CHIEF COMPLAINT: Trauma:  fall

PRESENT ILLNESS: Chief Complaint: UNWITNESSED FALL/R ARM PAIN

MEDICAL HISTORY: COPD, followed by Dr. [**Last Name (STitle) **], on 2L O2 with activity and at
night
Cervical Spondylosis
HCV
HTN
GERD
Hypothyroidism
Osteoporosis
s/p bilateral hip replacement
CKD, baseline Cr 1.1
h/o GIB
Diverticulosis
Urinary incontinence and retention
Substance abuse on methadone
h/o gallstones
Anxiety/Depression
Chronic axial lumbosacral pain and degenerative scoliosis
Dysphagia
s/p TAH BSO
Moderate to severe spinal stenosis as seen on MRI [**6-/2194**]

MEDICATION ON ADMISSION: MED: Protonix 40 mg daily, MVI, advair 500/50mcg [**Hospital1 **], Lexapro 20
mg
daily, Spiriva, Vitamin D3, methadone 10mg/5mL Oral Soln daily,
Calcium, Acetaminophen, albuterol, lisinopril 20mg [**Hospital1 **],
Docusate, levothyroxine 125mcg daily, Estrace 0.01% Vaginal
Cream, Loratadine 10 mg daily, Iron

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAMINATION:  upon admission

FAMILY HISTORY: Father had emphysema

SOCIAL HISTORY: Widowed. Lives alone. Son is involved in her care. She smokes
[**2-16**] ppd currently (approx 30 pack year history). Denies ETOH.
She has a prior history of IVDU (last use>40 years ago) and is
on methadone. Previously worked as a buyer for [**Doctor Last Name 64441**]in
[**State 531**]. Uses walker.
Closed fracture of distal end of ulna (alone),Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Urinary tract infection, site not specified,Closed fracture of fifth cervical vertebra,Opioid type dependence, continuous,Osteoporosis, unspecified,Hip joint replacement,Fall from other slipping, tripping, or stumbling,Lumbosacral spondylosis without myelopathy,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary incontinence, unspecified,Atrial fibrillation,Dysthymic disorder,Esophageal reflux,Unspecified acquired hypothyroidism,Personal history of allergy to penicillin
Fx distal ulna-closed,Subarachnoid hem-no coma,Urin tract infection NOS,Fx c5 vertebra-closed,Opioid dependence-contin,Osteoporosis NOS,Joint replaced hip,Fall from slipping NEC,Lumbosacral spondylosis,Chr airway obstruct NEC,Tobacco use disorder,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Urinary incontinence NOS,Atrial fibrillation,Dysthymic disorder,Esophageal reflux,Hypothyroidism NOS,Hx-penicillin allergy
Admission Date:  [**2194-8-8**]              Discharge Date:   [**2194-8-11**]

Date of Birth:  [**2112-8-6**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Trauma:  fall

Bilateral SAHs
Right ulnar fracture
? C5 fracture


Major Surgical or Invasive Procedure:
none


History of Present Illness:
Chief Complaint: UNWITNESSED FALL/R ARM PAIN

Note: 0655 Pt required pain rx after ortho manip. She then
awoke again and in agitated state went into af with RVR at
150-160. Re-sedation and diltiazem with good rate control
and reversion to NSR; ECG w/o new [**Last Name (un) **] changes. At 0700 pt
had good gag, maintained oxygenation, and was arousable.
Await [**Doctor First Name **] dispo re ICU accept.


Past Medical History:
COPD, followed by Dr. [**Last Name (STitle) **], on 2L O2 with activity and at
night
Cervical Spondylosis
HCV
HTN
GERD
Hypothyroidism
Osteoporosis
s/p bilateral hip replacement
CKD, baseline Cr 1.1
h/o GIB
Diverticulosis
Urinary incontinence and retention
Substance abuse on methadone
h/o gallstones
Anxiety/Depression
Chronic axial lumbosacral pain and degenerative scoliosis
Dysphagia
s/p TAH BSO
Moderate to severe spinal stenosis as seen on MRI [**6-/2194**]


Social History:
Widowed. Lives alone. Son is involved in her care. She smokes
[**2-16**] ppd currently (approx 30 pack year history). Denies ETOH.
She has a prior history of IVDU (last use>40 years ago) and is
on methadone. Previously worked as a buyer for [**Doctor Last Name 64441**]in
[**State 531**]. Uses walker.


Family History:
Father had emphysema

Physical Exam:
PHYSICAL EXAMINATION:  upon admission

Temp: 98.2 HR: 128 to 100 BP: 137/100 Resp: 18 O(2)Sat: 98
Normal

HEENT: R forehead hematoma
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae



Pertinent Results:
[**2194-8-8**] 10:10PM BLOOD WBC-8.8 RBC-3.62* Hgb-11.4* Hct-34.4*
MCV-95 MCH-31.5 MCHC-33.2 RDW-14.3 Plt Ct-147*
[**2194-8-8**] 02:57PM BLOOD Hct-30.8*
[**2194-8-8**] 03:05AM BLOOD Neuts-82.1* Lymphs-11.9* Monos-4.8
Eos-0.7 Baso-0.4
[**2194-8-8**] 10:10PM BLOOD Plt Ct-147*
[**2194-8-8**] 03:05AM BLOOD PT-12.9 PTT-25.3 INR(PT)-1.1
[**2194-8-8**] 10:10PM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-132*
K-4.8 Cl-98 HCO3-29 AnGap-10
[**2194-8-8**] 02:57PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-132*
K-4.5 Cl-98 HCO3-28 AnGap-11
[**2194-8-8**] 10:10PM BLOOD cTropnT-0.08*
[**2194-8-8**] 02:57PM BLOOD cTropnT-0.15*
[**2194-8-8**] 08:35AM BLOOD cTropnT-0.17*
[**2194-8-8**] 10:10PM BLOOD Calcium-9.0 Phos-2.7 Mg-2.0
[**2194-8-8**] 02:57PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
[**2194-8-8**] 09:18AM BLOOD freeCa-1.25

[**2194-8-8**]:  EKG:

Sinus tachycardia with an atrial premature beat. Since the
previous tracing  of [**2194-7-16**] the rate is faster. ST segment
abnormalities are now present.

[**2194-8-8**]:  EKG:

Sinus tachycardia. Non-specific ST-T wave changes. Compared to
the previous tracing there is no definite change.

[**2194-8-8**]:  cat scan of the head:

IMPRESSION:
1. Bilateral foci of subarachnoid hemorrhage.
2. No subfalcine herniation.
3. No fracture.
4. Right subgaleal frontal hematoma.

[**2194-8-8**]: cat scan of c-spine:

IMPRESSION:

Moderate-to-severe degenerative changes in the cervical spine
gives suboptimal evaluation of the spine.
Lucent line through the left C5 transverse foramen could be a
fracture line; correlate with point tenderness.
If clinically concerning, consider CTA neck to exclude vessel
injury.

[**2194-8-8**]:  X-ray of right forearm:

 RIGHT WRIST: Degenerative changes are seen at the first and
second
carpometacarpal joints and triscaphe joint. No evidence of
fracture or
dislocation at the wrist. There is some widening of the
scapholunate
interval.

RIGHT FOREARM: There is a fracture at the distal ulna, minimally
impacted and with medial displacement of the distal fracture
fragment of 6 mm. No
radiopaque foreign body is seen.

[**2194-8-8**]: chest x-ray:

1.  Mild cardiac decompensation.
2. There is no displaced rib fracture

[**2194-8-8**]: cat scan of the head:

IMPRESSION: Unchanged appearance of bilateral subarachnoid
hemorrhage and
right frontal subgaleal hematoma. No new hemorrhage, large
vascular
territorial infarct, or mass effect.




Brief Hospital Course:
Admitted to the acute care service after falling.  Upon
admission, she was made NPO, given intravenous fluids, and
underwent imaging of the head, neck, and right arm.  She was
reported to have sustained bilateral subarachnoid hemorrhages.
Her initial lab work did indicate a bump in her troponin levels,
they have currently normalized.   She was evaluated by
Neurosurgery who made recommendations for a follow-up cat scan
upon discharge.  No immediate neuro-surgical interventions were
warrented at this time unless there was a change in her status.
She was also evaluated by Orthopedic/Spine/Trauma.  She was
placed in a cervical collar upon admission, but it was
clinically cleared for removal.  An x-ray of her right upper
extremity did show a fracture at the distal ulna, minimally
impacted and with medial displacement of the distal fracture
fragment.  No surgical intervention was needed.  Occupational
therapy placed a ulnar-gutter splint to her right arm.   During
her hospitalization, she was found to have a urinary tract
infection and started on an antibiotic. She was also evaluated
by the Geriatric service because of occasional episodes of
agitation. Upon there evaluation, she was found not to exhibit
any signs of delirium.
Her vital signs are stable and she is afebrile.  She is
tolerating a regular diet and voiding without difficulty.  She
has been evaluated by the Social Worker.
She is preparing for discharge to an extended care facility for
further evaluation and continued care.  She has been cleared by
neuro-surgery to resume aspirin.

Of note:  she will need physical therapy evaluation prior to
discharge home



Medications on Admission:
MED: Protonix 40 mg daily, MVI, advair 500/50mcg [**Hospital1 **], Lexapro 20
mg
daily, Spiriva, Vitamin D3, methadone 10mg/5mL Oral Soln daily,
Calcium, Acetaminophen, albuterol, lisinopril 20mg [**Hospital1 **],
Docusate, levothyroxine 125mcg daily, Estrace 0.01% Vaginal
Cream, Loratadine 10 mg daily, Iron


Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO Q12H (every 12 hours) for 7 days: started [**8-11**].
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours).
10. ipratropium bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: hold for increased sedation, resp.
rate <10.
Disp:*15 Tablet(s)* Refills:*0*
13. methadone 10 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.

15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
Trauma:  fall

Bilateral SAHs
Right ulnar fracture
? C5 fracture
UTI


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital after you fell at home.  You
hit your head and sustained a small bleed.  You also sustained a
fracture of the right arm for which a splint was applied.  You
are now preparing for discharge to a rehabilitation facility
with the following instructions:  Please follow up in the
emergency room if you experience:

*severe headache
*difficulty speaking
*weakness one side of your body
*drooping face
*visual changes
*nausea/vomitting associated with headache

Please report:

*numbness/tingling fingers right hand
*increased pain, swellling fingers right hand

Followup Instructions:
Please follow  up in the neurosurgical clinic in [**5-21**] weeks with
a non-contrast head CT with Dr. [**First Name (STitle) **].
This can be arranged by calling [**Telephone/Fax (1) 1669**].

Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Orthopedic nurse
practitioner in 2 weeks.  You can schedule your appointment by
calling # [**Telephone/Fax (1) 1228**]



Completed by:[**2194-8-11**]
{'Closed fracture of distal end of ulna (alone),Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Urinary tract infection, site not specified,Closed fracture of fifth cervical vertebra,Opioid type dependence, continuous,Osteoporosis, unspecified,Hip joint replacement,Fall from other slipping, tripping, or stumbling,Lumbosacral spondylosis without myelopathy,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary incontinence, unspecified,Atrial fibrillation,Dysthymic disorder,Esophageal reflux,Unspecified acquired hypothyroidism,Personal history of allergy to penicillin'}


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: Trauma:  fall

PRESENT ILLNESS: Chief Complaint: UNWITNESSED FALL/R ARM PAIN

MEDICAL HISTORY: COPD, followed by Dr. [**Last Name (STitle) **], on 2L O2 with activity and at
night
Cervical Spondylosis
HCV
HTN
GERD
Hypothyroidism
Osteoporosis
s/p bilateral hip replacement
CKD, baseline Cr 1.1
h/o GIB
Diverticulosis
Urinary incontinence and retention
Substance abuse on methadone
h/o gallstones
Anxiety/Depression
Chronic axial lumbosacral pain and degenerative scoliosis
Dysphagia
s/p TAH BSO
Moderate to severe spinal stenosis as seen on MRI [**6-/2194**]

MEDICATION ON ADMISSION: MED: Protonix 40 mg daily, MVI, advair 500/50mcg [**Hospital1 **], Lexapro 20
mg
daily, Spiriva, Vitamin D3, methadone 10mg/5mL Oral Soln daily,
Calcium, Acetaminophen, albuterol, lisinopril 20mg [**Hospital1 **],
Docusate, levothyroxine 125mcg daily, Estrace 0.01% Vaginal
Cream, Loratadine 10 mg daily, Iron

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAMINATION:  upon admission

FAMILY HISTORY: Father had emphysema

SOCIAL HISTORY: Widowed. Lives alone. Son is involved in her care. She smokes
[**2-16**] ppd currently (approx 30 pack year history). Denies ETOH.
She has a prior history of IVDU (last use>40 years ago) and is
on methadone. Previously worked as a buyer for [**Doctor Last Name 64441**]in
[**State 531**]. Uses walker. 

### Response:
{'Closed fracture of distal end of ulna (alone),Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Urinary tract infection, site not specified,Closed fracture of fifth cervical vertebra,Opioid type dependence, continuous,Osteoporosis, unspecified,Hip joint replacement,Fall from other slipping, tripping, or stumbling,Lumbosacral spondylosis without myelopathy,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Urinary incontinence, unspecified,Atrial fibrillation,Dysthymic disorder,Esophageal reflux,Unspecified acquired hypothyroidism,Personal history of allergy to penicillin'}
