CHIEF COMPLAINT: 62F presented as a trauma patient s/p fall

PRESENT ILLNESS: 62F s/p mechanical fall, no LOC

MEDICAL HISTORY: GERD
Rheumatoid arthritis

MEDICATION ON ADMISSION: Prednisone 4', Indocin, Prilosec 20'

ALLERGIES: Vicodin / Percocet

PHYSICAL EXAM: On day of discharge:
T 98.0 HR 62 BP 123/62  RR 16 99%RA
Gen: alert and oriented
Pulm: clear to auscultation bilaterally
CVS: RRR
Abd: soft/nontender/nondistended
Ext: no edema

FAMILY HISTORY: non contributory

SOCIAL HISTORY: non contributory
Closed fracture of seventh cervical vertebra,Traumatic pneumothorax without mention of open wound into thorax,Unspecified fall,Closed fracture of sternal end of clavicle,Rheumatoid arthritis,Esophageal reflux
Fx c7 vertebra-closed,Traum pneumothorax-close,Fall NOS,Fx clavicl, stern end-cl,Rheumatoid arthritis,Esophageal reflux
Admission Date:  [**2129-11-24**]              Discharge Date:   [**2129-11-28**]

Date of Birth:  [**2067-8-31**]             Sex:   F

Service: SURGERY

Allergies:
Vicodin / Percocet

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
62F presented as a trauma patient s/p fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
62F s/p mechanical fall, no LOC

Past Medical History:
GERD
Rheumatoid arthritis

Social History:
non contributory

Family History:
non contributory

Physical Exam:
On day of discharge:
T 98.0 HR 62 BP 123/62  RR 16 99%RA
Gen: alert and oriented
Pulm: clear to auscultation bilaterally
CVS: RRR
Abd: soft/nontender/nondistended
Ext: no edema

Pertinent Results:
[**11-24**] C spine
IMPRESSION:
1. The cervical spine is aligned normally.
2. Non-displaced fracture of the right C7 transverse process.
3. Bilateral 1st rib fractures.

[**11-24**] CT head
IMPRESSION: No hemorrhage.

[**11-24**] Chest/Abd/Pelvis
IMPRESSION:
1. Small right anterior pneumothorax.
2. Comminuted fracture of the right distal clavicle.
3. Multiple right-sided rib fractures and a fracture of the left
first rib.
4. Subcutaneous emphysema along the right chest wall and
inferior neck.
5. No evidence of intra-abdominal parenchymal organ injury.


Brief Hospital Course:
The patient was admitted to the ICU for continued monitoring
following her multiple rib fractures.  She was originally NPO
with IVF for hydration with a fentanyl PCA for pain control.
Her diet was advanced as tolerated.  She was transferred to the
floor on [**11-25**].

[**11-26**] d/c fentanyl PCA, started on gabapentin, PO dilaudid,
tylenol, fentanyl patch.

Her pain was well controlled, she was tolerating a regular diet
and ambulating without difficulty.

Medications on Admission:
Prednisone 4', Indocin, Prilosec 20'


Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).

2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation for 10 days.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) for 10 days.
Disp:*5 Patch 72 hr(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
s/p fall - C7 non-displaced transverse process fx, Right [**3-6**] rib
fractures, Right distal [**12-30**] clavicle fracture

Secondary:
GERD
Rheumatoid arthritis


Discharge Condition:
Good


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.


Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up
appointment in 1 week at [**Telephone/Fax (1) 600**]
{'Closed fracture of seventh cervical vertebra,Traumatic pneumothorax without mention of open wound into thorax,Unspecified fall,Closed fracture of sternal end of clavicle,Rheumatoid arthritis,Esophageal reflux'}


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: 62F presented as a trauma patient s/p fall

PRESENT ILLNESS: 62F s/p mechanical fall, no LOC

MEDICAL HISTORY: GERD
Rheumatoid arthritis

MEDICATION ON ADMISSION: Prednisone 4', Indocin, Prilosec 20'

ALLERGIES: Vicodin / Percocet

PHYSICAL EXAM: On day of discharge:
T 98.0 HR 62 BP 123/62  RR 16 99%RA
Gen: alert and oriented
Pulm: clear to auscultation bilaterally
CVS: RRR
Abd: soft/nontender/nondistended
Ext: no edema

FAMILY HISTORY: non contributory

SOCIAL HISTORY: non contributory 

### Response:
{'Closed fracture of seventh cervical vertebra,Traumatic pneumothorax without mention of open wound into thorax,Unspecified fall,Closed fracture of sternal end of clavicle,Rheumatoid arthritis,Esophageal reflux'}
