CHIEF COMPLAINT: Headache

PRESENT ILLNESS: This is a 63 yo M who presented to and OSH approximately 5 days
after a fall.  He had gotten out of bed and stood up and
reported feeling dizzy.
He states this occurs frequently when he stands from a lying
position.  He fell down on his left side and hit the left side
of
his head.  He denied LOC.  Since the fall, he had persistent
bifrontal
headache.  He had drove himself to [**Hospital **] Hospital today at the
recommendation of his PCP and had [**Name Initial (PRE) **] CT head which revealed IPH
and was transferred to [**Hospital1 18**] for further care.  He denied any
visual changes, weakness, numbness, paresthesias, bowel or
bladder changes on admission.  He was on aspirin 81 mg daily.

MEDICAL HISTORY: -DM2
-HLD
-Parkinson's disease
-hx Ampullary carcinoma s/p Whipple's procedure
-Hodgkins lymphoma
-hx CCY, appy, inguinal herniopathy

MEDICATION ON ADMISSION: -ASA 81
-primidone 50 prn (unknown dosing schedule)
-zocor 20 mg daily
-lisinopril 10 mg daily
-lantus 20 units sc daily
-fluoxetine 80 mg daily
-levothyroxine 150 mcg
-metformin 1000 mg [**Hospital1 **]

ALLERGIES: Penicillins / Darvocet A500 / Percodan / Morphine / Percocet

PHYSICAL EXAM: On admission:
VS; P 100 BP 134/59  RR 20  100% RA
Gen: lying in bed, NAD
HEENT: MMM, oropharynx clear.  Ecchymosis on left scalp.
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.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: -social etoh, occasional tobacco
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Paralysis agitans,Personal history of malignant neoplasm of other gastrointestinal tract
Brain lacer NEC w/o coma,Hdgk dis unsp xtrndl org,Fall from slipping NEC,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Paralysis agitans,Hx of GI malignancy NEC
Admission Date:  [**2150-9-25**]              Discharge Date:   [**2150-9-29**]

Date of Birth:  [**2087-5-31**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Darvocet A500 / Percodan / Morphine / Percocet

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 63 yo M who presented to and OSH approximately 5 days
after a fall.  He had gotten out of bed and stood up and
reported feeling dizzy.
He states this occurs frequently when he stands from a lying
position.  He fell down on his left side and hit the left side
of
his head.  He denied LOC.  Since the fall, he had persistent
bifrontal
headache.  He had drove himself to [**Hospital **] Hospital today at the
recommendation of his PCP and had [**Name Initial (PRE) **] CT head which revealed IPH
and was transferred to [**Hospital1 18**] for further care.  He denied any
visual changes, weakness, numbness, paresthesias, bowel or
bladder changes on admission.  He was on aspirin 81 mg daily.


Past Medical History:
-DM2
-HLD
-Parkinson's disease
-hx Ampullary carcinoma s/p Whipple's procedure
-Hodgkins lymphoma
-hx CCY, appy, inguinal herniopathy


Social History:
-social etoh, occasional tobacco


Family History:
NC

Physical Exam:
On admission:
VS; P 100 BP 134/59  RR 20  100% RA
Gen: lying in bed, NAD
HEENT: MMM, oropharynx clear.  Ecchymosis on left scalp.
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.
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, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact horizontally.
Decreased upgaze.  No 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. Resting tremor, R arm > L.  Mild cogwheeling
at wrists.  No pronator drift. 5/5 strength in R and L delt,
bicep, tricep, WrE, IP, quad, ham, DF, PF.

Sensation: Intact to light touch throughout

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

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger bilaterally

Gait: deferred

On discharge: Bilateral UE tremor. Right tongue deviation. He
was otherwise neurologically intact.

Pertinent Results:
[**2150-9-25**]: MRI brain
1. Hemorrhagic contusion in the inferior right frontal lobe with
hemorrhagic
contusion at the convexity in the right frontal lobe and a small
right frontal
subdural collection measuring no greater than 3 mm in size
without mass
effect.
2. Left parietal soft tissue hematoma.
3. No midline shift or hydrocephalus.
4. No acute infarcts or abnormal enhancement.

[**2150-9-27**]:CT head
No significant interval change of the multi-foci hemorrhagic
contusion as described above. No developing hydrocephalus.
Unchanged left
parietal scalp hematoma. Unchanged small subarachnoid hemorrhage
around the contusions sites.


Brief Hospital Course:
Mr. [**Known lastname 77792**] was admitted to [**Hospital1 18**] on [**2150-9-25**] under the care of Dr.
[**Last Name (STitle) **] of the neurosurgery department. He was observed inthe
SICU without any neurologic decline. Repeat CT imaging showed no
progression of the Right frontal IPH. On [**9-26**] he was transfered
to the floor. He was on phenytoin for seizure prophylaxis. He
required a bolus of 500 mg x1 on [**2150-9-26**] and 300mg on [**9-27**]. He
was seen by PT/OT. On [**9-28**] an  IV nurse was called to evaluate
his port which is no longer in use. they recommended TPA but
this was deferred secondary to his ICH. We reommened that he
follow up with is PCP for this port as an outpatient. On [**9-29**]
his corrected Dilantin level was 17.

He was cleared by PT/OT on [**2150-9-29**] and was discharged to home.

Medications on Admission:
-ASA 81
-primidone 50 prn (unknown dosing schedule)
-zocor 20 mg daily
-lisinopril 10 mg daily
-lantus 20 units sc daily
-fluoxetine 80 mg daily
-levothyroxine 150 mcg
-metformin 1000 mg [**Hospital1 **]


Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Primidone  Oral
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day.
Disp:*21 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Right frontal contusion - traumatic


Discharge Condition:
Stable


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.
??????	You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine. You will be required to take this medication for a
total of ten days.

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.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need an MRI of the brain with contrast prior to your
appointment. This can be scheduled when you call to make your
office visit appointment.

.      Please follow up with your primary care provider or
surgeon about the care of your portacath.



Completed by:[**2150-9-29**]
{"Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Paralysis agitans,Personal history of malignant neoplasm of other gastrointestinal tract"}


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: This is a 63 yo M who presented to and OSH approximately 5 days
after a fall.  He had gotten out of bed and stood up and
reported feeling dizzy.
He states this occurs frequently when he stands from a lying
position.  He fell down on his left side and hit the left side
of
his head.  He denied LOC.  Since the fall, he had persistent
bifrontal
headache.  He had drove himself to [**Hospital **] Hospital today at the
recommendation of his PCP and had [**Name Initial (PRE) **] CT head which revealed IPH
and was transferred to [**Hospital1 18**] for further care.  He denied any
visual changes, weakness, numbness, paresthesias, bowel or
bladder changes on admission.  He was on aspirin 81 mg daily.

MEDICAL HISTORY: -DM2
-HLD
-Parkinson's disease
-hx Ampullary carcinoma s/p Whipple's procedure
-Hodgkins lymphoma
-hx CCY, appy, inguinal herniopathy

MEDICATION ON ADMISSION: -ASA 81
-primidone 50 prn (unknown dosing schedule)
-zocor 20 mg daily
-lisinopril 10 mg daily
-lantus 20 units sc daily
-fluoxetine 80 mg daily
-levothyroxine 150 mcg
-metformin 1000 mg [**Hospital1 **]

ALLERGIES: Penicillins / Darvocet A500 / Percodan / Morphine / Percocet

PHYSICAL EXAM: On admission:
VS; P 100 BP 134/59  RR 20  100% RA
Gen: lying in bed, NAD
HEENT: MMM, oropharynx clear.  Ecchymosis on left scalp.
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.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: -social etoh, occasional tobacco 

### Response:
{"Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Fall from other slipping, tripping, or stumbling,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Paralysis agitans,Personal history of malignant neoplasm of other gastrointestinal tract"}
