CHIEF COMPLAINT: Back pain, Headache

PRESENT ILLNESS: HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is an 82 yo Right
handed woman with a PMH significant for HTN, COPD and
hyperlipidemia. At baseline she lives alone and is seemingly
independent of all ADLs (per her daughters).

MEDICAL HISTORY: 1. COPD (currently smokes 1 PPD)
2. HTN
3. HLD

MEDICATION ON ADMISSION: 1. KCl
2. HCTZ
3. Paxil 20mg daily
4. Diovan 80mg qd
5. Lipitor 20mg qd
6. Metoprolol 50mg daily
7. Spiriva
8. ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAMINATION (4:30 pm)
T 97.6 HR 62 BP 129/95 R 17 sat 98%

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives at home alone
Unspecified intracranial hemorrhage,Closed fracture of four ribs,Closed fracture of distal phalanx or phalanges of hand,Closed fracture of acromial end of clavicle,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Unspecified fall,Chronic airway obstruction, not elsewhere classified,Nausea with vomiting,Unspecified essential hypertension,Old myocardial infarction,Other and unspecified hyperlipidemia,Cyst of kidney, acquired,Tobacco use disorder
Intracranial hemorr NOS,Fracture four ribs-close,Fx dist phalanx, hand-cl,Fx clavicl, acrom end-cl,Abrasion head,Fall NOS,Chr airway obstruct NEC,Nausea with vomiting,Hypertension NOS,Old myocardial infarct,Hyperlipidemia NEC/NOS,Cyst of kidney, acquired,Tobacco use disorder
Admission Date:  [**2159-5-12**]              Discharge Date:   [**2159-5-17**]

Date of Birth:  [**2076-8-30**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Back pain, Headache

Major Surgical or Invasive Procedure:
None


History of Present Illness:
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is an 82 yo Right
handed woman with a PMH significant for HTN, COPD and
hyperlipidemia. At baseline she lives alone and is seemingly
independent of all ADLs (per her daughters).

Patient was last noted to be well (in phone conversation with
her
daughter) at 7:30pm yesterday, [**5-11**]. This am she was to meet
friends at 10 am and did not show. Her daughters were called and
they found her at 10:30 am. At that time she was noted to be
lying on her living room couch, smelling of urine and
complaining
of nausea and back pain. When questioned, she believes that she
slept upstairs in her bed and came downstairs that morning. She
is unaware of ever hitting her head.

She was taken to the [**Hospital3 4107**] ER where she was noted to
have a left scalp and left shoulder abrasion. She had a C-spine
CT which was negative. However, a head CT showed a Right
temporal
ICH so transferred to [**Hospital1 18**].

Past Medical History:
1. COPD (currently smokes 1 PPD)
2. HTN
3. HLD


Social History:
Lives at home alone

Family History:
N/C

Physical Exam:
EXAMINATION (4:30 pm)
T 97.6 HR 62 BP 129/95 R 17 sat 98%

No racoon eyes. No Battle's sign, no CSF rhinorrhea.

CTAB
RRR
soft, NT, ND
well healed midline incision
rectal good tone guiac neg
2+ DP and PT pulses with 2+ radial pulses

Neurological:
MS-Alert and visually attentive to me. Oriented to "[**2158**]," [**Month (only) **]
and hospital (not which one). Fluent speech. Names pen, earlobe,
keys, watch. Repeats simple and phonetically complex phrases.
Follows three step commands. Registers 3 objects but recalls 0/3
at 5 minutes. Cannot name president. Does 20 to 1 rapidly.

CN-Perrl 3 to 2mm bilaterally. VFF. EOM full. Smile symmetric.
Tongue midline. No dysarthria or dysphonia.

Motor-Normal tone, no drift.

    Delt  Bic [**Last Name (un) 1035**] WF WE IP Ant Tib [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] DF
R    5     5    5   5  5  5   5   5   5       5  5
L    5     5    5   5  5  5   5   5   5       5  5

Coord-No dysmetria to FNF.

DTRs-2+ and symmetric. Toes are DOWN bilaterally

Exam on Discharge:
Awake and oriented x3, full strenth on motor exam. Essentially
non focal.

Pertinent Results:
ADMISSION LABS:

[**2159-5-12**] 03:45PM   GLUCOSE-129* UREA N-29* CREAT-0.9 SODIUM-139
POTASSIUM-3.0* CHLORIDE-103 TOTAL CO2-26 ANION GAP-13
[**2159-5-12**] 03:45PM   WBC-14.0* RBC-4.22 HGB-13.1 HCT-38.9 MCV-92
MCH-31.0 MCHC-33.6 RDW-14.0
[**2159-5-12**] 03:45PM   PT-11.9 PTT-21.1* INR(PT)-1.0

IMAGING:
NC Head CT [**5-12**]:
There is a 3cm Right temporal ICH with surrounding edema. There
is also a very small focus of extraxial(subarrachnoid) blood
over the high right parietal convexity.

CTA HEad [**5-12**]:
IMPRESSION: Dense atherosclerotic calcifications with a
combination of soft plaques are demonstrated on the left carotid
bifurcation with no significant stenosis. A partially calcified
thyroid nodule is noted on the right, correlation with thyroid
ultrasound is recommended in a non-emergent basis, bilateral
pleural scarring and bilateral emphysematous changes

CT Head [**5-13**]:
1. Stable appearance to right temporal hemorrhage and edema.
2. Increased right frontal and parietal extra-axial blood may
represent
redistribution.
3. Apparently new isodense crescentic density overlying the left
convexity
likely represents subdural blood products.

CT Head [**5-14**]:
Right temporal intracranial hemorrhage redemonstrated and
unchanged. Trace
subarachnoid blood within the left parietal lobe and the
occipital [**Doctor Last Name 534**] of
the left lateral ventricle is also unchanged. No new hemorrhage
or mass
effect


Brief Hospital Course:
The patient was admitted to the NSurg service for close
observation. A CTA was performed to evaluate for an underlying
AVM, which was negative.  Her repeat Head CT upon admission was
stable from the previous image.  She received 6u platelets, and
her ASA was held.  She was started on keppra for seizure
prophylaxis, and her SBP was kept under 160. Her neurological
exam remained stable throughout the evening.

On [**5-13**], her repeat Head CT showed no evidence of interval
change.  She was seen by the pain consult service for her
chronic back pain, who recommended Tylenol and a muscle relaxer
PRN.  She was quite nauseated and dizzy with standing; zofran
was given, which gave her good relief, and a fluid bolus helped
with the orthostasis.

Because she had an obviously bruised R thumb, an xray was
ordered.  This revealed a trasnverse fracture of the distal
bone.  She was seen by plastics, who recommended conservative
management with a Spica Splint, and outpatient follow up.

She was seen by physical therapy who determined she met criteria
for an acute rehab center.

Her neurologic examination remained non-focal and unchanged
throughout the hospitalization.

Medications on Admission:
1. KCl
2. HCTZ
3. Paxil 20mg daily
4. Diovan 80mg qd
5. Lipitor 20mg qd
6. Metoprolol 50mg daily
7. Spiriva
8. ASA 81mg daily


Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze/sob.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheeze/dyspnea.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO TID, PRN
() as needed for back pain/spasm.
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
16. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Intracranial Hemorrhage
Right Thumb fracture
Rib fractures


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	You should stay off your baby ASA until [**2159-6-11**].
- You need to take your Keppra as ordered until follow-up

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.

Also, please follow up with the Hand Clinic for your Thumb
fracture on Tuesday, [**5-22**]. Please call ([**Telephone/Fax (1) 32269**] or
[**Telephone/Fax (1) 1228**] to make an appointment



Completed by:[**2159-5-17**]

Name:  [**Known lastname 3567**],[**Known firstname 13572**]                     Unit No:   [**Numeric Identifier 13573**]

Admission Date:  [**2159-5-12**]              Discharge Date:   [**2159-5-17**]

Date of Birth:  [**2076-8-30**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2112**]
Addendum:
Added to injiuries: Left clavicular fracture

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2115**] MD [**MD Number(2) 2116**]

Completed by:[**2159-5-17**]
{'Unspecified intracranial hemorrhage,Closed fracture of four ribs,Closed fracture of distal phalanx or phalanges of hand,Closed fracture of acromial end of clavicle,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Unspecified fall,Chronic airway obstruction, not elsewhere classified,Nausea with vomiting,Unspecified essential hypertension,Old myocardial infarction,Other and unspecified hyperlipidemia,Cyst of kidney, acquired,Tobacco use disorder'}


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: Back pain, Headache

PRESENT ILLNESS: HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname **] is an 82 yo Right
handed woman with a PMH significant for HTN, COPD and
hyperlipidemia. At baseline she lives alone and is seemingly
independent of all ADLs (per her daughters).

MEDICAL HISTORY: 1. COPD (currently smokes 1 PPD)
2. HTN
3. HLD

MEDICATION ON ADMISSION: 1. KCl
2. HCTZ
3. Paxil 20mg daily
4. Diovan 80mg qd
5. Lipitor 20mg qd
6. Metoprolol 50mg daily
7. Spiriva
8. ASA 81mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAMINATION (4:30 pm)
T 97.6 HR 62 BP 129/95 R 17 sat 98%

FAMILY HISTORY: N/C

SOCIAL HISTORY: Lives at home alone 

### Response:
{'Unspecified intracranial hemorrhage,Closed fracture of four ribs,Closed fracture of distal phalanx or phalanges of hand,Closed fracture of acromial end of clavicle,Abrasion or friction burn of face, neck, and scalp except eye, without mention of infection,Unspecified fall,Chronic airway obstruction, not elsewhere classified,Nausea with vomiting,Unspecified essential hypertension,Old myocardial infarction,Other and unspecified hyperlipidemia,Cyst of kidney, acquired,Tobacco use disorder'}
