CHIEF COMPLAINT: Pt s/p fall

PRESENT ILLNESS: HPI:  57 yo male with heavy EtOH use who presents after fall
from
standing and seizure activity to OSH. Pt with 1 quart vodka
intake 1day.  pt was in detox X 5 days until thursday and when
he
got out, he was drinking heavily (wife does not know quantity)
night prior to fall.  he was at baseline (post inebriated state)
~2pm when he was walking to bedroom - began mumbling and then
fell and hit head on door and had generalized convulsions with
urinary incontinence - convulsions X 3-4 minutes.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
GERD
depression
ETOHism

MEDICATION ON ADMISSION: MEDICATIONS:
none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAM
VS:  T  98  HR 90 BP 121/77     Sat 100% intubated
PE:     General, intubated
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, no rashes or petechiae

FAMILY HISTORY: no seizures

SOCIAL HISTORY: 1 cig/day
heavy ETOH use - 1 quart vodka/daily
lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**])
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonitis due to inhalation of food or vomitus,Fall from other slipping, tripping, or stumbling,Other convulsions,Other and unspecified alcohol dependence, continuous,Depressive disorder, not elsewhere classified,Esophageal reflux
Subdural hem w/o coma,Food/vomit pneumonitis,Fall from slipping NEC,Convulsions NEC,Alcoh dep NEC/NOS-contin,Depressive disorder NEC,Esophageal reflux
Admission Date:  [**2199-11-23**]              Discharge Date:   [**2199-12-5**]

Date of Birth:  [**2151-6-29**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
Pt s/p fall

Major Surgical or Invasive Procedure:
craniotomy for SDH evacuation


History of Present Illness:
HPI:  57 yo male with heavy EtOH use who presents after fall
from
standing and seizure activity to OSH. Pt with 1 quart vodka
intake 1day.  pt was in detox X 5 days until thursday and when
he
got out, he was drinking heavily (wife does not know quantity)
night prior to fall.  he was at baseline (post inebriated state)
~2pm when he was walking to bedroom - began mumbling and then
fell and hit head on door and had generalized convulsions with
urinary incontinence - convulsions X 3-4 minutes.

Pt brought to OSH where was intubated for airway protection.  CT
head done with L SDH and 3mm shift.

pt transferred to ED where repeat CT demonstrated similar amount
of ML shift and 1.1 cm in greatest diamter of acute SD blood.
pt
with chronic subdurals as well bilaterally.

ROS:
Gen:  No fevers/chills/sweats, CP, SOB, palpitations, N/V, URI,
cough, abd pain, dysuria, melena, BRBPR, rash, travel

Neurological:  No deficits noted in:  memory, personality,
vision, hearing, language/speech, swallowing, coordination,
writing, walking, bowel/bladder function.
No history of stroke, HA, seizures.  No weakness, no sensory
loss, no neck pain.


Past Medical History:
PAST MEDICAL HISTORY:
GERD
depression
ETOHism


Social History:
1 cig/day
heavy ETOH use - 1 quart vodka/daily
lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**])


Family History:
no seizures


Physical Exam:
EXAM
VS:  T  98  HR 90 BP 121/77     Sat 100% intubated
PE:     General, intubated
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, no rashes or petechiae

NEUROLOGICAL
MS: 	
General: alert, responds to voice, spontaneous eye opening
not following commands consistently

CN:
II,III: blinks to threat, pupils 3-2 mm bilaterally to light
III,IV,V: EOMI, no ptosis
V: 	+ corneals
VIII: 	responds to voice
IX,X: 	+ gag

Motor:	reaching for tube with both UE, moving all extremities
symmetrically.  nl tone, nl bulk.

Reflex:		

  	[**Hospital1 **]	Tri	Bra	Pat	An	Plantar
	C5	C7	C6	L4	S1	CST
L	2	2	2	2	2	Flexor
R	2	2	2	2	2	Flexor

Sensation:  	withdraws to noxious in all extremities equally

Exam on Discharge:
Tc 98.5 BP 102/66 HR 67 RR 18 O2 Sats 99% RA
GEN: Awake, A + O x3, follows commands
HEENT: eyes open, EOMI, PERRL, facial sensation intact, tongue
midline
CV: RRR
RESP: CTAB
ABD: soft, ND NT
Wound: C/D/I, staples removed
Neuro:
Motor: full strength in BUE and BLE equally and symmetric;
sensation intact to light touch; finger to nose intact


Pertinent Results:
LAB:
146/4.6/111/25/11/0.8<163
15.9> 38.8 <311
coags: 12.7/1.1/23.7         	          	

CK: 517  MB: Pnd  Trop-T: Pnd
[**Doctor First Name **]: 54 Lip:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative

Urine Benzos Pos
Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative

UA:
Color
Yellow  Appear
Hazy  SpecGr
1.018  pH
5.0  Urobil
Neg  Bili
Neg
Leuk
Neg  Bld
Tr  Nitr
Neg  Prot
Neg  Glu
250  Ket
Neg
RBC
0-2  WBC
0-2  Bact
Mod  Yeast
None  Epi
0  Amorph
Many

IMAGING:
CT brain:Left-sided subdural hematoma appears acute on chronic.
There is associated mass effect with effacement of the left
lateral ventricle and rightward subfalcine herniation by
approximately 3.5 mm.  Probable chronic subdural along the right
frontal lobe.

CT cspine: no fracture.
CT torso: no traumatic injury:  Small area of consolidation at
base of left lower lobe probably aspiration.

CT Head [**11-25**]:
FINDINGS:  Again demonstrated is extensive left subdural
hemorrhage
with no significant change. There is mass effect on the left
lateral
ventricle, effacement of its occipital [**Doctor Last Name 534**] and effacement of
the cerebral
sulci on the left side. The shift of the septum pellucidum is
similar,
approximately 3 mm.

Note is made of a small amount of blood layering within the
right occipital [**Doctor Last Name 534**] present on prior study however more
conspicuous today.

A large focal hypodensity, 4.8x2.3cm in the anterior right
middle cranial
fossa probably represents an arachnoid cyst with scalloping and
thinning of the adjacent squamous temporal bone and displacement
of the temporal lobe posteriorly. ([**2-12**])

A nasal bone deformity likely represents prior trauma and is
unchanged. There is no evidence of acute fracture.

Moderate opacification is noted  within the ethmoid and
maxillary sinuses.
The mastoid air cells are clear.

IMPRESSION:

1. Stable left extensive subdural hematoma.  Small amount of
blood within the right occipital [**Doctor Last Name 534**], more conspicuous than
prior study.  Stable rightward subfalcine herniation, 3 mm, mass
effect on the left lateral ventricle, effacement of left
occipital horna nd cerebral sulci.

2. Large, 4.8x2.3cm extra-axial hypodensity in the right
anterior middle
cranial fossa, with scalloping and thinning of adjacent squamous
temporal
bone, and posterior displacement of the temporal lobe likely
represents cyst- arachnoid/epidermoid cyst. The exact nature can
be confirmed with MR head without and with contrast, at clinical
discretion. Unclear if this can cause seizures.

3. Moderate sinus disease, as described above.

CT Head [**11-26**]:
FINDINGS:  Patient is now status post left frontal craniotomy,
with expected regional post-surgical change, and left frontal
pneumocephalus. Left subdural hemorrhage is decreased in extent,
although a moderate amount of dense subdural blood does remain,
predominantly posteriorly, and this also tracks inferiorly along
the left tentorium.  Slight rightward subfalcine herniation, and
mass effect on the left lateral ventricle is unchanged.  A small
amount of layering blood in the occipital [**Doctor Last Name 534**] of the right
lateral ventricle is unchanged. Sulcal effacement, left greater
than right, is unchanged.

Focal hypodensity in the anterior right middle cranial fossa is
unchanged,
completely described on prior exams, and most consistent with an
arachnoid
cyst.  Nasal bone deformity is unchanged.  Opacification of the
nasal
passages, maxillary and ethmoid sinuses also unchanged.

IMPRESSION:  Status post left frontal craniotomy, with expected
post-surgical change, and some interval decrease in left
subdural hemorrhage.


CT Head [**11-28**]:
NON-CONTRAST CT HEAD:  Post left frontal craniotomy changes with
reduced left frontal pneumocephalus and persistent mixed
attenuation left convexity and left tentorial subdural
hemorrhage, measuring at most 9mm from the inner table with mild
mass effect on the left lateral ventricle is grossly unchanged
since [**2199-11-25**]. There is no midline shift. A right frontal
hypodensity likely represents old subdural hemorrhage, unchanged
since [**2199-11-23**]. A focal hypodensity along the anterior right
middle cranial fossa with scalloping of the adjacent bone is
likely an arachnoid cyst, unchanged since [**2199-11-23**].

Moderate opacification of the ethmoid and maxillary sinuses is
unchanged since [**2199-11-25**].

IMPRESSION:  Left frontal craniotomy changes and left convexity
subdural
hematoma are grossly unchanged since [**2199-11-25**].


Brief Hospital Course:
Briefly, Mr. [**Known lastname 14840**] is a 48 y/o M who was initially seen at a
referring institution for falling and having a witnessed
generalized seizure. The patient was transferred to [**Hospital1 18**] with a
left acute subdural hematoma. The patient arrived to the
hospital intubated and was admitted to the intensive care unit.
He went to the OR for an evacuation of the hematoma on HD 3. He
was extubated on HD 4. His subgaleal drain was removed on POD 2.
He was transferred to the floor on POD 3. The patient failed his
physical therapy evaluation on POD 4. He was discharged home
with 24 hour supervision on POD 10 after being cleared by both
physical therapy and occupational therapy.

Neuro: The patient was intubated and sedated when he was
admitted. Preoperatively he was able to open his eyes to command
and followed commands while intubated. Postoperatively he opened
his eyes to noxious stimuli and partially followed commands.
Prior to discharge, the patient had no neurologic deficits. He
was initially started on dilantin but his serum levels were
subtherapeutic. He was subsequently switched to keppra. He was
discharged home with a prescription for keppra until his follow
up appointment with Dr. [**Last Name (STitle) 548**].

CV: Mr. [**Known lastname 14840**] remained in sinus rhythm throughout his
hospitalization.

RESP: The patient was intubated on admission. He was extubated
on POD 1. Since he was extubated, his respiratory status has
been excellent.

GI: The patient had GI prophylaxis during this admission. He had
no problems with vomiting during his stay. He did have some
episodes of nausea which resolved before he was discharged home.

GU: The patient had no problems with this system during this
hospitalization.

FEN: Mr. [**Known lastname 14840**] had some problems regarding his serum sodium
and serum potassium being too low. However, these values
corrected with minimal supplementation. He was discharged home
with normal electrolytes without supplementation. The patient
was started on a regular diet on HD 5. He was tolerating a
regular diet prior to his discharge home.

HEME: The patient had no problems with bleeding or hemostasis
during this hospitalization.

ID: The patient had no problems with this system during this
hospitalization.

Medications on Admission:
MEDICATIONS:
none

ALLERGIES:
NKDA


Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-4**]
Tablets PO Q4H (every 4 hours) as needed.
10. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain: Do not take more than 4gm acetaminophen per
day.
Disp:*20 Tablet(s)* Refills:*0*
11. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
SDH


Discharge Condition:
good, neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a 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,
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

You will need to have 24 hour supervision to ensure that you are
able to walk and perform everyday tasks safely. We will
reevaluate your functional status when you come in for your
follow up visit in 4 weeks. Your wife has agreed to provide 24
hour supervision while you are at home.

You are being sent home with a prescription for percocet, do not
drive, operate heavy machinery or make important medical
decisions while taking this medication.


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.

YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST

YOU NEED TO FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN [**Name Initial (PRE) **] 2
WEEKS OF DISCHARGE AND UPDATE HIM/HER ON YOUR HOSPITALIZATION.

YOU ALSO NEED YOUR DOCTOR [**First Name (Titles) **] [**Last Name (Titles) **] YOU FOR SLEEP APNEA.
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonitis due to inhalation of food or vomitus,Fall from other slipping, tripping, or stumbling,Other convulsions,Other and unspecified alcohol dependence, continuous,Depressive disorder, not elsewhere classified,Esophageal reflux'}


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: Pt s/p fall

PRESENT ILLNESS: HPI:  57 yo male with heavy EtOH use who presents after fall
from
standing and seizure activity to OSH. Pt with 1 quart vodka
intake 1day.  pt was in detox X 5 days until thursday and when
he
got out, he was drinking heavily (wife does not know quantity)
night prior to fall.  he was at baseline (post inebriated state)
~2pm when he was walking to bedroom - began mumbling and then
fell and hit head on door and had generalized convulsions with
urinary incontinence - convulsions X 3-4 minutes.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
GERD
depression
ETOHism

MEDICATION ON ADMISSION: MEDICATIONS:
none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: EXAM
VS:  T  98  HR 90 BP 121/77     Sat 100% intubated
PE:     General, intubated
HEENT 	AT/NC, MMM no lesions
Neck 	Supple, no bruits
Chest 	CTA B
CVS 	RRR, no m/r/g
ABD 	soft, NTND, + BS
EXT 	no C/C/E, no rashes or petechiae

FAMILY HISTORY: no seizures

SOCIAL HISTORY: 1 cig/day
heavy ETOH use - 1 quart vodka/daily
lives with wife [**Telephone/Fax (1) 77153**] ([**Doctor Last Name 1356**]) 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Pneumonitis due to inhalation of food or vomitus,Fall from other slipping, tripping, or stumbling,Other convulsions,Other and unspecified alcohol dependence, continuous,Depressive disorder, not elsewhere classified,Esophageal reflux'}
