CHIEF COMPLAINT: fall. Subdural hematoma

PRESENT ILLNESS: [**Age over 90 **] year old male transferred from [**Location (un) 620**] for evaluation of
left subdural hematoma. Per family patient fell from standing
striking head on [**2159-11-21**]. Head CT at that time was read as
normal and patient was discharged home. Over the past 2 weeks,
patient has had difficulty using utensils with right upper
extremity and has been dragging right lower extremity when
walking with walker. Patient is a poor historian secondary to
baseline dementia.  He lives at home with wife and son.
Ambulates
with walker at baseline. Denies headache. Denies vision changes.

MEDICAL HISTORY: PMHx: CHF, Dementia, Prostate CA, Cataracts

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: Vit D 1000mg qd; ASA 81mg QOD; Ativan 0.25mg QHS;  Travatan
rt eye qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 98.6 BP: 169/89  HR: 60  R: 16   O2Sats: 99% RA
Gen: elderly demented male, comfortable, NAD.
HEENT: Pupils: [**2-10**]     EOMs intact
Neck: Supple.
Lungs: breathing unlabored
Cardiac: pulses regular
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: difficulty remembering full name, not oriented to
place or date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with son
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Unspecified fall,Dementia, unspecified, without behavioral disturbance,Personal history of malignant neoplasm of prostate,Other alteration of consciousness,Congestive heart failure, unspecified
Subdural hem w/o coma,Fall NOS,Demen NOS w/o behv dstrb,Hx-prostatic malignancy,Other alter consciousnes,CHF NOS
Admission Date:  [**2160-1-7**]              Discharge Date:   [**2160-1-14**]


Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
fall. Subdural hematoma

Major Surgical or Invasive Procedure:
[**2160-1-11**] burr hole evacuation of sdh


History of Present Illness:
[**Age over 90 **] year old male transferred from [**Location (un) 620**] for evaluation of
left subdural hematoma. Per family patient fell from standing
striking head on [**2159-11-21**]. Head CT at that time was read as
normal and patient was discharged home. Over the past 2 weeks,
patient has had difficulty using utensils with right upper
extremity and has been dragging right lower extremity when
walking with walker. Patient is a poor historian secondary to
baseline dementia.  He lives at home with wife and son.
Ambulates
with walker at baseline. Denies headache. Denies vision changes.


Past Medical History:
PMHx: CHF, Dementia, Prostate CA, Cataracts


Social History:
Lives with son

Family History:
NC

Physical Exam:
PHYSICAL EXAM:
O: T: 98.6 BP: 169/89  HR: 60  R: 16   O2Sats: 99% RA
Gen: elderly demented male, comfortable, NAD.
HEENT: Pupils: [**2-10**]     EOMs intact
Neck: Supple.
Lungs: breathing unlabored
Cardiac: pulses regular
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: difficulty remembering full name, not oriented to
place or date
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  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 [**4-12**] throughout. slight pronator
drift on left

Sensation: decreased sensation in  bilateral lower extremities.

Reflexes: B T Br Pa Ac
Right 1+ throughout
Left 1+ throughout

On Discharge:
Oriented to self, follows commands with all 4 extremities, no
drift, face symmetric, tongue midline

Pertinent Results:
[**Known lastname 91800**],[**Known firstname **] [**Medical Record Number 91801**] M  97  [**2062-6-18**]

Cardiovascular Report ECG Study Date of [**2160-1-7**]  1:41:16 PM


Sinus rhythm. Probable left atrial abnormality. Complete right
bundle-branch
block with left anterior fascicular block. Minor non-specific
ST-T wave
abnormalities in the inferior leads.


Read by: [**Last Name (LF) **],[**First Name3 (LF) **]

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 [**Telephone/Fax (3) 91802**]/459 -1 -67 1

[**2159-1-8**]  CXR
FINDINGS: No previous images. Cardiac silhouette is within
normal limits.
There are areas of probable atelectasis at the bases. Minimal
fullness of
pulmonary vessels could reflect mild elevation of pulmonary
venous pressure.

[**2160-1-10**] CT Head
No interval change in chronic left subdural hematoma. No new
foci of hemorrhage.


[**2160-1-11**] CT Head
Interval craniotomies with reduced size of subdural collection
and improvement in rightward midline shift, now measuring 5 mm.
Expected
postoperative changes including pneumocephalus, subcutaneous
emphysema, and possible small amount of hemorrhage.


Brief Hospital Course:
[**Age over 90 **] year old male transferred from [**Location (un) 620**] for evaluation of left
subdural hematoma.
He was admitted to the floor.  Medicine was called for medical
clearance.

He was taken to the OR on [**2160-1-11**] for left cranial burr holes.
This was uneventful and he awoke from anesthesia without
difficulty.  Post operatively he was admitted to the ICU for
close neuro monitoring. On [**1-12**] his neuro exam was at baseline
and he was transferred to the floor. He remained stable on [**1-13**]
while on the floor and worked with PT and OT who deemed he
required rehab. On [**1-14**] he was screened for rehab and given a
bed. He was dsicharged to rehab on the afternoon of [**1-14**] with
instructions for follow-up.


Medications on Admission:
[**Last Name (un) 1724**]: Vit D 1000mg qd; ASA 81mg QOD; Ativan 0.25mg QHS;  Travatan
rt eye qd


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain; temp > 101.4; HA.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Multivitamins With Fluoride 1 mg Tablet, Chewable Sig: One
(1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Ondansetron 4 mg IV Q8H:PRN nausea
10. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
12. HydrALAzine 10 mg IV Q6H:PRN to maintain SBP <160


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
Left frontal SDH

Discharge Condition:
Mental Status: dementia at baseline.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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.
??????	You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	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 in [**6-17**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
 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.
??????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.



Completed by:[**2160-1-14**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Unspecified fall,Dementia, unspecified, without behavioral disturbance,Personal history of malignant neoplasm of prostate,Other alteration of consciousness,Congestive heart failure, unspecified'}


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: fall. Subdural hematoma

PRESENT ILLNESS: [**Age over 90 **] year old male transferred from [**Location (un) 620**] for evaluation of
left subdural hematoma. Per family patient fell from standing
striking head on [**2159-11-21**]. Head CT at that time was read as
normal and patient was discharged home. Over the past 2 weeks,
patient has had difficulty using utensils with right upper
extremity and has been dragging right lower extremity when
walking with walker. Patient is a poor historian secondary to
baseline dementia.  He lives at home with wife and son.
Ambulates
with walker at baseline. Denies headache. Denies vision changes.

MEDICAL HISTORY: PMHx: CHF, Dementia, Prostate CA, Cataracts

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: Vit D 1000mg qd; ASA 81mg QOD; Ativan 0.25mg QHS;  Travatan
rt eye qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: 98.6 BP: 169/89  HR: 60  R: 16   O2Sats: 99% RA
Gen: elderly demented male, comfortable, NAD.
HEENT: Pupils: [**2-10**]     EOMs intact
Neck: Supple.
Lungs: breathing unlabored
Cardiac: pulses regular
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: difficulty remembering full name, not oriented to
place or date
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives with son 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Unspecified fall,Dementia, unspecified, without behavioral disturbance,Personal history of malignant neoplasm of prostate,Other alteration of consciousness,Congestive heart failure, unspecified'}
