CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: This is a 55 year old right handed male with a hisotry of
alcoholism who was found by family confused and having
difficulty walking.  Family reports
that he had fallen 3 times that day. He had bruises on his right
flank and shoulder.  He was taken to [**Hospital3 **] where a head CT
demonstrated a SDH.  Pt was taken to [**Hospital1 18**] for further
management.

MEDICAL HISTORY: IDDM

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]
Insulin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
O: BP: 99 132/73 16 96%
Gen: WD/WN, NAD, impulsive with aspen collar in place
HEENT: atraumatic, normocephalic with graying of hair. eyes are
clear, ears: no drainage, hearing intact, nasal passages patent,
oropharynx pink  Pupils:  [**3-10**] b/l       EOMs full
Neck: Supple.
Lungs: CTA bilaterally. eccymosis right side of body
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:  GCS 15, AAOX3 although day was off by one day, PERRL
4-2mm, EOM intact, face symmetric, slight left pronator drift,
strength 5/5 bilaterally, reflexes are 2+ throughout, babinski
is
flexor, no clonus
Handedness Right

FAMILY HISTORY: NC

SOCIAL HISTORY: owns a Masonry company, lives alone, right handed,
drinks at least 1 bottle of wine daily, no ilicit drugs
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other and unspecified alcohol dependence, continuous,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,History of fall,Fall from other slipping, tripping, or stumbling,Long-term (current) use of insulin
Subdural hem w/o coma,Alcoh dep NEC/NOS-contin,DMII wo cmp nt st uncntr,Personal history of fall,Fall from slipping NEC,Long-term use of insulin
Admission Date:  [**2142-9-10**]              Discharge Date:   [**2142-9-12**]

Date of Birth:  [**2086-12-20**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 55 year old right handed male with a hisotry of
alcoholism who was found by family confused and having
difficulty walking.  Family reports
that he had fallen 3 times that day. He had bruises on his right
flank and shoulder.  He was taken to [**Hospital3 **] where a head CT
demonstrated a SDH.  Pt was taken to [**Hospital1 18**] for further
management.

Past Medical History:
IDDM

Social History:
owns a Masonry company, lives alone, right handed,
drinks at least 1 bottle of wine daily, no ilicit drugs


Family History:
NC

Physical Exam:
On Admission:
PHYSICAL EXAM:
O: BP: 99 132/73 16 96%
Gen: WD/WN, NAD, impulsive with aspen collar in place
HEENT: atraumatic, normocephalic with graying of hair. eyes are
clear, ears: no drainage, hearing intact, nasal passages patent,
oropharynx pink  Pupils:  [**3-10**] b/l       EOMs full
Neck: Supple.
Lungs: CTA bilaterally. eccymosis right side of body
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:  GCS 15, AAOX3 although day was off by one day, PERRL
4-2mm, EOM intact, face symmetric, slight left pronator drift,
strength 5/5 bilaterally, reflexes are 2+ throughout, babinski
is
flexor, no clonus
Handedness Right

At discharge: He had no cranial nerve or motor deficit. His
speeach was fluent and he was oriented and alert.


Pertinent Results:
CT head [**9-10**]: large interhemispheric blood ~1.3 cm on the right,
there is an associated right SDH ~8mm with effacement and edema
R>L.  There is no hydrocephalus

CT C-spine [**9-10**]: no fracture or malalignment

CXR [**9-10**]: The lungs are clear, the cardiomediastinal silhouette
and hila are normal. There is no pleural effusion and no
pneumothorax.

CT Head [**9-11**]: Mild interval decrease in the size of the right
subdural
hematoma.


Brief Hospital Course:
Mr. [**Known lastname 90883**] was admitted to the ICU for frequent neuro checks and
systolic blood pressure management less than 140.  Repeat head
CT showed some improvement. He had no C-spine injury and no pain
and his collar was cleared when he was alert and oriented.  The
patient's mental status improved as intoxication decreased.  He
remained in the ICU until [**9-11**]. He was transferred to the SDU
and was getting Ativan for CIWA scale. He was less confused on
[**9-12**]. He was seen by social work and given contact information
about detox centers. He was seen by PT who recommended use of a
walker and 24 hr supervision. This was plan was discussed with
his brother who lives with him and his sister. They agreed with
this plan.  He was discharged to home on [**9-12**].

Medications on Admission:
Metformin 500mg [**Hospital1 **]
Insulin

Discharge Medications:
1. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for HA, fever.
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
Resume home insulin use

Discharge Disposition:
Home

Discharge Diagnosis:
Right sided subdural hematoma
Alcohol withdrawal


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


Discharge Instructions:
General Instructions
You need 24 hr supervision.
Use a walker to prevent falls
No heavy lifting >10 lbs. no strenuous activity
Do not ingest alcohol, it puts you at risk for a fall or
seizure.
??????	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 and follow up with laboratory
blood drawing in one week.  This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**]. CALL
YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy 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.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], 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**].


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

Completed by:[**2142-9-12**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other and unspecified alcohol dependence, continuous,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,History of fall,Fall from other slipping, tripping, or stumbling,Long-term (current) use of insulin'}


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: altered mental status

PRESENT ILLNESS: This is a 55 year old right handed male with a hisotry of
alcoholism who was found by family confused and having
difficulty walking.  Family reports
that he had fallen 3 times that day. He had bruises on his right
flank and shoulder.  He was taken to [**Hospital3 **] where a head CT
demonstrated a SDH.  Pt was taken to [**Hospital1 18**] for further
management.

MEDICAL HISTORY: IDDM

MEDICATION ON ADMISSION: Metformin 500mg [**Hospital1 **]
Insulin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
O: BP: 99 132/73 16 96%
Gen: WD/WN, NAD, impulsive with aspen collar in place
HEENT: atraumatic, normocephalic with graying of hair. eyes are
clear, ears: no drainage, hearing intact, nasal passages patent,
oropharynx pink  Pupils:  [**3-10**] b/l       EOMs full
Neck: Supple.
Lungs: CTA bilaterally. eccymosis right side of body
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:  GCS 15, AAOX3 although day was off by one day, PERRL
4-2mm, EOM intact, face symmetric, slight left pronator drift,
strength 5/5 bilaterally, reflexes are 2+ throughout, babinski
is
flexor, no clonus
Handedness Right

FAMILY HISTORY: NC

SOCIAL HISTORY: owns a Masonry company, lives alone, right handed,
drinks at least 1 bottle of wine daily, no ilicit drugs 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other and unspecified alcohol dependence, continuous,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,History of fall,Fall from other slipping, tripping, or stumbling,Long-term (current) use of insulin'}
