CHIEF COMPLAINT: Fall

PRESENT ILLNESS: 80F transferred from OSH s/p mechanical fall in her yard,
hit her occiput on vinyl siding. No reported LOC. OSH head CT
revealed small SDH, INR 4.3, arrived to [**Hospital1 18**] receiving 2u ffp.

MEDICAL HISTORY: PMHx: Afib, DM2 neuropathy LLE>RLE, macular degeneration, HTN,
pacemaker
All: [**First Name9 (NamePattern2) **]
[**Last Name (un) 1724**]: coumadin, fe, lasix, incor, glyburide, digoxin, indural

MEDICATION ON ADMISSION: coumadin, fe, lasix, incor, glyburide, digoxin, indural

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
98.2 60 170/74 18 98%RA
Gen: WD/WN, comfortable, pleasant, NAD.
HEENT: Pupils: R pupil 1.5->1mm, L pupil macular degeneration,
assymetric, 6mm. EOMI, no nystagmus.
Neck: Supple.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: BS+, S, NT/ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: AA+Ox3, cooperative with exam, nl affect.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: 

SOCIAL HISTORY: lives alone
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Unspecified fall,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension
Subdural hem w/o coma,Atrial fibrillation,Fall NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hypertension NOS
Name:  [**Known lastname 12357**],[**Known firstname 300**]                   Unit No:   [**Numeric Identifier 12358**]

Admission Date:  [**2195-10-4**]              Discharge Date:   [**2195-10-9**]

Date of Birth:  [**2114-12-19**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 599**]
Addendum:
Pt home with VNA Services

Discharge Medications/Orders:   Home medications
please continue all home medications unless otherwise instructed

  Levetiracetam  500 mg Tablet  Sig:  One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14  Tablet(s)*  Refills:*0*
  Tylenol  325 mg Tablet  Sig:  1-2 Tablets PO every 4-6 hours
as needed for pain.
  Home medications
Restart coumadin at home dose on [**2195-10-11**]. You should schedule a
follow-up appointment with your PCP or Cardiologist for [**10-13**] or
[**10-14**] to monitor your INR.
  Ativan  0.5 mg Tablet  Sig:  1-2 Tablets PO every 4-6 hours as
needed for agitation.
Disp:*30  Tablet(s)*  Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 328**] VNA

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]

Completed by:[**2195-10-9**]

Admission Date:  [**2195-10-4**]              Discharge Date:   [**2195-10-9**]

Date of Birth:  [**2114-12-19**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
80F transferred from OSH s/p mechanical fall in her yard,
hit her occiput on vinyl siding. No reported LOC. OSH head CT
revealed small SDH, INR 4.3, arrived to [**Hospital1 18**] receiving 2u ffp.

Past Medical History:
PMHx: Afib, DM2 neuropathy LLE>RLE, macular degeneration, HTN,
pacemaker
All: [**First Name9 (NamePattern2) **]
[**Last Name (un) 1724**]: coumadin, fe, lasix, incor, glyburide, digoxin, indural


Social History:
lives alone

Physical Exam:
On Admission:
98.2 60 170/74 18 98%RA
Gen: WD/WN, comfortable, pleasant, NAD.
HEENT: Pupils: R pupil 1.5->1mm, L pupil macular degeneration,
assymetric, 6mm. EOMI, no nystagmus.
Neck: Supple.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: BS+, S, NT/ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: AA+Ox3, cooperative with exam, nl affect.
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, to
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
or
tremors. Strength full power [**5-30**] throughout except L IP 5-/5. No
pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally.


Pertinent Results:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-10-4**]
8:26 PM
IMPRESSION:  Small focus of high-density material tracking along
the right
lateral aspect of the falx consistent with a small subdural
hematoma, with
minimal mass-effect.

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-10-5**]
4:01 AM
IMPRESSION:
1.  Stable small subdural hematoma along the falx cerebri.
2.  Multiple foci of air seen within the soft tissues, likely
within veins, and likely due to venous access.

Radiology Report CT HEAD W/O CONTRAST Study Date of [**2195-10-6**]
11:59 PM
IMPRESSION:  Stable appearance of small subdural hematoma along
the falx
cerebri.


Brief Hospital Course:
Pt was admitted to the neurosurgical service on [**2195-10-4**] s/p
mechanical fall p/w small SDH. In stable condition.  Pt was
admitted to the SICU for strict blood pressure control and Q1h
neuro checks. Repeat head CT on HD 2 and HD 3 showed a stable
subdural hematoma with no continued bleeding.  Pt's neurological
status remained stable with no focal neurological deficits.
However, while in the ICU pt would become agitated and confused
at night. The evening of HD2/HD3, an emergent psychiatry consult
was ordered for agitation and confusion.  Anticonvulsant
medication was switched from dilantin to keppra to r/o dilantin
as exacerbating confusion. Pt was given IV Haldol and agitation
improved. A repeat head CT showed no interval change. Pt
remained on Haldol PRN until her transfer to the neurosurgical
floor.  Agitation was resolved and confusion improved after
being transferred from the ICU and Haldol was discontinued.  At
time of discharge pt was ambulatory, tolerating a regular diet
and had no focal neurological deficits.


Medications on Admission:
coumadin, fe, lasix, incor, glyburide, digoxin, indural

Discharge Medications:
1. Home medications
please continue all home medications unless otherwise instructed
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Continue medication until your follow-up
appointment.
Disp:*30 Tablet(s)* Refills:*2*
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Subdural Hematoma


Discharge Condition:
Good


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	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
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. YOU WILL NEED A CAT SCAN OF THE
BRAIN WITHOUT CONTRAST
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Unspecified fall,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,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: 80F transferred from OSH s/p mechanical fall in her yard,
hit her occiput on vinyl siding. No reported LOC. OSH head CT
revealed small SDH, INR 4.3, arrived to [**Hospital1 18**] receiving 2u ffp.

MEDICAL HISTORY: PMHx: Afib, DM2 neuropathy LLE>RLE, macular degeneration, HTN,
pacemaker
All: [**First Name9 (NamePattern2) **]
[**Last Name (un) 1724**]: coumadin, fe, lasix, incor, glyburide, digoxin, indural

MEDICATION ON ADMISSION: coumadin, fe, lasix, incor, glyburide, digoxin, indural

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
98.2 60 170/74 18 98%RA
Gen: WD/WN, comfortable, pleasant, NAD.
HEENT: Pupils: R pupil 1.5->1mm, L pupil macular degeneration,
assymetric, 6mm. EOMI, no nystagmus.
Neck: Supple.
Lungs: CTAB.
Cardiac: RRR. nl S1/S2.
Abd: BS+, S, NT/ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: AA+Ox3, cooperative with exam, nl affect.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: 

SOCIAL HISTORY: lives alone 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Unspecified fall,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Unspecified essential hypertension'}
