CHIEF COMPLAINT: CC:[**CC Contact Info 90884**]

PRESENT ILLNESS: HPI:  This is a 55 year old RH alcoholic male who was found by
family confused and having difficulty walking.  Family reports
that he had fallen 3 times today. 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, GERD, ETOH abuse

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

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  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,Compression of brain,Hyposmolality and/or hyponatremia,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified alcohol dependence, continuous,Long-term (current) use of insulin,Fall from other slipping, tripping, or stumbling
Subdural hem w/o coma,Compression of brain,Hyposmolality,Phlbts sprfc vn up extrm,DMII wo cmp nt st uncntr,Esophageal reflux,Alcoh dep NEC/NOS-contin,Long-term use of insulin,Fall from slipping NEC
Admission Date:  [**2142-9-23**]              Discharge Date:   [**2142-9-28**]

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

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 90884**]

Major Surgical or Invasive Procedure:
[**2142-9-24**] right sided burr holes


History of Present Illness:
HPI:  This is a 55 year old RH alcoholic male who was found by
family confused and having difficulty walking.  Family reports
that he had fallen 3 times today. 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, GERD, ETOH abuse

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

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


Family History:
NC

Physical Exam:
PHYSICAL EXAM:
O: T:  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

Discharge exam
pleasant and cooperative, AOx3, speech is clear and fluent, no
drift
Motor is [**4-12**] bilaterally
sensory intact
Incision is c/d/i with staples

Pertinent Results:
[**2142-9-22**]  CT BRAIN
IMPRESSION: Except for evolution of blood products, there has
been no change in the size and associated mass effect on the
right-sided subdural hematoma and interhemispheric subdural
hematoma.

[**2142-9-23**] CT BRAIN
IMPRESSION:
1. Minimal increase in size of the right frontoparietal subdural
hematoma,
stable hemorrhage along the falx. Mildly increased local mass
effect and
compression of the ipsilateral ventricle. Increased dilation of
the
contralateral temporal [**Doctor Last Name 534**].
2. Increasing midline shift, now 8 mm to the left compared to 5
mm on the
prior, findings indicative of worsening subfalcine herniation.
Patent basilar cisterns without signs of downward transtentorial
herniation.
3. No new area of intra- or extra-axial hemorrhage or acute
large territorial infarction.

[**2142-9-24**] CT BRAIN
IMPRESSION: Status post recent burr holes for right
frontoparietal subdural hematoma evacuation. Persistent smaller
right subdural hematoma. No interval new hemorrhage. Interval
decrease in shift of midline structures from 8 to 6 mm.
Persistent mass effect on the right lateral ventricle and
dilatation of the left temporal [**Doctor Last Name 534**].

[**2142-9-25**] CT head
1. Small right subdural hematoma similar in size, with no
interval acute
hemorrhage.
2. Stable 6 mm leftward shift of midline structures.
3. Persistent mass effect on the right lateral ventricle and
dilatation of
the left temporal [**Doctor Last Name 534**].
4. Focal hypodensity in the right frontal subcortical white
matter similar
dating back to [**2142-9-22**], possible focal ischemia.


Brief Hospital Course:
Mr. [**Known lastname 90883**] was admitted to the hospital through the emergency
department tot he NICU for complaints of persistent nausea and
vomiting.   CT imaging revealed persistent subdural hematoma.
He was previously admitted to our service and sent home with
conservative management.  With his persistent symptomology it
was decided to take him to the OR for evacuation fo the subdural
hematoma.  He underwent the burr hole evacuation without
difficulty.  He was returned to the NICU extubated. CT shoed no
new hemorrhage. On POD1 he continued to have severe headache and
nausea. He also had left hand numbness and was dropping objects.
CT head done on this day showed improvement in shift and new
area of infarct in the right frontal area. He was started on
Mannitol and his symtpoms improved on [**9-26**]. The dosing was
changed to [**Hospital1 **] on [**9-26**] and SDU orders were written. He required
an increase in his Dilantin for subtherepeutic levels.

His was doing well on [**9-27**] and his sodium was 139. His salt
tabs and  mannitol were discontinued. He was mobilized.

Now DOD, patient is afebrile, VSS, and neurologically stable.
Patient's pain is well-controlled and the patient is tolerating
a good oral diet.  Pt's incision is clean, dry and inctact
without evidence of infection.  He is set for discharge home in
stable condition and will follow-up accordingly.


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


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. phenytoin sodium extended 100 mg Capsule Sig: Three (3)
Capsule PO BID (2 times a day).
Disp:*180 Capsule(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
right subdural hematoma
nausea
vomiting
Insulin dependent diabetes


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


Discharge Instructions:
You have been discharged with the diagnosis of subdural
hematoma.  This is blood layering on top of your brain.  You
continue to have small residual blood since the operation.  You
will require a follow-up in [**3-14**] weeks to determine extent of
improval. It is imperative that you cease drinking alcohol.

General Instructions

??????	Have a friend/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,
or excessive bending.
??????       Keep your staples clean and dry until removal.
??????	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, and
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**].
??????	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, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**6-17**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
 Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Name (NI) 739**]_, to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.

-  Please follow up with your Primary care provider as soon as
possible (within 2-4 days) upon discharge from hospital to have
your blood pressure checked and dilantin level.  Labetalol can
be discontinued as per your PCP if clinically indicated.


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

Completed by:[**2142-9-28**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Compression of brain,Hyposmolality and/or hyponatremia,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified alcohol dependence, continuous,Long-term (current) use of insulin,Fall from other slipping, tripping, or stumbling'}


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: CC:[**CC Contact Info 90884**]

PRESENT ILLNESS: HPI:  This is a 55 year old RH alcoholic male who was found by
family confused and having difficulty walking.  Family reports
that he had fallen 3 times today. 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, GERD, ETOH abuse

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

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  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,Compression of brain,Hyposmolality and/or hyponatremia,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Other and unspecified alcohol dependence, continuous,Long-term (current) use of insulin,Fall from other slipping, tripping, or stumbling'}
