CHIEF COMPLAINT: 

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4297**] is a 33-year-old
male who was a restrained passenger in a 110 mile per hour
motor vehicle versus tree collision in [**Hospital3 4298**] on
[**2132-7-8**].  The driver in the same vehicle was dead on
arrival.

MEDICAL HISTORY: History of drug abuse and ethanol
abuse.

MEDICATION ON ADMISSION: None.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has recently moved back to
[**Hospital3 4298**] where his family lives from [**Hospital1 8**].  He
is a journalist on a local paper and is a member of a band.
History of drug abuse and ethanol abuse.
Open fracture of astragalus,Closed fracture of unspecified part of neck of femur,Other, mixed, or unspecified drug abuse, unspecified,Open wound of forehead, without mention of complication,Open wound of knee, leg [except thigh], and ankle, complicated,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle
Fx astragalus-open,Fx neck of femur NOS-cl,Drug abuse NEC-unspec,Open wound of forehead,Open wnd knee/leg-compl,Loss control mv acc-psgr
Admission Date:  [**2132-7-9**]       Discharge Date:

Date of Birth:   [**2098-11-23**]       Sex:  M

Service:  Orthopaedic Surgery

HISTORY OF PRESENT ILLNESS:  [**Known firstname **] [**Known lastname 4297**] is a 33-year-old
male who was a restrained passenger in a 110 mile per hour
motor vehicle versus tree collision in [**Hospital3 4298**] on
[**2132-7-8**].  The driver in the same vehicle was dead on
arrival.

The patient was transferred by med-flight from [**Hospital6 4299**] to the [**Hospital1 188**].  By report, he was awake and alert at the outside
hospital.  He was then sedated and intubated.  He was noted
to be tachycardic and hypotensive on arrival at [**Hospital1 346**].  Evidence of multiple fractures and
dislocations.

He was admitted to [**Hospital1 69**] on
[**2132-7-9**]; initially under the service of the Trauma Team.

PAST MEDICAL HISTORY:   History of drug abuse and ethanol
abuse.

MEDICATIONS ON ADMISSION:  None.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  The patient has recently moved back to
[**Hospital3 4298**] where his family lives from [**Hospital1 8**].  He
is a journalist on a local paper and is a member of a band.
History of drug abuse and ethanol abuse.

PHYSICAL EXAMINATION ON PRESENTATION:  On initial
examination, his blood pressure was in the 170s systolic over
the 80s diastolic, with a heart rate in the 140s.  He arrived
sedated and intubated.  There was a 4-inch laceration on the
right forehead which was stapled in the Emergency Department.
The trachea was midline.  No obvious facial deformities were
noted.  Lungs were clear to auscultation bilaterally.  No
crepitus was noted.  Heart had a regular rate and rhythm.
Normal first heart sound and second heart sound.  The abdomen
was soft and flat.  The pelvis was stable.  Back was negative
for stepoff or deformities.  Rectal examination was
heme-negative with normal tone.  Examination of the
extremities revealed multiple long-bone fractures and
dislocations.  The left leg was shortened and internally
rotated.  The left ankle had a gross deformity noted with an
open wound posteriorly.  Pulses were palpable.  The right
ankle had a gross deformity with dopplerable pulses and an
open wound.  Positive swelling to posterior thigh.  Left hip
posterior dislocation.  Examination of the upper extremity
revealed normal range of motion with no gross deformities.
Pulses were palpable.  Capillary refill time was brisk.

RADIOLOGY/IMAGING:  X-rays revealed AP view of the pelvis
showed a left hip posterior dislocation.  The pelvic ring was
intact.  Left calcaneous fracture with talus dislocation.
[**Last Name (un) 4300**] class II subtalar dislocation.  Right nondisplaced
femoral neck fractures were noted.  Right [**Last Name (un) 4300**] class IV
subtalar dislocation.

A chest x-ray was negative.

PERTINENT LABORATORY DATA ON PRESENTATION:  White blood cell
count was 15.5, hematocrit was 29.2, platelets were 212,00.
PT was 14.8, PTT was 27.5, INR was 1.5.  Sodium was 140,
potassium was 3.7, chloride was 11, bicarbonate was 19, blood
urea nitrogen was 12, creatinine was 0.6, blood glucose
was 162.  Lactate was 5.2.  Urinalysis was clean and
negative.  Ethanol level was 63.

HOSPITAL COURSE:  [**Known firstname **] [**Known lastname 4297**] was admitted to the [**Hospital1 1444**] Trauma Service under the
attending Dr. [**Last Name (STitle) **].

Initially, he was fluid resuscitated in the Emergency
Department with crystalloid and blood products.  He was noted
to have bilateral open ankle fractures which were reduced
along with a left hip posterior dislocation which was
reduced.  Extremities were splinted.  A cervical collar was
placed.

On the day of admission, the patient received 7 liters of
crystalloid; consisting of 4 liters of lactated Ringer's, 3
liters of normal sterile saline; 3 units of packed red blood
cells were transfused.  One unit of fresh frozen plasma was
transfused.

The Orthopaedic Surgery Service team was consulted.  The
patient was taken to the operating room for the following
procedures:  Right femoral intramedullary nail/femoral neck
open reduction with internal fixation; incision and drainage
of bilateral ankle fractures with open reduction/internal
fixation of the left talus, right talectomy.  These
procedures were performed for a right femoral neck fracture,
right femoral shaft fracture, bilateral talar fractures, open
grade II.  External fixation was placed to the patient's
bilateral lower extremities.

The surgery was performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**].  Estimated
blood loss was 1200 cc.  The urine output was 550 cc.
Intravenous fluids were 6 liters in.  The patient was sent to
the Surgical Intensive Care Unit in stable condition.  The
patient remained intubated with a cervical collar placed.
His pupils were equal, round, and reactive; although sluggish
at 3 mm.  The patient was aggressively hydrated.  A CT scan
was planned to rule out any source of bleeding.  The patient
was empirically placed on broad spectrum antibiotic coverage.
The patient was placed on a morphine sulfate and propofol
drip.  He remained tachycardic with a regular rhythm.

On postoperative day one, the patient remained sedated and
intubated.  He had been receiving a banana bag, Protonix, and
Lovenox, as well as Ativan.  Serial hematocrits were
followed.

Laboratory data on postoperative day one included a white
blood cell count of 11.4, hematocrit was 31.5, platelets
were 162,000.  Sodium was 135, potassium was 4.3, chloride
was 106, bicarbonate was 23, blood urea nitrogen was 11,
creatinine was 0.8, blood glucose was 141.  Lactate was 2.8.
Calcium was 1.14, magnesium was 1.8.  ALT was 101, AST
was 304, alkaline phosphatase was 27.

The plan was to wean the patient off the ventilator.  His
urine output was good.  He was hemodynamically stable.  He
was continued on the intravenous Kefzol.  An inpatient
clinical nutrition assessment was obtained on [**7-10**].

Pin site wound care was begun on postoperative day two,
consisting of half-strength hydrogen peroxide b.i.d.  The
Orthopaedic team followed as a consultation service.  On this
day, the patient spiked a temperature of 102.7.  Late on
postoperative day two, the patient was successfully
extubated.  He was alert and following commands.  Pain
control regimen was changed to a patient-controlled
analgesia.  Lovenox was continued for deep venous thrombosis
prophylaxis.  His cervical collar remained in place.

On postoperative day three, the patient was transferred to
the floor with the plan to clear the cervical spine the
following day.  He was transferred to the floor extubated.
After the patient was alert, examination revealed a decreased
light touch sensation and motor sensation to the left lower
extremity.  It was felt that this deficit was likely
secondary to sciatic nerve palsy after his left hip posterior
dislocation which was successfully reduced in the Emergency
Department upon admission.  His neurologic and motor status
was closely followed thereafter.

The patient continued to spike fevers to 101.4 on
postoperative day four.

A Neurology Service consultation was obtained for the
patient's left foot weakness.  Examination was limited by the
presence of external fixation, but the pattern was felt to be
consistent with a peripheral lesion.  A sensory distribution
encompasses peroneal and tibial distributions (from the
lesion to sciatic or L5 nerve root), and the saphenous is
spared.  Given that the patient had no back pain and the left
hip was displaced posteriorly, injury to the sciatic nerve
seemed most likely.  The Neurology Service recommended
electromyogram/nerve conduction studies once the patient was
more stable to give some prognostic information; mostly
determining if the nerve is functionally transected.  If the
patient regained function prior to that testing, then the
testing would not be necessary.

On [**2132-8-14**], Physical Therapy team involvement was
begun.  The patient tolerated transfers using his upper
extremities well.  Pin care was performed as stated above.
The patient received a continuous passive motion machine
which he tolerated for 0 to 30 minutes for 1.5 hours for his
right lower extremity.

On [**2132-7-17**], an Addiction Service consultation was
obtained.  The patient was transferred to the Orthopaedic
Surgery Service under the attending, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**].  The
patient began to get more comfortable gradually moving his
legs.  He continued to work with Physical Therapy.  Due to
the patient's open fractures, he did continue to receive
wound care b.i.d. to left and right foot and ankle wounds.
The left ankle wound exhibited some skin edge necrosis.  No
gross purulence was expressed.  The patient was tolerating a
regular diet and using the urinal at the bedside.  The
patient continued to perform successful out of bed to chair
transfers.  Pain control was reasonably well tolerated with
oral Percocet.  A first-step mattress was obtained to provide
additional protective measures for the prevention of pressure
ulcerations.  The patient was voiding adequately.  He was
tolerating an oral diet well.  Pain control was adequate on
p.o.  Local wound care to the heels and lower legs was
continued.  The patient remained stable.  The left heel had
an eschar that was gradually resolving with time.  External
fixation remained intact.  Pin sites showed no evidence of
local infection.

On [**2132-7-27**], the patient Plastic Surgery team was
consulted for their input regarding possible procedures for
closure of the patient's bilateral open wounds to the lower
extremities.  The patient's staples were removed on [**2132-7-28**].  The plan was that the patient would probably need skin
graft procedures performed when the patient returned to the
operating room for Orthopaedic Surgery revisions in three
weeks.  The patient was placed in Balkan frame.  His
weightbearing status remained nonweightbearing on the
bilateral lower extremities with full weightbearing on the
upper extremities.  He was allowed to perform out of bed to
wheelchair transfers, which he did frequently and
successfully.

On postoperative day 26 ([**2132-8-4**]), the patient's left
heel was debrided at the bedside by the Plastic Surgery team
who planned to place a vacuum assisted closure device then to
promote granulation tissue over the patient's left heel
because of some tendon exposure.  The plan was for future
skin graft procedure.  The patient was instructed on the
self-administration of Lovenox injections.  He understood and
performed this successfully.  The patient was also instructed
on performing his own pin care.  Again, he understood and
performed this with good results.

On [**2132-8-8**], the patient was doing well with his vac
system placed to his left heel.  The Plastic Service
performed a sponge change on this day with note of good
granulation tissue forming, but with tendon still exposed.
The patient still complained numbness and decrease to light
touch sensation to the left lower extremity; as described
previously.  This was consistent with the patient's baseline
status post transfer to the floor.  At this time, the patient
had been afebrile for approximately one week.

On [**2132-8-14**], Case Management (which had been closely
following the patient) noted that the patient did have a
Medicaid number effective as of that date.  Discharge
planning had begun in terms of search for acceptable skilled
nursing facilities, needed secondary to the patient's
bilateral nonweightbearing status.  He also had a vacuum
assisted closure device and the bilateral external fixation
system.

On [**2132-8-19**], a CT examination of the right foot was
obtained which revealed a third metatarsal-base fragment
(corresponding to a palpable prominence on the patient's
dorsal foot).  Comminuted fractures of the anterior process
of the talus, cuboid, third cuneiform, metatarsals 3, 4,
and 5.  A small plantar rim fracture of the base of the
second metatarsal.  Talar fragments were displaced medially
and inferiorly into the tarsal tunnel over the flexor
hallucis longus muscle and the neurovascular bundle.

On [**2132-8-22**], the patient remained with bilateral
external fixators to the lower extremities with a vac
dressing to the left heel; which functioned well with scant
serosanguineous drainage, and no apparent leaks.  The plan
was for the external fixation system to be in for a total of
approximately three months.  On this day, the vac sponge was
changed by the Plastic Service team, who noted excellent
coverage of the previously exposed Achilles tendon.
Additional vac therapy was instituted to insure adequate
granulation tissue coverage over the tendon before any
Plastic Surgery procedure.

On [**2132-9-1**], the patient was brought to the operating
room for a split-thickness skin graft from his left thigh to
be placed on the patient's left heel to cover the open wound.
He tolerated the procedure well without complications and was
transferred from the operating room to the Postanesthesia
Care Unit with stable vital signs, and a vascular status
intact.  For additional details, please see the corresponding
Operative Report.  Again, a vac dressing was placed to the
patient's left heel and left there for five days.  The
patient was temporarily placed on a patient-controlled
analgesia for pain control postoperatively.  Intravenous
Kefzol was continued.

On hospital day 57 ([**2132-9-4**]), the patient's vac was
functioning well with no apparent leaks.  The right heel
medial aspect exhibited scant purulence with compression.  It
was nontender.  There was no surrounding or ascending
erythema.  No evidence of cellulitis.  Normal saline
wet-to-dry dressing changes b.i.d. were instituted.
Antibiotics were continued.  Discharge planning issues
remained due to the patient's ambulatory status and insurance
issues.

On [**2132-9-9**] (on hospital day 62), the patient was
placed on Ancef and levofloxacin antibiotics.  He continued
to perform his own pin care, Lovenox injections.  The patient
was out of bed to wheelchair frequently.  The right heel
wound at the medial aspect of the ankle had an eschar which
was beginning to sluff with underlying pink epithelialized
tissue.  No purulence or malodor was noted.  The pin sites
remained clean without signs of infection.  The patient's
split-thickness skin graft donor site from the left thigh
remained viable with no evidence of infection.

On hospital day 65 (on [**2132-9-12**]), the patient's eschar
at the right medial field was debrided at the bedside.  The
patient tolerated this procedure well.  A black eschar was
noted to be covering the wound bed of mixed granular and
fibrotic tissue.

On [**2132-9-22**], the patient returned to the operating
room for external fixation removal bilaterally with
application of splints to the legs.  This procedure was
performed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] and was tolerated well.  Please
refer to the corresponding Operative Note for details.

On [**2132-9-24**], the wounds looked clean.  The dressing
change regimen consisted of xeroform dressing over the right
wound with normal saline wet-to-dry dressing changes for the
remainder.  The heel wound needed to epithelialize prior to
any additional surgical procedures to be performed.  The
patient was to remain nonweightbearing bilaterally.  The
fixation appeared to be stable.  The right medial ankle wound
still had some fibrotic tissue as well as some granulation
tissue.  No purulence, malodor, or surrounding/ascending
erythema was noted.  The right lateral midfoot wound had a
beefy red granular base.  However, it was exquisitely tender
upon dressing changes.  There was no purulence.  The left
posterior heel had an eschar with a proximal area consisting
of erythematous but epithelializing regions.  No bulla.  No
purulence noted.  Other pin sites were clean and dry without
signs of infection or drainage.  The patient was placed on
bilateral bivalve casts to facilitate wound inspection and
dressing changes.  He was to remain nonweightbearing
bilaterally until the next surgical procedure; at least,
which is removal of osseus fragments at the right foot and
perhaps the right knee.

The plan was for this to be scheduled in mid-[**Month (only) **].  The
patient was to call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] office (telephone
number [**Telephone/Fax (1) 4301**]) to arrange an appointment.  The plan was
also for the patient to make a Neurology appointment in early
[**Month (only) **] for possible electromyogram or nerve conduction
studies to assess the patient's sciatic nerve palsy on the
left lower extremity.

According to Physical Therapy, the patient was stable for
discharge home; assuming that his house was wheelchair
assessable.  However, it was not, so it was deemed that the
only safe option was for Mr. [**Known lastname 4297**] to be discharged to a
rehabilitation or skilled nursing facility.  Case Management
was involved in trying to secure an appropriate facility.
Local wound care change regimen was performed as described
above.

The patient was deemed stable for discharge to a
rehabilitation/skilled nursing facility with
self-administration of Lovenox injections.  He was to remain
nonweightbearing bilaterally.  He may use a wheelchair.
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] and Neurology as described
above.

CONDITION AT DISCHARGE:  Condition on discharge was stable.

DISCHARGE STATUS:  To rehabilitation/skilled nursing
facility.




                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 4302**]
MEDQUIST36

D:  [**2132-9-25**]  19:32
T:  [**2132-9-25**]  20:02
JOB#:  [**Job Number 4303**]


Admission Date:  [**2132-12-3**]       Discharge Date:  [**2132-10-1**]

Date of Birth:   [**2098-11-23**]       Sex:  M

Service:

HOSPITAL COURSE:  The patient is a 34 year old male, status
post motor vehicle accident on [**2132-7-9**], status post
talectomy on the right foot and bilateral ....... here for a
right tibiocalcaneal fusion and a right iliac bone graft and
internal hardware placement.

The patient tolerated the procedure well.  On postoperative
day number one, he had a maximum temperature of 101.5 that
spontaneously defervesced.  He was maintained on intravenous
antibiotics throughout the course of his stay.  His incision
was clean, dry and intact.

The patient was seen by physical therapy and, after plain
films were reviewed, it was deemed appropriate to allow the
patient to have weightbearing as tolerated on the left lower
extremity with a walker boot in place and nonweightbearing on
the right ankle.  He was discharged to rehabilitation on an
AFO boot and is to follow up with Dr. [**Last Name (STitle) 284**] in two
weeks.  Dr. ...... will be following him as an outpatient
regarding his sciatic nerve issues.






Dictated By:[**Name8 (MD) 4385**]
MEDQUIST36

D:  [**2132-12-5**]  14:52
T:  [**2132-12-5**]  15:17
JOB#:  [**Job Number 4386**]


Admission Date:  [**2132-7-9**]       Discharge Date:  [**2132-10-1**]

Date of Birth:   [**2098-11-23**]       Sex:  M

Service:

ADMISSION DIAGNOSIS:
IM roding of right femur, open reduction and internal
fixation of right femoral head rod left talus, right
caliectomy, ________ bilateral ankles, right talus fracture
dislocation, left posterior acetabular fracture dislocation,
left femur posterior dislocation.

HISTORY OF PRESENT ILLNESS:  As per previous discharge
summary.

HOSPITAL COURSE:  Since the previous discharge summary there
have been no significant changes to the patient's physical
examination.  The skin graft of the right medial ankle
continues to heal well.  The patient's bilateral lower
extremities are without evidence of infection.  There is no
swelling or discharge from any of the wound sites.  The
patient is doing well.

FOLLOW UP INSTRUCTIONS:  As per previous discharge summary.
The patient is nonweight bearing both legs.

MEDICATIONS:  Acetaminophen 325 mg po q 4 to 6 hours,
Bisacodyl 10 mg q.h.s. prn, Cefalexin 500 mg po q 6 hours
times two weeks, Docusate sodium 100 mg po b.i.d. prn, iron
sulfate 325 mg po q.d., Gabapentin 100 mg po t.i.d.,
Lorazepam 0.5 mg po q 6 hours prn, Miconazole apply 2% powder
TP prn.  Oxycodone, Acetaminophen one tab po q 4 to 6 hours
prn.  Pantoprazole 40 mg po q.d., morphine sulfate 2 mg po q
4 hours prn.






                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) **]

Dictated By:[**Last Name (NamePattern1) 4348**]
MEDQUIST36

D:  [**2132-10-1**]  08:03
T:  [**2132-10-1**]  08:57
JOB#:  [**Job Number 4349**]
{'Open fracture of astragalus,Closed fracture of unspecified part of neck of femur,Other, mixed, or unspecified drug abuse, unspecified,Open wound of forehead, without mention of complication,Open wound of knee, leg [except thigh], and ankle, complicated,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in 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: 

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 4297**] is a 33-year-old
male who was a restrained passenger in a 110 mile per hour
motor vehicle versus tree collision in [**Hospital3 4298**] on
[**2132-7-8**].  The driver in the same vehicle was dead on
arrival.

MEDICAL HISTORY: History of drug abuse and ethanol
abuse.

MEDICATION ON ADMISSION: None.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has recently moved back to
[**Hospital3 4298**] where his family lives from [**Hospital1 8**].  He
is a journalist on a local paper and is a member of a band.
History of drug abuse and ethanol abuse. 

### Response:
{'Open fracture of astragalus,Closed fracture of unspecified part of neck of femur,Other, mixed, or unspecified drug abuse, unspecified,Open wound of forehead, without mention of complication,Open wound of knee, leg [except thigh], and ankle, complicated,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle'}
