CHIEF COMPLAINT: headache s/p fall

PRESENT ILLNESS: HPI: 25 yo man with no significant PMH presents to ED s/p fall
and headache. He had a fall on saturday , [**2166-8-9**] at around 7
pm. He was going down the stairs and slipped,. he hit his head
on
the back. the height from which he fell was about [**3-20**] steps,
approx 7 feet as per patient. He did not lose consciousness, did
not notice any symptoms such as headache, nausea , vomiting
immediately after fall. He immediately got up and was
asymptomatic till yesterday afternnon about [**11-15**] pm. He noticed
mild dull headache , which kept on increasing and did not
respond
to OTC pain killers. the headache was more on right side than
left. due to this he went to OSH today, was found to have EDH
and
was sent to [**Hospital1 18**].

MEDICAL HISTORY: PMHx: GERD

MEDICATION ON ADMISSION: Zantac 150 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:99.1  BP: 135 / 77        HR:70    R 16       O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: tenderness on palpation on right parietotemporal area.
Pupils: [**1-15**] BL reactive symmetric        EOMs- Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

FAMILY HISTORY: Family Hx: not significant

SOCIAL HISTORY: Social Hx: works for fishing comp, does not smoke, 1-2 beers per
week. no drug abuse
Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Esophageal reflux,Accidental fall on or from other stairs or steps
Cl skl w oth fx w/o coma,Esophageal reflux,Fall on stair/step NEC
Admission Date:  [**2166-8-11**]              Discharge Date:   [**2166-8-15**]

Date of Birth:  [**2140-8-16**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache s/p fall


Major Surgical or Invasive Procedure:
None


History of Present Illness:
HPI: 25 yo man with no significant PMH presents to ED s/p fall
and headache. He had a fall on saturday , [**2166-8-9**] at around 7
pm. He was going down the stairs and slipped,. he hit his head
on
the back. the height from which he fell was about [**3-20**] steps,
approx 7 feet as per patient. He did not lose consciousness, did
not notice any symptoms such as headache, nausea , vomiting
immediately after fall. He immediately got up and was
asymptomatic till yesterday afternnon about [**11-15**] pm. He noticed
mild dull headache , which kept on increasing and did not
respond
to OTC pain killers. the headache was more on right side than
left. due to this he went to OSH today, was found to have EDH
and
was sent to [**Hospital1 18**].


Past Medical History:
PMHx: GERD


Social History:
Social Hx: works for fishing comp, does not smoke, 1-2 beers per
week. no drug abuse


Family History:
Family Hx: not significant


Physical Exam:
PHYSICAL EXAM:
O: T:99.1  BP: 135 / 77        HR:70    R 16       O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: tenderness on palpation on right parietotemporal area.
Pupils: [**1-15**] BL reactive symmetric        EOMs- Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 voice.
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 [**3-18**] throughout. No pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     2 2 2  2   1
Left      2 2 2  2   1

Toes mute bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

Gait -normal, Rhombergs sign negative

Upon Discharge

Exam nonfocal

Pertinent Results:
NCHCT [**8-11**] shows Right temporoparietal fracture with large
epidural and smaller subdural hemorrhage and associated mass
effect, all not significantly changed compared to a few hours
prior.

NCHCT [**8-12**] IMPRESSION:

Unchanged large right epidural hematoma and small right subdural
hematoma.

NCHCT  [**8-14**]

IMPRESSION:
1. Stable appearing right-sided apical hematoma.
2. No evidence of hydrocephalus.
3. Possible right-sided subdural hematoma versus right
transverse sinus
thrombosis.

NCHCT [**8-15**]

Stable epidural hematoma




Brief Hospital Course:
25M admitted for close clinical observation of mental status s/p
fall with epidural hematoma. He was admitted to the ICU and
later transferred to step down unit then floor with serial
stable head CTs. He has tolerated PO diet, pain is controlled,
ambulated without difficulty.

Medications on Admission:
Zantac 150 [**Hospital1 **]


Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-15**]
Tablets PO Q4H (every 4 hours) as needed for headache.
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 1 months.
Disp:*90 Capsule(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
R Epidural Hematoma
R temporal bone fx

Discharge Condition:
Neurologically intact


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	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, or
Ibuprofen etc.
??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy 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.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 1 wk.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.



Completed by:[**2166-8-15**]
{'Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Esophageal reflux,Accidental fall on or from other stairs or steps'}


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: headache s/p fall

PRESENT ILLNESS: HPI: 25 yo man with no significant PMH presents to ED s/p fall
and headache. He had a fall on saturday , [**2166-8-9**] at around 7
pm. He was going down the stairs and slipped,. he hit his head
on
the back. the height from which he fell was about [**3-20**] steps,
approx 7 feet as per patient. He did not lose consciousness, did
not notice any symptoms such as headache, nausea , vomiting
immediately after fall. He immediately got up and was
asymptomatic till yesterday afternnon about [**11-15**] pm. He noticed
mild dull headache , which kept on increasing and did not
respond
to OTC pain killers. the headache was more on right side than
left. due to this he went to OSH today, was found to have EDH
and
was sent to [**Hospital1 18**].

MEDICAL HISTORY: PMHx: GERD

MEDICATION ON ADMISSION: Zantac 150 [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:99.1  BP: 135 / 77        HR:70    R 16       O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: tenderness on palpation on right parietotemporal area.
Pupils: [**1-15**] BL reactive symmetric        EOMs- Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

FAMILY HISTORY: Family Hx: not significant

SOCIAL HISTORY: Social Hx: works for fishing comp, does not smoke, 1-2 beers per
week. no drug abuse 

### Response:
{'Closed fractures involving skull or face with other bones with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Esophageal reflux,Accidental fall on or from other stairs or steps'}
