CHIEF COMPLAINT: Headache

PRESENT ILLNESS: 73 year old female presents with a headache x 24 hours. She
was recently on the neurosurgery service with bilateral SDH and
she had the right one evacuated by Dr. [**Last Name (STitle) 548**] on [**2134-7-10**]. The
patient did well post-operatively and was discharged on [**7-13**].
She
was seen in the office for suture removal on [**7-20**] and was doing
well and had no headache that day. The patient called
neurosurgery in the evening of [**2134-7-30**] complaining of a headache

MEDICAL HISTORY: 1.Right sided subdural hematoma
2.DMII-insulin dependent
3.Osteoporosis
4.chronic low back pain
5.R sciatica pain

MEDICATION ON ADMISSION: Lisinopril
Dilantin
Zantac

ALLERGIES: Penicillins / Aleve / Ibuprofen / Valium / Codeine / Morphine /
Oxycodone Hcl/Acetaminophen / Darvocet-N 100 / Vicodin /
Levaquin / Rocephin / Cipro

PHYSICAL EXAM: T:97.9 BP:126/58 HR:80 RR:16 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 1+ bilateral pedal edema.
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: Mother and sister both had intracranial aneurysms

SOCIAL HISTORY: Lives with daughter and husband in [**Name (NI) 1475**]
Subdural hemorrhage,Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Subdural hemorrhage,Osteoporosis NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2134-7-31**]              Discharge Date:   [**2134-8-4**]

Date of Birth:  [**2061-4-30**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins / Aleve / Ibuprofen / Valium / Codeine / Morphine /
Oxycodone Hcl/Acetaminophen / Darvocet-N 100 / Vicodin /
Levaquin / Rocephin / Cipro

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Headache

Major Surgical or Invasive Procedure:
Craniotomy for subdural evacuation


History of Present Illness:
73 year old female presents with a headache x 24 hours. She
was recently on the neurosurgery service with bilateral SDH and
she had the right one evacuated by Dr. [**Last Name (STitle) 548**] on [**2134-7-10**]. The
patient did well post-operatively and was discharged on [**7-13**].
She
was seen in the office for suture removal on [**7-20**] and was doing
well and had no headache that day. The patient called
neurosurgery in the evening of [**2134-7-30**] complaining of a headache

that began the night before. She was told to go to the nearest
ER. She had a head CT at the OSH that showed acute on chronic
SDHs so she was transferred to [**Hospital1 18**]. The patient had a dilantin

level of 3.0 and was given 500 mg at the OSH. She continues to
have a headache that is behind her left eye but no other
symptoms


Past Medical History:
1.Right sided subdural hematoma
2.DMII-insulin dependent
3.Osteoporosis
4.chronic low back pain
5.R sciatica pain


Social History:
Lives with daughter and husband in [**Name (NI) 1475**]


Family History:
Mother and sister both had intracranial aneurysms

Physical Exam:
T:97.9 BP:126/58 HR:80 RR:16 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 1+ bilateral pedal edema.
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, 1.5 to 1 mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
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 and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-20**] throughout. No pronator drift.

Sensation: Intact to light touch bilaterally.

Toes downgoing bilaterally



Pertinent Results:
[**2134-7-31**] 04:00AM   PT-11.9 PTT-25.0 INR(PT)-1.0
[**2134-7-31**] 04:00AM   PLT COUNT-267
[**2134-7-31**] 04:00AM   NEUTS-62.2 LYMPHS-28.9 MONOS-4.5 EOS-4.0
BASOS-0.4
[**2134-7-31**] 04:00AM   WBC-8.7 RBC-3.89* HGB-11.9* HCT-34.3* MCV-88
MCH-30.7 MCHC-34.7 RDW-13.9
[**2134-7-31**] 04:00AM   estGFR-Using this
[**2134-7-31**] 04:00AM   GLUCOSE-109* UREA N-16 CREAT-0.8 SODIUM-138
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14
[**2134-7-31**] 07:30AM   PT-12.1 PTT-26.7 INR(PT)-1.0
[**2134-7-31**] 07:30AM   WBC-8.7 RBC-3.66* HGB-11.4* HCT-32.4* MCV-89
MCH-31.2 MCHC-35.2* RDW-13.6
[**2134-7-31**] 07:30AM   PHENYTOIN-9.7*

Brief Hospital Course:
Ms [**Known lastname 1458**] was admitted to the Neurosurgery and followed with serial
neuro exams and CT's. On [**8-1**] her CT there was a question of
worsening size of subdural with a questionable right sided
drift. Her dilantin levels were kept greater than 10.  She went
to the OR on [**8-3**] she had a subdural drain in place.
Neurologically post operatively she was intact.  On her first
post operative day she only required Tylenol for pain and had no
drift.  She tolerated a regular diet and cleared by PT to go
home.  Her drain was removed earlier in the day before
discharge.

Medications on Admission:
Lisinopril
Dilantin
Zantac

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Right sided Subdural Hematoma


Discharge Condition:
Neurologically stable


Discharge Instructions:
??????	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


Followup Instructions:
Have your staples out in Dr[**Name (NI) 4674**] office on [**8-12**], [**2133**] between 0900-1200
Follow up with Dr [**Last Name (STitle) 739**] in 6 weeks with a head CT at
that time
Cancel your appointment with Dr [**Last Name (STitle) 548**]
Have your primary care physician check your Dilantin level in
one week


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2134-8-4**]
{'Subdural hemorrhage,Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 73 year old female presents with a headache x 24 hours. She
was recently on the neurosurgery service with bilateral SDH and
she had the right one evacuated by Dr. [**Last Name (STitle) 548**] on [**2134-7-10**]. The
patient did well post-operatively and was discharged on [**7-13**].
She
was seen in the office for suture removal on [**7-20**] and was doing
well and had no headache that day. The patient called
neurosurgery in the evening of [**2134-7-30**] complaining of a headache

MEDICAL HISTORY: 1.Right sided subdural hematoma
2.DMII-insulin dependent
3.Osteoporosis
4.chronic low back pain
5.R sciatica pain

MEDICATION ON ADMISSION: Lisinopril
Dilantin
Zantac

ALLERGIES: Penicillins / Aleve / Ibuprofen / Valium / Codeine / Morphine /
Oxycodone Hcl/Acetaminophen / Darvocet-N 100 / Vicodin /
Levaquin / Rocephin / Cipro

PHYSICAL EXAM: T:97.9 BP:126/58 HR:80 RR:16 O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. 1+ bilateral pedal edema.
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: Mother and sister both had intracranial aneurysms

SOCIAL HISTORY: Lives with daughter and husband in [**Name (NI) 1475**] 

### Response:
{'Subdural hemorrhage,Osteoporosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
