance after falling down 4
stairs while taking out her trash.  She underwent trauma
evaluation in the Emergency Department, and was admitted to the
Trauma ICU for further evaluation and management.

Past Medical History:
PMH: CHF, Afib on coumadin, MI, chronic back pain
PSH: right hip tfn, vertebroplasty (NWH)

Social History:
Lived independently.  No EtOH or tobacco.

Family History:
Non-contributory.

Physical Exam:
On Admission:
Gen: alert and oriented x3, nad
HEENT: normocephalic, atraumatic, PERRLA, EOMI, no evidence of
facial or neck trauma
CV: systolic ejection murmur, rrr
Resp: severe bilateral crackles
Abd: soft, NT, ND, +BS
Extr: no abrasions, ecchymoses, or deformity, 2+ pulses

Pertinent Results:
Admission Labs:
WBC-20.0* RBC-4.58 Hgb-13.3 Hct-43.6 MCV-95 MCH-29.0 MCHC-30.5*
RDW-15.3 Plt Ct-94*
PT-39.4* PTT-43.6* INR(PT)-3.9*
Glucose-158* UreaN-42* Creat-1.4* Na-142 K-4.1 Cl-101 HCO3-29
AnGap-16
Calcium-8.0* Phos-6.4* Mg-2.3
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG

Imaging:
1. Fracture of the T10 vertebral body with small anterior
hematoma within the posterior mediastinum. This is an unstable
fracture, and although there is no obvious protrusion of
fragments or hematoma into the spinal canal, would recommend MRI
for further evaluation.
2. Sacral fracture with associated small presacral hematoma.
3. Interlobular septal thickening and ground-glass opacities in
the bilateral lungs are likely secondary to fluid overload.
4. Cardiomegaly.
5. Multiple pulmonary nodules, likely related to pulmonary
edema, although if clinically indicated, could repeat scan when
patient is more euvolemic to assess for resolution.
6. Gallbladder sludge without evidence of cholecystitis.
7. Mild thickening of the left adrenal gland.


Brief Hospital Course:
Ms [**Known lastname 92207**] was admitted to the Trauma ICU for further
evaluation and management.  Her traumatic injuries were limited
to a T10 vertebral body fracture and an oblique mid-sacral
fracture.  The spine service was consulted for these injuries.
She was also in a severe CHF exacerbation, which was severely
impairing her respiratory mechanics.  After discussion with the
patient and her family, and in keeping with her expressed
wishes, she was made DNR/DNI.  She did have a brief period of
Bipap, and was weaned to a non-rebreather mask with 100% O2.
Despite aggressive management of her CHF, she was unable to wean
off oxygen and vasopressors.  Another family meeting was held on
[**11-11**], as her respiratory status was worsening, and she was
likely going to require intubation.  At which time the family
decided to make her comfort measures only.  All aggressive
interventions and monitoring were discontinued at 3pm on [**11-11**],
and she passed away at 1922pm on [**2190-11-11**].

Medications on Admission:
coumadin, lasix

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired

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

Completed by:[**2190-11-11**]
{'Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Old myocardial infarction,Accidental fall on or from other stairs or steps,Other household maintenance,Encounter for palliative care,Do not resuscitate status,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status'}


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: [**Age over 90 **]F who presented to [**Hospital1 18**] via ambulance after falling down 4
stairs while taking out her trash.  She underwent trauma
evaluation in the Emergency Department, and was admitted to the
Trauma ICU for further evaluation and management.

MEDICAL HISTORY: PMH: CHF, Afib on coumadin, MI, chronic back pain
PSH: right hip tfn, vertebroplasty (NWH)

MEDICATION ON ADMISSION: coumadin, lasix

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Gen: alert and oriented x3, nad
HEENT: normocephalic, atraumatic, PERRLA, EOMI, no evidence of
facial or neck trauma
CV: systolic ejection murmur, rrr
Resp: severe bilateral crackles
Abd: soft, NT, ND, +BS
Extr: no abrasions, ecchymoses, or deformity, 2+ pulses

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lived independently.  No EtOH or tobacco. 

### Response:
{'Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Acute on chronic diastolic heart failure,Coronary atherosclerosis of native coronary artery,Aortic valve disorders,Atrial fibrillation,Old myocardial infarction,Accidental fall on or from other stairs or steps,Other household maintenance,Encounter for palliative care,Do not resuscitate status,Long-term (current) use of anticoagulants,Percutaneous transluminal coronary angioplasty status'}
