CHIEF COMPLAINT: s/p Fall
Cervical spine fracture

PRESENT ILLNESS: 77 yo female with history of dementia and expressive aphasia
after complicated MVR, living at home with her husband and
24hour home health care. While ambulating using her walker she
had a ?syncopal episode, falling and striking her head and neck
on a chair. + LOC, GCS 13, home health aid activated 911. She
was taken to an area hospital where it was nted she had a
cervical fracture. she was then transferred to [**Hospital1 18**] for further
care.

MEDICAL HISTORY: HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

MEDICATION ON ADMISSION: lopressor 25", colace, folate, omega-3, mvi, tums, vit e,
amiodarone 200', prozac 40', zyprexa 5', levaquin, aricept 10',
melatonin 3mg hs,

ALLERGIES: Keflex / Vancomycin

PHYSICAL EXAM: difficult due to aphasia.
CTA b/l
RRR
soft NTND
UE sensation appears intact but no motor. Neg [**Doctor Last Name 937**]. LE
sensation questionable. Spastic bilat LE. [**5-4**] GS on command, all
other muscle groups [**2-4**]. Toes upgoing bilat. 1+ biceps, 2+
patella. No thoracolumbar tenderness to palpation. No rectal
tone.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 30 PY smoker (30 x 1), EtOH - cocktail/night
Married and lives with her husband
Closed fracture of first cervical vertebra,Atrial fibrillation,Heart valve replaced by transplant,Pressure ulcer, heel,Fall from other slipping, tripping, or stumbling,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension
Fx c1 vertebra-closed,Atrial fibrillation,Heart valve transplant,Pressure ulcer, heel,Fall from slipping NEC,Mental disor NEC oth dis,Hypertension NOS
Admission Date:  [**2152-5-4**]              Discharge Date:   [**2152-5-11**]

Date of Birth:  [**2074-9-25**]             Sex:   F

Service: SURGERY

Allergies:
Keflex / Vancomycin

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall
Cervical spine fracture

Major Surgical or Invasive Procedure:
None


History of Present Illness:
77 yo female with history of dementia and expressive aphasia
after complicated MVR, living at home with her husband and
24hour home health care. While ambulating using her walker she
had a ?syncopal episode, falling and striking her head and neck
on a chair. + LOC, GCS 13, home health aid activated 911. She
was taken to an area hospital where it was nted she had a
cervical fracture. she was then transferred to [**Hospital1 18**] for further
care.

Past Medical History:
HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

Social History:
30 PY smoker (30 x 1), EtOH - cocktail/night
Married and lives with her husband


Family History:
Noncontributory

Physical Exam:
difficult due to aphasia.
CTA b/l
RRR
soft NTND
UE sensation appears intact but no motor. Neg [**Doctor Last Name 937**]. LE
sensation questionable. Spastic bilat LE. [**5-4**] GS on command, all
other muscle groups [**2-4**]. Toes upgoing bilat. 1+ biceps, 2+
patella. No thoracolumbar tenderness to palpation. No rectal
tone.

Pertinent Results:
[**2152-5-4**] 08:05PM BLOOD WBC-14.6*# RBC-4.01* Hgb-12.3 Hct-39.4
MCV-98 MCH-30.7 MCHC-31.3 RDW-15.5 Plt Ct-183#
[**2152-5-7**] 03:33AM BLOOD WBC-10.9 RBC-3.30* Hgb-10.0* Hct-29.7*
MCV-90 MCH-30.3 MCHC-33.7 RDW-16.1* Plt Ct-183
[**2152-5-4**] 08:05PM BLOOD Glucose-128* UreaN-33* Creat-1.3* Na-136
K-5.6* Cl-108 HCO3-15* AnGap-19
[**2152-5-7**] 02:28AM BLOOD Glucose-105 UreaN-41* Creat-1.4* Na-141
K-4.3 Cl-108 HCO3-23 AnGap-14
[**2152-5-4**] 08:05PM BLOOD CK(CPK)-99
[**2152-5-5**] 02:18AM BLOOD Amylase-43
[**2152-5-5**] 02:18AM BLOOD Lipase-33
[**2152-5-4**] 08:05PM BLOOD CK-MB-NotDone
[**2152-5-5**] 02:18AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-5-4**] 08:05PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2152-5-4**] 08:05PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0
[**2152-5-4**] 08:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]->1.035

MR [**5-5**]: Type II odontoid fracture with malalignment and
distraction of the fragments as described above with narrowing
of the spinal canal at C1 level. Increased signal is seen within
the spinal cord extending from C1 to C3 level indicating cord
edema.
CT Head [**5-5**]: Persisting small left frontal hyperdense
extra-axial collection, which given its persistence after 24
hours and the fact that the patient has had prior subdural
hematomas in this location is felt likely to represent an acute
on chronic subdural hematoma.

CT HD: Equivocal hyperdensity L frontal region, contrast in
dural sinus vs. small L SDH repeat scan in 24hrs
CT A/P [**5-4**]: Hypoperfusion lateral cortex spleen, contusion vs
chronic infarct. CHF, mild dependent consolidation. Complex
cystic lesion LUP kidney, concerning for RCC. Multiple hepatic &
renal hypodensities, too small to characterize. Left adrenal
lesion, not fully characterized. PA HTN. abn GB - contusion &
hemobilia. No cholecystitis or rupture; polyp, cholesterolosis,
or GB carcinoma.


Brief Hospital Course:
She was admitted to the Trauma Service; once stabilized in the
Emergency Department she was transferred to the TSICU.
Orthopedic Spine Surgery was consulted given the nature of her
injuries. She did receive a 24 hour steroid protocol per initial
request of family for any possible treatment that could help
prevent sequelae of her cervical spine fracture. It was felt by
Orthopedic Spine Surgery that conservative treatment with use of
a cervical collar would be the safest alternative given her age
and co-morbidities as high risk for surgical intervention.

Family/team meetings were held to discuss alternatives such as
Palliative care, given her less than favorable prognosis with
this type of injury. It was decided after lengthy discussions
regarding quality of life for patient that the family wished to
honor her wishes and she was made DNR/CMO. The family did
however wish to have a bedside swallow evaluation more so for
pleasurable intake for patient. Sh was also placed on an
adequate pain regimen that the family was agreeable to. Plans
were then initiated to make arrangements for hospice care at
home.


Medications on Admission:
lopressor 25", colace, folate, omega-3, mvi, tums, vit e,
amiodarone 200', prozac 40', zyprexa 5', levaquin, aricept 10',
melatonin 3mg hs,

Discharge Medications:


1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day).
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution Sig: 0.15 ml PO Q 3H
(): [**Month (only) 116**] give an additional 3 mg (0.15 ml's) q 1 hr prn for
breakthrough pain.
Disp:*60 ml* Refills:*0*
3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
4. Tylenol suppository  Sig: One (1)   every 4-6 hours as needed
for fever or pain: 650 mg supp PR.


Discharge Disposition:
Home With Service

Facility:
VistaCare

Discharge Diagnosis:
s/p Fall
Type II odontoid fracture


Discharge Condition:
Stable


Discharge Instructions:
Because of your cervical spine fracture it is being recommended
that you continue wear your cervical collar.


Followup Instructions:
No follow up with Orthopedic Spine or Trauma Surgery is being
recommended at this time. If there are specific issues that are
of concern to you related to your recent hospital stay you may
contact [**Name (NI) **] [**Name2 (NI) 1093**] Surgery at [**Telephone/Fax (1) 3573**] or Trauma
Surgery at [**Telephone/Fax (1) 6429**].



Completed by:[**2152-5-11**]
{'Closed fracture of first cervical vertebra,Atrial fibrillation,Heart valve replaced by transplant,Pressure ulcer, heel,Fall from other slipping, tripping, or stumbling,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}


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
Cervical spine fracture

PRESENT ILLNESS: 77 yo female with history of dementia and expressive aphasia
after complicated MVR, living at home with her husband and
24hour home health care. While ambulating using her walker she
had a ?syncopal episode, falling and striking her head and neck
on a chair. + LOC, GCS 13, home health aid activated 911. She
was taken to an area hospital where it was nted she had a
cervical fracture. she was then transferred to [**Hospital1 18**] for further
care.

MEDICAL HISTORY: HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

MEDICATION ON ADMISSION: lopressor 25", colace, folate, omega-3, mvi, tums, vit e,
amiodarone 200', prozac 40', zyprexa 5', levaquin, aricept 10',
melatonin 3mg hs,

ALLERGIES: Keflex / Vancomycin

PHYSICAL EXAM: difficult due to aphasia.
CTA b/l
RRR
soft NTND
UE sensation appears intact but no motor. Neg [**Doctor Last Name 937**]. LE
sensation questionable. Spastic bilat LE. [**5-4**] GS on command, all
other muscle groups [**2-4**]. Toes upgoing bilat. 1+ biceps, 2+
patella. No thoracolumbar tenderness to palpation. No rectal
tone.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 30 PY smoker (30 x 1), EtOH - cocktail/night
Married and lives with her husband 

### Response:
{'Closed fracture of first cervical vertebra,Atrial fibrillation,Heart valve replaced by transplant,Pressure ulcer, heel,Fall from other slipping, tripping, or stumbling,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}
