CHIEF COMPLAINT: fell out of bed

PRESENT ILLNESS: 83 y/o female transferred from outside facility after a CT of
the
head revealed a SDH/SAH and punctate contusion. Per transfer
notes patient fell from standing this morning at [**Hospital3 **]
while in the bathroom, it is unclear per the patient and per
transfer notes whether this was a syncopal episode or a
traumatic
fall.
Upon questioning the patient was alert and oriented but
completely amnestic to the event. She states that she fell out
of
bed while sleeping.

MEDICAL HISTORY: Hypothyroidism
Breast CA, s/p right mastectomy

MEDICATION ON ADMISSION: Levoxyl 50 mcg Po daily
ASA 81 mg PO Daily
Calcium supplement

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:97 BP:119 /72         HR:98    R 13       O2Sats: 98% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4-2mm b         EOMs: intact
Neck: Hard cervical collar

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] with her husband
Remote history of smoking
Other postprocedural status,Cerebellar or brain stem contusion without mention of open intracranial wound, with no loss of consciousness,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial fibrillation,Other left bundle branch block,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Unspecified fall,Accidents occurring in residential institution,Coronary atherosclerosis of native coronary artery,Other abnormal glucose,Old myocardial infarction,Mitral valve disorders,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Pain in joint, shoulder region,Anemia, unspecified
Post-proc states NEC,Cerebell contus w/o coma,Subendo infarct, initial,Ac diastolic hrt failure,Delirium d/t other cond,Atrial fibrillation,Left bb block NEC,Hypothyroidism NOS,Hx of breast malignancy,Fall NOS,Accid in resident instit,Crnry athrscl natve vssl,Abnormal glucose NEC,Old myocardial infarct,Mitral valve disorder,Hypertension NOS,Chr pulmon heart dis NEC,Joint pain-shlder,Anemia NOS
Admission Date:  [**2122-9-22**]              Discharge Date:   [**2122-9-30**]

Date of Birth:  [**2039-8-7**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
fell out of bed

Major Surgical or Invasive Procedure:
none


History of Present Illness:
83 y/o female transferred from outside facility after a CT of
the
head revealed a SDH/SAH and punctate contusion. Per transfer
notes patient fell from standing this morning at [**Hospital3 **]
while in the bathroom, it is unclear per the patient and per
transfer notes whether this was a syncopal episode or a
traumatic
fall.
Upon questioning the patient was alert and oriented but
completely amnestic to the event. She states that she fell out
of
bed while sleeping.


Past Medical History:
Hypothyroidism
Breast CA, s/p right mastectomy


Social History:
Lives in [**Hospital3 **] with her husband
Remote history of smoking


Family History:
non contributory

Physical Exam:
T:97 BP:119 /72         HR:98    R 13       O2Sats: 98% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4-2mm b         EOMs: intact
Neck: Hard cervical collar

Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: poor recall
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm 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 and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-21**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger


Pertinent Results:
[**2122-9-22**] 12:20PM   WBC-10.7 RBC-4.46 HGB-13.7 HCT-41.0 MCV-92
MCH-30.7 MCHC-33.4 RDW-14.1
[**2122-9-22**] 12:20PM   NEUTS-86.5* LYMPHS-9.0* MONOS-4.2 EOS-0.2
BASOS-0.1
[**2122-9-22**] 12:20PM   PLT COUNT-140*
[**2122-9-22**] 12:20PM   PT-12.8 PTT-25.2 INR(PT)-1.1
[**2122-9-22**] 12:20PM   GLUCOSE-129* UREA N-16 CREAT-0.8 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
[**2122-9-22**] 12:20PM   CK-MB-9 cTropnT-0.30*
[**2122-9-22**] 08:23PM   LACTATE-1.9

[**2122-9-22**] Head CT : 1. Small right frontoparietal subdural
hematoma and subarachnoid hemorrhage with foci of subarachnoid
bleed in the left parietal and left occipital suggesting
contrecoup injury. No significant change since the prior study
done at outside hospital.
  2. No fractures identified.

[**2122-9-22**] C Spine CT : 1. No acute C-spine fractures or abnormal
alignment detected. Please note that MRI is more sensitive for
ligamentous /cord injury.
2. Mild degenerative changes of the C-spine, without significant
spinal canal stenosis.
3. Bilateral apical lung opacities. Correlate with dedicated
chest imaging, either x-ray or CT.

[**2122-9-22**] Chest/Abd ST : 1. Consolidation in the dependent portion
of the lungs bilaterally, possibly due aspiration, atelectasis
or infection. Small bilateral pleural effusions.
  2. No evidence of traumatic injury to the remainder of the
torso.
  3. Moderate diverticulosis without diverticulitis.
  4. Over-distention of the endotracheal tube balloon.
  5. 6 mm enhancing lesion within the periphery of the left lobe
of the liver is non-specific and may represent a flash-filling
hemangioma, adenoma, or area of FNH.

[**2122-9-23**] Cardiac echo : The left atrium is dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate regional left
ventricular systolic dysfunction with akinesis of the distal 40
percent of the left ventricle. Estimated left ventricular
ejection fraction is 30 percent. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild functional mitral stenosis (mean
gradient 3 mmHg) due to mitral annular calcification. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.

[**2122-9-24**] Cardiac Echo :
The left atrium is moderately dilated. The left atrium is
elongated. No atrial septal defect is seen by 2D or color
Doppler. There is moderate to severe regional left ventricular
systolic dysfunction with hypokinesis of mid left ventricular
walls and akineisis of apical walls and apex. Overall left
ventricular systolic function is severely depressed. Estimated
ejection fraction is 25-30%. There is evidence of diastolic
dysfunction. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is moderate
pulmonary artery systolic hypertension. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. No mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2122-9-23**], there is worsening of the of pulmonary artery
systolic hypertension, which is now moderate.
IMPRESSION: Severly depressed left ventricular systolic
function, evidence of diastolic dysfunction with elevated PAWP
(> 18 mmHg). Moderate [2+] tricuspid regurgitation, moderate
pulmonary artery systolic hypertension.

[**2122-9-27**] CXR : There are small bilateral pleural effusions,
mildly decreased on the right since prior study. Clips are
present in the right axilla. Heart and mediastinum are within
normal limits. Lungs are otherwise grossly clear.

Carotid duplex [**9-29**]: no stenosis


Brief Hospital Course:
Mrs. [**Known lastname **] was transferred  to [**Hospital1 18**] for further evaluation and
management of her SDH.  During her stay in the ER she
desaturated to the mid 80's and was urgently intubated.  A
repeat Head CT was done which showed no change and she was
subsequently transferred to the Trauma ICU.  Her vital signs
were stable and her neurologic status was evaluated off
sedation.  She was able to move all four extremities and
responded appropriately to commands.  She was extubated 24 hours
later successfully and again her neuro exam was unchanged.  She
was then transferred to the Trauma floor for further management

Unfortunately on [**2122-9-24**] she desaturated again and was
transferred back to the ICU. She was in CHF and required
vigorous diuresis and BIPAP.  A cardiac echo was done which
revealed diastolic heart failure, pulmonary hypertension and an
EF of 25%.  She subsequently developed atrial fibrillation and
was placed on a diltiazem drip.  She eventually converted to NSR
and the cardiology service was consulted. Their recommendations
included further diuresis then [**Hospital1 **] Lasix, beta blockers for afib
with discontinuation of diltiazem and starting an ACEI.  A
follow up echo is recommended in [**5-25**] weeks with her cardiologist
and if her diastolic dysfunction improves then her ACEI may be
able to be stopped.  Their thought is that she may have
Takotsubo's stress cardiomyopathy which may resolve in time.
Carotid studies were normal.

She was transferred back to the Trauma floor and was seen on
multiple occasions by PT and OT.  She was slowly making progress
with ambulation.  Her neurologic exam was unchanged and she will
need to have a repeat non contrast head CT in 8 weeks followed
by an appointment with Dr. [**Last Name (STitle) **].  She received a 10 day course
of phenytoin prophylactically and had no seizures.

Mrs. [**Known lastname **] was transferred to rehab on [**2122-9-30**] to increase her
mobility and get her back to her baseline.

Medications on Admission:
Levoxyl 50 mcg Po daily
ASA 81 mg PO Daily
Calcium supplement

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold SBP < 100 HR < 60.
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
9. Levolyl 50 mcg PO Daily


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]

Discharge Diagnosis:
Right frontal/parietal subdural hematoma
Small SAH
CHF
Atrial fibrillation
Cardiomyopathy


Discharge Condition:
stable


Discharge Instructions:
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, or
Ibuprofen etc.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2359**] for a follow up
appointment in [**1-20**] weeks

Call Dr. [**Last Name (STitle) 41243**] for a follow up appointment in [**12-19**] weeks

Call Dr. [**Last Name (STitle) **] ( Neurosurgery) at [**Telephone/Fax (1) 1669**] for a follow up
appointment in 8 weeks.  You will need a non contrast head CT
before the visit.  This can be booked when you call to make the
appointment.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

Completed by:[**2122-9-30**]
{'Other postprocedural status,Cerebellar or brain stem contusion without mention of open intracranial wound, with no loss of consciousness,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial fibrillation,Other left bundle branch block,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Unspecified fall,Accidents occurring in residential institution,Coronary atherosclerosis of native coronary artery,Other abnormal glucose,Old myocardial infarction,Mitral valve disorders,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Pain in joint, shoulder region,Anemia, 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: fell out of bed

PRESENT ILLNESS: 83 y/o female transferred from outside facility after a CT of
the
head revealed a SDH/SAH and punctate contusion. Per transfer
notes patient fell from standing this morning at [**Hospital3 **]
while in the bathroom, it is unclear per the patient and per
transfer notes whether this was a syncopal episode or a
traumatic
fall.
Upon questioning the patient was alert and oriented but
completely amnestic to the event. She states that she fell out
of
bed while sleeping.

MEDICAL HISTORY: Hypothyroidism
Breast CA, s/p right mastectomy

MEDICATION ON ADMISSION: Levoxyl 50 mcg Po daily
ASA 81 mg PO Daily
Calcium supplement

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:97 BP:119 /72         HR:98    R 13       O2Sats: 98% 2L
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4-2mm b         EOMs: intact
Neck: Hard cervical collar

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Lives in [**Hospital3 **] with her husband
Remote history of smoking 

### Response:
{'Other postprocedural status,Cerebellar or brain stem contusion without mention of open intracranial wound, with no loss of consciousness,Subendocardial infarction, initial episode of care,Acute diastolic heart failure,Delirium due to conditions classified elsewhere,Atrial fibrillation,Other left bundle branch block,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Unspecified fall,Accidents occurring in residential institution,Coronary atherosclerosis of native coronary artery,Other abnormal glucose,Old myocardial infarction,Mitral valve disorders,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Pain in joint, shoulder region,Anemia, unspecified'}
