CHIEF COMPLAINT: Motor Vehicle Collision

PRESENT ILLNESS: 36M medflighted from [**Hospital3 3583**] sp MVC in which car that
patient was driving crossed the median into oncoming traffic.
There were reports that the patient had a grand mal seizure
immediately following the collision and another while at [**Hospital1 3325**]. Pt was intubated and sedated prior to transfer to
[**Hospital1 18**].

MEDICAL HISTORY: No hx of seizures.  No other pertinent medical history.

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance
Vitals AVSS
NAD, A x O x 3
HEENT: PERRLA, EOMI, no LAD
Cor: RRR, no/r/g
Lung: CTAB, no r/r/c, left post rib angle pain to palpation
Abd: NT/ND, (+) BS, soft
Ext: warm and well perfused, no c/c/e

FAMILY HISTORY: Two first-degree relatives with positive, unspecified, seizure
history.

SOCIAL HISTORY: Pt is a heavy smoker---smokes 3-4 packs per day for 26 years.
Pt also is a heavy drinker---drinks 3-4 drinks per day.
Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Closed fracture of one rib,Contusion of lung without mention of open wound into thorax,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Alcohol abuse, unspecified,Other convulsions,Unspecified essential hypertension
Traumatic brain hem NEC,Fracture one rib-closed,Lung contusion-closed,Mv collision NOS-driver,Alcohol abuse-unspec,Convulsions NEC,Hypertension NOS
Admission Date:  [**2101-1-11**]              Discharge Date:   [**2101-1-15**]

Date of Birth:  [**2064-8-14**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Motor Vehicle Collision

Major Surgical or Invasive Procedure:
None


History of Present Illness:
36M medflighted from [**Hospital3 3583**] sp MVC in which car that
patient was driving crossed the median into oncoming traffic.
There were reports that the patient had a grand mal seizure
immediately following the collision and another while at [**Hospital1 3325**]. Pt was intubated and sedated prior to transfer to
[**Hospital1 18**].

Past Medical History:
No hx of seizures.  No other pertinent medical history.

Social History:
Pt is a heavy smoker---smokes 3-4 packs per day for 26 years.
Pt also is a heavy drinker---drinks 3-4 drinks per day.

Family History:
Two first-degree relatives with positive, unspecified, seizure
history.

Physical Exam:
General Appearance
Vitals AVSS
NAD, A x O x 3
HEENT: PERRLA, EOMI, no LAD
Cor: RRR, no/r/g
Lung: CTAB, no r/r/c, left post rib angle pain to palpation
Abd: NT/ND, (+) BS, soft
Ext: warm and well perfused, no c/c/e


Pertinent Results:
[**1-14**] MR HEAD:
IMPRESSION:  8 x 5 mm hemorrhagic focus in the right superior
collicular
region consistent with hemorrhage.  Given the significant
susceptibility, the underlying vascular abnormality such as
developmental venous anomaly or cavernoma can be present.  Close
followup is recommended.
.
[**1-11**] CT HEAD TRAUMA: IMPRESSION:  Focal area of
intraparenchymal hemorrhage in the region of the superior
colliculus on the right, within the mid brain.  Otherwise, no
intracranial hemorrhage or edema identified.
.
[**1-11**] CT TORSO TRAUMA: IMPRESSION:
1.  Near-complete collapse of the right upper lobe and partial
collapse of the left lower lobe. 2.  Non-displaced left sixth
rib fracture.  No pneumothorax. 3.  No acute intra-abdominal
injury.
.
[**1-11**] CT C-SPINE:
IMPRESSION:  No CT evidence of fracture or subluxation.
.
[**2101-1-11**] 10:41PM   TYPE-ART PO2-238* PCO2-41 PH-7.34* TOTAL
CO2-23 BASE XS--3
[**2101-1-11**] 08:31PM   PH-7.23*
[**2101-1-11**] 08:31PM   GLUCOSE-116* LACTATE-1.5 NA+-140 K+-3.9
CL--103 TCO2-26
[**2101-1-11**] 08:31PM   HGB-17.4 calcHCT-52 O2 SAT-55 CARBOXYHB-5.6*
MET HGB-0.1
[**2101-1-11**] 08:31PM   freeCa-1.08*
[**2101-1-11**] 08:20PM   UREA N-13
[**2101-1-11**] 08:20PM   AMYLASE-29
[**2101-1-11**] 08:20PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2101-1-11**] 08:20PM   WBC-21.0* RBC-5.25 HGB-17.2 HCT-49.3 MCV-94
MCH-32.7* MCHC-34.9 RDW-12.4
[**2101-1-11**] 08:20PM   PLT COUNT-279
[**2101-1-11**] 08:20PM   PT-11.5 PTT-22.4 INR(PT)-1.0
[**2101-1-11**] 08:20PM   FIBRINOGE-252

Brief Hospital Course:
Pt admitted to the TSICU after MVC. Pt was unrestrained when he
crossed the median and got into a head on collision with an
oncoming car.
.
Pt with midbrain hemorrhage, right sixth rib fracture, right
pulmonary contusion, left upper and lower lobe atelectasis, left
upper chest contusion.
.
Neuro: Midbrain hemmorhage-Pt was seen and evaluated by
neurosurgery.  Pt was determined to not be a candidate for
operative management given the small size of his hemorrhage.  Pt
then seen by neurology service recommended an MRI and an EEG to
both characterize the lesion and to establish the presence of a
seizure disorder.  Frequent neurologic checks were recommended
and pt was loaded with dilantin.  Pt's mental status returned to
baseline by the end of his hospital course.  Also, given pt's
penchant for drinking, he was placed on the CIWA scale to guard
against withdrawal.
.
CVS- Stable.  Rate has been WNL.
.
Pulmonary: Pt initially intubated to control his airway in the
setting of seizure activity at OSH.  This was DC'd within 24
hours of ICU admission.  Pt had one episode of of temporary
desaturation to 85 percent on first try of ambulation with PT,
but came back up to >92 percent on Room Air.  At the time of
discharge the pt had excellent breath sounds bilaterally, with
no complaints of SOB, and was satting > 92 percent on room air.
He was encouraged to stop smoking.
.
Renal: Mg and K were replaced as needed.  Pt with good urine
output and labs demonstrating a creatinine of .7 and a bun of 9.
.
GI: given gi prophylaxis, no other issues.
.
Heme: Crit remained stable throughout hospital stay.
.
endo: Pt on RISS.


Medications on Admission:
None.

Discharge Medications:
1. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day for 1 months.
Disp:*90 Capsule(s)* Refills:*2*
2. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*60 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
1 months: Please take while taking narcotics to prevent
constipation.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. 6 mm IPH in R sup colliculus
2. Left posteriof 6th rib fx


Discharge Condition:
Stable, to home


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.


Followup Instructions:
You will need to follow up with the Neurology service in 1
month.  You will need to stay on your Dilantin (Phenytoin) until
this time.  Please call ([**Telephone/Fax (1) 2528**] to schedule an
appointment.
.
You will also need to follow up with Dr. [**Last Name (STitle) **] in Trauma
Surgery in 2 weeks. Please call ([**Telephone/Fax (1) 22750**] to schedule an
appointment at your convenience.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Closed fracture of one rib,Contusion of lung without mention of open wound into thorax,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Alcohol abuse, unspecified,Other convulsions,Unspecified essential hypertension'}


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: Motor Vehicle Collision

PRESENT ILLNESS: 36M medflighted from [**Hospital3 3583**] sp MVC in which car that
patient was driving crossed the median into oncoming traffic.
There were reports that the patient had a grand mal seizure
immediately following the collision and another while at [**Hospital1 3325**]. Pt was intubated and sedated prior to transfer to
[**Hospital1 18**].

MEDICAL HISTORY: No hx of seizures.  No other pertinent medical history.

MEDICATION ON ADMISSION: None.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General Appearance
Vitals AVSS
NAD, A x O x 3
HEENT: PERRLA, EOMI, no LAD
Cor: RRR, no/r/g
Lung: CTAB, no r/r/c, left post rib angle pain to palpation
Abd: NT/ND, (+) BS, soft
Ext: warm and well perfused, no c/c/e

FAMILY HISTORY: Two first-degree relatives with positive, unspecified, seizure
history.

SOCIAL HISTORY: Pt is a heavy smoker---smokes 3-4 packs per day for 26 years.
Pt also is a heavy drinker---drinks 3-4 drinks per day. 

### Response:
{'Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Closed fracture of one rib,Contusion of lung without mention of open wound into thorax,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Alcohol abuse, unspecified,Other convulsions,Unspecified essential hypertension'}
