CHIEF COMPLAINT: Head ache, fall from standing

PRESENT ILLNESS: 51yo male who fell from standing while under EtOH. Presented to
ED complaining of sever headache. No nausea or vomiting or
visual changes. H/o old left sided weakness secondary to old
cord contusion.

MEDICAL HISTORY: HTN
pancreatitis
degenerative joint disease
left hemiparesis 2 to old cord contusion
h/o left foot osteomyelitis
cervical spondylosis
right ulnar ORIF
left foot surgery
right shoulder surgery
umbilical hernia repair
L5S1 laminectomy

MEDICATION ON ADMISSION: fentanyl patch
oxycodone prn

ALLERGIES: Penicillins / Levaquin

PHYSICAL EXAM: VS: 98.2, 88, 135/87,14,96%
alert and oriented X3, no apparent distress, Ht regular rat and
rhythm, lungs clear, abdomen soft, full pulses lower
extremities, cranial nerves 2 thru 12 intact, motor shows [**3-12**]
left leg strength otherwise full, no pronator drift, sensory
intact, speech and comprehension intact

FAMILY HISTORY: not obtained

SOCIAL HISTORY: homeless, former wide receiver for [**Location (un) 511**] Colonials, farm
team to [**Company **]
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified fall,Chronic pancreatitis
Subarachnoid hem-no coma,Fx lumbar vertebra-close,Fall NOS,Chronic pancreatitis
Admission Date:  [**2120-2-22**]              Discharge Date:   [**2120-3-2**]

Date of Birth:  [**2068-12-26**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Levaquin

Attending:[**First Name3 (LF) 38982**]
Chief Complaint:
Head ache, fall from standing

Major Surgical or Invasive Procedure:
None this admission.


History of Present Illness:
51yo male who fell from standing while under EtOH. Presented to
ED complaining of sever headache. No nausea or vomiting or
visual changes. H/o old left sided weakness secondary to old
cord contusion.

Past Medical History:
HTN
pancreatitis
degenerative joint disease
left hemiparesis 2 to old cord contusion
h/o left foot osteomyelitis
cervical spondylosis
right ulnar ORIF
left foot surgery
right shoulder surgery
umbilical hernia repair
L5S1 laminectomy

Social History:
homeless, former wide receiver for [**Location (un) 511**] Colonials, farm
team to [**Company **]

Family History:
not obtained

Physical Exam:
VS: 98.2, 88, 135/87,14,96%
alert and oriented X3, no apparent distress, Ht regular rat and
rhythm, lungs clear, abdomen soft, full pulses lower
extremities, cranial nerves 2 thru 12 intact, motor shows [**3-12**]
left leg strength otherwise full, no pronator drift, sensory
intact, speech and comprehension intact

Pertinent Results:
[**2120-2-22**] 02:05PM BLOOD WBC-3.1* RBC-3.85* Hgb-12.0* Hct-38.2*
MCV-99* MCH-31.3 MCHC-31.5 RDW-15.4 Plt Ct-106*
[**2120-2-22**] 02:05PM BLOOD Neuts-59.5 Lymphs-29.4 Monos-5.8 Eos-4.7*
Baso-0.5
[**2120-2-22**] 06:35PM BLOOD PT-11.7 PTT-26.5 INR(PT)-0.9
[**2120-2-22**] 02:05PM BLOOD Plt Ct-106*
[**2120-2-22**] 02:05PM BLOOD Glucose-60* UreaN-24* Creat-0.9 Na-138
K-4.0 Cl-100 HCO3-21* AnGap-21*
[**2120-2-22**] 02:05PM BLOOD ALT-18 AST-46* LD(LDH)-265* AlkPhos-58
Amylase-205* TotBili-0.8
[**2120-2-22**] 02:05PM BLOOD Lipase-21
[**2120-2-23**] 04:28AM BLOOD Albumin-3.7 Calcium-8.4 Phos-3.9 Mg-2.0
[**2120-2-22**] 02:05PM BLOOD ASA-NEG Ethanol-135* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
Patient was admitted to ICU for close neurological monitoring
after CT of head showed acute subarachnoid hemorrhage. Also had
xray of spine. Pt was kept in hard collar until cervical studies
were clear then it was removed. Thoracic studies showed old
compression fractures. Lumbar studies showed acute wedge
fracture at L1 and was fit in TLSO brace. Head CT was repeated
and showed improvement but not complete resolution of blood. He
was trnsferred out of the ICU to floor bed on [**2-24**]. He continued
to be neurologically intact with the exception of left leg
strength. GI was consulted in regard to  elevated LFT's but was
felt consistent with chronic pancreatitis.patient was seen by
PT/OT and felt to be safe for discharge.

Medications on Admission:
fentanyl patch
oxycodone prn

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Amitriptyline HCl 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Hydromorphone HCl 2 mg Tablet Sig: 1 to 3 Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).


Discharge Disposition:
Extended Care

Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] house

Discharge Diagnosis:
Traumatic subarachnoid hemorrhage
L1 wedge fracture


Discharge Condition:
Neurologically stable

Discharge Instructions:
Wear TLSO brace whenever upright or sitting up in bed.

Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in one month with xrays lumbar spine AP
and Lat, call [**Telephone/Fax (1) 2731**] for appt.



Completed by:[**2120-3-1**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified fall,Chronic pancreatitis'}


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: Head ache, fall from standing

PRESENT ILLNESS: 51yo male who fell from standing while under EtOH. Presented to
ED complaining of sever headache. No nausea or vomiting or
visual changes. H/o old left sided weakness secondary to old
cord contusion.

MEDICAL HISTORY: HTN
pancreatitis
degenerative joint disease
left hemiparesis 2 to old cord contusion
h/o left foot osteomyelitis
cervical spondylosis
right ulnar ORIF
left foot surgery
right shoulder surgery
umbilical hernia repair
L5S1 laminectomy

MEDICATION ON ADMISSION: fentanyl patch
oxycodone prn

ALLERGIES: Penicillins / Levaquin

PHYSICAL EXAM: VS: 98.2, 88, 135/87,14,96%
alert and oriented X3, no apparent distress, Ht regular rat and
rhythm, lungs clear, abdomen soft, full pulses lower
extremities, cranial nerves 2 thru 12 intact, motor shows [**3-12**]
left leg strength otherwise full, no pronator drift, sensory
intact, speech and comprehension intact

FAMILY HISTORY: not obtained

SOCIAL HISTORY: homeless, former wide receiver for [**Location (un) 511**] Colonials, farm
team to [**Company **] 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified fall,Chronic pancreatitis'}
