CHIEF COMPLAINT: fall

PRESENT ILLNESS: 85 M s/p unwitnessed fall today - wife heard him fall, found him
on his back on the living room floor - complained of a headache
and nausea afterwards.  No LOC, mild confusion and solmnent.

MEDICAL HISTORY: PMH:
Hypertension
MI last year
s/p multiple falls, COPD, Anemia
Pulmonary fibrosis
polymyalgia rheumatica
neck arthritis

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1
QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone
5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva,
MiraLax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 97.9 90 161/96 16 95%3L NC
Oriented to year, not month, oriented to state, mild confusion,
somnolent
Difficulty following commands and participated with physical
exam
Moves all extremities with good strength
RRR
CTAB
soft NT.ND
2+ LE edema, swelling in hands

FAMILY HISTORY: FH: NC

SOCIAL HISTORY: SH: remote tob, no ETOH or drugs, retired salesman, lives in
[**Location 583**] with wife
Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified fall,Home accidents,Chronic airway obstruction, not elsewhere classified,Anemia, unspecified,Polymyalgia rheumatica,Unspecified essential hypertension
Subdural hemorr-coma NOS,Fall NOS,Accident in home,Chr airway obstruct NEC,Anemia NOS,Polymyalgia rheumatica,Hypertension NOS
Admission Date:  [**2167-8-14**]              Discharge Date:   [**2167-8-15**]


Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
none

History of Present Illness:
85 M s/p unwitnessed fall today - wife heard him fall, found him
on his back on the living room floor - complained of a headache
and nausea afterwards.  No LOC, mild confusion and solmnent.

Past Medical History:
PMH:
Hypertension
MI last year
s/p multiple falls, COPD, Anemia
Pulmonary fibrosis
polymyalgia rheumatica
neck arthritis

PSH:
Cataract surgery
TURP
R colectomy

Social History:
SH: remote tob, no ETOH or drugs, retired salesman, lives in
[**Location 583**] with wife

Family History:
FH: NC

Physical Exam:
PE: 97.9 90 161/96 16 95%3L NC
Oriented to year, not month, oriented to state, mild confusion,
somnolent
Difficulty following commands and participated with physical
exam
Moves all extremities with good strength
RRR
CTAB
soft NT.ND
2+ LE edema, swelling in hands


Pertinent Results:
Labs:
Trop-T: 0.03

138  100  11  116   AGap=15
3.6  27  1.0

estGFR: 71 / >75 (click for details)
CK: 81  MB: Notdone

Ca: 9.0 Mg: 2.1 P: 2.6

5.8>33.9<242

Rads:
CT Head:
Acute right 16 mm SDH overlying cerebral convexity with shift to
the left of 3 mm. Compression of the right lateral ventricle.
Subdural blood also layers along the falx superiorly and along
the tentorium bilaterally. Right parietal subgaleal hematoma.
No fracture.

CT C-spine:
Slightly limited by motion.
Mild anterior widening of the interspace at C2-3, C3-4, C4-[**5-11**]
be chronic but acute ligamentous injury cannot be excluded.
No fracture or subluxation. Mild septal thickening may reflect
pulmonary edema.

Brief Hospital Course:
 Patient was intubated for airway protection -repeat CT with
shift - Dr. [**Last Name (STitle) 739**] thought if we were to proceed that
this would need to be surgically evacuated and given pts
comorbidities, worsening status, and being on aspirin and
plavix he thought the prognosis was very grave.  Upon discussion
with his daughter and wife the decision was made that Mr.
[**Known lastname 168**] would not have wanted to proceed and that he would be
comfort measures only.  He was extubated in ICU and keep him
comfortable. He expired [**2167-8-15**].

Medications on Admission:
[**Last Name (un) 1724**]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1
QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone
5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva,
MiraLax

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
traumatic cerebral hemorrhage

Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none

                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2167-10-13**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified fall,Home accidents,Chronic airway obstruction, not elsewhere classified,Anemia, unspecified,Polymyalgia rheumatica,Unspecified essential hypertension'}


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: 85 M s/p unwitnessed fall today - wife heard him fall, found him
on his back on the living room floor - complained of a headache
and nausea afterwards.  No LOC, mild confusion and solmnent.

MEDICAL HISTORY: PMH:
Hypertension
MI last year
s/p multiple falls, COPD, Anemia
Pulmonary fibrosis
polymyalgia rheumatica
neck arthritis

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: aspirin 325', B12, cymbalta 60', FeSO4 325', florinef 0.1
QOD, Lasix 20', Lipitor 80', Torprol 25', Plavix 75', Prednisone
5', Proscar 5', Protonix 40', senna, tylenol, tramadol', spriva,
MiraLax

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 97.9 90 161/96 16 95%3L NC
Oriented to year, not month, oriented to state, mild confusion,
somnolent
Difficulty following commands and participated with physical
exam
Moves all extremities with good strength
RRR
CTAB
soft NT.ND
2+ LE edema, swelling in hands

FAMILY HISTORY: FH: NC

SOCIAL HISTORY: SH: remote tob, no ETOH or drugs, retired salesman, lives in
[**Location 583**] with wife 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified fall,Home accidents,Chronic airway obstruction, not elsewhere classified,Anemia, unspecified,Polymyalgia rheumatica,Unspecified essential hypertension'}
