CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at
scene. She was taken to an area hospital and later transferred
to [**Hospital1 18**] for further care.

MEDICAL HISTORY: HTN
Osteoporosis
h/o Falls
Rib fractures
Pneumothorax

MEDICATION ON ADMISSION: Dilt 60
Celexa 10
Aricept 10
Lisinopril 10
Protonix 40

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of ischium,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Hypotension, unspecified,Open wound of forehead, without mention of complication,Accidental fall from bed,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere
Brain hem NEC-coma NOS,Fracture ischium-closed,Fall on stair/step NEC,Hypertension NOS,Hypotension NOS,Open wound of forehead,Fall from bed,Osteoporosis NOS,Mental disor NEC oth dis
Admission Date:  [**2199-5-7**]              Discharge Date:   [**2199-5-10**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at
scene. She was taken to an area hospital and later transferred
to [**Hospital1 18**] for further care.

Past Medical History:
HTN
Osteoporosis
h/o Falls
Rib fractures
Pneumothorax

Family History:
Noncontributory

Pertinent Results:
[**2199-5-7**] 07:13PM   GLUCOSE-186* LACTATE-3.3* NA+-138 K+-3.5
CL--96* TCO2-28
[**2199-5-7**] 07:10PM   UREA N-8 CREAT-0.5
[**2199-5-7**] 07:10PM   AMYLASE-51
[**2199-5-7**] 07:10PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2199-5-7**] 07:10PM   WBC-23.2* RBC-4.77 HGB-17.3* HCT-49.8*
MCV-104* MCH-36.2* MCHC-34.7 RDW-15.2
[**2199-5-7**] 07:10PM   PLT COUNT-304
[**2199-5-7**] 07:10PM   PT-12.5 PTT-23.2 INR(PT)-1.1
[**2199-5-7**] 07:10PM   FIBRINOGE-224

CHEST (PORTABLE AP)

Reason: ? shoulder fx

[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall from bed, unwitnessed, hit head,
c/o neck pain but unreliable PE
REASON FOR THIS EXAMINATION:
? shoulder fx
REASON FOR EXAMINATION: Trauma.

Portable AP chest radiograph compared to [**2199-5-7**].

The heart size is normal. The mediastinal contours are
unremarkable. The aorta is calcified. The hila are slightly
enlarged bilaterally, most likely due to dilatation of the
pulmonary veins, which may be related to pulmonary hypertension.
The lungs are essentially clear but over inflated, which may
represent emphysema. There is no sizeable pleural effusion or
pneumothorax.

CT HEAD W/O CONTRAST

Reason: S/P FALL UNWITNESSED EVAL FOR BLEED

[**Hospital 93**] MEDICAL CONDITION:
83 yF s/p fall from bed, unwitnessed, hit head, forehead lac,
unreliable physical exam
REASON FOR THIS EXAMINATION:
? bleed
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: Status post fall from bed.

COMPARISON: Non-contrast head CT from yesterday.

FINDINGS: Again seen is stable focal hemorrhage in the splenium
of the corpus collosum. There is no mass effect or shift of
normally midline structures, or acute major vascular territorial
infarction. The density values of the brain parenchyma again
show periventricular white matter hypodensity consistent with
chronic microvascular infarction. Again seen is enlargement of
the lateral and third ventricles which may be related to
communicating hydrocephalus or age-related involutional change.
The surrounding soft tissue structures again show a large left
parietal scalp hematoma and new soft tissue swelling overlying
the left frontal bone. There is no skull fracture.

IMPRESSION:
1. Stable hemorrhage in the splenium of the corpus callosum
without evidence for new hemorrhage.

2. New soft tissue swelling overlying the left frontal bone.
Stable left parietal scalp hematoma.

3. Again seen is enlargement of the lateral and third ventricles
which may be related to communicating hydrocephalus or
age-related involutional change. Clinical correlation is
recommended.

CT C-SPINE W/O CONTRAST

Reason: S/P FALL EVAL FOR FX

[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall from bed, unwitnessed, hit head,
c/o neck pain but unreliable PE
REASON FOR THIS EXAMINATION:
?fx
CONTRAINDICATIONS for IV CONTRAST: None.

C-SPINE

TECHNIQUE: Multidetector axial CT images were obtained through
the cervical spine. Coronal and sagittal reformatted images were
obtained.

COMPARISON: CT C-spine from [**2199-5-7**].

CT C-SPINE: There is no evidence of fracture, malalignment, or
prevertebral soft tissue swelling. The vertebral bodies and disc
space heights are normal. There are extensive degenerative
changes in the cervical spine which are stable. Again seen are
calcifications within the bilateral carotid arteries and within
the posterior longitudinal ligament. Again seen is scarring in
the bilateral lung apices. The visualized outline of the thecal
sac is unremarkable; however, CT is not able to provide any
intrathecal detail.

IMPRESSION: No evidence for cervical spine fracture or
malalignment.

CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST

Reason: ? injury
Field of view: 32 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
86 year old woman with s/p fall down flight of stairs
REASON FOR THIS EXAMINATION:
? injury
CONTRAINDICATIONS for IV CONTRAST: None.

CT ABDOMEN AND PELVIS WITH CONTRAST

INDICATION: 86-year-old woman with status post fall down flight
of stairs. Rule out injury.

COMPARISON: Not available.

TECHNIQUE: MDCT axial images of abdomen and pelvis were obtained
following the administration of 130 cc of Optiray intravenously.
Coronal and sagittal reformatted images were obtained.

CT ABDOMEN WITH INTRAVENOUS CONTRAST: The liver, spleen, adrenal
glands, stomach, abdominal loops of large and small bowel are
unremarkable. Kidneys enhance equally and excrete contrast
normally. There is no free fluid in the abdomen, and no
pathologically enlarged mesenteric or retroperitoneal lymphatic
nodes.

CT PELVIS WITH INTRAVENOUS CONTRAST: The rectum, urinary bladder
are unremarkable. There is a high density material in the
iliacus muscle, adjacent to the left ilium, likely representing
hematoma.

There is no free pelvic fluid.

BONE WINDOWS: Demonstrate no suspicious lytic or sclerotic
lesions. There are extensive degenerative changes, as well as
rotatory scoliosis. There is a compression deformity of
vertebral body of L1 of uncertain chronicity, but most likely
chronic, with extensive vertebral body sclerosis.

There is a lucent line, in the left ilium, extending from the
mid-aspect of the ilium, reaching the acetabular roof. There is
no significant displacement. There is another lucent line
extending to the superior-posterior aspect of the ilium, with
minimal displacement of the fracture fragments. No other
fractures are noted on this study.

IMPRESSION:

1. No evidence of traumatic injury of solid abdominal organs.

2. Two separate, and apparently discrete, essentially
non-displaced fractures of the left ilium, one of which involves
the left acetabular roof, with associated iliacus muscle
hematoma.

3. Chronic-appearing L1 compression fracture.

COMMENT: Findings were discussed with the Trauma Surgery team at
the time of the completion of the scan, at 20:15h, [**2199-5-7**].


Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery and
Orthopedic Surgery were consulted because of her injuries.
Repeat head CT imaging was performed which revealed a stable
intracranial hemorrhage; the injury was non operative. It was
recommended that she follow up in 4 weeks with Dr.[**Last Name (STitle) **],
Neurosurgery, at which time she will have an MRI of her brain.
She will also be evaluated for normal pressure hydrocephalus
based on a finding on head CT.

Orthopedic Surgery was consulted for her left ilium fracture;
this injury was deemed nonoperative; she is to remain touchdown
weight bearing and will require follow up with Dr. [**Last Name (STitle) 1005**] in
2 weeks. She was also started on bone prophylaxis with Calcium
and Vitamin D.

Physical and Occupational therapy were consulted and have
recommended rehab stay after discharge from the hospital.

Medications on Admission:
Dilt 60
Celexa 10
Aricept 10
Lisinopril 10
Protonix 40

Discharge Medications:


1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): hold fro SBP <110 & HR <60.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection [**Hospital1 **] (2 times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
9. Aricept 10 mg Tablet Sig: One (1) Tablet PO at bedtime.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
s/p Fall
Large left parietal sub-galeal hematoma
Small intracranial hemorrhage left splenium/corpus collosum
Nondisplaced left ilium fracture involving the acetabular roof


Discharge Condition:
Stable


Discharge Instructions:
You may ONLY touchdown weight bear on your left lower extremity.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Neurosurgey in 4 weeks. Inform the
office that you will need an MRI of the brain w/ and w/out
contrast and that also you will need evaluation for possible
normal pressure hydrocephalus. Call [**Telephone/Fax (1) 1669**] for an
appointment.

Follow up with Dr. [**Last Name (STitle) 1005**], Orthopedic Surgery, in 2 weeks.
Call [**Telephone/Fax (1) 1228**] for an appointment.
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of ischium,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Hypotension, unspecified,Open wound of forehead, without mention of complication,Accidental fall from bed,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}


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: 84 yo female s/p unwitnessd fall down stairs; ? LOC, GCS 15 at
scene. She was taken to an area hospital and later transferred
to [**Hospital1 18**] for further care.

MEDICAL HISTORY: HTN
Osteoporosis
h/o Falls
Rib fractures
Pneumothorax

MEDICATION ON ADMISSION: Dilt 60
Celexa 10
Aricept 10
Lisinopril 10
Protonix 40

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Closed fracture of ischium,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Hypotension, unspecified,Open wound of forehead, without mention of complication,Accidental fall from bed,Osteoporosis, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}
