CHIEF COMPLAINT: 

PRESENT ILLNESS: Patient is a 68-year-old woman
status post a fall down six stairs witnessed by her husband
with positive loss of consciousness and positive ETOH on
board.  Patient was hemodynamically stable and transferred to
[**Hospital6 256**] by ambulance.  Her
[**Location (un) 2611**] Coma Scale score was 14.  She had no reports of
seizure, loss of bowel or bladder function.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Cortex (cerebral) contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Alcohol abuse, unspecified,Unspecified essential hypertension,Accidental fall on or from other stairs or steps
Subdural hem-brief coma,Cortex contus-brief coma,Alcohol abuse-unspec,Hypertension NOS,Fall on stair/step NEC
Admission Date:  [**2179-5-30**]     Discharge Date:  [**2179-6-8**]

Date of Birth:   [**2110-12-15**]     Sex:  F

Service:

HISTORY OF PRESENT ILLNESS:  Patient is a 68-year-old woman
status post a fall down six stairs witnessed by her husband
with positive loss of consciousness and positive ETOH on
board.  Patient was hemodynamically stable and transferred to
[**Hospital6 256**] by ambulance.  Her
[**Location (un) 2611**] Coma Scale score was 14.  She had no reports of
seizure, loss of bowel or bladder function.

PHYSICAL EXAMINATION:  Her pupils equal, round and reactive
to light.  Her head CT showed a large posterior fossa large
occipital hematoma.  Her neck was supple.  Her lungs were
clear to auscultation and cardiac S1, S2 were normal.  She
had no murmurs, rubs or gallops.  Abdomen was soft,
nontender.  Her pelvis was stable.  Extremities with slight
abrasions of her left knee.  Neurological exam was that she
was awake and alert.

LABORATORIES ON ADMISSION:  Her hematocrit was 37.6, her
white blood cell count was 8.1, platelets 212,000.  Sodium
127, potassium 4.2, chloride 94, co2 23, BUN 14, creatinine
.8, glucose 89.  Her ETOH level was 353.  Her coags were
within normal limits.

Head CT also showed a right temporal intracranial hematoma
and a left subdural hematoma with edema and slight midline
shift and a small scalp hematoma on the left side.
Neurologically, she was drowsy but easily arousable to voice,
responded to her name, was attentive to exam and she has,
like I said, a left occipital hematoma.  Her pupils were 3
down to 2 bilaterally.  Extraocular movements full.  Smile
symmetric with no facial droop.  Tongue midline.  Palate rise
is symmetric. Shoulder shrug [**6-20**] bilaterally.  Motor exam:
Moves all extremities with good strength against gravity.
Sensation was intact to light touch.  She had no drift and
her toes were downgoing.  Patient was monitored in the
Intensive Care Unit.  On repeat head CT, patient had a
blossoming right temporal contusion.  She was started on
mannitol 25 grams intravenous q. 6.

Repeat head CT on the 15th showed again slight evolution of
the right temporal contusion without change in mental status.
Patient was awake, alert, conversant and oriented times three
with right periorbital ecchymosis.  Pupils were 4 down to 3.5
and brisk on the left and 3.5 to 2 on the right with no drift
and moving all extremities strongly.  She was transferred to
the regular floor.  She was seen by Physical Therapy and
Occupational Therapy and found to be safe for discharge to
home with 24 hour supervision by her family.  She will be
discharged to home with follow-up with Dr. [**Last Name (STitle) 1132**] in two weeks
with repeat head CT.

MEDICATIONS AT THE TIME OF DISCHARGE:
1.  Percocet 1-2 tablets po q. 4 hours prn.
2.  Dilantin 100 mg po t.i.d.

DISCHARGE CONDITION:  Patient was in stable condition at the
time of discharge and will follow-up with Dr. [**Last Name (STitle) 1132**] in two to
three weeks time with a repeat head CT.



                          [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]

Dictated By:[**Last Name (NamePattern1) 344**]

MEDQUIST36

D:  [**2179-6-8**]  01:59
T:  [**2179-6-8**]  01:59
JOB#:  [**Job Number 40147**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Cortex (cerebral) contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Alcohol abuse, unspecified,Unspecified essential hypertension,Accidental fall on or from other stairs or steps'}


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: 

PRESENT ILLNESS: Patient is a 68-year-old woman
status post a fall down six stairs witnessed by her husband
with positive loss of consciousness and positive ETOH on
board.  Patient was hemodynamically stable and transferred to
[**Hospital6 256**] by ambulance.  Her
[**Location (un) 2611**] Coma Scale score was 14.  She had no reports of
seizure, loss of bowel or bladder function.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Cortex (cerebral) contusion without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Alcohol abuse, unspecified,Unspecified essential hypertension,Accidental fall on or from other stairs or steps'}
