CHIEF COMPLAINT: cranial defect

PRESENT ILLNESS: lThis is a 40 year old woman who had a left basal ganglionic
hemorrhage in
[**State 4565**] and had a craniectomy and cranioplasty done.  She has
subsequently recovered and is able to walk with the use of a
hemiwalker. The cranioplasty has been settling, and there is a
very significant indentation on the left side of her head, which
is confirmed on the CT scan.  A cranioplasty was scheduled.

MEDICAL HISTORY: status post hysterectomy at age 23 and cervical cancer for which
she underwent radiation therapy.

MEDICATION ON ADMISSION: nortriptyline, MiraLax, Fioricet, baclofen, dantrolene, Keppra,
Benadryl,

ALLERGIES: IV Dye, Iodine Containing Contrast Media / bell pepper; fennel

PHYSICAL EXAM: At admission: a&ox3, L side full strength, RUE 0/5, RLE [**2-25**] IP,
0/5 distally. c/o R peripheral visual field cut, intermittent on
assessment.

FAMILY HISTORY: NC

SOCIAL HISTORY: She worked in IT prior to her hemorrhage.  She has not returned
to work since.  She is married.  She smoked less than a pack of
cigarettes a day for the last 20 years.  She denies recreational
drug use.  She consumes wine on occasional basis.
Other specified acquired deformity of head,Hemiplegia, unspecified, affecting unspecified side,Personal history of malignant neoplasm of cervix uteri,Personal history of venous thrombosis and embolism
Oth spcf deformity head,Unsp hemiplga unspf side,Hx-cervical malignancy,Hx-ven thrombosis/embols
Admission Date:  [**2158-9-27**]              Discharge Date:   [**2158-9-29**]

Date of Birth:  [**2118-2-19**]             Sex:   F

Service: NEUROSURGERY

Allergies:
IV Dye, Iodine Containing Contrast Media / bell pepper; fennel

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
cranial defect

Major Surgical or Invasive Procedure:
Left cranioplasty


History of Present Illness:
lThis is a 40 year old woman who had a left basal ganglionic
hemorrhage in
[**State 4565**] and had a craniectomy and cranioplasty done.  She has
subsequently recovered and is able to walk with the use of a
hemiwalker. The cranioplasty has been settling, and there is a
very significant indentation on the left side of her head, which
is confirmed on the CT scan.  A cranioplasty was scheduled.

Past Medical History:
status post hysterectomy at age 23 and cervical cancer for which
she underwent radiation therapy.


Social History:
She worked in IT prior to her hemorrhage.  She has not returned
to work since.  She is married.  She smoked less than a pack of
cigarettes a day for the last 20 years.  She denies recreational
drug use.  She consumes wine on occasional basis.


Family History:
NC

Physical Exam:
At admission: a&ox3, L side full strength, RUE 0/5, RLE [**2-25**] IP,
0/5 distally. c/o R peripheral visual field cut, intermittent on
assessment.

At discharge the patient remains at her baseline.


Pertinent Results:
CT Head [**9-27**]

Expected postoperative appearance status post left
frontoparietal
cranioplasty without acute complications.


Brief Hospital Course:
Ms. [**Known lastname 15852**] was admitted to [**Hospital1 18**] and was taken to the OR on
[**9-27**] with Dr. [**First Name (STitle) **] for an elective cranioplasty. She tolerated
the procedure well and was extubated and trasnfered to the PACU.
She remained under ICU care for the night. On post op exam she
was doing well. She remained at her neurological baseline and
her dressing was clean and dry. Her post op CT Head showed no
hemorrhage. Her drain was removed on [**9-28**] without difficulty and
she was transferred to the floor in stable condition. She will
be DC'd home in stable condition on [**2158-9-29**].

Medications on Admission:
nortriptyline, MiraLax, Fioricet, baclofen, dantrolene, Keppra,
Benadryl,

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. baclofen 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Sanctura 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).

8. bacitracin-polymyxin B     Ointment Sig: One (1) Appl Topical
Q6H (every 6 hours) as needed for R thumb granuloma excision.
Disp:*1 QS* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Cranial Defect


Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.


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.
??????	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.
??????	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.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**7-2**] days(from your date of
surgery) for removal of your staples/sutures and/or 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 [**3-29**] weeks.
??????You will need a CT scan of the brain without contrast.



Completed by:[**2158-9-29**]
{'Other specified acquired deformity of head,Hemiplegia, unspecified, affecting unspecified side,Personal history of malignant neoplasm of cervix uteri,Personal history of venous thrombosis and embolism'}


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: cranial defect

PRESENT ILLNESS: lThis is a 40 year old woman who had a left basal ganglionic
hemorrhage in
[**State 4565**] and had a craniectomy and cranioplasty done.  She has
subsequently recovered and is able to walk with the use of a
hemiwalker. The cranioplasty has been settling, and there is a
very significant indentation on the left side of her head, which
is confirmed on the CT scan.  A cranioplasty was scheduled.

MEDICAL HISTORY: status post hysterectomy at age 23 and cervical cancer for which
she underwent radiation therapy.

MEDICATION ON ADMISSION: nortriptyline, MiraLax, Fioricet, baclofen, dantrolene, Keppra,
Benadryl,

ALLERGIES: IV Dye, Iodine Containing Contrast Media / bell pepper; fennel

PHYSICAL EXAM: At admission: a&ox3, L side full strength, RUE 0/5, RLE [**2-25**] IP,
0/5 distally. c/o R peripheral visual field cut, intermittent on
assessment.

FAMILY HISTORY: NC

SOCIAL HISTORY: She worked in IT prior to her hemorrhage.  She has not returned
to work since.  She is married.  She smoked less than a pack of
cigarettes a day for the last 20 years.  She denies recreational
drug use.  She consumes wine on occasional basis. 

### Response:
{'Other specified acquired deformity of head,Hemiplegia, unspecified, affecting unspecified side,Personal history of malignant neoplasm of cervix uteri,Personal history of venous thrombosis and embolism'}
