CHIEF COMPLAINT: SDH

PRESENT ILLNESS: HPI:71 y.o. F. who has complained of a headache for the past
three weeks according to family. She had a negative MRI at
[**Hospital **] hospital three weeks ago. Family reports frequent falls
due to drinking. Found trying to unlock her neighbor's house,
confused, with a bruise over L thigh. She was transported to an
outside hospital, where a head CT showed a sdh with uncal
herniation, which prompted [**Hospital1 18**] transfer. She was intubated for
the transfer, and received Mannitol 40 gm, and dilantin 750 mg
bolus.

MEDICAL HISTORY: PMHx:
low platelet count;
alcoholic
HTN
Hypothyroidism
Hearing loss
Depression

MEDICATION ON ADMISSION: family usure, knows of antihypertensives and hypothyroid drugs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ARRIVAL

FAMILY HISTORY: Family Hx:unknown

SOCIAL HISTORY: Social Hx: alcoholic, binges daily, family thinks last drink 4
days ago, lives alone, smoke pack year history 106. She has six
children, and her healthcare proxy is [**Name (NI) **] [**Name (NI) 11135**].
Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Compression of brain,Other fall,Home accidents,Tobacco use disorder,Thrombocytopenia, unspecified,Postsurgical hypothyroidism,Other and unspecified alcohol dependence, unspecified,Unspecified hearing loss,Depressive disorder, not elsewhere classified,Unspecified essential hypertension
Brain lacer NEC w/o coma,Compression of brain,Fall NEC,Accident in home,Tobacco use disorder,Thrombocytopenia NOS,Postsurgical hypothyroid,Alcoh dep NEC/NOS-unspec,Hearing loss NOS,Depressive disorder NEC,Hypertension NOS
Admission Date:  [**2179-11-10**]              Discharge Date:   [**2179-11-17**]

Date of Birth:  [**2108-11-8**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
RIGHT CRANIOTOMY FOR SDH EVACUATION


History of Present Illness:
HPI:71 y.o. F. who has complained of a headache for the past
three weeks according to family. She had a negative MRI at
[**Hospital **] hospital three weeks ago. Family reports frequent falls
due to drinking. Found trying to unlock her neighbor's house,
confused, with a bruise over L thigh. She was transported to an
outside hospital, where a head CT showed a sdh with uncal
herniation, which prompted [**Hospital1 18**] transfer. She was intubated for
the transfer, and received Mannitol 40 gm, and dilantin 750 mg
bolus.


Past Medical History:
PMHx:
low platelet count;
alcoholic
HTN
Hypothyroidism
Hearing loss
Depression




Social History:
Social Hx: alcoholic, binges daily, family thinks last drink 4
days ago, lives alone, smoke pack year history 106. She has six
children, and her healthcare proxy is [**Name (NI) **] [**Name (NI) 11135**].


Family History:
Family Hx:unknown


Physical Exam:
ON ARRIVAL

PHYSICAL EXAM:
O: BP: 116/78 HR:58 R 15 O2Sats 100% intubated, FiO2 100%, PeeP
5
HEENT: Pupils: unreactive  EOMs unable to assess
Extrem: Warm appears malnourished, multiple scratches on legs.
Neuro:
Mental status: Intubated
Orientation: does not follow commands.

Cranial Nerves:
II: Pupils equally round non-reactive to light, 1.5
mm bilaterally.

Motor: Localizes to noxious stimuli with bilateral upper
extremities, withdraws bilateral lower extremities to noxious
stimuli, tows up-going.


Pertinent Results:
RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2179-11-15**] 11:28 AM

CHEST (PORTABLE AP)

Reason: r/o pneumonia

[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with s/p SDH, large smoking history, desating
REASON FOR THIS EXAMINATION:
r/o pneumonia
HISTORY: Status post subdural hematoma, desaturation, evaluate
for pneumonia.

COMPARISONS: [**2179-11-10**].

FINDINGS: Single semi-upright portable chest radiograph
performed at 11:45 a.m. demonstrates interval removal of
endotracheal tube. Lungs are clear. There is no pneumothorax or
pleural effusions. Cardiomediastinal silhouette is normal and
unchanged. Left clavicular fracture is unchanged. Healing right
posterior lower rib fracture seen.

IMPRESSION: No acute cardiopulmonary process.

   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2179-11-12**] 8:37 AM

CT HEAD W/O CONTRAST

Reason: assess for interval change

[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH, uncal herniation s/p evacuation
REASON FOR THIS EXAMINATION:
assess for interval change
CONTRAINDICATIONS for IV CONTRAST: None.

COMPARISON: [**2179-11-10**].

NON-CONTRAST HEAD CT: There is a large right frontal, parietal,
and temporal subdural hematoma with mixed acute and chronic
components that has decreased in size and now measures
approximately 1 cm from the skull base. Decreased associated
pneumocephalus is noted. There is an approximately 3 mm midline
shift, and there is no evidence of subfalcine or uncal
herniation. The mastoid air cells are well aerated. There are
air-fluid levels within the right and left maxillary sinus and
opacification of the anterior ethmoid air cells, unchanged.

IMPRESSION:

1. Improved appearance of large right acute on chronic subdural
hematoma with markedly decreased midline shift and no evidence
of subfalcine or uncal herniation.

2. Multiple air-fluid levels in the maxillary and sphenoid
sinuses with near complete opacifications of air cells may
represent sinusitis, although not significantly changed from
prior exam. Recommend clinical correlation.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 94**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SUN [**11-14**],
   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2179-11-10**] 8:55 PM

CT HEAD W/O CONTRAST

Reason: FOUND DOWN

[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH and ?herniation
REASON FOR THIS EXAMINATION:
eval ich
CONTRAINDICATIONS for IV CONTRAST: None.

HISTORY: Subdural hematoma. Evaluate for herniation.

No priors are available.

NON-CONTRAST HEAD CT:

FINDINGS: There is a large right frontal, parietal and temporal
subdural hematoma with mixed acute and chronic components
causing extensive effacement of the adjacent sulci, severe
subfalcine herniation of approximately 17 mm, and mild uncal
herniation causing mass effect on the brainstem and effacement
of the ambient cistern. There is prominence to the left
occipital/temporal horns, likely related to mass effect on the
third ventricle. The fourth ventricle also appears slightly
prominent. There is no evidence of intraparenchymal hemorrhage
with periventricular hypoattenuation likely related to chronic
small vessel disease. Soft tissues appear unremarkable with
mastoid air cells appearing well aerated. There are air-fluid
levels noted within the right and left maxillary sinus and right
sphenoid sinus with near-complete opacification of the majority
of the anterior middle ethmoid air cells. Mild mucosal
thickening is noted within the frontal sinuses. Large amount of
secretions is noted within the oropharynx consistent with the
patient's intubation.

IMPRESSION:

1. Large right acute on chronic subdural hematoma causing
significant subfalcine herniation and mild-to-moderate uncal
herniation. Prominence to the left occipital and temporal horns
along with effacement of the third ventricle is suggestive of
hydrocephalus/outflow obstruction.

2. Multiple air-fluid levels within the maxillary sinus and
sphenoid sinus with near-complete opacification of ethmoid air
cells in this intubated patient. Findings are worrisome for
developing sinusitis. Please correlate clinically.



   RADIOLOGY  Final Report

CT C-SPINE W/O CONTRAST  [**2179-11-10**] 8:55 PM

CT C-SPINE W/O CONTRAST

Reason: FOUND DOWN

[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with SDH and ?herniation
REASON FOR THIS EXAMINATION:
eval fx
CONTRAINDICATIONS for IV CONTRAST: None.

HISTORY: Known subdural hematoma. Evaluate for acute fracture.

No prior comparison exams are available.

CT OF THE CERVICAL SPINE WITH CORONAL AND SAGITTAL REFORMATIONS:

IMPRESSION:
No evidence of acute fracture or malalignment. Vertebral body
heights appear well preserved. Small ossific fragment anterior
to C4-C5 is likely degenerative in nature, and there is mild
multilevel degenerative joint and disc disease. Visualized
contents of the intrathecal sac appear unremarkable; however,
MRI is more sensitive for evaluation of spinal cord injury.
There is no prevertebral soft tissue swelling. Pooled secretions
are noted within the oropharynx consistent with patient's
intubation. Please refer to dedicated CT head for better
description of sinus findings. The soft tissues display atrophic
or absent right thyroid gland with multiple calcifications noted
within the left thyroid gland. There is biapical pleural
scarring and areas of linear atelectasis along with mild
centrilobular emphysema.

Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-11-14**] 08:00AM    7.3 2.88* 9.7* 30.3* 105* 33.8* 32.1 15.5
253
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2179-11-10**] 08:45PM    70.3*   24.4 3.3 1.6 0.5
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2179-11-14**] 08:00AM        253

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-11-14**] 08:00AM    85 2* 0.4 141 3.8 105 30 10



Brief Hospital Course:
Pt was seen and admitted through the emergency department on
[**2179-11-10**] for complaint of a headache for the past three weeks
according to family. She had a negative MRI at [**Hospital **] hospital
three weeks ago. Family reports frequent falls due to drinking.
Found trying to unlock her neighbor's house, confused, with a
bruise over L thigh. She was transported to an outside hospital,
where a head CT showed a sdh with uncal herniation, which
prompted [**Hospital1 18**] transfer. She was intubated for the transfer, and
received Mannitol 40 gm, and dilantin 750 mg bolus. Pt was
brought to OR emergently for evacuation of R SDH. Pt underwent
the procedure and awoke from anesthesia without complication.
She was extubated in SICU the following morning. Her exam
improved and she was following commands.  Her post-op CT scan
was stable. Diet and acitivity were advanced.  She was seen by
PT/OT/ST for eval. She passed swallow eval and was recommended
for rehab from PT/OT perspective.  Foley was d/c'd and pt is
voiding. She will require follow up in [**4-23**] weeks with CT scan of
brain - dilanitin should continue unitl that time and be managed
by PCP.

Upon discharge, she is neurologically stable, she is oriented
x3; following commands; no focal deficit found on her neuro
exam.


Medications on Admission:
family usure, knows of antihypertensives and hypothyroid drugs


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection TID (3 times a day).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
4. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for dose per CIWA scale: Please dose according to CIWA
scale. .
5. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): Patient should continue taking this
medication at least until seen in [**Hospital 4695**] clinic. .
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
 Inhalation Q6H (every 6 hours) as needed.
13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN
14. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.


Discharge Disposition:
Extended Care

Facility:
Highgate Manor

Discharge Diagnosis:
RIGHT SUBDURAL HEMATOMA


Discharge Condition:
NEUROLOGICALLY STABLE


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY

??????	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:
PLEASE HAVE THE REHAB FACILITY REMOVE THE STAPLES ON [**11-23**]
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN [**4-23**] WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST

YOU SHOULD FOLLOW UP WITH YOUR PCP REGARDING YOUR
HOSPITALIZATION - IT IS BEST TO BE SEEN WITHIN 2 WEEKS / Your
PCP will manage your dilantin levels.



Completed by:[**2179-11-17**]
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Compression of brain,Other fall,Home accidents,Tobacco use disorder,Thrombocytopenia, unspecified,Postsurgical hypothyroidism,Other and unspecified alcohol dependence, unspecified,Unspecified hearing loss,Depressive disorder, not elsewhere classified,Unspecified essential hypertension'}


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: SDH

PRESENT ILLNESS: HPI:71 y.o. F. who has complained of a headache for the past
three weeks according to family. She had a negative MRI at
[**Hospital **] hospital three weeks ago. Family reports frequent falls
due to drinking. Found trying to unlock her neighbor's house,
confused, with a bruise over L thigh. She was transported to an
outside hospital, where a head CT showed a sdh with uncal
herniation, which prompted [**Hospital1 18**] transfer. She was intubated for
the transfer, and received Mannitol 40 gm, and dilantin 750 mg
bolus.

MEDICAL HISTORY: PMHx:
low platelet count;
alcoholic
HTN
Hypothyroidism
Hearing loss
Depression

MEDICATION ON ADMISSION: family usure, knows of antihypertensives and hypothyroid drugs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ARRIVAL

FAMILY HISTORY: Family Hx:unknown

SOCIAL HISTORY: Social Hx: alcoholic, binges daily, family thinks last drink 4
days ago, lives alone, smoke pack year history 106. She has six
children, and her healthcare proxy is [**Name (NI) **] [**Name (NI) 11135**]. 

### Response:
{'Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness,Compression of brain,Other fall,Home accidents,Tobacco use disorder,Thrombocytopenia, unspecified,Postsurgical hypothyroidism,Other and unspecified alcohol dependence, unspecified,Unspecified hearing loss,Depressive disorder, not elsewhere classified,Unspecified essential hypertension'}
