CHIEF COMPLAINT: FALL

PRESENT ILLNESS: HPI: 85 y/o female who lives independently until yesterday when
she fell down a flight of stairs.  Per her family, she was
neurologically unchanged until this morning when she
demonstrated
confusion and difficulty ambulating.  She was taken to an
outside
hospital where head CT revealed 3mm left parietal subdural
hematoma and bilateral temporal lobe contusions.  There was no
evidence of mass effect or midline shift.  She was transferred
to
[**Hospital1 18**] ER for higher level of care.

MEDICAL HISTORY: PMHx:
atrial fibrillation

MEDICATION ON ADMISSION: Medications prior to admission:
lipitor
coumadin
atenolol
aspirin
digoxin

ALLERGIES: Zocor

PHYSICAL EXAM: PHYSICAL EXAM when seen in SICU:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-25**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
eyes open spontaneously
Mental status: Awake but confused
Orientation: She is not oriented to person, place, or date.
Language: Confused speech and poor comprehension.

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx:
lives alone, retired, denies tobacco, EtOH, or IVDU
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Unspecified protein-calorie malnutrition,Accidental fall on or from other stairs or steps,Atrial fibrillation,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Heart valve replaced by other means
Brain lacer NEC-coma NOS,Food/vomit pneumonitis,Acute kidney failure NOS,Diastolc hrt failure NOS,Protein-cal malnutr NOS,Fall on stair/step NEC,Atrial fibrillation,Hypertension NOS,Acq esophag diverticulum,Heart valve replac NEC
Admission Date:  [**2136-3-31**]              Discharge Date:   [**2136-4-17**]


Service: MEDICINE

Allergies:
Zocor

Attending:[**First Name3 (LF) 1828**]
Chief Complaint:
FALL

Major Surgical or Invasive Procedure:
PERCUTANEOUS GASTRIC TUBE PLACEMENT

History of Present Illness:
HPI: 85 y/o female who lives independently until yesterday when
she fell down a flight of stairs.  Per her family, she was
neurologically unchanged until this morning when she
demonstrated
confusion and difficulty ambulating.  She was taken to an
outside
hospital where head CT revealed 3mm left parietal subdural
hematoma and bilateral temporal lobe contusions.  There was no
evidence of mass effect or midline shift.  She was transferred
to
[**Hospital1 18**] ER for higher level of care.


Past Medical History:
PMHx:
atrial fibrillation

PSHx:
unknown

All:
zocor


Social History:
Social Hx:
lives alone, retired, denies tobacco, EtOH, or IVDU


Family History:
nc

Physical Exam:
PHYSICAL EXAM when seen in SICU:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-25**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
eyes open spontaneously
Mental status: Awake but confused
Orientation: She is not oriented to person, place, or date.
Language: Confused speech and poor comprehension.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.

Motor: Normal bulk and tone bilaterally. Moves all extremities
with equal strength, but does not follow commands. Pronator
drift
could not be tested.

Toes downgoing bilaterally
Physical exam on discharge:


Pertinent Results:
CT:
head CT [**2136-3-31**]- Bitemporal hemorrhagic contusions with
surrounding edema and subarachnoid blood.  3mm left parietal
subdural hematoma and bilateral
temporal lobe contusions.  There was no evidence of mass effect
or midline shift.
Head CT [**2136-4-1**]: 1.  Unchanged appearance of small bilateral
extra-axial fluid collections that may represent enlarged
subarachnoid spaces, although chronic subdural hematomas or
subdural hygromas cannot be excluded. 2.  Stable appearance of
bitemporal hemorrhagic contusion with surrounding edema and
subarachnoid blood.  No new focus of hemorrhage is identified.
Head CT [**2136-4-4**]: No significant change since the prior study
[**2136-4-1**].
.
CT c-spine [**2136-4-4**]: 1.  Extensive multilevel degenerative
changes in the cervical spine, most prominent at C5-6, C6-7 and
C7-T1 levels, with posterior osteophytes, causing mild
indentation on the ventral thecal sac.
2.  Mild bulging of the posterior cortex of the C4, with a small
focus of bony discontinuity, causing mild indentation on the
ventral thecal sac.  No evidence of cord compression (CT is
limited for a more accurate assessment of intrathecal details).
CT T/L spine [**2136-4-4**]: 1.  Moderate collapse of the T5 vertebral
body, diffusely, with mild bulging of the posterior cortex, with
small posterior osteophyte, causing mild indentation on the
ventral thecal sac.  Mild focal kyphotic deformity is noted at
this level. 2.  Severe collapse of the T11 and L1 vertebral
bodies, especially involving the anterior and the middle
portions of the vertebral bodies with mild bulging of the
posterior cortex, causing mild indentation on the ventral thecal
sac. Continuity of the cortical outline posteriorly is not well
appreciated at the level of L1, which may be due to cortical
break/osteopenia-related lucency. Focal kyphotic deformity noted
at the level of L1.  Degenerative changes are noted in the
adjacent T12-L1 with vacuum phenomena.
.
===============
 CARDIAC ECHO
===============
The left atrial volume is markedly increased (>32ml/m2). The
left atrium is dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is unusually small.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The number of aortic valve leaflets
cannot be determined. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

IMPRESSION: Mild symmetric LVH with a small LV cavity size.
There is no obvious LVOT gradient. Diastolic dysfunction. Mild
aortic stenosis. At least mild aortic and mitral regurgitation.
Moderate pulmonary artery systolic hypertension.

===========
  LABS
===========
[**2136-3-31**] 06:19PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2136-3-31**] 06:19PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-8* PH-6.5 LEUK-NEG
[**2136-3-31**] 06:19PM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2136-3-31**] 04:27PM   GLUCOSE-124* UREA N-27* CREAT-0.9 SODIUM-136
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15
[**2136-3-31**] 04:27PM   WBC-14.1* RBC-3.62* HGB-11.7* HCT-34.4*
MCV-95 MCH-32.4* MCHC-34.2 RDW-13.6
[**2136-3-31**] 04:27PM   NEUTS-82* BANDS-5 LYMPHS-7* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2136-3-31**] 04:27PM   HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2136-3-31**] 04:27PM   PLT SMR-NORMAL PLT COUNT-184
[**2136-3-31**] 04:27PM   PT-17.1* PTT-28.3 INR(PT)-1.5*

=================
 DISCHARGE LABS
=================
WBC-11.8*  RBC-3.70* HGB-11.8* HCT-34.5* MCV-93 MCH-31.8
3MCHC-4.1 RDW-13.6 PLT-402 PT-14.3* PTT-31.5 INR-1.2*
GLUCOSE-102 UREA N-20 CREAT-0.8 SODIUM-139 POTASSIUM-3.5
CHLORIDE-99 TOTAL CO2-32 ANION GAP-12 T3-81 Free T4-1.2
DIGOXIN-0.6*

Brief Hospital Course:
This 85yo female admitted with left parietal SDH with [**Hospital1 **]
temporal contusions.
Patient loaded with dilantin and followed with q8hour dosing,
admited to neurosurgery ICU.  Several repeat head CTs were
stable with no significant increase in ICH.  Her ICH was managed
non-operatively.  Due to her multiple complex medical problems
(see below), the pt was transferred to the medicine inpatient
service on HD#11.

Hospital course by system:

Neuro: The patient's ICH were followed with several CT scans
that showed stable small hemorrhages with no significant
increase. The pt was originally loaded with dilantin but this
was transitioned to Keppra, given its fewer side effects. The pt
suffered no neurologic deficits from ICH.  However, due to the
pt's extended stay in the ICU she did suffer from delirium,
likely ICU delerium, requiring haldol and zyprexa as well as
upper extremity soft restraints that complete resolved after he
stay on the floor.

CV: The pt had a history of HTN and afib on admission treated
with lopressor, digoxin and coumadin.  While in the ICU she went
into RVR and required a diltiazem drip for several days.  A
cardiology consultation was obtained and the pt was weaned to IV
lopressor. Digoxin was continued. At baseline she was taking
HCTZ but required supplemental IV lasix for fluid overload. A
transthoracic echo showed mild aortic stenosis, mild or greater
aortic regurgitation and mild mitral regurgitation, with
ventricular enlargement, diastolic dysfunction with EF>55%.
Patient was continued on daily diuresis with lasix 20mg NG daily
with potassium supplementation with improving O2 requirement and
improvement in crackles on exam. Please continue titrate lasix
therapy until patient is evoluemic.

Pulmonary: Part of the reason for transfer to [**Hospital1 18**] was a result
of the pt aspirating and requiring intubation at the referring
hospital for aspiration pneumonitis.   Post-extubation the pt
persistently required supplemental oxygen, likely from a
hospital acquired aspiration pneumonia with superimposed
pulmonary edema. Patient improved with diuresis and antibiotics,
and is being discharged on vancomycin and zosyn to complete 2
more days of therapy.

GI: Post-extubation, a speech and swollow consult was obtained
given the pt's history of aspiration.  This revealed a large
Zenker's diverticulum.  Numerous attempts at Dobhoff and NG tube
placement were done without success (likely given the Zenker's
diverticulum), including an attempt of fluoroscopic NGT
placement.  Speech and swollow services recommended pureed foods
but given the pt's waxing and [**Doctor Last Name 688**] delirium her caloric intake
was suboptimal.  The patient thus underwent PEG placement on
[**2136-4-11**]. Tube feeds with probalance were advance to goal of
45cc/hr by the time of discharge. Patient to follow up in [**Month (only) 547**]
with Dr. [**Last Name (STitle) 77866**] for surgical correction of her Zenker's
Diverticulum.

GU: The pt required a foley during hospitalization.
Discontinued before discharge.

HEME: No issues, HCT stable

ID: Urine and blood cx from [**3-31**] and [**4-2**] were negative.  VRE and
MRSA swabs were negative while in ICU.

Musculoskeletal: CT of her C/T/L spine showed evidence of
degenerative changes in the spine as well as multiple
compression fractures (old) of her vertebral bodies.  No
evidence of significant canal compromise or cord impingment.
This was managed conservatively.

Endocrine: The pt was kept on an insulin sliding scale to
monitor her blood sugars which was discontinued prior to
discharge as patient did not require insulin supplementation.
No steroids were indicated.

Anticoagulation: The pt was reversed with FFP at the referring
hospital. After it was determined that her ICH was stable, the
pt was started on subcutaneous heparin for DVT prophylaxis.  The
neurosurgical services recommended that she could restart her
coumadin one month after accident, [**2136-5-1**]. Defer re-starting
anticoagulation to primary care team.

Dispo: PT and OT services were consulted and recommended rehab
placement for the pt

Medications on Admission:
Medications prior to admission:
lipitor
coumadin
atenolol
aspirin
digoxin


Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please give through PEG.
3. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day: please administer only
on days that lasix is given. Tab Sust.Rel. Particle/Crystal(s)
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please administer through PEG.
5. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed.
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous Q 24H (Every 24 Hours) for 2 days.
7. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 gm Intravenous Q8H (every 8 hours) for 2 days.
8. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): please administer through PEG.
9. Levetiracetam 100 mg/mL Solution Sig: Five (5) ml PO BID (2
times a day): please administer though PEg.
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
please administer per PEG.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please administer through PEG.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation: please administer through PEG.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Protonix 40 mg Recon Soln Sig: Forty (40) mg Intravenous
once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Left Parietal Sub Dural Hematoma with [**Hospital1 **]-temporal contusions
Zenker's Diverticulum
Aspiration Pneumonia
Diastolic Heart Failure, ejection fraction >55%
Atrial Fibrillation
Hypertension


Discharge Condition:
Hemodynamically stable, requiring 1L of O2 supplementation via
nasal canula.


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR HEAD INJURY

??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, Ibuprofen
etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	New onset of tremors or seizures
??????	Any confusion or change in mental status
??????	Any numbness, tingling, weakness in your extremities
??????	Pain or headache that is continually increasing or not
relieved by pain medication

YOU [**Month (only) **] RE-START YOUR COUMADIN ON [**2136-5-1**]
CONTINUE THE KEPPRA UNTIL YOU ARE SEEN IN THE NEUROSURGERY
OFFICE

You have also been treated for an aspiration pneumonia caused by
your Zenker's Diverticulum. Please complete a 9 day course of
antibiotics and do not eat or drink anything until your Zenker's
has been repaired as scheduled one month from now. We also have
been removing excess fluid from you lungs with diuretics. Please
continue to take your lasix with potassium supplementation until
your are instructed by a doctor to stop taking them.

At rehab, you will have your Oxygen weaned off as tolerated and
have your diuretics adjusted.

Please return to the hospital if you have any new concerning
symptoms.

Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SEE DR [**Last Name (STitle) **] ON OR AROUND
[**2136-5-1**]
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST FOR THAT
APPOINTMENT

Please follow up with [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**0-0-**]
Date/Time:[**2136-5-10**] 2:30 PM. He is the surgeon who will be
repairing your Zenker's Diverticulum.
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Unspecified protein-calorie malnutrition,Accidental fall on or from other stairs or steps,Atrial fibrillation,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Heart valve replaced by other means'}


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: FALL

PRESENT ILLNESS: HPI: 85 y/o female who lives independently until yesterday when
she fell down a flight of stairs.  Per her family, she was
neurologically unchanged until this morning when she
demonstrated
confusion and difficulty ambulating.  She was taken to an
outside
hospital where head CT revealed 3mm left parietal subdural
hematoma and bilateral temporal lobe contusions.  There was no
evidence of mass effect or midline shift.  She was transferred
to
[**Hospital1 18**] ER for higher level of care.

MEDICAL HISTORY: PMHx:
atrial fibrillation

MEDICATION ON ADMISSION: Medications prior to admission:
lipitor
coumadin
atenolol
aspirin
digoxin

ALLERGIES: Zocor

PHYSICAL EXAM: PHYSICAL EXAM when seen in SICU:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-25**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
eyes open spontaneously
Mental status: Awake but confused
Orientation: She is not oriented to person, place, or date.
Language: Confused speech and poor comprehension.

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx:
lives alone, retired, denies tobacco, EtOH, or IVDU 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Diastolic heart failure, unspecified,Unspecified protein-calorie malnutrition,Accidental fall on or from other stairs or steps,Atrial fibrillation,Unspecified essential hypertension,Diverticulum of esophagus, acquired,Heart valve replaced by other means'}
