CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 19 yo female s/p witnessed fall down [**6-5**] steps, +ETOH. Patient
[**Name (NI) 63136**] to [**Hospital1 18**] for trauma care.

MEDICAL HISTORY: Hypertension
Polycystic Kidney Disease
s/p Left Mastoidectomy

MEDICATION ON ADMISSION: Lisinopril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS upon admission to trauma bay:
143/83  100  98.8 rectally   O2 Sat 97%
GCS 15
Gen; Paralyzed & sedated
HEENT: blood in left ear, right TM clear; PERRL, sluggish
2mm-1mm
Neck: c-collar; trachea midline
Chest: CTA bilat, no crepitus
Cor: tachycardiac, S1 S2
Abd: soft, NT
Pelvis: stable
Rectum: decreased rectal tone; guaiac negative
Skin: abrasions on lumbar, left buttock and right posterior
thigh

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with her father.
+occassional ETOH
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol abuse, unspecified,Other convulsions,Accidental fall on or from other stairs or steps
Subdural hem w/o coma,Alcohol abuse-unspec,Convulsions NEC,Fall on stair/step NEC
Admission Date:  [**2105-8-23**]              Discharge Date:   [**2105-8-27**]

Date of Birth:  [**2086-6-10**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
19 yo female s/p witnessed fall down [**6-5**] steps, +ETOH. Patient
[**Name (NI) 63136**] to [**Hospital1 18**] for trauma care.

Past Medical History:
Hypertension
Polycystic Kidney Disease
s/p Left Mastoidectomy

Social History:
Lives with her father.
+occassional ETOH

Family History:
Noncontributory

Physical Exam:
VS upon admission to trauma bay:
143/83  100  98.8 rectally   O2 Sat 97%
GCS 15
Gen; Paralyzed & sedated
HEENT: blood in left ear, right TM clear; PERRL, sluggish
2mm-1mm
Neck: c-collar; trachea midline
Chest: CTA bilat, no crepitus
Cor: tachycardiac, S1 S2
Abd: soft, NT
Pelvis: stable
Rectum: decreased rectal tone; guaiac negative
Skin: abrasions on lumbar, left buttock and right posterior
thigh

Pertinent Results:
[**2105-8-23**] 05:38AM   TYPE-ART PO2-206* PCO2-34* PH-7.41 TOTAL
CO2-22 BASE XS--1 COMMENTS-GREEN TOP
[**2105-8-23**] 05:38AM   GLUCOSE-148* LACTATE-4.5* NA+-144 K+-3.5
CL--107
[**2105-8-23**] 05:38AM   HGB-12.4 calcHCT-37
[**2105-8-23**] 05:10AM   UREA N-9 CREAT-0.7
[**2105-8-23**] 05:10AM   AMYLASE-71
[**2105-8-23**] 05:10AM   ASA-NEG ETHANOL-141* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2105-8-23**] 05:10AM   WBC-15.0* RBC-4.02* HGB-11.9* HCT-35.0*
MCV-87 MCH-29.7 MCHC-34.1 RDW-12.8
[**2105-8-23**] 05:10AM   PLT COUNT-235

MR CERVICAL SPINE  [**2105-8-26**] 10:20 AM

MR CERVICAL SPINE

Reason: evidence of ligamentous injury?

[**Hospital 93**] MEDICAL CONDITION:
19 year old woman with posterior cervical tenderness s/p MVC and
equivical flex/ex c-spine films
REASON FOR THIS EXAMINATION:
evidence of ligamentous injury?
CLINICAL HISTORY: Posterior cervical tenderness and some
anterior displacement of C3 relative to [**Name (NI) **] and of C4 relative to
[**Name (NI) **] with flexion.

TECHNIQUE: Sagittal T1-weighted, T2-weighted and STIR images and
axial T2-weighted and gradient echo images were obtained.

FINDINGS:

No bone marrow or ligamentous edema is seen to suggest a
fracture or ligamentous injury. The vertebral bodies are
normally aligned when the patient is positioned for MRI. No disc
herniation is seen. The canal and neural foramina are well
maintained. The spinal cord and craniovertebral junction appear
normal.

CT HEAD W/O CONTRAST  [**2105-8-24**] 9:39 AM

CT HEAD W/O CONTRAST

Reason: interval change

[**Hospital 93**] MEDICAL CONDITION:
19 year old woman with
REASON FOR THIS EXAMINATION:
interval change
CONTRAINDICATIONS for IV CONTRAST: None.

NONCONTRAST HEAD CT SCAN

HISTORY: Followup study for previously diagnosed multiple
subdural hemorrhages and subarachnoid hemorrhage.

TECHNIQUE: Noncontrast head CT scan.

FINDINGS: The study is degraded to a moderate degree by motion
artifacts. Allowing for this limitation, there is no significant
interval change in the size or configuration of the small left
cerebral convexity acute subdural hemorrhages. At this time, it
is somewhat difficult to appreciate the suspected left temporal
lobe contusion, perhaps due to the presence of overlying streak
artifacts. At this time, as well, it is difficult to detect
subarachnoid hemorrhage. There is no hydrocephalus or shift of
normally midline structures.

Once again, there is a left mastoidectomy defect. Please secure
history regarding the underlying pathology that prompted this
surgical procedure (unusual for a patient of this age). There is
no other definite interval change seen aside from slightly more
mucosal thickening along the right lateral wall of the right
sphenoid sinus air cell.

CONCLUSION: Stable appearance of small left cerebral convexity
subdural hemorrhages. Please see above report for additional
discussion.


Brief Hospital Course:
Patient admitted to the Trauma Service. Neurosurgery was
consulted for her subdural hemorrhage and recommended admission
to Trauma ICU; every 1 hour neuro checks; Dilantin load with 1
GM; then 100 tid and repeat head CT on following a.m. repeat
scan stable. Her Dilantin was placed on hold secondary to supra
therapeutic levels 37; when rechecked on following day it had
come down to 23.7. She will be discharged to home with a lower
dose of Dilantin to continue for next 5 days per Neurosurgery
recommendations. Otolaryngology was consulted for the blood in
left ear canal and recent mastoidectomy who recommended
Cortisporin ear drops for 5 days and follow up with her primary
Otolaryngologist after discharge; she is to avoid water in her
ear until follow up. Orthopedic Spine also consulted because of
findings on her CT C-spine; it has been recommended that she
wear a hard cervical collar for next 2 weeks and follow up with
Orthopedic Spine at that time. Of note, MRI of her cervical
spine was negative. On HD# 5 patient noted with mild hematuria;
she reports that her LMP was approximately one week ago. A
urinalysis and urine culture were obtained; results pending at
time of this dictation.

Medications on Admission:
Lisinopril

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
4. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Four (4) Drop Otic TID (3 times a day) for 7
days.
5. Dilantin 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 5 days: COntinue for 5 days then discontinue.
Disp:*10 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Fall
Left fronto-parietal subdural hemorrhages


Discharge Condition:
Stable


Discharge Instructions:
-Please take your medication as prescribed; continue your
Dilantin for next 5 days.
-You must continue to wear your neck collar for the next 2 weeks
until you followup with Orthopedic Spine.
-Avoid water in your left ear until you follow up with your
Otolaryngologist.
-Please take part in activities as you can tolerate them
-Your medication may include narcotic pain medication. Please do
not drive a car, operate heavy machinery or partake in
activities that may be dangerous if fine motor skill is not
employed. These medications may impair your functionality during
these activities.

Followup Instructions:
1.Call [**Telephone/Fax (1) 3573**], Orthopedic Spine for an appointment in 2
weeks.
2.Call [**Telephone/Fax (1) 1669**], Neurosurgery for a followup appointment in
6 weeks. Please inform the clinic that you will need a repeat
head CT scan set up prior to this appointment.
3. Follow up with your primary doctor after your discharge.



Completed by:[**2105-8-27**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol abuse, unspecified,Other convulsions,Accidental fall on or from other stairs or steps'}


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: 19 yo female s/p witnessed fall down [**6-5**] steps, +ETOH. Patient
[**Name (NI) 63136**] to [**Hospital1 18**] for trauma care.

MEDICAL HISTORY: Hypertension
Polycystic Kidney Disease
s/p Left Mastoidectomy

MEDICATION ON ADMISSION: Lisinopril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS upon admission to trauma bay:
143/83  100  98.8 rectally   O2 Sat 97%
GCS 15
Gen; Paralyzed & sedated
HEENT: blood in left ear, right TM clear; PERRL, sluggish
2mm-1mm
Neck: c-collar; trachea midline
Chest: CTA bilat, no crepitus
Cor: tachycardiac, S1 S2
Abd: soft, NT
Pelvis: stable
Rectum: decreased rectal tone; guaiac negative
Skin: abrasions on lumbar, left buttock and right posterior
thigh

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with her father.
+occassional ETOH 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol abuse, unspecified,Other convulsions,Accidental fall on or from other stairs or steps'}
