CHIEF COMPLAINT: S/P MVC, intubated at scene

PRESENT ILLNESS: 27 yo F s/p single car MVC. Patient was unrestrained. Patient
struck guard rail at 65 mph and ejected from her car. Patient
was found by EMS on the ground, with GCS 4. Patient reported to
be combative. Patient intubated/sedated and taken to [**Hospital3 12748**] where found to have a small left parietal SDH
as well as a pelvic fracture. Patient transferred to [**Hospital1 18**] for
further evaluation.

MEDICAL HISTORY: PMH
1. Polysubstance abuse

MEDICATION ON ADMISSION: Unknown

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen: Intubated and sedated
T: afeb  BP: 130/80 HR: 60    R 12   100% vent O2Sats
HEENT: abrasions on face Pupils: 3mm sluggish bilat EOMs unable
to assess
Neck: Supple. Ccollar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated, off sedation pt with gag,
cough and corneals.  Bilaterally localizes with noxious stimuli.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: has an 18 month old child
+ Tobacco current
+ ETOH
+ drugs
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of ilium,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle
Subdural hem w/o coma,Fracture of ilium-closed,Fx sacrum/coccyx-closed,Mv coll w oth obj-driver
Admission Date:  [**2164-1-28**]              Discharge Date:   [**2164-1-31**]

Date of Birth:  [**2136-10-15**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
S/P MVC, intubated at scene

Major Surgical or Invasive Procedure:
none


History of Present Illness:
27 yo F s/p single car MVC. Patient was unrestrained. Patient
struck guard rail at 65 mph and ejected from her car. Patient
was found by EMS on the ground, with GCS 4. Patient reported to
be combative. Patient intubated/sedated and taken to [**Hospital3 12748**] where found to have a small left parietal SDH
as well as a pelvic fracture. Patient transferred to [**Hospital1 18**] for
further evaluation.


Past Medical History:
PMH
1. Polysubstance abuse

Social History:
has an 18 month old child
+ Tobacco current
+ ETOH
+ drugs

Family History:
non contributory

Physical Exam:
Gen: Intubated and sedated
T: afeb  BP: 130/80 HR: 60    R 12   100% vent O2Sats
HEENT: abrasions on face Pupils: 3mm sluggish bilat EOMs unable
to assess
Neck: Supple. Ccollar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated, off sedation pt with gag,
cough and corneals.  Bilaterally localizes with noxious stimuli.

Moves bilateral lowers to pain.  Does not follow commands.


Pertinent Results:
[**2164-1-28**] 01:11PM   GLUCOSE-114* UREA N-7 CREAT-0.6 SODIUM-135
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-11
[**2164-1-28**] 01:11PM   CALCIUM-8.0* PHOSPHATE-3.3 MAGNESIUM-2.1
[**2164-1-28**] 01:11PM   WBC-12.1* RBC-3.90* HGB-11.3* HCT-33.0*
MCV-84.2 MCH-29.0 MCHC-34.6 RDW-13.0
[**2164-1-28**] 01:11PM   PLT COUNT-181
[**2164-1-28**] 01:00AM   LIPASE-21
[**2164-1-28**] 01:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2164-1-28**] 01:00AM URINE  bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-1-28**] 01:00AM   PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2164-1-28**] 01:00AM   FIBRINOGE-393

[**2164-1-28**] CT Torso :
1. Nondisplaced fractures of the right sacrum, right iliac bone,
right
superior and inferior pubic rami with small associated internal
obturator
hematoma.
2. Ground-glass opacity in the right upper lobe might represent
early
pneumonia, or less likely contusion. 3. Ill-defined, low
attenuation areas of the liver, likely representing
heterogenous perfusion or heterogenous fatty deposition. Please
correlate with LFTs.

[**2163-1-28**] Head CT :  #1
Acute left subdural hematoma along the left parietal and
occipital lobes with associated mild left cerebral edema, but no
significant midline shift.
ADDENDUM AT ATTENDING REVIEW: I do not believe there is cerebral
edema
present at this time. Some of the images are degraded by motion
artifacts.

[**2164-1-28**] Head CT :   #2
Stable appearance of small left posterior temporal- parietal
subdural hemorrhage


Brief Hospital Course:
Ms. [**Known lastname 88335**] was evaluated by the Trauma team in the Emergency
Room and admitted to the Trauma ICU for further management. She
was evaluated by Orthopedics and Neurosurgery. Her small
subarachnoid hemorrhage was managed non operatively; she was
observed in the ICU for close neurologic monitoring. She was
given Dilantin load and continued on this for a total of 7 days
(is being discharged with several more days to complete course).
She was evaluated by occupational therapy due to her brain
injury and will be referred for outpatient Cognitive neurology
follow up. She will follow up in 4 weeks with a repeat head CT
scan.

Her pubic rami fracture did not require any operations, she was
initially made touch down weight bearing and because of
difficulty maintaining this Orthopedics decided that she could
be partial weight bearing. She was evaluated by Physical therapy
for gait training and issued crutches for ambulation. She will
follow up in 4 weeks for repeat pelvis films.

Her Dilantin dose was decreased prior to discharge due to
elevated levels; on day prior the Dilantin was withheld and
restarted at [**Hospital1 **] vs TID dosing.

Her pain was controlled with oral narcotics and adjunct therapy
with non narcotics analgesics.

She is being discharged to home with instructions for follow up.

Medications on Admission:
Unknown

Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO twice a day: thru [**2164-2-3**].
Disp:*16 Tablet, Chewable(s)* Refills:*0*
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
8. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:


S/P Motor vehicl crash
1. Right superior/inferior rami fracture
2. Left parietal subdural hematoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) Right leg is partial weight bearing

Discharge Instructions:
* You were admitted to the hospital after your car accident with
a Right pelvic fracture and a hematoma in a small area of you
brain from bleeding.
* Your injuries did not require surgery.  They will be managed
conservatively.
* You will need to follow up with the Neurosurgeon in 4 weeks
with a repeat Head CT.
* Continue your anti seizure medication thru [**2164-2-4**].
* The Ortho Trauma service recommends that your activity be
partial weight bearing on the right leg.
* Your pain can be controlled with narcotics but they can be
very constipating therefore take stool softeners and/or
laxatives as needed to prevent constipation.
* Do NOT drink alcohol or use any drugs other than those
prescribed.
* Do NOT drive while taking narcotic pain medication.
* If you develop any new symptoms that concern you please return
to the Emergency Room.

Followup Instructions:
It is being recommended that you follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], Cognitive Neurology in the next 2 weeks for ongoing
evaluation given your brain injury. Please call ([**Telephone/Fax (1) 1703**]
for an appointment.

Call Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 4296**] for a follow up appointment in 4
weeks with a non contrast head CT. The administartive assistant
staff can book that for you so please inform them of this when
calling.

Call the [**Hospital **] Clinic at [**Telephone/Fax (1) 1228**] for a follow up
appointment in 4 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.



Completed by:[**2164-1-31**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of ilium,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Other motor vehicle traffic accident involving collision on the highway injuring driver of 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: S/P MVC, intubated at scene

PRESENT ILLNESS: 27 yo F s/p single car MVC. Patient was unrestrained. Patient
struck guard rail at 65 mph and ejected from her car. Patient
was found by EMS on the ground, with GCS 4. Patient reported to
be combative. Patient intubated/sedated and taken to [**Hospital3 12748**] where found to have a small left parietal SDH
as well as a pelvic fracture. Patient transferred to [**Hospital1 18**] for
further evaluation.

MEDICAL HISTORY: PMH
1. Polysubstance abuse

MEDICATION ON ADMISSION: Unknown

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen: Intubated and sedated
T: afeb  BP: 130/80 HR: 60    R 12   100% vent O2Sats
HEENT: abrasions on face Pupils: 3mm sluggish bilat EOMs unable
to assess
Neck: Supple. Ccollar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated, off sedation pt with gag,
cough and corneals.  Bilaterally localizes with noxious stimuli.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: has an 18 month old child
+ Tobacco current
+ ETOH
+ drugs 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Closed fracture of ilium,Closed fracture of sacrum and coccyx without mention of spinal cord injury,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle'}
