CHIEF COMPLAINT: Headaches

PRESENT ILLNESS: This is a 29 year old male with occipital tussive headaches,
dizziness and UE/LLE paresthesias. MRI imaging revealed a Chiari
Malformation and he opted to procede for a decompression.

MEDICAL HISTORY: Asthma, Genital Herpes, Eczema, ADHD, allergic rhinitis,
anxiety, asthma, LBP, prediabetes, PTSD

MEDICATION ON ADMISSION: Valtrex, Cetirizine, Albuterol, Clobetasol, Fluticasone

ALLERGIES: Cephalexin / Penicillins

PHYSICAL EXAM: No apparent distress
Alert and oriented x3
CN's intact
PERRL
CTAB
RRR
Normal bulk and tone
5/5 strength and sensation intact in all 4 extremities
Ambulating on own
No pronator drift
Wound clean, dry and intact. No signs of infection.

FAMILY HISTORY: NC

SOCIAL HISTORY: He is a truck driver. He has two children. He has smokes [**11-28**] ppd
since age 8. He denies ETOH use.
Compression of brain,Genital herpes, unspecified,Complications affecting other specified body systems, not elsewhere classified, hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder
Compression of brain,Genital herpes NOS,Surg comp - hypertension,Abn react-procedure NEC,Asthma NOS,Obstructive sleep apnea,Tobacco use disorder
Admission Date:  [**2130-3-30**]              Discharge Date:   [**2130-4-2**]

Date of Birth:  [**2100-4-7**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Cephalexin / Penicillins

Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
Headaches

Major Surgical or Invasive Procedure:
[**2130-3-30**]: suboccipital craniotomy and C1 laminectomy for chiari
decompression


History of Present Illness:
This is a 29 year old male with occipital tussive headaches,
dizziness and UE/LLE paresthesias. MRI imaging revealed a Chiari
Malformation and he opted to procede for a decompression.

Past Medical History:
Asthma, Genital Herpes, Eczema, ADHD, allergic rhinitis,
anxiety, asthma, LBP, prediabetes, PTSD

Social History:
He is a truck driver. He has two children. He has smokes [**11-28**] ppd
since age 8. He denies ETOH use.


Family History:
NC

Physical Exam:
No apparent distress
Alert and oriented x3
CN's intact
PERRL
CTAB
RRR
Normal bulk and tone
5/5 strength and sensation intact in all 4 extremities
Ambulating on own
No pronator drift
Wound clean, dry and intact. No signs of infection.

Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] on [**3-30**] and was taken to the OR
with Dr. [**Last Name (STitle) **] for a suboccipital craniotomy and C1
laminectomy for decompression of a chiari malformtaion. He was
extubated post-op and was taken to the SICU for close
management. Post-op CT head showed good decompression. He
remained stable in the SICU. His pain was initially controlled
with a combination of IV and PO medications with a transition to
only PO medications. He was able to void and ambulate
independently. He progressed well and was transferred to the
regular hospital floor on [**4-1**]. On the floor he remained stable,
with stable vital signs, and was deemed ready for discharge on
[**4-2**]. He was given the appropriate prescriptions and instructions
for follow-up care.


Medications on Admission:
Valtrex, Cetirizine, Albuterol, Clobetasol, Fluticasone

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm: do not drive, drink alcohol or
operate machinery/appliances while taking this medication.
Disp:*40 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: do not drive, drink alcohol or operate
machinery/appliances while taking this medication.
Disp:*60 Tablet(s)* Refills:*0*
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. cetirizine 10 mg Tablet Sig: One (1) Tablet PO QD ().
7. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours) as needed for
sob/wheeze.
8. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): resume
home med.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day: resume home med.
10. Valtrex 500 mg Tablet Sig: One (1) Tablet PO once a day:
resume home med.


Discharge Disposition:
Home

Discharge Diagnosis:
Chiari malformation


Discharge Condition:
Stable
alert and oriented
ambulating independently


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.
??????	You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????	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.
??????	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.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**6-6**] days(from your date of
surgery) for removal of your staples/sutures 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.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast at that
time.
{'Compression of brain,Genital herpes, unspecified,Complications affecting other specified body systems, not elsewhere classified, hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder'}


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: Headaches

PRESENT ILLNESS: This is a 29 year old male with occipital tussive headaches,
dizziness and UE/LLE paresthesias. MRI imaging revealed a Chiari
Malformation and he opted to procede for a decompression.

MEDICAL HISTORY: Asthma, Genital Herpes, Eczema, ADHD, allergic rhinitis,
anxiety, asthma, LBP, prediabetes, PTSD

MEDICATION ON ADMISSION: Valtrex, Cetirizine, Albuterol, Clobetasol, Fluticasone

ALLERGIES: Cephalexin / Penicillins

PHYSICAL EXAM: No apparent distress
Alert and oriented x3
CN's intact
PERRL
CTAB
RRR
Normal bulk and tone
5/5 strength and sensation intact in all 4 extremities
Ambulating on own
No pronator drift
Wound clean, dry and intact. No signs of infection.

FAMILY HISTORY: NC

SOCIAL HISTORY: He is a truck driver. He has two children. He has smokes [**11-28**] ppd
since age 8. He denies ETOH use. 

### Response:
{'Compression of brain,Genital herpes, unspecified,Complications affecting other specified body systems, not elsewhere classified, hypertension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder'}
