CHIEF COMPLAINT: MVA

PRESENT ILLNESS: This is a 61 year-old female with a history of diabetes who was
involved in a motor vehicle collision. She was transferred to
the [**Hospital1 190**] by Life Flight.  On initial evaluation, she was
hemodynamically stable with a GCS of 15. She had a clearly
identifiable right lower extremity injury. The right ankle had a
compound fracture with the tibia protruding out
over the skin and the whole right foot displaced anteromedially.
There was clear avulsion of nearly all of the posterior and
medial as well as lateral structures and the foot was tethered
to the leg anteriorly by skin and connective tissue bridge. She
also had a degloving injury to the right thigh as well as a
laceration to the left thigh. She had bilateral Charcot foot and
her vascular exam was significant for palpable femoral and
popliteal pulses
bilaterally. She had pulses to her left foot, however, there was
no appreciable pulse on the right foot although the right foot
did have capillary refill.  Given the degree of the
neurovascular injury in combination with the orthopedic
injury, it was felt that there would be no meaningful recovery
of function for this mangled extremity and the decision was made
to amputate the foot after discussion with the patient and her
son who agreed with the plan.

MEDICAL HISTORY: -Asthma ?????? requiring steroid therapy for 13 years, never
intubated
-Breast cancer s/p L mastectomy in [**2123**] and XRT
-CAD dx in [**2118**] on echocardiogram; negative stress test [**1-13**]
-DM dx 1 year ago
-HTN
-GERD
-History of MRSA and VRE
-Anxiety
-L Foot ulcer s/p multiple surgeries (most recent [**1-13**]) and
infections. Recent use of vanc/levo/linezolid (>2 months rx)
-Glaucoma

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa (Sulfonamides) / Dilaudid / Percocet

PHYSICAL EXAM: PE:

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Ms. [**Known lastname **] is divorced, has a 38 year old son who lives in CT and
several grandchildren.   Her son has power of attorney and is
her health care proxy.  She owns a house in [**Location (un) **] where she
lives with a roommate and many cats; however, she has been in
rehab for a substantial portion of the past year. She expresses
concern that her insurance many not cover continued
rehabilitation.
Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication,Closed fracture of acetabulum,Acute posthemorrhagic anemia,Open wound of hip and thigh, without mention of complication,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Other closed fractures of distal end of radius (alone),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Arthropathy associated with neurological disorders,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health
Amputation foot, unilat,Fracture acetabulum-clos,Ac posthemorrhag anemia,Open wound of hip/thigh,Oth coll stndng obj-driv,Fx distal radius NEC-cl,DMII neuro nt st uncntrl,Open wnd knee/leg/ankle,Arthropathy w nerve dis,Delirium d/t other cond,Hypertension NOS,Asthma NOS,Hx of breast malignancy,Hx of irradiation
Admission Date:  [**2127-1-15**]              Discharge Date:   [**2127-1-29**]

Date of Birth:  [**2065-7-21**]             Sex:   F

Service: SURGERY

Allergies:
Sulfa (Sulfonamides) / Dilaudid / Percocet

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
MVA

Major Surgical or Invasive Procedure:
A. PROCEDURE:
1. Guillotine amputation of the right foot at the level of
the ankle.
2. Irrigation and debridement of right thigh degloving
injury with closure.
3. Closure of left thigh laceration.

B. PROCEDURE:
1. Open reduction, internal fixation of left posterior wall,
posterior column acetabular fracture.
2. Open reduction, internal fixation of left distal radius
fracture.
3. Aspiration and injection, left knee to rule out open
knee.

C. PROCEDURE PERFORMED: Right lower extremity below knee
amputation revision.


History of Present Illness:
This is a 61 year-old female with a history of diabetes who was
involved in a motor vehicle collision. She was transferred to
the [**Hospital1 190**] by Life Flight.  On initial evaluation, she was
hemodynamically stable with a GCS of 15. She had a clearly
identifiable right lower extremity injury. The right ankle had a
compound fracture with the tibia protruding out
over the skin and the whole right foot displaced anteromedially.
There was clear avulsion of nearly all of the posterior and
medial as well as lateral structures and the foot was tethered
to the leg anteriorly by skin and connective tissue bridge. She
also had a degloving injury to the right thigh as well as a
laceration to the left thigh. She had bilateral Charcot foot and
her vascular exam was significant for palpable femoral and
popliteal pulses
bilaterally. She had pulses to her left foot, however, there was
no appreciable pulse on the right foot although the right foot
did have capillary refill.  Given the degree of the
neurovascular injury in combination with the orthopedic
injury, it was felt that there would be no meaningful recovery
of function for this mangled extremity and the decision was made
to amputate the foot after discussion with the patient and her
son who agreed with the plan.


Past Medical History:
-Asthma ?????? requiring steroid therapy for 13 years, never
intubated
-Breast cancer s/p L mastectomy in [**2123**] and XRT
-CAD dx in [**2118**] on echocardiogram; negative stress test [**1-13**]
-DM dx 1 year ago
-HTN
-GERD
-History of MRSA and VRE
-Anxiety
-L Foot ulcer s/p multiple surgeries (most recent [**1-13**]) and
infections. Recent use of vanc/levo/linezolid (>2 months rx)
-Glaucoma

Social History:
Ms. [**Known lastname **] is divorced, has a 38 year old son who lives in CT and
several grandchildren.   Her son has power of attorney and is
her health care proxy.  She owns a house in [**Location (un) **] where she
lives with a roommate and many cats; however, she has been in
rehab for a substantial portion of the past year. She expresses
concern that her insurance many not cover continued
rehabilitation.


Family History:
Noncontributory.

Physical Exam:
PE:

AFVSS

NEURO:

PERRL / EOMI

MAE equally

Answers simple commands

Neg pronator drift

Sensation intact to ST

2 plus DTR

Neg Babinski

HEENT:

NCAT

Neg lesions nares, oral pharnyx, auditory

Supple / FAROM

neg lyphandopathy, supra clavicular nodes

LUNGS: CTA b/l

CARDIAC: RRR without murmers

ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness

EXT:

rle - palp fem, [**Doctor Last Name **], pt, dp

lle - palp fem, inc c/d/i


Pertinent Results:
[**2127-1-25**] 05:30AM BLOOD

PT-13.8* PTT-32.9 INR(PT)-1.2*

[**2127-1-25**] 05:30AM BLOOD

Glucose-108* UreaN-11 Creat-0.5 Na-138 K-3.8 Cl-108 HCO3-18*
AnGap-16

[**2127-1-25**] 05:30AM BLOOD

Calcium-7.7* Phos-3.7 Mg-2.4

[**2127-1-24**] 10:38AM

URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE Epi-0
URINE Hours-RANDOM

Cardiology Report ECG Study Date of [**2127-1-23**]  4:23:00 PM

Sinus rhythm with an atrial premature beat. Since the previous
tracing
of [**2127-1-20**] there is less atrial ectopic activity.

Intervals Axes
Rate PR QRS QT/QTc P QRS T
89 158 92 392/438.57 43 -10 51



Brief Hospital Course:
Mrs. [**Known lastname **]  presented to the emergency department with the
following injuries, Motor vehicle collision with near amputation
of the right foot as well as lacerations to the bilateral lower
extremities. She was evaluated by the Orthopaedics / Podiatry /
Vascular Surgery departments. She was also found to have the
following fracture's Left posterior wall, posterior column
acetabular fracture, Left distal radius fracture, Left knee
laceration.She was admitted and consented for surgery.

On [**2127-1-15**], she was prepped and brought down to the operating
room for surgery. She had the following procedures:

Orthopedics:

1.  Open reduction, internal fixation of left posterior wall,
    posterior column acetabular fracture.
2.  Open reduction, internal fixation of left distal radius
    fracture.
3.  Aspiration and injection, left knee to rule out open
    knee.

Vascular:

4.  Guillotine amputation of the right foot at the level of
    the ankle.
5.  Irrigation and debridement of right thigh degloving
    injury with closure.
6.  Closure of left thigh laceration.

Intra-operatively, she was closely monitored and remained
hemodynamically stable. She tolerated the procedure's well
without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring. She was then
transferred to the floor for further recovery.

[**2127-1-21**], she was prepped and brought down to the operating room
for surgery. She had the following procedures:

1. Right lower extremity below knee amputation revision.

Intra-operatively, she was closely monitored and remained
hemodynamically stable. She tolerated the procedure's well
without any difficulty or complication.
Post-operatively, she was extubated and transferred to the PACU
for further stabilization and monitoring. She was then
transferred to the floor for further recovery.

On the floor, she remained hemodynamically stable with her pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged to a rehabilitation
facility in stable condition.

To note pt had psych consult / 1:1 sitter

On DC pt denies suicidal tendencies


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
2. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Becaplermin 0.01 % Gel Sig: One (1) Appl Topical  DAILY
(Daily).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO tid ().
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: [**2-11**]  Subcutaneous Q12H
(every 12 hours).
14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB.
16. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED).
20. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Motor vehicle collision

1. With near amputation of the right foot.

2. Left posterior wall, posterior column acetabular
fracture.

3. Left distal radius fracture.

4. Left knee laceration.


Discharge Condition:
Stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW KNEE AMPUTATION

This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.

ACTIVITY:

There are restrictions on activity. On the side of your
amputation you are non weight bearing for 4-6 weeks. You should
keep this amputation site elevated when ever possible.

No driving until cleared by your Surgeon.

PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:

Redness in or drainage from your leg wound(s).

Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.

Exercise:

Limit strenuous activity for 6 weeks.

Do not drive a car unless cleared by your Surgeon.

No heavy lifting greater than 20 pounds for the next 14 days.

Try to keep leg elevated when able.

BATHING/SHOWERING:

You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.

WOUND CARE:

Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.

When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.

Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.

MEDICATIONS:

Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.

Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.

CAUTIONS:

NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.

Avoid pressure to your amputation site.

No strenuous activity for 6 weeks after surgery.

DIET:

There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.

For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.

If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.

If you have diabetes and would like additional guidance, you may
request a referral from your doctor.

FOLLOW-UP APPOINTMENT:

Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!

Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.

PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2127-1-29**] 11:30

Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2127-2-12**] 10:20



Completed by:[**2127-1-29**]
{'Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication,Closed fracture of acetabulum,Acute posthemorrhagic anemia,Open wound of hip and thigh, without mention of complication,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Other closed fractures of distal end of radius (alone),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Arthropathy associated with neurological disorders,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health'}


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: MVA

PRESENT ILLNESS: This is a 61 year-old female with a history of diabetes who was
involved in a motor vehicle collision. She was transferred to
the [**Hospital1 190**] by Life Flight.  On initial evaluation, she was
hemodynamically stable with a GCS of 15. She had a clearly
identifiable right lower extremity injury. The right ankle had a
compound fracture with the tibia protruding out
over the skin and the whole right foot displaced anteromedially.
There was clear avulsion of nearly all of the posterior and
medial as well as lateral structures and the foot was tethered
to the leg anteriorly by skin and connective tissue bridge. She
also had a degloving injury to the right thigh as well as a
laceration to the left thigh. She had bilateral Charcot foot and
her vascular exam was significant for palpable femoral and
popliteal pulses
bilaterally. She had pulses to her left foot, however, there was
no appreciable pulse on the right foot although the right foot
did have capillary refill.  Given the degree of the
neurovascular injury in combination with the orthopedic
injury, it was felt that there would be no meaningful recovery
of function for this mangled extremity and the decision was made
to amputate the foot after discussion with the patient and her
son who agreed with the plan.

MEDICAL HISTORY: -Asthma ?????? requiring steroid therapy for 13 years, never
intubated
-Breast cancer s/p L mastectomy in [**2123**] and XRT
-CAD dx in [**2118**] on echocardiogram; negative stress test [**1-13**]
-DM dx 1 year ago
-HTN
-GERD
-History of MRSA and VRE
-Anxiety
-L Foot ulcer s/p multiple surgeries (most recent [**1-13**]) and
infections. Recent use of vanc/levo/linezolid (>2 months rx)
-Glaucoma

MEDICATION ON ADMISSION: 

ALLERGIES: Sulfa (Sulfonamides) / Dilaudid / Percocet

PHYSICAL EXAM: PE:

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Ms. [**Known lastname **] is divorced, has a 38 year old son who lives in CT and
several grandchildren.   Her son has power of attorney and is
her health care proxy.  She owns a house in [**Location (un) **] where she
lives with a roommate and many cats; however, she has been in
rehab for a substantial portion of the past year. She expresses
concern that her insurance many not cover continued
rehabilitation. 

### Response:
{'Traumatic amputation of foot (complete) (partial), unilateral, without mention of complication,Closed fracture of acetabulum,Acute posthemorrhagic anemia,Open wound of hip and thigh, without mention of complication,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Other closed fractures of distal end of radius (alone),Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Arthropathy associated with neurological disorders,Delirium due to conditions classified elsewhere,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Personal history of irradiation, presenting hazards to health'}
