CHIEF COMPLAINT: CSF rhinorrhea

PRESENT ILLNESS: ICH, SAH, depressed skull fracture s/p trauma in [**7-3**] returns
with persistent CSF leak.

MEDICAL HISTORY: As stated above

MEDICATION ON ADMISSION: Keppra 500 [**Hospital1 **]
pantoprazole

ALLERGIES: Penicillins

PHYSICAL EXAM: AVSS
NCAT, NAD
EOM full, anicteric
Neck supple
Chest clear
Heart RRR, no MRG
Abdomen soft NTND
Ext 2+ DP, no edema
Neuro:
A&O x3, language fluent. Naming intact.
CN 2-12 intact. Motor: [**3-31**] throughout upper and lower
extremities.
Sensation intact throughout.  Fine motor normal.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory
Other nervous system complications,Disruption of internal operation (surgical) wound,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Surg comp nerv systm NEC,Disrup internal op wound,Abn react-surg proc NEC
Admission Date:  [**2181-10-4**]              Discharge Date:   [**2181-10-6**]

Date of Birth:  [**2120-4-1**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CSF rhinorrhea

Major Surgical or Invasive Procedure:
s/p intracranial repair of skull base defect

History of Present Illness:
ICH, SAH, depressed skull fracture s/p trauma in [**7-3**] returns
with persistent CSF leak.


Past Medical History:
As stated above

Social History:
non-contributory


Family History:
non-contributory

Physical Exam:
AVSS
NCAT, NAD
EOM full, anicteric
Neck supple
Chest clear
Heart RRR, no MRG
Abdomen soft NTND
Ext 2+ DP, no edema
Neuro:
A&O x3, language fluent. Naming intact.
CN 2-12 intact. Motor: [**3-31**] throughout upper and lower
extremities.
Sensation intact throughout.  Fine motor normal.

Brief Hospital Course:
Pt admitted postoperatively.  Neurologically he did well without
any neurological development.  On the floor his diet was
advanced and he was able to void without problems.  [**Name (NI) **] received
vancomycin and gentamycin x 3 doses each.  He remained afebrile,
and his pain was controlled with percocet.

On POD2, ENT removed the nasal packing and after 6 hours he
passed a CSF rhinorrhea challenge without evidence of discharge.


Medications on Admission:
Keppra 500 [**Hospital1 **]
pantoprazole

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
CSF leak, skull base defect

Discharge Condition:
good, neurologically intact

Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

??????	Have a 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,
excessive bending
??????	You may wash your hair only after sutures and/or staples have
been removed
??????	You may shower before this time with assistance and use of a
shower cap
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

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, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**9-9**] DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED AN MRI OF THE BRAIN WITH AND WITHOUT GADOLIDIUM

CALL ([**Telephone/Fax (1) 6213**] TO ARRANGE FOLLOWUP WITH DR. [**First Name (STitle) 3880**] ONCE YOU
ARE DISCHARGED FROM THE HOSPITAL.
{'Other nervous system complications,Disruption of internal operation (surgical) wound,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: CSF rhinorrhea

PRESENT ILLNESS: ICH, SAH, depressed skull fracture s/p trauma in [**7-3**] returns
with persistent CSF leak.

MEDICAL HISTORY: As stated above

MEDICATION ON ADMISSION: Keppra 500 [**Hospital1 **]
pantoprazole

ALLERGIES: Penicillins

PHYSICAL EXAM: AVSS
NCAT, NAD
EOM full, anicteric
Neck supple
Chest clear
Heart RRR, no MRG
Abdomen soft NTND
Ext 2+ DP, no edema
Neuro:
A&O x3, language fluent. Naming intact.
CN 2-12 intact. Motor: [**3-31**] throughout upper and lower
extremities.
Sensation intact throughout.  Fine motor normal.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory 

### Response:
{'Other nervous system complications,Disruption of internal operation (surgical) wound,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
