CHIEF COMPLAINT: s/p fall from sink

PRESENT ILLNESS: 73 yF fell from kitchen counter and hit head and back, unsure
about LOC, able to recall events surrounding fall.  Pt called
911, taken to OSH where she had BP 220/110, Tx with lasix and
found to havd a SDH, so she was transferred to [**Hospital1 18**] for further
care.

MEDICAL HISTORY: HTN
dyslipidemia

MEDICATION ON ADMISSION: ASA 81 mg
Zestril
Zocor

ALLERGIES: Penicillins

PHYSICAL EXAM: 97.1  108/63  89  16  89%on RA/100%on 2L
gen: NAD
HEENT: hematoma on L occiput, PERRL 3->2
Neck: supple, no midline TTP with full ROM and no pain
Chest: CTAB
CV: distand HS
Abd: soft, NT, ND, +BS
Extrem: WWP
Neuro: AOx3, coop with exam, appropriate, fluent speech with
good comprehension and repetition
CNII-XII tested and intach bilat
Motor- strength 5/5 throughout, no pronator drift
Sensation- intact throughout, reflexes intact bilat
Coordination- normal

FAMILY HISTORY: non-contrib

SOCIAL HISTORY: smokes 1.5 PPD x50 yrs, occ EtOH, no drug use
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hypoxemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Fall from other slipping, tripping, or stumbling
Traumatic subdural hem,Hypoxemia,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Fall from slipping NEC
Admission Date:  [**2185-4-19**]              Discharge Date:   [**2185-4-19**]

Date of Birth:  [**2111-7-26**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
s/p fall from sink

Major Surgical or Invasive Procedure:
none


History of Present Illness:
73 yF fell from kitchen counter and hit head and back, unsure
about LOC, able to recall events surrounding fall.  Pt called
911, taken to OSH where she had BP 220/110, Tx with lasix and
found to havd a SDH, so she was transferred to [**Hospital1 18**] for further
care.

Past Medical History:
HTN
dyslipidemia

Social History:
smokes 1.5 PPD x50 yrs, occ EtOH, no drug use

Family History:
non-contrib

Physical Exam:
97.1  108/63  89  16  89%on RA/100%on 2L
gen: NAD
HEENT: hematoma on L occiput, PERRL 3->2
Neck: supple, no midline TTP with full ROM and no pain
Chest: CTAB
CV: distand HS
Abd: soft, NT, ND, +BS
Extrem: WWP
Neuro: AOx3, coop with exam, appropriate, fluent speech with
good comprehension and repetition
CNII-XII tested and intach bilat
Motor- strength 5/5 throughout, no pronator drift
Sensation- intact throughout, reflexes intact bilat
Coordination- normal

Pertinent Results:
[**2185-4-18**] 06:25AM   PLT COUNT-239
[**2185-4-18**] 06:25AM   WBC-12.2* RBC-3.63* HGB-11.6* HCT-34.2*
MCV-94 MCH-32.0 MCHC-34.0 RDW-13.1
[**2185-4-18**] 06:25AM   CALCIUM-9.7 PHOSPHATE-2.5* MAGNESIUM-2.0
[**2185-4-18**] 06:25AM   GLUCOSE-151* UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-28 ANION GAP-13

T-SPINE  [**2185-4-18**] 2:22 PM
CT C-spine [**4-16**]:  noevidence of fx/disloc, small apical PTX
CT head [**4-16**]: IMPRESSION:  Left-sided subdural hemorrhage
tracking along the tentorium, and
right frontal arachnoid hemorrhage.  Left parietal subgaleal
hematoma, with
hematocrit level.

NOTE ADDED IN ATTENDING REVIEW: There is an approx. 2.2cm but
poorly defined,
largely CSF-attenuation lesion centered in the body of the left
lateral
ventricle, inseparable from the septum pellucidum. This
demonstrates numerous
punctate calcifications, but no soft tissue-attenuation, and
there is only
mild prominence of this ventricle, with no transependymal
migration of CSF.
This may represent a benign lesion, perhaps related to choroid
plexus, but is
atypical of meningioma, and other primary intraventricular
lesions would be
unusual in a patient of this age.

PA AND LATERAL CHEST, [**2185-4-17**] AT 01:20 HOURS.

The study is compared with the prior study of [**2185-4-16**].  The
pneumothorax seen
on the recent CT is not apparent on the current examination and
if present
will be tiny.  There is some patchy increase in lung markings at
both bases
since the prior examination which may represent some
subsegmental atelectasis
or early airspace disease.  No large pleural effusion is
evident.

MRI head [**4-17**]: IMPRESSION:

1.  Left subdural hematoma along the tentorium cerebelli as well
as along the
falx, extending over the cerebral convexity with an additional
right anterior
frontal subdural hematoma, with little mass effect.

2.  Small focus of subarachnoid hemorrhage in the right frontal
region.

3.  3 cm lesion in the body of the left lateral ventricle, with
foci of
calcification and chronic hemorrhage within and adjacent to it.
This may
represent old hematoma with dystrophic calcification,
representing so-called
"chronic intraventricular encapsulated hematoma," which may
relate to
underlying vascular abnormality. However, a vascular lesion like
angioma is
less likely, given the lack of enhancement. Choroid plexus
xanthogranuloma is
another diagnostic consideration.

CTA head [**4-17**] w/wo: IMPRESSION:
1.  Stable interval appearance of left tentorial subdural
hematoma and small
amount of subarachnoid hemorrhage.  No significant mass effect.
2.  Left intraventricular lesion which shows no significant
vascularization.
Please see the previous MRI of the head for the differential
possibilities,
but a xanthogranuloma of the choroid plexus should also be
considered in
addition.


Brief Hospital Course:
Pt was admitted to TSICU on [**4-16**] in stable condition under the
trauma service.  Her repeat head CT was unchanged, she remained
hemodynamically and neurologicaly stable, and on [**4-17**] pt was
transferred to the floor.  On [**4-18**], pt was transferred to
neurosurgery service, as her small apical PTX was asymptomatic
and stable, and no intervention was deemed necessary by the
trauma team.  Pt was evaluated by PT, who found her to have O2
sat 83-86% on [**Last Name (LF) **], [**First Name3 (LF) **] she was set up for home O2.  Her neurologic
condition was stable throughout her hospitalization, she was
maintained on dilantin for seizure prophylaxis and her pain was
treated with MS contin.  Pt signed herself out AMA in the
evening of [**4-18**], but was readmitted within 45 minutes.  Pt was
discharged home with VNA services for home O2, with recommended
follow-up with Dr. [**Last Name (STitle) **] in 4 weeks, and follow-up with her PCP
[**Last Name (NamePattern4) **]: her hypoxemia.

Medications on Admission:
ASA 81 mg
Zestril
Zocor

Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
left tentorial subdural hematoma
small right subarachnoid hemorrhage
small apical pneumothorax
asymptomatic hypoxemia (O2 sat 83-86 on RA while ambulating)


Discharge Condition:
stable, no neuro deficits


Discharge Instructions:
You were treated at [**Hospital1 18**] following a fall from your kitchen
counter.  You should [**Name6 (MD) 138**] [**Name8 (MD) **] Md or return to the ER for: severe
headache, chest pain, shortness of breath, severe
nausea/vomiting, fever greater than 101F, seizure, or any other
concerning symptoms.

Followup Instructions:
follow-up with Dr. [**Last Name (STitle) **] in 4 weeks with CT head - call
[**Telephone/Fax (1) 1669**] for appt.  No need for follow-up with the trauma
clinic, but you can call [**Telephone/Fax (1) 6429**] with questions.  You
should also follow-up with your primary care doctor regarding
you low oxygen saturation as soon as possible; additionally, you
should tell your PCP that there is a small calcified nodule in
your thyroid that should be further evaluated as an outpatient.



Completed by:[**2185-4-19**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hypoxemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Fall from other slipping, tripping, or stumbling'}


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 from sink

PRESENT ILLNESS: 73 yF fell from kitchen counter and hit head and back, unsure
about LOC, able to recall events surrounding fall.  Pt called
911, taken to OSH where she had BP 220/110, Tx with lasix and
found to havd a SDH, so she was transferred to [**Hospital1 18**] for further
care.

MEDICAL HISTORY: HTN
dyslipidemia

MEDICATION ON ADMISSION: ASA 81 mg
Zestril
Zocor

ALLERGIES: Penicillins

PHYSICAL EXAM: 97.1  108/63  89  16  89%on RA/100%on 2L
gen: NAD
HEENT: hematoma on L occiput, PERRL 3->2
Neck: supple, no midline TTP with full ROM and no pain
Chest: CTAB
CV: distand HS
Abd: soft, NT, ND, +BS
Extrem: WWP
Neuro: AOx3, coop with exam, appropriate, fluent speech with
good comprehension and repetition
CNII-XII tested and intach bilat
Motor- strength 5/5 throughout, no pronator drift
Sensation- intact throughout, reflexes intact bilat
Coordination- normal

FAMILY HISTORY: non-contrib

SOCIAL HISTORY: smokes 1.5 PPD x50 yrs, occ EtOH, no drug use 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Hypoxemia,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Fall from other slipping, tripping, or stumbling'}
