CHIEF COMPLAINT: trauma s/p MVC

PRESENT ILLNESS: 51 F passenger side of Jeep involved in MVC rollover confused at
scene and intubated at OSH for decreased mental status.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Involved in accident with her husband, son and son's girlfriend
[**Name (NI) **] patient's family drinks alcohol socially
Closed fracture of pubis,Acute respiratory failure following trauma and surgery,Flail chest,Traumatic shock,Injury to renal vein,Closed fracture of lumbar vertebra without mention of spinal cord injury,Delirium due to conditions classified elsewhere,Traumatic pneumothorax without mention of open wound into thorax,Contusion of lung without mention of open wound into thorax,Acute posthemorrhagic anemia,Concussion with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Other fluid overload,Open wound of finger(s), without mention of complication,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Open wound of forearm, without mention of complication,Closed fracture of scapula, other
Fracture of pubis-closed,Ac resp flr fol trma/srg,Flail chest,Traumatic shock,Injury renal vein,Fx lumbar vertebra-close,Delirium d/t other cond,Traum pneumothorax-close,Lung contusion-closed,Ac posthemorrhag anemia,Concussion w coma NOS,Urin tract infection NOS,Adrenal gland injury-cl,Fluid overload NEC,Open wound of finger,Loss control mv acc-psgr,Open wound of forearm,Fx scapula NEC-closed
Admission Date:  [**2189-7-8**]              Discharge Date:   [**2189-7-18**]

Date of Birth:  [**2137-9-8**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
trauma s/p MVC

Major Surgical or Invasive Procedure:
[**2189-7-9**] Examination under anesthesia and closed treatment of
pelvic ring fracture


History of Present Illness:
51 F passenger side of Jeep involved in MVC rollover confused at
scene and intubated at OSH for decreased mental status.

Past Medical History:
none

Social History:
Involved in accident with her husband, son and son's girlfriend
[**Name (NI) **] patient's family drinks alcohol socially

Family History:
Non-contributory

Physical Exam:
On admission:

HR: 114 BP: 104p Resp: 20 O(2)Sat: 100 Normal

HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light midface stable
C. collar placed
Chest: Left-sided chest wall crepitus rhonchorous breath
sounds bilaterally
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: Decreased rectal tone
Extr/Back: +2 DP bilaterally +2 radial pulse bilaterally
obvious degloving of the left proximal wrist elbow no active
bleeding no obvious deformity of the right upper extremity
or bilateral lower extremities
Skin: Warm and dry, No rash
Neuro: Sedated and not moving any extremities


Pertinent Results:
[**2189-7-8**] admission imaging

 CT Head:
 No evidence of acute intracranial hemorrhage

 CT Cspine: negative

CT OF THE CHEST:  Patient is intubated with the endotracheal
tube terminating
approximately 4 cm above the carina.  An NG tube is seen
coursing through the
esophagus with its tip terminating in the stomach.  No
mediastinal, axillary,
or hilar lymphadenopathy.

Substantial subcutaneous emphysema is noted at the left chest
tube insertion
site.  Small left pneumothorax is seen.  There are small
bilateral pleural
effusions.  Opacity in the left upper lobe measuring 1.7 x 1.0
cm is
identified (2:11) which could be related to contusion.
Additional areas of
ground-glass opacity (2:27) in the right lung as well as (2:22
and 2:25),
potentially sequela of trauma.

CT ABDOMEN:  Liver, gallbladder, and spleen are unremarkable.
Bilateral
kidneys enhance and excrete contrast symmetrically.  Cyst seen
at the superior
pole of the left kidney.  There is an outpouching of the left
renal vein
inferiorly concerning for pseudoaneurysm (2:59).  It measures
1.5 x 1.8 x 1.3
cm.  There is also a small amount of retroperitoneal fluid
tracking along the
pararenal fat planes bilaterally concerning for hemorrhage.
Additionally, the
right adrenal gland is enlarged measuring 3.0 x 3.6 cm.

The small and large bowel are unremarkable.  The pancreas is
normal in
appearance.

CT OF THE PELVIS:  There is a trace amount of pelvic free fluid.
 Bladder and
uterus are normal in appearance.  No pelvic or inguinal
adenopathy is noted.

BONES:  Multiple fractures are noted including the left-sided
superior and
inferior pubic rami (2:112), right pubic symphysis.  In
addition, a fracture
of the sacral ala is present on the left (2:89) as well as S1 on
the right.
Fracture of the left L1, L2, bilateral L3, L4 and right L5
transverse
processes identified.  In addition, rib fractures of the left
first, second,
third, fourth, fifth, sixth, seventh, eighth and eleventh left
ribs are
present as well as the left scapula (2:13) and right second rib.
 There are
posterior and anterolateral left rib fracures at 5 consecutive
levels.

IMPRESSION:
1.  Left renal vein pseudoaneurysm, presumably acute.
2.  Enlargement of the right adrenal gland conpatible with
hemorrhage in the trauma setting.
3.  Retroperitoneal hematoma seen bilaterally, likely due to
combination of right adrenal hemorrhage, left renal vein
pseudoaneurysm, transverse process fractures.
5.  Multiple fractures as described above, noting 5 consecutive
levels of
posterior and anterolateral fractures on the left raising
possibility of flail chest.  Lumbar transverse process and left
scapular fractures.
4.  Left-sided chest tube with small pneumothorax.
5.  Left upper lobe pulmonary contusion.



[**2189-7-8**] 06:51PM   WBC-13.3* RBC-2.54* HGB-8.4* HCT-25.7*
MCV-101* MCH-33.2* MCHC-32.7 RDW-13.7
[**2189-7-8**] 06:51PM   PLT COUNT-197
[**2189-7-8**] 06:51PM   PT-12.2 PTT-26.1 INR(PT)-1.1
[**2189-7-8**] 06:51PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2189-7-8**] 06:51PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2189-7-8**] 06:51PM URINE  RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-1 RENAL EPI-<1
[**2189-7-8**] 06:51PM URINE  HYALINE-4*
[**2189-7-8**] 06:51PM URINE  MUCOUS-RARE
[**2189-7-8**] 06:51PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2189-7-8**] 06:51PM   LIPASE-148*
[**2189-7-8**] 06:51PM   UREA N-8 CREAT-0.8
[**2189-7-8**] 07:08PM   freeCa-0.90*
[**2189-7-8**] 07:08PM   HGB-8.7* calcHCT-26 O2 SAT-94 CARBOXYHB-3 MET
HGB-0
[**2189-7-8**] 07:08PM   GLUCOSE-126* LACTATE-1.2 NA+-135 K+-3.1*
CL--115*
[**2189-7-8**] 07:08PM   PO2-104 PCO2-46* PH-7.21* TOTAL CO2-19* BASE
XS--9 COMMENTS-GREEN TOP
[**2189-7-8**] 10:06PM   TYPE-ART PO2-510* PCO2-38 PH-7.31* TOTAL
CO2-20* BASE XS--6
[**2189-7-8**] 11:05PM   PLT COUNT-148*
[**2189-7-8**] 11:05PM   WBC-10.6 RBC-3.76*# HGB-12.0# HCT-36.0#
MCV-96 MCH-31.8 MCHC-33.2 RDW-15.8*
[**2189-7-8**] 11:05PM   CALCIUM-6.6* PHOSPHATE-2.5* MAGNESIUM-1.6
[**2189-7-8**] 11:05PM   GLUCOSE-138* UREA N-9 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12

Labs on discharge:

[**2189-7-17**] 09:00AM BLOOD WBC-12.6* RBC-3.02* Hgb-9.3* Hct-29.2*
MCV-97 MCH-30.9 MCHC-31.9 RDW-16.7* Plt Ct-431
[**2189-7-16**] 06:00AM BLOOD Glucose-96 UreaN-13 Creat-0.4 Na-141
K-3.9 Cl-101 HCO3-36* AnGap-8
[**2189-7-16**] 06:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0
[**2189-7-17**] 06:30AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2189-7-17**] 06:30AM URINE RBC-1 WBC-12* Bacteri-MOD Yeast-NONE
Epi-1 TransE-<1
[**2189-7-17**] 06:30AM URINE CastGr-1*
[**2189-7-17**] 06:30AM URINE AmorphX-RARE
[**2189-7-17**] 06:30AM URINE Mucous-RARE


Brief Hospital Course:
The patient was admitted to the trauma ICU for close management
of her multiple traumatic injuries. She remained intubated until
HD#2 and required multiple blood transfusions initially. After
extubation she required Bipap for a short period of time as well
as some diuresis and her respiratory status improved so she was
transferred to the floor on [**2189-7-13**].

Her hospital course is summarized by systems below:

Neuro: She had altered mental status upon arrival and was
intubated for airway protection. She was extubated on HD2 and
was initially delirious and agitated. She required
antipsychotics and intermittent benzodiazepines for inital
concern for alcohol withdrawal. However, her mental status began
to improve and after further questioning of the patient and her
family no significant alcohol history was found. Benzos were
discontinued at that time and she was started on [**Hospital1 **] seroquel
which helped with her agitation. By the time of discharge she
was alert with intermittent confusion and lethargy, but calm and
cooperative. Her cognitive function was evaluated by
occupational therapy who recommended ongoing cognitive therapy
after discharge for her traumatic brain injury/concussion.

CV: She was initially hypotensive on admission likely due to
traumatic shock. She required initially resuscitation with
multiple units of RBC's and fluids. Her hemodynamics stablized
within 28 hours and she was extubated. While her blood pressure
was stable after extubation, she was persistently tachycardia
which was thoguht to be due to agitiation/delirium and given
that her hematocrit was stable and she had no signs of
infection. She was started on lopressor and clonidine and
transferred to the floor. On the floor she remained
hemodynamically stable and her clonidine was discontinued on
[**2189-7-16**].

Pulm: She had extensive bilat rib fractures, a L chest tube was
placed for pneumothorax. It was kept to suction. She was
initially ventilated and weaned to extubation on HD2. After
extubation fluid overload was evident on chest xray and
clinically and she was diuresed intermittently with lasix, to
which she responded well. When alert, pulmonary toileting and
incentive spirometry were encouraged. Her supplemental oxygen
was weaned as tolerated and she remained without respiratory
compromise. On [**7-17**] she had a chest xray which showed moderate
left sided pleural effusion but decrease in size from prior
xrays with no evidence of infiltrates or pneumothorax.

GI: She was kept NPO, with an OG tube. tube feeds were started
while in the ICU. After extubation her diet was advanced as
tolerated as her mental status improved. She was also started on
a bowel regimen given the administration of narcotics for pain
managment.

GU: Her UOP was closely monitored as a foley catheter was
inserted on admission. Her UOP responded appropriately to
initial resuscitation and her foley catheter was removed on
[**2189-7-14**] at which time she voided without difficulty. On [**7-16**] a
u/a was positive for infection and she was started on 5 days of
cipro starting [**7-17**].

MSK: She had extensive pelvic fractures, for which orthopedic
surgery took her to the operating room on [**2189-7-9**] to stress the
pelvis and check the stability. Her pelvis was determined to be
stable (see operative note by Dr. [**Last Name (STitle) 1005**] for details). She
was then made weightbearing as tolerated on bilateral lower
extremities and mobilized out of bed with physical therapy.
She also had multiple spinous process fractures for which no
intervention was needed aside from pain control.
She had a large degloving injury to her L forearm. Plastic
surgery was consulted and did a bedside washout and closure. [**Hospital1 **]
wet-to-dry dressing changes were performed thereafter, and f/u
was scheduled for after discharge for future management of the
injury and possible split thickness skin graft.

Prophylaxis: She was placed on pneumoboots and SC heparin for
DVT prophylaxis.

Social work was involved with the patient's course and her
family throughout her hospitalization given the circumstances
around the accident.

Ms. [**Known lastname **] is currently afebrile with stable vital signs. She is
tolerating a regular diet and voiding adequate amounts of urine.
She is without respiratory compromise. Her mental status is
improving and she remains alert and oriented, with intermittent
confusion. She is being discharged to rehab to continue her
recovery.

Medications on Admission:
none

Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Heparin 5000 UNIT SC TID
3. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
4. Quetiapine Fumarate 12.5 mg PO BID:PRN agitiation
5. Senna 1 TAB PO BID
6. Docusate Sodium 100 mg PO BID
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
8. Ipratropium Bromide Neb 1 NEB IH Q6H
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
10. Valsartan 320 mg PO DAILY
11. Rosuvastatin Calcium 20 mg PO DAILY
12. Potassium Chloride 40 mEq PO DAILY
Hold for K >
13. Hydrochlorothiazide 25 mg PO DAILY
Hold for sBP<100
14. Fish Oil (Omega 3) 1000 mg PO DAILY


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
s/p MVC:
1. Concussion
2. Stable pelvic fractures
3. Multiple rib fractures (Left [**1-11**], 11 rib fractures. Posterior
and anterior fractures at 5 levels, Right 2nd rib fracture)
4. Left upper lobe pulmonary hematoma
5. Small left apical pneumothorax
6. L1-L5 transverse process fractures of the spine
7. Left scapula fracture
8. Left renal vein pseudo aneurysm
9. Left forearm degloving injury
10. Acute blood loss anemia
11. Acute respiratory failure
12. Traumatic shock
13. Urinary tract infection


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital after being involved in a
motor vehicle accident. You sustained multiple injuries
including broken ribs, collapse in your lung, broken pelvis,
broken left scapula, breaks in the bony prominences of your
spine, and a left forearm "degloving injury". You also sustained
a concussion from your accident.

You were taken to the operating room by the orthopedic surgeons
to evaluate your pelvic fractures which were determined to be
stable. You may bear weight as tolerating on your legs.

Your left arm wound will require daily dressing changes with a
wet to dry dressing.  Keep your left arm dry and do not get
wound wet. Please follow up with the Plastic surgeons at the
appointment scheduled for you regarding further treatment for
you left arm wound.

You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedating, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal anti-inflammatory drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.

Followup Instructions:
Department: SPINE CENTER
When: MONDAY [**2189-7-20**] at 4:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD [**Telephone/Fax (1) 31444**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*You will need Xrays prior to this visit so please arrive 15
mins early to [**Hospital Ward Name **] CENTER [**Location (un) 551**] Radiology

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2189-7-30**] at 2:30 PM
With; Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
*You will need a chest x-ray prior to this appointment. Please
go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.

Department: ORTHOPEDICS
When: TUESDAY [**2189-8-4**] at 9:20 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: ORTHOPEDICS
When: TUESDAY [**2189-8-4**] at 9:40 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Closed fracture of pubis,Acute respiratory failure following trauma and surgery,Flail chest,Traumatic shock,Injury to renal vein,Closed fracture of lumbar vertebra without mention of spinal cord injury,Delirium due to conditions classified elsewhere,Traumatic pneumothorax without mention of open wound into thorax,Contusion of lung without mention of open wound into thorax,Acute posthemorrhagic anemia,Concussion with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Other fluid overload,Open wound of finger(s), without mention of complication,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Open wound of forearm, without mention of complication,Closed fracture of scapula, other'}


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: trauma s/p MVC

PRESENT ILLNESS: 51 F passenger side of Jeep involved in MVC rollover confused at
scene and intubated at OSH for decreased mental status.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Involved in accident with her husband, son and son's girlfriend
[**Name (NI) **] patient's family drinks alcohol socially 

### Response:
{'Closed fracture of pubis,Acute respiratory failure following trauma and surgery,Flail chest,Traumatic shock,Injury to renal vein,Closed fracture of lumbar vertebra without mention of spinal cord injury,Delirium due to conditions classified elsewhere,Traumatic pneumothorax without mention of open wound into thorax,Contusion of lung without mention of open wound into thorax,Acute posthemorrhagic anemia,Concussion with loss of consciousness of unspecified duration,Urinary tract infection, site not specified,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Other fluid overload,Open wound of finger(s), without mention of complication,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Open wound of forearm, without mention of complication,Closed fracture of scapula, other'}
