CHIEF COMPLAINT: 

PRESENT ILLNESS: Mr. [**Known lastname 58189**] is a 27-year-old male
with no significant past medical history.  He was status post
motor vehicle accident this a.m.  He is being transferred
from [**Hospital 8641**] hospital secondary to a subdural hematoma.  The
patient was an unrestrained passenger in the back seat of the
vehicle which was struck from behind by a truck.  He
experienced loss of consciousness at the scene.  There was a
prolonged extrication with periods of confusion.  The patient
was complaining of chin pain.  On arrival to [**Hospital 8641**] hospital,
the patient's vital signs were stable.  He had a left head
laceration which was sutured.  The CT scan showed right-sided
subdural hematoma of approximately 1 cm with minimal midline
shift.  The patient was transferred by EMS to [**Hospital1 346**].  He remained stable, alert,
oriented and intact.  Mental status throughout remained
intact.

MEDICAL HISTORY: Insignificant.

MEDICATION ON ADMISSION: 

ALLERGIES: HE IS ALLERGIC TO ASPIRIN.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient admits to 6 beers a day.  He
uses tobacco, does not use drugs.  He works as a logger in
[**Location (un) 3844**].
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle,Tobacco use disorder
Traumatic subdural hem,Mv collision NOS-pasngr,Tobacco use disorder
Admission Date: [**2196-8-7**]        Discharge Date: [**2196-8-10**]

Date of Birth:  [**2169-6-23**]        Sex:  M

Service:  NSU


Neurosurgery was called to the emergency department for a
consult on [**2196-8-7**].

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname 58189**] is a 27-year-old male
with no significant past medical history.  He was status post
motor vehicle accident this a.m.  He is being transferred
from [**Hospital 8641**] hospital secondary to a subdural hematoma.  The
patient was an unrestrained passenger in the back seat of the
vehicle which was struck from behind by a truck.  He
experienced loss of consciousness at the scene.  There was a
prolonged extrication with periods of confusion.  The patient
was complaining of chin pain.  On arrival to [**Hospital 8641**] hospital,
the patient's vital signs were stable.  He had a left head
laceration which was sutured.  The CT scan showed right-sided
subdural hematoma of approximately 1 cm with minimal midline
shift.  The patient was transferred by EMS to [**Hospital1 346**].  He remained stable, alert,
oriented and intact.  Mental status throughout remained
intact.

HOSPITAL COURSE:  The patient was admitted to [**Hospital1 346**].

PAST MEDICAL HISTORY:  Insignificant.

PAST SURGICAL HISTORY:  None.

MEDICATIONS:  He is not taking any.

ALLERGIES:  HE IS ALLERGIC TO ASPIRIN.

SOCIAL HISTORY:  The patient admits to 6 beers a day.  He
uses tobacco, does not use drugs.  He works as a logger in
[**Location (un) 3844**].

PHYSICAL EXAMINATION:  His physical exam upon admission, his
heart rate was 94, his blood pressure was 182/palp, his
respiratory rate was 18, and his O2 saturation was 97 percent
on room air.  He was lying on an ED stretcher in no apparent
distress.  HEENT:  Positive left head laceration sutured.  He
has anicteric sclerae.  Positive blood in left ear canal.
TMs clear bilaterally.  Neck had positive tenderness to
palpation at C5.  His lungs were clear to auscultation.
Cardiovascular:  He was tachycardic with a regular S1 and S2
audible.  His abdomen had positive bowel sounds in all 4
quadrants.  He was soft and nontender.  Rectal:  He had a
normal tone.  Back:  Positive tenderness, mid thoracic spine
to palpation.  Neurologically, his mental status, he was
alert and oriented x3 with no dysarthria.  He was intact in
naming and repeating.  Cranial nerves:  His fields were full.
He was PERRL.  Pupils were 3 to 2 mm bilaterally.
Extraocular movements were intact.  He had positive end-gaze
nystagmus.  No facial asymmetry.  Sensation was intact.
Palate elevated symmetrically.  Hearing intact to finger rub.
Tongue was midline.  SCM and trapezius were 5 out of 5.  His
motor exam showed a 5 out of 5 strength throughout without
drift.  Tone was normal.  Deep tendon reflexes were positive
2 and symmetric.  Toes were down pointing bilaterally.
Sensation was intact to light touch and pinprick and was also
intact to vibration and proprioception.  Cerebellar:  Finger-
nose-finger was intact.

LABORATORY DATA AT THE TIME OF ADMISSION:  White count of
14.9, hematocrit of 40, and platelets of 207.  His PT was
12.8 and PTT was 20.1.  His INR was 1.0.  Sodium 144,
potassium 4.3, chloride 107, BUN 16, creatinine 0.8, and his
glucose was 116.  Head CT showed a right subdural hematoma,
crescentic, bleed was less than 1 cm with minimal midline
shift of approximately 3 mm.  CT of the pelvis was negative.
CT of the abdomen was negative and a chest x-ray was
negative.

ASSESSMENT AND PLAN:  This is a 27-year-old without past
medical history, who is status post motor vehicle accident
with loss of consciousness, found to have a small subdural
hematoma.  His neurologic exam was stable.  He was admitted
to the Trauma SICU with neurologic checks every 1 hour.  He
was to have a repeat CT scan stat if there was a change in
neurologic status, otherwise, repeat CT in the a.m.  He was
to be kept euvolemic.  He was loaded with Dilantin 1 gm x1.
To check level in the a.m. and then to go on 100 mg q.8.  He
was also to remain on his seizure prophylaxis for 1 week.
This plan was discussed with Dr. [**First Name8 (NamePattern2) 6644**] [**Last Name (NamePattern1) 12184**], chief
resident.  Also his blood pressure was to be kept in the
140s.  On day 2 of subdural hematoma, the patient's vitals
were intact.  He was in the Trauma SICU.  Temperature was
99.2, heart rate was 50 to 92, blood pressure 122-160/66-90,
respiratory rate was 14 to 19, and he was sating 96 percent
to 98 percent on room air.  All patient's laboratory studies
were within normal limits.  He was alert and oriented.
Pupils were equal, round and reactive to light.  His
extraocular movements were intact.  His face was symmetric
and his tongue was midline.  Strength was 5 out of 5
throughout.  Plan at that time was to keep his blood pressure
less than 140.  For prophylaxis, the patient was wearing
pneumoboots and taking Dilantin x7 days.  He is due for a
head CT today.  He is to be kept euvolemic and his IV fluid
was changed to normal saline.  Check Dilantin level tomorrow
and to follow up with C spine CT [**Location (un) 1131**].  Day 3, after his
subdural hematoma, the patient was transferred to the regular
floor.  He is feeling well.  All his vital signs were stable.
His extraocular movements were intact.  He had facial
asymmetry.  Left lower extremity movement, however, was
reduced.  He showed no drift.  His strength was full
throughout.  His Foley was to be discontinued, and he could
get out of bed if his spine was cleared.  We were to check
TLS films.  On [**2196-8-10**], the patient is to be discharged to
home.  All his vital signs were stable.  The patient is doing
fine.  He is to follow up with Dr. [**Last Name (STitle) 1132**] in 3 weeks with a
followup head CT.  On [**2196-8-10**], the patient is to be
discharged to home.

DISCHARGE INSTRUCTIONS:  He is to keep his incision clean and
dry.  He is to report to his local hospital in 1 week for
suture removal that would be in [**Hospital 107**] Hospital in [**Location (un) 58190**], [**Location (un) 3844**].  He is to have no heavy lifting or
strenuous activity until his followup.  He is to continue
taking antiseizure medication for 7 days as directed.

FINAL DIAGNOSIS:  Right subdural hematoma.

RECOMMENDED FOLLOWUP:  He is to follow up with Dr. [**Last Name (STitle) 1132**] in 3
to 4 weeks with a head CT.  Dr.[**Name (NI) 9224**] office will call with
an appointment.

DISCHARGE CONDITION:  He is neurologically stable.  He is
ambulating and he is tolerating a p.o. diet.

DISCHARGE MEDICATIONS:  His discharge medications for which
he has received prescriptions are:
1. Oxycodone and acetaminophen 5/325 tablet, 1 to 2 tablets
   p.o. q.4-6h. as needed for pain, dispensed 60 tablets,
   with 0 refills.
2. Docusate sodium 100 mg capsule, 1 capsule p.o. b.i.d.,
   dispensed 60 capsules, with 2 refills.
3. He is also given Phenytoin sodium extended 100 mg capsule,
   2 capsules p.o. b.i.d., dispensed 20 capsules, refills 0.




                        [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]

Dictated By:[**Last Name (NamePattern1) 58191**]
MEDQUIST36
D:  [**2196-8-10**] 11:29:22
T:  [**2196-8-11**] 11:05:25
Job#:  [**Job Number 58192**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle,Tobacco use disorder'}


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: Mr. [**Known lastname 58189**] is a 27-year-old male
with no significant past medical history.  He was status post
motor vehicle accident this a.m.  He is being transferred
from [**Hospital 8641**] hospital secondary to a subdural hematoma.  The
patient was an unrestrained passenger in the back seat of the
vehicle which was struck from behind by a truck.  He
experienced loss of consciousness at the scene.  There was a
prolonged extrication with periods of confusion.  The patient
was complaining of chin pain.  On arrival to [**Hospital 8641**] hospital,
the patient's vital signs were stable.  He had a left head
laceration which was sutured.  The CT scan showed right-sided
subdural hematoma of approximately 1 cm with minimal midline
shift.  The patient was transferred by EMS to [**Hospital1 346**].  He remained stable, alert,
oriented and intact.  Mental status throughout remained
intact.

MEDICAL HISTORY: Insignificant.

MEDICATION ON ADMISSION: 

ALLERGIES: HE IS ALLERGIC TO ASPIRIN.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient admits to 6 beers a day.  He
uses tobacco, does not use drugs.  He works as a logger in
[**Location (un) 3844**]. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other motor vehicle traffic accident involving collision with motor vehicle injuring passenger in motor vehicle other than motorcycle,Tobacco use disorder'}
