CHIEF COMPLAINT: Transfer with SAH and contusion

PRESENT ILLNESS: 86 year old female presented s/p slip and fall on [**1-26**]. She
was seen at an outside hospital where a CT scan showed bilateral

MEDICAL HISTORY: dementia, cardiac disease, valvular heart disease,
arrhythmia, MVP, spinal stenosis, IBS, depression

MEDICATION ON ADMISSION: Digoxin 0.125 mg MWF
Aspirin 81 mg daily
Gabapentin 200 mg [**Hospital1 **]
Detrol 2 mg daily
Zoloft 25 mg daily
Plavix 75 mg daily
Famotidine 20 mg daily
Simvastatin 40 mg daily
Ferrous Sulfate 325 mg daily
Levothroid 25 milliequivalents daily

ALLERGIES: Darvocet-N 100 / Codeine / Lactose

PHYSICAL EXAM: T:97.8 BP:112/61 HR:67 RR:16 O2Sats:98% 2LNC
Gen: Thin, elderly lady laying on the stretcher.
HEENT: Pupils: left surgical, left pinpoint EOMs-right eye
deviates to the right (this is an old finding)
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irregularly irregular.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ bilateral pedal edema.
Right lower extremity has an area of red discoloration.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Slightly difficult to understand her speech.

FAMILY HISTORY: Not known

SOCIAL HISTORY: Nieces as HCP
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Home accidents,Contusion of hip,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Hypoxemia,Dysphagia, unspecified
Brain lacer NEC w/o coma,Fracture two ribs-closed,Fx up end humerus NOS-cl,Fall from slipping NEC,Accident in home,Contusion of hip,Hypothyroidism NOS,Mental disor NEC oth dis,Hypoxemia,Dysphagia NOS
Admission Date:  [**2161-1-25**]              Discharge Date:   [**2161-1-30**]


Service: NEUROSURGERY

Allergies:
Darvocet-N 100 / Codeine / Lactose

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Transfer with SAH and contusion

Major Surgical or Invasive Procedure:
None

History of Present Illness:
86 year old female presented s/p slip and fall on [**1-26**]. She
was seen at an outside hospital where a CT scan showed bilateral

SAH and a right sided contusion. The patient does not have a
headache or dizziness. She does have pain over her right hip and

under her right breast. She reports that she fell onto her right

side. The patient does not have chest pain or SOB.


Past Medical History:
dementia, cardiac disease, valvular heart disease,
arrhythmia, MVP, spinal stenosis, IBS, depression

Social History:
Nieces as HCP

Family History:
Not known

Physical Exam:
T:97.8 BP:112/61 HR:67 RR:16 O2Sats:98% 2LNC
Gen: Thin, elderly lady laying on the stretcher.
HEENT: Pupils: left surgical, left pinpoint EOMs-right eye
deviates to the right (this is an old finding)
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irregularly irregular.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ bilateral pedal edema.
Right lower extremity has an area of red discoloration.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Slightly difficult to understand her speech.

Cranial Nerves:
I: Not tested
II: Left pupil is surgical, right is pinpoint.
III, IV, VI: Right eye deviates to the right.
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. Strength full power [**6-1**] throughout. No pronator drift.

Sensation: Intact to light touch bilaterally.

Toes downgoing bilaterally


Pertinent Results:
[**2161-1-29**] 06:55AM BLOOD Plt Ct-169
[**2161-1-29**] 06:55AM BLOOD Glucose-116* UreaN-22* Creat-1.4* Na-146*
K-4.7 Cl-104 HCO3-34* AnGap-13
[**2161-1-29**] 06:55AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0
[**2161-1-29**] 06:55AM BLOOD CK-MB-17* MB Indx-16.0* cTropnT-0.76*
[**2161-1-28**] 03:30PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2161-1-26**] 04:51AM BLOOD Digoxin-1.0
[**2161-1-25**] 03:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
86 year old female presented s/p slip and fall om [**1-26**] and
suffered a bilateral SAH and a right sided contusion. She was on
Aspirin and Plavix. She had nieces as health care proxy and made
her wishes known to them that she would never want intubation.
She She had been experiencing worsening health and did not want
any life sustaining measures. She was monitored closely in the
ICU follow up head CTs were stable and eventually transferred to
the floor and was doing relatively well until [**1-28**] she
developed acute respiratory distress. In discussing her
condition with her family they decided to make the patient CMO.
She died on [**2161-1-30**].

Medications on Admission:
Digoxin 0.125 mg MWF
Aspirin 81 mg daily
Gabapentin 200 mg [**Hospital1 **]
Detrol 2 mg daily
Zoloft 25 mg daily
Plavix 75 mg daily
Famotidine 20 mg daily
Simvastatin 40 mg daily
Ferrous Sulfate 325 mg daily
Levothroid 25 milliequivalents daily

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Traumatic SAH and Contusions

Discharge Condition:
Expired

Discharge Instructions:
None

Followup Instructions:
None


Completed by:[**2161-3-5**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Home accidents,Contusion of hip,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Hypoxemia,Dysphagia, unspecified'}


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: Transfer with SAH and contusion

PRESENT ILLNESS: 86 year old female presented s/p slip and fall on [**1-26**]. She
was seen at an outside hospital where a CT scan showed bilateral

MEDICAL HISTORY: dementia, cardiac disease, valvular heart disease,
arrhythmia, MVP, spinal stenosis, IBS, depression

MEDICATION ON ADMISSION: Digoxin 0.125 mg MWF
Aspirin 81 mg daily
Gabapentin 200 mg [**Hospital1 **]
Detrol 2 mg daily
Zoloft 25 mg daily
Plavix 75 mg daily
Famotidine 20 mg daily
Simvastatin 40 mg daily
Ferrous Sulfate 325 mg daily
Levothroid 25 milliequivalents daily

ALLERGIES: Darvocet-N 100 / Codeine / Lactose

PHYSICAL EXAM: T:97.8 BP:112/61 HR:67 RR:16 O2Sats:98% 2LNC
Gen: Thin, elderly lady laying on the stretcher.
HEENT: Pupils: left surgical, left pinpoint EOMs-right eye
deviates to the right (this is an old finding)
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Irregularly irregular.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 2+ bilateral pedal edema.
Right lower extremity has an area of red discoloration.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Slightly difficult to understand her speech.

FAMILY HISTORY: Not known

SOCIAL HISTORY: Nieces as HCP 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Home accidents,Contusion of hip,Unspecified acquired hypothyroidism,Other persistent mental disorders due to conditions classified elsewhere,Hypoxemia,Dysphagia, unspecified'}
