CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: [**Age over 90 **]yo woman with h/o NIDDM, HTN, hyperchol, on ASA
transferred s/p fall with an OSH HCT showing SAH. She reportedly
had a mechanical fall witnessed by her sister. [**Name (NI) **] did hit her
head. She does not remember if she lost consciousness. Her
sister
brought her to [**Known lastname 68972**] hospital, where she had a HCT
and
was transferred here.

MEDICAL HISTORY: NIDDM
HTN
hypercholesterolemia

MEDICATION ON ADMISSION: ASA
glyburide
detrol
Fe
Vit C
simvastatin
allopurinol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: T96.5, HR 84, RR 16, SaO2 96%/RA
Genl: in a cervical collar, lying still
HEENT: NCAT, MMM, OP clear
CV: RRR, nl S1, S2
Chest: CTA bilaterally
Abd: soft, NTND, BS+
.
Neurologic examination:
Mental status: alert, awake, oriented to place and name, not
date
([**9-22**], ?year). Inattention, unable to perform [**Doctor Last Name 1841**] bw.
Difficulty w/ naming (called thumbnail "peanut").
Cranial nerves: pupils post-surgical but equally responsive
(minimal), EOM full w/o nystagmus, V1-3 intact, face symmetric,
decreased hearing, palate elevates symmetrically, tongue midline
with nl movements.
Motor: moves all extremities, lifts legs bilaterally, grip
strong
bilaterally.
Sensory: intact to LT throughout
Gait: deferred
.

FAMILY HISTORY: not elicited

SOCIAL HISTORY: lives with sister
Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Unspecified fall,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia
Traum subarachnoid hem,Food/vomit pneumonitis,Acute respiratry failure,Acute kidney failure NOS,Atrial fibrillation,Subendo infarct, initial,Urin tract infection NOS,CHF NOS,Fall NOS,Anemia NOS,DMII wo cmp nt st uncntr,Pure hypercholesterolem
Admission Date:  [**2104-11-9**]              Discharge Date:   [**2104-11-18**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
s/p fall


Major Surgical or Invasive Procedure:
None on this admission

History of Present Illness:
[**Age over 90 **]yo woman with h/o NIDDM, HTN, hyperchol, on ASA
transferred s/p fall with an OSH HCT showing SAH. She reportedly
had a mechanical fall witnessed by her sister. [**Name (NI) **] did hit her
head. She does not remember if she lost consciousness. Her
sister
brought her to [**Known lastname 68972**] hospital, where she had a HCT
and
was transferred here.


Past Medical History:
NIDDM
HTN
hypercholesterolemia


Social History:
lives with sister


Family History:
not elicited


Physical Exam:
PE: VS: T96.5, HR 84, RR 16, SaO2 96%/RA
Genl: in a cervical collar, lying still
HEENT: NCAT, MMM, OP clear
CV: RRR, nl S1, S2
Chest: CTA bilaterally
Abd: soft, NTND, BS+
.
Neurologic examination:
Mental status: alert, awake, oriented to place and name, not
date
([**9-22**], ?year). Inattention, unable to perform [**Doctor Last Name 1841**] bw.
Difficulty w/ naming (called thumbnail "peanut").
Cranial nerves: pupils post-surgical but equally responsive
(minimal), EOM full w/o nystagmus, V1-3 intact, face symmetric,
decreased hearing, palate elevates symmetrically, tongue midline
with nl movements.
Motor: moves all extremities, lifts legs bilaterally, grip
strong
bilaterally.
Sensory: intact to LT throughout
Gait: deferred
.

Pertinent Results:
[**2104-11-10**] 04:02AM BLOOD WBC-9.2 RBC-3.24* Hgb-10.2* Hct-30.1*
MCV-93 MCH-31.5 MCHC-33.9 RDW-16.9* Plt Ct-118*
[**2104-11-9**] 02:00PM BLOOD WBC-7.5 RBC-3.69* Hgb-11.5* Hct-33.6*
MCV-91 MCH-31.1 MCHC-34.2 RDW-16.7* Plt Ct-119*
[**2104-11-9**] 02:00PM BLOOD Neuts-83.6* Lymphs-13.3* Monos-2.6
Eos-0.5 Baso-0
[**2104-11-10**] 04:02AM BLOOD Plt Ct-118*
[**2104-11-10**] 04:02AM BLOOD Glucose-153* UreaN-21* Creat-1.1 Na-141
K-4.3 Cl-110* HCO3-23 AnGap-12
[**2104-11-9**] 02:00PM BLOOD Glucose-159* UreaN-19 Creat-1.1 Na-139
K-4.3 Cl-105 HCO3-27 AnGap-11
[**2104-11-10**] 04:02AM BLOOD Albumin-3.4 Calcium-8.2* Phos-2.5* Mg-2.1
[**2104-11-10**] 05:06PM BLOOD Type-ART pO2-179* pCO2-36 pH-7.34*
calTCO2-20* Base XS--5
[**2104-11-10**] 05:06PM BLOOD Glucose-174*
[**2104-11-10**] 02:21PM BLOOD freeCa-1.22
[**2104-11-9**] 06:15PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-MOD
[**2104-11-9**] 06:15PM URINE RBC-[**4-13**]* WBC-21-50* Bacteri-FEW
Yeast-NONE Epi-[**4-13**]
.
.
[**2104-11-10**] 1:31 am SPUTUM     Site: ENDOTRACHEAL

   GRAM STAIN (Final [**2104-11-10**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
.
.
CT HEAD W/O CONTRAST  [**2104-11-9**] 5:31 PM
IMPRESSION: No significant change in appearance of hypodense
material within the basal cisterns, consistent with subarachnoid
hemorrhage. CTA could be helpful for further evaluation, this
was discussed with Dr. [**First Name8 (NamePattern2) 2808**] [**Last Name (NamePattern1) 1726**]. There is a plan to obtain
CTA when the patient is more stable.
NOTE ADDED AT ATTENDING REVIEW: The value of CTa is
questionable, unless this is truly a spontaneous hemorrhage.
However, there are small amounts of dural thickening and
possible subdural hemorrhage along the falx anteriorly and
overlying the right frontal lobe. These suggest trauma, as does
the distribution of the blood into the inferior frontal
subarachnoid space. Thus, there may be a combination of
subarachnoid hemorrhage and inferior frontal hemorrhagiv
contusion- all compatible with trauma. Correlation with the
clinical history is recommended.
.
.
CT C-SPINE W/O CONTRAST  [**2104-11-9**] 3:29 PM
IMPRESSION:
1. No evidence of fracture or abnormal prevertebral soft tissue
swelling.
2. Cervical spondylosis.
3. Subarachnoid hemorrhage seen on CT of the head not well
evaluated on this study.
4. Small nodular density at the right apex possibly represents
convergence of vessels. Correlation with prior studies if
available is recommended.
.
.
CT HEAD W/O CONTRAST  [**2104-11-9**] 3:29 PM
IMPRESSION: Hyperdense material within the basal cisterns
consistent with subarachnoid hemorrhage. No evidence of shift of
normally midline structures or hydrocephalus.
NOTE ADDED AT ATTENDING REVIEW: There is a left parasagittal
linear skull fracture without depression.
.
.
CT HEAD W/O CONTRAST  [**2104-11-10**] 6:29 PM
IMPRESSION: No change in the subarachnoid and likely small
subdural hemorrhages.
.
.
CHEST (PORTABLE AP)  [**2104-11-10**] 2:38 PM
A single AP view of the chest is obtained [**2104-11-10**] at 1445 hours
and compared with the prior day's radiograph. The patient has
been extubated. Since the prior examination, the patient has
developed opacity in the right lower lobe. There is also
increased interstitial markings in the right upper lobe and to a
lesser extent in the left lung compared with the prior
examination. The findings may represent asymmetric pulmonary
edema. However, particularly in the right lower lobe, aspiration
or pneumonitis must be considered..
.
.


Brief Hospital Course:
This patient was admitted to [**Hospital1 18**] under the Neurosurgery
service on [**11-9**] after being transfered from an outside
hospital. The patient was evaluated in the ED and had a CT scan
(findings as above). The patient was intubated for airway
protection after an episode of vomiting. She was then brought to
the surgical ICU for furthur monitoring. Her initial CT scan of
her head was stable compared to that of the outside hospital.
.
On [**11-10**], the patient was extubated. She had some respiratory
difficulties, with tachypnea and a raised pC02. She was
evaluated via a chest xray. Her neurological status had greatly
improved overnight and through the course of the day.
.
The following day on [**11-11**],
.
A/P: [**Age over 90 **] yo female with history of HTN, hypercholesterolemia who
presented from OSH with subdural bleed and AMS who had a STEMI
and ARF while in house.
.
# STEMI: Apppears to be anterior wall
- Cardiology consulted - not a cath candidate because of ARF and
intracranial hemorrhage
- started on aspirin, statin, BB
- unable to start hydralazine for afterload reduction, given low
BPs
- ECHO to assess cardiac function - see results above -
consistent with R and L sided heart failure.
.
# ARF: Most likely secondary to poor forward flow in setting of
significantly depressed EF.
- creatinine rising from 1.1 on admission to 2.9
- Pt noted to have signif decreased UO, not significantly
responsive to fluids
- given Lasix with increased UO, then creat bumpted to 2.9
.
# Aspiration PNA: Patient with MS changes and 3-4L O2
requirement after aspiration. Would also account for her
elevated WBC count.
- oxygenating and ventilating well after event. ABG: 7.36/39/145
with normal lactate.
.
# Altered mental status: Several reasons for AMS including:
- MI, ARF, UTI, Aspiration PNA and intracranial bleed
.
# Subdural bleed:
- Neuro/Neurosurg recs
- dilantin for seizure prophylaxis - level 16.5 on day of
admission
- serial head CTs have been stable - patient with aneurysm - Per
neuro, would consider an MRI to properly assess this if pt
stable
.
# Anemia:
- Iron studies c/w ACD
.
# UTI:
- treat with Levofloxacin for 7 days since she has a Foley
- renally dosing levofloxacin
.
# FEN: TF
.
# Hypernatremia: D51/2NS to replete some free water.
.
# Diabetes Mellitus: titrate up SSI.
.
# PPX:
- PPI
- No heparin [**3-13**] intracranial bleeds
- pneumoboots
- sliding scale insulin
.
# Code Status: Patient can be intubated if it is felt it would
be for a short period of time. No chest compressions or
defibrillation


Medications on Admission:
ASA
glyburide
detrol
Fe
Vit C
simvastatin
allopurinol


Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
NA

Followup Instructions:
NA


Completed by:[**2104-12-20**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Unspecified fall,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia'}


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: [**Age over 90 **]yo woman with h/o NIDDM, HTN, hyperchol, on ASA
transferred s/p fall with an OSH HCT showing SAH. She reportedly
had a mechanical fall witnessed by her sister. [**Name (NI) **] did hit her
head. She does not remember if she lost consciousness. Her
sister
brought her to [**Known lastname 68972**] hospital, where she had a HCT
and
was transferred here.

MEDICAL HISTORY: NIDDM
HTN
hypercholesterolemia

MEDICATION ON ADMISSION: ASA
glyburide
detrol
Fe
Vit C
simvastatin
allopurinol

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: T96.5, HR 84, RR 16, SaO2 96%/RA
Genl: in a cervical collar, lying still
HEENT: NCAT, MMM, OP clear
CV: RRR, nl S1, S2
Chest: CTA bilaterally
Abd: soft, NTND, BS+
.
Neurologic examination:
Mental status: alert, awake, oriented to place and name, not
date
([**9-22**], ?year). Inattention, unable to perform [**Doctor Last Name 1841**] bw.
Difficulty w/ naming (called thumbnail "peanut").
Cranial nerves: pupils post-surgical but equally responsive
(minimal), EOM full w/o nystagmus, V1-3 intact, face symmetric,
decreased hearing, palate elevates symmetrically, tongue midline
with nl movements.
Motor: moves all extremities, lifts legs bilaterally, grip
strong
bilaterally.
Sensory: intact to LT throughout
Gait: deferred
.

FAMILY HISTORY: not elicited

SOCIAL HISTORY: lives with sister 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Acute kidney failure, unspecified,Atrial fibrillation,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Congestive heart failure, unspecified,Unspecified fall,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia'}
