CHIEF COMPLAINT: headaches

PRESENT ILLNESS: 49 m with history of EtOH abuse and withdrawal seizures, now
transferred from [**Hospital **] Hospital with acute subdural hematoma.
Patient reports he fell off bicycle approximately 1 week ago. He
was unhelmeted and hit head, although denies LOC. Since the
fall,
he has experienced frontal headaches and nausea. Patient reports
drinking 1pint Vodka per day "to ease the pain." Over the past
few days, patient had 2-3 episodes of emesis - non-bloody,
non-bilious. No fever or chills. Denies dizziness, unsteady
gait,
loss of balance. On presentation to [**Hospital **] Hospital, patient
had
tonic-clonic seizure - lasted <1 minute and was given 2mg ativan
with cessation of seizure. The patient was subsequently
transferred to [**Hospital1 18**] for further neurosurgical evaluation.

MEDICAL HISTORY: PMH: EtOH abuse, withdrawal seizures - 3 hospitalizations w/in
past 1 year
PSH: L. inguinal hernia repair

MEDICATION ON ADMISSION: Tegretol 20mg [**Hospital1 **], Metoprolol 25mg [**Hospital1 **], Flonase prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 97.4  BP: 151/95    HR:83   R:16   O2Sats: 97%RA
A&O X 3, comfortable, NAD
PERRL, 3 to 2mm bilateral, EOMI
No neck pain on palpation. C-collar in place.
RRR
Lungs CTAB
Abdomen soft, NT/ND, normal bs
L. flank bruise, non-tender
L. thigh bruise, non-tender
LE warm b/l

FAMILY HISTORY: non contributory

SOCIAL HISTORY: EtOH per HPI, smokes 1 ppd cigarettes, denies recreational
drug use
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of three ribs,Pedal cycle accident injuring pedal cyclist,Street and highway accidents,Atrial fibrillation,Acute alcoholic intoxication in alcoholism, continuous,Anxiety state, unspecified
Brain lacer NEC w/o coma,Fracture three ribs-clos,Ped cycl acc-ped cyclist,Accid on street/highway,Atrial fibrillation,Ac alcohol intox-contin,Anxiety state NOS
Admission Date:  [**2113-11-10**]              Discharge Date:   [**2113-11-14**]

Date of Birth:  [**2063-12-14**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
headaches

Major Surgical or Invasive Procedure:
none


History of Present Illness:
49 m with history of EtOH abuse and withdrawal seizures, now
transferred from [**Hospital **] Hospital with acute subdural hematoma.
Patient reports he fell off bicycle approximately 1 week ago. He
was unhelmeted and hit head, although denies LOC. Since the
fall,
he has experienced frontal headaches and nausea. Patient reports
drinking 1pint Vodka per day "to ease the pain." Over the past
few days, patient had 2-3 episodes of emesis - non-bloody,
non-bilious. No fever or chills. Denies dizziness, unsteady
gait,
loss of balance. On presentation to [**Hospital **] Hospital, patient
had
tonic-clonic seizure - lasted <1 minute and was given 2mg ativan
with cessation of seizure. The patient was subsequently
transferred to [**Hospital1 18**] for further neurosurgical evaluation.


Past Medical History:
PMH: EtOH abuse, withdrawal seizures - 3 hospitalizations w/in
past 1 year
PSH: L. inguinal hernia repair


Social History:
EtOH per HPI, smokes 1 ppd cigarettes, denies recreational
drug use


Family History:
non contributory

Physical Exam:
T: 97.4  BP: 151/95    HR:83   R:16   O2Sats: 97%RA
A&O X 3, comfortable, NAD
PERRL, 3 to 2mm bilateral, EOMI
No neck pain on palpation. C-collar in place.
RRR
Lungs CTAB
Abdomen soft, NT/ND, normal bs
L. flank bruise, non-tender
L. thigh bruise, non-tender
LE warm b/l


Pertinent Results:
[**2113-11-10**] 12:50AM   WBC-9.6 RBC-3.63* HGB-11.9* HCT-34.0* MCV-94
MCH-32.9* MCHC-35.1* RDW-13.3
[**2113-11-10**] 12:50AM   NEUTS-91.2* LYMPHS-5.2* MONOS-3.0 EOS-0.4
BASOS-0.2
[**2113-11-10**] 12:50AM   PLT COUNT-195
[**2113-11-10**] 12:50AM   PT-10.6 PTT-24.3 INR(PT)-0.9
[**2113-11-10**] 12:50AM   ASA-NEG ETHANOL-NEG CARBAMZPN-4.3
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2113-11-10**] 12:50AM   GLUCOSE-256* UREA N-4* CREAT-0.6 SODIUM-127*
POTASSIUM-3.0* CHLORIDE-87* TOTAL CO2-30 ANION GAP-13
[**2113-11-10**] 10:45AM   CALCIUM-8.9 PHOSPHATE-2.3* MAGNESIUM-2.0
[**2113-11-10**] 10:45AM   GLUCOSE-121* UREA N-4* CREAT-0.6 SODIUM-130*
POTASSIUM-3.4 CHLORIDE-92* TOTAL CO2-27 ANION GAP-14

[**2113-11-14**] 06:05AM BLOOD WBC-6.3 RBC-3.71* Hgb-11.8* Hct-35.3*
MCV-95 MCH-31.7 MCHC-33.3 RDW-14.4 Plt Ct-328
[**2113-11-14**] 06:05AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-136
K-3.8 Cl-99 HCO3-29 AnGap-12
[**2113-11-14**] 06:05AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.8

[**2113-11-10**] C Spine CT :
1. No fracture or malalignment of the cervical spine.

2. Posterior disc bulge at C4-5 contacting the thecal sac. If
neurologic
symptoms are referable to this location, MRI is recommended for
assessment of the spinal cord.

[**2113-11-10**] Head CT :1. Stable appearance of right subdural hematoma
overlying the right cerebral convexity and layering within the
falx and left tentorium. This is unchanged from the prior study
of approximately three and a half hours earlier.
  2. No new areas of hemorrhage. No herniation.

[**2113-11-10**] Abd CT : . Possible acute, nondisplaced fractures of
posterior right 9th-12th ribs superimposed upon chronic
fractures in this location. Correlate clinically.

2. No retroperitoneal hematoma.

3. Markedly distended urinary bladder.

[**2113-11-10**] Repeat Head CT :
The right frontal subdural mixed-density hematoma is relatively
stable. There is also stable subdural along the left tentorial
reflection. There is encephalomalacia, left greater than right
inferior frontal lobes which may be related to prior trauma and
is unchanged.
  The ventricles and sulci are stable in size and configuration.

  IMPRESSION:
  No significant change compared to the prior study.

[**2113-11-13**] Echo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.







Brief Hospital Course:
Mr. [**Known lastname 84474**] was admitted to the hospital for close neurologic
observation and monitoring of his vital signs.  He was admitted
to the hospital on Tegretol and therefore did not receive
Dilantin.  He was followed by the Neurosurgery service and a
repeat head CT was done 24 hours after admission and revealed no
shange in the hematoma. His neuro exam did not change. His
tegretol level was 4.3. He did not have any seizures during his
hospitalization.  Valium was used to treat the signs and
symptoms of withdrawal.

On multiple occasions he was seen by the social worker to help
assess his adiction needs as well as his families needs.  Mr.
[**Known lastname 84474**] has been doing poorly for many months and his drinking has
put him in a dangerous situation in regards to his safety and
his families ability to cope and care for him.

He developed rapid atrial fibrillation on [**2113-11-12**] with a
ventricular response to 150 BPM.  This prompted transfer to the
ICU for treatment with a diltiazem drip.  He denied chest pain,
shortness of breath, nausea or vomiting and serial enzymes were
negative.  A cardiac echo was done which showed a normal EF and
no wall motion abnormalities.  He converted to sinus rhythme
about 24 hours later and was converted to oral Lopressor.  His
heart rate was maintained at 74 bpm.

Following his transfer back to the Trauma floor he was up and
walking without difficulty, tolerating a regular diet and
preparing to deal with his addictions problem. [**Name (NI) 3003**] to
discharge he had a PPD placed. He remained in sinus rhythm,
vital signs were stable, pain well controlled.


Medications on Admission:
Tegretol 20mg [**Hospital1 **], Metoprolol 25mg [**Hospital1 **], Flonase prn


Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. right subdural hematoma
2. Right rib fractures [**10-21**]
3. Atrial fibrillation, now resolved


Discharge Condition:
stable


Discharge Instructions:
DO NOT DRINK ANY ALCOHOL
?????? Take your pain medicine as prescribed but gradually wean it
off.
?????? 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, Aspirin, 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:
Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 84475**] for a follow up appointment in 2
weeks

Call Dr. [**Last Name (STitle) 2093**] for a follow up appointment in [**2-10**] weeks.

Arrange for [**Hospital **] Rehabilitation based on the Social Workers
recommendations

Have and MD [**First Name (Titles) **] [**Last Name (Titles) **] read the PPD that was placed prior to DC
between 48-72h after placement.
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of three ribs,Pedal cycle accident injuring pedal cyclist,Street and highway accidents,Atrial fibrillation,Acute alcoholic intoxication in alcoholism, continuous,Anxiety state, 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: headaches

PRESENT ILLNESS: 49 m with history of EtOH abuse and withdrawal seizures, now
transferred from [**Hospital **] Hospital with acute subdural hematoma.
Patient reports he fell off bicycle approximately 1 week ago. He
was unhelmeted and hit head, although denies LOC. Since the
fall,
he has experienced frontal headaches and nausea. Patient reports
drinking 1pint Vodka per day "to ease the pain." Over the past
few days, patient had 2-3 episodes of emesis - non-bloody,
non-bilious. No fever or chills. Denies dizziness, unsteady
gait,
loss of balance. On presentation to [**Hospital **] Hospital, patient
had
tonic-clonic seizure - lasted <1 minute and was given 2mg ativan
with cessation of seizure. The patient was subsequently
transferred to [**Hospital1 18**] for further neurosurgical evaluation.

MEDICAL HISTORY: PMH: EtOH abuse, withdrawal seizures - 3 hospitalizations w/in
past 1 year
PSH: L. inguinal hernia repair

MEDICATION ON ADMISSION: Tegretol 20mg [**Hospital1 **], Metoprolol 25mg [**Hospital1 **], Flonase prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 97.4  BP: 151/95    HR:83   R:16   O2Sats: 97%RA
A&O X 3, comfortable, NAD
PERRL, 3 to 2mm bilateral, EOMI
No neck pain on palpation. C-collar in place.
RRR
Lungs CTAB
Abdomen soft, NT/ND, normal bs
L. flank bruise, non-tender
L. thigh bruise, non-tender
LE warm b/l

FAMILY HISTORY: non contributory

SOCIAL HISTORY: EtOH per HPI, smokes 1 ppd cigarettes, denies recreational
drug use 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Closed fracture of three ribs,Pedal cycle accident injuring pedal cyclist,Street and highway accidents,Atrial fibrillation,Acute alcoholic intoxication in alcoholism, continuous,Anxiety state, unspecified'}
