CHIEF COMPLAINT: CC: HA, L temporal lac, L shoulder/elbow pain s/p fall from
standing.

PRESENT ILLNESS: HPI: 80M s/p unwitnessed mech fall outside local Stop&Shop with
reported immediate MS changes.  No h/o sz or falls.  Per family,
highly independent and functioning at home but has become more
feeble in walking at home.

MEDICAL HISTORY: PMHx: prostate CA s/p XRT, hiatal hernia

MEDICATION ON ADMISSION: asa
detrol
nexium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival

FAMILY HISTORY: Family Hx: noncontributory. denies FH of falls or sz.

SOCIAL HISTORY: Social Hx: married, highly independently functioning, works as
dispatcher for auto shop, >150pky quit [**12-3**], recovering EtOH.
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hyposmolality and/or hyponatremia,Other fall,Accidents occurring in public building,Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health,Diaphragmatic hernia without mention of obstruction or gangrene,Contusion of face, scalp, and neck except eye(s),Calcifying tendinitis of shoulder
Brain lacer NEC w/o coma,Hyposmolality,Fall NEC,Accident in public bldg,Hx-prostatic malignancy,Hx of irradiation,Diaphragmatic hernia,Contusion face/scalp/nck,Calcif tendinitis shlder
Admission Date:  [**2126-9-23**]              Discharge Date:   [**2126-10-2**]

Date of Birth:  [**2045-12-26**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC: HA, L temporal lac, L shoulder/elbow pain s/p fall from
standing.


Major Surgical or Invasive Procedure:
none


History of Present Illness:
HPI: 80M s/p unwitnessed mech fall outside local Stop&Shop with
reported immediate MS changes.  No h/o sz or falls.  Per family,
highly independent and functioning at home but has become more
feeble in walking at home.


Past Medical History:
PMHx: prostate CA s/p XRT, hiatal hernia


Social History:
Social Hx: married, highly independently functioning, works as
dispatcher for auto shop, >150pky quit [**12-3**], recovering EtOH.

,


Family History:
Family Hx: noncontributory. denies FH of falls or sz.


Physical Exam:
On arrival

PHYSICAL EXAM:
96.6 66 175/77 15 95%/2L
Gen: thin, confused, perseverating.
HEENT: L temporal lac/hematoma, PERRLA, 3->2mm bilat, EOMI, no
orbital tenderness.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: +BS, S, NT/ND.
Extrem: cool.
Neuro:
Mental status: awake, attempts to cooperate with exam.
Orientation: Oriented to person and place. Slightly confused
with
respect to time.
Language: nonfluent speech, word-finding difficulty,
perseverates, confused.
CN II-XII grossly intact.

Motor:
LUE [**5-2**] throughout.
RUE 4+/5 throughout.
LEs 4+/5 IP/Q/H/TA/[**Last Name (un) 938**]/GS bilaterally.
No abnormal movements or tremors detected.
No pronator drift.
Sensation intact to light touch.
Toes downgoing bilaterally.

Currently - this day of discharge
pt is awake alert and oriented / this fluctuates slightly/
PERRL, speech clear, follows commands, no drift, ambulatory with
contact guard, [**Name2 (NI) **] facial asymmetry.

Pertinent Results:
   RADIOLOGY  Final Report

CHEST (PA & LAT)  [**2126-10-1**] 2:46 PM

CHEST (PA & LAT)

Reason: eval for silent aspiration

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with s/p intracerebral hemorrhage
REASON FOR THIS EXAMINATION:
eval for silent aspiration
CHEST

HISTORY: Intracerebral hemorrhage, possible aspiration.

Two views. Comparison with the previous study done [**2126-9-26**].
Interstitial markings are prominent. The lungs appear otherwise
clear. There is no focal consolidation. The heart is normal in
size. The aorta is mildly tortuous and calcified as before.
Feeding tube has been removed.

IMPRESSION: No evidence of aspiration post-feeding tube removal.
Prominence of the pulmonary interstitium which may reflect
interstitial lung disease.

DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Approved: WED [**2126-10-2**] 9:40 AM
   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2126-9-25**] 10:30 AM

CT HEAD W/O CONTRAST

Reason: eval for interval changes on [**9-25**]

[**Hospital 93**] MEDICAL CONDITION:
80m s/p fall likely due to sz, no h/o sz
REASON FOR THIS EXAMINATION:
eval for interval changes on [**9-25**]
CONTRAINDICATIONS for IV CONTRAST: None.

`INDICATION: Fall, extra-axial hemorrhage. Query interval
change.

NON-CONTRAST HEAD CT: Extra-axial hemorrhage is again seen along
the posterior falx, the left posterior frontal cerebral
convexity, and along the right temporal tip. There is
intraventricular hemorrhage layering in both posterior and
lateral ventricle horns. The area of cerebral contusion in the
right temporal frontoparietal lobe with hemorrhage and
surrounding edema is unchanged. There is no midline shift, or
evidence of acute major vascular territorial infarct. No
fractures are identified.

IMPRESSION: No significant change in appearance of extra-axial
hemorrhage and right temporal lobe contusion.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: MON [**2126-9-30**] 10:37 AM
Cardiology Report ECG Study Date of [**2126-9-23**]  1:43:22 PM


Sinus rhythm
Consider Left atrial enlargement
No previous tracing available for comparison


Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 178 92 400/440 59 63 52


([**-7/4486**])



   RADIOLOGY  Final Report

CT C-SPINE W/O CONTRAST  [**2126-9-23**] 1:56 PM

CT C-SPINE W/O CONTRAST

Reason: please eval for bony fx or malalignment.

[**Hospital 93**] MEDICAL CONDITION:
80 year old man s/p fall with altered mental status. Concern for
acute bleed. Ccollar.
REASON FOR THIS EXAMINATION:
please eval for bony fx or malalignment.
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: A 80-year-old male with fall, altered mental status.

C-SPINE CT WITHOUT CONTRAST: There is no comparison. The
cervical spine was visualized from the level of skull base to
the level of T2/T3. There is no prevertebral soft tissue
swelling. There are multilevel degenerative changes with
osteophyte formation, disc space narrowing, vacuum phenomenon
and endplate irregularity. There is no evidence of subluxation
or fracture. There is narrowing and degenerative change at the
atlantoaxial joint. In the visualized portion of the lung
apices, note is made of centrilobular emphysema. There is
minimal mucosal thickening in the ethmoid sinus, with
incidentally noted [**Doctor Last Name 13856**] bullosa. In the visualized portion of
the brain parenchyma, note is made of a hemorrhagic contusion in
the right temporal lobe with probable subdural and subarachnoid
component as described in detail in the head CT report.

IMPRESSION: Degenerative changes at multiple levels. No evidence
of fracture or subluxation. Intraparenchymal hemorrhagic
contusion in the right temporal lobe with subdural and
subarachnoid components, as described in the head CT report.
Centrilobular emphysema.

The wet read was provided to ED dashboard.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**]
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: MON [**2126-9-23**] 7:24 PM
   RADIOLOGY  Final Report

SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT PORT  [**2126-9-23**]
3:59 PM

SHOULDER (AP, NEUTRAL & AXILLA

Reason: left shoulder pain

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with left shoulder pain
REASON FOR THIS EXAMINATION:
left shoulder pain
INDICATION: Left shoulder pain.

COMPARISONS: None.

LEFT SHOULDER, 2 VIEWS: There is a tiny calcific fragment seen
adjacent to the greater tuberosity of the left humerus. This is
likely within the rotator cuff tendons and could represent
calcific tendonitis. No acute fracture is seen.

IMPRESSION:
1. Calcific tendinitis of the rotator cuff, adjacent to the
greater tuberosity of the left humerus.
2. No evidence of fracture.

DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Approved: MON [**2126-9-23**] 6:48 PM


Brief Hospital Course:
Pt was admitted through the ED to ICU. Pt neuro exam was
followed closely.  He was loaded with dilantin and then this was
continued 100 TID. His follow up CT scans of the head remained
stable without significant increase in hemorrhage.  He required
no neurosurgical intervention.  He had and NGT placed and this
was later d/c'd after passing speech and swallow evals.  His
dilantin was switched to keppra as he required multiple bolus'
of dilantin to maintain therapeutic levels. On [**9-29**] he was
transferred out of the ICU and his mental status improved daily.
His WBC count in the last two days has increased from 11 to
17.8.  The attending is aware and he was pan cultured today.
His CXR is without aspiration/PNA and he remains afebrile.  He
is participating with PT OT and plan is to dishcarge him today
[**2126-10-2**].  He agrees with this plan.

Medications on Admission:
asa
detrol
nexium

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
4. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 **]  Hospital [**Location (un) **]

Discharge Diagnosis:
Right Temporal intracereebral hemorrhage


Discharge Condition:
neurologically improved


Discharge Instructions:
HEAD INJURY

??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	New onset of tremors or seizures
??????	Any confusion 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
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
You will need to see Dr. [**Last Name (STitle) 739**] in 6 weeks with an MRI of
the brain, with and without contrast. please call [**Telephone/Fax (1) **]
for an appointment.

you should see your primary care physician shortly and let him
know about your admission to the hospital.


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2126-10-2**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hyposmolality and/or hyponatremia,Other fall,Accidents occurring in public building,Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health,Diaphragmatic hernia without mention of obstruction or gangrene,Contusion of face, scalp, and neck except eye(s),Calcifying tendinitis of shoulder'}


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: CC: HA, L temporal lac, L shoulder/elbow pain s/p fall from
standing.

PRESENT ILLNESS: HPI: 80M s/p unwitnessed mech fall outside local Stop&Shop with
reported immediate MS changes.  No h/o sz or falls.  Per family,
highly independent and functioning at home but has become more
feeble in walking at home.

MEDICAL HISTORY: PMHx: prostate CA s/p XRT, hiatal hernia

MEDICATION ON ADMISSION: asa
detrol
nexium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival

FAMILY HISTORY: Family Hx: noncontributory. denies FH of falls or sz.

SOCIAL HISTORY: Social Hx: married, highly independently functioning, works as
dispatcher for auto shop, >150pky quit [**12-3**], recovering EtOH. 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hyposmolality and/or hyponatremia,Other fall,Accidents occurring in public building,Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health,Diaphragmatic hernia without mention of obstruction or gangrene,Contusion of face, scalp, and neck except eye(s),Calcifying tendinitis of shoulder'}
