CHIEF COMPLAINT: Called by Emergency Department to evaluate: expanding SDH

PRESENT ILLNESS: Mr. [**Known lastname 41140**] is a 21 year-old left-handed man with a past medical
history including traumatic brain injury with residual cognitive
impairments and right exophoria last evlauted [**4-26**] for a small
(3mm) traumatic subdural hematoma (SDH) who presented to [**Location (un) **]
today with worsening headache and vomiting who was transferred
to
the [**Hospital1 18**] after a non-contrast CT of the head was thought to
show
an enlarging SDH.
.
The patient explains that he was discharged home on [**4-26**].  He
felt well, and even attended work at [**Month/Day (4) **] [**Male First Name (un) 45193**] this morning.
Because colleagues were concerned by the contusions on his face,
they urged him to return home.  While sitting waiting for his
girlfriend's grandmother to pick him up, he gradually developed
a
headache involving the left forehead.  He describes a "constant"
dull ache superimposed by throbbing.  The discomfort radiated to
the ears bilaterally.  Movement of any sort and lying down
exacerbated the discomfort.  Standing allevaited the discomfort
to some degree.  Associated symptoms included nausea, vomiting,
and the sense that his hearing was waxing and [**Doctor Last Name 688**] with ear
"popping."  He specifically denies associated lightheadedness,
vertigo, visual changes, weakness, sensory changes, and gait
disturbance.  The intensity of the pain increased, however,
until
he could "no longer stand it."  At its worst the pain rated
7.5/10. He called 911 and an ambulance transported him to
[**Hospital3 **] for evaluation.  He was given morphine 4 mg IV x 1.  A
non-contrast CT of the head was reported to show an SHD
measuring
10 mm with 7 mm of midline shift.  He was transferred to the
[**Hospital1 18**] for further evaluation and care.
.
At the time of the evaluation, the patient reports some
improvement in the headache (now [**2-3**]).  He denies nausea at
present.  He denies other appreciated deficits.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- TBI with residual right exophoria + horizontal diplopia,
pelvic, right femur, + jaw fractures, cognitive
impairement/short-term memory loss in setting of MVC 4 years ago
- Cardiorepiratory arrest x 3 requiring CPR during admission for
TBI, according to patient and girlfriend.
.
PAST SURGICAL HISTORY:
- placement of titanium rod in right femur
- "plate and screw in head"
- "mesh in face"

MEDICATION ON ADMISSION: None

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Exam upon admission:
Vitals: T:97.5 P: 74 R: 18  BP: 125/85  SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: multiple contusions, laceration over bridge of nose with
dried blood, left aspect of upper lip swollen. no scleral
icterus
noted. Mucus membranes dry, no lesions noted in oropharynx
Neck: Supple.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Flat. Normoactive bowel sounds.  Soft.  Non-tender,
non-distended. Extremities: Warm, well-perfused.
Skin: possible urticaria in left wrist region.

FAMILY HISTORY: - negative for stroke, known neurological conditions

SOCIAL HISTORY: HABITS:
- Tobacco Use: [**11-28**] PPD x 16 years
- Alcohol Use: 4 beers/night 1x/week
- Recreational Drug Use: MJ use
.
SOCIAL HISTORY:
- involved with girlfriend
- has a daughter named [**Name (NI) 46**] [**Name (NI) **]
- works at [**Name (NI) **] [**Name (NI) 45193**]
- enjoys riding four wheelers
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Anoxic brain damage,Late effects of injury purposely inflicted by other person,Exophoria,Diplopia,Mild cognitive impairment, so stated,Memory loss,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident
Subdural hem w/o coma,Anoxic brain damage,Late effect assault,Exophoria,Diplopia,Mild cognitive impairemt,Memory loss,Lt eff intracranial inj,Late eff motor vehic acc
Admission Date:  [**2117-4-28**]              Discharge Date:   [**2117-5-3**]

Date of Birth:  [**2096-1-12**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Drug Allergy Information on File

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Called by Emergency Department to evaluate: expanding SDH

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 41140**] is a 21 year-old left-handed man with a past medical
history including traumatic brain injury with residual cognitive
impairments and right exophoria last evlauted [**4-26**] for a small
(3mm) traumatic subdural hematoma (SDH) who presented to [**Location (un) **]
today with worsening headache and vomiting who was transferred
to
the [**Hospital1 18**] after a non-contrast CT of the head was thought to
show
an enlarging SDH.
.
The patient explains that he was discharged home on [**4-26**].  He
felt well, and even attended work at [**Month/Day (4) **] [**Male First Name (un) 45193**] this morning.
Because colleagues were concerned by the contusions on his face,
they urged him to return home.  While sitting waiting for his
girlfriend's grandmother to pick him up, he gradually developed
a
headache involving the left forehead.  He describes a "constant"
dull ache superimposed by throbbing.  The discomfort radiated to
the ears bilaterally.  Movement of any sort and lying down
exacerbated the discomfort.  Standing allevaited the discomfort
to some degree.  Associated symptoms included nausea, vomiting,
and the sense that his hearing was waxing and [**Doctor Last Name 688**] with ear
"popping."  He specifically denies associated lightheadedness,
vertigo, visual changes, weakness, sensory changes, and gait
disturbance.  The intensity of the pain increased, however,
until
he could "no longer stand it."  At its worst the pain rated
7.5/10. He called 911 and an ambulance transported him to
[**Hospital3 **] for evaluation.  He was given morphine 4 mg IV x 1.  A
non-contrast CT of the head was reported to show an SHD
measuring
10 mm with 7 mm of midline shift.  He was transferred to the
[**Hospital1 18**] for further evaluation and care.
.
At the time of the evaluation, the patient reports some
improvement in the headache (now [**2-3**]).  He denies nausea at
present.  He denies other appreciated deficits.


Past Medical History:
PAST MEDICAL HISTORY:
- TBI with residual right exophoria + horizontal diplopia,
pelvic, right femur, + jaw fractures, cognitive
impairement/short-term memory loss in setting of MVC 4 years ago
- Cardiorepiratory arrest x 3 requiring CPR during admission for
TBI, according to patient and girlfriend.
.
PAST SURGICAL HISTORY:
- placement of titanium rod in right femur
- "plate and screw in head"
- "mesh in face"


Social History:
HABITS:
- Tobacco Use: [**11-28**] PPD x 16 years
- Alcohol Use: 4 beers/night 1x/week
- Recreational Drug Use: MJ use
.
SOCIAL HISTORY:
- involved with girlfriend
- has a daughter named [**Name (NI) 46**] [**Name (NI) **]
- works at [**Name (NI) **] [**Name (NI) 45193**]
- enjoys riding four wheelers


Family History:
- negative for stroke, known neurological conditions


Physical Exam:
Exam upon admission:
Vitals: T:97.5 P: 74 R: 18  BP: 125/85  SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: multiple contusions, laceration over bridge of nose with
dried blood, left aspect of upper lip swollen. no scleral
icterus
noted. Mucus membranes dry, no lesions noted in oropharynx
Neck: Supple.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Flat. Normoactive bowel sounds.  Soft.  Non-tender,
non-distended. Extremities: Warm, well-perfused.
Skin: possible urticaria in left wrist region.

NEUROLOGIC EXAMINATION:

Mental Status:
* Degree of Alertness: Alert.  Able to relate history without
difficulty.
* Orientation: Oriented to person, place, day, month, year,
situation
* Attention: Attentive.  Able to name the days of the week
forwards and backwards without difficulty.
* Memory:  Pt able to repeat 3 words immediately and recall [**12-30**]
unassisted at 30-seconds and 5-minutes.
* Language: Language is fluent without evidence of paraphasic
errors.  Repetition is intact.  Comprehension appears intact; pt
able to correctly follow midline and appendicular commands.
Prosody is normal.  Pt able to name high (pen) and low frequency
objects (knuckles) without difficulty.  [**Location (un) **] and writing
abilities intact.
* Calculation: Pt able to calculate number of quarters in $1.50
* Neglect: No evidence of neglect.
* Praxis: No evidence of apraxia (can mimic brushing teeth and
saluting).

Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 4 to 2mm and brisk.  Visual fields full to
confrontation.  Fundi not well-visualized.
* III, IV, VI: EOMI with end-gaze nystagmus.  Saccadic
intrusions.  Reports horizontal dipolopia with right endgaze and
looking upwards in the midline (previously documented)
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: Slightly decreased excursion on left with showing of
teeth
(pt thinks asymm is baseline).
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.

Motor:
* Bulk: No evidence of atrophy.
* Tone: Normal.
* Drift: No pronator drift bilaterally.
* Adventitious Movements: No tremor or asterixis noted.

Strength:
* Left Upper Extremity:  5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity:  5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, 4+
Tib Ant, Gastroc, Ext Hollucis Longis

Reflexes:
* Left:  2+ throughout Biceps, Triceps, Bracheoradialis,
Patella,
2+ Achilles
* Right: 2+ thoughout Biceps, Triceps, Bracheoradialis, 3+
Patella, 2+ Achilles
+ crossed adduction
* Babinski: extensor on right, mute/flexor on left

Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Pinprick: intact bilaterally intact bilaterally in lower
extremities, upper extremities, trunk, face
* Temperature: intact to cold sensation
* Vibration: intact bilaterally at level of medial malleolus
* Proprioception: intact bilaterally at level of great toe
* Extinction: No extinction to double simultaneous stimulation
* Cortical: No evidence of agraphesthesia

Coordination
* Finger-to-nose: intact bilaterally
* Heel-to-shin: intact bilaterally

Gait:
* Description: Good initiation.  Narrow-based with normal-length
stride and symmetric arm-swing
* Tandem: Able to tandem walk without difficulty
* Romberg: negative

Exam upon discharge:
Intact no deficits

Pertinent Results:
Head CT [**2117-4-28**]:
There is interval increase in size of the left sided subdural
hematoma, which surrounds the entire left cerebral hemisphere,
measuring up to 9 mm in thickness. Subdural hematoma is also
noted layering along the midline falx and left tertorial
leaflet. There is associated mass effect with left sided sulcal
effacement and 6-mm shift of midline structures to the right,
new from prior CT. Mild mass effect on the left lateral
ventricle is also noted. There is no downward transtentorial
herniation. This is compared to scan from [**2117-4-26**].

Head CT [**2117-4-29**]: stable compared to previous study


Brief Hospital Course:
The patient was admitted to the neurosurgery service on [**4-28**]. He
was recently seen in the ER for a SDH, was kept for observation,
and discharged on [**4-26**]. The patient came back to the hospital
after having worsening headaches and vomiting. The SDH had
increased in size and there was midline shift. The patient was
admitted to the ICU for Q1 hour neuro checks and he was started
on dilantin. He remained neurologically stable and was
transferred to the stepdown unit on [**4-29**]. He had a repeat Head CT
which was stable.
On [**4-30**] pt was neurologically stable and was cleared for transfer
to the floor. A routine Head CT was obtained and revealed Stable
subdural hematoma with similar amount of midline shift,
approximately 4 mm. No hydrocephalus. He was monitored for 48
additional hours with decreasing headaches. He had a normal
neurological exam and was tolerating a regular diet and voiding
without difficulty. He had a repeat CT on day of discharge
([**5-3**])which showed similar stable appearance.


Medications on Admission:
None

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while taking pain medication.
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain: Gradually decrease the
number you take on a daily basis, you may switch to plain
tylenol.
Disp:*45 Tablet(s)* Refills:*0*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 30 days.
Disp:*90 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Left SDH along the frontoparietal convexity


Discharge Condition:
Neurologically 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.
??????	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:
??????You will need a CT scan of the brain without contrast prior to
your appointment on [**2117-5-19**] at 2:45
?????? You have been scheduled to see Dr [**Last Name (STitle) 739**] on [**5-19**] at
3:45    please call ([**Telephone/Fax (1) 4676**] if you have any questions or
concerns.


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

Completed by:[**2117-5-3**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Anoxic brain damage,Late effects of injury purposely inflicted by other person,Exophoria,Diplopia,Mild cognitive impairment, so stated,Memory loss,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident'}


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: Called by Emergency Department to evaluate: expanding SDH

PRESENT ILLNESS: Mr. [**Known lastname 41140**] is a 21 year-old left-handed man with a past medical
history including traumatic brain injury with residual cognitive
impairments and right exophoria last evlauted [**4-26**] for a small
(3mm) traumatic subdural hematoma (SDH) who presented to [**Location (un) **]
today with worsening headache and vomiting who was transferred
to
the [**Hospital1 18**] after a non-contrast CT of the head was thought to
show
an enlarging SDH.
.
The patient explains that he was discharged home on [**4-26**].  He
felt well, and even attended work at [**Month/Day (4) **] [**Male First Name (un) 45193**] this morning.
Because colleagues were concerned by the contusions on his face,
they urged him to return home.  While sitting waiting for his
girlfriend's grandmother to pick him up, he gradually developed
a
headache involving the left forehead.  He describes a "constant"
dull ache superimposed by throbbing.  The discomfort radiated to
the ears bilaterally.  Movement of any sort and lying down
exacerbated the discomfort.  Standing allevaited the discomfort
to some degree.  Associated symptoms included nausea, vomiting,
and the sense that his hearing was waxing and [**Doctor Last Name 688**] with ear
"popping."  He specifically denies associated lightheadedness,
vertigo, visual changes, weakness, sensory changes, and gait
disturbance.  The intensity of the pain increased, however,
until
he could "no longer stand it."  At its worst the pain rated
7.5/10. He called 911 and an ambulance transported him to
[**Hospital3 **] for evaluation.  He was given morphine 4 mg IV x 1.  A
non-contrast CT of the head was reported to show an SHD
measuring
10 mm with 7 mm of midline shift.  He was transferred to the
[**Hospital1 18**] for further evaluation and care.
.
At the time of the evaluation, the patient reports some
improvement in the headache (now [**2-3**]).  He denies nausea at
present.  He denies other appreciated deficits.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- TBI with residual right exophoria + horizontal diplopia,
pelvic, right femur, + jaw fractures, cognitive
impairement/short-term memory loss in setting of MVC 4 years ago
- Cardiorepiratory arrest x 3 requiring CPR during admission for
TBI, according to patient and girlfriend.
.
PAST SURGICAL HISTORY:
- placement of titanium rod in right femur
- "plate and screw in head"
- "mesh in face"

MEDICATION ON ADMISSION: None

ALLERGIES: No Drug Allergy Information on File

PHYSICAL EXAM: Exam upon admission:
Vitals: T:97.5 P: 74 R: 18  BP: 125/85  SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: multiple contusions, laceration over bridge of nose with
dried blood, left aspect of upper lip swollen. no scleral
icterus
noted. Mucus membranes dry, no lesions noted in oropharynx
Neck: Supple.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Flat. Normoactive bowel sounds.  Soft.  Non-tender,
non-distended. Extremities: Warm, well-perfused.
Skin: possible urticaria in left wrist region.

FAMILY HISTORY: - negative for stroke, known neurological conditions

SOCIAL HISTORY: HABITS:
- Tobacco Use: [**11-28**] PPD x 16 years
- Alcohol Use: 4 beers/night 1x/week
- Recreational Drug Use: MJ use
.
SOCIAL HISTORY:
- involved with girlfriend
- has a daughter named [**Name (NI) 46**] [**Name (NI) **]
- works at [**Name (NI) **] [**Name (NI) 45193**]
- enjoys riding four wheelers 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Anoxic brain damage,Late effects of injury purposely inflicted by other person,Exophoria,Diplopia,Mild cognitive impairment, so stated,Memory loss,Late effect of intracranial injury without mention of skull fracture,Late effects of motor vehicle accident'}
