CHIEF COMPLAINT: headache

PRESENT ILLNESS: asked to eval this 58 year old african american male who is
taking ASA 81 mg daily with c/o of HA x 3 days.  CT demonstrates
acute on subacute sdh on the right side with MLS 1.2cm.  No
obvious mass lesion is noted.  Pt lethargic at present and most
of history taken from brother who is at bedside.  Pt was out
with
family on friday and HA was severe enough that they drove him
home.  Brother states that pt did not remember the ride home.
There are no reprots of sz or LOC nor of any trauma.

MEDICAL HISTORY: HIV
HTN
High Cholesterol
Hypercholesterolemia        hypertriglyceridemia
overweight                  hypertension
low HDL                     sedentary lifestyle
HIV positive                new diagnosis of type 2 diabetes.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAM upon admission:
T: 98 T BP: 192/ 96        HR:88    R 18      O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:  3-2mm bilaterally EOMIs
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (thinks it is
the 15th but it is the 16th.
language: Speech fluent with good comprehension/ + accent /
brother at bedside does not recognize a problem.

FAMILY HISTORY: No DM, CAD, or cancer in family.

SOCIAL HISTORY: seperated from wife/ lives with sister - has a 23 year old son
whom he said can make decisions for him.  His name is [**Name (NI) 11777**]
[**Telephone/Fax (1) 11778**]
Subdural hemorrhage,Human immunodeficiency virus [HIV] disease,Benign intracranial hypertension,Unspecified essential hypertension,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified
Subdural hemorrhage,Human immuno virus dis,Pseudotumor cerebri,Hypertension NOS,Pure hypercholesterolem,DMII wo cmp nt st uncntr,Anemia NOS
Admission Date:  [**2100-8-22**]              Discharge Date:   [**2100-9-3**]

Date of Birth:  [**2042-6-3**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache

Major Surgical or Invasive Procedure:
evacuation of SDH
craniectomy


History of Present Illness:
asked to eval this 58 year old african american male who is
taking ASA 81 mg daily with c/o of HA x 3 days.  CT demonstrates
acute on subacute sdh on the right side with MLS 1.2cm.  No
obvious mass lesion is noted.  Pt lethargic at present and most
of history taken from brother who is at bedside.  Pt was out
with
family on friday and HA was severe enough that they drove him
home.  Brother states that pt did not remember the ride home.
There are no reprots of sz or LOC nor of any trauma.


Past Medical History:
HIV
HTN
High Cholesterol
Hypercholesterolemia        hypertriglyceridemia
overweight                  hypertension
low HDL                     sedentary lifestyle
HIV positive                new diagnosis of type 2 diabetes.


Social History:
seperated from wife/ lives with sister - has a 23 year old son
whom he said can make decisions for him.  His name is [**Name (NI) 11777**]
[**Telephone/Fax (1) 11778**]


Family History:
No DM, CAD, or cancer in family.

Physical Exam:
PHYSICAL EXAM upon admission:
T: 98 T BP: 192/ 96        HR:88    R 18      O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:  3-2mm bilaterally EOMIs
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (thinks it is
the 15th but it is the 16th.
language: Speech fluent with good comprehension/ + accent /
brother at bedside does not recognize a problem.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields grossly intact.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: ? slight right facial / sensation intact.
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 [**4-10**] throughout. slight right
pronation / no drift.

Sensation: Intact to light touch
Toes downgoing bilaterally
No clonus


Pertinent Results:
Head CT [**8-30**]:
IMPRESSION: No interval change in right subdural and
subarachnoid hemorrhage post-craniotomy. Improved leftward
subfalcine herniation, with less mass effect on the right
lateral and third ventricles today.

Head CT [**8-29**]:
IMPRESSION:
1. Interval increase in shift of the midline leftward from 6 mm
to 9 mm.
2. Stable sized, naturally evolving right temporoparietal
subdural hematoma.
3. No evidence of new intracranial hemorrhage.

MRI [**8-28**]:
FINDINGS: Again a T1 and T2 hyperintense subdural collection
identified from frontal to occipital region with air within this
collection. There are post- operative changes seen in the right
frontotemporal region. A small area of T2 hyperintensity in the
right temporal lobe may be the site for biopsy. NO parenchymal
enhancement is identified in this region. Following gadolinium
mild meningeal enhancement is identified. There is mass effect
on the right lateral ventricle with mild midline shift. No
evidence of acute infarct identified.

IMPRESSION: Status post craniotomy on the right side. Subdural
collection is identified on the right which is characteristic of
a subdural hematoma. Residual blood products are seen in this
region since the previous MRI of [**2100-8-22**]. Post-biopsy changes
are seen in the right temporal lobe. There is mass effect on the
right lateral ventricle with midline shift and mild uncal
herniation with deformity of the brainstem. No acute infarct is
identified.

Echo:
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5mmHg. There is mild  symmetric left ventricular
hypertrophy. The left ventricular cavity size is  normal.
Regional left ventricular wall motion is normal. Left
ventricular  systolic function is hyperdynamic (EF>75%).
Transmitral Doppler and tissue  velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction.  There is no
ventricular septal defect. Right ventricular chamber size and
free  wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the  aortic valve. Mild to moderate
([**12-8**]+) aortic regurgitation is seen. The mitral  valve leaflets
are mildly thickened. There is no mitral valve prolapse. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation
is seen. The left ventricular inflow pattern suggests impaired
relaxation. The  tricuspid valve leaflets are mildly thickened.
The estimated pulmonary artery  systolic pressure is normal.
There is no pericardial effusion.


Brief Hospital Course:
The patient was admitted with a SDH and went to the OR for
craniotomy for evacuation on [**2100-8-22**]. He went to the ICU
post-operatively and was slow to wake up. His post-op head CT
showed decreased midline shift. His mental status improved
slowly for the next 2 days and he was transferred to the floor
on [**8-26**]. Then on [**8-27**] the patient became unresponsive and repeat
CT scan showed increase in blood. He had a bedside tap via burr
hole and 50 cc of blood was drained. Repeat CT showed decreased
SDH, unchanged brain edema.  On [**8-28**] he went back to the OR for
a craniectomy. Following the procedure, his CT scan showed
decreased SDH and his neurologic exam improved significantly. He
was moving all extremities and was conversant by the time of
discharge. His mannitol was stopped on [**9-3**]. PT and OT felt the
patient was safe to be discharged to rehab.

Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Fosamprenavir 700 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
6. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
7. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
10. Enfuvirtide 90 mg Kit Sig: One (1) Kit Subcutaneous [**Hospital1 **] ().

11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QOD ().
12. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours).
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
14. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO Q48H (every 48 hours).
15. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(WE).
16. NPH insulin  Sig: Four (4)  Subcutaneous every twelve (12)
hours.
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: Dose per insulin sliding scale.
18. Levetiracetam 1500 mg IV BID


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
right SDH


Discharge Condition:
neurologically improved/stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a 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,
excessive bending
??????	You may wash your hair only after sutures and/or staples have
been removed
??????	You may shower before this time with assistance and use of a
shower cap
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

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


Followup Instructions:
You need to have your sutures/staples removed in 10 days. You
may have this done at rehab or call the office to set up an
appointment.

Follow up with Dr. [**Last Name (STitle) 739**] in 4 weeks with a head CT.
Call [**Telephone/Fax (1) 1669**] to make appointment.


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

Completed by:[**2100-9-3**]
{'Subdural hemorrhage,Human immunodeficiency virus [HIV] disease,Benign intracranial hypertension,Unspecified essential hypertension,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, 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: headache

PRESENT ILLNESS: asked to eval this 58 year old african american male who is
taking ASA 81 mg daily with c/o of HA x 3 days.  CT demonstrates
acute on subacute sdh on the right side with MLS 1.2cm.  No
obvious mass lesion is noted.  Pt lethargic at present and most
of history taken from brother who is at bedside.  Pt was out
with
family on friday and HA was severe enough that they drove him
home.  Brother states that pt did not remember the ride home.
There are no reprots of sz or LOC nor of any trauma.

MEDICAL HISTORY: HIV
HTN
High Cholesterol
Hypercholesterolemia        hypertriglyceridemia
overweight                  hypertension
low HDL                     sedentary lifestyle
HIV positive                new diagnosis of type 2 diabetes.

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins

PHYSICAL EXAM: PHYSICAL EXAM upon admission:
T: 98 T BP: 192/ 96        HR:88    R 18      O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:  3-2mm bilaterally EOMIs
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date (thinks it is
the 15th but it is the 16th.
language: Speech fluent with good comprehension/ + accent /
brother at bedside does not recognize a problem.

FAMILY HISTORY: No DM, CAD, or cancer in family.

SOCIAL HISTORY: seperated from wife/ lives with sister - has a 23 year old son
whom he said can make decisions for him.  His name is [**Name (NI) 11777**]
[**Telephone/Fax (1) 11778**] 

### Response:
{'Subdural hemorrhage,Human immunodeficiency virus [HIV] disease,Benign intracranial hypertension,Unspecified essential hypertension,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified'}
