CHIEF COMPLAINT: fall

PRESENT ILLNESS: HPI: 78yo M, with h/o Alz Dz, who presented with gait
disturbance
and fell x 3 this am. He also got lost in his apt building and
bladder incontinence, which had not happened before. He walks
leaning to the left side and decreased left arm swing. Per
family, he fell 3 weeks ago. Denied headache. Patient dose not
remember the falls. His CT head today showed large left acute on
chronic (lobulated) SDH with 1.2 subfalcine herniation.

MEDICAL HISTORY: PMHx:HTN, Alzheimer's dz, back pain.

MEDICATION ON ADMISSION: All: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: afebrile BP: 130/86    HR:113    R 22
Gen: Spanish spoken, entire interview is interpreted via [**Name8 (MD) **] RN
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient appears non-distressed. He is awake and
alert, but only oriented to self (not to age, says he is 32yo
now), not to year/place. He can not completely follow commands
and claims he is tired.
HEENT: Pupils: PERRLA        EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, follow simple commands
inconsistently.
Orientation: Oriented to person (his name, not age), not to
place, and date.
Recall: [**12-27**] objects at 2 minutes.
Language: Speech fluent, but sometime just repeat what was said
to him.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Social Hx:
Lives with wife in [**Hospital3 **] home. Nonsmoker, Nondriker.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Fall from other slipping, tripping, or stumbling,Unspecified essential hypertension,Alzheimer's disease,Aphasia,Hemiplegia, unspecified, affecting unspecified side
Subdural hem w/o coma,Pneumonia, organism NOS,Fall from slipping NEC,Hypertension NOS,Alzheimer's disease,Aphasia,Unsp hemiplga unspf side
Admission Date:  [**2125-4-6**]              Discharge Date:   [**2125-4-17**]

Date of Birth:  [**2046-7-12**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
Left burr hole evacuation of subdural hematoma

History of Present Illness:
HPI: 78yo M, with h/o Alz Dz, who presented with gait
disturbance
and fell x 3 this am. He also got lost in his apt building and
bladder incontinence, which had not happened before. He walks
leaning to the left side and decreased left arm swing. Per
family, he fell 3 weeks ago. Denied headache. Patient dose not
remember the falls. His CT head today showed large left acute on
chronic (lobulated) SDH with 1.2 subfalcine herniation.


Past Medical History:
PMHx:HTN, Alzheimer's dz, back pain.


Social History:
Social Hx:
Lives with wife in [**Hospital3 **] home. Nonsmoker, Nondriker.


Family History:
noncontributory

Physical Exam:
PHYSICAL EXAM:
O: T: afebrile BP: 130/86    HR:113    R 22
Gen: Spanish spoken, entire interview is interpreted via [**Name8 (MD) **] RN
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient appears non-distressed. He is awake and
alert, but only oriented to self (not to age, says he is 32yo
now), not to year/place. He can not completely follow commands
and claims he is tired.
HEENT: Pupils: PERRLA        EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, follow simple commands
inconsistently.
Orientation: Oriented to person (his name, not age), not to
place, and date.
Recall: [**12-27**] objects at 2 minutes.
Language: Speech fluent, but sometime just repeat what was said
to him.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light bilaterally.
Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk; slight increased tone bilaterally. No
abnormal movements. Strength full of left LE/UE. Mild weakness
noted of right side, difficult to precisely eval for motor
strength due to patient unable to fully participate. throughout.
Right-sided pronator drift

Sensation: Intact to light touch and vibration bilaterally.

Reflexes: [**1-28**] bilaterally

Toes downgoing left side/ upgoing on the right side.

Coordination: patient unable to follow the instruction.


Pertinent Results:
CT/MRI:
CT head: (final read pending) 1.  Large, multiloculated, left
cerebral convexity subdural hematoma with 1.2 cm of midline
shift.  There are both acute and subacute blood products
present.
2.  There is trapping of the temporal [**Doctor Last Name 534**] of the left lateral
ventricle.

[**2125-4-6**] 12:15PM   PLT COUNT-263
[**2125-4-6**] 12:15PM   NEUTS-74.4* LYMPHS-15.2* MONOS-8.5 EOS-0.7
BASOS-1.1
[**2125-4-6**] 12:15PM   WBC-5.5 RBC-4.50* HGB-14.3 HCT-42.8 MCV-95
MCH-31.8 MCHC-33.4 RDW-13.1
[**2125-4-6**] 12:15PM   ALBUMIN-4.1
[**2125-4-6**] 12:15PM   LIPASE-27
[**2125-4-6**] 12:15PM   ALT(SGPT)-21 AST(SGOT)-29 ALK PHOS-62
AMYLASE-61 TOT BILI-0.5
[**2125-4-6**] 12:15PM   estGFR-Using this
[**2125-4-6**] 12:15PM   GLUCOSE-97 UREA N-17 CREAT-1.0 SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
[**2125-4-6**] 05:30PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2125-4-6**] 05:30PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017

Brief Hospital Course:
Mr [**Known lastname **] was admitted originally to the neurological service as
his family initially did not want surgery, during the first two
days of admission he developed plegia of his right sided. He was
also found to have a left sided pneumonia. The famiy agree to
surgery and he underwent left sided burr holes on [**4-10**].  Post
operatively he was moving his right sided with 4/5 strength, he
followed commands but spoke nonsensically according to Spanish
interpreters.  His diet was advanced and he was seen by PT felt
he would best benefit from rehab. His staples were removed on
discharge his site was clean and intact.

Medications on Admission:
All: NKDA

Medications prior to admission:
Lisinopril, Aricept, Namenda, multi-vitamin


Discharge Medications:
1. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Morphine 2 mg/mL Syringe Sig: One (1)  Injection Q4H (every
4 hours) as needed.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Left SDH


Discharge Condition:
Neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????Have a family member check your incision daily for signs of
infection
??????Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????You may shower/wash your hair.
??????Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????Clearance to drive and return to work will be addressed at your
post-operative office visit

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????New onset of tremors or seizures
??????Any confusion 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
??????Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????Fever greater than or equal to 101.4?????? F


Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**] in [**3-30**] weeks with Head CT. Call
[**Telephone/Fax (1) 2992**] for appt.



Completed by:[**2125-4-17**]
{"Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Fall from other slipping, tripping, or stumbling,Unspecified essential hypertension,Alzheimer's disease,Aphasia,Hemiplegia, unspecified, affecting unspecified side"}


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: fall

PRESENT ILLNESS: HPI: 78yo M, with h/o Alz Dz, who presented with gait
disturbance
and fell x 3 this am. He also got lost in his apt building and
bladder incontinence, which had not happened before. He walks
leaning to the left side and decreased left arm swing. Per
family, he fell 3 weeks ago. Denied headache. Patient dose not
remember the falls. His CT head today showed large left acute on
chronic (lobulated) SDH with 1.2 subfalcine herniation.

MEDICAL HISTORY: PMHx:HTN, Alzheimer's dz, back pain.

MEDICATION ON ADMISSION: All: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: afebrile BP: 130/86    HR:113    R 22
Gen: Spanish spoken, entire interview is interpreted via [**Name8 (MD) **] RN
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Patient appears non-distressed. He is awake and
alert, but only oriented to self (not to age, says he is 32yo
now), not to year/place. He can not completely follow commands
and claims he is tired.
HEENT: Pupils: PERRLA        EOMs full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, follow simple commands
inconsistently.
Orientation: Oriented to person (his name, not age), not to
place, and date.
Recall: [**12-27**] objects at 2 minutes.
Language: Speech fluent, but sometime just repeat what was said
to him.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Social Hx:
Lives with wife in [**Hospital3 **] home. Nonsmoker, Nondriker. 

### Response:
{"Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonia, organism unspecified,Fall from other slipping, tripping, or stumbling,Unspecified essential hypertension,Alzheimer's disease,Aphasia,Hemiplegia, unspecified, affecting unspecified side"}
