CHIEF COMPLAINT: s/p fall with SDH

PRESENT ILLNESS: Ms. [**Known lastname 5263**] is a 88yo female with dementia who has recent history
of falls, presents with SDH s/p fall on Sunday. She was found to
have left head swelling and a laceration over her left eyebrow.
On day PTA she fell out of her wheelchair and was found to be
more lethargic with garbled speech and progressively became more
somnolent. She presented to [**Hospital3 **] and was then
transferred to [**Hospital1 18**] MICU on [**5-29**]. Neurosurgery followed patient
closely and did not feel that surgery was indicated. She was
loaded with Dilantin and maintained on IV dilantin. CT scan was
unchanged from OSH. She was then transferred to medical floor.

MEDICAL HISTORY: 1)Alzheimers
2)Hypertension
3)Hypothyroidism
4)CAD s/p stent in [**2181**] to LCx
5)LBP
6)DJD
7)Hyperlipidemia

MEDICATION ON ADMISSION: FE 325 mg qd
Propanolol 120 mg qd
Levothyroxine 50 mcg qd
Sertraline 50 mg qd
ASA 81 mg qd
MVI
Ativan 0.5 mg po q 6 prn
Oral peridex

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: vitals: T 98 BP 180/70 AR 81 RR 20 O2 sat 98%RA
Gen: Patient somnolent; responsive to sternal rub but does not
follow simple commands.
HEENT: PERRLA
Heart: RRR, nl s1/s2, no s3/s4, +systolic murmur
Lungs: CTAB
Abdomen: soft NT/ND, +BS
Extremities: no LE edema, 2+ DP/PT pulses bilaterally; left
raccon eye hematoma with laceration on eyebrow
Neuro: unable to assess given mental status

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] [**2-9**] to dementia for 3 weeks, prior was I ADLs
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute kidney failure, unspecified,Accidental fall from wheelchair,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Unspecified acquired hypothyroidism,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension
Traumatic subdural hem,Acute kidney failure NOS,Fall from wheelchair,Crnry athrscl natve vssl,Status-post ptca,Hyperlipidemia NEC/NOS,Iron defic anemia NOS,Hypothyroidism NOS,Alzheimer's disease,Dementia w/o behav dist,Hypertension NOS
Admission Date:  [**2187-5-29**]              Discharge Date:   [**2187-6-2**]


Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
s/p fall with SDH

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname 5263**] is a 88yo female with dementia who has recent history
of falls, presents with SDH s/p fall on Sunday. She was found to
have left head swelling and a laceration over her left eyebrow.
On day PTA she fell out of her wheelchair and was found to be
more lethargic with garbled speech and progressively became more
somnolent. She presented to [**Hospital3 **] and was then
transferred to [**Hospital1 18**] MICU on [**5-29**]. Neurosurgery followed patient
closely and did not feel that surgery was indicated. She was
loaded with Dilantin and maintained on IV dilantin. CT scan was
unchanged from OSH. She was then transferred to medical floor.

Past Medical History:
1)Alzheimers
2)Hypertension
3)Hypothyroidism
4)CAD s/p stent in [**2181**] to LCx
5)LBP
6)DJD
7)Hyperlipidemia

Social History:
Lives in [**Location **] [**2-9**] to dementia for 3 weeks, prior was I ADLs

Family History:
NC

Physical Exam:
vitals: T 98 BP 180/70 AR 81 RR 20 O2 sat 98%RA
Gen: Patient somnolent; responsive to sternal rub but does not
follow simple commands.
HEENT: PERRLA
Heart: RRR, nl s1/s2, no s3/s4, +systolic murmur
Lungs: CTAB
Abdomen: soft NT/ND, +BS
Extremities: no LE edema, 2+ DP/PT pulses bilaterally; left
raccon eye hematoma with laceration on eyebrow
Neuro: unable to assess given mental status


Pertinent Results:
Laboratory results:
[**2187-5-29**] 04:20PM BLOOD WBC-8.5 RBC-4.07* Hgb-10.7* Hct-32.7*
MCV-80* MCH-26.3* MCHC-32.8 RDW-16.9* Plt Ct-227
[**2187-5-29**] 04:20PM BLOOD PT-13.4* PTT-30.5 INR(PT)-1.2*
[**2187-5-29**] 04:20PM BLOOD Glucose-97 UreaN-21* Creat-1.2* Na-133
K-6.0* Cl-99 HCO3-26 AnGap-14
[**2187-5-30**] 02:23AM BLOOD Calcium-8.4 Phos-4.2 Mg-2.3
[**2187-5-29**] 04:20PM BLOOD calTIBC-328 Ferritn-63 TRF-252

Relevant Imaging:
1)Cxray ([**5-29**]): No acute cardiopulmonary process.

2)CT Head ([**5-29**]): 1. Left convexity acute subdural hematoma,
with associated mass effect and minimal rightward shift of
normally midline structures.

3)CT Head ([**5-31**]): Evolving left subdural hematoma without
increase in size or mass effect.

4)MRI head ([**5-31**]): Subdural and subarachnoid hemorrhages on the
left as described above, very similar in appearance to prior
studies.


Brief Hospital Course:
Ms. [**Known lastname 5263**] is a 88yo female with underlying dementia with recent
history of multiple falls, who presents s/p fall with SDH.

1)Subdural hematoma: Occurred in the setting of recent fall.
Etiology of fall likely mechanical. Infectious work-up was
negative. She was initially loaded with Dilantin and then
continued on an infusion. Neurosurgery was consulted on
admission and followed patient closely. They did not feel that
she was a surgical candidate since the bleed was thought to be a
chronic process. It was recommended that she undergo drainage in
1 month but the family does not want any invasive procedures to
be done. Patient's mental status was waxing and [**Doctor Last Name 688**]
throughout her stay and repeat CT scan
was mostly unchanged. Dilantin was stopped as per family
requests given plan for hospice care. She is being discharged on
Haldol, Ativan, Morphine, and Acetaminophen which she be given
if patient is agitated or appears to be in pain. Please monitor
for symptoms closely.

2)Hypertension: Patient was on Propranolol as outpatient. This
was initially held but then never restarted as per outcome of
the family meeting.

3)Dementia: Patient has dementia at baseline. No further work-up
at this time.

4)Anemia: Patient presented with Hct~ 31.7. Decreased to 24.9
during hospital stay. Unclear cause. Possibly related to SDH. No
further labs were checked after decision was made for hospice
care.

5)Hypothyroidism: Patient was initially started on Levothyroxine
IV since she was not able to take PO. After a family meeting
with the family the decision was made to stop all medications.
Levothyroxine was stopped at this time.

6)Code status: DNR/DNI. Housestaff team had family meeting with
patient and decision was made to arrange for hospice care.
Family does not want any agressive measures to be done including
IVFs and invasive procedures.

Medications on Admission:
FE 325 mg qd
Propanolol 120 mg qd
Levothyroxine 50 mcg qd
Sertraline 50 mg qd
ASA 81 mg qd
MVI
Ativan 0.5 mg po q 6 prn
Oral peridex

Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours).
2. Haloperidol 1 mg IV TID:PRN
3. Lorazepam 0.5 mg IV Q4H:PRN
4. Morphine Sulfate 1-5 mg IV Q4H:PRN


Discharge Disposition:
Extended Care

Facility:
Hellenic - [**Location (un) 2624**]

Discharge Diagnosis:
Primary diagnoses:
1)Subdural hematoma

Secondary diagnoses:
1)Anemia
2)Hypertension
3)Hypothyroidism


Discharge Condition:
Stable to be discharged to nursing home with hospice services


Discharge Instructions:
1)Patient was admitted and found to have a subdural hematoma.
After discussions with the family, the decision was made to make
patient DNR/DNI with arrangement for hospice services. All
medications were stopped except for anxiolytics, pain, and
sedative medications which should be continued.

Followup Instructions:
None





Name:  [**Known lastname 4345**],[**Known firstname 6705**]                  Unit No:   [**Numeric Identifier 6706**]

Admission Date:  [**2187-5-29**]              Discharge Date:   [**2187-6-2**]

Date of Birth:  [**2098-12-29**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 653**]
Addendum:
Per family request, PICC line was d/c'ed. As a result her IV
pain and sedative medications were changed to oral concentration
and IM forms.

Discharge Disposition:
Extended Care

Facility:
Hellenic - [**Location (un) 271**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 655**] MD [**MD Number(2) 656**]

Completed by:[**2187-6-2**]
{"Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute kidney failure, unspecified,Accidental fall from wheelchair,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Unspecified acquired hypothyroidism,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension"}


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 with SDH

PRESENT ILLNESS: Ms. [**Known lastname 5263**] is a 88yo female with dementia who has recent history
of falls, presents with SDH s/p fall on Sunday. She was found to
have left head swelling and a laceration over her left eyebrow.
On day PTA she fell out of her wheelchair and was found to be
more lethargic with garbled speech and progressively became more
somnolent. She presented to [**Hospital3 **] and was then
transferred to [**Hospital1 18**] MICU on [**5-29**]. Neurosurgery followed patient
closely and did not feel that surgery was indicated. She was
loaded with Dilantin and maintained on IV dilantin. CT scan was
unchanged from OSH. She was then transferred to medical floor.

MEDICAL HISTORY: 1)Alzheimers
2)Hypertension
3)Hypothyroidism
4)CAD s/p stent in [**2181**] to LCx
5)LBP
6)DJD
7)Hyperlipidemia

MEDICATION ON ADMISSION: FE 325 mg qd
Propanolol 120 mg qd
Levothyroxine 50 mcg qd
Sertraline 50 mg qd
ASA 81 mg qd
MVI
Ativan 0.5 mg po q 6 prn
Oral peridex

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: vitals: T 98 BP 180/70 AR 81 RR 20 O2 sat 98%RA
Gen: Patient somnolent; responsive to sternal rub but does not
follow simple commands.
HEENT: PERRLA
Heart: RRR, nl s1/s2, no s3/s4, +systolic murmur
Lungs: CTAB
Abdomen: soft NT/ND, +BS
Extremities: no LE edema, 2+ DP/PT pulses bilaterally; left
raccon eye hematoma with laceration on eyebrow
Neuro: unable to assess given mental status

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives in [**Location **] [**2-9**] to dementia for 3 weeks, prior was I ADLs 

### Response:
{"Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Acute kidney failure, unspecified,Accidental fall from wheelchair,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Other and unspecified hyperlipidemia,Iron deficiency anemia, unspecified,Unspecified acquired hypothyroidism,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension"}
