CHIEF COMPLAINT: "My headaches are constant"

PRESENT ILLNESS: Mr. [**Known lastname 63844**] is a 47 year old right handed male known to
service with bilateral chronic SDH.  He was being followed by us
and was seen last week in the clinic and was told to follow-up
in
2 weeks.  However, for the past several days his headache
intensity had increased from intermittent to constant.  He was
taking Fioricet with minimal relief.  He describes the headache
as a dull pressure sensation.  Additional symptoms include
increase dizziness and gait instability.  He also noticed brief
episodes of paresthesia in both UEs lasting several minutes but
since resolved.  He called to the office and was seen in the ED
several hours later.  A repeat head CT demonstrated increase in
size of bilateral chronic SDH R>L with stable midline shift
compared to CT head on [**2188-6-14**].

MEDICAL HISTORY: Lyme disease, bilateral SDH

MEDICATION ON ADMISSION: Fioricet 1 tab TID as needed for headache

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T:98.5  BP: 122/73  HR:72    R 18  O2Sats 99%RA
Gen: WD/WN, comfortable, NAD with long hair.
HEENT: atraumatic, normocephalic, long hair, kept; eyes: clear,
no exudate; ears: no otorrhea; nose: nasal passages patent,
septum midline, no rhinorrhea; throat - oropharynx pink w.o.
exudate Pupils: PERRL        EOMs - full
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r, tattoos on back
Cardiac: RRR. S1/S2. no heaves, lifts or rubs, no murmurs
Abd: Soft,flat, NT, BS+
Extrem: Warm and well-perfused, no c/c/e

FAMILY HISTORY: Family Hx: negative for stroke in age <50 (father and
grandmother had strokes in 60-70s), negative for ICH, aneurysm

SOCIAL HISTORY: Social Hx: lives with mother, unemployed. [**Name2 (NI) **] tobacco, ETOH or
illicits.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Personal history of other infectious and parasitic diseases,Striking against or struck accidentally by objects or persons in sports,Activities involving boxing
Subdural hem w/o coma,Prsnl hst oth nfct parst,Sports acc w/o sub fall,Boxing
Admission Date:  [**2188-5-22**]              Discharge Date:   [**2188-5-26**]

Date of Birth:  [**2141-1-18**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
"My headaches are constant"


Major Surgical or Invasive Procedure:
Bilateral burr holes for evacuation of SDH


History of Present Illness:
Mr. [**Known lastname 63844**] is a 47 year old right handed male known to
service with bilateral chronic SDH.  He was being followed by us
and was seen last week in the clinic and was told to follow-up
in
2 weeks.  However, for the past several days his headache
intensity had increased from intermittent to constant.  He was
taking Fioricet with minimal relief.  He describes the headache
as a dull pressure sensation.  Additional symptoms include
increase dizziness and gait instability.  He also noticed brief
episodes of paresthesia in both UEs lasting several minutes but
since resolved.  He called to the office and was seen in the ED
several hours later.  A repeat head CT demonstrated increase in
size of bilateral chronic SDH R>L with stable midline shift
compared to CT head on [**2188-6-14**].

On review of systems he denies any diplopia, seizures or
weakness
in arms or legs.  He was instructed to take Keppra but did not
fill prescription due to cost.  He does have mild nausea without
vomiting.  Of note he did take Excedrin for head previously the
past few days. he also denies any contact sport such as boxing
since the diagnosis. he reports that he was in [**Location (un) 5583**], MA
for business.


Past Medical History:
Lyme disease, bilateral SDH

Social History:
Social Hx: lives with mother, unemployed. [**Name2 (NI) **] tobacco, ETOH or
illicits.


Family History:
Family Hx: negative for stroke in age <50 (father and
grandmother had strokes in 60-70s), negative for ICH, aneurysm


Physical Exam:
O: T:98.5  BP: 122/73  HR:72    R 18  O2Sats 99%RA
Gen: WD/WN, comfortable, NAD with long hair.
HEENT: atraumatic, normocephalic, long hair, kept; eyes: clear,
no exudate; ears: no otorrhea; nose: nasal passages patent,
septum midline, no rhinorrhea; throat - oropharynx pink w.o.
exudate Pupils: PERRL        EOMs - full
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r, tattoos on back
Cardiac: RRR. S1/S2. no heaves, lifts or rubs, no murmurs
Abd: Soft,flat, NT, BS+
Extrem: Warm and well-perfused, no c/c/e

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

Cranial Nerves:
GCS 15
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 [**6-19**] throughout. No pronator drift

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

Pronator drift - slight upward drift on the right.

On Discharge:
A&Ox3
PERRL 3-2mm bilaterally
EOMS intact
Face symmetrical
Tongue midline
Motor: [**6-19**] throughout
No pronator drift
Incision c/d/i staples in place

Pertinent Results:
CT HEAD W/O CONTRAST [**2188-5-22**]
Evolving bilateral subdural hemorrhages essentially unchanged in
size compared to the prior examination given differences in
technique.

CT HEAD W/O CONTRAST [**2188-5-25**]
1. Bilateral hemispheric subdural hematomas with mixed density
are again
noted with low attenuation along the bilateral frontoparietal
hemisphere as well as with some of high density material noted
along the bilateral frontal hemispheres (3, 8).
3. There is persistent mass effect on the underlying brain
parenchyma and on the left lateral ventricle.
4. Postoperative changes including pneumocephalus again noted


Brief Hospital Course:
47 y/o M with h/o bilateral SDH presents with constant headaches
to ED. CT head shows worsening SDH. He was admitted to TSICU for
monitoring. On [**5-23**], patient was taken to the OR for bilateral
burr holes for evacuation of SDHs. He was transferred back to
TSICU and on examination, patient was a&ox3, full strength.
Subdural drains were leveled to the floor. Post op head CT
showed pneumocephalus and L SDH was replaced with CSF. Patient's
exam remained intact. His subdural drains were removed on [**5-24**]
and patient was transferred to step down unit. A repeat head CT
was done on [**5-25**] which was unchanged from previous scan. He was
OOB ambulating with PT. On [**5-26**], patient's exam intact and was
discharged home after being cleared by PT.

Medications on Admission:
Fioricet 1 tab TID as needed for headache


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Bilateral SDH


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge 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.
??????	If 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**].
If 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 [**8-24**] days(from your date of
surgery) for removal of your staples a wound check. 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.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.


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

Completed by:[**2188-5-26**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Personal history of other infectious and parasitic diseases,Striking against or struck accidentally by objects or persons in sports,Activities involving boxing'}


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: "My headaches are constant"

PRESENT ILLNESS: Mr. [**Known lastname 63844**] is a 47 year old right handed male known to
service with bilateral chronic SDH.  He was being followed by us
and was seen last week in the clinic and was told to follow-up
in
2 weeks.  However, for the past several days his headache
intensity had increased from intermittent to constant.  He was
taking Fioricet with minimal relief.  He describes the headache
as a dull pressure sensation.  Additional symptoms include
increase dizziness and gait instability.  He also noticed brief
episodes of paresthesia in both UEs lasting several minutes but
since resolved.  He called to the office and was seen in the ED
several hours later.  A repeat head CT demonstrated increase in
size of bilateral chronic SDH R>L with stable midline shift
compared to CT head on [**2188-6-14**].

MEDICAL HISTORY: Lyme disease, bilateral SDH

MEDICATION ON ADMISSION: Fioricet 1 tab TID as needed for headache

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T:98.5  BP: 122/73  HR:72    R 18  O2Sats 99%RA
Gen: WD/WN, comfortable, NAD with long hair.
HEENT: atraumatic, normocephalic, long hair, kept; eyes: clear,
no exudate; ears: no otorrhea; nose: nasal passages patent,
septum midline, no rhinorrhea; throat - oropharynx pink w.o.
exudate Pupils: PERRL        EOMs - full
Neck: Supple.
Lungs: CTA bilaterally, no w/c/r, tattoos on back
Cardiac: RRR. S1/S2. no heaves, lifts or rubs, no murmurs
Abd: Soft,flat, NT, BS+
Extrem: Warm and well-perfused, no c/c/e

FAMILY HISTORY: Family Hx: negative for stroke in age <50 (father and
grandmother had strokes in 60-70s), negative for ICH, aneurysm

SOCIAL HISTORY: Social Hx: lives with mother, unemployed. [**Name2 (NI) **] tobacco, ETOH or
illicits. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Personal history of other infectious and parasitic diseases,Striking against or struck accidentally by objects or persons in sports,Activities involving boxing'}
