CHIEF COMPLAINT: Chronic SDH with continued symptoms

PRESENT ILLNESS: The pt is a 58F transferred from OSH with chronic SDH on CT.
Had known bifrontal SDH since a fall at the end of [**Month (only) **]. Her
symptoms have been worsening this week according to her
daughter:
worsening headache, word finding difficulties, stumbling,
difficulty writing. Pt awake, alert, oriented and was ambulating
with steady gait at OSH. Her main complaint is HA.

MEDICAL HISTORY: depression/anxiety, HTN, hyperlipidemia

MEDICATION ON ADMISSION: Citalopram 20', Pravastatin 40', Diltiazem 30', Lisinopril
40', Percocet 5/325prn, Trazodone 50 QHS, Proair

ALLERGIES: Penicillins

PHYSICAL EXAM: PE:
98.1  74  96/64  16  98% RA
Gen: NAD
CV: RRR
Resp: CTA B
Abd: Soft/NT/ND
Neuro exam: Intact, no focal deficits, normal strength all
extremties, sensation intact, speech fluent, cognition & memory
intact, pupils equal, round, and reactive

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses
Subdural hemorrhage,Late effect of certain complications of trauma,Late effects of accidental fall,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other diseases of lung, not elsewhere classified
Subdural hemorrhage,Late eff complic trauma,Late eff accidental fall,Depressive disorder NEC,Anxiety state NOS,Hyperlipidemia NEC/NOS,Hypertension NOS,Other lung disease NEC
Admission Date:  [**2151-1-23**]              Discharge Date:   [**2151-1-26**]

Date of Birth:  [**2092-5-31**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Chronic SDH with continued symptoms


Major Surgical or Invasive Procedure:
[**2151-1-24**] bilateral burr hole evacuation of subdural hematoma


History of Present Illness:
The pt is a 58F transferred from OSH with chronic SDH on CT.
Had known bifrontal SDH since a fall at the end of [**Month (only) **]. Her
symptoms have been worsening this week according to her
daughter:
worsening headache, word finding difficulties, stumbling,
difficulty writing. Pt awake, alert, oriented and was ambulating
with steady gait at OSH. Her main complaint is HA.


Past Medical History:
depression/anxiety, HTN, hyperlipidemia

Social History:
Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses


Family History:
non contributory

Physical Exam:
PE:
98.1  74  96/64  16  98% RA
Gen: NAD
CV: RRR
Resp: CTA B
Abd: Soft/NT/ND
Neuro exam: Intact, no focal deficits, normal strength all
extremties, sensation intact, speech fluent, cognition & memory
intact, pupils equal, round, and reactive

On the day of discharge:
she is awake, alert, interactive and well.  Her vs are stable
and she is afebrile - her pain is well controlled. She is
tolerating an oral diet.  She is voiding freely without dysuria.
 Her neurological exam is nonfocal.  Her incisions are clean and
dry with staples present.

Pertinent Results:
CHEST (PRE-OP PA & LAT) Study Date of [**2151-1-23**] 1:33 PM
 COMPARISON: None.

FINDINGS: AP and two lateral radiographs were obtained of the
chest. The
lungs are clear. No effusion, pneumothorax or consolidation is
identified.  The heart and mediastinal contours are normal. A
2-3 mm left apical lung nodule is identified. Lower cervical
spine fixation plate and screws are identified without evidence
of hardware failure.

IMPRESSION: No acute cardiopulmonary process, 2-3 mm left apical
lung nodule.

[**2151-1-24**] CT Brain
IMPRESSION: Status post bilateral parietal burr holes, with
interval
placement of bilateral subdural fluid collections with a mixture
of gas and low-density fluid on the right, and mixture of
high-density fluid, gas and low-density fluid on the left. The
overall mass effect is slightly reduced when compared with the
prior head CT.

[**2151-1-25**] 03:41AM BLOOD WBC-13.0* RBC-3.51* Hgb-11.2* Hct-34.3*
MCV-98 MCH-32.0 MCHC-32.7 RDW-12.7 Plt Ct-268
[**2151-1-25**] 03:41AM BLOOD Plt Ct-268
[**2151-1-25**] 03:41AM BLOOD PT-11.0 PTT-29.0 INR(PT)-1.0
[**2151-1-26**] 04:20AM BLOOD Glucose-124* UreaN-8 Creat-0.7 Na-143
K-4.0 Cl-108 HCO3-27 AnGap-12
[**2151-1-24**] 05:40AM BLOOD ALT-20 AST-20 LD(LDH)-179 AlkPhos-61
TotBili-0.2
[**2151-1-26**] 04:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0
[**2151-1-25**] 03:41AM BLOOD Phenyto-15.3

Brief Hospital Course:
Pt was admitted through the emergency department for continued
headaches for known SDH's bilaterally since a fall back in
[**Month (only) **] of this year.  She was brought to the operating room
for bilateral burr holes and underwent the procedure without
event.  She recovered in the ICU and was transferred to the
floor the following am.  Her dilantin was transitioned to
Keppra. PT on OT were consulted and cleared her for home wiht a
recommendation for outpaitnet speech for language and memory
issues.  SHe feels quite well today and is eager for d/c.  Her
daughter agrees with this plan.

Medications on Admission:
Citalopram 20', Pravastatin 40', Diltiazem 30', Lisinopril
40', Percocet 5/325prn, Trazodone 50 QHS, Proair


Discharge Medications:
1. Outpatient Speech/Swallowing Therapy
language / memory evaluation
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-15**]
Tablets PO Q6H (every 6 hours) as needed for pain: limit your
intake of tylenol to 4gms / 24 hours .
Disp:*40 Tablet(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: use only for severe headache.
Disp:*10 Tablet(s)* Refills:*0*
4. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO QD  () for 3
days: please take 3 tablets on [**2151-1-27**]
2 tablets on [**2151-1-28**] and one tablet on [**2151-1-29**] then stop .
Disp:*6 Tablet(s)* Refills:*0*
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
14. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Acute on Chronic subdural hematoma / bilaterally
headache


Discharge Condition:
.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
.
General Instructions
- DO NOT DRINK ALCOHOL
??????	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.
??????	You may wash your hair only after staples have been removed.
??????	You may shower before this time using a shower cap to cover
your head.
??????	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.
??????	You were NOT on medications such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury. If
another physician recommends [**Name Initial (PRE) **] medication such as these after
your surgery you must discuss this with Dr [**First Name (STitle) **] prior to
initiation of the medication.
You have been discharged on Keppra (Levetiracetam), you will not
require blood work monitoring.
??????	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.

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.

Your chest Xray from [**2151-1-23**] was consistent with 2-3 mm left
apical lung nodule you will need to see your primary care
physician for further evaluation of this nodule. Please make an
appointment to see your primary care physician in the next [**2-15**]
weeks.


Followup Instructions:
.
Follow-Up Appointment Instructions

??????Please return to the office in [**8-23**] days(from your date of
surgery) for removal of your staples and a wound check. This
appointment can be made with the Nurse Practitioner.  Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks.
??????You will need a CT scan of the brain without contrast.

PLEASE CALL YOUR PRIMARY CARE PHYSICIAN WHEN YOU GET HOME FOR AN
APPOINTMENT TO BE SEEN WITHIN 2 WEEKS

Your chest Xray from [**2151-1-23**] was consistent with 2-3 mm left
apical lung nodule.  You will need to see your primary care
physician for further evaluation of this nodule. Please make an
appointment to see your primary care physician in the next [**2-15**]
weeks.



Completed by:[**2151-1-26**]
{'Subdural hemorrhage,Late effect of certain complications of trauma,Late effects of accidental fall,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other diseases of lung, not elsewhere classified'}


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: Chronic SDH with continued symptoms

PRESENT ILLNESS: The pt is a 58F transferred from OSH with chronic SDH on CT.
Had known bifrontal SDH since a fall at the end of [**Month (only) **]. Her
symptoms have been worsening this week according to her
daughter:
worsening headache, word finding difficulties, stumbling,
difficulty writing. Pt awake, alert, oriented and was ambulating
with steady gait at OSH. Her main complaint is HA.

MEDICAL HISTORY: depression/anxiety, HTN, hyperlipidemia

MEDICATION ON ADMISSION: Citalopram 20', Pravastatin 40', Diltiazem 30', Lisinopril
40', Percocet 5/325prn, Trazodone 50 QHS, Proair

ALLERGIES: Penicillins

PHYSICAL EXAM: PE:
98.1  74  96/64  16  98% RA
Gen: NAD
CV: RRR
Resp: CTA B
Abd: Soft/NT/ND
Neuro exam: Intact, no focal deficits, normal strength all
extremties, sensation intact, speech fluent, cognition & memory
intact, pupils equal, round, and reactive

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Widowed, works in medical records, smokes [**2-15**] ppd.  drinks three
beers a night to help her to sleep. denies illicit drug uses 

### Response:
{'Subdural hemorrhage,Late effect of certain complications of trauma,Late effects of accidental fall,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Other diseases of lung, not elsewhere classified'}
