CHIEF COMPLAINT: I fell in my bathroom

PRESENT ILLNESS: HPI: This is a 57 year old male who was transfered to [**Hospital1 18**] from
[**Hospital 27217**] Hospital. At 11am on [**9-30**], the patient was urinating
in
his bathroom at home when he suddenly fell and hit his head
against the toilet. There may have been a period of
lightheadedness prior to falling down but the patient is unsure.
He denies any loss of consciousness and was able to get up, go
downstairs and watch TV. Throughout the day, he states he began
to progressively feel lethargic and weak (entire body weakness).
He called EMS and was taken to [**Hospital 27217**] Hospital, which showed
cerebral contusions and a possible SAH. at [**Hospital1 18**], he was
re-imaged and evaluated. The patient denies
nausea/vomiting/chest
pain/shortness of breath. Currently, at time of evaluation, the
pt is complaining of a headache.

MEDICAL HISTORY: PMHx:
- Seizure ([**2-18**])
- Pneumonia ([**2-18**])
- Bronchitis ([**2-18**])
- Numerous visits to the ED s/p alcoholic episodes with various
falls or episodes of unconsciousness

MEDICATION ON ADMISSION: - oxycontin (prescribed for the last 2 weeks as he has rib
fractures from a previous fall)
- regular vitamins

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on admission
-----PHYSICAL EXAM:-------------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2mm bilaterally.       EOMs intact. No
nystagmus. C-collar in place.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and orientated X 2. Oriented to person,
place,
but not date.
Recall: [**3-15**] objects at 5 minutes.
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,2.5 to 2
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 finger rub bilaterally.
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 [**5-17**] throughout. No pronator drift
.
Sensation: Intact to light touch bilaterally.
.

FAMILY HISTORY: Family Hx: Noncontributory.

SOCIAL HISTORY: Social Hx: This patient lives alone. He drinks 1 pint/day and
smokes approximately 2 packs a day of cigarettes for the last 40
years (=80 pack year history). The patient is not married. He
works for a company which restores cars. He lives in [**Location **].
He
has 3 children.
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, unspecified state of consciousness,Other emphysema,Fall from other slipping, tripping, or stumbling,Alcohol abuse, continuous,Closed fracture of nasal bones
Brain laceration NEC,Emphysema NEC,Fall from slipping NEC,Alcohol abuse-continuous,Nasal bone fx-closed
Admission Date:  [**2126-10-11**]              Discharge Date:   [**2126-10-15**]

Date of Birth:  [**2069-4-23**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
I fell in my bathroom

Major Surgical or Invasive Procedure:
none


History of Present Illness:
HPI: This is a 57 year old male who was transfered to [**Hospital1 18**] from
[**Hospital 27217**] Hospital. At 11am on [**9-30**], the patient was urinating
in
his bathroom at home when he suddenly fell and hit his head
against the toilet. There may have been a period of
lightheadedness prior to falling down but the patient is unsure.
He denies any loss of consciousness and was able to get up, go
downstairs and watch TV. Throughout the day, he states he began
to progressively feel lethargic and weak (entire body weakness).
He called EMS and was taken to [**Hospital 27217**] Hospital, which showed
cerebral contusions and a possible SAH. at [**Hospital1 18**], he was
re-imaged and evaluated. The patient denies
nausea/vomiting/chest
pain/shortness of breath. Currently, at time of evaluation, the
pt is complaining of a headache.


Past Medical History:
PMHx:
- Seizure ([**2-18**])
- Pneumonia ([**2-18**])
- Bronchitis ([**2-18**])
- Numerous visits to the ED s/p alcoholic episodes with various
falls or episodes of unconsciousness


Social History:
Social Hx: This patient lives alone. He drinks 1 pint/day and
smokes approximately 2 packs a day of cigarettes for the last 40
years (=80 pack year history). The patient is not married. He
works for a company which restores cars. He lives in [**Location **].
He
has 3 children.


Family History:
Family Hx: Noncontributory.


Physical Exam:
on admission
-----PHYSICAL EXAM:-------------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2mm bilaterally.       EOMs intact. No
nystagmus. C-collar in place.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and orientated X 2. Oriented to person,
place,
but not date.
Recall: [**3-15**] objects at 5 minutes.
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,2.5 to 2
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 finger rub bilaterally.
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 [**5-17**] throughout. No pronator drift
.
Sensation: Intact to light touch bilaterally.
.

Pertinent Results:
[**2126-10-10**] 11:00PM   PT-11.5 PTT-24.9 INR(PT)-1.0
[**2126-10-10**] 11:00PM   PLT COUNT-325
[**2126-10-10**] 11:00PM   MACROCYT-1+
[**2126-10-10**] 11:00PM   NEUTS-80.6* LYMPHS-13.6* MONOS-4.4 EOS-0.5
BASOS-0.9
[**2126-10-10**] 11:00PM   WBC-6.7 RBC-3.96* HGB-13.9* HCT-39.8*
MCV-100* MCH-35.0* MCHC-34.9 RDW-13.2
[**2126-10-10**] 11:00PM   GLUCOSE-86 UREA N-17 CREAT-0.6 SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-20
[**2126-10-11**] 02:45AM URINE  RBC-<1 WBC-<1 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2126-10-11**] 02:45AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-6.0 LEUK-NEG
[**2126-10-11**] 02:45AM URINE  COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2126-10-11**] 02:45AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
.
.
CT HEAD W/O CONTRAST  [**2126-10-11**] 1:24 AM
IMPRESSION:
1. Hemorrhagic contusion in the left frontal lobe.
2. Small subdural hematoma along the falx cerebri and tentorium.
3. Probable chronic subdural hematoma along the left frontal
convexity, and possibly along the right as well. The latter
appearance of extraaxial widening is felt more likely due to
atrophy, however.
4. Sinus mucosal thickening with a small air-fluid level in the
sphenoid.
5. Nasal bone fractures.
NOTE ADDED AT ATTENDING REVIEW: I agree that the right frontal
extra axial fluid is most likely an enlarged subarachnoid space.

.
.
CT C-SPINE W/O CONTRAST  [**2126-10-11**] 1:24 AM
IMPRESSION:
1. No evidence of fracture or dislocation.
2. Moderately severe emphysema.
3. Findings suggesting chronic sinusitis in the left maxillary
sinus.
4. Cervical spondylosis.
.
.


Brief Hospital Course:
This patient was admitted to [**Hospital1 18**] on [**2126-10-11**] after a fall in
his bathroom. He was evaluated and admitted to the trauma
service initially for neuro checks, a repeat CT head the
following morning and observation (especially given his history
of alcohol). Overnight, the patient was stable and he
neurlogically was intact. A repeat CT in the morning showed a
contusion which potentially was read as an underlying mass. The
patient was hence kept for furthur observation. As an MRI was
unable to be done, a repeat CT head with and without contrast
was done, which showed no underlying lesions. THe patient had no
other medical or surgical issues and was stable. Over the
weekend from [**10-11**] to [**10-13**], the patient remained in the trauma
ICU awaiting a bed on the floor. He remained stable and without
issues. He was put on a CIWA scale per his alcoholic history. He
was intermittently confused at some points overnight, likely due
to his pain medications and alcoholic history.
He was seen by physical therapy on [**2126-10-14**], who reccomended one
more session prior to discharge on [**2126-10-15**]. On [**10-15**] he was seen
and evaluated by physical therapy and cleared for discharge.  He
was seen by physical therapy on [**2126-10-15**], and then discharged in
a stable condition. He is due to follow-up with Dr [**Last Name (STitle) **] in the
clinic in 4 weeks with another repeat head scan.

Medications on Admission:
- oxycontin (prescribed for the last 2 weeks as he has rib
fractures from a previous fall)
- regular vitamins


Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 30 days.
Disp:*45 Capsule(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
traumatic brain injury s/p fall


Discharge Condition:
neurologically stable


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
 call if you have any lethargy, numbness tingling weakness,
seizure or slurred speech.
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.


Followup Instructions:
please call the office to be seen in 4 weeks with a cat scan of
the brain.  The cat scan should be with and without contrast.
Please call Dr.[**Name (NI) 9034**] office at [**Telephone/Fax (1) **] for and
appointment.  You should see your primary care doctor within 2
weeks for evaluation and follow up.



Completed by:[**2126-10-15**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, unspecified state of consciousness,Other emphysema,Fall from other slipping, tripping, or stumbling,Alcohol abuse, continuous,Closed fracture of nasal bones'}


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: I fell in my bathroom

PRESENT ILLNESS: HPI: This is a 57 year old male who was transfered to [**Hospital1 18**] from
[**Hospital 27217**] Hospital. At 11am on [**9-30**], the patient was urinating
in
his bathroom at home when he suddenly fell and hit his head
against the toilet. There may have been a period of
lightheadedness prior to falling down but the patient is unsure.
He denies any loss of consciousness and was able to get up, go
downstairs and watch TV. Throughout the day, he states he began
to progressively feel lethargic and weak (entire body weakness).
He called EMS and was taken to [**Hospital 27217**] Hospital, which showed
cerebral contusions and a possible SAH. at [**Hospital1 18**], he was
re-imaged and evaluated. The patient denies
nausea/vomiting/chest
pain/shortness of breath. Currently, at time of evaluation, the
pt is complaining of a headache.

MEDICAL HISTORY: PMHx:
- Seizure ([**2-18**])
- Pneumonia ([**2-18**])
- Bronchitis ([**2-18**])
- Numerous visits to the ED s/p alcoholic episodes with various
falls or episodes of unconsciousness

MEDICATION ON ADMISSION: - oxycontin (prescribed for the last 2 weeks as he has rib
fractures from a previous fall)
- regular vitamins

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on admission
-----PHYSICAL EXAM:-------------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2mm bilaterally.       EOMs intact. No
nystagmus. C-collar in place.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and orientated X 2. Oriented to person,
place,
but not date.
Recall: [**3-15**] objects at 5 minutes.
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,2.5 to 2
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 finger rub bilaterally.
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 [**5-17**] throughout. No pronator drift
.
Sensation: Intact to light touch bilaterally.
.

FAMILY HISTORY: Family Hx: Noncontributory.

SOCIAL HISTORY: Social Hx: This patient lives alone. He drinks 1 pint/day and
smokes approximately 2 packs a day of cigarettes for the last 40
years (=80 pack year history). The patient is not married. He
works for a company which restores cars. He lives in [**Location **].
He
has 3 children. 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, unspecified state of consciousness,Other emphysema,Fall from other slipping, tripping, or stumbling,Alcohol abuse, continuous,Closed fracture of nasal bones'}
