CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an otherwise
healthy, 28 year old who was admitted to the emergency
department after slipping on a wet metal plank on the ground
and falling from a standing position on to the back of his
head.  He had no loss of consciousness, however, he did have
a large occipital laceration with bleeding.  He had no vision
changes.  He complained of no numbness or tingling.  He did
have a headache and some nausea with vomiting.  The patient
was intoxicated at the time of his arrival to the emergency
department.

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married and works as a
computer programmer.  He drinks socially on weekends.  He
denies recreational drug use.  He does not smoke cigarettes.
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Alcohol abuse, unspecified,Open wound of scalp, without mention of complication
Subarachnoid hem-no coma,Fall from slipping NEC,Alcohol abuse-unspec,Open wound of scalp
Admission Date: [**2145-4-14**]        Discharge Date: [**2145-4-15**]

Date of Birth:  [**2116-12-11**]        Sex:  M

Service:  [**Last Name (un) **]


HISTORY OF PRESENT ILLNESS:  The patient is an otherwise
healthy, 28 year old who was admitted to the emergency
department after slipping on a wet metal plank on the ground
and falling from a standing position on to the back of his
head.  He had no loss of consciousness, however, he did have
a large occipital laceration with bleeding.  He had no vision
changes.  He complained of no numbness or tingling.  He did
have a headache and some nausea with vomiting.  The patient
was intoxicated at the time of his arrival to the emergency
department.

PAST MEDICAL HISTORY:  None.

MEDICATIONS:  None.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient is married and works as a
computer programmer.  He drinks socially on weekends.  He
denies recreational drug use.  He does not smoke cigarettes.

PHYSICAL EXAMINATION:  On physical examination temperature
was 96.0, heart rate 93, blood pressure 117/83, respiratory
rate 16, sating 98 percent in room air.  He was alert and
oriented times three with a GCS of 15, in no apparent
distress with a clear oropharynx and midline trachea.  He had
an occipital laceration approximately 5 cm in length which
was stable in the emergency department after it was
irrigated.  Heart had regular rate and rhythm with no murmur.
Lungs were clear to auscultation bilaterally.  Abdomen was
soft, nontender with no palpable mass.  He had full range of
motion in all extremities.  No deformities noted.  He had
normal tone on rectal exam with a regular prostate and guaiac
negative.  He had a completely normal neuro exam.

LABORATORY DATA:  The patient's laboratories were significant
for normal hematocrit of 41.2 and an alcohol level of 198.
All other labs were within normal limits.

RADIOLOGY:  The patient had a normal pelvis film and normal
chest x-ray.  Cervical spine CAT scan was normal.  CT of the
head showed a subarachnoid hemorrhage of the right frontal
lobe and a small subdural hemorrhage in the tentorium on the
right side.  He also had an intraparenchymal hemorrhage in
the right frontal lobe.  There was no fracture, no shift and
no mass effect.

HOSPITAL COURSE:  The patient was admitted to the ICU for
blood pressure control, glycemic control and q.one neuro
checks.  He had completely normal neuro exams, so no
medication was started.  His cervical spine was cleared once
the patient was able to be sober and give us a reliable exam.
Neurosurgery was consulted and recommended a CTA.  It was
felt that the intracranial hemorrhage was most likely from
the fall, however, it was necessary to rule out an aneurysm.
CTA was performed which was negative.  At the time of this
dictation the patient is pending the read of a noncontrast
head CT to see if there is any change in his bleed.  He has
remained alert and oriented times three and completely
neurologically intact.  His diet has been advanced to a
regular diet.  His Foley has been discontinued and he is
voiding normally.  He is ambulating.  The plan is that
assuming the repeat head CT shows no change, the patient will
be able to be discharged home with neurosurgery followup in
one month.

The patient talked with house staff, specifically Dr. [**Last Name (STitle) **],
about his alcohol use.  He states that he only drinks
socially.  He does not drink every day and on this night in
particular, he went out with a couple of coworkers after a
hard day for weekend drinks.  He was on his way home when he
slipped and fell.  He has agreed to be contact[**Name (NI) **] by our
addiction specialist, [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 2412**].  An e-mail has been sent
to her to follow up with the patient.

The patient will be discharged in good condition to his home
where he will be under the care of his wife.

DIAGNOSES:
1. Alcohol abuse.
2. Subarachnoid hemorrhage right suprasellar.
3. Intraparenchymal hemorrhage.
4. Small subdural hemorrhage right side.
5. Occipital scalp laceration status post staples.


FOLLOWUP:  The patient is to follow up with neurosurgery, Dr.
[**Last Name (STitle) 1132**], in one month.  He is to obtain a head CT prior to this
appointment.  The patient is to follow up in trauma clinic
within one to two weeks for staple removal.

DISCHARGE MEDICATIONS:
1. Vicodin one to two tablets p.o. q.four to six hours.
2. Colace 100 mg b.i.d.




                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], MD 2211

Dictated By:[**Last Name (NamePattern1) 41037**]
MEDQUIST36
D:  [**2145-4-15**] 17:55:29
T:  [**2145-4-15**] 18:24:55
Job#:  [**Job Number 43448**]
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Alcohol abuse, unspecified,Open wound of scalp, without mention of complication'}


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: 

PRESENT ILLNESS: The patient is an otherwise
healthy, 28 year old who was admitted to the emergency
department after slipping on a wet metal plank on the ground
and falling from a standing position on to the back of his
head.  He had no loss of consciousness, however, he did have
a large occipital laceration with bleeding.  He had no vision
changes.  He complained of no numbness or tingling.  He did
have a headache and some nausea with vomiting.  The patient
was intoxicated at the time of his arrival to the emergency
department.

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is married and works as a
computer programmer.  He drinks socially on weekends.  He
denies recreational drug use.  He does not smoke cigarettes. 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Alcohol abuse, unspecified,Open wound of scalp, without mention of complication'}
