CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: PER ADMITTING RESIDENT:
76 year-old female with unknown past medical history found
down at the bottom of approximately 10 steps.

MEDICAL HISTORY: Per h/o from outside hospital, HTN, GERD, EndoCA-TAH-BSO

MEDICATION ON ADMISSION: unknown

ALLERGIES: Robaxin

PHYSICAL EXAM: ON ADMISSION:
O: T:  BP: 155/85  HR: 87  RR: 26  O2Sats: 95% room air
Gen: NAD, lethargic
HEENT: EOMs unable to be assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
intermittently, non-verbal.
Orientation: Unable to be assessed.

FAMILY HISTORY: Unknown at this time

SOCIAL HISTORY: Unknown at this time
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Cervical spondylosis with myelopathy,Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Open wound of scalp, without mention of complication,Other convulsions,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Other diseases of lung, not elsewhere classified,Tachypnea,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of other parts of uterus,Other postprocedural status
Cl skul base fx-coma NOS,Encephalopathy NOS,Int inf clstrdium dfcile,Urin tract infection NOS,Cerv spondyl w myelopath,Cl skull vlt fx-coma NOS,Open wound of scalp,Convulsions NEC,Fall on stair/step NEC,Hypertension NOS,Esophageal reflux,Diaphragmatic hernia,Other lung disease NEC,Tachypnea,Adv eff medicinal NEC,Elev transaminase/ldh,Hx-uterus malignancy NEC,Post-proc states NEC
Admission Date:  [**2161-9-30**]              Discharge Date:   [**2161-10-14**]

Date of Birth:  [**2085-9-8**]             Sex:   F

Service: NEUROLOGY

Allergies:
Robaxin

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
None

History of Present Illness:
PER ADMITTING RESIDENT:
76 year-old female with unknown past medical history found
down at the bottom of approximately 10 steps.

In the [**Last Name (LF) **], [**First Name3 (LF) **] report has been non-verbal and intermittently
following commands with upper extremities only.  She has moved
all extremities spontaneously and per nursing report did say a
few words.  After her CT scan in the emergency room, she had a
witnessed seizure, which stopped before Ativan was given.

Per social work via witnesses, she was walking up stairs in a
church, gazed-up and fell posteriorly.  She has a husband, who
social work has called without success to contact, however, has
left a message.


Past Medical History:
Per h/o from outside hospital, HTN, GERD, EndoCA-TAH-BSO


Social History:
Unknown at this time


Family History:
Unknown at this time


Physical Exam:
ON ADMISSION:
O: T:  BP: 155/85  HR: 87  RR: 26  O2Sats: 95% room air
Gen: NAD, lethargic
HEENT: EOMs unable to be assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
intermittently, non-verbal.
Orientation: Unable to be assessed.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2-3mm bilaterally.
III, IV, VI: Not able to assess, right lateral gaze.
V, VII: Not able to assess.
VIII: Hearing intact to voice.
IX, X: Not able to assess.
[**Doctor First Name 81**]: Not able to assess..
XII: Not able to assess..

Motor: Not able to assess

Sensation: Not able to assess.

Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+

Exam at time of discharge:

ON ADMISSION:
O: T:  BP: 155/85  HR: 87  RR: 26  O2Sats: 95% room air
Gen: NAD, lethargic
HEENT: EOMs unable to be assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
intermittently, non-verbal.
Orientation: Unable to be assessed.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2-3mm bilaterally.
III, IV, VI: Not able to assess, right lateral gaze.
V, VII: Not able to assess.
VIII: Hearing intact to voice.
IX, X: Not able to assess.
[**Doctor First Name 81**]: Not able to assess..
XII: Not able to assess..

Motor: Not able to assess

Sensation: Not able to assess.

Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+

Exam at time of discharge:

O: T:  BP: 155/85  HR: 87  RR: 26  O2Sats: 95% room air
Gen: NAD, lethargic
HEENT: EOMs unable to be assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
intermittently, non-verbal.
Orientation: Unable to be assessed.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2-3mm bilaterally.
III, IV, VI: Not able to assess, right lateral gaze.
V, VII: Not able to assess.
VIII: Hearing intact to voice.
IX, X: Not able to assess.
[**Doctor First Name 81**]: Not able to assess..
XII: Not able to assess..

Motor: Not able to assess

Sensation: Not able to assess.

Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 2+ 2+
Left 2+ 2+ 2+ 2+ 2+

Exam at time of discharge:

T:98.9 tmax  BP: 133-159/80s  HR: 70s-90  RR: 18-22  O2Sats: 98%
room air
Gen: NAD, in bed, unsettled, moving around in bed.
HEENT: supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT/ND, PEG in place, mild tenderness peri-PEG, no
erythema
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, oriented to place, self and
[**2161-3-11**].  Inattentive, incooperative with exam.  Intact
repetition, naming.

Cranial Nerves:
VFF intact to threat.  Pupils equally round and reactive to
light, to 4-2mm bilaterally. EOMi, no nystagmus, face symmetric.
 shoulder shrug intact, tongue midline.

Motor: Moves all extremities antigravity, does not follow
commands reproducibly, at least 4+ at triceps and bicepts.  [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] antigravity for > 5 seconds.

Sensation: Not able to assess.

Reflexes: Brisk in patella b/l, otherwise 2+ in UEs.
Gait: not assessed.

Pertinent Results:
Admission Labs:
.
WBC-7.8 RBC-4.39 HGB-13.6 HCT-39.8 MCV-91 MCH-31.0 MCHC-34.2
RDW-14.3
GLUCOSE-165* UREA N-18 CREAT-0.9 SODIUM-139 POTASSIUM-3.1*
CHLORIDE-99 TOTAL CO2-29 ANION GAP-14
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-0.2 PH-7.5 LEUK-NEG
URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
IMAGING
.
CT Head without Contrast ([**2161-9-29**]):
IMPRESSION:
Right frontotemporal subdural and subarachnoid hemorrhage with 5
mm of right to left midline shift. Subarachnoid hemorrhage
extends into the basilar cisterns and fourth ventricle. 3-mm
focus of probable extraaxial hemorrhage in the left occipital
region adjacent to skull base fracture.
.
Large left parietooccipital skull fracture extending anteriorly
to the left aspect of the clivus.
.
Air-fluid level in the sphenoid sinus with air noted in the
bilateral
cavernous sinus and right middle temporal fossa. These findings
are very
suspicious for a nondisplaced fracture of the sphenoid sinus
although no
discrete fracture is visualized.
.
Fluid in the left middle ear cavity and mastoid air cells with
possible
longitudinal fracture through the left temporal bone. A
dedicated CT temporal bone is recommended for further
characterization.
.
Large left parietooccipital subgaleal hematoma.
.
Marked rotation of C1 on C2, which may be positional in nature.
However,
rotary subluxation cannot be excluded.
.
MR C/T/L spine:

IMPRESSION:
1. No acute fracture, cord compression, or cord signal
abnormality is
identified. Findings of a chronic wedge deformity of L1.
2. Fluid-fluid layer within the inferior thecal sac likely due
to
subarachnoid hemorrhage from the brain..

.
CXR [**10-1**]
FINDINGS: The lung volumes are low. In the retrocardiac lung
areas and at
the right lung bases, minimal interstitial thickening suggesting
potential
chronic airways disease is seen. Moderate scoliosis leads to
asymmetry of the
rib cage. Borderline size of the cardiac silhouette, no evidence
of
overhydration. Minimal left-sided pleural effusion. No focal
parenchymal
opacity suggesting pneumonia, normal appearance of the
mediastinum.

MR head [**10-2**]
IMPRESSION:
1. Acute left cerebellar infarct with small amount of blood
products.
2. Extensive parenchymal contusions and subarachnoid hemorrhage
as seen on
the previous CT examinations.
3. Small vessel disease.
4. Mild enhancement surrounding the right temporal contusion
appears
secondary to loss of blood brain barrier from trauma. However,
follow up
should be obtained.

CTA head and neck:

IMPRESSION:
1. Multiple areas of intraparenchymal, subarachnoid, subdural,
intraventricular hemorrhage, unchanged in appearance from prior
CT
examination.
2. No evidence of new hemorrhage or mass effect.
3. The carotid and vertebral arteries and their major branches
are patent
with no evidence of stenoses or dissection. There is no evidence
of aneurysm formation.

KUB [**10-13**]

IMPRESSION: No evidence of free air. Mild-to-moderate dilatation
of large
and small bowel without evidence of bowel obstruction

CTA of chest [**10-5**]

IMPRESSION:
1. No pulmonary embolus. No aortic dissection.
2. Moderate hiatal hernia.
3. Mild hyperplasia of the left adrenal gland.
4. Pulmonary nodules up to 5mm in size. Per the [**Last Name (un) 8773**]
Society
Guidelines, recommend followup chest CT at six months if high
risk (for
example smoking history or history of malignancy) or 12 months
if low risk.

ECHO [**10-5**]

The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No definite structural cardiac source of
embolism identified.

Labs at time of discharge:

139  105  16  82
-------------[
4.5  24  0.7

Ca: 8.9 Mg: 2.2 P: 3.5


CBC 9.5/11.7/36/441

ENZYMES & BILIRUBIN
                    ALT AST  LDH  AlkPhos  TotBili
[**2161-10-8**] 06:30AM 64* 37   280*   51     0.2
[**2161-10-6**] 10:30AM 80* 72*  474*   61     0.5

Microbiology:

[**2161-10-9**]  BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2161-10-9**]  BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
.
[**2161-10-8**]  BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Aerobic Bottle Gram
Stain-FINAL INPATIENT
[**2161-10-7**]  BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT

[**2161-10-7**]  URINE URINE CULTURE-FINAL INPATIENT
[**2161-10-6**]  STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B - Positive
[**2161-10-6**]  BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT

[**2161-10-5**]  BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT

[**2161-10-5**]  URINE URINE CULTURE-FINAL INPATIENT
[**2161-10-2**]  URINE URINE CULTURE-FINAL INPATIENT
[**2161-9-30**]  MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2161-9-29**]  URINE URINE CULTURE-FINAL INPATIENT


Brief Hospital Course:
This is a 76 y/o woman who was initially admitted to the
neurosurgery service from the [**Hospital1 18**] ED. She reported looked up
while climbing upstairs at her
church, lost her balance and retropulsed landing on her back and
hitting the posterior aspect of her head. It was reported that
she was initally awake and alert at presentation but became more
lethargic en route to  [**Hospital1 18**].

She was found to have a GCS of 6 in ED. CT imaging revealed a
right frontotemporal subdural and subarachnoid hemorrhage with 5
mm of right to left midline shift. Subarachnoid hemorrhage
extends into the basilar cisterns and fourth ventricle. 3-mm
focus of probable extraaxial hemorrhage in the left occipital
region adjacent to skull base fracture. There was a large left
parietooccipital skull fracture extending anteriorly to the left
aspect of the clivus.

There was the concern of increased ICP and the possibility of
placing a bolt was entertained. Once imaging was obtained, Dr.
[**First Name (STitle) **] (neurosurgery attending) reassessed the patient and felt
this measure was not required.

She suffered a generalized tonic clonic seizure at 18:40 on
[**9-30**] for approximately 90 seconds. She then received lorazepam
2 mg twice. Eventually, she seized again at 19:30 for less than
one minute. This seizure activity was characterized by b/l
forehead and left hand twitching. She received ativan 1 mg iv
was loaded with Dilantin.

She was admitted to the SICU. She was on spine precautions.
Serial CT scans showed no increase in ventricular size or
hemorrhage. CT imaging from [**9-30**] pm was reported with left
cerebellar hypodensity. An MRI was ordered on [**2161-10-1**]. Spine
MRi imaging was reviewed with Dr. [**Last Name (STitle) **]. She has some old
compression deeformities but no sign of acute fracture. Her TLS
spine was cleared on [**2161-10-1**]. She was chnaged to a soft collar.
This will be maintained until she can reliably report on
potential neck pain.

She was transfered to the neurology service on [**2161-10-1**].

While on neurology service:

- Intracranial Hemorrhage.  Patient was noted to have areas of
hemorrhage within the right anterior and inferior temporal lobes
with surrounding edema, narrowing of
the right perimesencephalic cistern as well as subdural
hemorrhage adjacent to the right occipital lobe extending to the
midline. In addition, there were: subdural hemorrhage tracking
along the posterior falx, scattered hyperdense subarachnoid
hemorrhages within the bilateral frontal and parietal lobes and
collections of blood within the dependent portions of the
lateral ventricles as well as the fourth ventricle.  These
collections remained stable through imaging with mild increase
in edema around the temporal bleed during the [**10-2**] and [**10-5**] CT
head images.  These were deemed to be traumatic.  No evidence of
aneurysm was seen on CTA head.

Patient was maintained on hydralazine prn and captorpil standing
for SBP control of 140-160 (due to cocurrent stroke, see below
(It was later discovered that patient had bronchospasm due to
AcEI, she was switched to norvasc).  Due to altered mental
status, she received two days of mannitol on [**10-4**] and [**10-5**].
She was treated with Keppra 750mg [**Hospital1 **] for Sz prophylaxis, given
seizure in the ED.  AMS was felt to be due ICH, C.Diff coilitis
and UTI.  Upon treatment of the above, her mental status
improved significantly, she became alert, oriented to self and
place and responding appropriately.

Due to oropharyngeal dysfunction/incoordination, patient was
unable to swallow safely, and thus underwent PEG placement on
[**2161-10-9**].  TF were restarted on [**10-10**].  Follow up imaging and
HCT showed normal placement and stable HCT of 36 at time of
discharge.

She will require follow up with neurology clinic and head CT to
be completed on an as needed basis.

- L cerebellar stroke. Noted on evaluation with CT head.  MRI
confirmed an acute L cerebellar infarct with small amount of
blood products per-infarct.  This may have been the cause of her
fall.  She was started on ASA 81mg. SBP control was maintained
as above to balance with goals of ICH.  CTA neck was unrevealing
for a source of embolism, as was the echocardiogram.  A1C was
5.7.  Fasting Lipids were not peformed and should be obtained in
a less acute setting.  Statin therapy should be started as
guided by lipid status.

- Altered mental status.  Patient was encephalopathic,
somnlolent w/ waxing and [**Doctor Last Name 688**] alertness, at times requiring a
sternal rub to awaken, other times with eyes open and following
one step commands.  She underwen a routing EEG showing no sz
activity, but encephalopathy. She underwent an infectious work
up revealing a negative UA, CXR, and BCx.  There were no
electrolyte abnormalities that could account for her altered
mental status.  She finally developed C.Diff coilitis and was
started on Flagyl on [**10-6**] for total of 14 days.  In addition,
she was noted to have a UTI and started on Bactrim DS on [**10-7**]
for a total of a 10 day course. Finally, she was noted to have
one of eight blood cultures positive for coag. neg. staph, which
was felt to be a contaminant and was not treated.  Patient
remained afebrile and HD stable.

Although patient became more alert, awake and interactive, she
remained disoriented to time and at times agitated, requiring an
abodminal binder for protection of her PEG.  She was not treated
with antipsychotics, as it was imperative to monitor her mental
state.

- Tachypnea.  On [**2161-10-5**] patient developed tachypnea,
tachycardia to 30s and 110s respectively.  There was no evidence
of CHF or PNA clinically or on imaging.  ABG showed acute
respiratory alkalosis.  CTA of chest showed no PE, a moderate
hiatal hernia, mild hyperplasia of the left adrenal gland and
pumonary nodules up to 5mm in size, per the [**Last Name (un) 8773**] Society
Guidelines, recommended followup chest CT at six months.
Tachypnea resolved within 2 days and was felt to be due to
bronchoconstriction due to ACE-I use, which was changed to
norvasc.

- Lower and upper extremity spasticity.  This was initially felt
to be due to cervical spine disease and possible myelopathy.
Her C/T/L spine MRI revealed mild spondyloarthropathy, no
fracture, cord compression, or cord signal abnormality or
ligamentous injury.  There was a chronic wedge deformity of L1.
Her B12, A1C and Folate were wnl.

- Mild transaminitis.  Noted during encephalopathy evaluation.
These were elevated to < 100 each and trended down.  She will
require further trending and outpatient evaluation if these
persist.

Medications on Admission:
unknown

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary: Basilar skull fracture; intraparenchymal, subdural,
subarachnoid hemorrhages; Left cerebellar stroke; C.Difficile
coilitis; urinary tract infection; Encephalopathy
Secondary: Hypertension


Discharge Condition:
Stable.

T:98.9 tmax  BP: 133-159/80s  HR: 70s-90  RR: 18-22  O2Sats: 98%
room air
Gen: NAD, in bed, unsettled, moving around in bed.
HEENT: supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT/ND, PEG in place, mild tenderness peri-PEG, no
erythema
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, oriented to place, self and
[**2161-3-11**].  Inattentive, incooperative with exam.  Intact
repetition, naming.

Cranial Nerves:
VFF intact to threat.  Pupils equally round and reactive to
light, to 4-2mm bilaterally. EOMi, no nystagmus, face symmetric.
 shoulder shrug intact, tongue midline.

Motor: Moves all extremities antigravity, does not follow
commands reproducibly, at least 4+ at triceps and bicepts.  [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] antigravity for > 5 seconds.

Sensation: Not able to assess.

Reflexes: Brisk in patella b/l, otherwise 2+ in UEs.
Gait: not assessed.


Discharge Instructions:
You were admitted to [**Hospital1 18**] after a fall which had caused you to
have multiple fractures in your skull (non displaced, not
requiring neurosurgery) as well as multiple bleed in your head.
Your course was complicated by coilitis (colon infection) and
urinary tract infection, for which you were treated with
antibiotics.

Because of your head trauma and bleeds, you will may have
neurological deficits, including left arm and leg weakness,
difficulty with maintaining concentration and others.  You
required rehabiliation and thus were discharged from the
hospital to the rehabilitation center.

There were multiple medication changes made to your regimen,
please continue to take the prescribed medications, as this may
be altered while you are at rehabilitation.

You were discharged in stable condition, yet with impaired
attention, confusion and motor deficits.  See below.

Should you develop any further weakness, changes in vision,
difficulties with balance, fever, chills, shortness of breath,
chest pain or any other symptom concerning to you, please call
your doctor or go to the emergency room.

Followup Instructions:
Please follow up with the following appointments:

Please follow up with your primary care doctor, Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] C. please call [**Telephone/Fax (1) 8927**] to set up a follow up
appointment.

Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2161-11-17**] 3:30


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2161-10-14**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Cervical spondylosis with myelopathy,Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Open wound of scalp, without mention of complication,Other convulsions,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Other diseases of lung, not elsewhere classified,Tachypnea,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of other parts of uterus,Other postprocedural status'}


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: PER ADMITTING RESIDENT:
76 year-old female with unknown past medical history found
down at the bottom of approximately 10 steps.

MEDICAL HISTORY: Per h/o from outside hospital, HTN, GERD, EndoCA-TAH-BSO

MEDICATION ON ADMISSION: unknown

ALLERGIES: Robaxin

PHYSICAL EXAM: ON ADMISSION:
O: T:  BP: 155/85  HR: 87  RR: 26  O2Sats: 95% room air
Gen: NAD, lethargic
HEENT: EOMs unable to be assessed
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam
intermittently, non-verbal.
Orientation: Unable to be assessed.

FAMILY HISTORY: Unknown at this time

SOCIAL HISTORY: Unknown at this time 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Encephalopathy, unspecified,Intestinal infection due to Clostridium difficile,Urinary tract infection, site not specified,Cervical spondylosis with myelopathy,Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Open wound of scalp, without mention of complication,Other convulsions,Accidental fall on or from other stairs or steps,Unspecified essential hypertension,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Other diseases of lung, not elsewhere classified,Tachypnea,Other drugs and medicinal substances causing adverse effects in therapeutic use,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of other parts of uterus,Other postprocedural status'}
