CHIEF COMPLAINT: S/p fall

PRESENT ILLNESS: 89F lives in [**Hospital3 **] facility, s/p fall this
morning, pt does not remember falling but remembers waking up on
the floor of her apartment and was able to go to the bathroom
and
pull the cord for help. Pt was taken to OSH where a CT showed an
intraparenchymal hemorrhage. Pt was transfered to [**Hospital1 18**] where a
head CT shows a 1.5cm bleed into the posteriomedial left
temporal
lobe. Nonfocal neurological exam, pt is A&Ox2, is at baseline
per
daughter. Pt reports having a headache since [**Month (only) 547**], no change.

MEDICAL HISTORY: PMHx: HTN, Hypothythyroidism, RA, Osteoperosis

MEDICATION ON ADMISSION: Boniva 150mg Q month
Calcium 500mg TID
ASA 325 QDay
Centrum Silver MV
Dicyclomide 10mg QHS
HCTZ 50mg QD
Levothyroxine 75mcg QD
Meclizine 25mg TID
Fluoxetine 10mg QD
Citalopram 10mg QHS

ALLERGIES: Novocain / Zantac

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  BP: 172/42   HR:67    R 16, 97% RA
Gen: Well, comfortable, NAD.
HEENT: Normocephallic, atraumatic, PERRL, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and oriented x2. Oriented to person, knows
she
is in a hospital but did not know where, oriented to year and
season.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] apartment. Ambulatory without
assistance at baseline
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified circulatory system disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Delirium due to conditions classified elsewhere,Cataract extraction status,Unspecified fall,Home accidents
Brain lacer NEC w/o coma,Hypertension NOS,Hypothyroidism NOS,Osteoporosis NOS,Pure hypercholesterolem,Depressive disorder NEC,Circulatory disease NOS,Spin sten,lumbr wo claud,Delirium d/t other cond,Cataract extract status,Fall NOS,Accident in home
Admission Date:  [**2198-8-20**]              Discharge Date:   [**2198-8-24**]


Service: NEUROSURGERY

Allergies:
Novocain / Zantac

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
S/p fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
89F lives in [**Hospital3 **] facility, s/p fall this
morning, pt does not remember falling but remembers waking up on
the floor of her apartment and was able to go to the bathroom
and
pull the cord for help. Pt was taken to OSH where a CT showed an
intraparenchymal hemorrhage. Pt was transfered to [**Hospital1 18**] where a
head CT shows a 1.5cm bleed into the posteriomedial left
temporal
lobe. Nonfocal neurological exam, pt is A&Ox2, is at baseline
per
daughter. Pt reports having a headache since [**Month (only) 547**], no change.


Past Medical History:
PMHx: HTN, Hypothythyroidism, RA, Osteoperosis


Social History:
Lives in [**Hospital3 **] apartment. Ambulatory without
assistance at baseline


Family History:
non contributory

Physical Exam:
PHYSICAL EXAM:
O: T:  BP: 172/42   HR:67    R 16, 97% RA
Gen: Well, comfortable, NAD.
HEENT: Normocephallic, atraumatic, PERRL, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and oriented x2. Oriented to person, knows
she
is in a hospital but did not know where, oriented to year and
season.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 down to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Proximal leg weakness 4+/5 IP and Quads bilaterally,
Triceps/Biceps 5-/5 bilaterally, otherwise full strength
throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: Patellar and achilles reflexes intact b/l

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements


Pertinent Results:
[**2198-8-20**] 04:36PM   PT-12.1 PTT-23.6 INR(PT)-1.0
[**2198-8-20**] 04:21PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2198-8-20**] 04:21PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2198-8-20**] 04:21PM URINE  RBC-[**2-12**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2198-8-20**] 04:21PM URINE  AMORPH-MOD
[**2198-8-20**] 02:55PM   GLUCOSE-85 UREA N-24* CREAT-1.2* SODIUM-137
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-30 ANION GAP-12
[**2198-8-20**] 02:55PM   estGFR-Using this
[**2198-8-20**] 02:55PM   CK(CPK)-124
[**2198-8-20**] 02:55PM   CK-MB-6 cTropnT-0.01
[**2198-8-20**] 02:55PM   WBC-9.5 RBC-4.08* HGB-13.7 HCT-38.0 MCV-93
MCH-33.5* MCHC-35.9* RDW-12.9
[**2198-8-20**] 02:55PM   NEUTS-73.1* LYMPHS-19.4 MONOS-4.5 EOS-2.7
BASOS-0.3
[**2198-8-20**] 02:55PM   PLT COUNT-215
CT HEAD W/O CONTRAST  [**2198-8-20**] 2:21 PM

IMPRESSION: 1.5-cm parenchymal hemorrhage in the medial
posterior left temporal lobe with leptomeningeal extension.
Given the pattern and location of the hemorrhage, and patient
age, amyloid angiopathy is suspected for the etiology of the
bleed. Please correlate clinically.

CT HEAD W/O CONTRAST  [**2198-8-21**] 6:04 PM

FINDINGS: Again demonstrated within the medial posterior left
temporal lobe is an area of hyperdensity that appears grossly
similar in extent compared to prior study. This comparison is
limited given the extreme motion on prior CT. No new areas of
hemorrhage are identified. There is no evidence of mass effect.
The ventricles are symmetric. There is atrophy of the frontal
lobes bilaterally. There is no evidence of acute major vascular
territorial infarction.

The paranasal sinuses and mastoid air cells are stable.

IMPRESSION: Grossly stable left medial posterior temporal lower
lobe intraparenchymal hemorrhage.





Brief Hospital Course:
Ms [**Known lastname 75116**] was admitted to neurosurgery service on [**2198-8-20**] for
intraparenchymal hemorrhage (left temporal lobe) s/p fall.
Patient was taking daily ASA 325MG prior to the fall. Upon
admission, she was oriented to person/hospital/year and season,
which was her baseline. Her motor exam was non focal. Her ASA
was on hold since admission and restarted on [**2198-8-24**].
Neurologically she remains stable, and her intracranial
hemorrhage also remains stable with repeat CT scan of head.
Geriatric service was consulted regarding intermittent
confusion, she was recommended starting celexa/haldol and
increasing activity. PT was also consulted and recommended pt to
be discharged to rehabilitation.
A MRI of brain was performed and reviewed by neurologist Dr
[**First Name (STitle) **]. MRI showed possible amyloid angiopathy, she is
recommended follow up with her PCP and keep her BP < 140/90. She
is also recommended to repeat MRI brain with and without
contrast to rule out underline mass.
Upon discharge, pt is neurologically stable, and tolerating
regular diet.


Medications on Admission:
Boniva 150mg Q month
Calcium 500mg TID
ASA 325 QDay
Centrum Silver MV
Dicyclomide 10mg QHS
HCTZ 50mg QD
Levothyroxine 75mcg QD
Meclizine 25mg TID
Fluoxetine 10mg QD
Citalopram 10mg QHS


Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for delirium.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Intra parenchymal hemorrhage (left temporal lobe), possible
amyloid angiopathy.


Discharge Condition:
Neurologically stable.


Discharge Instructions:
??????	Take your medicine, including your pre-admission medication as
prescribed.
*       Please keep your blood pressure less than 140/90.
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, 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


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST PRIOR TO
YOUR VISIT.



Completed by:[**2198-8-24**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified circulatory system disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Delirium due to conditions classified elsewhere,Cataract extraction status,Unspecified fall,Home accidents'}


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

PRESENT ILLNESS: 89F lives in [**Hospital3 **] facility, s/p fall this
morning, pt does not remember falling but remembers waking up on
the floor of her apartment and was able to go to the bathroom
and
pull the cord for help. Pt was taken to OSH where a CT showed an
intraparenchymal hemorrhage. Pt was transfered to [**Hospital1 18**] where a
head CT shows a 1.5cm bleed into the posteriomedial left
temporal
lobe. Nonfocal neurological exam, pt is A&Ox2, is at baseline
per
daughter. Pt reports having a headache since [**Month (only) 547**], no change.

MEDICAL HISTORY: PMHx: HTN, Hypothythyroidism, RA, Osteoperosis

MEDICATION ON ADMISSION: Boniva 150mg Q month
Calcium 500mg TID
ASA 325 QDay
Centrum Silver MV
Dicyclomide 10mg QHS
HCTZ 50mg QD
Levothyroxine 75mcg QD
Meclizine 25mg TID
Fluoxetine 10mg QD
Citalopram 10mg QHS

ALLERGIES: Novocain / Zantac

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  BP: 172/42   HR:67    R 16, 97% RA
Gen: Well, comfortable, NAD.
HEENT: Normocephallic, atraumatic, PERRL, EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Alert and oriented x2. Oriented to person, knows
she
is in a hospital but did not know where, oriented to year and
season.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] apartment. Ambulatory without
assistance at baseline 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified circulatory system disorder,Spinal stenosis, lumbar region, without neurogenic claudication,Delirium due to conditions classified elsewhere,Cataract extraction status,Unspecified fall,Home accidents'}
