CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: 61M s/p fall from standing while playing soccer today
w/report of SDH from CT head at OSH (not available). Pt is
primarily Korean speaking male who states that he did lose
consciousness for a few seconds after the fall. He does report
+HA but no diplopia, no photophobia, no nuchal rigidity. Upon
transfer via [**Location (un) **] patient with one episode of vomiting.
Otherwise, GCS 15 on arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals P88 149/88 16 97%RA
Gen: NAD
HEENT: small occipital laceration, PERRLA, EOMI
Neck: Supple, C collar in place with no tenderness to palp
Lungs: CTA bilaterally
Cardiac: RRR. S1/S2
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E

FAMILY HISTORY: NK

SOCIAL HISTORY: Married with children
From [**Country 10181**] originally
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Unspecified fall
Cl skul base fx/brf coma,Fall NOS
Admission Date:  [**2126-4-29**]              Discharge Date:   [**2126-5-1**]

Date of Birth:  [**2064-12-11**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
61M s/p fall from standing while playing soccer today
w/report of SDH from CT head at OSH (not available). Pt is
primarily Korean speaking male who states that he did lose
consciousness for a few seconds after the fall. He does report
+HA but no diplopia, no photophobia, no nuchal rigidity. Upon
transfer via [**Location (un) **] patient with one episode of vomiting.
Otherwise, GCS 15 on arrival.


Past Medical History:
None

Social History:
Married with children
From [**Country 10181**] originally

Family History:
NK

Physical Exam:
Vitals P88 149/88 16 97%RA
Gen: NAD
HEENT: small occipital laceration, PERRLA, EOMI
Neck: Supple, C collar in place with no tenderness to palp
Lungs: CTA bilaterally
Cardiac: RRR. S1/S2
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
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 finger rub bilaterally.
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 [**4-5**] throughout. No pronator drift

Sensation: Intact to light touch throughout.

Reflexes: deferred in trauma bay


Pertinent Results:
[**2126-4-29**] 04:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2126-4-29**] 04:45PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2126-4-29**] 04:45PM   FIBRINOGE-252
[**2126-4-29**] 04:45PM   PT-11.1 PTT-18.5* INR(PT)-0.9
[**2126-4-29**] 04:45PM   PLT COUNT-152
[**2126-4-29**] 04:45PM   WBC-14.7* RBC-4.55* HGB-15.0 HCT-40.9 MCV-90
MCH-33.0* MCHC-36.7* RDW-12.8
[**2126-4-29**] 04:45PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-4-29**] 04:45PM URINE  HOURS-RANDOM

CT Head [**2126-4-29**]: Subarachnoid hemorrhage in the right sylvian
fissure, could be secondary to trauma or secondary to ruptured
aneurysm. CTA of the head could be performed.
2. Convex hemorrhage in the left occipital region bounded by
seizures could represent epidural hemorrhage.
3. Left occipital fracture.
Note added at attending review: The left parieto-occipital
extra-axial
hematoma crosses the lambdoid suture and is probably subdural.
The fracture of the left parietal bone does not definitely cross
the lambdoid suture.

CTA Head [**2126-4-29**]: No evidence of aneurysm.

CT Head [**2126-4-30**]: Improving right subarachnoid hemorrhage with
stable small left subdural hematoma.


Brief Hospital Course:
Mr [**Known lastname 1022**] was admitted to the Trauma SICU and a CTA was performed
to rule out an anuerysmal source of blood.  CTA was negative, he
was neurologically intact overnight and repeat head CT showed no
worsening of his subarachnoid blood or subdural blood.  He was
transferred to the neurostep down unit and remained on seizure
prophylaxis and nimodipine. He remained stable and was
discharged to home on HD3 in good condition. He was instructed
to follow up with Dr. [**Last Name (STitle) 548**] with a repeat MRA of his head in [**12-3**]
weeks.

Medications on Admission:
None

Discharge Medications:
1. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
Disp:*120 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
R traumatic subarachnoid hemorrhage
L occipital fracture
L subdural hemorrhage


Discharge Condition:
Neurologically stable


Discharge Instructions:
Return if you have any worsening headaches, confusion,
difficulty walking or talking or weakness.


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] in 2 weeks after you have had an
MRA image performed of your head. Call his office at
[**Telephone/Fax (1) 1669**] to schedule both the MRA and an appointment.
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Unspecified fall'}


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: s/p fall

PRESENT ILLNESS: 61M s/p fall from standing while playing soccer today
w/report of SDH from CT head at OSH (not available). Pt is
primarily Korean speaking male who states that he did lose
consciousness for a few seconds after the fall. He does report
+HA but no diplopia, no photophobia, no nuchal rigidity. Upon
transfer via [**Location (un) **] patient with one episode of vomiting.
Otherwise, GCS 15 on arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals P88 149/88 16 97%RA
Gen: NAD
HEENT: small occipital laceration, PERRLA, EOMI
Neck: Supple, C collar in place with no tenderness to palp
Lungs: CTA bilaterally
Cardiac: RRR. S1/S2
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E

FAMILY HISTORY: NK

SOCIAL HISTORY: Married with children
From [**Country 10181**] originally 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Unspecified fall'}
