CHIEF COMPLAINT: s/p Motor vehicle crash

PRESENT ILLNESS: 40 y/o female restrained driver with + EtOH who was involved in
a single car crash on [**2165-5-30**]. +air bag deployment. +LOC. She
was taken to an area hospital where she was reportedly alert and
awake with no discernable neurological defecits and underwent
imaging studies which revealed a small subdural hematoma,
pulmonary contusion, possible C7 transverse process fracture,
pelvic fracture, and open fracture of right foot.  She was
transferred to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Multiple sclerosis

MEDICATION ON ADMISSION: Copaxone 20mg SC'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
GCS 15
BP 120/palp  HR 84  RR 18  T 99.2
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-17**] bilaterally   EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ FAST neg
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-18**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH
Closed Colles' fracture,Closed fracture of pubis,Contusion of lung without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Multiple sclerosis,Injury to liver without mention of open wound into cavity laceration, unspecified,Open fracture of metatarsal bone(s),Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Street and highway accidents
Colles' fracture-closed,Fracture of pubis-closed,Lung contusion-closed,Fx c7 vertebra-closed,Subdural hem-brief coma,Multiple sclerosis,Liver lacerat unspcf cls,Fx metatarsal-open,Loss control mv acc-driv,Accid on street/highway
Admission Date:  [**2165-5-30**]              Discharge Date:   [**2165-6-4**]

Date of Birth:  [**2124-6-8**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:
[**2165-5-30**]  Inferior vena cava filter placement

[**2165-5-30**] Irrigation and debridement open fracture/Open reduction
internal fixation of Lisfranc fractur with percutaneous K-wires.


History of Present Illness:
40 y/o female restrained driver with + EtOH who was involved in
a single car crash on [**2165-5-30**]. +air bag deployment. +LOC. She
was taken to an area hospital where she was reportedly alert and
awake with no discernable neurological defecits and underwent
imaging studies which revealed a small subdural hematoma,
pulmonary contusion, possible C7 transverse process fracture,
pelvic fracture, and open fracture of right foot.  She was
transferred to [**Hospital1 18**] for further care.


Past Medical History:
Multiple sclerosis

Social History:
+EtOH

Family History:
Noncontributory

Physical Exam:
Upon admission:
GCS 15
BP 120/palp  HR 84  RR 18  T 99.2
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-17**] bilaterally   EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ FAST neg
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-18**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 [**4-22**] throughout; but could not
effectively test the right arm/leg due to splints in place. No
pronator drift

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Toes downgoing bilaterally

Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin




Pertinent Results:
[**2165-5-31**] 12:00AM   GLUCOSE-131* UREA N-7 CREAT-0.6 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-27 ANION GAP-11
[**2165-5-31**] 12:00AM   CALCIUM-8.5 PHOSPHATE-2.6* MAGNESIUM-1.8
[**2165-5-31**] 12:00AM   PHENYTOIN-13.5
[**2165-5-31**] 12:00AM   WBC-6.2# RBC-3.64* HGB-11.3* HCT-34.6* MCV-95
MCH-31.1 MCHC-32.7 RDW-13.5
[**2165-5-31**] 12:00AM   PLT COUNT-228
[**2165-5-31**] 12:00AM   PT-13.6* PTT-28.9 INR(PT)-1.2*
[**2165-5-30**] 04:00AM   ASA-NEG ETHANOL-17* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-5-30**] 04:00AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG

CT HEAD W/O CONTRAST  [**2165-5-30**] 2:35 PM

Comparison is made with study performed at 455 hours on the same
day.

The size of the acute left parietal subdural hematoma is
unchanged. A low-density right frontal extra-axial collection is
also unchanged. There is soft tissue swelling in the right
frontal region. Ventricles and sulci are stable and age
appropriate.

No bony abnormality is seen. Scattered ethmoid opacification is
noted.

IMPRESSION:

No change in size of subdural hematoma.

CT HEAD W/O CONTRAST  [**2165-5-31**] 9:47 AM
CT HEAD: The size of the acute left parietal subdural hematoma
is unchanged. A low-density right frontal extra-axial collection
appears slightly more prominent, though without new hyperdense
material, which is consistent with a hygroma. Soft tissue
swelling along the right frontal region is improved compared to
the earliest study; however, there appears to be new left
temporal soft tissue swelling. No underlying fracture is seen.
Mild mucosal thickening is noted in the sphenoid and left
maxillary sinuses along with opacification of some of the
ethmoid air cells.

IMPRESSION: Acute left parietal subdural hematoma, unchanged.
Slight increase in right frontal low-density collection,
consistent with hygroma. New left temporal soft tissue swelling,
without evidence of underlying fracture.

CT LOW EXT W/O C RIGHT  [**2165-5-30**] 2:35 PM
FINDINGS:

Numerous comminuted fractures are present throughout the right
mid and hind foot.

Multiple comminuted fractures of the first, second, and third
metatarsal bases, with lateral and dorsal dislocation of the
second metatarsal base, are consistent with a Lisfranc
fracture-dislocation. The fracture at the base of the second
metatarsal also extends into the metatarsal shaft. The medial
and lateral cuneiforms also demonstrate extensively comminuted
fractures. At the medial cuneiform, a large fracture fragment is
inferomedially displaced. The middle cuneiform is relatively
intact, with only several small avulsion fragments.

Through the body of the cuboid, there is an oblique, comminuted
fracture. The navicular is spared, and intact. The calcaneus
demonstrates a longitudinal, moderately anteromedially displaced
fracture along its plantar surface. The talus is intact, without
fracture. The ankle mortise is symmetric, and the distal tibia
and fibula are intact.

Finally, an oblique, intra-articular fracture extends across the
base of the fourth proximal phalanx. The remaining phalanges are
spared.

Extensive soft tissue edema and fat stranding is present
circumferentially about the hind, mid, and forefoot. There is no
evidence of soft tissue entrapment in any of the fracture
fragments. Supporting muscles and tendons are largely
unremarkable.

IMPRESSION:

1. Findings consistent with Lisfranc fracture-dislocation, with
lateral displacement of the 2nd-5th metatarsals, but without
displacement of the first metatarsal. Extensively comminuted
fractures of the 1st-3rd metatarsal bases, the medial and
lateral cuneiforms, and the cuboid. Additional fractures of the
fourth metatarsal base, the calcaneus and the fourth proximal
phalanx.


Brief Hospital Course:
She was admitted to the Trauma Service. Because of her injuries
Neurosurgery and Orthopedics were consulted. She was taken to
the operating room for right femoral percutaneous placement of
inferior vena cava filter, irrigation and debridement open
fracture and open reduction internal fixation of Lisfranc
fracture with percutaneous K-wires. There were no intraoperative
complications. She was placed in a bivalve cast on her right leg
and is non weight bearing on that extremity.

Her small left subdural was managed non operatively, she was
loaded with Dilantin and will need to remain on this for a total
of 10 days. She remained in a hard cervical collar because of
the C7 transverse process fracture. An MRI was done to assess
for ligamentous injury; this was ruled out, the cervical collar
was removed.

Postoperatively she remained in the Trauma ICU for several days
and was then transferred to the regular nursing unit. She was
initially on IV narcotics for pain control and was later changed
to long acting narcotics with shorter acting ones for
breakthrough pain. Her pain was adequately controlled with this
regimen.

She was evaluated by Physical and Occupational therapy who have
recommended rehab following her acute hospital stay. She was
also seen by Social work for her alcohol related issues
surrounding the motor vehicle crash.


Medications on Admission:
Copaxone 20mg SC'

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H:PRN as needed
for breakthrough pain.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
10. Dulcolax 10 mg Suppository Sig: One (1)  Rectal once a day
as needed for constipation.
11. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
s/p Motor vehicle crash
Small left subdural hematoma
C7 tranverse process fracture
Right rib fracture
Left pulmonary contusion
Grade I liver laceration
Left superior/inferior pubic rami fracture
Right ankle/foot: open lis franc injury, calcaneal/cuboid
fracture
Right distal radius fracture


Discharge Condition:
Good


Discharge Instructions:
NEUROSURGERY D/C INSTRUCTIONS
NOTIFY DR. [**Last Name (STitle) **], NEUROSURGERY ([**Telephone/Fax (1) 1669**]) IMMEDIATELY IF
YOU EXPERIENCE ANY OF THE FOLLOWING:

-New onset of tremors or seizures
-Any confusion or change in mental status
-Any numbness, tingling, weakness in your extremities
-Pain or headache that is continually increasing or not relieved
by pain medication











Followup Instructions:




Follow up in [**Hospital 5498**] clinic in 2 weeks with Dr[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7376**] &
[**Doctor Last Name 1005**], call [**Telephone/Fax (1) 1228**] for an appointment.

Follow up in with Dr. [**Last Name (STitle) **], Trauma Surgery, in 2 weeks, call
[**Telephone/Fax (1) 600**] for an appointment.

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE 2 FOLLOW-UP APPOINTMENTS
WITH DR. [**Last Name (STitle) **] TO BE SEEN IN:

APPOINTMENT IN 8 WEEKS
PLEASE INFORM THE OFFICE THAT YOU WILL NEED TO HAVE
FLEXION/EXTENSION X-RAYS OF C-SPINE PRIOR TO THIS APPOINTMENT

APPOINTMENT IN 4 WEEKS
PLEASE INFORM THE OFFICETHAT YOU WILL NEED TO HAVE A NONCONTRAST
BRAIN CAT SCAN PERFORMED PRIOR TO THIS APPOINTMENT






Completed by:[**2165-6-4**]
{"Closed Colles' fracture,Closed fracture of pubis,Contusion of lung without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Multiple sclerosis,Injury to liver without mention of open wound into cavity laceration, unspecified,Open fracture of metatarsal bone(s),Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Street and highway accidents"}


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: 40 y/o female restrained driver with + EtOH who was involved in
a single car crash on [**2165-5-30**]. +air bag deployment. +LOC. She
was taken to an area hospital where she was reportedly alert and
awake with no discernable neurological defecits and underwent
imaging studies which revealed a small subdural hematoma,
pulmonary contusion, possible C7 transverse process fracture,
pelvic fracture, and open fracture of right foot.  She was
transferred to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Multiple sclerosis

MEDICATION ON ADMISSION: Copaxone 20mg SC'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
GCS 15
BP 120/palp  HR 84  RR 18  T 99.2
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-17**] bilaterally   EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+ FAST neg
Extrem: Warm and well-perfused.
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-18**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH 

### Response:
{"Closed Colles' fracture,Closed fracture of pubis,Contusion of lung without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Multiple sclerosis,Injury to liver without mention of open wound into cavity laceration, unspecified,Open fracture of metatarsal bone(s),Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Street and highway accidents"}
