CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: Pt is an 83 year old female transferred from [**Hospital **] hospital as
a trauma basic after she fell down a flight of [**3-29**] stairs
earlier in the day. Per report from OSH, the fall was witnessed
and patient sustained a loss of consciousnes. She was found
confused and aggitated at the scene. A CT scan of the head at
the OSH showed a L frontal contusion, R occipital contusion, and
L subdural hematoma. She arrived to [**Hospital1 **] intubated.

MEDICAL HISTORY: unknown - lives alone, estranged from family, not reliable
historian

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
V/S 99.2,83, 140/80, 18, 100% 2L NC
Gen: Intubated elderly woman, sedated, responds to painful
stimulation, spontaneously moves all 4 extremities
Neuro: 2+ bilateral patellar reflexes, 1+ bilateral heel
reflexes, plantar responses extensor bilaterally
HEENT: L frontal hematoma, PEERLA, no hemotympanum
CHEST: mild rhonchi bilaterally, on ventilation, nl chest wall
expansion
CV: RRR, no murmurs/rubs/gallops
Abdomen: soft, nontender/nondistended, quiet
Extrem: superficial abrasion L shin, no edema
Rectal: normal tone, guaic negative

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,Accidental fall on or from other stairs or steps
Brain lacer NEC-coma NOS,Fall on stair/step NEC
Admission Date:  [**2106-9-15**]              Discharge Date:   [**2106-9-24**]


Service: [**Last Name (un) **]

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Pt is an 83 year old female transferred from [**Hospital **] hospital as
a trauma basic after she fell down a flight of [**3-29**] stairs
earlier in the day. Per report from OSH, the fall was witnessed
and patient sustained a loss of consciousnes. She was found
confused and aggitated at the scene. A CT scan of the head at
the OSH showed a L frontal contusion, R occipital contusion, and
L subdural hematoma. She arrived to [**Hospital1 **] intubated.

Past Medical History:
unknown - lives alone, estranged from family, not reliable
historian

Social History:
unknown

Family History:
unknown

Physical Exam:
On Admission:
V/S 99.2,83, 140/80, 18, 100% 2L NC
Gen: Intubated elderly woman, sedated, responds to painful
stimulation, spontaneously moves all 4 extremities
Neuro: 2+ bilateral patellar reflexes, 1+ bilateral heel
reflexes, plantar responses extensor bilaterally
HEENT: L frontal hematoma, PEERLA, no hemotympanum
CHEST: mild rhonchi bilaterally, on ventilation, nl chest wall
expansion
CV: RRR, no murmurs/rubs/gallops
Abdomen: soft, nontender/nondistended, quiet
Extrem: superficial abrasion L shin, no edema
Rectal: normal tone, guaic negative

Pertinent Results:
[**2106-9-15**] 11:40PM BLOOD WBC-17.2* RBC-3.74* Hgb-11.3* Hct-32.4*
MCV-87 MCH-30.1 MCHC-34.7 RDW-13.5 Plt Ct-284
[**2106-9-19**] 05:10AM BLOOD WBC-13.1* RBC-3.62* Hgb-10.9* Hct-30.9*
MCV-85 MCH-30.1 MCHC-35.2* RDW-13.4 Plt Ct-277

[**2106-9-15**] 08:05PM BLOOD PT-12.6 PTT-24.5 INR(PT)-1.0

[**2106-9-15**] 08:05PM BLOOD Glucose-168* UreaN-14 Creat-0.8 Na-138
K-3.7 Cl-102 HCO3-22 AnGap-18
[**2106-9-19**] 05:10AM BLOOD Glucose-130* UreaN-11 Creat-0.7 Na-138
K-3.7 Cl-100 HCO3-27 AnGap-15

[**2106-9-15**] 08:05PM BLOOD CK(CPK)-229*
[**2106-9-15**] 08:05PM BLOOD cTropnT-<0.01
[**2106-9-15**] 08:05PM BLOOD CK-MB-3

[**2106-9-15**] 11:40PM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
[**2106-9-19**] 05:10AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.0

[**2106-9-15**] 08:05PM BLOOD Phenyto-<0.6*
[**2106-9-16**] 02:50AM BLOOD Phenyto-5.7*
[**2106-9-17**] 03:46AM BLOOD Phenyto-7.1*
[**2106-9-18**] 03:11AM BLOOD Phenyto-10.6

[**2106-9-15**] 08:08PM BLOOD Type-ART pO2-148* pCO2-32* pH-7.49*
calHCO3-25 Base XS-2 Intubat-INTUBATED
[**2106-9-16**] 03:09AM BLOOD Type-ART pO2-155* pCO2-41 pH-7.40
calHCO3-26 Base XS-0

[**2106-9-15**] 11:56PM BLOOD Lactate-2.8*
[**2106-9-16**] 03:09AM BLOOD Lactate-4.3*

RADIOLOGY:
[**9-15**] Head CT: Contusions in the right occipital lobe, right
temporal  lobe and left cerebellum. Small hemorrhagic foci are
also noted in the left
frontal lobe superiorly along the convexity and along the left
anterior
temporal lobe, probably within the sulci (subaracnoid space). A
very small
amount of intraventricular blood is also identified. There are
two hemorragic
foci in the high left frontal lobe white matter, which may
represent shear
injury. There is subdural hemorrhage along the left tentorial
incisura. A tiny
subdural hematoma runs along the inner table of the left
parietal skull, but
the brain is not appreciably displaced. The ventricles,
cisterns, and sulci
are prominent consistent with involutional changes, but there is
no
hydrocephalus. Areas of low attenuation are seen in the
periventricular white
matter consistent with chronic ischemic changes. No skull
fractures. A left frontal subcutaneous hematoma is identified.

[**9-16**] Head CT: no interval change from [**9-15**]
[**9-17**] Head CT: no interval change from [**9-16**]

[**9-15**] CT C-spine: no fracture ; degenerative changes; grade-1
anterolisthesis of C3 over C4

[**9-17**] C-spine flex/ext films: no fracture or dislocation

[**9-15**] Thoracic and Lumbar spine plain films: no fractures or
dislocations

[**9-15**] CXR: no airway disease; no fractures
[**9-15**] Pelvic XR: no fracture or instability

[**9-17**] Left Tib/Fib: no fracture or dislocation

Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**9-15**], on arrival she was
intubated. She was admitted to the Trauma SICU. She was
evaluated by the neurosurgery service. She was started on
Dilantin for seizure prophylaxis given her traumatic SAH &
cerebral contusions.
On HD 2, she was extubated successfully. Serial Head CTs were as
above - no progression of her SAH, contusions.
Since she initally failed a swallow evaluation, a postpyloric
tube was placed and tube feeds were started. She was evaluated
by PT/OT and did well with some ambulation with assistance.
On HD 4, she was transferred out of the SICU to the floor.
On HD 5, she passed a swallow eval, and was started with
supervised feedings. She had occasional episodes of vomiting
after eating, with no evidence of aspiration. Her abdominal exam
remained benigh, and she was having bowel movements, with no
evidence of obstruction. Her liver functions showed slightly
elevated transaminases, but were otherwise normal. She had a
repeat CT scan Head on HD8 taht showed a slight increase in the
size of the frontal subdural and a slight increase in the size
of the ventricles. She was re-evaluated by neurosurgery who
noted no new deficits, an repeat CT scan on the day of discharge
showed a stable appearance of her subdurals. She was cleared by
neurosurgery to go to rehab with a followup CT in [**2-25**] weeks.
She was evaluated by behavioral neurology who noted poor
attention and some cognitive deficits (note in process of being
dictated).
Her Dilantin was D/C'd on HD7.
On HD9, she was discharged to rehab at [**Hospital3 7**]/Rehab.

Medications on Admission:
unknown

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
2. Heparin Sodium 5,000 unit/0.5 mL Syringe Sig: 5000 (5000)
units Injection TID (3 times a day): subcutaneously.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
traumatic cerebral contusions
subdural hematoma
s/p fall

Discharge Condition:
good

Discharge Instructions:
PT/OT as needed.
Supervised feedings.
Should have full medical evaluation by a geriatrician given
uncertain medical history.
Out of bed with assistance
Will need home evaluation for safety before returning home.

Followup Instructions:
For any problems, please call the Trauma clinic at  ([**Telephone/Fax (1) 4336**] for follow-up care.
Please have an evaluation by a geriatrics doctor as soon as
possible. If you need help getting an appointment or getting a
primary care doctor, call ([**Telephone/Fax (1) 56960**].
You need to be seen by the [**Hospital 4695**] clinic in [**2-25**] weeks.
Please call them as soon as possible ([**Telephone/Fax (1) 88**] to schedule
a follow-up appointment and a follow-up CT scan of your head.
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,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: s/p fall

PRESENT ILLNESS: Pt is an 83 year old female transferred from [**Hospital **] hospital as
a trauma basic after she fell down a flight of [**3-29**] stairs
earlier in the day. Per report from OSH, the fall was witnessed
and patient sustained a loss of consciousnes. She was found
confused and aggitated at the scene. A CT scan of the head at
the OSH showed a L frontal contusion, R occipital contusion, and
L subdural hematoma. She arrived to [**Hospital1 **] intubated.

MEDICAL HISTORY: unknown - lives alone, estranged from family, not reliable
historian

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
V/S 99.2,83, 140/80, 18, 100% 2L NC
Gen: Intubated elderly woman, sedated, responds to painful
stimulation, spontaneously moves all 4 extremities
Neuro: 2+ bilateral patellar reflexes, 1+ bilateral heel
reflexes, plantar responses extensor bilaterally
HEENT: L frontal hematoma, PEERLA, no hemotympanum
CHEST: mild rhonchi bilaterally, on ventilation, nl chest wall
expansion
CV: RRR, no murmurs/rubs/gallops
Abdomen: soft, nontender/nondistended, quiet
Extrem: superficial abrasion L shin, no edema
Rectal: normal tone, guaic negative

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with loss of consciousness of unspecified duration,Accidental fall on or from other stairs or steps'}
