CHIEF COMPLAINT: s/p Motor vehicle crash

PRESENT ILLNESS: 22-year-old male restrained driver, who was involved in a motor
vehicle crash. He was speaking in the field; was brought to an
area hospital and ultimately intubated electively. He was found
to have a tension pneumothorax, initially treated by needle
decompression followed by placement of a left chest
tube. A chest x-ray suggested the presence of the stomach
within the left chest, supporting the diagnosis of a
traumatic diaphragmatic eventration. He was hemodynamically
stable. He was also noted to have a comminuted closed femur
fracture with intact distal pulses. He was transferred
emergently to [**Hospital1 18**] for further care given his injuries.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 96.2F, Tm 99.8F, BP 131/89, HR 115, RR 24, Sat 99%RA
GENERAL: Well-appearing, no acute distress
HEENT: Mild anisocoria, mucus membranes moist, no sinus
tenderness
NECK: Supple, trachea midline
CARD: Tachycardic, normal S1/S2, no m/r/g
RESP: Clear to auscultation bilaterally
ABD: Soft, non-distended. Mildly tender to palpation over
surgical scar. No rebound/guarding. Normal bowel sounds.
EXT: LLE in brace, RLE leg wrapped; Right forearm in cast, LUE
wrapped; non-pitting edema of UE, LE
NEURO: Difficult to perform exam. Able to move all extremities,
alert and oriented x 3. Fluent speech that
PSYCH: Denies SI/HI. Endorses occasional visual and auditory
hallucinations (no command auditory hallucinations).

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Graduate student at Suffock.  Patient graduated from [**University/College **].  He is a talented musician.
Closed fracture of shaft of femur,Injury to diaphragm, with open wound into cavity,Other closed fractures of distal end of radius (alone),Drug-induced delirium,Systemic inflammatory response syndrome, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Essential thrombocythemia,Other and unspecified alcohol dependence, unspecified,Open fracture of unspecified part of fibula with tibia,Hepatitis, unspecified
Fx femur shaft-closed,Diaphragm injury-open,Fx distal radius NEC-cl,Drug-induced delirium,SIRS, NOS,Traum pneumothorax-close,Mv coll w oth obj-driver,Adv eff analgesics NEC,Cardiac dysrhythmias NEC,Essntial thrombocythemia,Alcoh dep NEC/NOS-unspec,Fx tibia w fib NOS-open,Hepatitis NOS
Admission Date:  [**2115-12-18**]              Discharge Date:   [**2116-1-10**]

Date of Birth:  [**2093-6-30**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:

[**2115-12-18**] Exploratory lap and repair of diaphragmatic injury
[**2115-12-18**] Washout and debridement of left open tibia fracture to
bone; closed reduction left supracondylar femur fracture with
manipulation; closed reduction left proximal tibia fracture with
manipulation; application multiplanar external fixator; IM nail
left femur and closed reduction right wrist fracture with
manipulation.


History of Present Illness:
22-year-old male restrained driver, who was involved in a motor
vehicle crash. He was speaking in the field; was brought to an
area hospital and ultimately intubated electively. He was found
to have a tension pneumothorax, initially treated by needle
decompression followed by placement of a left chest
tube. A chest x-ray suggested the presence of the stomach
within the left chest, supporting the diagnosis of a
traumatic diaphragmatic eventration. He was hemodynamically
stable. He was also noted to have a comminuted closed femur
fracture with intact distal pulses. He was transferred
emergently to [**Hospital1 18**] for further care given his injuries.

Past Medical History:
None

Social History:
Graduate student at Suffock.  Patient graduated from [**University/College **].  He is a talented musician.

Family History:
Noncontributory

Physical Exam:
VITALS: T 96.2F, Tm 99.8F, BP 131/89, HR 115, RR 24, Sat 99%RA
GENERAL: Well-appearing, no acute distress
HEENT: Mild anisocoria, mucus membranes moist, no sinus
tenderness
NECK: Supple, trachea midline
CARD: Tachycardic, normal S1/S2, no m/r/g
RESP: Clear to auscultation bilaterally
ABD: Soft, non-distended. Mildly tender to palpation over
surgical scar. No rebound/guarding. Normal bowel sounds.
EXT: LLE in brace, RLE leg wrapped; Right forearm in cast, LUE
wrapped; non-pitting edema of UE, LE
NEURO: Difficult to perform exam. Able to move all extremities,
alert and oriented x 3. Fluent speech that
PSYCH: Denies SI/HI. Endorses occasional visual and auditory
hallucinations (no command auditory hallucinations).


Pertinent Results:
12/12/07CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial hemorrhage.
.
[**2115-12-18**] CT TORSO WITH INTRAVENOUS CONTRAST
IMPRESSION:
1. Stomach and spleen located within the thoracic cavity, very
concerning for extensive left diaphragmatic rupture, with
retraction.

2. Left lower lobe collapse/consolidation.

3. Patchy opacities predominantly at the right lung base, in the
setting of trauma likely represent parenchymal contusions;
aspiration is another diagnostic consideration.

3. Small amount of intraperitoneal air, an unusual finding in a
setting of blunt trauma, and free fluid, likely related to chest
tube placement, traversing the peritoneal space. While no bowel
injury is seen, this cannot be completely excluded. Comparison
with any CT done prior to the chest tube placement would be most
helpful if available.
.
[**2115-12-18**].  Left elbow film.
IMPRESSION: Extensively comminuted, intra-articular left
olecranon fracture.
.
[**2115-12-18**].  Left leg film.  IMPRESSION: Extensively comminuted
fractures of the distal femur and proximal tibia, with displaced
and angulated fractures of the proximal femur and fibula.
.
[**2116-1-1**].  Brain MRI. IMPRESSION: Normal study.
.
[**2116-1-2**] .  LENIs.  IMPRESSION: No ultrasonographic evidence of
DVT.
.
[**2116-1-1**]. Echo.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
No pericardial effusion. Resting tachycardia.

[**2116-1-10**]  WBC-9.3 RBC-4.44* Hgb-13.2* Hct-39.4* Plt Ct-844*
[**2116-1-10**] Glucose-163* UreaN-18 Creat-0.7 Na-138 K-4.3 Cl-96
HCO3-31
[**2116-1-10**] ALT-106* AST-23 LD(LDH)-258* AlkPhos-405* TotBili-0.8
[**2116-1-10**] 09:55AM BLOOD Albumin-4.0 Calcium-10.4* Phos-5.3*
Mg-2.0

Brief Hospital Course:
In summary, Mr. [**Known lastname **] is a 22 year old male admitted following
motor vehicle accident for multiple fractures and diaphragmatic
rupture.  Hospital course was complicated by delerium, peristent
tachycardia, and transaminitis.
.
S/p MVA.  Patient was admitted to the Trauma Service and taken
directly to the operating room for exploratory lap and repair of
his diaphragmatic injury. Orthopedics was consulted given his
multiple bone fractures; he was taken to the operating room for
washout and debridement of left open tibia fracture to bone;
closed reduction left supracondylar femur fracture with
manipulation; closed reduction left proximal tibia fracture with
manipulation; application multiplanar external fixator; IM nail
left femur and closed reduction right wrist fracture with
manipulation. There were no intraoperative complications.
.
Pain.  Patient had difficulty with pain control initially.  PCA
Dilaudid was initiated and the dose was quickly increased to
0.37 mg. Dilaudid 1-2 mg IV prn for rescue pain was also added
and he did seem to benefit from this. It was discussed with
patient and his mother that at some point long acting narcotics
would likely be initiated for long term pain control. He was
placed on an aggressive bowel regimen.  However, patient
developed delerium in setting of opioid use, so opioids were
discontinued and patient was started on ultram.  Tylenol is
being avoided due to elevated LFTs.  NSAIDs are being avoided
due to impaired bone healing.  Opioids are being avoided due to
recent delerium.  Pain was adequately controlled at time of
discharge on standing ultram.
.
Delerium.  Patient developed delerium during hospitalization.
It was felt to be due to opioid pain medications which were
stopped.  Patient was evaluated by neurology and psychiatry.
Vit B12, folate, TSH, RPR within normal limits. LP performed
[**1-1**] showed no evidence of infection.  EEG and Brain MRI were
normal.  He was placed on standing seroquel at night.  Opioids
were avoided.  Delerium resolved and patient was alert and
oriented on day of discharged.
.
Elevated transaminases. Likely multifactorial etiology,
including systemic inflammatory response, medications including
Zosyn. LFTs continue to trend down.  ALT peaked at 385 on [**1-3**],
AST peaked at 220 on [**12-31**], LDH peaked at 457 on [**1-1**].  Alk
Phos continued to trend up on discharge, likely secondary to
active bone remodeling. Acetaminophen was discontinued on [**1-1**].
Please check LFTs weekly until fully resolved.
.
Thrombocytosis.  Patient had elevated platelet count to 1.5
million, likely reactive thrombocytosis due to systemic
inflammatory state due to trauma and multiple operations.
Platelets were trending down and were 1 million at time of
discharge.
.
Tachycardia.  Patient had sinus tachycardia post-operatively to
the 150s, that was thought to be pain and stress related.  A PE
CT was done and was negative for PE.  Metoprolol was started to
prevent tachycardia-induced cardiomyopathy.  An echo was done
and was normal.  Metoprolol is being titrated down beginning on
[**1-5**].   Goal is to stop metoprolol as HR improves.   Overall
tachycardia is improving.
.
Insomnia.  Patient reported difficulty sleeping due to
discomfort, multiple braces/casts in place, etc.  He was getting
standing seroquel at night with minimal improvement.
Benzodiazepines and ambien were avoided due to delerium.  He was
given prn benadryl and standing seroquel.  Seroquel should
ultimately be stopped but patient is currently using it for
insomina.
.
Prophylaxis. Patient was maintained on Lovenox daily.  S/p
prophylactic IVC filter placement.
.
Communication. Patient and mother [**Telephone/Fax (1) 75595**].


Medications on Admission:
None

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous QD
().
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
6. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
7. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q 8H
(Every 8 Hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
s/p Motor vehicle crash
Right pulmonary contusion
Left diaphragmatic rupture
Left olecranon fracture
Left femoral shaft fracture
Left supracondylar femur fracture
Left proximal tibia fracture
Left distal radius fracture
Delirium, resolved


Discharge Condition:
Good. Patient is tolerating oral intake with assistance and able
to work effectively with physical therapy.


Discharge Instructions:
You were admitted to the hospital after your car accident. You
were found to have broken many bones and to have ruptured your
diaphragm. You were treated in surgery for your bone fractures
and your diaphragm rupture and have done well after surgery. You
also became quite confused after your surgery, which was thought
most likely secondary to your strong pain medications. After
your narcotic pain medications were stopped, your confusion
improved greatly.
.
Please take all your medications as prescribed. We have started
you on ultram as needed for pain.
.
If you have any symptoms of fevers, chills, night sweats,
shortness of breath, chest pain, lower extremity swelling, upper
extremity swelling, lightheadedness, or dizziness, please seek
immediate medical attention.


Followup Instructions:
Please follow-up with your primary care doctor Dr. [**First Name4 (NamePattern1) 4597**] [**Last Name (NamePattern1) 16801**].
His address office is: The Medical Group, Inc, [**Last Name (un) **],
[**Apartment Address(1) **], [**Hospital1 **], [**Numeric Identifier 26668**].  Please call him at [**Telephone/Fax (1) 10508**] to
schedule an appointment.
.
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, Thursday [**2120-1-23**]:10 PM. Call [**Telephone/Fax (1) 1228**] if you need to re-schedule your
appointment.  Please arrive 20 minutes early.  The office is
located on the [**Location (un) **] of [**Hospital Ward Name 23**] Clinical Center on the [**Hospital Ward Name 5074**] of [**Hospital1 **].
.
Follow up with Dr. [**Last Name (STitle) 519**], Trauma/Surgery in [**2115-2-3**] at
10 AM.  His office is located on the [**Location (un) 470**] of the [**Hospital Ward Name 23**]
Clinical Center on the [**Hospital Ward Name **] of [**Hospital1 18**].  Please call
[**Telephone/Fax (1) 6554**] if you need to re-schedule.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Closed fracture of shaft of femur,Injury to diaphragm, with open wound into cavity,Other closed fractures of distal end of radius (alone),Drug-induced delirium,Systemic inflammatory response syndrome, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Essential thrombocythemia,Other and unspecified alcohol dependence, unspecified,Open fracture of unspecified part of fibula with tibia,Hepatitis, unspecified'}


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: 22-year-old male restrained driver, who was involved in a motor
vehicle crash. He was speaking in the field; was brought to an
area hospital and ultimately intubated electively. He was found
to have a tension pneumothorax, initially treated by needle
decompression followed by placement of a left chest
tube. A chest x-ray suggested the presence of the stomach
within the left chest, supporting the diagnosis of a
traumatic diaphragmatic eventration. He was hemodynamically
stable. He was also noted to have a comminuted closed femur
fracture with intact distal pulses. He was transferred
emergently to [**Hospital1 18**] for further care given his injuries.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T 96.2F, Tm 99.8F, BP 131/89, HR 115, RR 24, Sat 99%RA
GENERAL: Well-appearing, no acute distress
HEENT: Mild anisocoria, mucus membranes moist, no sinus
tenderness
NECK: Supple, trachea midline
CARD: Tachycardic, normal S1/S2, no m/r/g
RESP: Clear to auscultation bilaterally
ABD: Soft, non-distended. Mildly tender to palpation over
surgical scar. No rebound/guarding. Normal bowel sounds.
EXT: LLE in brace, RLE leg wrapped; Right forearm in cast, LUE
wrapped; non-pitting edema of UE, LE
NEURO: Difficult to perform exam. Able to move all extremities,
alert and oriented x 3. Fluent speech that
PSYCH: Denies SI/HI. Endorses occasional visual and auditory
hallucinations (no command auditory hallucinations).

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Graduate student at Suffock.  Patient graduated from [**University/College **].  He is a talented musician. 

### Response:
{'Closed fracture of shaft of femur,Injury to diaphragm, with open wound into cavity,Other closed fractures of distal end of radius (alone),Drug-induced delirium,Systemic inflammatory response syndrome, unspecified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Other specified cardiac dysrhythmias,Essential thrombocythemia,Other and unspecified alcohol dependence, unspecified,Open fracture of unspecified part of fibula with tibia,Hepatitis, unspecified'}
