CHIEF COMPLAINT: Elective admission for microvascular decompression

PRESENT ILLNESS: 53 yo F presents with right sided facial pain that has been
present for 1yr and 7mos and has worsened over the past 2 weeks.

MEDICAL HISTORY: HTN, hypothyroid, trigeminal neuralgia, hysterectomy [**2109**]

MEDICATION ON ADMISSION: BACLOFEN -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 3 times daily
DULOXETINE [CYMBALTA] -  (Prescribed by Other Provider) - 30 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
HYDROCHLOROTHIAZIDE -  (Prescribed by Other Provider) - 12.5 mg
Capsule - 1 Capsule(s) by mouth daily
LEVOTHYROXINE -  (Prescribed by Other Provider) - 112 mcg Tablet
- 1 Tablet(s) by mouth daily on empty stomach
NORTRIPTYLINE -  (Prescribed by Other Provider) - 25 mg Capsule
-
3 Capsule(s) by mouth bedtime daily
OXCARBAZEPINE -  (Prescribed by Other Provider) - 300 mg Tablet
-
1 Tablet(s) by mouth twice daily

ALLERGIES: Percocet / Vicodin / Codeine

PHYSICAL EXAM: Gen: WD/WN, NAD, appears uncomfortable.
HEENT: Pupils:equal and brisk   EOMs: full
Neck: Supple.
Lungs: no audible wheeze of cough.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension No dysarthria or
paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: no tobacco, social etoh, none recently
Trigeminal neuralgia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Acquired absence of both cervix and uterus
Trigeminal neuralgia,Hypertension NOS,Hypothyroidism NOS,Acq absnce cervix/uterus
Admission Date:  [**2113-9-20**]              Discharge Date:   [**2113-9-23**]

Date of Birth:  [**2059-12-21**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Percocet / Vicodin / Codeine

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Elective admission for microvascular decompression

Major Surgical or Invasive Procedure:
Suboccipital craniotomy for microvascular decompression of
trigeminal nerve


History of Present Illness:
53 yo F presents with right sided facial pain that has been
present for 1yr and 7mos and has worsened over the past 2 weeks.

Baseline pain is [**9-11**] into her cheek and jaw and she
experiences
sharp shooting pain intermittently. Pain is exacerbated by
chewing, swallowing and touch to the inside or outside of cheek.

She cannot sleep due to the pain.  She has tried several
medications including Cymbalta, baclofen and low dose
oxcarbazepine without good effect.  She denies numbness,
weakness, vision changes, or hearing changes


Past Medical History:
HTN, hypothyroid, trigeminal neuralgia, hysterectomy [**2109**]


Social History:
no tobacco, social etoh, none recently


Family History:
NC

Physical Exam:
Gen: WD/WN, NAD, appears uncomfortable.
HEENT: Pupils:equal and brisk   EOMs: full
Neck: Supple.
Lungs: no audible wheeze of cough.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension No dysarthria or
paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: unable to test due to patient's pain with mouth opening.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. No pronator drift

Sensation: Intact to light touch bilaterally.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin

Handedness Left

On discharge she is non focal without complaints of pain.


Pertinent Results:
MRI Head [**2113-8-27**] with and without contrast, thin cuts: Possible
vessel
draped over right sided CN V

[**2113-9-20**] CT BRAIN
FINDINGS: Status post craniotomy, with pneumocephalus in the
frontal
regions, right side of the posterior fossa and small amount in
the right side of spinal canal and adjacent soft tissues ( se 2,
im 2); scattered foci in the cortical veins and posterior
superior sag. sinus and sella. There is no evidence of large
acute hemorrhage, large acute territorial infarction. A small
dense focus is noted in the left side of the spinal adjacent to
the surface of the cord ( se 2, im 4)- of uncertain nature-
attention on f/u to exclude hemorrhage. A small heterogeneously
dense focus is noted anteromedial to the right petrous apex (
[**1-12**]) related to the procedure and gelfoam placement. There is
no shift of midline structures. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. The ventricles and sulci are
normal in size and configuration. There is no shift of midline
structures. Visualized portion of paranasal sinuses and mastoid
air cells appear within normal limits.

IMPRESSION: Post-surgical changes, status post craniotomy with
pneumocephalus as described above. No large hemorrhage. A tiny
dense focus in the left side of the posterior cord at the level
of dens- attention on close follow up.



Brief Hospital Course:
Pt was admitted to the neurosurgery service and underwent a
suboccipital craniotomy for microvascular decompression. She
tolerated the procedure well with no complications. Post
operatively she was taken to the PACU for further care and then
to the ICU for SBP control and Q1 neuro checks. A post op head
ct showed no acute hemorrhage. Her post op exam remained stable.
On [**9-21**], patient was lethargic on examination, but intact. She
was transferred to the floor.
On [**9-22**] the patient was again neurologically stable but
lethargic. PT consult was obtained but the patient refused to
fully participate. She did not feel comfortable going home at
this time because she is too tired.

She was discharged the follwoing morning.

Medications on Admission:
BACLOFEN -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 3 times daily
DULOXETINE [CYMBALTA] -  (Prescribed by Other Provider) - 30 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
HYDROCHLOROTHIAZIDE -  (Prescribed by Other Provider) - 12.5 mg
Capsule - 1 Capsule(s) by mouth daily
LEVOTHYROXINE -  (Prescribed by Other Provider) - 112 mcg Tablet
- 1 Tablet(s) by mouth daily on empty stomach
NORTRIPTYLINE -  (Prescribed by Other Provider) - 25 mg Capsule
-
3 Capsule(s) by mouth bedtime daily
OXCARBAZEPINE -  (Prescribed by Other Provider) - 300 mg Tablet
-
1 Tablet(s) by mouth twice daily


Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. methocarbamol 500 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. fiorocet  Sig: 1-2 tabs  every 4-6 hours as needed for pain.
Disp:*60 * Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Trigeminal neuralgia


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


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 have dissolvable sutures so you may wash your hair
and get your incision wet day 3 after surgery.  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.
??????	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 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.



Completed by:[**2113-9-23**]
{'Trigeminal neuralgia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Acquired absence of both cervix and uterus'}


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: Elective admission for microvascular decompression

PRESENT ILLNESS: 53 yo F presents with right sided facial pain that has been
present for 1yr and 7mos and has worsened over the past 2 weeks.

MEDICAL HISTORY: HTN, hypothyroid, trigeminal neuralgia, hysterectomy [**2109**]

MEDICATION ON ADMISSION: BACLOFEN -  (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth 3 times daily
DULOXETINE [CYMBALTA] -  (Prescribed by Other Provider) - 30 mg
Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
HYDROCHLOROTHIAZIDE -  (Prescribed by Other Provider) - 12.5 mg
Capsule - 1 Capsule(s) by mouth daily
LEVOTHYROXINE -  (Prescribed by Other Provider) - 112 mcg Tablet
- 1 Tablet(s) by mouth daily on empty stomach
NORTRIPTYLINE -  (Prescribed by Other Provider) - 25 mg Capsule
-
3 Capsule(s) by mouth bedtime daily
OXCARBAZEPINE -  (Prescribed by Other Provider) - 300 mg Tablet
-
1 Tablet(s) by mouth twice daily

ALLERGIES: Percocet / Vicodin / Codeine

PHYSICAL EXAM: Gen: WD/WN, NAD, appears uncomfortable.
HEENT: Pupils:equal and brisk   EOMs: full
Neck: Supple.
Lungs: no audible wheeze of cough.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, ND
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension No dysarthria or
paraphasic errors.

FAMILY HISTORY: NC

SOCIAL HISTORY: no tobacco, social etoh, none recently 

### Response:
{'Trigeminal neuralgia,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Acquired absence of both cervix and uterus'}
