CHIEF COMPLAINT: headache

PRESENT ILLNESS: Called to the ED to see this patient who was transferred from
[**Hospital3 26615**] Hospital after an assault and head trauma.
Reportidly patient was assaulted by another male, he was punched
and then had a fall with head strike. He was taken to AJH where
he was somewhat perseverative and confused. Head CT revealed a
left frontal SDH and non displaced occipital fracture.

MEDICAL HISTORY: denies

MEDICATION ON ADMISSION: denies

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T:  BP:113 / 66        HR: 89   R 18      O2Sats
Gen: Intubated and sedated
HEENT: No evidence of lacerations, No battle sign
Neck: trauma collar
Cardiac: RRR. S1/S2
Extrem: Warm and well-perfused.
Neuro:
Mental statu:No EO to voice or noxious.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
Motor: localizes with uppers to deep noxious, withdraws lowers.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: +etoh
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Cervicalgia,Alcohol abuse, unspecified,Unarmed fight or brawl
Cl skul base fx w/o coma,Cervicalgia,Alcohol abuse-unspec,Unarmed fight or brawl
Admission Date:  [**2141-8-4**]              Discharge Date:   [**2141-8-6**]

Date of Birth:  [**2110-9-19**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
headache

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Called to the ED to see this patient who was transferred from
[**Hospital3 26615**] Hospital after an assault and head trauma.
Reportidly patient was assaulted by another male, he was punched
and then had a fall with head strike. He was taken to AJH where
he was somewhat perseverative and confused. Head CT revealed a
left frontal SDH and non displaced occipital fracture.


Past Medical History:
denies

Social History:
+etoh

Family History:
non-contributory

Physical Exam:
O: T:  BP:113 / 66        HR: 89   R 18      O2Sats
Gen: Intubated and sedated
HEENT: No evidence of lacerations, No battle sign
Neck: trauma collar
Cardiac: RRR. S1/S2
Extrem: Warm and well-perfused.
Neuro:
Mental statu:No EO to voice or noxious.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
Motor: localizes with uppers to deep noxious, withdraws lowers.

PHYSICAL EXAM UPON DISCHARGE:

Pertinent Results:
[**8-4**] CXR: No acute intrathoracic process.  The ET tube is too low
and should be pulled back by 2 cm.

[**8-4**] NCHCT: 1. In comparison to study obtained eight hours prior,
there is no significant change in 4 mm left frontal subdural
hematoma and left parafalcine subdural collection.  Bilateral
linear areas of hyperattenuation represent subarachnoid
hemorrhage, not clearly seen on prior exam and likely represent
redistribution of blood products.

2.  A non-displaced fracture of the occipital bone extends to
the foramen
magnum, unchanged.  There is also a nondisplaced fracture of the
right wall of the sphenoid sinus, which containes high density
material, likely hemorrhage.

[**8-5**] C-spine CT:

Brief Hospital Course:
On [**8-4**], patient was admitted to the TSICU for head trauma, on
the Neurosurgery service. He was started on dilantin at the OSH
so he was continued on a maintenance dose for seizure
prophylaxsis. He had a repeat Head CT that revealed stable
hemorrhage and an occipital fracture. Shortly after arriving to
the ICU he was successfully exubated and remained stable
overnight.

 On [**8-5**] he was neurologically intact. A CT of his C-spine was
performed due to neck pain and he was still in a hard collar.
The results of this were negative for fracture or dislocation.
He was cleared for transfer to the floor. Dilantin level was 9
so he was given a bolus of 300mg. C-collar was removed.

 On [**8-6**], the patient was having equivocal tenderness at occiput
so a flexion/extension xray was ordered which did not show any
instability.  Physicial therapy was consulted and recommended
discharge home. Patient expressed readiness for discharge. All
questions were answered. The patient will follow-up as below. He
will remain on dilantin for seizure prophylaxis for 7 days.

Medications on Admission:
denies

Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO/PR DAILY
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
hold rr < 12
RX *oxycodone 5 mg [**1-2**] tablet(s) by mouth q4hr Disp #*60 Tablet
Refills:*0
5. Phenytoin Sodium Extended 100 mg PO TID
RX *Dilantin Extended 100 mg 1 capsule(s) by mouth three times a
day Disp #*21 Capsule Refills:*0
6. Senna 1 TAB PO BID


Discharge Disposition:
Home

Discharge Diagnosis:
Traumatic Brain Injury
Subdural hematoma
subarachnoid hemorrhage
occipital fracture extending to the occipital condyle
alcohol intoxication
cervical spine pain


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


Discharge Instructions:
Nonsurgical Brain Hemorrhage

??????	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.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
	**You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed for a total of
seven days. You may discontinue te medication on [**2141-8-11**].

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 a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].



Completed by:[**2141-8-6**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Cervicalgia,Alcohol abuse, unspecified,Unarmed fight or brawl'}


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: Called to the ED to see this patient who was transferred from
[**Hospital3 26615**] Hospital after an assault and head trauma.
Reportidly patient was assaulted by another male, he was punched
and then had a fall with head strike. He was taken to AJH where
he was somewhat perseverative and confused. Head CT revealed a
left frontal SDH and non displaced occipital fracture.

MEDICAL HISTORY: denies

MEDICATION ON ADMISSION: denies

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T:  BP:113 / 66        HR: 89   R 18      O2Sats
Gen: Intubated and sedated
HEENT: No evidence of lacerations, No battle sign
Neck: trauma collar
Cardiac: RRR. S1/S2
Extrem: Warm and well-perfused.
Neuro:
Mental statu:No EO to voice or noxious.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
Motor: localizes with uppers to deep noxious, withdraws lowers.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: +etoh 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Cervicalgia,Alcohol abuse, unspecified,Unarmed fight or brawl'}
