CHIEF COMPLAINT: Left sided headaches

PRESENT ILLNESS: Ms. [**Known lastname 59190**] is a 58-year-old female who presented with bilateral
subdural hematoma after a fall.  She subsequently had bilateral
burr holes on [**2151-1-24**].  Following this, she has improved but
still continues to have left-sided headaches and the ;eft
collection never fully resolved and she opted to procede for
surgery.

MEDICAL HISTORY: depression, anxiety,
hyperlipidemia, and hypertension.

MEDICATION ON ADMISSION: Citalopram 30mg daily, Pravastatin 40mg daily, Diltiazem 30mg
QID, Lisinopril 40mg daily, Percocet 5/325mg prn, Trazodone 50mg
QHS, Keppra 750mg [**Hospital1 **], famotadine 20mg [**Hospital1 **]

ALLERGIES: Penicillins

PHYSICAL EXAM: At discharge:
Alert and oriented x3, PERRL, speech clear, follows commands,
MAE [**6-19**], incision C/D/I with sutures

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses
Subdural hemorrhage,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Extrinsic asthma, unspecified,Unspecified essential hypertension,Tobacco use disorder,History of fall,Personal history of allergy to penicillin
Subdural hemorrhage,Anxiety state NOS,Hyperlipidemia NEC/NOS,Extrinsic asthma NOS,Hypertension NOS,Tobacco use disorder,Personal history of fall,Hx-penicillin allergy
Admission Date:  [**2151-3-2**]              Discharge Date:   [**2151-3-5**]

Date of Birth:  [**2092-5-31**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Left sided headaches

Major Surgical or Invasive Procedure:
[**2151-3-2**]: Left Craniotomy for SDH


History of Present Illness:
Ms. [**Known lastname 59190**] is a 58-year-old female who presented with bilateral
subdural hematoma after a fall.  She subsequently had bilateral
burr holes on [**2151-1-24**].  Following this, she has improved but
still continues to have left-sided headaches and the ;eft
collection never fully resolved and she opted to procede for
surgery.


Past Medical History:
depression, anxiety,
hyperlipidemia, and hypertension.

Social History:
Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses


Family History:
non contributory

Physical Exam:
At discharge:
Alert and oriented x3, PERRL, speech clear, follows commands,
MAE [**6-19**], incision C/D/I with sutures

Pertinent Results:
[**2151-3-2**] 02:37PM   PT-10.8 PTT-32.5 INR(PT)-1.0

CT head [**2151-3-2**]:
IMPRESSION:
Interval left craniotomy with expected pneumocephalus and
decrease in size of the subdural hematoma layering over the left
cerebral convexity. No evidence of re-accumulation.


Brief Hospital Course:
Ms. [**Known lastname 59190**] was admitted to [**Hospital1 18**] under the care of DR. [**First Name (STitle) **].
She proceded to the OR and underwent a left craniotomy for SDH
for evacuation. She was extubated and taken to PACU. CT head
showed some residaul hematoma but she was neurologically stable
and remained in the ICU overnight. She was on CIWA precautions
to follow for possible ETOH withdraw. Her exam remained stable
and she was transferred to the floor on [**3-3**]. She remained
stable. On [**3-4**], she was observed by PT and acute PT was not
recommended. Outpatient PT was given as an option for endurance
training if the patient wanted.

She was discharged home with her daughter on [**3-5**]. She was
discharged on Keppra and with a outpatient PT order in case she
decides to go ahead with PT.

Medications on Admission:
Citalopram 30mg daily, Pravastatin 40mg daily, Diltiazem 30mg
QID, Lisinopril 40mg daily, Percocet 5/325mg prn, Trazodone 50mg
QHS, Keppra 750mg [**Hospital1 **], famotadine 20mg [**Hospital1 **]


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. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*QS Patch 24 hr(s)* Refills:*0*
3. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
11. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day:
Continue until seen by Dr [**First Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
Subdural hematoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
General Instructions

??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting > 10 lbs,
straining, or excessive bending.
??????	You may wash your hair only after sutures have been removed.
??????	You may shower before this time using a shower cap to cover
your head.
??????	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, and
Ibuprofen etc.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this when cleared by your neurosurgeon.
??????	You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.


Followup Instructions:
??????Please return to the office in 10 days (from your date of
surgery) for removal of your sutures. This appointment can be
made by calling [**Telephone/Fax (1) 4296**]. If you live quite a distance from
our office, please make arrangements for the same, with your
PCP.
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2151-3-5**]
{'Subdural hemorrhage,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Extrinsic asthma, unspecified,Unspecified essential hypertension,Tobacco use disorder,History of fall,Personal history of allergy to penicillin'}


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: Left sided headaches

PRESENT ILLNESS: Ms. [**Known lastname 59190**] is a 58-year-old female who presented with bilateral
subdural hematoma after a fall.  She subsequently had bilateral
burr holes on [**2151-1-24**].  Following this, she has improved but
still continues to have left-sided headaches and the ;eft
collection never fully resolved and she opted to procede for
surgery.

MEDICAL HISTORY: depression, anxiety,
hyperlipidemia, and hypertension.

MEDICATION ON ADMISSION: Citalopram 30mg daily, Pravastatin 40mg daily, Diltiazem 30mg
QID, Lisinopril 40mg daily, Percocet 5/325mg prn, Trazodone 50mg
QHS, Keppra 750mg [**Hospital1 **], famotadine 20mg [**Hospital1 **]

ALLERGIES: Penicillins

PHYSICAL EXAM: At discharge:
Alert and oriented x3, PERRL, speech clear, follows commands,
MAE [**6-19**], incision C/D/I with sutures

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses 

### Response:
{'Subdural hemorrhage,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Extrinsic asthma, unspecified,Unspecified essential hypertension,Tobacco use disorder,History of fall,Personal history of allergy to penicillin'}
