CHIEF COMPLAINT: consulted for SDH found on outside head CT

PRESENT ILLNESS: HPI: 58 year old male s/p craniotomy 20 years ago after he was
hit by a 2x4. He began having seizures post-operatively but has
been seizure free for ~15 years. He takes his Tegretol as
directed. He presented today to an OSH after having fallen at
work and hitting his head. He does not recall the episode. On
outside CT there was a right frontal and a right temporal SDH in
the area of the previous surgery. The patient reports a [**6-26**]
headache. He has no dizziness, no blurred vision, no weakness,
no
N/V. Recently he completed a course of antibiotics for a cough
and sneezing. He has no chest pain or SOB.

MEDICAL HISTORY: PMHx:s/p craniotomy 20 years ago
     h/o seizures

MEDICATION ON ADMISSION: Medications prior to admission:
Tegretol

ALLERGIES: Codeine

PHYSICAL EXAM: on arrival...

FAMILY HISTORY: Family Hx:non-contributory

SOCIAL HISTORY: Social Hx:smokes tobacco
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Closed fracture of rib(s), unspecified,Head injury, unspecified,Headache,Unspecified fall
Subdural hem w/o coma,Convulsions NEC,Fracture rib NOS-closed,Head injury NOS,Headache,Fall NOS
Admission Date:  [**2159-1-29**]              Discharge Date:   [**2159-2-7**]

Date of Birth:  [**2100-10-10**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Codeine

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
consulted for SDH found on outside head CT


Major Surgical or Invasive Procedure:
none


History of Present Illness:
HPI: 58 year old male s/p craniotomy 20 years ago after he was
hit by a 2x4. He began having seizures post-operatively but has
been seizure free for ~15 years. He takes his Tegretol as
directed. He presented today to an OSH after having fallen at
work and hitting his head. He does not recall the episode. On
outside CT there was a right frontal and a right temporal SDH in
the area of the previous surgery. The patient reports a [**6-26**]
headache. He has no dizziness, no blurred vision, no weakness,
no
N/V. Recently he completed a course of antibiotics for a cough
and sneezing. He has no chest pain or SOB.


Past Medical History:
PMHx:s/p craniotomy 20 years ago
     h/o seizures


Social History:
Social Hx:smokes tobacco


Family History:
Family Hx:non-contributory


Physical Exam:
on arrival...

PHYSICAL EXAM:
T:97.1  BP:160/76    HR:74    RR:16       O2Sats:96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL, right slower to react    EOMs-intact
Neck: Supple.
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.
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, 4 to 3 mm
bilaterally.
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 [**4-21**] throughout. No pronator drift.

Sensation: Intact to light touch bilaterally.

currently...pt awake alert with non focal neuro exam.

Pertinent Results:
[**2159-1-29**] 07:30PM   GLUCOSE-145* UREA N-9 CREAT-0.8 SODIUM-134
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-10
[**2159-1-29**] 07:30PM   estGFR-Using this
[**2159-1-29**] 07:30PM   CALCIUM-8.8 PHOSPHATE-2.3* MAGNESIUM-2.1
[**2159-1-29**] 07:30PM   WBC-9.3 RBC-4.84 HGB-15.5 HCT-44.8 MCV-92
MCH-32.0 MCHC-34.6 RDW-13.5
[**2159-1-29**] 07:30PM   NEUTS-83.4* LYMPHS-13.0* MONOS-2.5 EOS-0.3
BASOS-0.9
[**2159-1-29**] 07:30PM   PLT COUNT-230
[**2159-1-29**] 07:30PM   PT-13.1 PTT-31.9 INR(PT)-1.1

Brief Hospital Course:
Pt was admitted through the emergency room for ICH s/p
fall/trauma/seizure.
Follow up CT scans of the brain have remained stable.  Rib
fractures on the Left side were identified.Pt appeared to be in
distress on [**1-30**] however had no complaints. Work up without
findings.  Pt remained stable.  Pt with shallow breathing [**1-19**]
rib fractures.  Cough and deep breath and Incentive spirometry
encouraged daily as well as to increase mobility however pt non
compliant.  An EEG was obtained on [**1-31**] to assess for
subclinical sz activity and this report was as follows:This is
an abnormal EEG in the waking and drowsy state due to the right
temporal greater than frontal discharges, at times rhythmically
lasting up to 90 seconds. This suggests a focal temporal
electrographic seizure, as well as right temporal and frontal
foci of epileptogenesis. The right frontotemporal slowing
suggests right frontotemporal subcortical dysfunction. Finally,
the bursts of generalized slowing and the slow and disorganized
background suggests an encephalopathic pattern. This may be seen
with infections, medication effect, toxic metabolic
abnormalities or ischemia. He was started on Keppra and titrated
up to 1000mg [**Hospital1 **] - this is in addition to his tegretol which he
has been compliant with.  He had emesis on almost a daily basis
but this has subsided with medication. His pain was
predominantly headache and left rib cage pain.  A pain
management regime was initiated and titrated PRN. Abd xrays were
obtained for eval of the emesis - this was negative for
obstruction. At this time [**2-6**] he has poor room air saturation
and this is thought to be due to poor inspiratory effort.  Again
he has been encouraged to cough and deep breath as well as
ambulate in the [**Doctor Last Name **].  He remains noncompliant.  We anticipate
that he will be discharged to home in the am [**2-7**].


Medications on Admission:

Medications prior to admission:
Tegretol


Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO tid:
[**Month (only) 116**] hold for diarrhea. Please take while taking narcotics.
Disp:*60 Capsule(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Metaxalone 800 mg Tablet Sig: One (1) Tablet PO tid, prn rib
pain as needed for HA: No heavy lifting, driving if taking this
medication as can cause drowsiness.
Disp:*40 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO q8 hours as
needed for rib pain as needed for rib pain.
Disp:*50 Tablet(s)* Refills:*0*
10. incentive spirometry
Please use your incentive spirometer 10 times per hour while
awake. This will help you prevent a pneumonia.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
s/p Closed head injury
s/p left rib fractures


Discharge Condition:
stable


Discharge Instructions:
??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????	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, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST.

Please make an appointment with your PCP [**Last Name (NamePattern4) **] 2 days. Let him/her
know that you have been started on antihypertensive medication.
You will need your blood pressure checked.

Please call [**Hospital 878**] Clinic [**Telephone/Fax (1) 44**] with Dr. [**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **]
to make follow-up Neurology appointment for seizures (request
appointment date 2 months from date of discharge)



Completed by:[**2159-2-13**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Closed fracture of rib(s), unspecified,Head injury, unspecified,Headache,Unspecified fall'}


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: consulted for SDH found on outside head CT

PRESENT ILLNESS: HPI: 58 year old male s/p craniotomy 20 years ago after he was
hit by a 2x4. He began having seizures post-operatively but has
been seizure free for ~15 years. He takes his Tegretol as
directed. He presented today to an OSH after having fallen at
work and hitting his head. He does not recall the episode. On
outside CT there was a right frontal and a right temporal SDH in
the area of the previous surgery. The patient reports a [**6-26**]
headache. He has no dizziness, no blurred vision, no weakness,
no
N/V. Recently he completed a course of antibiotics for a cough
and sneezing. He has no chest pain or SOB.

MEDICAL HISTORY: PMHx:s/p craniotomy 20 years ago
     h/o seizures

MEDICATION ON ADMISSION: Medications prior to admission:
Tegretol

ALLERGIES: Codeine

PHYSICAL EXAM: on arrival...

FAMILY HISTORY: Family Hx:non-contributory

SOCIAL HISTORY: Social Hx:smokes tobacco 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other convulsions,Closed fracture of rib(s), unspecified,Head injury, unspecified,Headache,Unspecified fall'}
