CHIEF COMPLAINT: CC:[**CC Contact Info 91271**]

PRESENT ILLNESS: HPI:This is a 17 year old male who was riding a Dirt Bike on
dirt trails with friends with Helmet and neck gear.  He was
found face down at approximately 1200 noon in the dirt
approximately 6 feet away from his bicycle.  There was loss of
consciousness and he is amnestic to the event.  He was taken to
[**Hospital6 3105**]. He was given fentanyl for headache.
A Head Ct was
performed which was read by a radiologist and states there is a
5 mm hyperdense focus within the R putamen which may represent
hemorrhage or mineralization. Upon arrival to this Emergency
Department the patient was vomiting and was given Zofran.

MEDICAL HISTORY: T 7 fx no brace or surgery required [**2156**] after skiing
accident

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
O:T: 99.4 BP: 115/58  HR:86   R: 26  O2Sats
Gen: lethargic but arousable, comfortable, NAD.
HEENT: NO laceration, NO hemotympanum, No ottorhea, NO Battle
sign/ NO raccoon sign Pupils: 4.5-3        EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: unable to perform task at this time
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: Social Hx:lives at home with mother. [**Name (NI) **] goes to [**Location (un) 8641**] High
School.
Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Legal blindness, as defined in U.S.A.,Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle,Leukocytosis, unspecified
Brain hem NEC-coma NOS,Legal blindness-usa def,Oth off-road mv acc-driv,Leukocytosis NOS
Admission Date:  [**2157-10-16**]              Discharge Date:   [**2157-10-18**]

Date of Birth:  [**2140-7-25**]             Sex:   M

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 91271**]

Major Surgical or Invasive Procedure:
None


History of Present Illness:
HPI:This is a 17 year old male who was riding a Dirt Bike on
dirt trails with friends with Helmet and neck gear.  He was
found face down at approximately 1200 noon in the dirt
approximately 6 feet away from his bicycle.  There was loss of
consciousness and he is amnestic to the event.  He was taken to
[**Hospital6 3105**]. He was given fentanyl for headache.
A Head Ct was
performed which was read by a radiologist and states there is a
5 mm hyperdense focus within the R putamen which may represent
hemorrhage or mineralization. Upon arrival to this Emergency
Department the patient was vomiting and was given Zofran.

The patient states that he does not remember the event. He
denies
headache, nausea, vomiting, weakness, numbness, tingling, visual
or hearing deficit, bowel or bladder dysfunction.  His family is
present and states that the patient is legally blind in the
right
eye.


Past Medical History:
T 7 fx no brace or surgery required [**2156**] after skiing
accident


Social History:
Social Hx:lives at home with mother. [**Name (NI) **] goes to [**Location (un) 8641**] High
School.


Family History:
NC

Physical Exam:
On Admission:
PHYSICAL EXAM:
O:T: 99.4 BP: 115/58  HR:86   R: 26  O2Sats
Gen: lethargic but arousable, comfortable, NAD.
HEENT: NO laceration, NO hemotympanum, No ottorhea, NO Battle
sign/ NO raccoon sign Pupils: 4.5-3        EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: unable to perform task at this time
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,  4.5 to 3
mm bilaterally. Visual fields are impaired and this is the
patients baseline per family
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 [**5-5**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

At discharge:
He was neurologically intact. There was no motor or sensory
deficit.

Pertinent Results:
CT HEAD W/O CONTRAST Study Date of [**2157-10-16**] 4:16 PM Head CT:
Small 4 mm Right IPH. No mass effect or herniation.
No scalp hematoma, no skull fracture
Labs:              WBC    RBC  Hgb  Hct  Plt Ct
[**2157-10-16**] 16:00    25.6* 4.91 15.1 43.3  464*
BASIC COAGULATION  PT     PTT    INR
[**2157-10-16**] 16:00    14.7* 25.5   1.3*

Chemistry
                 Glucose UreaN Creat Na  K   Cl  HCO3 AnGap
[**2157-10-16**] 16:00    108   16   0.9   138 4.3 101 24   17

[**2157-10-16**] CXR
Frontal and lateral views of the chest were obtained. The lungs
are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
unremarkable. No displaced fracture is identified.
IMPRESSION: No acute cardiopulmonary process

[**2157-10-17**] CT head
Small hyperdensity at the lateral margin of the putamen and
external capsule is unchanged and likely represents dystrophic
calcification, rather than hemorrhage.

[**10-17**] right hand X-rays
Normal appearing right hand radiographs. Salter-[**Doctor Last Name 6164**] type I
fractures cannot be excluded on radiographs, correlate
clinically.

[**10-18**]: Left Shoulder X-ray: verbal read, no fracture or
dislocation.

Brief Hospital Course:
Mr. [**Known lastname 5730**] was admitted to neurosurgery ICU for observation
following his head injury.  He did well overnight without nausea
and emesis.  He had mild headache.  A repeat head CT showed
stable tiny punctate SAH hardly seen on this repeat scan.  As a
result, he was transferred to floor in stable condition.  He
complained about right hand pain and X-ray imaging could not
exclude a Salter [**Doctor Last Name 6164**] 1 fracture. Orthopedics did not feel
that this was a fracture and elevation and splinting prn was
recommended. He also complained of left shoulder pain. Imaging
showed no fracture or dislocation. He was mobilized. He was
voiding well and tolerating a regular diet. He required
medication for headache and nausea. He was discharged to home
with his mother. A note was faxed to his school to refrain from
school for one month and contact sports for 3 months.


Medications on Admission:
none

Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
4. metoclopramide 5 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
IPH


Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
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.
??????	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.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

Elevate your Right hand and wear the splint as needed for pain.

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:

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in ___4____weeks.
??????You will  need a CT scan of the brain without contrast.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].

You can follow up in the  Hand Clinic in [**2-3**] weeks if pain
persists,
Call [**Telephone/Fax (1) 1228**] for this appointment


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

Completed by:[**2157-10-18**]
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Legal blindness, as defined in U.S.A.,Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle,Leukocytosis, unspecified'}


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 91271**]

PRESENT ILLNESS: HPI:This is a 17 year old male who was riding a Dirt Bike on
dirt trails with friends with Helmet and neck gear.  He was
found face down at approximately 1200 noon in the dirt
approximately 6 feet away from his bicycle.  There was loss of
consciousness and he is amnestic to the event.  He was taken to
[**Hospital6 3105**]. He was given fentanyl for headache.
A Head Ct was
performed which was read by a radiologist and states there is a
5 mm hyperdense focus within the R putamen which may represent
hemorrhage or mineralization. Upon arrival to this Emergency
Department the patient was vomiting and was given Zofran.

MEDICAL HISTORY: T 7 fx no brace or surgery required [**2156**] after skiing
accident

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
O:T: 99.4 BP: 115/58  HR:86   R: 26  O2Sats
Gen: lethargic but arousable, comfortable, NAD.
HEENT: NO laceration, NO hemotympanum, No ottorhea, NO Battle
sign/ NO raccoon sign Pupils: 4.5-3        EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: unable to perform task at this time
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: Social Hx:lives at home with mother. [**Name (NI) **] goes to [**Location (un) 8641**] High
School. 

### Response:
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Legal blindness, as defined in U.S.A.,Nontraffic accident involving other off-road motor vehicle injuring driver of motor vehicle other than motorcycle,Leukocytosis, unspecified'}
