CHIEF COMPLAINT: s/p Rollover motor vehicle crash

PRESENT ILLNESS: 63 yo male s/p rollover motor vehicle crash, high speed with
ejection, unrestrained driver, +EtOH. Initial GCS 14. He was
taken to an area hospital and found to have bilateral
pneumothoraces with left hemothorax.

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Lisinopril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH
Other open fractures of distal end of radius (alone),Open dislocation of radioulnar (joint), distal,Other specified open wounds of ocular adnexa,Closed fracture of unspecified part of upper end of humerus,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of eight or more ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of other facial bones,Closed fracture of phalanx or phalanges of hand, unspecified,Closed fracture of scapula, other,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Long-term (current) use of insulin,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle
Fx distal radius NEC-opn,Disloc dist radiouln-opn,Opn wnd ocular adnex NEC,Fx up end humerus NOS-cl,Traum pneumohemothor-cl,Fx eight/more rib-closed,Fx dorsal vertebra-close,Fx facial bone NEC-close,Fx phalanx, hand NOS-cl,Fx scapula NEC-closed,DMII wo cmp nt st uncntr,Hypertension NOS,Long-term use of insulin,Mv collision NOS-driver
Admission Date:  [**2126-3-20**]              Discharge Date:   [**2126-4-9**]

Date of Birth:  [**2062-3-4**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Rollover motor vehicle crash

Major Surgical or Invasive Procedure:
s/p External fixation Left radial/Ulnar fracture, canthoplasty;
s/p ORIF L humerus [**3-25**];
s/p Trach/peg on [**3-28**]; s/p IVCF


History of Present Illness:
63 yo male s/p rollover motor vehicle crash, high speed with
ejection, unrestrained driver, +EtOH. Initial GCS 14. He was
taken to an area hospital and found to have bilateral
pneumothoraces with left hemothorax.

Past Medical History:
HTN

Social History:
+EtOH

Family History:
Noncontributory

Pertinent Results:
Upon admission:
[**2126-3-21**] 01:15AM BLOOD WBC-6.0 RBC-3.82* Hgb-11.3* Hct-32.7*
MCV-86 MCH-29.6 MCHC-34.6 RDW-14.9 Plt Ct-171
[**2126-3-20**] 05:55PM BLOOD PT-12.9 PTT-27.1 INR(PT)-1.1
[**2126-3-21**] 01:15AM BLOOD Glucose-178* UreaN-23* Creat-0.9 Na-137
K-4.7 Cl-109* HCO3-21* AnGap-12
[**2126-4-4**] 02:17AM BLOOD Glucose-61* UreaN-22* Creat-0.5 Na-143
K-4.6 Cl-104 HCO3-32 AnGap-12
[**2126-3-21**] 08:16AM BLOOD CK-MB-95* MB Indx-0.9 cTropnT-<0.01
[**2126-4-2**] 03:35AM BLOOD calTIBC-160* Ferritn-481* TRF-123*
[**2126-4-1**] 06:15AM BLOOD Lactate-0.9
[**2126-3-20**] 06:06PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2126-3-20**] 06:06PM URINE RBC-[**11-14**]* WBC-[**2-27**] Bacteri-RARE
Yeast-NONE Epi-0-2 TransE-[**2-27**]
[**2126-3-20**] 06:06PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.048*

CT HEAD W/O CONTRAST  [**2126-3-22**] 10:19 AM

IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Blood air level within the right maxillary sinus is
suspicious for fracture involving the right maxillary sinus and
facial CT can help for further assessment as described above.

CT C-SPINE W/O CONTRAST  [**2126-3-22**] 10:19 AM

IMPRESSION:
1. No definite fracture or subluxation in the cervical region.
MRI can help to exclude ligamentous injury if clinically
indicated. There is no abnormal widening of the disc space or
widening of interspinous distances to indicate unstable injury.
2. Extensive subcutaneous emphysema in the neck. Correlation
with chest CT recommended.
3. Rib fractures as described above.
4. Degenerative changes.

CT CHEST W/O CONTRAST  [**2126-3-22**] 10:20 AM

IMPRESSION:

1. Bilateral hemopneumothorax with bilateral chest tubes in
place.

2. Pneumomediastinum and extensive subcutaneous and chest wall
gas.

3. No definite evidence of mediastinal hematoma or of injury to
the great vessels. However, this examination is limited due to
lack of intravenous contrast.

4. Bilateral lower lobe and lingular pulmonary consolidation and
additional areas of patchy probable contusions in the upper
lobes.

5. Numerous and extensive fractures including left humerus,
bilateral scapula, multiple ribs, and thoracic spine. Dedicated
evaluation of the thoracic spine is recommended due to probable
but incompletely evaluated T8 burst fracture and inadequate
evaluation of the canal and its contents.

6. Limited evaluation of the upper abdomen without definite
evidence of hemoperitoneum.

CHEST (PORTABLE AP)  [**2126-4-4**] 5:43 AM

COMPARISON: [**2126-4-2**].

As compared to the previous radiograph, there is no relevant
change. The PICC line and the tracheostomy tube are in unchanged
positions. There still is mild cardiomegaly with minimal signs
of overhydration. At the left lung base and in the retrocardiac
lung areas, older peribronchial opacities, potentially of
atelectatic nature, are identified. Otherwise, there are no
focal parenchymal lung opacities suggestive of pneumonia. No
pneumothorax.


Brief Hospital Course:
He was admitted to the Trauma Service. His hospital course by
systems as follows:

Neuro - He was vented and sedated prior to arrival to [**Hospital1 18**].
Because of his injuries he remained sedated in the Trauma ICU
for the majority of his stay there. There were no intracranial
processess identified on CT imaging of his head. He was placed
on Ativan per CIWA protocol given his history of EtOH. His
sedation was eventually weaned and he did awaken; he is awake,
alert, able to answer simple questions and follows commands. he
was started on Haldol prn for agitation; this has been used very
infrequently. For pain control he was evaluated by Acute Pain
Service for epidural catheter given his multiple rib fractures.
It was eventually decided that Methadone should be used for his
pain control.

HEENT - Plastic Surgery and Opthamology were consulted becasue
of an orbital wall fracture on the right and laceration to the
right lower lid. The laceration was repaired by Plastics injury;
a canthoplasty was performed by Opthamology [**3-23**] and he was
started on eye drops. He will require follow up in [**Hospital 8095**]
clinic in 2 weeks after discharge.

Cardiac - His initial Hematocrit was 41.4; prior to his arrival
to [**Hospital1 18**] he had received 4 units PRBC's at the referring
hospital due to profound hypotension. His most recent Hct is
32.7. Vascular surgery was immediately consulted given the open
left distal radius fracture and abscence of pulse; no operative
intervention was warranted by Vascular. Recommendations were
made for consultation by Plastc/Hand Surgery for definitive
care. He required beta blockade and Hydralazine to control his
HR and blood pressure during his ICU stay. He was transferred to
the regular nursing unit on Lopressor 37.5 mg tid; the dosage
and frequency were both decreased becasue of two noted episodes
of bradycardia on telemetry; in both instances the bradycardia
did resolve. An IVC filter was placed because of his multiple
bone fractures. His Lisinopril was restarted on [**4-9**].

Resp - Pt arrived to [**Hospital1 18**] intubated.  His respiratory status
was originally tenuous due to his multiple rib fractures (see
below) and bilateral pneumothoraxes.  He remained intubated on
the ventilator in the ICU and was later taken to the operating
room for an open tracheostomy and PEG on [**3-28**]. He was eventually
weaned from the ventilator and transferred to the floor on trach
mask. His chest tubes were pulled when the output had
sufficiently decreased.  He had a consult placed for speech
therapy/passy muir valve on [**4-8**], and has been cleared to
continue sessions.

Musculoskeletal - Patient is cleared for activity as tolerated
w/ TLSO brace in place and LUE non-weightbearing.  Injuries
include:
1) Open L radial ulnar fracture taken to the OR [**3-21**] by
plastics.  An exfix was placed.  Pt will be on augmentin x7d for
cellutic skin at exfix sites
2) L humerus fracture s/p ORIF [**3-25**] with orthopedics. staples
removed from incision, steri strips in place
3) L ribs [**1-5**], with 1-5 with multiple fracture locations.
4) R ribs multiple fx, w/ #7 fractured in >1 location
5) Comminuted R scapular fracture, non-operative
6) L scapular body fracture: non operative
7) Spine/Vertebral Injuries: non-operative, per Spine c/s, okay
for pt to sit, TLSO brace
--T5-T8, T10-T12 spinous process fractures
--Transverse process fractures R T2/4/5/7
--T8 body fracture
--T12 wedge fracture
--L5 compression fracture
8) R orbital wall fractures: non-operative

Pain Control: Pt originally required extremely a high dose
fentanyl drip for pain control given his multiple injuries.
Over the course of his ICU stay, the fentanyl was weaned and the
patient was transitioned to methadone (started [**3-30**]).  He is now
in the process of being tapered off methadone (see methodone
taper in medication orders).

ID: From an ID standpoint the patient has been stable.  He has
not had any major hospital aquired or other infections.  His
MRSA screens were negative, blood cultures were negative, and
catheter tip was also negative.  His ex fix pin sites developed
some erythema concerning for infection, and patient was started
on augmentin.  Plastic Surgery would like this continued until
his follow up appointment in 2 weeks.

Heme: Pt is s/p IVC filter on [**4-1**], placed for concern over
DVT/PE given state of decreased activity.


Medications on Admission:
Lisinopril

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 176 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
6. Erythromycin 5 mg/g Ointment Sig: One (1)  Ophthalmic [**Hospital1 **] (2
times a day).
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Pilocarpine HCl 2 % Drops Sig: One (1) Drop Ophthalmic Q6H
(every 6 hours).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
10. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q6H (every 6 hours) as needed.
12. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
13. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D ().
14. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
15. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
17. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QMON (every Monday).
18. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<110, HR<60 RN please check HR just
prior to giving Lopressor doses.  .
19. Methadone 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day): 6 doses via PEG, then d/c TID dosing, begin [**Hospital1 **] dosing
with plan to taper off methadone after [**Hospital1 **] dosing.
20. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: One (1)  PO Q8H (every 8 hours).
21. Oxycodone 5 mg/5 mL Solution Sig: One (1)  PO Q4H (every 4
hours) as needed for pain.
22. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
23. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 4 doses: 4 doses, START AFTER TID DOING FINISHED.
24. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
25. Haldol 5 mg/mL Solution Sig: 1-2 MG Injection every six (6)
hours as needed for agitation.
26. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
27. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1970**] - [**Hospital1 1559**]

Discharge Diagnosis:


s/p Rollover Motor vehicle crash
Injuries:
1. Left radio-ulnar Fx (open),
2. Left ribs [**1-5**] Fx, with 1-5 2 fx locations,
3. Multiple R rib fx with R7 with 2 fx,
4. Comminuted R scapula, L scapula body fx,
5. Left distal clavicle, comminuted L proximal humerus
(displaced),
6. Spinous processes of T5-8, [**10-6**], R transverse processes
T2,4,5, 7. T8 body fx, T12 wedge, L5 compression fx;
8. Right orbital wall fractures


Discharge Condition:
Good


Discharge Instructions:
The antibiotic will continue until ex-fix removed

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks.
Call [**Telephone/Fax (1) 2537**] for an appointment.

Please follow up with Plastics Hand clinic in 2 weeks. Call [**Telephone/Fax (1) 40054**] for an appointment.

Please follow up with Dr. [**Last Name (STitle) 1005**], Orthopedics in 2 weeks.
Call [**Telephone/Fax (1) 9769**] for an appointment.

Please follow up in [**Hospital 8095**] clinic in 2 weeks, call
[**Telephone/Fax (1) 253**] for an appointment.
{'Other open fractures of distal end of radius (alone),Open dislocation of radioulnar (joint), distal,Other specified open wounds of ocular adnexa,Closed fracture of unspecified part of upper end of humerus,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of eight or more ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of other facial bones,Closed fracture of phalanx or phalanges of hand, unspecified,Closed fracture of scapula, other,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Long-term (current) use of insulin,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle'}


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 Rollover motor vehicle crash

PRESENT ILLNESS: 63 yo male s/p rollover motor vehicle crash, high speed with
ejection, unrestrained driver, +EtOH. Initial GCS 14. He was
taken to an area hospital and found to have bilateral
pneumothoraces with left hemothorax.

MEDICAL HISTORY: HTN

MEDICATION ON ADMISSION: Lisinopril

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH 

### Response:
{'Other open fractures of distal end of radius (alone),Open dislocation of radioulnar (joint), distal,Other specified open wounds of ocular adnexa,Closed fracture of unspecified part of upper end of humerus,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of eight or more ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Closed fracture of other facial bones,Closed fracture of phalanx or phalanges of hand, unspecified,Closed fracture of scapula, other,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Long-term (current) use of insulin,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle'}
