CHIEF COMPLAINT: Increased L SDH on follow up CT

PRESENT ILLNESS: 76 F with 1-yr h/o dementia, frequent falls, treated
conservatively at [**Hospital1 18**] for L SDH in [**3-8**]. SDH was stable and
she had been d/c to nursing home on [**2151-3-15**]. Coumadin was held
at time of discharge. Patient had f/up head CT 02\03 which
showed increase in L SDH and she was readmitted to the ED.

MEDICAL HISTORY: HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

MEDICATION ON ADMISSION: Dilantin 100", Protonix 40', Amiodarone 200', Seroquel 25'
+ q6h PRN agitation, Celexa 40', Lopressor 25", Aricept 10',
Namenda 5",

ALLERGIES: Keflex

PHYSICAL EXAM: PE:
GEN:Alert, occasionally aggressive and non-cooperative, oriented
in time, partially in space; NAD; difficulty finding words;
Cardio: RRR, [**2-5**] murmur
Resp: CTA B
Ext.: no edema, no cyanosis;

FAMILY HISTORY: nc

SOCIAL HISTORY: 30 PY smoker (30 x 1), EtOH - cocktail/night
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Heart valve replaced by transplant,Unspecified fall,Long-term (current) use of anticoagulants,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension
Subdural hem w/o coma,Atrial fibrillation,Heart valve transplant,Fall NOS,Long-term use anticoagul,Mental disor NEC oth dis,Hypertension NOS
Admission Date:  [**2151-4-2**]              Discharge Date:   [**2151-4-6**]

Date of Birth:  [**2074-9-25**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Keflex

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Increased L SDH on follow up CT

Major Surgical or Invasive Procedure:
Left sided Craniotomy


History of Present Illness:
76 F with 1-yr h/o dementia, frequent falls, treated
conservatively at [**Hospital1 18**] for L SDH in [**3-8**]. SDH was stable and
she had been d/c to nursing home on [**2151-3-15**]. Coumadin was held
at time of discharge. Patient had f/up head CT 02\03 which
showed increase in L SDH and she was readmitted to the ED.


Past Medical History:
HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

Social History:
30 PY smoker (30 x 1), EtOH - cocktail/night


Family History:
nc

Physical Exam:
PE:
GEN:Alert, occasionally aggressive and non-cooperative, oriented
in time, partially in space; NAD; difficulty finding words;
Cardio: RRR, [**2-5**] murmur
Resp: CTA B
Ext.: no edema, no cyanosis;

Neuro: CN II-XII grossly intact
UE and LE: no motor (biceps, triceps, hand grip) and LE (psoas,
quadriceps, foot dorsiflexion/plantar flexion) or sensory
deficit; no pronator drift;
Coordination intact;


Pertinent Results:
[**2151-4-2**] GLUCOSE-152* UREA N-18 CREAT-1.1 SODIUM-136 POTASSIUM-
         3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-14
         CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-2.2
         WBC-7.4 RBC-3.07* HGB-9.6* HCT-28.4* MCV-93 MCH-31.4
         MCHC-33.9 RDW-14.0
         PLT COUNT-144* PT-13.5* PTT-27.4 INR(PT)-1.2*


   RADIOLOGY  Final Report

CT HEAD W/O CONTRAST  [**2151-4-4**] 10:15 AM

CT HEAD W/O CONTRAST

Reason: s/p SDH evac

[**Hospital 93**] MEDICAL CONDITION:
76 year old woman with SDH
REASON FOR THIS EXAMINATION:
s/p SDH evac
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATIONS: 76-year-old woman status post subdural hematoma
evacuation.

COMPARISONS: [**2151-4-3**].

TECHNIQUE: Non-contrast head CT.

FINDINGS: As before, the patient is status post craniotomy.
There is persistent associated pneumocephalus, but somewhat less
than on the prior study. A parenchymal hemorrhage overlying the
left frontoparietal lobe is similar in appearance and may have
represented a contusion. There is persistent mixed-density
subdural overlying the left frontal convexity beneath the site
of evacuation. Drains have been removed. The hemorrhage within
the postoperative bed is mixed with both acute to subacute and
chronic components. Elsewhere, the right subdural hematoma, of
up to 7 mm in thickness, has a hypodense appearance and is
probably more subacute to chronic. The maximum width of the
subdural hematoma overlying the left convexity within this
postoperative bed is also 7 mm. A similar low-density subdural
remains along the falx and probably the tentorium as well. There
is no significant shift of the normally midline structures.
Hypodensity in the anterior left frontal lobe, probably small
infarction or edema, is not significantly changed allowing for
differences in technique. The degree of mass effect is similar
allowing for changes in the degree of pneumocephalus. The
[**Doctor Last Name 352**]-white matter differentiation outside of the postoperative
bed, in particularly the areas of the tip of the anterior left
frontal lobe and along the posterior margin of the evacuation
bed, is preserved elsewhere. The ventricles are prominent as
before, but this may be due atrophic change and is similar.

The patient is status post left frontal craniotomy. The
visualized paranasal sinuses and mastoid air cells are clear.

IMPRESSION:

1. Status post removal of drain and status post craniotomy.

2. Mixed subdural hematoma in the resection bed. Chronic
subdurals elsewhere.

3. Reduction in pneumocephalus.


Brief Hospital Course:
Patient had been treated conservatively at [**Hospital1 18**] for L SDH in
[**3-8**] and had been d/c to nursing home on [**2151-3-15**].
Patient had f/up head CT 03\02 which showed increase in L SDH
and she was readmitted via ED.
She went to the OR 03\03 for L frontal temporal craniotomy with
evacuation of SDH.
Pat. remained in PACU overnight for monitoring and went to the
step down unit on HD#3. The drains were removed HD#3. She
received one unit of blood for Hypotension. On HD#6 she fell in
the bathroom with no further injury or headbleed.CT results done
[**2151-4-4**] show status post removal of drain and status post
craniotomy
with mixed subdural hematoma in the resection bed, chronic
subdurals and reduction in pneumocephalus.
She is oriented in time and space with some assistance, but
still has problems finding words, her neurolgical exam shows a
minor weekness on her right side; cranial nerves intact, no
pronator drift. Her acitivity and diet were advanced.  Foley was
removed and she was able to void.


Medications on Admission:
Dilantin 100", Protonix 40', Amiodarone 200', Seroquel 25'
+ q6h PRN agitation, Celexa 40', Lopressor 25", Aricept 10',
Namenda 5",


Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

6. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Left sided subdural hematoma


Discharge Condition:
Neurologically stable


Discharge Instructions:
Keep incision clean and dry do not get wet
Watch incision for redness, drainage, swelling, bleeding or if
you develop a fever greater than 101.5 call Dr[**Name (NI) 4674**]
office
No heavy lifting
Fall Precautions

Followup Instructions:
Have staples removed at Rehab facility on Friday [**4-16**]
Follow up in 6 weeks with Dr [**Last Name (STitle) 739**] obtain a CT prior to
that time
call [**Telephone/Fax (1) 1669**]


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

Completed by:[**2151-4-6**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Heart valve replaced by transplant,Unspecified fall,Long-term (current) use of anticoagulants,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}


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: Increased L SDH on follow up CT

PRESENT ILLNESS: 76 F with 1-yr h/o dementia, frequent falls, treated
conservatively at [**Hospital1 18**] for L SDH in [**3-8**]. SDH was stable and
she had been d/c to nursing home on [**2151-3-15**]. Coumadin was held
at time of discharge. Patient had f/up head CT 02\03 which
showed increase in L SDH and she was readmitted to the ED.

MEDICAL HISTORY: HTN
Dementia
Mitral valve replacement ([**Last Name (un) 3843**]-[**Doctor Last Name **] valve per [**Hospital1 2177**])
Afib

MEDICATION ON ADMISSION: Dilantin 100", Protonix 40', Amiodarone 200', Seroquel 25'
+ q6h PRN agitation, Celexa 40', Lopressor 25", Aricept 10',
Namenda 5",

ALLERGIES: Keflex

PHYSICAL EXAM: PE:
GEN:Alert, occasionally aggressive and non-cooperative, oriented
in time, partially in space; NAD; difficulty finding words;
Cardio: RRR, [**2-5**] murmur
Resp: CTA B
Ext.: no edema, no cyanosis;

FAMILY HISTORY: nc

SOCIAL HISTORY: 30 PY smoker (30 x 1), EtOH - cocktail/night 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Atrial fibrillation,Heart valve replaced by transplant,Unspecified fall,Long-term (current) use of anticoagulants,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension'}
