CHIEF COMPLAINT: Trauma: MVC

PRESENT ILLNESS: This patient is a 23 year old female who complains of MVC.
The patient was seen upon arrival. She was in a car that was
in a rollover accident she was ejected from the car. In the
field she was awake alert oriented. She has stable vital
signs peaches 2 intravenous lines. Her glucose was 120. She
has an abrasion to the right elbow and the right shoulder is
hurting her. She did receive fentanyl 50 mcg. She was
transported by med flight.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: albuterol

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:  upon admission

FAMILY HISTORY: nc

SOCIAL HISTORY: She reports that she is a social drinker, denies daily use, and
denies ever experiencing any withdrawal symptoms. Also denies
use
of any illicit substances. She is in a "complicated"
relationship
when asked if she is single. She lives w/ mom full time and
works
at [**Name (NI) 41976**]. She finds the visits from her family and friends
to
be supportive at this time.
Closed fracture of second cervical vertebra,Closed fracture of surgical neck of humerus,Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness,Closed fracture of nasal bones,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Asthma, unspecified type, unspecified,Alcohol abuse, unspecified,Street and highway accidents
Fx c2 vertebra-closed,Fx surg nck humerus-clos,Clos skull base fracture,Nasal bone fx-closed,Traffic acc NOS-pers NOS,Asthma NOS,Alcohol abuse-unspec,Accid on street/highway
Admission Date:  [**2173-9-24**]              Discharge Date:   [**2173-9-28**]

Date of Birth:  [**2151-6-11**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Doctor Last Name 19844**]
Chief Complaint:
Trauma: MVC

Right humeral head fracture
Type 3 dens fracture
Axis fracture
T11 superior endplate compression
nasal-septal fracture


Major Surgical or Invasive Procedure:
none


History of Present Illness:
This patient is a 23 year old female who complains of MVC.
The patient was seen upon arrival. She was in a car that was
in a rollover accident she was ejected from the car. In the
field she was awake alert oriented. She has stable vital
signs peaches 2 intravenous lines. Her glucose was 120. She
has an abrasion to the right elbow and the right shoulder is
hurting her. She did receive fentanyl 50 mcg. She was
transported by med flight.



Past Medical History:
none

Social History:
She reports that she is a social drinker, denies daily use, and
denies ever experiencing any withdrawal symptoms. Also denies
use
of any illicit substances. She is in a "complicated"
relationship
when asked if she is single. She lives w/ mom full time and
works
at [**Name (NI) 41976**]. She finds the visits from her family and friends
to
be supportive at this time.


Family History:
nc

Physical Exam:
PHYSICAL EXAMINATION:  upon admission

Constitutional: Collar and backboard
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact, no facial
bone tenderness, no hemotympanum
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Right flank abrasion, Nontender, Soft
Extr/Back: Right humerus is tender right shoulder and right
elbow are tender. There is no obvious deformity. The right
upper extremity is neurovascular intact. Back is nontender
Neuro: Speech fluent, awake alert oriented, normal motor
normal sensory


Pertinent Results:
[**2173-9-25**] 02:07AM BLOOD WBC-9.7 RBC-3.86* Hgb-12.2 Hct-36.1
MCV-93 MCH-31.6 MCHC-33.8 RDW-13.0 Plt Ct-202
[**2173-9-24**] 02:15AM BLOOD WBC-17.2* RBC-4.50 Hgb-14.2 Hct-42.2
MCV-94 MCH-31.5 MCHC-33.5 RDW-12.8 Plt Ct-309
[**2173-9-25**] 02:07AM BLOOD Plt Ct-202
[**2173-9-24**] 02:15AM BLOOD PT-10.5 PTT-25.7 INR(PT)-1.0
[**2173-9-24**] 02:15AM BLOOD Fibrino-188
[**2173-9-25**] 02:07AM BLOOD Glucose-117* UreaN-5* Creat-0.5 Na-137
K-3.3 Cl-107 HCO3-25 AnGap-8
[**2173-9-24**] 02:15AM BLOOD Lipase-28
[**2173-9-25**] 02:07AM BLOOD Calcium-9.2 Phos-2.5* Mg-1.9
[**2173-9-24**] 02:15AM BLOOD ASA-NEG Ethanol-147* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2173-9-24**] 02:20AM BLOOD Glucose-109* Lactate-2.4* Na-142 K-3.4
Cl-107 calHCO3-22

[**2173-9-24**]:  chest x-ray:

FINDINGS:  The lungs are clear, and the cardiomediastinal
silhouette and hila are normal.  There is no pleural effusion or
pneumothorax.  Right surgical neck humeral fracture is seen.

[**2173-9-24**]:  cat scan of the c-spine:

IMPRESSION:  Type 3 odontoid fracture involving the base of the
odontoid
process extending into the body of the axis and into the left
foramen
transversarium with a small fracture fragment off the left
superior articular surface of C2, displaced posteriorly between
the left lateral mass of C1 and left superior articular surface
of C2 and in close proximity to the expected position of
vertebral artery.  CTA of the neck is recommended for further
workup

[**2173-9-24**]:  cat scan of the head:

.  No acute intracranial process including no intracranial
hemorrhage.

2.  Nasal septum fractures with hemorrhage in the paranasal
sinuses and
inflammatory sinus disease.

[**2173-9-24**]:  cat scan of abdomen and pelvis:

IMPRESSION:
1.  Superior endplate fracture of T12 with minimal posterior
retropulsion.
2.  Right surgical neck humerus fracture without shoulder
dislocation.
3.  No other acute injuries to the chest, abdomen, and pelvis

[**2173-9-24**]:   cat scan of sinus/mandible:

IMPRESSION:  Nasoseptal fractures.  Moderate paranasal sinus
inflammatory
disease

[**2173-9-24**]:  CTA of neck:

IMPRESSION:  No evidence of vascular injury to the vertebral or
carotid
arteries.

[**2173-9-24**]:  x-ray of right forearm:

 FINDINGS:  There is a slightly impacted and medially displaced
right humeral fracture through the surgical neck without
evidence of dislocation.  There are no additional fractures
including no fractures of the right upper thorax, clavicle,
scapular, radius, or ulna.

[**2173-9-24**]:  right shoulder x-ray:

FINDINGS:  There is a slightly impacted and medially displaced
right humeral fracture through the surgical neck without
evidence of dislocation.  There are no additional fractures
including no fractures of the right upper thorax, clavicle,
scapular, radius, or ulna.

[**2173-9-24**]:  right elbow:

 FINDINGS:  There is a slightly impacted and medially displaced
right humeral fracture through the surgical neck without
evidence of dislocation.  There are no additional fractures
including no fractures of the right upper thorax, clavicle,
scapular, radius, or ulna.

[**2173-9-24**]:  MR thoracic spine:

 IMPRESSION:
1.  Mild acute compression of T11 superior endplate.
2.  No ligamentous injury.
3.  Previously noted odontoid fracture is not well visualized on
this study but subtle linear intensity change is seen. No
significant marrow edema.

[**2173-9-24**]:  MR cervical spine:

IMPRESSION:
1.  Mild acute compression of T11 superior endplate.
2.  No ligamentous injury.
3.  Previously noted odontoid fracture is not well visualized on
this study but subtle linear intensity change is seen. No
significant marrow edema.












Brief Hospital Course:
The patient was admitted to the hospital after being involved in
a rollover accident. She was reported to have a GCS of 15.  Upon
admission, she was made NPO, given intravenous fluids, and
underwent imaging.  After review of the films, she was noted to
have a right humeral head fracture, type 3 DENS fracture, and a
T11 endplate compression fracture.  She was also reported to
have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-septal fracture. Because of the injuries, the
patient  was transferred to the trauma intensive care unit for
close monitoring and neurological checks. During her stay in the
intensive care unit, she remained hemodynamically stable on
log-roll precautions.

Neurosurgery was consulted regarding the DENS fracture and
recommended a hard collar at all times for neck immobilization.
An MRI was performed to evaluate her spinal fractures, which did
not show ligamentous injury or hematoma. A TLSO brace was
ordered for the T11 compression fracture.  Upon examination, she
was found not to have any neurological deficits related to this
fracture. Her head cat scan was normal. The orthopedic service
was consulted regarding the right humeral head fractue.  No
surgical intervention was indicated and a sling was applied for
comfort with recommendations for follow-up.  Plastic surgery
recommended out-patient follow-up for the nasal septum fracture
and she was placed on sinus precautions.

She was transferred to the surgical floor on HD # 2.  Her vital
signs remained stable.  She was tolerating a regular diet.  Her
pain medication was converted to oral analgesia. Upon arrival of
the TLSO brace, she was seen by physcial therapy and
instructions provided for the application of the brace.  Her
foley catheter was removed and she was voiding without
difficulty.

She was cleared by physical therapy for discharge home with
instructions to follow-up with the Orthopedic, Neurosurgery, and
Plastic service.



Medications on Admission:
albuterol

Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**2-8**] tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
4. Senna 1 TAB PO BID:PRN constipation
5. Albuterol Inhaler [**2-8**] PUFF IH Q4H:PRN wheeze
6. TraMADOL (Ultram) 50 mg PO QID
RX *tramadol 50 mg 1 tablet(s) by mouth four times a day Disp
#*20 Tablet Refills:*0
7. Tizanidine 4 mg PO TID
RX *tizanidine 4 mg 1 tablet(s) by mouth three times a day Disp
#*12 Tablet Refills:*0


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] vna

Discharge Diagnosis:
Trauma: MVC

Right humeral head fracture
Type 3 dens fracture
Axis fracture
T11 superior endplate compression
nasal-septumm fracture


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).( needs TLSO brace, needs cervical collar at all times)


Discharge Instructions:
You were involved in a high speed rollover accident. You
sustained a fractured right arm and a fracture to your upper
neck.  You were also found to have a compression fracture of
your mid-back. You also were found to have a fracture of your
nose. You were monitored in the intensive care unit. You were
evaluated by the Orhtopedic and Neurosurgery services.  YOu did
not require any operative intervention.  Your vital signs have
been stable and you have been working with physical therapy to
prepare you for discharge home.  You are being discharged home
with the following instructions:

Because you had a nasal fracture, please follow these
instructions:

Because of the close relationship between the upper back teeth
and the sinus, a communication between the sinus and the mouth
sometimes results from surgery. This condition has occurred in
your case, which often heals slowly and with difficulty. Certain
precautions will assist healing and we ask that you faithfully
follow these instructions:

 Do not smoke for several days.

 Do not use straws for several days.

 Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel ??????stuffy?????? or there may be some nasal
drainage.

 Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.

It is important that you wear the neck collar at all times
because of the fracture in your neck and mid-back. If you note
the following, please inform us:

*increased numbness fingers
*weakness arms
*decreased strength in fingers
*difficulty moving your arm, shoulders
*increased pain in arms
*difficulty breathing
* fever greater than 101
*cough
*chills
*night sweats

*please wear the TLSO brace when out of bed or ambulating.  If
is important that you continue to use the incentive spirometer
every hour as directed.

Please wear the sling on the right arm, no weight bearing to
right arm.


Followup Instructions:
Department: DIV. OF PLASTIC SURGERY
When: FRIDAY [**2173-10-8**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD [**Telephone/Fax (1) 6331**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: RADIOLOGY
When: WEDNESDAY [**2173-10-20**] at 2:15 PM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: WEDNESDAY [**2173-10-20**] at 3:00 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROSURGERY
When: WEDNESDAY [**2173-10-27**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

We are working on a follow up appt with Dr. [**First Name (STitle) **] in the next
few weeks. You will be called at home with the appointment.   If
you have not heard or have questions, please call [**Telephone/Fax (1) 14916**].

We are working on a follow up appt with Dr. [**Last Name (STitle) **] in the [**3-12**]
weeks. You will be called at home with the appointment.   If you
have not heard or have questions, please call [**Telephone/Fax (1) 1228**].



Completed by:[**2173-10-5**]
{'Closed fracture of second cervical vertebra,Closed fracture of surgical neck of humerus,Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness,Closed fracture of nasal bones,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Asthma, unspecified type, unspecified,Alcohol abuse, unspecified,Street and highway accidents'}


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: Trauma: MVC

PRESENT ILLNESS: This patient is a 23 year old female who complains of MVC.
The patient was seen upon arrival. She was in a car that was
in a rollover accident she was ejected from the car. In the
field she was awake alert oriented. She has stable vital
signs peaches 2 intravenous lines. Her glucose was 120. She
has an abrasion to the right elbow and the right shoulder is
hurting her. She did receive fentanyl 50 mcg. She was
transported by med flight.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: albuterol

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:  upon admission

FAMILY HISTORY: nc

SOCIAL HISTORY: She reports that she is a social drinker, denies daily use, and
denies ever experiencing any withdrawal symptoms. Also denies
use
of any illicit substances. She is in a "complicated"
relationship
when asked if she is single. She lives w/ mom full time and
works
at [**Name (NI) 41976**]. She finds the visits from her family and friends
to
be supportive at this time. 

### Response:
{'Closed fracture of second cervical vertebra,Closed fracture of surgical neck of humerus,Closed fracture of base of skull without mention of intra cranial injury, unspecified state of consciousness,Closed fracture of nasal bones,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Asthma, unspecified type, unspecified,Alcohol abuse, unspecified,Street and highway accidents'}
