CHIEF COMPLAINT: fall

PRESENT ILLNESS: Pt is a [**Age over 90 **] yo male who presents after falling, striking his
head. Pt has a history of multifactorial gait disorder at
baseline. Pt was at home and attempted to stand. Denies LOC, and
can fully recall events. Denies dizzinesss, shortness of breath,
chest pain, and palpitations. Currently without complaints.

MEDICAL HISTORY: HTN
Prostate CA with bony mets
Spondylosis
Essential trauma and gait disorder
Anal Fissure
+gallstones
Depression
Insomnia

MEDICATION ON ADMISSION: Pravachol
Trazodone
Lasix
Naprosyn
ASA
Metoprolol
Restoril
Mysoline
Norvasc
Hydralazine
Lupron
Primidone
Zometa
Procrit

ALLERGIES: Oxycodone

PHYSICAL EXAM: 99.3    72   178/60   16  98%RA
Alert, elderly male in NAD
Superior abrasion in left forehead
Pupils: 3mm-->2mm, EOMI
Trachea midline
Chest stable, CTA anterior
RRR
Abdomen soft, NT, ND
Rectal: guaiac negative, normal rectal tone
Ext: no deformities
Spine nontender

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone
Daughter very involved with care, lives close by
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of fourth cervical vertebra,Secondary malignant neoplasm of bone and bone marrow,Heart valve replaced by transplant,Fall from other slipping, tripping, or stumbling,Abnormality of gait,Personal history of malignant neoplasm of prostate,Essential and other specified forms of tremor
Subdural hem w/o coma,Fx c4 vertebra-closed,Secondary malig neo bone,Heart valve transplant,Fall from slipping NEC,Abnormality of gait,Hx-prostatic malignancy,Tremor NEC
Name:  [**Known lastname 18041**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 18042**]

Admission Date:  [**2121-3-18**]              Discharge Date:   [**2121-3-20**]

Date of Birth:  [**2031-3-6**]             Sex:   M

Service: SURGERY

Allergies:
Oxycodone

Attending:[**First Name3 (LF) 844**]
Addendum:
The patient's c-spine was cleared clinically as neurosurgery
felt the C4 fracture to be a stable fracture that did not
require a c-collar.

Brief Hospital Course:
Neurosurgery considers the fracture at C4 stable and therefore
the patient's c-spine was cleared prior to discharge.

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO TID (3 times a day) for 1 weeks.
Disp:*42 Capsule(s)* Refills:*0*
5. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Temazepam 15 mg Capsule Sig: [**12-8**] Capsules PO HS (at bedtime)
as needed.
Disp:*30 Capsule(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]

Discharge Diagnosis:
status post fall
C4 transverse foraminal fracture
Right frontoparietal subdural hematoma


Discharge Condition:
Stable

Discharge Instructions:
Please make and keep all follow up appointments.
Take all medication as directed.
Use a cane or walker to ambulate.

Followup Instructions:
Call [**Telephone/Fax (1) 4958**] to make an appointment within 4 weeks of
discharge from the hospital for neurosurgery, Dr. [**Last Name (STitle) **].

Autonomic testing as an outpatient with neurology, call your
neurologist to make an appointment for 2 weeks.

Provider [**First Name11 (Name Pattern1) 2147**] [**Last Name (NamePattern4) 18043**], MD Where: [**Hospital6 189**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 1578**] Date/Time:[**2121-4-1**] 2:00

Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18044**], RN Where: [**Hospital6 189**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 1578**] Date/Time:[**2121-4-1**] 2:30


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**] MD [**MD Number(1) 846**]

Completed by:[**2121-3-20**]

Admission Date:  [**2121-3-18**]              Discharge Date:   [**2121-3-20**]


Service: SURGERY

Allergies:
Oxycodone

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Pt is a [**Age over 90 **] yo male who presents after falling, striking his
head. Pt has a history of multifactorial gait disorder at
baseline. Pt was at home and attempted to stand. Denies LOC, and
can fully recall events. Denies dizzinesss, shortness of breath,
chest pain, and palpitations. Currently without complaints.

Past Medical History:
HTN
Prostate CA with bony mets
Spondylosis
Essential trauma and gait disorder
Anal Fissure
+gallstones
Depression
Insomnia

PSH: TURP [**2116**]
AVR [**2113**]
Inguinal hernia repair


Social History:
Lives alone
Daughter very involved with care, lives close by

Family History:
NC

Physical Exam:
99.3    72   178/60   16  98%RA
Alert, elderly male in NAD
Superior abrasion in left forehead
Pupils: 3mm-->2mm, EOMI
Trachea midline
Chest stable, CTA anterior
RRR
Abdomen soft, NT, ND
Rectal: guaiac negative, normal rectal tone
Ext: no deformities
Spine nontender

Pertinent Results:
[**2121-3-18**] 05:11PM   PT-14.3* INR(PT)-1.3
[**2121-3-18**] 04:03PM   CK(CPK)-283*
[**2121-3-18**] 04:03PM   CK-MB-2 cTropnT-0.02*
[**2121-3-18**] 04:30AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2121-3-18**] 12:45AM   WBC-8.7 RBC-3.76* HGB-10.6* HCT-32.3* MCV-86
MCH-28.2 MCHC-32.8 RDW-16.1*
[**2121-3-18**] 12:45AM   NEUTS-74.9* LYMPHS-18.1 MONOS-5.6 EOS-0.9
BASOS-0.5
[**2121-3-17**] 11:30PM   GLUCOSE-108* UREA N-39* CREAT-1.4* SODIUM-138
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15

CT head: small right SDH, no shift
CT Cspine: C4 fracture transverse foramen
CXR:neg

Brief Hospital Course:
Patient initally brought to trauma SICU. INR was elevated upon
admission at 1.7, for which patient was given 2 U FFP. No
complications due to elevated INR throughout course.
Neurosurgery called to evaluate patient. MRA/MRI ordered to
further evaluate C4 fracture, which showed soft tissue swelling
in prevertebral area and edema posterior to mid Cspine, with
high grade stenosis likely secondary to prostatic metastasis to
vertebrae, but patent Carotids bilaterally. Pt placed on hourly
neuro checks and dilantin started. Neurology called to evaluate
patient and noted new left upper extremity weakness, with
unclear etiology, perhaps due shoulder injury incurred during
fall. Etiology of falls remains unclear, though multifactorial
gait disturbance in conjunction with possible orthostatic
hypotension was considered. Pt encouraged to use cane/walker
with continued care by the neurology service once at rehab.

Pt discharged with 1 week of dilantin and follow up with
neurology for further evaluation of falls.

Medications on Admission:
Pravachol
Trazodone
Lasix
Naprosyn
ASA
Metoprolol
Restoril
Mysoline
Norvasc
Hydralazine
Lupron
Primidone
Zometa
Procrit

Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO TID (3 times a day) for 1 weeks.
Disp:*42 Capsule(s)* Refills:*0*
6. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Sertraline HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Temazepam 15 mg Capsule Sig: [**12-8**] Capsules PO HS (at bedtime)
as needed.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
status post fall
C4 transverse foraminal fracture
Right frontoparietal subdural hematoma


Discharge Condition:
Stable

Discharge Instructions:
Please make and keep all follow up appointments.
Take all medication as directed.
Wear C Collar at all times.
Use a cane or walker to ambulate.

Followup Instructions:
Call [**Telephone/Fax (1) 3231**] to make an appointment within 4 weeks of
discharge from the hospital for neurosurgery, Dr. [**Last Name (STitle) 1327**].

Autonomic testing as an outpatient with neurology, call
[**Telephone/Fax (1) 109977**] to make an appointment.

Provider [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2121-4-1**] 2:00

Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2121-4-1**] 2:30



Completed by:[**2121-3-20**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of fourth cervical vertebra,Secondary malignant neoplasm of bone and bone marrow,Heart valve replaced by transplant,Fall from other slipping, tripping, or stumbling,Abnormality of gait,Personal history of malignant neoplasm of prostate,Essential and other specified forms of tremor'}


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: fall

PRESENT ILLNESS: Pt is a [**Age over 90 **] yo male who presents after falling, striking his
head. Pt has a history of multifactorial gait disorder at
baseline. Pt was at home and attempted to stand. Denies LOC, and
can fully recall events. Denies dizzinesss, shortness of breath,
chest pain, and palpitations. Currently without complaints.

MEDICAL HISTORY: HTN
Prostate CA with bony mets
Spondylosis
Essential trauma and gait disorder
Anal Fissure
+gallstones
Depression
Insomnia

MEDICATION ON ADMISSION: Pravachol
Trazodone
Lasix
Naprosyn
ASA
Metoprolol
Restoril
Mysoline
Norvasc
Hydralazine
Lupron
Primidone
Zometa
Procrit

ALLERGIES: Oxycodone

PHYSICAL EXAM: 99.3    72   178/60   16  98%RA
Alert, elderly male in NAD
Superior abrasion in left forehead
Pupils: 3mm-->2mm, EOMI
Trachea midline
Chest stable, CTA anterior
RRR
Abdomen soft, NT, ND
Rectal: guaiac negative, normal rectal tone
Ext: no deformities
Spine nontender

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone
Daughter very involved with care, lives close by 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of fourth cervical vertebra,Secondary malignant neoplasm of bone and bone marrow,Heart valve replaced by transplant,Fall from other slipping, tripping, or stumbling,Abnormality of gait,Personal history of malignant neoplasm of prostate,Essential and other specified forms of tremor'}
