CHIEF COMPLAINT: found down

PRESENT ILLNESS: The patient is a 79 yo F with history of hypertension,
hyperlipidemia, NIDDM and pituitary mass that presents having
been found down. It is unclear how long the patient was down.
She states she think that she fell after veterans day. She
thinks she fell trying to sit on her kitchen chair. She states
she has felt lightheaded for up to several months and had a cold
for the past week but otherwise she reports no specific
symptoms. She denies vertigo, chest pain, palpitations, nausea,
vomiting. Her closest contact is her [**First Name9 (NamePattern2) **] [**Name (NI) 44286**] who was the
one who called the police. [**First Name8 (NamePattern2) **] [**Last Name (un) 44286**], she has been "this
close" to her needing to be in an asissted living facility. He
hasn't been feeling well for the past year. He picks up her
medications. He last saw her a week ago and las talked to her
today when she said she was on the floor. He talked to her prior
to then several days before. Today, she seemed "groggy" to him.
He confirmed that she did not drunk. In the ED, she was
hypothermic to 94. BP was 88/45, HR 97, oxygen 98 on room air.
She was given 2L NS. She had one episode of hypotension to the
70/40 which responded to an additional 1L of NS. She was also
started on [**1-24**] NS for hypernatremia. Vitals on transfer were P
79 Bp 125/35 14 100% 2L

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Diabetes
Memory Loss
Unsteady gait
pituitary macroadenoma

MEDICATION ON ADMISSION: LISINOPRIL 20 MG TABS 1 tab po every day
METFORMIN HCL 500 MG TABS 1 tab po daily in the morning
SIMVASTATIN 40 MG TABS 1 tab by mouth QHS
HYDROCHLOROTHIAZIDE TAB 25MG 1 tab po every day

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
place, year, month, Movement: Purposeful, Tone: Not assessed,
neuro non focal

FAMILY HISTORY: nc

SOCIAL HISTORY: lives at home. reports that her son beats her if she doesnt give
him money. prior h/o etoh but quit in [**2125**] and quit smoking in
[**2125**]
Acute kidney failure, unspecified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Unspecified fall,Pressure ulcer, lower back,Hypothermia
Acute kidney failure NOS,Pneumonia, organism NOS,Hyperosmolality,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Benign neo pituitary,Fall NOS,Pressure ulcer, low back,Hypothermia
Admission Date:  [**2145-12-11**]              Discharge Date:   [**2145-12-15**]

Date of Birth:  [**2066-12-10**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
found down

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 79 yo F with history of hypertension,
hyperlipidemia, NIDDM and pituitary mass that presents having
been found down. It is unclear how long the patient was down.
She states she think that she fell after veterans day. She
thinks she fell trying to sit on her kitchen chair. She states
she has felt lightheaded for up to several months and had a cold
for the past week but otherwise she reports no specific
symptoms. She denies vertigo, chest pain, palpitations, nausea,
vomiting. Her closest contact is her [**First Name9 (NamePattern2) **] [**Name (NI) 44286**] who was the
one who called the police. [**First Name8 (NamePattern2) **] [**Last Name (un) 44286**], she has been "this
close" to her needing to be in an asissted living facility. He
hasn't been feeling well for the past year. He picks up her
medications. He last saw her a week ago and las talked to her
today when she said she was on the floor. He talked to her prior
to then several days before. Today, she seemed "groggy" to him.
He confirmed that she did not drunk. In the ED, she was
hypothermic to 94. BP was 88/45, HR 97, oxygen 98 on room air.
She was given 2L NS. She had one episode of hypotension to the
70/40 which responded to an additional 1L of NS. She was also
started on [**1-24**] NS for hypernatremia. Vitals on transfer were P
79 Bp 125/35 14 100% 2L

Past Medical History:
Hypertension
Hyperlipidemia
Diabetes
Memory Loss
Unsteady gait
pituitary macroadenoma

Social History:
lives at home. reports that her son beats her if she doesnt give
him money. prior h/o etoh but quit in [**2125**] and quit smoking in
[**2125**]

Family History:
nc

Physical Exam:
ADMISSION EXAM:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
place, year, month, Movement: Purposeful, Tone: Not assessed,
neuro non focal

On discharge: Exam stable, with ability to walk to bathroom with
assistance and mild ear congestion.  Vital signs stable, with
normal blood pressure.

Pertinent Results:
ADMISSION LABS:
[**2145-12-11**] 12:30PM BLOOD WBC-12.2* RBC-4.64 Hgb-13.7 Hct-41.9
MCV-90 MCH-29.6 MCHC-32.7 RDW-12.9 Plt Ct-286
[**2145-12-11**] 12:30PM BLOOD Neuts-68.6 Lymphs-26.2 Monos-2.6 Eos-2.2
Baso-0.3
[**2145-12-11**] 03:05PM BLOOD PT-15.9* PTT-33.7 INR(PT)-1.4*
[**2145-12-11**] 09:20PM BLOOD Glucose-142* UreaN-124* Creat-3.0*
Na-146* K-3.8 Cl-111* HCO3-20* AnGap-19
[**2145-12-11**] 09:20PM BLOOD ALT-19 AST-26 LD(LDH)-264* CK(CPK)-107
AlkPhos-50 TotBili-0.3
[**2145-12-11**] 03:05PM BLOOD cTropnT-0.04*
[**2145-12-11**] 09:20PM BLOOD Albumin-3.4* Calcium-8.5 Phos-4.8* Mg-2.4
[**2145-12-11**] 04:18PM BLOOD Type-ART Temp-36.4 Rates-/14 pO2-157*
pCO2-28* pH-7.40 calTCO2-18* Base XS--5 Intubat-NOT INTUBA
Comment-GREEN TOP
[**2145-12-11**] 12:43PM BLOOD Glucose-151* Lactate-3.3* Na-155* K-4.2
Cl-114* calHCO3-16*

On discharge:
[**2145-12-15**] 06:15AM BLOOD Glucose-87 UreaN-27* Creat-1.1 Na-143
K-3.8 Cl-111* HCO3-24 AnGap-12

URINE:
[**2145-12-11**] 12:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2145-12-11**] 12:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

MICRO:
[**2145-12-11**] BCx: pending on discharge
[**2145-12-11**] UCx: negative
[**2145-12-11**] MRSA screen: negative
[**2145-12-11**] Legionella: negative

STUDIES:
[**2145-12-11**] CT head:
1. No evidence of acute intracranial process.
2. Small left basal ganglia lacune.
3. Age-related involution and small vessel ischemic disease.
4. Findings suspicious for pituitary adenoma with erosion of
sellar floor. Correlation with clinical history recommended. MRI
can help for further assessment as clinically indicated.
5. Complete opacification of the sphenoid sinus with extension
of disease into posterior ethmoidal air cells.

[**2145-12-11**] CT Cspine:
No acute cervical spine injury. Erosive changes are seen in
clivus. Please see head CT for further details.

[**2145-12-11**] CXR:
Possible aspiration in the bases. Large gallstone.

[**2145-12-12**] MR Pituitary:
MR EXAMINATION OF THE BRAIN AND PITUITARY GLAND WITHOUT
CONTRAST, [**2145-12-12**].

HISTORY: 79-year-old female with history of "pituitary mass"
presents with
fall; "stroke protocol" for subacute stroke and evaluate
pituitary lesion.

TECHNIQUE: Routine [**Hospital1 18**] non-enhanced MR examination of the
brain and sella
turcica was performed. N.B. Given the patient's severe renal
insufficiency
(BUN 124, creatinine 3.0 with eGFR 13 mL/min), no intravenous
gadolinium
contrast material was administered.

FINDINGS: The study is compared with the recent NECT of the head
dated
[**2145-12-11**]. As on that study, there is a markedly abnormal
appearance to the
sella turcica, which is markedly expanded with much of the
cortex of its
floor, completely eroded. The normal pituitary tissue is
replaced by an
ill-defined and somewhat heterogeneous mass, roughly
isointense-to-normal [**Doctor Last Name 352**] matter. Though its precise borders are
difficult to delineate, this process measures at least 17 (AP) x
22 (TRV) x 18 mm (CC) and likely represents a large
macroadenoma, occupying much of the sella and transgressing its
floor and possibly anterior wall. Of note, no definite posterior
pituitary "bright spot" is identified. The process within the
sella blends into the contents of the largely opacified sphenoid
sinus, which is nearly completely filled with abnormal soft
tissue material, with only its most superior-anterior portion
apparently aerated, as on the CT. The sphenoid air cells contain
foci of relative [**Name (NI) **] and more marked T2-hypointensity, with
"blooming" susceptibility artifact, which likely represent
secretions with various degrees of inspissation. The extent of
intrasphenoidal extension of the sellar mass is very difficult
to assess.

Allowing for the lack of intravenous contrast, a normal-caliber
infundibular stalk is identified, and slightly deviated to the
right with a grossly normal appearance. Though there is
effacement of the suprasellar cistern, there is no contact with
or mass effect upon the optic chiasm or the hypothalamus. Based
on the coronal T2-weighted sequence, there is no evidence of
cavernous sinus invasion, and the normal cavernous carotid
arterial flow voids are preserved.

The limited whole brain imaging is notable for moderate global
atrophy. There is relatively mild [**Name (NI) **]/FLAIR-hyperintensity,
largely limited to bifrontal periventricular white matter,
likely the sequelae of chronic small vessel ischemic disease.
There is no focus of slow diffusion to suggest an acute ischemic
event and the principal intracranial vascular flow voids,
including those of the dural venous sinuses, are preserved.
There is no evidence of intra- or extra-axial hemorrhage,
including in the sella, itself. Incidentally noted is a likely
Tornwaldt cyst in the midline nasopharynx, as well as relatively
mild chronic-appearing inflammatory changes in the maxillary
sinuses and anterior ethmoidal air cells, bilaterally, as on the
recent CT.

IMPRESSION:
1. Limited study, in the absence of intravenous contrast (which
could not be given, due to the patient's profound renal
insufficiency), redemonstrates a markedly abnormal appearance to
the sella turcica. In conjunction with the recent NECT, this
suggests an aggressive pituitary macroadenoma with marked
erosion and frank dehiscence of the sellar floor, as well as the
anterior aspect of the clivus.
2. Markedly abnormal appearance to the sphenoid air cell, which,
as on the
CT, is virtually-completely opacified with heterogeneous-signal
contents, most suggestive of differing degrees of inspissation.
However, the full extent of transgression of sphenoid by the
sellar mass is impossible to assess without contrast
enhancement. Additionally, fungal colonization cannot be
excluded, with this appearance.
3. Though there is effacement of the suprasellar cistern, there
is no
definite mass effect upon the optic chiasm or invasion of the
cavernous
sinuses.
4. No finding to suggest an acute ischemic event, with no
evidence of
previous territorial infarction.
5. Global atrophy.
.
ECHO:
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Regional left ventricular wall motion is normal.
Left ventricular systolic function is hyperdynamic (EF>75%). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular cavity size and free wall motion are normal. The
ascending aorta and aortic arch are mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.

IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal regional/hyperdynamic global systolic function. Mild
aortic regurgitation.Borderline pulmonary artery hypertension.
Dilated thoracic aorta.

CLINICAL IMPLICATIONS:
Based on [**2141**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

Brief Hospital Course:
Ms. [**Known lastname 39602**] is a 79 yo F with h/o hypertension, hyperlipidemia,
diabetes mellitus and pituitary macroadenoma presenting found
down.

# Found down: Differential includes acute illness (h/o cold
symptopms and ?infiltrate on cxr), vs stroke, vs encephalopathy
[**2-24**] renal failure vs cardiogenic syncope. Treated for CAP with
Azithromycin. MR head did reveal a clear reason for fall. ECHO
was equally unremarkable.. Cardiac enzymes were negative. Given
constellation of bradycardia, hypothermia, and known pituitary
mass, possible endocrinopathy as well. TSH and cortisol were
both normal. Physical therapy evaluated the patient who was very
deconditioned--a simple mechanical fall may have been the
culprit as no other etiology was identified.

# PNA: No risk factors for resistant organisms, treated for CAP
with Azithromycin. Urinary Legionella was negative.

# Acute kidney injury: improved with hydration, creatinine 1.1
upon discharge.  HCTZ, lisinopril, and metformin held during
stay, with metformin started on discharge.  Creatinine should be
checked after discharge at which time, if blood pressure can
support and creatinine remains stable, lisinopril 20mg and then
HCTZ 25mg can be reinitiated daily.

# Diabetes: on insulin sliding scale

# Elevated inr: INR 1.4 on admission, possibly [**2-24**] poor
nutrition.  Should be rechecked as outpatient.

# Pituitary mass: No evidence of endocrine abnormality on labs,
but imaging demonstrated possibility of slightly larger mass
versus prior images.  Will need primary care followup.

Transitional issues
# Please follow creatinine/electrolytes to ensure safe
reinitiation of lisinopril and HCTZ.
# Please follow INR as well and encourage good nutrition.
# Follow-up imaging on pituitary macroadenoma.

Medications on Admission:
LISINOPRIL 20 MG TABS 1 tab po every day
METFORMIN HCL 500 MG TABS 1 tab po daily in the morning
SIMVASTATIN 40 MG TABS 1 tab by mouth QHS
HYDROCHLOROTHIAZIDE TAB 25MG 1 tab po every day

Discharge Medications:
1. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]

Discharge Diagnosis:
Primary diagnoses:
Renal failure
Mechanical fall
Domestic violence


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 39602**],

It was a pleasure caring for you at the [**Hospital1 827**].  You came to the hospital after a fall.  You
were found to be weak and to have failure of your kidneys.

You improved with IV fluids.

Medication changes:
START azithromycin for your infection, for only 1 more day.
STOP lisinopril and hydrochlorothiazide for now.  The doctors at
your facility will restart these slowly to control your blood
pressure.

You should continue taking the rest of your medications as
prescribed

Followup Instructions:
Please follow up with your primary care physician [**Last Name (LF) **],[**Name9 (PRE) **]
[**Telephone/Fax (1) 798**] after leaving your rehab.  Your [**Hospital1 778**] social
worker will help coordinate your living situation.

You also have the following appointments already scheduled:
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2146-1-5**] at 9:00 AM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2146-1-5**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
{'Acute kidney failure, unspecified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Unspecified fall,Pressure ulcer, lower back,Hypothermia'}


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: found down

PRESENT ILLNESS: The patient is a 79 yo F with history of hypertension,
hyperlipidemia, NIDDM and pituitary mass that presents having
been found down. It is unclear how long the patient was down.
She states she think that she fell after veterans day. She
thinks she fell trying to sit on her kitchen chair. She states
she has felt lightheaded for up to several months and had a cold
for the past week but otherwise she reports no specific
symptoms. She denies vertigo, chest pain, palpitations, nausea,
vomiting. Her closest contact is her [**First Name9 (NamePattern2) **] [**Name (NI) 44286**] who was the
one who called the police. [**First Name8 (NamePattern2) **] [**Last Name (un) 44286**], she has been "this
close" to her needing to be in an asissted living facility. He
hasn't been feeling well for the past year. He picks up her
medications. He last saw her a week ago and las talked to her
today when she said she was on the floor. He talked to her prior
to then several days before. Today, she seemed "groggy" to him.
He confirmed that she did not drunk. In the ED, she was
hypothermic to 94. BP was 88/45, HR 97, oxygen 98 on room air.
She was given 2L NS. She had one episode of hypotension to the
70/40 which responded to an additional 1L of NS. She was also
started on [**1-24**] NS for hypernatremia. Vitals on transfer were P
79 Bp 125/35 14 100% 2L

MEDICAL HISTORY: Hypertension
Hyperlipidemia
Diabetes
Memory Loss
Unsteady gait
pituitary macroadenoma

MEDICATION ON ADMISSION: LISINOPRIL 20 MG TABS 1 tab po every day
METFORMIN HCL 500 MG TABS 1 tab po daily in the morning
SIMVASTATIN 40 MG TABS 1 tab by mouth QHS
HYDROCHLOROTHIAZIDE TAB 25MG 1 tab po every day

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Bronchial: , No(t) Wheezes :
)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin:  Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Oriented (to):
place, year, month, Movement: Purposeful, Tone: Not assessed,
neuro non focal

FAMILY HISTORY: nc

SOCIAL HISTORY: lives at home. reports that her son beats her if she doesnt give
him money. prior h/o etoh but quit in [**2125**] and quit smoking in
[**2125**] 

### Response:
{'Acute kidney failure, unspecified,Pneumonia, organism unspecified,Hyperosmolality and/or hypernatremia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Benign neoplasm of pituitary gland and craniopharyngeal duct,Unspecified fall,Pressure ulcer, lower back,Hypothermia'}
