CHIEF COMPLAINT: s/p Scooter crash vs auto

PRESENT ILLNESS: 46 yo male helmeted driver of a scooter; s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8886**] with auto;
no reproted LOC; c/o mild neck tenderness. He was admitted to
[**Hospital1 18**] for trauma evaluation.

MEDICAL HISTORY: DM Type II, HTN

MEDICATION ON ADMISSION: Metformin 1000", Lisinopril 10", Actos 30', Atenolol 50', ASA
325'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
PHYSICAL EXAM:
Upon admission:
BP: 105/65    HR: 90    R: 16     O2Sats: 94%
Awake, alert, Ox3; NAD;
Speech intact; VF grossly intact
Perla, EOMI, face symetric, tongue midline; sensation intact
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     NT    NT    5     5      5

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Closed fracture of subtrochanteric section of neck of femur,Closed fracture of pubis,Closed fracture of third cervical vertebra,Closed fracture of four ribs,Bimalleolar fracture, closed,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one or more phalanges of foot,Closed fracture of middle or proximal phalanx or phalanges of hand,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism
Subtrochanteric fx-close,Fracture of pubis-closed,Fx c3 vertebra-closed,Fracture four ribs-close,Fx bimalleolar-closed,Mv collis NOS-motorcycl,Traum pneumothorax-close,Fx phalanx, foot-closed,Fx mid/prx phal, hand-cl,DMII wo cmp nt st uncntr,Hypertension NOS,Hx-ven thrombosis/embols
Admission Date:  [**2143-10-25**]              Discharge Date:   [**2143-10-29**]

Date of Birth:  [**2090-5-31**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Scooter crash vs auto

Major Surgical or Invasive Procedure:
[**2143-10-29**] ORIF left femur, ankle, foot

History of Present Illness:
46 yo male helmeted driver of a scooter; s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8886**] with auto;
no reproted LOC; c/o mild neck tenderness. He was admitted to
[**Hospital1 18**] for trauma evaluation.


Past Medical History:
DM Type II, HTN

Family History:
Noncontributory

Physical Exam:
Upon admission:
PHYSICAL EXAM:
Upon admission:
BP: 105/65    HR: 90    R: 16     O2Sats: 94%
Awake, alert, Ox3; NAD;
Speech intact; VF grossly intact
Perla, EOMI, face symetric, tongue midline; sensation intact
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     NT    NT    5     5      5

(NT = not tested, due to immobilization for hip fx)

Sensation: Intact to light touch, propioception, bilat. in UE
and
LE

Reflexes: B T  Pa Ac
Right     2 2  2  2
Left      2 2  NT NT
Toes downgoing bilaterally


Pertinent Results:
[**2143-10-25**] 12:13PM   GLUCOSE-157* UREA N-23* CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-27 ANION GAP-10
[**2143-10-25**] 12:13PM   CALCIUM-7.8* PHOSPHATE-3.3 MAGNESIUM-1.8
[**2143-10-25**] 12:13PM   WBC-9.9 RBC-3.19* HGB-9.8* HCT-27.1* MCV-85
MCH-30.9 MCHC-36.3* RDW-13.8
[**2143-10-25**] 12:13PM   PLT COUNT-177
[**2143-10-25**] 12:13PM   PT-15.0* PTT-27.8 INR(PT)-1.3*
[**2143-10-24**] 08:36PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-10-24**] 08:36PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG

CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS [**2143-10-24**]
IMPRESSION:
1. No evidence for vertebral artery injury associated with right
C3
transverse process fracture.
2. Nondisplaced right occipital condyle fracture.
3. Possible osteophyte fracture along the anteroinferior corner
of C5.
3. Left fourth rib fracture and associated small left
pneumothorax are
partially imaged. Potential for a left scapular fracture should
be correlated
with outside imaging.

MR Cervical spine [**2143-10-25**]
IMPRESSION: Prevertebral edema and potential small ALL tear at
C5/6. Disc STIR
hyperintensity and anterior annular tear at C5-[**4-30**] represent
acute
traumatic changes, though chronic degenerative changes can
appear similar.

FINGER(S),2+VIEWS RIGHT   [**2143-10-28**]
FINDINGS: In comparison with study of [**2143-10-25**], there is little
overall
change in the comminuted fracture of the base of the proximal
phalanx of the
second digit that extends into the metacarpophalangeal joint.
The ossific
density in the radial aspect of the second distal phalanx is
again seen.
IMPRESSION: Little change.









Brief Hospital Course:
He was admitted to the Trauma Service. Orthopedics, Neurosurgery
spine and Plastics were consulted given his multiple injuries.
He was taken to the operating room for repair of his left leg
injuries; there were no intraoperative complications. His spine
fracture was nonoperative; the cervical collar was removed after
clinical and radiographic examination ruling out ligamentous
injury. It was initially felt that  he would require surgical
repair of his right comminuted 2nd proximal phalanx fracture but
then the decision was made to place a short arm cast. He will
follow up in 1 week in Hand clinic with Dr. [**Last Name (STitle) 23606**].

His home medications were restarted. He was started on a regular
diet and is tolerating this without any difficulties. His pain
was initially controlled with IV narcotics and he was later
changed to oral form with adequate control. He is on a bowel
regimen and is having regular bowel movements.

He was evaluated by Physical therapy and is being recommended
for rehab after his acute hospital stay.


Medications on Admission:
Metformin 1000", Lisinopril 10", Actos 30', Atenolol 50', ASA
325'



Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML's
Injection TID (3 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn.
7. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Insulin Lispro 100 unit/mL Solution Sig: One (1) Dose
Subcutaneous four times a day as needed for per sliding scale:
See attached sliding scale.
10. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
Northeast Acute Rehab

Discharge Diagnosis:
s/p Scooter crash vs. auto
Injuries:
C3 Right facet fracture w/ extension into transverse foramen
Left rib [**4-2**] fractures
10-15% anterobasilar pneumothorax
Left greater trochanter fracture
Left foot/ankle fracture
Left superior pubic ramus fracture in the parasymphyseal region

Right comminuted 2nd prox phalanx fracture
Left gluteal hematoma



Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.

Followup Instructions:
Follow up in 1 week in Plastics Hand Clinic with Dr. [**Last Name (STitle) 23606**],
call [**Telephone/Fax (1) 3009**].

Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Trauma surgery, call
[**Telephone/Fax (1) 6429**] for an appointment.

Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP - Orthopedics,
call [**Telephone/Fax (1) 1228**] for an appointment.

Follow up in [**3-31**] weeks with Dr. [**Last Name (STitle) 548**], Neurosurgery for your
spine fracture. Inform the office that you will need repeat CT
spine imaging for this appointment.



Completed by:[**2143-10-30**]
{'Closed fracture of subtrochanteric section of neck of femur,Closed fracture of pubis,Closed fracture of third cervical vertebra,Closed fracture of four ribs,Bimalleolar fracture, closed,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one or more phalanges of foot,Closed fracture of middle or proximal phalanx or phalanges of hand,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,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: s/p Scooter crash vs auto

PRESENT ILLNESS: 46 yo male helmeted driver of a scooter; s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8886**] with auto;
no reproted LOC; c/o mild neck tenderness. He was admitted to
[**Hospital1 18**] for trauma evaluation.

MEDICAL HISTORY: DM Type II, HTN

MEDICATION ON ADMISSION: Metformin 1000", Lisinopril 10", Actos 30', Atenolol 50', ASA
325'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
PHYSICAL EXAM:
Upon admission:
BP: 105/65    HR: 90    R: 16     O2Sats: 94%
Awake, alert, Ox3; NAD;
Speech intact; VF grossly intact
Perla, EOMI, face symetric, tongue midline; sensation intact
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     NT    NT    5     5      5

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Closed fracture of subtrochanteric section of neck of femur,Closed fracture of pubis,Closed fracture of third cervical vertebra,Closed fracture of four ribs,Bimalleolar fracture, closed,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of one or more phalanges of foot,Closed fracture of middle or proximal phalanx or phalanges of hand,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Personal history of venous thrombosis and embolism'}
