CHIEF COMPLAINT: Head Injury scalp laceration

PRESENT ILLNESS: 52 y/o male found in the middle of a four [**Male First Name (un) **] highway with
trauma to scalp. Pt brought in by ems for eval on arrival to ER
to see pt for SAH/ SDH and IPH. On arrival to ER pt was
combatitive and and speaking.  He became obtunded prior to our
team assessing him.  We asked for a stat CT which showed SAH
predominently on the left side with left temporal IPH 1.8 x 1.1
with SDH with associated MLS. No obvious bone fracture noted.

MEDICAL HISTORY: Alcoholism
Left leg skin graft

MEDICATION ON ADMISSION: None

ALLERGIES: Penicillins / Codeine / Morphine / Amitriptyline / Neurontin /
Tramadol / Percocet / Niacin / Naprosyn

PHYSICAL EXAM: BP: 169/94, HR: 86 R22 99 O2Sats on 100% NRB
Gen: WD/WN
HEENT: NC, abrasion with STS to right parietal region - no open
lacs noted. Negative battles, negative raccoon sign, unable to
visualize left TM, Right TM without hemotypanum.
Pupils: 3mm trace reaction / + corneals, roving eye movements /
non attentive to examiner, no eye opening to voice or noxious,
no
grimace.
Neck: IN collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS= 3 Eye=1, Voice =none/ 1 Motor= 1
s at 5 minutes.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Unmarried has four children.  Disabled after work injury.  Post
traumatic stress disorder treated at VA
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Chronic airway obstruction, not elsewhere classified,Assault by unspecified means,Open wound of scalp, without mention of complication,Unspecified essential hypertension
Traumatic subdural hem,Traumatic brain hem NEC,Chr airway obstruct NEC,Assault NOS,Open wound of scalp,Hypertension NOS
Admission Date:  [**2103-7-25**]              Discharge Date:   [**2103-8-2**]

Date of Birth:  [**2051-2-19**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Codeine / Morphine / Amitriptyline / Neurontin /
Tramadol / Percocet / Niacin / Naprosyn

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Head Injury scalp laceration

Major Surgical or Invasive Procedure:
Craniotomy for Subdural Hematoma Evacuation


History of Present Illness:
52 y/o male found in the middle of a four [**Male First Name (un) **] highway with
trauma to scalp. Pt brought in by ems for eval on arrival to ER
to see pt for SAH/ SDH and IPH. On arrival to ER pt was
combatitive and and speaking.  He became obtunded prior to our
team assessing him.  We asked for a stat CT which showed SAH
predominently on the left side with left temporal IPH 1.8 x 1.1
with SDH with associated MLS. No obvious bone fracture noted.

Past Medical History:
Alcoholism
Left leg skin graft

Social History:
Unmarried has four children.  Disabled after work injury.  Post
traumatic stress disorder treated at VA

Family History:
Unknown

Physical Exam:
BP: 169/94, HR: 86 R22 99 O2Sats on 100% NRB
Gen: WD/WN
HEENT: NC, abrasion with STS to right parietal region - no open
lacs noted. Negative battles, negative raccoon sign, unable to
visualize left TM, Right TM without hemotypanum.
Pupils: 3mm trace reaction / + corneals, roving eye movements /
non attentive to examiner, no eye opening to voice or noxious,
no
grimace.
Neck: IN collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS= 3 Eye=1, Voice =none/ 1 Motor= 1
s at 5 minutes.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 trace reaction

bilaterally.
III, IV, VI: Extraocular movements = not able to test/ roving
eye
movements
V, VII: unable to assess.
VIII: unable to assess.
IX, X: unable to assess.
[**Doctor First Name 81**]: unable to assess.
XII: unable to assess.

Motor: Strength full power [**4-21**] throughout on arrival - now with
some finger movement and toe movement on the left without w/d to

noxious.

Toes downgoing bilaterally


Pertinent Results:
[**2103-7-25**] 02:00AM   PT-11.9 PTT-24.9 INR(PT)-1.0
[**2103-7-31**] 02:45AM BLOOD Plt Ct-279
[**2103-7-31**] 02:45AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-134
K-4.2 Cl-104 HCO3-22 AnGap-12
[**2103-7-31**] 02:45AM BLOOD Albumin-3.0* Calcium-8.5 Phos-2.9 Mg-2.2
[**2103-7-25**] 02:00AM BLOOD ASA-NEG Ethanol-460* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2103-7-31**] 03:11AM BLOOD Type-ART pO2-138* pCO2-31* pH-7.48*
calTCO2-24 Base XS-1
[**2103-7-31**] 03:11AM BLOOD Lactate-1.6
[**2103-7-25**] 06:14AM BLOOD Hgb-10.0* calcHCT-30
[**2103-7-31**] 03:11AM BLOOD freeCa-1.17

Brief Hospital Course:
Mr [**Known lastname 1007**] was seen by Neurosurgery and taken emergently to the OR
to undergo a left sided craniotomy for evacuation of left sided
subdural hematoma and partial lobectomy.  Post operatively he
did not respond to any painful stimuli until approx 24 hours
post operatively.  He would attempt to localize his right arm
and infrequently his left arm with very little movemment of his
lower extremeties.  His immediate post op course was complicated
by high fevers with only source was HFlu in his sputum.

His post operative CT that showed extensive hemorrhagic
contusion within the left temporal lobe, a large quantity of
pneumocephalus within the left frontal region, as well was as
within an apparent partially evacuated left cerebral convexity
subdural hematoma. There does appear to be persistent mass
effect, as well as continued rightward subfalcine herniation.

An EEG showed some generalized slowing.

His exam continued to show roving eye movement, occasional eye
opening, localizing on right>left.  On [**7-30**] a CT showed some
increase mass effect causing midline shift.

His family was adament that Mr [**Known lastname 1007**] would not want a Trach or
PEG or 24 hour nursing care on [**8-1**] they made him CMO.  He was
started on a Morphine drip and passed away on [**8-2**].

Medications on Admission:
None

Discharge Medications:
None

Discharge Disposition:
Expired

Discharge Diagnosis:
Traumatic Brain Injury


Discharge Condition:
Deceased


Discharge Instructions:
N/A

Followup Instructions:
N/A


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

Completed by:[**2103-8-6**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Chronic airway obstruction, not elsewhere classified,Assault by unspecified means,Open wound of scalp, without mention of complication,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: Head Injury scalp laceration

PRESENT ILLNESS: 52 y/o male found in the middle of a four [**Male First Name (un) **] highway with
trauma to scalp. Pt brought in by ems for eval on arrival to ER
to see pt for SAH/ SDH and IPH. On arrival to ER pt was
combatitive and and speaking.  He became obtunded prior to our
team assessing him.  We asked for a stat CT which showed SAH
predominently on the left side with left temporal IPH 1.8 x 1.1
with SDH with associated MLS. No obvious bone fracture noted.

MEDICAL HISTORY: Alcoholism
Left leg skin graft

MEDICATION ON ADMISSION: None

ALLERGIES: Penicillins / Codeine / Morphine / Amitriptyline / Neurontin /
Tramadol / Percocet / Niacin / Naprosyn

PHYSICAL EXAM: BP: 169/94, HR: 86 R22 99 O2Sats on 100% NRB
Gen: WD/WN
HEENT: NC, abrasion with STS to right parietal region - no open
lacs noted. Negative battles, negative raccoon sign, unable to
visualize left TM, Right TM without hemotypanum.
Pupils: 3mm trace reaction / + corneals, roving eye movements /
non attentive to examiner, no eye opening to voice or noxious,
no
grimace.
Neck: IN collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS= 3 Eye=1, Voice =none/ 1 Motor= 1
s at 5 minutes.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Unmarried has four children.  Disabled after work injury.  Post
traumatic stress disorder treated at VA 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Chronic airway obstruction, not elsewhere classified,Assault by unspecified means,Open wound of scalp, without mention of complication,Unspecified essential hypertension'}
