CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 85 yo female with multiple medical problems include recent
stroke,
[**Name (NI) 7792**] s/p with fall at [**Hospital3 **] facility, found down,
+LOC, doesn't recall details of fall. She is on Coumadin and
Plavix for A fib. She was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Type II DM
HTN
Hypothyroid
H/o TIA
Ehrlos Danlos

MEDICATION ON ADMISSION: Lidocaine 5% Patch 1 PTCH TD Q 24H
Chlorothiazide 500 mg PO DAILY
Meclizine 12.5 mg PO Q24H Order date: [**3-26**] @ 2301
Vytorin
Metformin 500mg [**Hospital1 **]
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 20 mg PO DAILY
Atenolol 25mg QD
Vesacare
Allergies- Demerol / Codeine / Percocet / Darvocet-N 50

ALLERGIES: Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)

PHYSICAL EXAM: Upon exam:
Gen: In hard collar
HEENT: significant swelling and ecchymosis R face, R eye,
bleeding cut near R eye
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date..
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II: unable to see right eye due to swelling, L eye PERRL, 5 to
3mm.
III, IV, VI: L Extraocular movements intact, R could not assess.
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.

FAMILY HISTORY: Family history of Ehrlos Danlos. There is no family history of
premature coronary artery disease or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration,Ehlers-Danlos syndrome,Delirium due to conditions classified elsewhere,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified fall,Accidents occurring in residential institution,Closed fracture of other facial bones,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Syncope and collapse,Old myocardial infarction,Alzheimer's disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs
Cl skul base fx-coma NOS,Ehlers-danlos syndrome,Delirium d/t other cond,Dementia w behavior dist,Fall NOS,Accid in resident instit,Fx facial bone NEC-close,Atrial fibrillation,DMII wo cmp nt st uncntr,Hypertension NOS,Hypothyroidism NOS,Abnrml coagultion prfile,Long-term use anticoagul,Crnry athrscl natve vssl,Status-post ptca,Syncope and collapse,Old myocardial infarct,Alzheimer's disease,Late effect CV dis NEC,Muscskel sympt limb NEC
Admission Date:  [**2149-9-27**]              Discharge Date:   [**2149-10-2**]


Service: SURGERY

Allergies:
Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)

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

Major Surgical or Invasive Procedure:
None


History of Present Illness:
85 yo female with multiple medical problems include recent
stroke,
[**Name (NI) 7792**] s/p with fall at [**Hospital3 **] facility, found down,
+LOC, doesn't recall details of fall. She is on Coumadin and
Plavix for A fib. She was transported to [**Hospital1 18**] for further care.

Past Medical History:
Type II DM
HTN
Hypothyroid
H/o TIA
Ehrlos Danlos

Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.


Family History:
Family history of Ehrlos Danlos. There is no family history of
premature coronary artery disease or sudden death.

Physical Exam:
Upon exam:
Gen: In hard collar
HEENT: significant swelling and ecchymosis R face, R eye,
bleeding cut near R eye
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date..
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II: unable to see right eye due to swelling, L eye PERRL, 5 to
3mm.
III, IV, VI: L Extraocular movements intact, R could not assess.
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 full power [**6-9**] throughout. No pronator drift

Sensation: Intact to light touch, bilaterally.

Toes downgoing bilaterally


Pertinent Results:
[**2149-9-27**] 10:20PM   GLUCOSE-158* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-29 ANION GAP-15
[**2149-9-27**] 10:20PM   CK(CPK)-81
[**2149-9-27**] 10:20PM   CK-MB-NotDone cTropnT-<0.01
[**2149-9-27**] 10:20PM   CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.5*
[**2149-9-27**] 10:20PM   WBC-8.7 RBC-3.04* HGB-8.1* HCT-23.6* MCV-78*
MCH-26.7* MCHC-34.4 RDW-14.0
[**2149-9-27**] 10:20PM   PLT COUNT-284
[**2149-9-27**] 10:20PM   PT-14.5* PTT-26.6 INR(PT)-1.3*

Head CT scan - [**2149-9-28**]
FINDINGS: The previously noted region of high attenuation,
representing clot,
in the right lateral ventricular body is now slightly smaller,
measuring 6 x
22 mm compared to prior 5 x 29 mm. There is a small amount of
blood layering
dependently in bilateral lateral ventricular occipital horns and
atria, more
represent interval redistribution of blood, rather than true
additional
hemorrhage. There are no other foci of intra- or extra- axial
hemorrhage.
There is no edema, mass effect, or shift of normally midline
structures.
Multifocal low attenuation in the bilateral periventricular and
subcortical
white matter, unchanged, likely represent chronic small vessel
ischemic
changes.

Again is noted mucosal thickening in bilateral ethmoid air cells
and air-fluid
level in the right sphenoid sinus. The right maxillary sinus and

orbital floor fractures are not included in the field of view or
well-
depicted in the current study. There is persistent swelling in
the right
periorbital region. The known right zygomatic arch fracture is
only partially
visualized.

IMPRESSION:
1. Slight reduction in size of the right lateral ventricular
thrombus, likely
adherent to choroid plexus, with some blood in the bilateral
occipital horns
and atria, likely representing redistribution of
intraventricular hemorrhage
rather than interval progression.

2. Persistent opacification of bilateral ethmoid air cells and
air-fluid
level in the right sphenoid sinus. The known facial fractures
are not
completely visualized on the current study. Please refer to
prior report
of dedicated maxillofacial CT for details.
3. Unchanged periorbital soft tissue swelling and preseptal
thickening.

Repeat head CT scan - [**2149-9-29**]
NON-CONTRAST HEAD CT: Compared to prior exam, right
intraventricular hematoma
is minimally decreased in size. Small amount of blood is seen
layering in the
dependent portions of the lateral ventricle, unchanged. No new
focus of
hemorrhage is identified. There is no hydrocephalus, shift of
normally
midline structure or evidence of major [**Month/Day/Year 1106**] territorial
infarct. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. Hypodensities in
the
periventricular and subcortical white matter reflect chronic
microvascular
ischemic change. The cavernous carotid show atherosclerotic
calcification.
Again noted are ethmoid mucosal thickeninge, air-fluid level in
the right
sphenoid sinus and complete opacification of the right maxillary
sinus. Right-
sided facial fractures are better evaluated on dedicated CT from
[**2149-9-27**].

IMPRESSION: Compared to prior exam from [**2149-9-28**], there
is minimally
decreased size of right intraventricular hematoma. Small amount
of blood
layering within the dependent portion of the ventricle is
unchanged. No new
hemorrhage is identified.

[**2149-9-27**]  CT SINUS/MANDIBLE/MAXIL

FINDINGS: Marked right-sided facial swelling and preseptal
swelling has been
evident. There is a depressed fracture involving the lateral
wall of the
right maxillary sinus by approximately 3 mm. There are several
comminuted
fractures of the lateral wall as well. An inferior maxillary
sinus fracture
is also evident. Comminuted fracture involving the medial wall
of the
maxillary sinus is noted. Hemorrhage and foci of emphysema fill
the right
maxillary sinus. Hemorrhage extends in to the ethmoid sinus at
the level of
the fracture of the medial wall. A comminuted fracture also
involves the
superior wall of the maxillary sinus. The right orbit appears
intact. No
fracture of the lamina papyracea is appreciated. The left
maxillary sinus is
intact. A small amount of high-attenuation material is also
noted within the
right sphenoid sinus and may indicate extension of right-sided
facial
fractures into the level of the sphenoid sinus. An acute
fracture of the
right zygomatic arch is again noted. No left-sided facial
fractures are
identified.

IMPRESSION: Right -sided facial fractures with hemorrhage
filling the right
maxillary sinus and extending into the right ethmoid and
sphenoid sinuses.
Fractures involving all walls of the maxillary sinus, including
the inferior
orbital wall. The right globe appears otherwise intact. There is
no evidence
of muscle entrapement but right inferior rectus is thicked
indicating trauma.





Brief Hospital Course:
She was admitted to the Trauma service. Her INR was reversed in
the Emergency room and her anticoagulants were withheld.
Neurosurgery and Plastic surgery were consulted. Her injuries
were non operative. She was taken to the Trauma ICU for close
monitoring. Serial neuro exams and head CT scans were performed.
There were no new areas of intracranial hemorrhage noted on
repeat scans. It is being recommended that her anticoagulants
not be restarted.

She was eventually transferred to the regular nursing unit.
Geriatrics was also consulted given her age and mechanism of
injury. Several recommendations were made pertaining to her
medications. She has a known history of hypertension and has
been on several medications to control this. Her systolic blood
pressures have ranged between 160-170's; she was previously on
Norvasc amongst her other blood pressure medications (see
Medications at home section) and this was resumed. Her PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] was contact[**Name (NI) **] and he reports that her baseline systolic
blood pressure ranges between 130-140's and has recommended to
increase the Norvasc from 2.5 mg to 5 mg.

She was noted to be delirious and it was recommended that she be
started on Zyprexa which has improved her mental status. Of
note, there have not been any behavioral issues.

Social work was consulted for patient and family emotional
support.

Medications on Admission:
Lidocaine 5% Patch 1 PTCH TD Q 24H
Chlorothiazide 500 mg PO DAILY
Meclizine 12.5 mg PO Q24H Order date: [**3-26**] @ 2301
Vytorin
Metformin 500mg [**Hospital1 **]
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 20 mg PO DAILY
Atenolol 25mg QD
Vesacare
Allergies- Demerol / Codeine / Percocet / Darvocet-N 50


Discharge Medications:


1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <130; HR <60.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO daily ().
10. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold fro SBP<130.
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO Q6PM: hold
for increased sedation.
14. Erythromycin 5 mg/g Ointment Sig: One (1) APPL Ophthalmic
TID (3 times a day) for 2 days: Apply OD.
15. Nevanac 0.1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
16. Moxifloxacin 0.5 % Drops Sig: One (1) GTT Ophthalmic TID (3
times a day): Apply OS.
17. Omnipred 1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 5481**]

Discharge Diagnosis:
s/p Fall
Maxillary sinus fracture
Inferior orbital wall fracture
Intraventricular head bleed
Coagulopathy secondary to elevated INR


Discharge Condition:
Hemodynamically stable, pain adequately controlled


Discharge Instructions:
AVOID any anticoagulants (except for Heparin SQ) until follow up
in 2 weeks with Neurosurgery.

Followup Instructions:
Follow up in 1 week with Plastic surgery for your facial
fractures, call [**Telephone/Fax (1) 5343**] for an appointment.

Follow up next week in [**Hospital 8095**] Clinic next week, call
[**Telephone/Fax (1) 253**] for an appointment.

Follow up in 2 weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.

The following appointments were made prior to this
hospitalization:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-10-14**]
11:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2149-10-14**]
12:00



Completed by:[**2149-10-2**]

Name:  [**Known lastname 12392**],[**Known firstname **]                     Unit No:   [**Numeric Identifier 12393**]

Admission Date:  [**2149-9-27**]              Discharge Date:   [**2149-10-2**]

Date of Birth:  [**2064-4-3**]             Sex:   F

Service: SURGERY

Allergies:
Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)

Attending:[**First Name3 (LF) 3524**]
Addendum:
It was recommended by Geriatrics that her Zyprexa be decreased
to 1.25 mg every evening.

Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): hold for HR <130; HR <60.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Solifenacin 5 mg Tablet Sig: Two (2) Tablet PO daily ().
10. Amlodipine 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): hold fro SBP<130.
11. Hydrochlorothiazide 12.5 mg Capsule Sig: Three (3) Capsule
PO DAILY (Daily).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Olanzapine 2.5 mg Tablet Sig: [**2-5**] Tablet PO Q6PM: hold for
increased sedation.
14. Erythromycin 5 mg/g Ointment Sig: One (1) APPL Ophthalmic
TID (3 times a day) for 2 days: Apply OD.
15. Nevanac 0.1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
16. Moxifloxacin 0.5 % Drops Sig: One (1) GTT Ophthalmic TID (3
times a day): Apply OS.
17. Omnipred 1 % Drops, Suspension Sig: One (1) GTT Ophthalmic
TID (3 times a day): Apply OS.
18. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 1267**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**]

Completed by:[**2149-10-2**]
{"Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration,Ehlers-Danlos syndrome,Delirium due to conditions classified elsewhere,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified fall,Accidents occurring in residential institution,Closed fracture of other facial bones,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Syncope and collapse,Old myocardial infarction,Alzheimer's disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs"}


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: 85 yo female with multiple medical problems include recent
stroke,
[**Name (NI) 7792**] s/p with fall at [**Hospital3 **] facility, found down,
+LOC, doesn't recall details of fall. She is on Coumadin and
Plavix for A fib. She was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Type II DM
HTN
Hypothyroid
H/o TIA
Ehrlos Danlos

MEDICATION ON ADMISSION: Lidocaine 5% Patch 1 PTCH TD Q 24H
Chlorothiazide 500 mg PO DAILY
Meclizine 12.5 mg PO Q24H Order date: [**3-26**] @ 2301
Vytorin
Metformin 500mg [**Hospital1 **]
Levothyroxine Sodium 50 mcg PO DAILY
Lisinopril 20 mg PO DAILY
Atenolol 25mg QD
Vesacare
Allergies- Demerol / Codeine / Percocet / Darvocet-N 50

ALLERGIES: Demerol / Codeine / Percocet / Darvocet-N 50 / Sulfa
(Sulfonamides)

PHYSICAL EXAM: Upon exam:
Gen: In hard collar
HEENT: significant swelling and ecchymosis R face, R eye,
bleeding cut near R eye
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date..
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
II: unable to see right eye due to swelling, L eye PERRL, 5 to
3mm.
III, IV, VI: L Extraocular movements intact, R could not assess.
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.

FAMILY HISTORY: Family history of Ehrlos Danlos. There is no family history of
premature coronary artery disease or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. 

### Response:
{"Closed fracture of base of skull with other and unspecified intracranial hemorrhage, with loss of consciousness of unspecified duration,Ehlers-Danlos syndrome,Delirium due to conditions classified elsewhere,Dementia in conditions classified elsewhere with behavioral disturbance,Unspecified fall,Accidents occurring in residential institution,Closed fracture of other facial bones,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Abnormal coagulation profile,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Syncope and collapse,Old myocardial infarction,Alzheimer's disease,Other late effects of cerebrovascular disease,Other musculoskeletal symptoms referable to limbs"}
