CHIEF COMPLAINT: Fall

PRESENT ILLNESS: 83 y/o women who fell off the side of her bed this morning
reacing for her blancket, She denies head trauma. Taken to
outside facilty where a head Ct was done and reveals a acute on
chronic, mixed density left frontal subdural hematoma with mass
effect on the lateral ventricle.

MEDICAL HISTORY: Hypothyroidism
Breast CA, s/p right mastectomy

MEDICATION ON ADMISSION: Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold SBP < 100 HR < 60.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On Admission:
T: 97.3 BP: 149/70   HR:72    R: 16       O2Sats: 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Normodephalic, Atraumatic. Pupils: 1.5-1.0  EOMs intact
Neck: Supple.
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.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] with her husband
Remote history of smoking
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pulmonary collapse,Accidental fall from bed,Unspecified psychosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Unspecified essential hypertension,Other left bundle branch block,Old myocardial infarction,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple
Subdural hem w/o coma,Pulmonary collapse,Fall from bed,Psychosis NOS,Hypothyroidism NOS,Atrial fibrillation,Hypertension NOS,Left bb block NEC,Old myocardial infarct,Hx of breast malignancy,Acq absnce breast/nipple
Name:  [**Known lastname **],[**Known firstname **]                      Unit No:   [**Numeric Identifier 13418**]

Admission Date:  [**2122-11-10**]              Discharge Date:   [**2122-11-18**]

Date of Birth:  [**2039-8-7**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 40**]
Addendum:
Added to follow up care:

Staples need to be removed on [**2122-11-20**], this can be done at the
rehab facility or you may make an appointment at our office for
removal.

Discharge Disposition:
Extended Care

Facility:
Port Rehab & Skilled Nursing - [**Location (un) 6451**]

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]

Completed by:[**2122-11-18**]

Admission Date:  [**2122-11-10**]              Discharge Date:   [**2122-11-18**]

Date of Birth:  [**2039-8-7**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
[**11-10**] Left Craniotomy for SDH

History of Present Illness:
83 y/o women who fell off the side of her bed this morning
reacing for her blancket, She denies head trauma. Taken to
outside facilty where a head Ct was done and reveals a acute on
chronic, mixed density left frontal subdural hematoma with mass
effect on the lateral ventricle.


Past Medical History:
Hypothyroidism
Breast CA, s/p right mastectomy


Social History:
Lives in [**Hospital3 **] with her husband
Remote history of smoking


Family History:
non contributory

Physical Exam:
On Admission:
T: 97.3 BP: 149/70   HR:72    R: 16       O2Sats: 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Normodephalic, Atraumatic. Pupils: 1.5-1.0  EOMs intact
Neck: Supple.
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.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 1.5 to 1.0
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: 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 [**4-21**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Exam on discharge:
Well healing left frontal cranial incision closed with staples.

Patient awake and cooperative, confused, Oriented to self and
president.
Moves all extremities to command. Antigravity with all four
extremities. Right drift and slight right facial.


Pertinent Results:
[**2122-11-10**] 03:30PM   GLUCOSE-108* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
WBC-7.0 RBC-3.87* HGB-12.1 HCT-35.5* MCV-92 MCH-31.2 MCHC-34.0
RDW-13.6
 NEUTS-69.2 LYMPHS-20.8 MONOS-8.4 EOS-0.8 BASOS-0.8
PLT COUNT-202 PT-13.0 PTT-24.6 INR(PT)-1.1

CT head [**11-12**]:
1. Interval decrease in left-sided subdural hematoma. No
evidence of shift
of normally midline structures. External drain is identified
with the tip
within the subdural collection.
2. Post-surgical changes. No new foci of hemorrhage identified.

Chest X-ray [**2122-11-14**]
No active pulmonary disease.


Brief Hospital Course:
Ms. [**Known lastname **] was admitted to [**Hospital1 18**] on [**11-10**] after falling out of bed
at her nursing facility. She has a history of falls most
recently in early [**Month (only) **]. Her CT showed
showed a mixed density left frontal SDH. She was admitted to the
neurosurgery service to the ICU. She was pre-op for surgery and
given platelets to reverse the aspirin she was taking. On [**11-11**]
she underwent a left sided craniotomy for evacuation of a
subdural hematoma post operatively she was noted to have some
mild right sided weakness. On the overnight [**11-13**] to [**11-14**] her
O2 saturation dropped but the patient refused CXR. Lasix was
given and a Foley was placed. She had a temp of 101 axillary and
blood and urine cultures were sent. [**11-14**] CXR showed mild left
atelectasis. She had some periods of confusion during her
hospital stay with a stable head CT thought to be realted to
sundowning. Fever work up revealed negative UA and blood
cultures are still pending at this writing. Neurologically she
was awake, alert and orientated X2 with a right drift and right
facial droop. A CT of the head showed a stable subacute left
frontal residual SDH on [**11-18**]. She was found to be a candidate
for rehabiltation.

Medications on Admission:
Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold SBP < 100 HR < 60.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a

day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Levolyl 50 mcg PO Daily


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
12. Levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
Port Rehab & Skilled Nursing - [**Location (un) 5028**]

Discharge Diagnosis:
Left sided subdural hematoma


Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Lethargic but arousable
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)


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.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.


Followup Instructions:
Follow up with Dr [**First Name (STitle) **] in 2 weeks with a head CT call
[**Telephone/Fax (1) 4296**] for an appointment



Completed by:[**2122-11-18**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pulmonary collapse,Accidental fall from bed,Unspecified psychosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Unspecified essential hypertension,Other left bundle branch block,Old myocardial infarction,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple'}


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: 83 y/o women who fell off the side of her bed this morning
reacing for her blancket, She denies head trauma. Taken to
outside facilty where a head Ct was done and reveals a acute on
chronic, mixed density left frontal subdural hematoma with mass
effect on the lateral ventricle.

MEDICAL HISTORY: Hypothyroidism
Breast CA, s/p right mastectomy

MEDICATION ON ADMISSION: Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold SBP < 100 HR < 60.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: On Admission:
T: 97.3 BP: 149/70   HR:72    R: 16       O2Sats: 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Normodephalic, Atraumatic. Pupils: 1.5-1.0  EOMs intact
Neck: Supple.
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.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] with her husband
Remote history of smoking 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pulmonary collapse,Accidental fall from bed,Unspecified psychosis,Unspecified acquired hypothyroidism,Atrial fibrillation,Unspecified essential hypertension,Other left bundle branch block,Old myocardial infarction,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple'}
