CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 81 yo male, transfer from a [**Hospital 48825**] hospital, s/p fall from
standing. Near syncope, ? LOC. Outside imaging (CT Chest/[**Last Name (un) **])
showed Grade I splenic laceration and left rib fractures [**7-18**],
no pneumothorax. He was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: NIDDM, Neuropathy

MEDICATION ON ADMISSION: Metformin, Zocor, ASA, Gabapentin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Injury to spleen without mention of open wound into cavity, unspecified injury,Closed fracture of three ribs,Unspecified fall,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Spleen injury NOS-closed,Fracture three ribs-clos,Fall NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2123-10-3**]              Discharge Date:   [**2123-10-7**]

Date of Birth:  [**2042-4-22**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
None

History of Present Illness:
81 yo male, transfer from a [**Hospital 48825**] hospital, s/p fall from
standing. Near syncope, ? LOC. Outside imaging (CT Chest/[**Last Name (un) **])
showed Grade I splenic laceration and left rib fractures [**7-18**],
no pneumothorax. He was transported to [**Hospital1 18**] for further care.


Past Medical History:
NIDDM, Neuropathy

Family History:
Noncontributory

Pertinent Results:
[**2123-10-3**] 06:30PM   UREA N-15 CREAT-1.0
[**2123-10-3**] 06:30PM   CK-MB-NotDone
[**2123-10-3**] 06:30PM   cTropnT-<0.01
[**2123-10-3**] 06:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-10-3**] 06:30PM   WBC-11.3* RBC-4.71 HGB-13.0* HCT-38.4*
MCV-81* MCH-27.7 MCHC-34.0 RDW-13.7
[**2123-10-3**] 06:30PM   PT-13.8* PTT-26.2 INR(PT)-1.2*
[**2123-10-3**] 06:30PM   PLT COUNT-283

CT Head [**2123-10-3**]
IMPRESSION: No evidence of acute intracranial traumatic injury
seen.
Evidence of inflammatory changes in the paranasal sinuses.

CT C-spine [**2123-10-5**]
IMPRESSION:
1. No evidence of acute fracture, malalignment, or paravertebral
hematoma.
2. Multilevel degenerative changes, particularly at the C4-5
level and C5-6
level, with exaggerated kyphosis centered about C5. If there is
concern for
cord or ligamentous injury, MRI would be recommended for more
sensitive
evaluation.
3. Evidence of sinus disease again noted.
4. Dilated proximal intrathoracic esophagus which is filled with
oral
contrast, which was administered at the outside hospital.

ECHO [**2123-10-5**]
Conclusions
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.

IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. No structural
cardiac cause of syncope identified.



[**2123-10-5**]
CAROTID SERIES COMPLETE

CAROTID SERIES COMPLETE.

Duplex evaluation was performed of both carotid arteries.
Minimal plaque was
identified.

On the right, peak systolic velocities are 56, 195, 79 in the
ICA, CCA, ECA
respectively. The ICA/CCA ratio is 0.6. This is consistent with
no stenosis.

On the left, peak systolic velocities are 90, 98, 81 in the ICA,
CCA, ECA
respectively. The ICA/CCA ratio is 0.9. This is consistent with
no stenosis.

There is antegrade flow in both vertebral arteries. The left
vertebral artery
shows an elevated velocity consistent with some intrinsic
disease.

IMPRESSION: No evidence of stenosis in either carotid artery.





Brief Hospital Course:
He was admitted to the Trauma service. He was transferred to the
Trauma ICU given his injuries; especially the rib fractures and
concern for respiratory complications. The Acute Pain Service
was consulted for possible epidural catheter placement. Upon
their evaluation it was noted that patient had previous spine
surgery and would require epidural catheter placement under
fluoroscopic guidance. Discussion took place with patient and
team to try alternative medications for pain control. He was
started on an oral narcotic regimen which included Oxycodone.
This made him a bit confused and it was stopped. He was placed
on around the clock Tylenol, Lidoderm patch and standing Ultram
which per patient report was effective in controlling the pain.
His home dose Neurontin was also restarted.

He was evaluated by Physical and Occupational therapy; he made
significant gains and was eventually cleared for discharge to
home with services.

Medications on Admission:
Metformin, Zocor, ASA, Gabapentin


Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to left chest region.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*1*
7. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.


Discharge Disposition:
Home With Service

Facility:
[**Last Name (LF) **], [**First Name3 (LF) 487**]

Discharge Diagnosis:
s/p Fall
Rib fractures - left [**7-18**]
Grade I splenic laceration

Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.

Discharge Instructions:
Return to the Emergency room if you develop any headaches,
fevers, chills, dizziness, shortness of breath, productive
cough, chest pain, rib pain not relieved with the pain
medication, abdominal pain, nausea, vomiting, diarrhea and/or
any other symptoms that are concerning to you.

AVOID any activity that may cause injury to your abdominal area
because of your spleen injury for the next 6 weeks.

It is important that you cough, deep breathe and use the
incentive spirometer every hour as instructed while you are
awake in order to minimize the likelihood of getting pneumonia.
Take the pain medication as precribed.

You may resume your home medications.


Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **], Trauma Surgery. Call
[**Telephone/Fax (1) 6429**]. Inform the office that you will need a chest xray
for this appointment.

Follow up with your primary care doctor in the next 1-2 weeks.

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

Completed by:[**2123-10-19**]
{'Injury to spleen without mention of open wound into cavity, unspecified injury,Closed fracture of three ribs,Unspecified fall,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 81 yo male, transfer from a [**Hospital 48825**] hospital, s/p fall from
standing. Near syncope, ? LOC. Outside imaging (CT Chest/[**Last Name (un) **])
showed Grade I splenic laceration and left rib fractures [**7-18**],
no pneumothorax. He was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: NIDDM, Neuropathy

MEDICATION ON ADMISSION: Metformin, Zocor, ASA, Gabapentin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Injury to spleen without mention of open wound into cavity, unspecified injury,Closed fracture of three ribs,Unspecified fall,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
