CHIEF COMPLAINT: s/p Motor vehicle crash

PRESENT ILLNESS: 24 yo in rollover motor vehicle crash as unrestrained passenger
with
prolonged extraction. Pinned at waist and right shoulder. At
scene GCS
13-14 with initial abdominal pain and difficulty breathing.
Intubated for dyspnea. Hypotensive in field to 70's, which
resolved upon arrival to ED. Injuries include eyelid
lacaeration, sternal fracture, pulmonary contusion, bilateral 1
st rib fracture, right maxillary sinus fracture, C2 pedicle
fracture.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Contusion of lung without mention of open wound into thorax,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Bacteremia,Closed fracture of one rib,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Closed fracture of second cervical vertebra,Closed fracture of shaft of clavicle,Laceration of skin of eyelid and periocular area,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Tobacco use disorder,Anemia, unspecified,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist
Lung contusion-closed,Cl skul base fx w/o coma,Bacteremia,Fracture one rib-closed,Pneumococcal pneumonia,Fx c2 vertebra-closed,Fx clavicle shaft-closed,Lac eyelid skn/perioculr,Open wnd knee/leg/ankle,Tobacco use disorder,Anemia NOS,Loss control mv-mocycl
Admission Date:  [**2196-3-8**]              Discharge Date:   [**2196-3-12**]

Date of Birth:  [**2170-7-25**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:
[**2196-3-8**] Suture eyelid laceration


History of Present Illness:
24 yo in rollover motor vehicle crash as unrestrained passenger
with
prolonged extraction. Pinned at waist and right shoulder. At
scene GCS
13-14 with initial abdominal pain and difficulty breathing.
Intubated for dyspnea. Hypotensive in field to 70's, which
resolved upon arrival to ED. Injuries include eyelid
lacaeration, sternal fracture, pulmonary contusion, bilateral 1
st rib fracture, right maxillary sinus fracture, C2 pedicle
fracture.

Past Medical History:
Denies

Family History:
Noncontributory

Pertinent Results:
[**2196-3-8**] 08:59PM URINE  RBC-[**10-28**]* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**2196-3-8**] 07:55PM   GLUCOSE-126* UREA N-15 CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-24 ANION GAP-10
[**2196-3-8**] 02:16AM   WBC-11.8* RBC-4.35* HGB-12.9* HCT-38.0*
MCV-88 MCH-29.8 MCHC-34.0 RDW-13.7
[**2196-3-8**] 02:16AM   PLT COUNT-217
[**2196-3-7**] 11:10PM   ASA-NEG ETHANOL-35* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-3-7**] 11:10PM   PLT COUNT-211
[**2196-3-7**] 11:10PM   PT-15.5* PTT-22.2 INR(PT)-1.4*

CT Head [**2196-3-8**]
IMPRESSION: Non-displaced fracture of the right anterior
maxillary wall
associated with right maxillary sinus blood. Consider facial CT
characterization.

CT Cervical spine [**2196-3-8**]
IMPRESSION: Hairline fracture of C2 left pedicle/lamina.

CT Chest/Abdomen/Pelvis [**2196-3-8**]
IMPRESSION:

1. Sternal and first rib fractures raise the possibility of
cardiac
contusion. No evidence of mediastinal blood in this limited
study.

2. Right pulmonary contusion/multifocal pulmonary hemorrhage.
Recommend
CT / CXR followup to assess progression/resolution.

3. Left clavicle fracture

4. Abdominal solid organs intact.

ECHO  [**2196-3-8**]
 LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).

RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Nl
interventricular septal motion.

AORTA: Normal ascending aorta diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: The patient appears to be in sinus rhythm.
Emergency study. Results were personally reviewed with the MD
caring for the patient.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. Interventricular septal motion is normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. The mitral valve appears structurally normal. There is
no pericardial effusion.
IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function. No
pericardial effusion.

Renal U/S [**2196-3-8**]
Portable scans were performed at the bedside showing the right
kidney to
measure 10.8 cm in length and the left kidney 11.4 cm. There is
no evidence
of hydronephrosis or renal stone disease. No masses or
perinephric fluid
collections are seen. Both kidneys show vascularization on color
flow
imaging. The bladder was empty via a Foley catheter.

CONCLUSION: Normal-sized kidneys without evidence of
obstruction.

Chest xray [**2196-3-10**]
FINDINGS: As compared to the previous examination, the patient
has been
extubated and a nasogastric tube has been placed. The right
hemidiaphragm is now better seen, suggesting a decrease in
extent of the pre-existing right effusion. The extensive right
upper lobe opacity is unchanged in
extent. Also unchanged is the apical portion of a right pleural
effusion.
The left lung shows no evidence of focal parenchymal opacities,
except for
minimal retrocardiac atelectasis. Unchanged size of the cardiac
silhouette.









Brief Hospital Course:
He was admitted to the Trauma Service. Plastics consulted for
the eyelid laceration; this was irrigated and sutured. He will
follow up in a week in [**Hospital 3595**] clinic. His clavicle fracture
was evaluated by Orthopedics and was managed nonoperative with a
sling. He will follow up in [**Hospital 5498**] clinic in [**1-12**] weeks
time. It was initially thought that he may have a very small;
hairline fracture through C2 pedicle, further imaging using MRI
was done and no fractures of the spine were noted. He was
clinically without any symptoms and his cervical collar was
cleared as a result.

He did suffer significant chest wall injuries and required
moderate doses of narcotics for pain control. He was eventually
placed on an oral pain regimen which was effective in
controlling his pain.

A renal ultrasound was performed secondary to low urinary output
and was negative for any hydronephrosis or obstructive process.
He was eventually able to void without any difficulty. He also
underwent an ECHO which revealed preserved [**Hospital1 **]-ventricular
systolic function and no pericardial effusion.

He was evaluated by Physical therapy and was cleared for
discharge to home. Follow up instructions were provided to
patient at time of discharge.


Medications on Admission:
None

Discharge Medications:
1. Erythromycin 5 mg/g Ointment Sig: One (1) Appl Ophthalmic QID
(4 times a day): Apply to right eye.
Disp:*1 tube* Refills:*1*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
three times a day: Apply to facial abrasions.
Disp:*1 tube* Refills:*1*
7. Oxycodone-Acetaminophen 7.5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
8. Toradol 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Rollover motor vehicle crash
Right eyelid laceration
Right maxillary sinus fracture
Pulmonary contusion
Left clavicle fracture
Sternal fracture
Bilateral 1st rib fractures


Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.


Discharge Instructions:
DO NOT bear any weight on your left arm because of your
fracture. Wear the sling for comfort.

It is very important that you cough, deep breathe and use the
incentive spirometer 10x every hour while you are awake.

You should walk at least 4-5x/day throughout the day. Sitting up
in a chair vs lying down throughotu the day will help promote
better expansion of your lungs.

Return to the Emergency room if you develop any fevers, chills,
productive cough, increased pain not relieved by the pain
medication, shortness of breath, nausea, vomiting, diarrhea
and/or any other symptoms that are not concerning to you.

AVOID any alcohol, illicit drug use, driving and/or operating
any heavy machinery while you are taking the n

Followup Instructions:
Follow up in [**12-11**] weeks in [**Hospital 3595**] clinic for your eyelid
laceration and facial fracture. Call [**Telephone/Fax (1) 5343**] for an
appointment.

Follow up in 2 weeks in clinic with Dr. [**Last Name (STitle) **], Trauma surgery
for your rib & sternal fractures. Call [**Telephone/Fax (1) 6429**] for an
appointment.

Follow up in 2 weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics for your
clavicle fracture. Call [**Telephone/Fax (1) 1228**] for an appointment.



Completed by:[**2196-3-17**]
{'Contusion of lung without mention of open wound into thorax,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Bacteremia,Closed fracture of one rib,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Closed fracture of second cervical vertebra,Closed fracture of shaft of clavicle,Laceration of skin of eyelid and periocular area,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Tobacco use disorder,Anemia, unspecified,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist'}


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: 24 yo in rollover motor vehicle crash as unrestrained passenger
with
prolonged extraction. Pinned at waist and right shoulder. At
scene GCS
13-14 with initial abdominal pain and difficulty breathing.
Intubated for dyspnea. Hypotensive in field to 70's, which
resolved upon arrival to ED. Injuries include eyelid
lacaeration, sternal fracture, pulmonary contusion, bilateral 1
st rib fracture, right maxillary sinus fracture, C2 pedicle
fracture.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Contusion of lung without mention of open wound into thorax,Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Bacteremia,Closed fracture of one rib,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Closed fracture of second cervical vertebra,Closed fracture of shaft of clavicle,Laceration of skin of eyelid and periocular area,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Tobacco use disorder,Anemia, unspecified,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist'}
