CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: 89yo woman on asa/plavix for Afib was in usual state of health
until she had a mechanical fall from the toilet this evening.
denies LOC but left facial ecchymosis so son called EMS. OSH CT
revealed SDH. Transferred to [**Hospital1 18**] for evaluation. Pt examined
with son who states that the patient appears to be at
her baseline.

MEDICAL HISTORY: UTI
CVA with L hemiplegia
HL
HTN
GERD
shingles
cholecystectomy
PEG
hernia repair
depression

MEDICATION ON ADMISSION: asa 325
plavix 75
nasonex
dexilant
fioricet
pravastatin
lidoderm patch
glycolax
lisinopril 5
erythromycin eye ointment

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
O: T:97.2  BP: 146/56   HR: 70    R 18   O2Sats 98% 2L NC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 3-2 L surgical      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: afib 80's
Abd: Soft, NT,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and place only.
Language: Speech slurred but baseline per son.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with son & his family. Wheelchair bound but ambulates with
walker 100ft per day with son. [**Name (NI) **] tobacco/etoh/drugs
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Paralytic ileus,Atrial fibrillation,Accidental fall from commode,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified
Subdural hem w/o coma,Late ef-hemplga side NOS,Paralytic ileus,Atrial fibrillation,Fall from commode,Long-term use anticoagul,Hyperlipidemia NEC/NOS,Hypertension NOS,Esophageal reflux,Depressive disorder NEC
Admission Date:  [**2128-9-8**]              Discharge Date:   [**2128-9-15**]


Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
none


History of Present Illness:
89yo woman on asa/plavix for Afib was in usual state of health
until she had a mechanical fall from the toilet this evening.
denies LOC but left facial ecchymosis so son called EMS. OSH CT
revealed SDH. Transferred to [**Hospital1 18**] for evaluation. Pt examined
with son who states that the patient appears to be at
her baseline.


Past Medical History:
UTI
CVA with L hemiplegia
HL
HTN
GERD
shingles
cholecystectomy
PEG
hernia repair
depression


Social History:
Lives with son & his family. Wheelchair bound but ambulates with
walker 100ft per day with son. [**Name (NI) **] tobacco/etoh/drugs


Family History:
NC

Physical Exam:
On admission:
PHYSICAL EXAM:
O: T:97.2  BP: 146/56   HR: 70    R 18   O2Sats 98% 2L NC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 3-2 L surgical      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: afib 80's
Abd: Soft, NT,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and place only.
Language: Speech slurred but baseline per son.

Cranial Nerves:
I: Not tested
II: right pupil round and reactive to light, left surgical to
mm bilaterally.
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 and tone on right. left hemiplegic. Strength
full power [**4-29**] throughout on right.

Sensation: Intact to light touch

PHYSICAL EXAM UPON DISCHARGE:
asleep, arouses to voice
alert to self, hospital and month/year
R eye reactive, L surgical
Left slight droop
tongue deviates left
following commands on R UE and LE, full strength
L hemiplegia

Pertinent Results:
Head CT [**2128-9-8**]:
Left SDH, stable from OSH imaging, no midline shift noted.
Multiple prior infarcts.

Head CT [**2128-9-8**]:
IMPRESSION: No short-interval change in left posterior subdural
hematoma. No new hemorrhage or change in mass effect.

Head CT [**2128-9-8**]: IMPRESSION:
No interval change in the size of left parieto-temporal subdural
hematoma with local mass effect but no evidence of shift of
midline structures or central brain herniation.
Redemonstration of chronic small vessel changes and chronic
right
frontoparietal infarct.


Brief Hospital Course:
89F admitted to the Neuro ICU after sustaining a left SDH from a
fall. She was given platelets as she was on ASA/Plavix. A repeat
CT was stable. Overnight, she remained stable and a repeat Head
CT in the AM showed no interval changes. An intense bowel
regimen was initiated after a KUB was obtained for abdominal
pain.
On [**9-9**] she was cleared for transfer to the floor. Her diet was
advanced to clears. Dilantin level was therapeutic at 10.9. PT
and OT were consulted for assistance with discharge planning.
Bowel Regimen was continued and was successful.
On [**9-10**] the patient was neurologically stable and tolerating a
full PO diet.
On [**9-11**] she was seen by PT and OT who recommended rehab
placement unless a [**Doctor Last Name **] lift could be obtained at her home. She
remained inhouse awaiting further evaluation and possible rehab
placement.
On [**9-13**] the patient was restarted on her home dose of aspirin
and plavix and continued to wait for discharge location.

On DOD the patient was neurologically stable. She is tolerating
a PO diet and voiding without difficulty.
She will follow up with Dr. [**Last Name (STitle) **] in [**3-31**] weeks with a repeat
head CT.

Medications on Admission:
asa 325
plavix 75
nasonex
dexilant
fioricet
pravastatin
lidoderm patch
glycolax
lisinopril 5
erythromycin eye ointment


Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*0*
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
9. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Subdural Hematoma


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Awake and alert.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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, Advil, or Ibuprofen
etc.
??????	You were on the medication Plavix (clopidogrel), and Aspirin
prior to your injury, you resumed taking this on [**2128-9-13**].
??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**]. You
should continue to take this until you see Dr. [**Last Name (STitle) **] for follow
up.

Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) **] in [**3-31**] weeks with a Head CT
without contrast. Please call [**Telephone/Fax (1) 3231**] to make this
appointment.



Completed by:[**2128-9-14**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Paralytic ileus,Atrial fibrillation,Accidental fall from commode,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified'}


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: 89yo woman on asa/plavix for Afib was in usual state of health
until she had a mechanical fall from the toilet this evening.
denies LOC but left facial ecchymosis so son called EMS. OSH CT
revealed SDH. Transferred to [**Hospital1 18**] for evaluation. Pt examined
with son who states that the patient appears to be at
her baseline.

MEDICAL HISTORY: UTI
CVA with L hemiplegia
HL
HTN
GERD
shingles
cholecystectomy
PEG
hernia repair
depression

MEDICATION ON ADMISSION: asa 325
plavix 75
nasonex
dexilant
fioricet
pravastatin
lidoderm patch
glycolax
lisinopril 5
erythromycin eye ointment

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
PHYSICAL EXAM:
O: T:97.2  BP: 146/56   HR: 70    R 18   O2Sats 98% 2L NC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 3-2 L surgical      EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: afib 80's
Abd: Soft, NT,
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and place only.
Language: Speech slurred but baseline per son.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with son & his family. Wheelchair bound but ambulates with
walker 100ft per day with son. [**Name (NI) **] tobacco/etoh/drugs 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Paralytic ileus,Atrial fibrillation,Accidental fall from commode,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified'}
