CHIEF COMPLAINT: Severe Headache x 1wk

PRESENT ILLNESS: 55 yo male who reports a [**10-22**] headache x 1 week. He reports
hitting his head about 2 weeks ago on a cabinet, then had the
flu
with vomiting and diarrhea. After vomiting he began to
experience
sharp headaches from the R occipital region to the right
parietal
area. The headache would be severe with vomiting and coughing.
Although he began to feel better, the headache continued. Today,
his wife felt he was groggy and slightly more lethargic and
called 911.

MEDICAL HISTORY: Gastritis
HTN
Borderline high cholesterol
Rheumatic fever at 18 yo
Tonsillectomy

MEDICATION ON ADMISSION: Calcium w/ Vit D, Atenolol/HCTZ 50/25, MVI

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:98.5  BP: 125/80   HR: 62   R 16  O2Sats 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2 bilaterally  EOMs intact w/o nystagmus
Extrem: Warm and well-perfused.

FAMILY HISTORY: Father: Alive, NPH, Cardiac hx
Mother: Deceased, [**Name (NI) **] CA
Siblings: 4, HTN, NPH

SOCIAL HISTORY: Works for [**Location (un) 932**] Woodworkers as a sales person. Lives with
wife,
no children. Reports alot of stress secondary to work and
helping
his father who is elderly. Denies tobacco, ETOH 1x wk, denies
recreational drug use.
Intracerebral hemorrhage,Unspecified essential hypertension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Rheumatic heart disease, unspecified,Esophageal reflux,Homonymous bilateral field defects
Intracerebral hemorrhage,Hypertension NOS,Gstr/ddnts NOS w/o hmrhg,Rheumatic heart dis NOS,Esophageal reflux,Homonymous hemianopsia
Admission Date:  [**2122-12-29**]              Discharge Date:   [**2123-1-4**]

Date of Birth:  [**2067-5-16**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Severe Headache x 1wk

Major Surgical or Invasive Procedure:
CEREBRAL ANGIOGRAM on [**2123-1-1**] with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]


History of Present Illness:
55 yo male who reports a [**10-22**] headache x 1 week. He reports
hitting his head about 2 weeks ago on a cabinet, then had the
flu
with vomiting and diarrhea. After vomiting he began to
experience
sharp headaches from the R occipital region to the right
parietal
area. The headache would be severe with vomiting and coughing.
Although he began to feel better, the headache continued. Today,
his wife felt he was groggy and slightly more lethargic and
called 911.


Past Medical History:
Gastritis
HTN
Borderline high cholesterol
Rheumatic fever at 18 yo
Tonsillectomy


Social History:
Works for [**Location (un) 932**] Woodworkers as a sales person. Lives with
wife,
no children. Reports alot of stress secondary to work and
helping
his father who is elderly. Denies tobacco, ETOH 1x wk, denies
recreational drug use.


Family History:
Father: Alive, NPH, Cardiac hx
Mother: Deceased, [**Name (NI) **] CA
Siblings: 4, HTN, NPH


Physical Exam:
PHYSICAL EXAM:
O: T:98.5  BP: 125/80   HR: 62   R 16  O2Sats 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2 bilaterally  EOMs intact w/o nystagmus
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert; cooperative with exam, normal
affect.
Orientation: Oriented to person, said he was at [**Hospital1 112**], and thought
it was [**2122-12-25**]
Recall: able to name current and past president. Able to recall
[**10-23**] events; able to recall 3 current events
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to
2 mm bilaterally. Visual fields reveal left visual field cut.
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 [**6-16**] throughout. No pronator drift

Sensation: Intact to light touch

Toes downgoing on left, right

Does appear to have a left sided neglect- could "hear" the
person
on his left but would not turn towards him or acknowledge.

Upon Discharge:
Awake alert oriented x 3 - non focal exam / distracted at times
/poor at identifying social skills.

Pertinent Results:
CT Head [**2122-12-29**]:
IMPRESSION:
1. Large intraparenchymal hemorrhage within the right
frontotemporal lobe
with a small subdural component, neighboring mass effect with up
to a 4 mm
leftward shift of midline structures, and trace intraventricular
extension
along the occipital [**Doctor Last Name 534**] of the right lateral ventricle. These
findings are relatively stable in comparison to the prior
outside hospital study earlier this morning.
2. Large frontal extra-axial spaces likely secondary to chronic
frontal lobe atrophy. Differential diagnosis remains broad,
however given particulars of appearance, consideration can be
given to frontotemporal dementia.


CTA Head and Neck [**2122-12-29**]:
No vascular anomalies or aneurysms noted.

CT Head [**2122-12-30**]:
IMPRESSION:
1. Essentially unchanged large intraparenchymal hemorrhage in
the right
frontotemporal lobe with a tiny subdural component.
2. Unchanged mass effect as described. No new foci of
hemorrhage. No
evidence of developing hydrocephalus.

Cerebral Angiogram [**2123-1-1**]:
Negative angiogram: no vascular anomaly or aneurysm seen.

CT Head [**2123-1-1**]:
IMPRESSION:
1. Stable parenchymal hemorrhage at the right frontotemporal
lobe with very small subdural component, likely representing
slowly resolving hematoma, with stable mass effect.
2. Extensive region of perihemorrhagic vasogenic edema, overall
unchanged;
however, the disproportionate edema, particularly
anterosuperiorly, raises the possibility of an underlying
lesion. Enhanced MRI is recommended for better characterization,
as suggested
previously.
3. No new focus of hemorrhage.


Brief Hospital Course:
55 yo male admitted after c/o a [**10-22**] headache x 1 week. CT Head
revealed a right IPH w/ effacement of the right lateral
ventricle and small right SDH. He was admitted to the ICU for
close monitoring. A CTA of the head and neck was done to r/o any
vascular anomalies because of his report that the headache began
after vomitting. His exam and Head CT remained stable and on
[**12-30**] he was transferred from the ICU to Step Down. On [**1-1**] a
diagnostic cerebral angiogram was done and showed no indication
of aneurysm or venous anomaly; he was then transferred to the
floor. Physical therapy and Occupational therapy was consulted
and cleared the patient for home but felt that he would need
cognitive rehab.

Medications on Admission:
Calcium w/ Vit D, Atenolol/HCTZ 50/25, MVI


Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: [**2-13**] Capsules PO
DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
RIGHT INTRAPARENCHYMAL HEMMORRHAGE
RIGHT SUBDURAL HEMATOMA


Discharge Condition:
stable & nonfocal exam but cognitive problems


Discharge Instructions:
*Take your pain medicine as prescribed
??????Exercise should be limited to walking; no lifting, straining,
excessive bending
??????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 in 7
days and fax results to [**Telephone/Fax (1) 87**].
??????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:
You will need an MRI/MRA, which you can at [**Hospital3 3583**].
Please call Dr. [**Last Name (STitle) **] office to set this up.
NO DRIVING UNTIL YOU  ARE CLEARED TO DO SO BY YOUR PRIMARY CARE
PHYSICIAN
please call your primary care physian to arrange for neuro-psych
testing
PLEASE CALL [**Telephone/Fax (1) 4296**] TO SCHEDULE AN APPOINTMENT WITH
DR.[**First Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST.

Please call [**Telephone/Fax (1) 4296**] with any questions or concerns.



Completed by:[**2123-1-5**]
{'Intracerebral hemorrhage,Unspecified essential hypertension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Rheumatic heart disease, unspecified,Esophageal reflux,Homonymous bilateral field defects'}


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: Severe Headache x 1wk

PRESENT ILLNESS: 55 yo male who reports a [**10-22**] headache x 1 week. He reports
hitting his head about 2 weeks ago on a cabinet, then had the
flu
with vomiting and diarrhea. After vomiting he began to
experience
sharp headaches from the R occipital region to the right
parietal
area. The headache would be severe with vomiting and coughing.
Although he began to feel better, the headache continued. Today,
his wife felt he was groggy and slightly more lethargic and
called 911.

MEDICAL HISTORY: Gastritis
HTN
Borderline high cholesterol
Rheumatic fever at 18 yo
Tonsillectomy

MEDICATION ON ADMISSION: Calcium w/ Vit D, Atenolol/HCTZ 50/25, MVI

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:98.5  BP: 125/80   HR: 62   R 16  O2Sats 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5 to 2 bilaterally  EOMs intact w/o nystagmus
Extrem: Warm and well-perfused.

FAMILY HISTORY: Father: Alive, NPH, Cardiac hx
Mother: Deceased, [**Name (NI) **] CA
Siblings: 4, HTN, NPH

SOCIAL HISTORY: Works for [**Location (un) 932**] Woodworkers as a sales person. Lives with
wife,
no children. Reports alot of stress secondary to work and
helping
his father who is elderly. Denies tobacco, ETOH 1x wk, denies
recreational drug use. 

### Response:
{'Intracerebral hemorrhage,Unspecified essential hypertension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Rheumatic heart disease, unspecified,Esophageal reflux,Homonymous bilateral field defects'}
