CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 83 yo female s/p fall down stairs; unknown LOC. Taken to an area
hospital, found to have a left temporal subarachnoid hemorrhage.
She was transferred to [**Hospital1 18**] for continued trauma care.

MEDICAL HISTORY: CAD
CRI
AAA s/p repair
COPD
PVD
CHF
AFib
h/o DVT

MEDICATION ON ADMISSION: Verapamil 180'
HCTZ 50'
Dig .125'
Coumadin 2'

ALLERGIES: Aspirin

PHYSICAL EXAM: VS upon admission to the trauma bay:
GCS 15
BP 144/palp HR 80  RR 16
EOMI, occipital laceration, TM's clear, clotted blood in
pharynx, mid face stable
Cervical collar, no crepitus
Midthoracic tenderenss, no stepoffs, BS clear
Abdomen soft, nontender, reducible hernia
Pelvis stable
Normal rectal tone, guaiac negative
Extr no deformities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married, lives with husband who reportedly has some Dementia.
Has a son and daughter.
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Unspecified fall,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Unspecified disorder of kidney and ureter,Peripheral vascular disease, unspecified
Subarachnoid hem-no coma,Chr airway obstruct NEC,CHF NOS,Atrial fibrillation,Fall NOS,Cor ath unsp vsl ntv/gft,Hypertension NOS,Renal & ureteral dis NOS,Periph vascular dis NOS
Admission Date:  [**2175-5-16**]              Discharge Date:   [**2175-5-19**]


Service: SURGERY

Allergies:
Aspirin

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

Major Surgical or Invasive Procedure:
None


History of Present Illness:
83 yo female s/p fall down stairs; unknown LOC. Taken to an area
hospital, found to have a left temporal subarachnoid hemorrhage.
She was transferred to [**Hospital1 18**] for continued trauma care.

Past Medical History:
CAD
CRI
AAA s/p repair
COPD
PVD
CHF
AFib
h/o DVT

Social History:
Married, lives with husband who reportedly has some Dementia.
Has a son and daughter.

Family History:
Noncontributory

Physical Exam:
VS upon admission to the trauma bay:
GCS 15
BP 144/palp HR 80  RR 16
EOMI, occipital laceration, TM's clear, clotted blood in
pharynx, mid face stable
Cervical collar, no crepitus
Midthoracic tenderenss, no stepoffs, BS clear
Abdomen soft, nontender, reducible hernia
Pelvis stable
Normal rectal tone, guaiac negative
Extr no deformities

Pertinent Results:
[**2175-5-16**] 04:59PM   GLUCOSE-149* LACTATE-1.7 NA+-135 K+-7.7*
CL--98* TCO2-23
[**2175-5-16**] 04:50PM   UREA N-49* CREAT-3.1*
[**2175-5-16**] 04:50PM   AMYLASE-101*
[**2175-5-16**] 04:50PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2175-5-16**] 04:50PM   WBC-11.3* RBC-5.10 HGB-12.9 HCT-39.7 MCV-78*
MCH-25.3* MCHC-32.5 RDW-16.6*
[**2175-5-16**] 04:50PM   PT-34.8* PTT-41.1* INR(PT)-3.8*
[**2175-5-16**] 04:50PM   PLT COUNT-331

CT HEAD W/O CONTRAST  [**2175-5-17**] 9:56 AM

CT HEAD W/O CONTRAST

Reason: F/u head bleed

[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with AH/SDH
REASON FOR THIS EXAMINATION:
F/u head bleed
CONTRAINDICATIONS for IV CONTRAST: renal failure

CT OF THE HEAD WITHOUT CONTRAST, DATED [**2175-5-17**]

HISTORY: 81-year-old female with known intracranial hemorrhage
after trauma; followup.

TECHNIQUE: Contiguous 5-mm axial tomographic sections were
obtained from the skull base through the vertex and viewed in
brain and bone window. Much of the study is significantly
degraded by patient motion artifact and several sections were
repeated.

FINDINGS: The study is compared with the examination obtained
approximately 17 hours earlier. Allowing for the
motion-degradation, there has been no significant change in the
bifrontal parenchymal hemorrhages, likely representing
hemorrhagic contusions. There is no interval increase in
adjacent edema, mass effect or associated shift of the midline
structures. Assessment of the small hemorrhagic focus in the
anterior aspect of the right middle cranial fossa is limited,
but this, too, is not grossly changed, and no new hemorrhagic
focus is identified. Again demonstrated are large right
occipital scalp subgaleal hematoma with underlying right
basiocciput fracture and fluid layering in the right sphenoid
sinus, with no definite sphenoid fracture seen.

IMPRESSION: Motion-limited study, with no significant change
since the admission examination obtained on the preceding day.

CT C-SPINE W/O CONTRAST  [**2175-5-16**] 4:45 PM

CT C-SPINE W/O CONTRAST

Reason: ? fx

[**Hospital 93**] MEDICAL CONDITION:
82 year old woman s/p fall on coumadin
REASON FOR THIS EXAMINATION:
? fx
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 82-year-old female with status post fall, on
Coumadin. Evaluate for fracture.

No prior studies for comparison.

TECHNIQUE: Axial non-contrast images of the cervical spine were
obtained. Sagittal and coronal reconstructions were performed.

FINDINGS: On sagittal images, the base of the occiput to the T2
vertebra is clearly visualized. The prevertebral soft tissues
are unremarkable. There is slight grade 1 retrolisthesis of C4
on C5. A C4 inferior endplate deformity most likely represents a
Schmorl node, although inferior endplate fracture cannot be
definitively excluded. Moderately severe degenerative changes of
the cervical spine. Facet joint proliferative changes and
posterior osteophytes result in mild spinal canal narrowing,
most marked at C5/6. There are emphysematous changes of the
lungs with scarring of the right lung apex. MRI is better in the
evaluation of the thecal sac, but there are no gross thecal sac
abnormalities.

IMPRESSION:
1. Grade 1 retrolisthesis of C4 on C5. A C4 inferior endplate
deformity likely represents a Schmorl's node, although inferior
endplate fracture cannot be definitively excluded. Clinically
correlate.
2. Degenerative changes of the cervical spine.

NOTE ADDED IN ATTENDING REVIEW:
1. Right basiocciput fracture well seen in coronal reformatted
images; exits at the jugular foramen but spares the occipital
condyle, and atlanto- occipital relationship is maintained.
2. Moderately severe degenerative changes, particularly at the
C5/6 > C4/5, with moderate canal stenosis and slight indentation
of the thecal sac (and cord). Might be at risk for "central
cord" injury at these levels (with appropriate mechanism). b/l
neural foraminal narrowing at these levels.
3. Evidence of severe bullous emphysema, w/irreg, focal
pleuroparench thickening, R lung apex; a pleural-based mass is a
consideration.
4. D/W Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] (Trauma [**Doctor First Name **]), 0915h, [**2175-5-17**].

CT CHEST W/CONTRAST  [**2175-5-16**] 4:45 PM

CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST

Reason: ? bleeding
Field of view: 50 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
82 year old woman s/p fall on coumadin
REASON FOR THIS EXAMINATION:
? bleeding
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 82-year-old female status post fall, on Coumadin.

Comparison to prior CT abdomen/pelvis of [**2169-4-7**].

TECHNIQUE: MDCT axial images of the chest, abdomen and pelvis
were obtained after the administration of IV Optiray contrast.
Multiplanar reformatted images were also obtained.

CT CHEST WITH IV CONTRAST: Heart and great vessels are
unremarkable. There are scattered mediastinal lymph nodes. A
pretracheal lymph node measures 1.2 cm. There is apical
scarring. A right upper lobe pulmonary nodule measures 4 mm.
There is bibasilar atelectasis. Incidental note is made of a
1-cm spiculated right breast opacity concerning for malignancy.

CT ABDOMEN WITH IV CONTRAST: The liver, pancreas, adrenal
glands, and left kidney are unremarkable. Right kidney
hydronephrosis and ureteral stent is seen. A right kidney
hypodensity likely represents a cyst, but cannot be further
characterized on this examination. The spleen is heterogeneous
likely secondary to the phase of filling. There is a small
gallstone. Again seen is a suprarenal abdominal aortic aneurysm
measuring 3.7 cm. This has decreased in size compared to the
prior examination and there is evidence of surgical
intervention. There are bilateral common iliac artery grafts
with partial thrombosis. No free fluid or free air within the
mesentery.

CT PELVIS WITH IV CONTRAST: The rectum is normal. There is
sigmoid diverticulosis without evidence of diverticulitis. A 1.5
x 1.0 cm cystic structure is seen within the uterus. There is a
moderate amount of high- attenuation fluid within the pelvis,
likely representing hematoma. Incidental note is made of left
internal iliac aneurysm.

OSSEOUS WINDOWS: Demonstrate a partially displaced sacral
fracture.

IMPRESSION:
1. Partially displaced sacral fracture with adjacent presacral
pelvic hematoma.
2. Suprarenal abdominal aortic aneurysm measuring 3.7 x 3.2 cm,
decreased in size compared to the previous examination. There
are common iliac artery grafts with partial thrombosis.
3. Right-sided hydronephrosis with right ureteral stent.
4. Gallstone.
5. Spiculated opacity in the right breast concerning for
malignancy, for which mammogram is recommended.
6. Cystic density within the uterus, for which pelvic ultrasound
is recommended.


Brief Hospital Course:
Patient admitted to the trauma service. Neurosurgery and
Orthopedic surgery were consulted because of her injuries. Her
SAH was managed non operatively; she was loaded with Dilantin
and will continue for the next 4 weeks until follow up with Dr.
[**Last Name (STitle) **], Neurosurgery in 3 months at which time she will have a
repeat head CT scan.
Her Coumadin should not be restarted until [**2175-5-25**].

Her Orthopedic injuries were managed conservatively as well.
There were no cervical spine fractures identified and so her
cervical collar was removed. She can be WBAT with her sacral
fracture. For pain control she was placed on ATC Tylenol and prn
Dilaudid 1 mg for breakthrough pain.

Geriatrics was consulted because of her age and mechanism of
injury. Several recommendations regarding her medication
regimine were made; she was also started on Calcium and Vit D
prophylaxis. Her HCTZ was restarted at a lower dose; was on 50
mg QD at home.

There was an incidental finding on her chest CT scan; a
spiculated opacity right breast was noted and on exam there is a
palpable mass. Her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30106**] was contact[**Name (NI) **] regarding
this; a copy of the CT report was forwarded to him as well. She
will need to follow up with him after discharge from rehab.

Physical and Occupational therapy were consulted and have
recommended short term rehab stay.

Medications on Admission:
Verapamil 180'
HCTZ 50'
Dig .125'
Coumadin 2'


Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold fro HR <60 and/or SBP <110.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for breakthrough pain.
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day): Continue for 4 weeks then
discontinue.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
s/p Fall
Left Temporal Subarachnoid Hemorrhage
Transverse Sacral Fracture


Discharge Condition:
Stable


Discharge Instructions:
DO NOT restart your Coumadin until [**2175-5-25**]

Follow up in 2 months with Orthopedics

Follow up with Neurosurgery in 3 months

Followup Instructions:
Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 30106**] regarding the finding on
chest CT; you will also need a mammogram scheduled within the
next 1-2 weeks.

Call [**Telephone/Fax (1) 1228**] for an appointment in 2 months with Dr.
[**Last Name (STitle) 1005**], Orthopedics.

Call [**Telephone/Fax (1) 2731**] for an appointment with Dr. [**Last Name (STitle) **],
Neurosurgery. Infrom the office that you will need a repeat head
CT scan for this appointment.



Completed by:[**2175-5-19**]

Name:  [**Known lastname 5246**],[**Known firstname 3344**]                    Unit No:   [**Numeric Identifier 5247**]

Admission Date:  [**2175-5-16**]              Discharge Date:   [**2175-5-19**]

Date of Birth:  [**2093-6-13**]             Sex:   F

Service: SURGERY

Allergies:
Aspirin

Attending:[**First Name3 (LF) 813**]
Addendum:
[**Name (NI) **] PTH level came back at 131; her Vitamin D should be
changed to either Vitamin D3 or calcitriol. Also her Dilantin
was 10.0 today as well. This information was provided to [**Location (un) 5248**] which is where patient was discharged to today and
also provided to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5249**], patient's primary care
physician.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 3465**] - [**Location (un) 824**]

                             [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**]

Completed by:[**2175-5-19**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Unspecified fall,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Unspecified disorder of kidney and ureter,Peripheral vascular disease, unspecified'}


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: 83 yo female s/p fall down stairs; unknown LOC. Taken to an area
hospital, found to have a left temporal subarachnoid hemorrhage.
She was transferred to [**Hospital1 18**] for continued trauma care.

MEDICAL HISTORY: CAD
CRI
AAA s/p repair
COPD
PVD
CHF
AFib
h/o DVT

MEDICATION ON ADMISSION: Verapamil 180'
HCTZ 50'
Dig .125'
Coumadin 2'

ALLERGIES: Aspirin

PHYSICAL EXAM: VS upon admission to the trauma bay:
GCS 15
BP 144/palp HR 80  RR 16
EOMI, occipital laceration, TM's clear, clotted blood in
pharynx, mid face stable
Cervical collar, no crepitus
Midthoracic tenderenss, no stepoffs, BS clear
Abdomen soft, nontender, reducible hernia
Pelvis stable
Normal rectal tone, guaiac negative
Extr no deformities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married, lives with husband who reportedly has some Dementia.
Has a son and daughter. 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Chronic airway obstruction, not elsewhere classified,Congestive heart failure, unspecified,Atrial fibrillation,Unspecified fall,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension,Unspecified disorder of kidney and ureter,Peripheral vascular disease, unspecified'}
