CHIEF COMPLAINT: Left Occipital Epidural Hematoma

PRESENT ILLNESS: 50yo WF with PMH significant for cervical disc herniation
that presented to outside neurosurgeon 2-2.5 weeks ago for
evaluation. Following that appointment for which no intervention

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: Per patient: zoloft, and "some other depression medication"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.9 HR 113 BP 167/97 RR 23 Sat 99% RA

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives alone, divorced, denies etoh/tobacco/ivda
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Closed fracture of second cervical vertebra,Accidental fall on or from other stairs or steps,Displacement of cervical intervertebral disc without myelopathy,Dizziness and giddiness
Brain lac NEC-brief coma,Fx c2 vertebra-closed,Fall on stair/step NEC,Cervical disc displacmnt,Dizziness and giddiness
Admission Date:  [**2127-9-20**]              Discharge Date:   [**2127-9-30**]

Date of Birth:  [**2077-7-23**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Left Occipital Epidural Hematoma

Major Surgical or Invasive Procedure:
Evacuation of left occipital epidural hematoma


History of Present Illness:
50yo WF with PMH significant for cervical disc herniation
that presented to outside neurosurgeon 2-2.5 weeks ago for
evaluation. Following that appointment for which no intervention

was pursued, patient started to have episodes of falling to the
ground with any attempt at standing up. Patient denied HA,
seizure activity/symptoms, LOC, or lightheadedness with each
episode, simply stating that "the world started to spin around"
whenever she experienced one of these episodes; pt did c/o
occasional nausea and retching with the episodes. Pt began to
require balance assistance to stand each time, and still had
multiple episodes of going to ground resulting numerous
abrasions, and three broken ribs. On the evening of [**9-19**],
patient
had another episode resulting in a backward fall onto a concrete

slab that did not cause LOC but was worrisome enough for patient

to contact her PCP who told her to have a low threshold for
visiting an ER. On morning of [**9-20**], with no resolution of sxs
patient was seen at OSH where CTH showed large left occipital
EDH.


Past Medical History:
Depression

Social History:
Lives alone, divorced, denies etoh/tobacco/ivda

Family History:
Non-contributory

Physical Exam:
VS: T 98.9 HR 113 BP 167/97 RR 23 Sat 99% RA

PE: Well-appearing, well-nourished, with moderate level anxiety
from hospitalization.
HEENT: Occipital pain on palpation, L Hemotympanum
CV: RRR s m/g/r

Neuro
MS: AA&Ox3, speech fluent, follows 3-point commands, easily
comprehensible No neologisms or paraphrasic errors.
CN: I--not tested; II-could read nametag,III-PERRLA 5-3mm,
III,IV,VI-EOMI w/ left beat nystagmus, V--sensation intact to
LT,
and masseter strength; VII-no facial asymmetry, muscles of
facial
expression strong; VIII- intact to FR bilaterally; IX,X--voice
normal, palate elevates symmetrically, uvula midline;
XII--tongue
protrudes midline, no atrophy or fasciculation.
Motor: normal bulk and tone, no pronator drift. Strength:

Delt [**Hospital1 **] Tri Grip IO Psoas Quad Ham TA [**First Name9 (NamePattern2) 3568**] [**Last Name (un) 938**]
C5-6 C5-6 C6-8 C7-8 C7-8 L2-4 L2-4 L5-S2 L5-S1 S1-2 L4-5
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5

Coord: no dysmetria. FNF intact bilaterally, right better than
left
Refl:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 2 | 2 | 2 | 2 | 2 | dn |
R | 2 | 2 | 2 | 2 | 2 | up |

[**Last Name (un) **]: LT intact to all four extremities/trunk


Pertinent Results:
[**2127-9-20**] 06:20PM   PT-12.4 PTT-20.5* INR(PT)-1.0
[**2127-9-20**] 06:20PM   PLT COUNT-246
[**2127-9-20**] 06:20PM   NEUTS-90.1* BANDS-0 LYMPHS-2.7* MONOS-3.5
EOS-0.1 BASOS-0.1
[**2127-9-20**] 06:20PM   WBC-7.9 RBC-3.12* HGB-11.4* HCT-30.7* MCV-99*
MCH-36.6* MCHC-37.2* RDW-15.8*

CTH [**9-20**] Large left epidural hematoma with adjacent mass effect,
cerebral
edema, compression of the ventricle and concern for uncal
herniation

CTH [**9-21**] Interval drainage of epidural hemorrhage. No evidence
of new
bleeding.

CTH [**9-22**] Unchanged pneumocephalus in the left supratentorial
epidural
space. Stable small epidural hematoma in left posterior fossa.
No new
hemorrhage or evidence of major vascular territorial infarction
or
hydrocephalus.

CT C-Spine [**9-20**] Abnormality at the left C1-C2 facet, of
uncertain age. The lytic and sclerotic appearance could be
consistent with a less acute process, although an acute injury
cannot be excluded

Plain Films Bilateral Knees [**9-21**] Unremarkable radiographs of the
bilateral knees

Plain Films Bilateral Ankles [**9-23**] Acute left lateral malleolar
avulsion fracture. Left medial malleolar tiny avulsion fracture
of uncertain chronicity (no soft tissue swelling). Clinical
correlation needed.
No right ankle fracture. Right calcaneal tuberosity is excluded
from the
image.

MRI C-spine [**9-23**] Small right-sided foraminal disc herniation at
C6-C7 level possibly contacting the right exiting [**Name (NI) 3569**] nerve root.
Small left paracentral disc herniation at C5-C6 level. T2
hyperintensity involving the right facet joint at C3-C4 and
C4-C5 levels with slight hyperintensity within the right C3
pedicle. This could be related to possible osseous contusion and
neck injury. No definite fractures are identified; however,
thin-section CT might be useful for further imaging to detect
any suspected subtle fractures


Brief Hospital Course:
Patient taken directly from ER Trauma bay on [**9-20**] to OR for
emergent evacuation of large left occipital epidural hematoma.
Pt tolerated the procedure well and was transferred after
stabilization in the PACU to ICU.  Pt was maintained in ICU in
stable condition until HD 3 (POD #1) at which time head drain
was removed, patient was transfused two pRBC's for anemia, and
transferred to step-down [**Hospital Ward Name 121**] 5.  Based on C1-C2 facet joint
irregularity seen on CT c-spine, Spine Consult was obtained, and
with f/u MRI of spine, it was determined that the patient needed
to maintain hard c-spine collar on for 6 weeks, until follow up
with orthopaedic spine.  On HD4, orthopaedics was consulted for
left ankle fx and their recommendations were to place patient
leg in air splint, with weight bearing on foot as tolerated.  Pt
was transferred to regular floor status on [**9-24**] while awaiting
PT and social work recommendations.

Pt continued to have headaches a repeat head CT was done on
[**9-25**]

Neurology saw patient for vertigo they felt shecharacteristics
of this patient's dangerous and disabling vertigo do have a
peripheral vestibular not central quality. The features are not
lateralized enough to suggest vertebrobasilar vascular
insufficiency, nor are there the assoc. features of this DX. The

gradual escalation of symptoms is not compat. with stroke, but
also not with most of the acute labyrinthitidies, and is also
not typical of vertigo due to demyelinating disease. Rather I
suspect an otovestibular condition such as Meniere's disease, or

a more subacute process such SLE . Doubt mass lesion as the
hearing loss (if indeed not directly due to resolving
hemotympanium) is spontaneously remitting.

[**Last Name (un) 3570**].: In view of her severe multiple trauma, hemotympanium,
neck
[**Last Name (LF) **], [**First Name3 (LF) **] not feel it useful, practicable or safe to begin a
diagnostic evaluation of this patient's vertigo. Both hearing
testing (site of lesion) and otovestibular testing must be
delayed until cervical stability is established. Until then her
vertigo must still be considered to place her at risk for
further
unpredictable falls, and life-threatening injury. Until a
definitive W/U can be realized, I would therefore recommend that

she be placed in Rehab ([**Location (un) 38**]-Healthcare South would be
ideal because of the excellent otovestibular lab. there) or at
the very least, a [**Hospital1 1501**] facility until w/u can proceed.


Medications on Admission:
Per patient: zoloft, and "some other depression medication"

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*1*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours).
6. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).


Discharge Disposition:
Extended Care

Facility:
Aberjona Nursing Center - [**Hospital1 2436**]

Discharge Diagnosis:
Left Occipital Epidural Hematoma


Discharge Condition:
Stable


Discharge Instructions:
Please resume all home medications. Please return to hospital ER
if you experience fever in excess of 101 degrees, begin to have
worsening nausea/vomiting or headaches, or note increased
redness or purulent drainage from head wound.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 739**] in 6 weeks with a Head
CT prior to visit. Please call [**Telephone/Fax (1) 3571**] to schedule an
appointment

Please follow up with orthopaedic spine, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3572**]
office, in six weeks. Please call [**Telephone/Fax (1) 3573**] to schedule an
appointment
If you continue to have foot pain you can follow up with Dr
[**Last Name (STitle) 2637**] from Orthopedics otherwise just wear air cast for 2
weeks

Please follow up with your primary care provider [**Last Name (NamePattern4) **] 2 weeks
regarding high blood pressure


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2127-9-30**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Closed fracture of second cervical vertebra,Accidental fall on or from other stairs or steps,Displacement of cervical intervertebral disc without myelopathy,Dizziness and giddiness'}


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 Occipital Epidural Hematoma

PRESENT ILLNESS: 50yo WF with PMH significant for cervical disc herniation
that presented to outside neurosurgeon 2-2.5 weeks ago for
evaluation. Following that appointment for which no intervention

MEDICAL HISTORY: Depression

MEDICATION ON ADMISSION: Per patient: zoloft, and "some other depression medication"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98.9 HR 113 BP 167/97 RR 23 Sat 99% RA

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives alone, divorced, denies etoh/tobacco/ivda 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Closed fracture of second cervical vertebra,Accidental fall on or from other stairs or steps,Displacement of cervical intervertebral disc without myelopathy,Dizziness and giddiness'}
