CHIEF COMPLAINT: Communicating hydrocephalus, status post traumatic brain injury
as well as right frontal hygroma.

PRESENT ILLNESS: the patient is a 35-year old male who had a traumatic
brain injury when he fell from a tree in [**7-26**]. The patient
underwent emergent surgery in New [**Country 6679**]. A bicoronal
craniectomy and insertion of right frontal extraventricular
catheter was performed for a complex right frontal fracture
extending through his frontal sinus and along the roof of his
orbits. There was extensive facial fracturing and massive
bilateral frontal contusions, worse on the right. The patient
has recovered from his surgery with significant impairment
secondary to his TBI. He follows up with us because sequential
imaging has revealed that he has dilated ventricles which seem
to
be out of proportion to the amount of injury that he sustained.

MEDICAL HISTORY: s/p TBI after fall from tree in [**7-26**]
seizures

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Able to say few pnrases; able to move all extremities; spends
most of time in wheelchair; able to recognize family but no
other orientation

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with parents
Communicating hydrocephalus,Subdural hemorrhage,Epilepsy, unspecified, without mention of intractable epilepsy,Late effect of fracture of skull and face bones,Late effects of accidental fall,Other musculoskeletal symptoms referable to limbs,Lack of coordination,Unspecified persistent mental disorders due to conditions classified elsewhere
Communicat hydrocephalus,Subdural hemorrhage,Epilep NOS w/o intr epil,Late effec skull/face fx,Late eff accidental fall,Muscskel sympt limb NEC,Lack of coordination,Mental disor NOS oth dis
Admission Date:  [**2159-6-5**]              Discharge Date:   [**2159-6-7**]

Date of Birth:  [**2123-5-22**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Communicating hydrocephalus, status post traumatic brain injury
as well as right frontal hygroma.


Major Surgical or Invasive Procedure:
VP shunt

History of Present Illness:
the patient is a 35-year old male who had a traumatic
brain injury when he fell from a tree in [**7-26**]. The patient
underwent emergent surgery in New [**Country 6679**]. A bicoronal
craniectomy and insertion of right frontal extraventricular
catheter was performed for a complex right frontal fracture
extending through his frontal sinus and along the roof of his
orbits. There was extensive facial fracturing and massive
bilateral frontal contusions, worse on the right. The patient
has recovered from his surgery with significant impairment
secondary to his TBI. He follows up with us because sequential
imaging has revealed that he has dilated ventricles which seem
to
be out of proportion to the amount of injury that he sustained.

The question is whether the patient would benefit from
ventricular shunting as well as shunting from bifrontal
hygromas.
The patient is seen with his parents in the office. The patient
is in a wheelchair. He is able to communicate in limited
phrases. He remains oriented to himself and to his family, he is

not fully oriented to other qualities. He can follow commands.
He has the ability to move all four extremities. The patient
overall has extensive periods of keeping still. He also suffers
from seizure activities, increased during the months of [**Month (only) 404**]
and [**Month (only) 956**]. The patient is currently on anticonvulsants. He
was last imaged at [**Hospital1 18**] on [**2159-2-15**].

Overall, the patient has extensive areas of encephalomalacia in
a
bifrontal pattern suggestive of posttraumatic encephalopathy. He

has disproportionate ventriculomegaly with compressed
ventricles.
There are signs of communicating hydrocephalus as well as
anterior extradural CSF collection underlying the bifrontal
craniotomy. We have discussed the situation with the family at
large. The family has reviewed for me his overall course of
recovery and they feel that the patient has somewhat been
stagnant at his current level. It is unclear to all of us
whether the majority of his changes are secondary to tissue loss

frontally; however, this seems to be clearly a component of
increased pressure.


Past Medical History:
s/p TBI after fall from tree in [**7-26**]
seizures

Social History:
lives with parents

Family History:
NC

Physical Exam:
Able to say few pnrases; able to move all extremities; spends
most of time in wheelchair; able to recognize family but no
other orientation

Pertinent Results:
[**2159-6-7**] 05:15AM BLOOD WBC-7.7 RBC-4.74 Hgb-14.4 Hct-41.3 MCV-87
MCH-30.4 MCHC-34.9 RDW-13.2 Plt Ct-189
[**2159-6-6**] 02:46AM BLOOD WBC-9.6# RBC-4.74 Hgb-14.3 Hct-40.5
MCV-86 MCH-30.1 MCHC-35.2* RDW-13.4 Plt Ct-195
[**2159-6-7**] 05:15AM BLOOD Plt Ct-189
[**2159-6-7**] 05:15AM BLOOD PT-13.0 PTT-34.7 INR(PT)-1.1
[**2159-6-6**] 02:46AM BLOOD Plt Ct-195
[**2159-6-7**] 05:15AM BLOOD Glucose-84 UreaN-7 Creat-0.9 Na-136 K-4.7
Cl-98 HCO3-26 AnGap-17
[**2159-6-6**] 02:46AM BLOOD Glucose-94 UreaN-7 Creat-0.8 Na-132*
K-5.1 Cl-100 HCO3-27 AnGap-10
[**2159-6-7**] 05:15AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
[**2159-6-6**] 02:46AM BLOOD Calcium-9.1 Phos-3.9 Mg-1.9

Head CT [**6-5**]:
FINDINGS: There has been interval placement of a ventriculostomy
catheter via the right frontal approach, terminating in the left
frontal [**Doctor Last Name 534**] of lateral ventricles. No significant change in
moderate hydrocephalus and mild sulcal effacement. The
previously seen anterior extraaxial fluid collection is now
almost entirely replaced with air. There is displacement of the
calcified frontal dura. Low density within the left posterior
temporal/occipital region and inferior frontal lobes are
consistent with encephalomalacia due to prior trauma. Extensive
microplates and screws fixate known facial fractures, unchanged
in position compared to the prior exam. There is a tiny degree
of subcutaneous emphysema along the right frontal scalp from
recent surgery. No evidence of new hemorrhage or major vascular
territorial infarct.

IMPRESSION:
1. Interval placement of ventriculostomy catheter terminating in
the left lateral frontal [**Doctor Last Name 534**] with no change in hydrocephalus.
2. Status post drainage of frontal extraaxial fluid collection,
now mostly replaced with air.
3. No evidence of acute hemorrhage or major vascular territorial
infarct.
4. Extensive sequela of prior trauma as described above.


Brief Hospital Course:
Pt taken to the operating room for insertion of VP shunt by Dr.
[**Last Name (STitle) **] from Neurosurgery and Dr. [**Last Name (STitle) **] from General Surgery.
Procedure without complication and patient was transferred to
ICU overnoc for observation.  With in first 24hrs postop pt with
2 generalized tonic clonic seizures each lasting approximately 2
minutes and breaking on their own without additional medication.
 Dr. [**Name (NI) **] (pts neurologist) was contact[**Name (NI) **] and
recommendations were made.  Following Dr.[**Name (NI) 66745**]
recommendations there were no medication changes made and pt
with no further seizures.  Transferred to the floor on POD#1 and
was ready for discharge on POD#2.

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Please take cautiously with percocet as
both products contain acetaminophen. Tablet(s)
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): please take while taking narcotics.
Disp:*90 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Communicating Hydrocephalus; Hygromas


Discharge Condition:
good


Discharge Instructions:
Please call the office with any questions that you may have.
Please call the office or come to the emergency room for any
change in mental status, seizure or weakness.
Please call the office or come to the emergency room if incision
becomes reddened, has drainage or patient develops fever >101.5.
Please do not soak incision site in bathtub or pool.  You may
hand was hair around incision site but keep incision dry.
Please continue your home presurgery medications

Followup Instructions:
Please call Dr. [**Last Name (STitle) 17511**] office to make a follow up appointment.
You will need an appointment in 4-6weeks with a CT scan at that
time.  You also need to come to the office on [**2159-6-15**] to have
your sutures removed.  Please call the office to schedule a time
for that appointment.  The office number is ([**Telephone/Fax (1) 11314**].
You will also need an appointment to see Dr. [**Last Name (STitle) **] from general
surgery.  Please call his office at [**Telephone/Fax (1) 600**] to make an
appointment with in 2 weeks



Completed by:[**2159-6-7**]
{'Communicating hydrocephalus,Subdural hemorrhage,Epilepsy, unspecified, without mention of intractable epilepsy,Late effect of fracture of skull and face bones,Late effects of accidental fall,Other musculoskeletal symptoms referable to limbs,Lack of coordination,Unspecified persistent mental disorders due to conditions classified elsewhere'}


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: Communicating hydrocephalus, status post traumatic brain injury
as well as right frontal hygroma.

PRESENT ILLNESS: the patient is a 35-year old male who had a traumatic
brain injury when he fell from a tree in [**7-26**]. The patient
underwent emergent surgery in New [**Country 6679**]. A bicoronal
craniectomy and insertion of right frontal extraventricular
catheter was performed for a complex right frontal fracture
extending through his frontal sinus and along the roof of his
orbits. There was extensive facial fracturing and massive
bilateral frontal contusions, worse on the right. The patient
has recovered from his surgery with significant impairment
secondary to his TBI. He follows up with us because sequential
imaging has revealed that he has dilated ventricles which seem
to
be out of proportion to the amount of injury that he sustained.

MEDICAL HISTORY: s/p TBI after fall from tree in [**7-26**]
seizures

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Able to say few pnrases; able to move all extremities; spends
most of time in wheelchair; able to recognize family but no
other orientation

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with parents 

### Response:
{'Communicating hydrocephalus,Subdural hemorrhage,Epilepsy, unspecified, without mention of intractable epilepsy,Late effect of fracture of skull and face bones,Late effects of accidental fall,Other musculoskeletal symptoms referable to limbs,Lack of coordination,Unspecified persistent mental disorders due to conditions classified elsewhere'}
