CHIEF COMPLAINT: 48 y/o male s/p MVA and closed head injury who had undergone a
craniectomy on his last admission returns on this admission for
replacement of bone flap.

PRESENT ILLNESS: s/p TBI returns for elective cranioplasty

MEDICAL HISTORY: previous right craniectomy
TBI

MEDICATION ON ADMISSION: Heparin 5000 UNIT SC TID
Quetiapine Fumarate 25 mg PO/NG Q6H agitation
Lisinopril 5 mg PO/NG DAILY
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Vitamin D 1000 UNIT PO/NG DAILY
Oxcarbazepine 600 mg PO BID
Famotidine 20 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release)  5-10 mg PO/NG Q4H:PRN pain
LeVETiracetam Oral Solution 1000 mg PO/NG [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission the patient barely verbalizes.  He is able to
respond to occasional questions.  Pupils are equal and reactive
to light.  Extraocular movements are intact.  Face is symmetric.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: construction worker, married, 2 children in college. + etoh
Other specified acquired deformity of head,Delirium due to conditions classified elsewhere,Hemiplegia, unspecified, affecting unspecified side,Unspecified persistent mental disorders due to conditions classified elsewhere,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident,Facial weakness
Oth spcf deformity head,Delirium d/t other cond,Unsp hemiplga unspf side,Mental disor NOS oth dis,Lt eff intracranial inj,Late eff motor vehic acc,Facial weakness
Admission Date:  [**2159-12-12**]              Discharge Date:   [**2159-12-17**]

Date of Birth:  [**2111-6-29**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
48 y/o male s/p MVA and closed head injury who had undergone a
craniectomy on his last admission returns on this admission for
replacement of bone flap.

Major Surgical or Invasive Procedure:
Cranioplasty


History of Present Illness:
s/p TBI returns for elective cranioplasty

Past Medical History:
previous right craniectomy
TBI

Social History:
construction worker, married, 2 children in college. + etoh


Family History:
non-contributory

Physical Exam:
On admission the patient barely verbalizes.  He is able to
respond to occasional questions.  Pupils are equal and reactive
to light.  Extraocular movements are intact.  Face is symmetric.

He does have a pronator drift on his left side.  He moves all
extremities without any focal weakness.

ON DISCHARGE:
Patient is awake, confused interactive
Pupils are 4mm to 3mm bilaterally
Left sided neglect and some paresis ( degree difficult to assess
with specific muscle group testing, given patient's agitation
and confusion)
Able to move all extremities, right greater than left.

Cranial incision is clean and dry with staples and sutures in
place.


Pertinent Results:
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2159-12-13**]
6:59 PM

NON-CONTRAST HEAD CT:

There has been interval right cranioplasty. There is no
underlying
hemorrhage. A drain is seen in the overlying soft tissues. Small
foci of air are compatible with recent surgery.

Intracranially, there is no significant change. There is
persistent ex vacuo dilatation of the right lateral ventricle,
with extensive overlying cystic encephalomalacia, which is
stable in extent and appearance compared to [**2159-11-15**].
There is no evidence of acute territorial infarction.  There is
no mass effect. Midline structures demonstrate no shift, and the
basal cisterns are patent. There are no abnormal extra-axial
fluid collections. Accounting for postoperative changes, the
bones are unremarkable. There is partial opacification of the
right mastoid air cells.  The remainder of the paranasal sinuses
and left mastoids are normally aerated.

IMPRESSION:
1. Expected postoperative changes following right cranioplasty.
No
intracranial hemorrhage or other complication is identified.
2. Stable extensive encephalomalacia in the right frontoparietal
temporal
lobes, with associated ex vacuo dilatation of the adjacent
ventricle.




Cardiology Report ECG Study Date of [**2159-12-14**]  8:07:54 AM


Sinus tachycardia. Possible inferior wall myocardial infarction
of
indeterminate age. Compared to the previous tracing of [**2159-9-18**]
there is no
significant diagnostic change.


Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
103 162 94 328/403 45 -19 62



Display/Print ECG (Requires a Software Download)


([**-9/8374**])


Brief Hospital Course:
Mr. [**Known lastname 87367**] returned to the [**Hospital1 18**] from [**Hospital6 **] for a
cranioplasty. Operative course was uncomplicated.

Post operatively he was transferred to the floor with a foley
catheter and a subgalial JP drain.

POD #1 patient was slightly agitated and recieved a small dose
of haldol with good effect. Post operative CT showed expected
post operative changes.

Patient's agitation and aggression continued to escelate and he
was placed on Seroquel around the clock. We asked Psychiatry to
consult and help in the care of this patient.  They recommended
continuing standing Seroquel with a larger dose in the evening
before bedtime.  The patient's behavior improved while on
Seroquel.

He continued to improve and was calm enough to participate with
PT OT for dispo planning.  His diet and activity were advanced
and foley removed. He was discharged to rehab in stable
condition and will follow up in the office for suture removal
and general follow up in 6 weeks.

Medications on Admission:
Heparin 5000 UNIT SC TID
Quetiapine Fumarate 25 mg PO/NG Q6H agitation
Lisinopril 5 mg PO/NG DAILY
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Vitamin D 1000 UNIT PO/NG DAILY
Oxcarbazepine 600 mg PO BID
Famotidine 20 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release)  5-10 mg PO/NG Q4H:PRN pain
LeVETiracetam Oral Solution 1000 mg PO/NG [**Hospital1 **]

Discharge Medications:
1. levetiracetam 100 mg/mL Solution Sig: Ten (10) ml PO BID (2
times a day).
2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. oxcarbazepine 300 mg/5 mL Suspension Sig: Ten (10) ml PO BID
(2 times a day).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for agitation.
9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
10. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q NOON ().
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-30**]
Tablets PO Q4H (every 4 hours) as needed for headache.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
TBI
Confusional state


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


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, straining,
or excessive bending.
??????	You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????	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.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

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, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office by [**2159-12-22**] for removal of your
staples & sutures and wound check. This appointment can be made
with the Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] [**Name Initial (PRE) 19158**].  Please make
this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a
distance from our office, please make arrangements for the same,
with your PCP. [**Name10 (NameIs) **] can also be done at the rehab facility.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Known firstname **], to be seen in 4 weeks.
??????You will need a CT scan of the brain  without contrast at that
time.



Completed by:[**2159-12-18**]
{'Other specified acquired deformity of head,Delirium due to conditions classified elsewhere,Hemiplegia, unspecified, affecting unspecified side,Unspecified persistent mental disorders due to conditions classified elsewhere,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident,Facial weakness'}


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: 48 y/o male s/p MVA and closed head injury who had undergone a
craniectomy on his last admission returns on this admission for
replacement of bone flap.

PRESENT ILLNESS: s/p TBI returns for elective cranioplasty

MEDICAL HISTORY: previous right craniectomy
TBI

MEDICATION ON ADMISSION: Heparin 5000 UNIT SC TID
Quetiapine Fumarate 25 mg PO/NG Q6H agitation
Lisinopril 5 mg PO/NG DAILY
Docusate Sodium (Liquid) 100 mg PO/NG [**Hospital1 **]
Vitamin D 1000 UNIT PO/NG DAILY
Oxcarbazepine 600 mg PO BID
Famotidine 20 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release)  5-10 mg PO/NG Q4H:PRN pain
LeVETiracetam Oral Solution 1000 mg PO/NG [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission the patient barely verbalizes.  He is able to
respond to occasional questions.  Pupils are equal and reactive
to light.  Extraocular movements are intact.  Face is symmetric.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: construction worker, married, 2 children in college. + etoh 

### Response:
{'Other specified acquired deformity of head,Delirium due to conditions classified elsewhere,Hemiplegia, unspecified, affecting unspecified side,Unspecified persistent mental disorders due to conditions classified elsewhere,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident,Facial weakness'}
