CHIEF COMPLAINT: Dizziness; s/p fall

PRESENT ILLNESS: 40M w/ no significant past medical history was having "dizzy
spell and palpitations" several times during the week preceding
hospitalization.  He reported having an episode of dizziness a
few minutes prior to him falling from a standing postition. Wife
witnessed, no apparent seizures, no slurred speech. Patient
initially AOx1 and responding inappropriately.  Mental status
slowly improved with time. Pt presents to [**Hospital1 18**] with short term
memory impairment, dizziness and headache.

MEDICAL HISTORY: subjective heart racing
1 kidney (donated kidney to mother}

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T:97  BP: 136/84    HR:73    R:19    O2Sats:100% 2L N/C
Gen: mild discomfort
HEENT: Pupils: 3->2 B/L     EOMI
Neck: Cervical Collar - no tenderness to palpation
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-24**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Mother-[**Name (NI) **] disease; Father; Deceased colon CA

SOCIAL HISTORY: Married, lives with spouse.
[**Name (NI) **] ETOH use, nonsmoker,  no ilicit drug use
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Syncope and collapse,Open wound of scalp, without mention of complication
Cl skul base fx w/o coma,Fall from slipping NEC,Atrial fibrillation,Syncope and collapse,Open wound of scalp
Admission Date:  [**2166-10-18**]              Discharge Date:   [**2166-10-23**]

Date of Birth:  [**2126-4-23**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Dizziness; s/p fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
 40M w/ no significant past medical history was having "dizzy
spell and palpitations" several times during the week preceding
hospitalization.  He reported having an episode of dizziness a
few minutes prior to him falling from a standing postition. Wife
witnessed, no apparent seizures, no slurred speech. Patient
initially AOx1 and responding inappropriately.  Mental status
slowly improved with time. Pt presents to [**Hospital1 18**] with short term
memory impairment, dizziness and headache.

Past Medical History:
subjective heart racing
1 kidney (donated kidney to mother}


Social History:
Married, lives with spouse.
[**Name (NI) **] ETOH use, nonsmoker,  no ilicit drug use

Family History:
Mother-[**Name (NI) **] disease; Father; Deceased colon CA

Physical Exam:
On Admission:
O: T:97  BP: 136/84    HR:73    R:19    O2Sats:100% 2L N/C
Gen: mild discomfort
HEENT: Pupils: 3->2 B/L     EOMI
Neck: Cervical Collar - no tenderness to palpation
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-24**] objects at 5 minutes.
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, to 3->2
mm bilaterally. Visual fields are full to confrontation.
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 [**4-28**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.

On Discharge:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Pertinent Results:
Labs on Admission:
[**2166-10-18**] 04:30PM BLOOD WBC-8.1 RBC-5.25 Hgb-16.0 Hct-42.8 MCV-82
MCH-30.6 MCHC-37.5* RDW-13.3 Plt Ct-208
[**2166-10-18**] 04:30PM BLOOD Neuts-59.7 Lymphs-31.6 Monos-2.9 Eos-4.8*
Baso-1.0
[**2166-10-18**] 08:09PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2166-10-18**] 04:30PM BLOOD PT-13.1 PTT-23.5 INR(PT)-1.1
[**2166-10-18**] 04:30PM BLOOD Glucose-135* UreaN-23* Creat-1.2 Na-137
K-3.3 Cl-100 HCO3-27 AnGap-13
[**2166-10-18**] 04:30PM BLOOD Calcium-9.4 Phos-2.5* Mg-1.9
[**2166-10-18**] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Labs on Discharge:
XXXXXXXXXXX

Imaging:
Head CT [**10-18**]:
IMPRESSION:
1. Multifocal, small regions of right-sided subdural hemorrhage
with adjacent regions of subarachnoid hemorrhage. No significant
midline shift or mass effect.
2. Soft tissue swelling along the left occipital parietal region
with
adjacent linear nondisplaced left occipital fracture extending
towards the
condyle.

C-Spine [**10-18**]:
IMPRESSION: Mild superior endplate deformity with slight loss of
height
involving the anterior portion of C6, likely within normal
limits. Otherwise, no evidence of acute fracture within the
cervical spine. Known left occipital bone fracture as described
in head CT.

MRV [**10-19**]:
IMPRESSION:
1. Asymmetry of the transverse sinuses may be due to anatomic
variation, right dominant transverse sinus.
2. Apparent tubular filling defect in the right jugular vein may
be due to
flow related artifact vs. thrombus.

Head CT [**10-22**]:
Edema of right frontal contusion, similar in appearance since
prior scan with slight decrease in hemorrhage of foci seen.


Brief Hospital Course:
Patient is a 40 year old male with 4mm rt SDH, SAH, fx of left
occipital bone after fall from standing position - felt dizzy
with palpitations and was found to have new onset of Afib.

[**10-19**] Cardiology consulted. ASA 325', atenolol 12.5mg begun.
Pts cervical spine
was also cleared clinically. Pt continued to have non focal
neurologic exam.

Repeat CT of brain done on [**10-20**] showed the frontal blood
collection as slightly increased in size. Neuro exam remaining
unchanged with short term memory
impairment. Pt needing frequent reminders for instructions and
details.  MRI/V was completed on [**10-19**] revealing no definite
thrombus. Left transverse sinus is smaller than the right. [**Month (only) 116**]
be anatomic variation. Right jugular with filling defect as
well.

[**10-20**] TTE showing basal wall hypokinesthis. Because of the
hypokinesthis, Cardiology felt it would be better to obtain a
Cardiac MR prior to EPS study which was done on [**2166-10-22**] without
complication. The patient had an implanted cardiac holter
recorder (REVEAL) placed in the cath lab.

Patient reported frontal headache without positional component
on [**10-22**] - repeat CT of head showed stable edema of right
frontal contusion, similar in appearance since prior scan with
slight decrease in hemorrhage of foci seen.

The patient and his wife will be obtaining CD copies of all
images done during his hospitalization at [**Hospital1 18**]. Images will be
for the medical providers who will follow him when he returns to
[**Location 8398**]where he will need neurology follow-up with
continuing Dilantin for at least 3 months plus neuropsych
evaluation before returning to work.  Also, needs cardiology
follow-up as well.



Medications on Admission:
None

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please dispense enteric coated tablets.
Disp:*30 Tablet(s)* Refills:*0*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 30 days: Discontinue on [**11-18**].
Disp:*90 Capsule(s)* Refills:*0*
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Headache.
Disp:*50 Tablet(s)* Refills:*1*
9. Atenolol 25 mg Tablet Sig: [**12-25**] Tablet PO twice a day: Hold
for HR less than 54 and Systolic Blood pressure <90.
Disp:*30 Tablet(s)* Refills:*2*
10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID; PRN as
needed for anxiety.
Disp:*42 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
New Onset Atrial Fibrillation
Traumatic SDH, SAH from fall while standing.


Discharge Condition:
Stable


Discharge Instructions:
General Instructions
??????	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.
??????	You have been prescribed an anti-seizure medicine, take it as
prescribed for 30 days. You should have your blood drawn every
three days to ensure an adequate level. This should be monitored
by your PCP [**Name Initial (PRE) **]/or Neurologist.
??????	
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.

Followup Instructions:
Neurosurgery Follow Up Recommendations:

*You will need to follow up with a neurologist for your head
injury, and Neuro psychiatry testing once back in [**Location (un) 7349**]. You will
need to continue on Dilantin for one month. Dilantin blood
levels must be checked every three days and reported to your PCP
or [**Name9 (PRE) 702**] Neurologist.
*Cardiology follow up also will occur in [**Location (un) 7349**]. You will need an
Electrophysiologic Cardiologist to follow your monitor.

You will be given prescriptions for enough medication to cover
for one month.



Completed by:[**2166-10-23**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Syncope and collapse,Open wound of scalp, without mention of complication'}


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: Dizziness; s/p fall

PRESENT ILLNESS: 40M w/ no significant past medical history was having "dizzy
spell and palpitations" several times during the week preceding
hospitalization.  He reported having an episode of dizziness a
few minutes prior to him falling from a standing postition. Wife
witnessed, no apparent seizures, no slurred speech. Patient
initially AOx1 and responding inappropriately.  Mental status
slowly improved with time. Pt presents to [**Hospital1 18**] with short term
memory impairment, dizziness and headache.

MEDICAL HISTORY: subjective heart racing
1 kidney (donated kidney to mother}

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
O: T:97  BP: 136/84    HR:73    R:19    O2Sats:100% 2L N/C
Gen: mild discomfort
HEENT: Pupils: 3->2 B/L     EOMI
Neck: Cervical Collar - no tenderness to palpation
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-24**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Mother-[**Name (NI) **] disease; Father; Deceased colon CA

SOCIAL HISTORY: Married, lives with spouse.
[**Name (NI) **] ETOH use, nonsmoker,  no ilicit drug use 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Fall from other slipping, tripping, or stumbling,Atrial fibrillation,Syncope and collapse,Open wound of scalp, without mention of complication'}
