CHIEF COMPLAINT: unhelmeted MCC

PRESENT ILLNESS: 49yo gentleman involved in MCC this evening, unhelmeted, ETOH=
107. GCS reportedly 8 on scene. [**Location (un) 7622**] to [**Hospital1 18**],vecoronium
given but unable to secure airway. Upon arrival to ED, multiple
airway attempts and more vecoronium given. Short airway placed
and patient rushed to OR for emergent trach. After tracheostomy
patient was taken for a CT scan which revealed a large right
SDH/IPH.

MEDICAL HISTORY: previous right craniectomy

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  BP: 103/59   HR: 63   R 16   O2Sats 100%
Gen: short airway in place
HEENT: Pupils: 1.5mm b/l nonreactive, no corneals
Neck: hard collar
Abd: distended, obese
Extrem: no mvmt

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: construction worker, married, 2 children in college. + etoh
Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified protein-calorie malnutrition,Acidosis,Ventilator associated pneumonia,Other diseases of respiratory system, not elsewhere classified,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Motor vehicle traffic accident of unspecified nature injuring motorcyclist,Accidents occurring in unspecified place
Subdural hemorr-coma NOS,Protein-cal malnutr NOS,Acidosis,Ventltr assoc pneumonia,Resp system disease NEC,Brain hem NEC-coma NOS,Traffic acc NOS-motcycl,Accident in place NOS
Admission Date:  [**2159-9-13**]              Discharge Date:   [**2159-9-28**]

Date of Birth:  [**2111-6-29**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
unhelmeted MCC

Major Surgical or Invasive Procedure:
[**9-13**]: Emergent placement of tracheostomy
[**9-13**]: Right Craniectomy and evacuation of hemorrhage
[**9-18**]: PEG placement and IVC Filter placement


History of Present Illness:
49yo gentleman involved in MCC this evening, unhelmeted, ETOH=
107. GCS reportedly 8 on scene. [**Location (un) 7622**] to [**Hospital1 18**],vecoronium
given but unable to secure airway. Upon arrival to ED, multiple
airway attempts and more vecoronium given. Short airway placed
and patient rushed to OR for emergent trach. After tracheostomy
patient was taken for a CT scan which revealed a large right
SDH/IPH.


Past Medical History:
previous right craniectomy

Social History:
construction worker, married, 2 children in college. + etoh

Family History:
non-contributory

Physical Exam:
PHYSICAL EXAM:
O: T:  BP: 103/59   HR: 63   R 16   O2Sats 100%
Gen: short airway in place
HEENT: Pupils: 1.5mm b/l nonreactive, no corneals
Neck: hard collar
Abd: distended, obese
Extrem: no mvmt

Cranial Nerves:
unable to obtain

PHYSICAL EXAM UPON DISCHARGE:
No eye opening
PERRL 4mm
trach mask (sutures out)
following commands with right upper and lower extremity
spontaneous movement of left and upper and lower extremity
Peg tube site C/D/I

Pertinent Results:
[**9-13**] Head CT: IMPRESSION: Multicompartmental subdural,
subarachnoid, intraparenchymal and intraventricular hemorrhage
as detailed above. Intraventricular hemorrhage extends into the
third ventricle. There is associated 10 mm leftward midline
shift. A component of low attenuation seen immediately adjacent
to the right frontal lobe suggestive of a hyperacute component
to this extensive multicompartmental hemorrhage. Associated
scalp hematoma. There is no ventriculomegaly as of yet.

[**9-13**] Cspine CT: IMPRESSION:
1. No acute fracture or dislocation. Extensive pharyngeal edema
with the
patient noted to be status post tracheostomy with tip
terminating within the mid trachea.
2. Bilateral posteriorly located right greater than left air
space
consolidation, likely massive aspiration.

[**9-13**] Cspine CTA: IMPRESSION:
1. No acute fracture or dislocation. Extensive pharyngeal edema
with the
patient noted to be status post tracheostomy with tip
terminating within the mid trachea.
2. Bilateral posteriorly located right greater than left air
space
consolidation, likely massive aspiration.

[**9-13**] Trauma Panel: IMPRESSION:
1. Collapse of left lower lobe; change of atelectasis/aspiration
within
bilateral lower lobes are dependently as described above. In
addition, small foci of centrilobular opacities seen in the
right upper lobe may also represent the change of aspiration.
2. Status post tracheostomy and associated postsurgical changes.

3. No post-traumatic visceral injury is visualized within the
chest, abdomen, and pelvis, allowing for the contrast injection
technique, which is suboptimal as it was tailored for the next
CT.
4. Distention of stomach, small, and large bowel with gas,
likely related to laryngeal mask, airway ventilation in the
field.
5. Congenital absence of the left kidney and left seminal
vesicles

[**9-13**] Head MRI: IMPRESSION:
1. Punctate areas of restricted diffusion at the [**Doctor Last Name 352**]-white
matter junction in the bilateral frontoparietal lobes with
associated microhemorrhage, consistent with diffuse axonal
injury. No evidence of hypoxic injury.
2. Stable leftward shift of midline structures with right-sided
extensive
subdural hematoma, subarachnoid hemorrhage, and intraparenchymal
hemorrhage as
described above and on the prior head CT.

[**9-13**] Head CT: IMPRESSION:
1. Status post right frontoparietal craniotomy with improved
appearance of
right ventricle and midline shift and expected subcutaneous
emphysema and
pneumocephalus.
2. Relatively unchanged appearance of previously described right

frontoparietal intraparenchymal hemorrhage, subarachnoid
hemorrhage, subdural hemorrhage, and intraventricular
hemorrhage.
3. Paranasal sinus air-fluid levels likely indicate facial
fractures, better evaluated on facial bone CT performed on the
same day.

[**9-13**] CT Max-Face: IMPRESSION:
1. Minimally rightwardly displaced nasal bone fracture.
2. No evidence of orbital or mandibular injury.

[**9-14**] LE duplex: IMPRESSION:
No evidence of acute deep venous thrombosis in the evaluated
bilateral lower extremities, although evaluation is limited in
the right inguinal regionespecially at the level of the common
femoral vein and greater saphenous vein junction.

[**9-14**] R TIB/FIB Xray: IMPRESSION: No evidence of acute fracture

[**9-15**] Head CT: IMPRESSION:
1. Slight interval increase in size of the lateral and third
ventricles,
concerning for developing hydrocephalus. 2. Unchanged amount of
distribution of multicompartmental intracranial hemorrhage.
3. 4 mm rightward shift of midline structures (previously 4 mm
leftward shift of midline structures on [**2159-9-13**]).

[**9-16**] Head CT: IMPRESSION: Overall unchanged appearance of the
brain compared with [**2159-9-15**] with right-sided craniectomy and
intraparenchymal, subdural as well as subarachnoid and
intraventricular blood. No evidence of hydrocephalus.

[**9-21**] LENI's: IMPRESSIONS: No evidence of DVT in either lower
extremity.

[**9-22**] CT Chest: IMPRESSION: 1. No definite evidence of pneumonia.
Mild persistent bibasilar and lingular volume loss are
significantly improved as compared to [**2159-9-13**]. 2.
Multiple sub-4-mm right upper lobe and right middle lobe
pulmonary nodules. As [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] guideline, follow-up in 12
months is recommended in a patient with increased risk for lung
cancer. Otherwise no follow-up is indicated. 3. Persistent
moderate pneumoperitoneum.

[**9-22**] CT head:
Overall stable appearance of the brain as compared to [**9-16**], [**2158**]. No new focal hemorrhage

[**9-25**] CXR: No evidence of pneumonia as can be identified on
single AP chest
view bedside examination.


Brief Hospital Course:
This patient was admitted after emergent tracheostomy. Mannitol
was given in attempt to reduce intracranial pressure. Patients
examination did not show sign of improvement therefore an MRI
was requested to evaluate for hypoxic injury. This was negative
therefore it was decided to take the patient for surgical
decompression. He was taken for a right craniectomy which was
performed without complication.
A routine postoperative head CT was performed which revealed
post operative changes and excellent decompression.
On [**9-14**] his neurological exam was slightly improved. He
continued on mannitol and dilantin. A lower extremity duplex was
performed which was negative for DVT.
On [**9-15**] The patient was off the ventilator and tolerating a
trach mask. dilantin was rebolused and physical exam was
slightly improved. Head CT was done and stable.
On [**9-16**] Repeat head CT was stable and the patient began
following commands. Dilantin was increased for persistant low
level. mannitol wean was started.
On [**9-17**] subdural drain was removed and sutured. Peg and Filter
consultations were requested.
On [**9-18**] transfer orders to the stepdown were written. Social
Work consultation for gaurdianship was requested. mannitol cont
to be weaned. Peg & IVC Filter were placed.
[**9-19**] Pt was febrile to 103. Pan culture sent. Mannitol wean
completed. Seen by PT and OT who recommend discharge to rehab.
[**9-21**] Fevers continued therefore ID was consulted and he was
started on Vancomycin and Zosyn.
[**9-23**] the patient was again febrile and was noted to have streaks
of blood in his stools. HCT checked and followed.
[**9-25**] Pt pan cultured again for low grade fever per ID rec's.
[**9-26**] neurologically stable. cultures all NGTD. has remained
afebrile x 24 hrs. Will check urine cx and vanco trough per ID.
PICC line placed and central line removed.
[**9-27**] Pt again febrile overnight. Subgaleal collection tapped per
ID recommendations.
[**9-28**] Pt afebrile, gram stain for fluid collection negative for
any cells. Infectious Disease cleared the patient for discharge.
He is to continue current antibiotic regimen through [**9-30**]
for VAP. Pt was cleared for discharge to rehab.

Medications on Admission:
none

Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution Sig: [**12-30**]  PO Q6H (every
6 hours) as needed for fever.
2. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dryness.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
9. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) ml PO Q6H
(every 6 hours) as needed for fever.
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 8H (Every 8 Hours): Continue through [**9-30**].
13. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1)  Intravenous Q8H (every 8 hours): continue through
[**9-30**].
14. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Traumatic Brain Injury, right SDH/IPH/IVH


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
??????	You or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????	Keep your incision clean and dry.
??????	You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
??????	Do NOT apply any lotions, ointments or other products to your
incision.
??????	DO NOT DRIVE until you are seen at the first follow up
appointment.
??????	Do not lift objects over 10 pounds until approved by your
physician.

DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.

MEDICATIONS
??????	Take all of your medications as ordered.  You do not have to
take pain medication unless it is needed.  It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????	Do not use alcohol while taking pain medication.
??????	Medications that may be prescribed include:
o	Narcotic pain medication such as Dilaudid (hydromorphone).
o	An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
??????	If 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**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, you may
safely resume taking this on XXXXXXXXXXX.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.

ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
??????	Follow the activity instructions given to you by your doctor
and therapist.
??????	Increase your activity slowly; do not do too much because you
are feeling good.
??????	You may resume sexual activity as your tolerance allows.
??????	If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
??????	DO NOT DRIVE until you speak with your physician.
??????	Do not lift objects over 10 pounds until approved by your
physician.
??????	Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????	   Do your breathing exercises every two hours.
??????	   Use your incentive spirometer 10 times every hour, that you
are awake.


Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Known firstname **],  to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2159-9-28**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified protein-calorie malnutrition,Acidosis,Ventilator associated pneumonia,Other diseases of respiratory system, not elsewhere classified,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Motor vehicle traffic accident of unspecified nature injuring motorcyclist,Accidents occurring in unspecified place'}


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: unhelmeted MCC

PRESENT ILLNESS: 49yo gentleman involved in MCC this evening, unhelmeted, ETOH=
107. GCS reportedly 8 on scene. [**Location (un) 7622**] to [**Hospital1 18**],vecoronium
given but unable to secure airway. Upon arrival to ED, multiple
airway attempts and more vecoronium given. Short airway placed
and patient rushed to OR for emergent trach. After tracheostomy
patient was taken for a CT scan which revealed a large right
SDH/IPH.

MEDICAL HISTORY: previous right craniectomy

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM:
O: T:  BP: 103/59   HR: 63   R 16   O2Sats 100%
Gen: short airway in place
HEENT: Pupils: 1.5mm b/l nonreactive, no corneals
Neck: hard collar
Abd: distended, obese
Extrem: no mvmt

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: construction worker, married, 2 children in college. + etoh 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Unspecified protein-calorie malnutrition,Acidosis,Ventilator associated pneumonia,Other diseases of respiratory system, not elsewhere classified,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration,Motor vehicle traffic accident of unspecified nature injuring motorcyclist,Accidents occurring in unspecified place'}
