Subdural hematoma diagnosed. Patient presented with [chief complaint e.g., headache, altered mental status, neurological deficit] following [mechanism of injury e.g., fall, trauma, anticoagulant therapy]. Onset of symptoms was [onset e.g., acute, subacute, chronic]. Physical examination revealed [positive neurological findings e.g., anisocoria, hemiparesis, decreased level of consciousness].  Imaging studies, including [imaging modality e.g., CT scan of the head without contrast, MRI brain], demonstrated a [description of hematoma e.g., crescent-shaped, lenticular] subdural hematoma measuring [size of hematoma] with [location of hematoma e.g., frontoparietal, temporal] involvement.  Midline shift of [measurement] present. Differential diagnosis included epidural hematoma, intracerebral hemorrhage, and contusion.  Assessment includes traumatic brain injury, intracranial hemorrhage, and increased intracranial pressure.  Plan includes [management plan e.g., neurosurgical consultation, serial neurological examinations, medical management of intracranial pressure, repeat imaging]. Patient is currently [patient status e.g., stable, critical, improving] and will be [disposition plan e.g., admitted for observation, transferred to ICU, discharged with follow-up]. Current medications include [list medications].  ICD-10 code S06.5X assigned.