CHIEF COMPLAINT: The patient presented as a trauma from a motor vehicle accident

PRESENT ILLNESS: 38M who was involved in a rollover MVA early this morning.
Ejected from vehicle, found on pavement about 50 feet from
automobile. GCS at the scene reportedly 12. Multiple abrasions
noted. Taken to OSH where NCHCT reportedly demonstrated right
temporal epidural hematoma. Transferred to [**Hospital1 18**] ED for further
care. En route, decompensated in terms of mental status, GCS
went
from 12 to 6. Intubated for airway protection. On arrival to [**Name (NI) **],
pt seen to be moving all extremities prior to sedation. Pt
unable
to offer complaints at the time of my encounter.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On day of admission:
O: T: AF BP: 149/84  HR: 115   R 14 O2Sats 100%
Gen: Lying in bed, eyes closed.
HEENT: Multiple abrasions, including large right frontal
abrasion.
Neck: In hard collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown
Traumatic subcutaneous emphysema,Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of vault of skull without mention of intracranial injury, with no loss of consciousness,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,External ophthalmoplegia
Traum subcutan emphysema,Extradural hem w/o coma,Cl skull vlt fx w/o coma,Cl skul base fx w/o coma,Loss control mv acc-driv,Fx clavicle NOS-closed,External ophthalmoplegia
Admission Date:  [**2160-10-11**]              Discharge Date:   [**2160-10-16**]

Date of Birth:  [**2128-8-1**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
The patient presented as a trauma from a motor vehicle accident

Major Surgical or Invasive Procedure:
None


History of Present Illness:
38M who was involved in a rollover MVA early this morning.
Ejected from vehicle, found on pavement about 50 feet from
automobile. GCS at the scene reportedly 12. Multiple abrasions
noted. Taken to OSH where NCHCT reportedly demonstrated right
temporal epidural hematoma. Transferred to [**Hospital1 18**] ED for further
care. En route, decompensated in terms of mental status, GCS
went
from 12 to 6. Intubated for airway protection. On arrival to [**Name (NI) **],
pt seen to be moving all extremities prior to sedation. Pt
unable
to offer complaints at the time of my encounter.


Past Medical History:
unknown

Social History:
unknown

Family History:
unknown

Physical Exam:
On day of admission:
O: T: AF BP: 149/84  HR: 115   R 14 O2Sats 100%
Gen: Lying in bed, eyes closed.
HEENT: Multiple abrasions, including large right frontal
abrasion.
Neck: In hard collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.


Pertinent Results:
CT head [**10-11**]
IMPRESSION:
1. 14-mm right anterior temporal epidural hematoma. No mass
effect or shift of normally midline structures.
2. Right parietal/temporal fracture extending through the
greater [**Doctor First Name 362**] into the right posterior orbit and right sphenoid
sinus.
3. Right orbital emphysema and preseptal subcutaneous emphysema.

4. Partial opacification of the left mastoid air cells, without
definite
fracture identified.

CT C spine [**10-11**]
IMPRESSION:
1. No fracture or malalignment of the cervical spine.
2. Increased denstiy dependently at the lung apices, concerning
for
aspiration.

XRay Wrists
RIGHT WRIST: No fracture or dislocation is identified.

LEFT WRIST, THREE VIEWS: No fracture or dislocation is present.

IMPRESSION: No fracture.

Chest x ray [**10-11**]
Comminuted right mid clavicular fracture.


Brief Hospital Course:
The patient was admitted to the trauma service.  He was
intubated and sedated for airway protection.  His ventilatory
support was weaned as tolerated and he was extubated on [**10-12**].

[**10-12**] following extubation, his diet was advanced, he was
started on antibiotics by the facial trauma service for
fractures and transferred to the surgical floor for continued
monitoring.

[**10-13**] Physical therapy and occupational therapy worked with the
patient towards a goal of being discharged home.  He was started
on Keppra per neurosurgery.  His pain was well controlled on
oral medication.

Physical and occupational therapy continued working with the
patient and he was cleared for home on [**10-16**]

Medications on Admission:
none

Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. Comminuted right mid clavicular fracture.
2. Right anterior temporal epidural hematoma without shift
3. Right parietal/temporal fracture extending into Right
posterior orbit & Right sphenoid sinus
4. Right lateral rectus paralysis


Discharge Condition:
Stable


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.
* 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 becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* 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.

Head of bed elevated >30 degrees
Sneeze with an open mouth
Do not use a straw
Continue antibiotics for 5 days

Followup Instructions:
Please call the office of Plastic Surgery to arrange a follow up
appointment in [**11-21**] weeks at ([**Telephone/Fax (1) 2868**]

Orthopedics - please call ([**Telephone/Fax (1) 2007**] to arrange a follow up
appointment in [**12-23**] weeks.

Please call the office of Opthalmology to arrange a follow up in
2 weeks at ([**Telephone/Fax (1) 5120**]

Please call the office of Dr. [**First Name (STitle) **] of neurosurgery to arrange
a follow up appointment in 1 month.  You will need a head CT on
day of follow up. ([**Telephone/Fax (1) 88**]
{'Traumatic subcutaneous emphysema,Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of vault of skull without mention of intracranial injury, with no loss of consciousness,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,External ophthalmoplegia'}


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: The patient presented as a trauma from a motor vehicle accident

PRESENT ILLNESS: 38M who was involved in a rollover MVA early this morning.
Ejected from vehicle, found on pavement about 50 feet from
automobile. GCS at the scene reportedly 12. Multiple abrasions
noted. Taken to OSH where NCHCT reportedly demonstrated right
temporal epidural hematoma. Transferred to [**Hospital1 18**] ED for further
care. En route, decompensated in terms of mental status, GCS
went
from 12 to 6. Intubated for airway protection. On arrival to [**Name (NI) **],
pt seen to be moving all extremities prior to sedation. Pt
unable
to offer complaints at the time of my encounter.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On day of admission:
O: T: AF BP: 149/84  HR: 115   R 14 O2Sats 100%
Gen: Lying in bed, eyes closed.
HEENT: Multiple abrasions, including large right frontal
abrasion.
Neck: In hard collar.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Traumatic subcutaneous emphysema,Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of vault of skull without mention of intracranial injury, with no loss of consciousness,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of clavicle, unspecified part,External ophthalmoplegia'}
