CHIEF COMPLAINT: 54 F s/p MVC w/ multi-trauma

PRESENT ILLNESS: Ms. [**Known lastname **] is an unfortunate woman who was involved in a
high-energy MVC. She was an unrestrained driver who drove
head-on into a tractor [**Last Name (un) 28523**] at high speed (50-55mph). Her
immediate injuries included:
-aortic transection
-Left distal femur fracture
-left ischial fracture
-right distal radius/ulna fracture
-left metacarpal fractures
-open left tib/fib fracture.

MEDICAL HISTORY: DM2, CAD w/ + stress test, obesity

MEDICATION ON ADMISSION: Insulin, ASA.

ALLERGIES: Iodine; Iodine Containing / Heparin Agents

PHYSICAL EXAM: Pt was medflighted from [**Location (un) 3844**] and was intubated and
sedated on arrival.

FAMILY HISTORY: 

SOCIAL HISTORY: Lives alone.
Injury to thoracic aorta,Traumatic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Disruption of internal operation (surgical) wound,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of leg, except foot,Unspecified septicemia,Disseminated candidiasis,Pressure ulcer, heel,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Severe sepsis,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Open supracondylar fracture of femur,Open fracture of upper end of tibia alone,Closed fracture of lower end of radius with ulna,Closed fracture of metacarpal bone(s), site unspecified,Anticoagulants causing adverse effects in therapeutic use,Morbid obesity,Injury to brachial blood vessels,Closed fracture of ischium,Closed fracture of two ribs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Cardiac pacemaker in situ
Injury thoracic aorta,Traumatic shock,Iatrogen CV infarc/hmrhg,React-oth int ortho dev,Disrup internal op wound,Lower extremity embolism,Cellulitis of leg,Septicemia NOS,Disseminated candidiasis,Pressure ulcer, heel,Pseudomonal pneumonia,Int inf clstrdium dfcile,Atrial fibrillation,Severe sepsis,Mv collision NOS-driver,Supracondyl fx femur-opn,Fx upper end tibia-open,Fx low radius w ulna-cl,Fx metacarpal NOS-closed,Adv eff anticoagulants,Morbid obesity,Injury brachial vessels,Fracture ischium-closed,Fracture two ribs-closed,DMII wo cmp nt st uncntr,Hypertension NOS,Status cardiac pacemaker
Admission Date:  [**2166-11-20**]              Discharge Date:   [**2167-4-15**]

Date of Birth:  [**2112-1-3**]             Sex:   F

Service: SURGERY

Allergies:
Iodine; Iodine Containing / Heparin Agents

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
54 F s/p MVC w/ multi-trauma

Major Surgical or Invasive Procedure:
[**2166-11-20**]
-Laparoscopic gastrostomy tube placement.
[**2166-11-20**]
-Closed reduction of splinting of left distal radius and
ulna fracture.
-Irrigation debridement, extensive of left supracondylar
femur fracture.
-Irrigation debridement, extensive to bone of left
Schatzker 6 tibial plateau fracture.
-Closed reduction application external fixator left
supracondylar femur fracture.
-Closed reduction application external fixator
left Schatzker 6 tibial plateau fracture
-Closed reduction left metacarpal fractures and CMC joint.
[**2166-11-24**]
-Removal of external fixation left lower extremity.
-Irrigation and debridement down to bone open left femur
fracture.
-Irrigation and debridement down to bone open left tibia
fracture.
-Open reduction and internal fixation left femur with [**Last Name (un) 101**]
plate, 13 hole.
-Open reduction and internal fixation tibia with [**Last Name (un) 101**]
plate.
-Open reduction and internal fixation right distal radius.
-Open reduction and internal fixation right distal ulna.
-Open reduction and internal fixation left fourth, fifth
and third metacarpocarpal dislocations.
[**2166-11-25**]
IVC filter placement.

Left femoral thrombectomy and bovine patch
angioplasty/intraoperative angiogram.
[**2166-12-12**]
Removal of femoral bovine patch and replacement
with saphenous vein patch after artery debridement. Left
lower extremity angiography.
[**2166-12-23**]
Evacuation of left groin hematoma, debridement of
subcutaneous tissue and placement of a VAC dressing.
[**2166-12-26**]
1. Debridement of necrotic wounds of left abdomen, groin and
thigh.
2. Debridement of right wrist wound.
[**2167-1-14**]:
1.  Irrigation and debridement down to bone of open wounds.
2.  Removal of fixation hardware, radial and ulnar plates.
3.  Placement of expanding external fixator, right wrist.
[**2167-1-21**]:
Irrigation, debridement and part layered closure
as well as VAC change to wounds of right arm and left abdomen
and leg.
[**2167-1-25**]:
Exploration of left groin wound, evacuation of
clot. Examination and then repacking of left groin wound.
[**2167-2-11**]:
Irrigation and debridement of left knee
wound.
[**2167-2-24**]:
1.  Incision and drainage of left knee wound with exploration
    of left knee joint.
2.  Removal of implant, left knee.
3.  Removal of external fixator, right wrist.
[**2167-3-2**]:
1.  Irrigation and debridement left wound dehiscence down to
    bone with removal of necrotic bone areas.
2.  Removal of hardware from distal femur and proximal tibia
    in the form of 3.5 mm screws and locking screws.
[**2167-3-6**]:
Irrigation and debridement and replacement of
vacuum dressing.
[**2167-3-11**]:
1.  Irrigation and debridement, left wound.
2.  Removal of femoral [**Last Name (un) 101**] plate.
3.  Placement of external fixator.
4.  Placement of vacuum dressing.
[**2167-3-20**]:
1.  Irrigation and debridement left leg (irrigation and
    debridement of skin, muscle and bone).
2.  Adjustment of external fixator left leg.
[**2167-3-30**]
1. Irrigation and debridement left leg (irrigation and
debridement of skin, muscle and bone).

History of Present Illness:
Ms. [**Known lastname **] is an unfortunate woman who was involved in a
high-energy MVC. She was an unrestrained driver who drove
head-on into a tractor [**Last Name (un) 28523**] at high speed (50-55mph). Her
immediate injuries included:
-aortic transection
-Left distal femur fracture
-left ischial fracture
-right distal radius/ulna fracture
-left metacarpal fractures
-open left tib/fib fracture.

Past Medical History:
DM2, CAD w/ + stress test, obesity

Social History:
Lives alone.

Physical Exam:
Pt was medflighted from [**Location (un) 3844**] and was intubated and
sedated on arrival.


Pertinent Results:
[**2166-11-20**] 06:55PM   FIBRINOGE-244
[**2166-11-20**] 06:55PM   PT-12.7 PTT-23.4 INR(PT)-1.1
[**2166-11-20**] 06:55PM   PLT COUNT-286
[**2166-11-20**] 06:55PM   WBC-17.3* RBC-4.27 HGB-13.0 HCT-37.1 MCV-87
MCH-30.4 MCHC-35.0 RDW-13.9
[**2166-11-20**] 06:55PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2166-11-20**] 06:55PM   AMYLASE-45
[**2166-11-20**] 06:55PM   UREA N-27* CREAT-1.2*
[**2166-11-20**] 06:58PM   GLUCOSE-481* LACTATE-3.5* NA+-138 K+-4.2
CL--101 TCO2-24
[**2166-11-20**] 06:58PM   GLUCOSE-481* LACTATE-3.5* NA+-138 K+-4.2
CL--101 TCO2-24
[**2166-11-20**] 07:00PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2166-11-20**] 07:00PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035

Brief Hospital Course:
This is the discharge summary of a patient who expired under the
care of the Trauma Service after a prolonged hospitalization for
multiple severe injuries.  On [**2166-11-20**] she was a restrained
driver in a head-on [**Last Name (un) 8886**] between her car and a
tractor-[**Last Name (un) 28523**].  After a prolonged extrication she was
transferred to the [**Hospital1 18**] where she was found to have the
following injuries:

-thoracic aortic tear at the level of the proximal descending
aorta
-R [**9-20**] rib fracture
-L ischium fracture
-R distal radius & distal ulna fractures
-L 4th metacarpal fracture
-L femur fracture
-L open tibia/fibula fractures

She had multiple surgical procedures throughout her hospital
stay. These included:
[**11-20**]: endovascular stent placed in thoracic aorta. ex-fix L
femur/L tibia, CRPP L metacarpal. closed reduction/splint R
radius/ulna
[**11-24**]: [**Last Name (un) 101**] plate L tibia, [**Last Name (un) 101**] plate L femur, ORIF R distal
radius/ distal ulna, CRPP R MC fx's, R volar orthoplast, L ulnar
gutter orthoplast.
[**11-25**]: IVC filter
[**11-26**]: iliac artery stented. L femoral embolectomy and bovine
patch angioplasty
[**11-28**]: open trach. No PEG [**2-12**] body habitus.
[**12-12**]: removal of femoral bovine patch and replacement with
saphenous vein patch
[**12-23**]: I&D L knee and primary closure, I&D R wrist
[**12-26**]: I&D L abdomen/groin and R wrist
[**1-14**]: I&D L groin, [**Last Name (un) **] and exfix of R wrist
[**1-21**]: partial closure L groin. I&D R wrist. Washout L knee.
[**1-24**]: exploration L groin wound & evacuation of clot.
[**Date range (1) 63248**]: multiple washouts L knee, with ultimate removal of
all hardware and placement of a spanning external fixator, VAC
placement.

Her hospital course was complicated by the following events:
-SEPTIS/PNEUMONIA: Multiple episodes of enterococcal bactermia
and pseudomonal pneumoniam treated with appropriate antibiotics
and resolved.

-HIT+
--found on [**12-2**].
--Received 9 week course of lepirudin gtt anticoagulation.
--Maintained on fondaparinux prophylaxis afterwards.

-POSTERIOR CIRCULATION CVA
--found on [**12-15**]
--neurology consulted, no intervention performed other than
continued anti-coagulation.

-RISING DIRECT BILIRUBIN.
--[**12-4**]: hepatology consulted
--us dopplers: patent vessels, hyperechogenic liver
--[**12-6**]: CT & RUQ US showed no dilated ducts, s/p choly, no
abscesses
--ERCP?
--[**12-7**] GI consulted. Poor ERCP candidate, likely cholestatic
from drug rxn.
--Resolved.

-ATRIAL FIBRILLATION.
--early in hospital course had rapid AF --> cardioversion -->
bradycardic arrest --> atropine
--[**2-15**] transferred to SICU for rapid AF with resulting
hypotension. Chemically cardioverted with Amiodarone,
transferred back to floor. She was maintained on amiodarone and
instructed to follow-up with cardiology as an outpatient.

-L KNEE WOUND INFECTION: her left knee wound had prolonged
drainage and multiple I+D's after the original ORIF on [**2166-11-24**].
The organisms found on multiple wound cultures were pseudomonas
(ceftazadime sensitive) and MRSA. She had multiple courses of
antibiotics and VAC dressing changes to treat these infections.
Eventually all hardware was removed and she was placed back in a
spanning external fixator ([**2167-3-11**]). VAC dressing treatment was
continued.

-R WRIST WOUND DEHISCENCE: The patient's R wrist wound dehisced
after her original ORIF. The hardware was removed for concern of
infection (though all intra-op cultures were negative) and an
external fixator was placed. This was later removed on [**2167-2-24**].
The wound was treated with prolonged VAC dressing.

-L GROIN WOUND-- During her original stent grafting of her
thoracic aorta, she sustained an injury to her left femoral
artery during access, which led to thrombosis. This required
thrombectomy and stenting in the cardiac catheterization
laboratory. Ultimately she also required a thrombectomy and a
bovine patch repair of her left femoral artery, but
unfortunately this became infected and was replaced with a vein
patch (for details see above and dictated operative notes). The
soft tissue over the patient's left groin eventually became
necrotic due to her morbid obesity and her tenous cardiovascular
status when she presented. She underwent multiple debridements
and VAC placements. Femoral vessels were never exposed. She was
brought to the operating room once on [**2167-1-25**] for concern of
increased bleeding around the VAC, but the femoral vessels were
intact and no source of vigorous bleeding was identified. She
was maintained on bleeding precautions and her VAC dressing
outputs were monitored carefully throughout her course. This
wound has been stable and treated with a VAC since exploration
on [**2167-1-25**].

-PROLONGED ICU COURSE: A tracheostomy ([**2166-11-28**]) and
laparoscopic G-tube ([**2167-12-15**]) were placed. She was maintained on
tube feeds and followed by the nutritional service.

Ms. [**Known lastname **] continued to require frequent wound care and washouts
of her left leg wound.  On [**2167-3-31**] she became acutely confused,
bradycardic, hypotensive and hypothermic and required transfer
to the ICU.  She required broad spectrum antibiotics, mechanical
ventillation and pressor support.  At the time of her admission
to the ICU, her left leg grew pseudomonas, VRE, and
enterococcus.  After more than a week reequiring norepinephrine
for blood pressure support, amputation of the left leg was
discussed.  Ms. [**Known lastname **] had very explicit advanced directives
against this very procedure.  After many discussions with her
healthcare proxy, it was determined that Ms. [**Known lastname **] would not want
amputation even if it meant that it would save her life.  On
[**2167-4-15**] she still required norepinephrine and was making no
clinical improvement.  She was made CMO by her healthcare proxy.

Medications on Admission:
Insulin, ASA.

Discharge Disposition:
Expired

Discharge Diagnosis:
-Thoracic aorta tear, s/p stent graft.
-Left groin pseudoaneurysm and infected bovine patch
angioplasty.
-Left Grade III open Schatzker 6 tibial plateau fracture--> VAC.
-Left Grade III open supracondylar femur fracture--> VAC.
-Right distal radius ulnar fracture, w/ wound dehiscence--> VAC.
-Left fourth, third and fifth metacarpocarpal dislocations in
the hand.
-Non-healing necrotic left groin wounds--> VAC.
-DM2
-atrial fibrillation
-prolonged ventilator dependence s/p tracheostomy
-prolonged poor nutrition s/p g-tube placement


Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none
{'Injury to thoracic aorta,Traumatic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Disruption of internal operation (surgical) wound,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of leg, except foot,Unspecified septicemia,Disseminated candidiasis,Pressure ulcer, heel,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Severe sepsis,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Open supracondylar fracture of femur,Open fracture of upper end of tibia alone,Closed fracture of lower end of radius with ulna,Closed fracture of metacarpal bone(s), site unspecified,Anticoagulants causing adverse effects in therapeutic use,Morbid obesity,Injury to brachial blood vessels,Closed fracture of ischium,Closed fracture of two ribs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Cardiac pacemaker in situ'}


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: 54 F s/p MVC w/ multi-trauma

PRESENT ILLNESS: Ms. [**Known lastname **] is an unfortunate woman who was involved in a
high-energy MVC. She was an unrestrained driver who drove
head-on into a tractor [**Last Name (un) 28523**] at high speed (50-55mph). Her
immediate injuries included:
-aortic transection
-Left distal femur fracture
-left ischial fracture
-right distal radius/ulna fracture
-left metacarpal fractures
-open left tib/fib fracture.

MEDICAL HISTORY: DM2, CAD w/ + stress test, obesity

MEDICATION ON ADMISSION: Insulin, ASA.

ALLERGIES: Iodine; Iodine Containing / Heparin Agents

PHYSICAL EXAM: Pt was medflighted from [**Location (un) 3844**] and was intubated and
sedated on arrival.

FAMILY HISTORY: 

SOCIAL HISTORY: Lives alone. 

### Response:
{'Injury to thoracic aorta,Traumatic shock,Iatrogenic cerebrovascular infarction or hemorrhage,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Disruption of internal operation (surgical) wound,Arterial embolism and thrombosis of lower extremity,Cellulitis and abscess of leg, except foot,Unspecified septicemia,Disseminated candidiasis,Pressure ulcer, heel,Pneumonia due to Pseudomonas,Intestinal infection due to Clostridium difficile,Atrial fibrillation,Severe sepsis,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Open supracondylar fracture of femur,Open fracture of upper end of tibia alone,Closed fracture of lower end of radius with ulna,Closed fracture of metacarpal bone(s), site unspecified,Anticoagulants causing adverse effects in therapeutic use,Morbid obesity,Injury to brachial blood vessels,Closed fracture of ischium,Closed fracture of two ribs,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Cardiac pacemaker in situ'}
