CHIEF COMPLAINT: s/p Motor vehicle crash

PRESENT ILLNESS: 52 y/o female who was an unrestrained backseat passenger
involved in a motor vehicle crash on [**2146-5-19**]. Denies loss of
consciousness. She presents with bifrontal headache, nausea and
right shoulder pain.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. s/p right eye cataract surgery
4. s/p C-section
5. h/o right frozen shoulder

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
BP: 108/53         HR: 78    R: 18      91% on 6L NC O2Sats
Gen: WD/WN, NAD.
HEENT: Pupils: 4->3 B/L       intact EOMs   bilateral
periorbital
ecchymosis
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital in [**Location (un) 86**], and date.
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension. Patient is
asking questions repetitively.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of lower end of radius with ulna,Closed fracture of other facial bones,Closed fracture of shaft of clavicle,Open wound of forehead, without mention of complication,Motor vehicle traffic accident of unspecified nature injuring passenger in motor vehicle other than motorcycle,Conjunctival hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia
Cl skull vlt fx w/o coma,Fracture two ribs-closed,Fx low radius w ulna-cl,Fx facial bone NEC-close,Fx clavicle shaft-closed,Open wound of forehead,Traffic acc NOS-pasngr,Conjunctival hemorrhage,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2146-5-20**]              Discharge Date:   [**2146-5-27**]

Date of Birth:  [**2093-2-27**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:
[**2146-5-20**] Suture facial laceration
[**2146-5-21**] Application of cast right arm


History of Present Illness:
52 y/o female who was an unrestrained backseat passenger
involved in a motor vehicle crash on [**2146-5-19**]. Denies loss of
consciousness. She presents with bifrontal headache, nausea and
right shoulder pain.


Past Medical History:
1. HTN
2. Hypercholesterolemia
3. s/p right eye cataract surgery
4. s/p C-section
5. h/o right frozen shoulder


Social History:
Married

Family History:
Noncontributory

Physical Exam:
Upon admission:
BP: 108/53         HR: 78    R: 18      91% on 6L NC O2Sats
Gen: WD/WN, NAD.
HEENT: Pupils: 4->3 B/L       intact EOMs   bilateral
periorbital
ecchymosis
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital in [**Location (un) 86**], and date.
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension. Patient is
asking questions repetitively.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-2**] throughout B/L lower
extremities
and throughout LUE. Strength 4+/5 RUE (limited by pain secondary
to right clavicle fracture). No pronator drift

Sensation: Intact to light touch bilaterally.

Reflexes: B  T  Br Pa Ac
Right     2+ 2+ 2+ 3+ 1+
Left      2+ 2+ 2+ 3+ 1+

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger


Pertinent Results:
CT HEAD W/O CONTRAST  [**2146-5-19**] 8:53 PM

FINDINGS: There are extensive facial fractures, which will be
detailed in the accompanying facial bone CT report. The overall
pattern is a central smash injury with a fracture extending over
the right frontal bone. The right side component extends through
and through of the inner and outer tables of the right frontal
sinus and over the roof of the right orbit. There is a minimally
depressed segment of approximately 1-2 mm of the right frontal
bone. There is resulting pneumocephalus most notable in the
basal right anterior cranial fossa. Air is also noted
ectopically located within the bilateral cavernous sinuses and
in the superior sagittal sinus posteriorly. Extensive soft
tissue swelling is noted over the facial structures as
anticipated. There is subcutaneous air over the forehead with a
soft tissue defect, likely laceration. No embedded radiopaque
foreign bodies are seen. There is a small cephalohematoma right
posteriorly at the vertex. The globes themselves are intact.
There are attenuated lenses consistent with cataracts.

Intracranially, there is a small extra-axial hematoma anterior
to the right frontal lobe. The configuration is most consistent
with a subdural subtype. No definite subarachnoid hemorrhage is
identified. The ventricles are midline and normal in size and
configuration. The cortical sulci and subarachnoid cisterns are
otherwise unremarkable. The [**Doctor Last Name 352**] matter-white matter interface
is well defined. There is no CT evidence of acute cortical
stroke.

IMPRESSION: Extensive facial fractures, which will be detailed
in the accompanying facial bone CT report. There is extension of
the facial fractures to involve in a depressed segment of the
right frontal bone as well. There is an associated small right
subdural hematoma anterior to the right frontal lobe with no
significant mass effect. Otherwise, no definite brain trauma
identified. Please note there is resulting pneumocephalus from
the extensive facial fractures.

CT C-SPINE W/O CONTRAST  [**2146-5-19**] 8:53 PM

FINDINGS: Extensive facial fractures are incidentally noted and
will be detailed in the facial bones CT report dictated
separately.

The vertebral bodies are intact without fracture. There is
marked disc space narrowing at C5-C6 and C6-C7. Marginal
osteophyte formation accompanies the changes at these levels
with no critical canal or neural foraminal stenosis identified.
The prevertebral soft tissues are within normal limits.
Extensive secretions are pooling in the posterior hypopharynx.
The remaining soft tissues of the neck are unremarkable. The
included lung apices are clear. There is a comminuted fracture
of the mid diaphysis of the right clavicle incompletely imaged.
Normal cervical lordosis is somewhat straightened likely due to
immobilization collar.

IMPRESSION: No cervical spine trauma as above. There is
pre-existing degenerative disease as detailed above. A right
clavicle fracture is incidentally noted. There are extensive
facial fractures incompletely imaged which will be detailed in
the accompanying facial bone CT report.

WRIST(3 + VIEWS) RIGHT  [**2146-5-20**] 8:07 AM

FINDINGS: Inner aspect of the distal radius that runs primarily
vertically and extends into the radiocarpal articular surface.
Separation of the ulnar styloid process is seen. Suggestion of
some degree of impaction on both the frontal and lateral views.

Of incidental note is a short fifth metacarpal. It is unclear
whether this is a congenital or possibly related to previous
trauma.

IMPRESSION: Distal radial fracture with avulsion of the ulnar
styloid process.

    Cardiology Report ECG Study Date of [**2146-5-24**]  11:33:30 AM


Sinus rhythm
Normal ECG
Since previous tracing of [**2146-5-20**], no significant change


  Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 194 82 [**Telephone/Fax (2) 78485**] 53




[**2146-5-20**] 05:05AM   GLUCOSE-195* UREA N-14 CREAT-0.7 SODIUM-143
POTASSIUM-3.7 CHLORIDE-111* TOTAL CO2-19* ANION GAP-17
[**2146-5-20**] 05:05AM   CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-2.1
[**2146-5-20**] 05:05AM   PHENYTOIN-14.4
[**2146-5-20**] 05:05AM   WBC-8.5 RBC-3.74*# HGB-11.5*# HCT-33.4*#
MCV-89 MCH-30.7 MCHC-34.4 RDW-13.6
[**2146-5-20**] 05:05AM   PLT COUNT-222
[**2146-5-19**] 08:53PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

Brief Hospital Course:
She was admitted to the Trauma Service. Neurosurgery,
Orthopedics and Plastic Surgery were consulted because of her
injuries. Her subdural was managed non operatively; she was
loaded with Dilantin and remained on this for a total of 7 days;
serial head CT and Physical exams were stable. She did complain
of intermittent dizziness. She will follow up in neurosurgery
clinic in 1 month for repeat imaging.

Orthopedics was consulted because of her right clavicle and
radius fractures; these were also managed nonoperative. She was
placed in a cast fro the radius fracture; a sling was
recommended for the clavicle fracture. She is to remain non
weight bearing on this extremity.

Her facial lacerations and facial fractures were evaluated by
Plastic Surgery. She will likely require operative intervention
of her facial fractures in the very near future; the lacerations
were sutured; the sutures were removed within 4 days.

She was evaluated by Physical therapy; initially she refused
treatment on several occasions. She did eventually agree to work
with rehab and was cleared for discharge to home with her
family.

Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
1) Small Right SDH
2) Pneumocephalus
3) Bilateral max sinuses & orbital wall fx R>L
4) Depressed segment R frontal bone
5) Inner & outer table fx thr R frontal sinus
6) Forehead laceration
7) Right clavicle fx, mildly displaced
8) Right rib [**1-31**] fx, mildly displaced
9) Right distal radial fx w/ avulsion of ulnar styloid process



Discharge Condition:
Good


Discharge Instructions:
You may experience intermittent dizziness and fatigue because of
your traumatic injuries. It is important that you continue to
walk several times throughout the day when you go home.

Return to the Emergency room if you develop any fevers, chills,
headache, worsening dizziness, chest pain, shortness of breath,
abdominal pain, nausea, vomiting, diarrhea and/or any other
symptoms that are concerning to you.

Wear the sling for comfort; do not bear any weight on your right
arm.

Followup Instructions:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics call, call
[**Telephone/Fax (1) 1228**] for an appointment.

Follow up with Plastic Surgery in [**12-29**] weeks, call [**Telephone/Fax (1) 5343**].

Follow up with Dr. [**First Name (STitle) **], Neurosurgery, in 1 month. Call
[**Telephone/Fax (1) 1669**] for an appointment.



Completed by:[**2146-5-27**]
{'Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of lower end of radius with ulna,Closed fracture of other facial bones,Closed fracture of shaft of clavicle,Open wound of forehead, without mention of complication,Motor vehicle traffic accident of unspecified nature injuring passenger in motor vehicle other than motorcycle,Conjunctival hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia'}


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 Motor vehicle crash

PRESENT ILLNESS: 52 y/o female who was an unrestrained backseat passenger
involved in a motor vehicle crash on [**2146-5-19**]. Denies loss of
consciousness. She presents with bifrontal headache, nausea and
right shoulder pain.

MEDICAL HISTORY: 1. HTN
2. Hypercholesterolemia
3. s/p right eye cataract surgery
4. s/p C-section
5. h/o right frozen shoulder

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
BP: 108/53         HR: 78    R: 18      91% on 6L NC O2Sats
Gen: WD/WN, NAD.
HEENT: Pupils: 4->3 B/L       intact EOMs   bilateral
periorbital
ecchymosis
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, hospital in [**Location (un) 86**], and date.
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension. Patient is
asking questions repetitively.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Married 

### Response:
{'Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of two ribs,Closed fracture of lower end of radius with ulna,Closed fracture of other facial bones,Closed fracture of shaft of clavicle,Open wound of forehead, without mention of complication,Motor vehicle traffic accident of unspecified nature injuring passenger in motor vehicle other than motorcycle,Conjunctival hemorrhage,Unspecified essential hypertension,Pure hypercholesterolemia'}
