CHIEF COMPLAINT: headache and neck pain

PRESENT ILLNESS: HPI:24F who was playing softball this afternoon at approximately
4pm, when she collided head-on with another player.  Per
wittiness, she fell to the ground with positive loss of
consciousness for "a few seconds".  Witness states that when she
awoke, she was a little confused, but was fully herself after a
couple minutes. Patient states that she also experienced burning
on the right side of her head after the collision and some
blurry
vision.

MEDICAL HISTORY: PMHx:
1. Migraine Headaches
2. Wisdom teeth extraction
3. Hx of concussion during cheerleading incident.

MEDICATION ON ADMISSION: 1. Imitrex prn
2. OCP

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival

FAMILY HISTORY: Family Hx: non-contributory

SOCIAL HISTORY: Social Hx: denies ETOH and illicit substances, lives with
parents
Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Fall on same level from collision, pushing, or shoving, by or with other person in sports
Cl skul base fx-brf coma,Fall in sports
Admission Date:  [**2165-6-16**]              Discharge Date:   [**2165-6-20**]

Date of Birth:  [**2141-5-8**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache and neck pain

Major Surgical or Invasive Procedure:
NONE


History of Present Illness:
HPI:24F who was playing softball this afternoon at approximately
4pm, when she collided head-on with another player.  Per
wittiness, she fell to the ground with positive loss of
consciousness for "a few seconds".  Witness states that when she
awoke, she was a little confused, but was fully herself after a
couple minutes. Patient states that she also experienced burning
on the right side of her head after the collision and some
blurry
vision.


Past Medical History:
PMHx:
1. Migraine Headaches
2. Wisdom teeth extraction
3. Hx of concussion during cheerleading incident.


Social History:
Social Hx: denies ETOH and illicit substances, lives with
parents


Family History:
Family Hx: non-contributory


Physical Exam:
on arrival

PHYSICAL EXAM:
O: T: 98.4  BP:116/74   HR:90   RR:12   O2Sats 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Pupils: PERRL      EOMs intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
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, 4mm to
2mm 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 [**6-3**] throughout. No pronator drift.
No Dysmetria

Sensation: Intact to light touch, proprioception.

Reflexes: B T Br Pa Ac
Right     2 2 2  2  2
Left      2 2 2  2  2

Toes downgoing bilaterally, no clonus
Coordination: normal on finger-nose-finger

on discharge
non focal neurological exam


Pertinent Results:
   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2165-6-17**] 7:55 AM

CT HEAD W/O CONTRAST

Reason: evaluate evolution of EDH. Please do at 7am on [**6-17**].

[**Hospital 93**] MEDICAL CONDITION:
24 year old woman with EDh s/p head on collision during softball
game
REASON FOR THIS EXAMINATION:
evaluate evolution of EDH. Please do at 7am on [**6-17**].
CONTRAINDICATIONS for IV CONTRAST: None.

ROUTINE NON-ENHANCED CT HEAD.

HISTORY: Trauma, follow up epidural hematoma.

Comparison is made with prior study of 2236 hours on [**2165-6-16**].

FINDINGS:

Accounting for differences in technique and head positioning,
the left temporal epidural hematoma is essentially stable. There
is a stable left temporal bone fracture. The basilar cisterns
appear to be patent. Asymmetric mild enlargement of the right
temporal [**Doctor Last Name 534**] is unchanged. There is stable effacement of the
left temporal [**Doctor Last Name 534**].

IMPRESSION:

Unchanged left temporal epidural hematoma.

RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2165-6-16**] 5:08 PM

CT HEAD W/O CONTRAST

Reason: eval for ICH

[**Hospital 93**] MEDICAL CONDITION:
24 year old woman with collision with another player, LOC,
amnesia
REASON FOR THIS EXAMINATION:
eval for ICH
CONTRAINDICATIONS for IV CONTRAST: None.

CT HEAD WITHOUT CONTRAST.

COMPARISON: None.

HISTORY: 24-year-old female with collision with loss of
consciousness, amnesia, evaluate for intracranial hemorrhage.

TECHNIQUE: MDCT axially acquired images through the head were
obtained. IV contrast was not administered.

FINDINGS: Hyperdense extraaxial collection is seen along the
left middle cranial fossa (2A:6). This likely represents a large
epidural hematoma measuring up to 1.7 cm and extending over the
left temporal lobe. Extensive soft tissue swelling is noted over
the left parietotemporal bone. There is no shift of normally
midline structures. The sulci are unremarkable. There is
effacement of the left temporal [**Doctor Last Name 534**]. A linear nondisplaced and
nondepressed fracture of the left squamous parietal bone (3A:15)
and (3A:12) is identified and likely extends to the petrous
portion of the left temporal bone due to the left mastoid air
cells being partially opacified with fluid.

IMPRESSION: Large epidural hematoma within the left middle
cranial fossa with overlying soft tissue swelling and left
parietal bone fracture. Possible extension to the left temporal
bone is suspected due to opacified left mastoid air cells. No
shift of normally midline structures at this time.

RADIOLOGY  Final Report

CT C-SPINE W/O CONTRAST  [**2165-6-16**] 5:08 PM

CT C-SPINE W/O CONTRAST

Reason: eval for fx

[**Hospital 93**] MEDICAL CONDITION:
24 year old woman with collision with another player, LOC,
amnesia, TTP c spine
REASON FOR THIS EXAMINATION:
eval for fx
CONTRAINDICATIONS for IV CONTRAST: None.

CT C-SPINE WITHOUT CONTRAST.

COMPARISON: None.

HISTORY: 24-year-old female status post trauma.

TECHNIQUE: MDCT axially acquired images of the cervical spine
with coronal and sagittal reformats were performed.

FINDINGS: There is no prevertebral soft tissue swelling. The
intervertebral alignment is preserved. There are no degenerative
changes, dislocations, or acute fractures noted. Partial
opacification of the left mastoid air cells is noted.

IMPRESSION: No evidence of acute fracture or dislocation.

RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2165-6-16**] 10:26 PM

CT HEAD W/O CONTRAST

Reason: evaluate evolution of EDH. Please do at 11pm

[**Hospital 93**] MEDICAL CONDITION:
24 year old woman with EDh s/p head on collision during softball
game
REASON FOR THIS EXAMINATION:
evaluate evolution of EDH. Please do at 11pm
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: Status post head on collision, with epidural
hematoma. Evaluate for change.

COMPARISON: Comparison is made to study performed four hours
earlier.

TECHNIQUE: Non-contrast head CT scan.

FINDINGS: Allowing for slight positional differences, no
significant change seen compared to prior study. Hyperdense
extra-axial collection along the left middle cranial fossa
likely representing epidural hematoma is unchanged from prior
study. This again measures upwards of approximately 1.6 cm in
greatest width, extending over the left temporal lobe. Subgaleal
hematoma over the left parietotemporal bone is unchanged. There
is no shift of midline structures. Unchanged effacement of the
left temporal [**Doctor Last Name 534**] is again noted. Nondisplaced fracture of the
left squamous parietal bone is also again seen, with partially
opacified left mastoid air cells.

IMPRESSION: Allowing for slight positional differences, no
significant change compared to prior study, with left epidural
hematoma again identified.


Brief Hospital Course:
Pt was admitted to the SICU after initial eval in the ED for
EDH.  Serial cat scans of the brain demonstrated stable
appearance of the EDH.  On Hospital day number 2 her diet was
advanced to clears. On hosp day 3 she was tranfered to a regular
floor.  Her diet was advanced further.  She tolerated po intake
and is voiding freely.  She was also started on dilantin and
this will continue for a total of 30 days. Follow up CT showed
beginning of resolution of blood She was seen by PT for safety
with ambulation and she cleared to go home. Her course has been
uneventful and she is safe for discharge home.

Medications on Admission:
1. Imitrex prn
2. OCP


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed.
Disp:*45 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 30 days.
Disp:*90 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
EPIDURAL HEMATOMA / LEFT SIDED


Discharge Condition:
neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a family member check your incision daily for signs of
infection
??????	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 as
ordered

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
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE CALL THE OFFICE TO BE SEEN BY DR. [**First Name (STitle) **]  NEUROSURGEON TO
BE SEEN IN 4 weeks time.  [**Telephone/Fax (1) **]  YOU WILL NEED A CAT SCAN
OF THE BRAIN AT THAT TIME.

Have your primary care physician order [**Name Initial (PRE) **] dilantin level in one
week.



Completed by:[**2165-6-20**]
{'Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Fall on same level from collision, pushing, or shoving, by or with other person in sports'}


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: headache and neck pain

PRESENT ILLNESS: HPI:24F who was playing softball this afternoon at approximately
4pm, when she collided head-on with another player.  Per
wittiness, she fell to the ground with positive loss of
consciousness for "a few seconds".  Witness states that when she
awoke, she was a little confused, but was fully herself after a
couple minutes. Patient states that she also experienced burning
on the right side of her head after the collision and some
blurry
vision.

MEDICAL HISTORY: PMHx:
1. Migraine Headaches
2. Wisdom teeth extraction
3. Hx of concussion during cheerleading incident.

MEDICATION ON ADMISSION: 1. Imitrex prn
2. OCP

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival

FAMILY HISTORY: Family Hx: non-contributory

SOCIAL HISTORY: Social Hx: denies ETOH and illicit substances, lives with
parents 

### Response:
{'Closed fracture of base of skull without mention of intra cranial injury, with brief [less than one hour] loss of consciousness,Fall on same level from collision, pushing, or shoving, by or with other person in sports'}
