CHIEF COMPLAINT: Multitrauma

PRESENT ILLNESS: Patient is a 43M firefighter directing traffic at mvc scene
[**2148-8-10**], hit by high speed passing car.  Had partial amputation
of right arm, and bilateral leg deformity, and bleeding from
head. Arrived to ED in vfib arrest, and was successfully
resuscitated after 28 minutes.  Intubated, bilateral chest tubes
in ED. and taken to the operating room immediately for ex fix of
bilateral LE, bolt placment, and degloving injury of RUE, and
revascularization of LLE with harvest of saphenous vein from
right.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 99.7  HR 96  BP 143/64  RR 14  Spo2 100% on AC FiO2 40 TV 600
PEEP 5

FAMILY HISTORY: no pertinent history

SOCIAL HISTORY: Firefighter
Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated,Cardiac arrest,Intracranial injury of other and unspecified nature without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Anoxic brain damage,Other open fracture of upper end of humerus,Open wound of upper arm, with tendon involvement,Closed fracture of upper end of fibula with tibia,Closed fracture of shaft of clavicle,Injury to brachial blood vessels,Injury to popliteal artery,Injury to multiple nerves of shoulder girdle and upper limb,Injury to peroneal nerve,Traumatic compartment syndrome of lower extremity,Closed fracture of one rib,Traumatic pneumothorax without mention of open wound into thorax,Grand mal status,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other tracheostomy complications,Acute posthemorrhagic anemia,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian
Amput arm, unil NOS-comp,Cardiac arrest,Brain inj NEC-deep coma,Anoxic brain damage,Fx upper humerus NEC-opn,Open wnd up arm w tendon,Fx up tibia w fibula-cl,Fx clavicle shaft-closed,Injury brachial vessels,Injury popliteal artery,Inj mult nerve shldr/arm,Injury peroneal nerve,Trauma comp synd low ext,Fracture one rib-closed,Traum pneumothorax-close,Grand mal status,Pressure ulcer, low back,Hemorrhage complic proc,Malfunc vasc device/graf,Pneumonia, organism NOS,Urin tract infection NOS,Tracheostomy comp NEC,Ac posthemorrhag anemia,Mv coll w pedest-pedest
Admission Date:  [**2148-8-11**]              Discharge Date:   [**2148-9-18**]

Date of Birth:  [**2104-12-17**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Multitrauma

Major Surgical or Invasive Procedure:
[**2148-8-11**]:
1. Right forearm and upper arm exploration with debridement of
nonviable skin and muscle.
2. Exploration of the brachial artery with restoration of blood
flow to the radial artery.
3. Repair of median nerve x 1 with tagging of the distal median
nerve and the ulnar nerve endings.
4.  Forearm fasciotomy.
5.  Local advancement flap closure.
6.  Vacuum-assisted closure dressing.
7.  Bilateral catheters in aorta
8.  Bilateral lower extremity angiogram
9.  Bilateral Lower extremity 4-compartment fasciotomies
10. Ligation of transected left popliteal artery.
11. Left above-knee popliteal to posterior tibial artery bypass
graft with reversed right greater saphenous vein
12. Bilateral lower extremity spanning external fixator
placement from the femur to the tibia
.
[**2148-8-12**]
1. Reexploration of right arm with repair of median nerve x1 and
ulnar nerve x2, reapproximation of biceps muscle, extensor carpi
ulnaris, flexor carpi ulnaris, local advancement flap closure of
wound.
2. Bilateral lower extremity washout with dressing changes, and
partial closure left lower extremity wound
.
[**2148-8-16**] (disruption of left [**Doctor Last Name **]-tib vein graft)
1. Ligation of vein graft and below-knee popliteal to proximal
posterior tibial bypass with non reversed saphenous vein.
2. Bilateral lower extremity removal of external fixator.
3. Debridement of bilateral lower extremity fasciotomies
4. ORIF of left proximal tibia with lateral plating
5. ORIF proximal tibia RLE with transverse 7.3 mm screw.
6. ORIF right segmental shaft fracture with intramedullary
nailing
7. Exploration left peroneal nerve
.
[**2148-8-19**] (bleeding in RUE)
1. Emergent right arm exploration
2. Ligation of arterial bleeder.
3. Median nerve repair with repair of previous neurorrhaphy
.
[**2148-8-27**]
1. Percutaneous tracheostomy tube insertion
2. Percutaneous endoscopic gastrostomy
3. Placement of right femoral vena caval filter


History of Present Illness:
Patient is a 43M firefighter directing traffic at mvc scene
[**2148-8-10**], hit by high speed passing car.  Had partial amputation
of right arm, and bilateral leg deformity, and bleeding from
head. Arrived to ED in vfib arrest, and was successfully
resuscitated after 28 minutes.  Intubated, bilateral chest tubes
in ED. and taken to the operating room immediately for ex fix of
bilateral LE, bolt placment, and degloving injury of RUE, and
revascularization of LLE with harvest of saphenous vein from
right.

Past Medical History:
None

Social History:
Firefighter

Family History:
no pertinent history

Physical Exam:
T 99.7  HR 96  BP 143/64  RR 14  Spo2 100% on AC FiO2 40 TV 600
PEEP 5

Gen: unresponsive
HEENT: PERRLA, eyes opening spontneously
Resp: Tracheostomy, course breath sounds bilaterally.  Trach
site without drainage or erythema
CV: RRR, strong pedal pulses
AB: soft, mildly distended, + BS.  PEG tube w/o drainage or
erythema
GU: foley in place
Ext: cast on RUE, multipodus boots on bilateral LE, bilat LE
wrapped with gauze dressing; PIC on Left arm, c/d/i
Skin: pressure sore on coccyx - stage 3, covered wtih tegaderm
Neuro: no gag response, + corneal response, No motor seizure
activity

Pertinent Results:
[**8-15**] CXR: small bilateral PTX s/p CT removal
[**8-14**] CXR: no interval change
[**8-13**] EEG: pending
[**8-13**] MRI brain: Findings consistent with hypoxic ischemic injury.
No evidence of hemorrhagic diffuse axonal injury
[**8-12**] CT leg: Occlusion of the left popliteal artery at the level
of a fractured left tibial plateau.  The above the knee left
popliteal bypass graft is partially visualized and is patent.
[**8-12**] CT Torso: Large right sided pneumothorax.  Recommend
repositioning of the right sided chest tube.  Tiny residual left
sided pneumothorax
[**8-12**] CT head: grey white matter differentiation has become less
distinct.  Marked increase in subcutaneous swelling likely
secondary to volume resuscitation with unchanged right parietal
subgaleal hematoma.
[**8-12**] CT c-spine: negative
[**8-12**] CXR: little change
[**8-11**] CXR: decrease size of R PTX
[**8-11**] CT head: negative
[**8-10**] CXR and Pelvis: left calvicle Fx


Brief Hospital Course:
Patient is a 43M firefighter who was directing traffic at the
scene of a motor vehicle crash on [**2148-8-10**], and was hit by high
speed passing car.  He suffered multiple injuries including a
near-amputation of right arm, severe bilateral leg fractures, as
well as head trauma. He arrived to the ED in vfib arrest, and
was successfully resuscitated after 28 minutes.  The patient was
intubated, and had bilateral chest tubes placed in ED. He was
taken to the operating room emergently for exploration of his
right upper extremity degloving injury, external fixation of
bilateral lower extremity fractures, bolt placment, and
revascularization of left lower extremity with harvest of
saphenous vein from right as well as bilateral fasciotomies.  In
the operating room the patient also underwent an exploratory
laparotomy for a tense distended abdomen and falling blood
pressure.  By hospital day 2, when the patient returned from the
operating room, he was hemodynamically stable and remained so
throughout his hospitalization. However, his traumatic and
anoxic brain injury caused profound neurologic injury portending
an extremely poor prognosis. During his extended stay, the
patient underwent numerous procedures and diagnostic tests.  The
following summarizes his course by system:
.
Neuro:
[**8-11**] On the day of admission a cranial bolt was emergently placed
with an opening pressure of 21, but without good wave form.
[**8-12**] CT scan: Showed loss of grey white matter differentiation
[**8-13**]: The bolt was removed. He had an MRI that day that showed
findings consistent with hypoxic ischemic injury; no evidence of
hemorrhagic diffuse axonal injury, however the radiologists also
reported a tiny focus of signal abnormality in the left thalamus
could potentially relate to a focus of non-hemorrhagic [**Doctor First Name **].
Of note, the patient suffered from convulsive and non-convulsive
status epilepticus from approx [**8-14**] until [**9-11**].  He was placed on
continueous EEG monitoring from [**8-25**] until [**9-13**].  To arrest his
seizures, he required a phenobarbitol coma while optimizing
anti-seizure mediations. He required an array of anti-seizure
medications.  Numerous attempts were made to withdraw
pentabarbitol before he was able to ween without return of
seizures. He was weaned off Pentobarb completely on [**9-9**].  On
the day of discharge, he was requiring several anti-seizure
medications including dilantin, depakote, Topamax, and Keppra.
.
Pulmonary:
The patient was emergently intubated in ED.
[**8-27**]: The patient underwent percutaneous tracheostomy tube
insertion.
[**9-10**]: The patient was weened to trach mask
On the day of discharge, the was on on mechanical ventilation:
assist control (volume targeted(Tidal volume 600 cc  rr 14, PEEP
5  FIO2 40%  ween to PSV as tolerated
.
Cardiovascular:
In the initial resuscitation, the patient recieved multiple
units PRBC.
[**8-27**]: The patient underwent placement of a right femoral vena
caval filter
After the initial resuscitation, the patient remained
hemodynamically stable.
.
GI:
On [**8-27**], the patient underwent percutaneous endoscopic
gastrostomy.
Nutrition: The patient's current tube feeding regimen is as
follows - Nutren pulmonary full strength with Beneprotein 40
gm/day at rate of 65 mL/hr.  Check residual q4hr, and hold
feeding for residual >100 mL. Flush with 200 mL water q6hr
.
Skin
On [**9-9**], it was noted that the patient was developing a sacral
decubitus ulcer (superficial level 2).  We treated this with
close wound site monitoring, continuous placement on KinAir air
matress throughout hospital course with meticulously frequent
position changes.  His nutrition was optimized with tubefeeding
as well.
.
Infectious disease: During his hospital course, the patient
frequently spiked low grade and high fevers on many occasions.
Most of these were considered to be centrally mediated febrile
responses secondary to his seizure activity and profound
cerebral injury.  Empiric courses of antibiotics were given
multiple times and cultures were positive on several occasions
as outlined below.  Overall, it was felt that most of his fevers
were central, and not infectious in nature.
[**8-11**] Ancef begun prophylactically
7/5 blood cx - negative, sputum - H. Flu
[**8-16**] start zosyn and vanc, stop ancef
[**8-21**] wound cx: 2+ PMLs, 2+ Gram - rods, bacilus
[**8-21**] sputum 2+ gram + cocci in pairs and clusters. 1+ gram -
rods: STAPH AUREUS COAG +. pending sensitivity and ACINETOBACTER
BAUMANNII pansensitive
[**8-23**] sputum: 2+ PMLs, 1+ Gram - rods
[**8-25**]:sputum GRAM POSITIVE COCCI and gram - rods. MRSA and E.coli

[**8-26**] sputum: gram + cocci and gram - rods, yeast. MRSA and gram
- rods
     blood cx negative
[**8-30**] discontinued vancomysin and zosyn
[**8-31**] Urine/Sputum with GNR (klebsiella and E-coli)
[**8-31**] blood cx negative MRSA
[**9-3**] start Cipro for Ecoli
[**9-5**] sputum coag + staph, GNRs
     blood cultures negative x 2
     urine culture negative
[**9-6**] sputum coag + staph, GNRs
     blood cultures negative x 2
     urine culture negative
[**9-10**] stop cipro begin vanco for suspected line infection
[**9-11**] catheter tip neg
[**9-11**] blood cx pending
[**9-14**] begin cipro and cefepime for GNR in sputum
[**9-14**] sputum NGR and Staph aureus, urine - no growth
.
Extremities: The patient sustained a severe degloving/near
amputation of his right upper extremity with neurovascular
compromise.  The patient also suffered a left leg popliteal
artery transection and fractures that resulted in distal
ischemia and muscle necrosis. His complex right lower extremity
fractures also lead to distal ischemia. The treatment for these
were extensive. On [**2148-8-11**], the patient underwent:
1. Right forearm debridement/fasciotomy with reattachment of
radial artery
2. Bilateral LE 4-compartment fasciotomies
3. Ligation of transected left popliteal artery.
4. Left above-knee popliteal to posterior tibial artery bypass
graft with reversed right greater saphenous vein
5. Bilateral lower extremity spanning external fixator placement
from the femur to the tibia
.
On [**2148-8-12**], the patient underwent:
1. Reexploration of right arm with repair of median nerve x1 and
ulnar nerve x2, reapproximation of biceps muscle, extensor carpi
ulnaris, flexor carpi ulnaris, local advancement flap closure of
wound.
2. Bilateral washout LE with dressing changes, and partial
closure LLE wound
.
On [**2148-8-16**], the patient's left lower extremity was found to have
disruption of left [**Doctor Last Name **]-tib vein graft.  He was taken emergently
to receive:
1. Ligation of vein graft and below-knee popliteal to proximal
posterior tibial bypass with non reversed saphenous vein.
2. Bilateral lower extremity removal of external fixator.
3. Debridement of bilateral lower extremity fasciotomies
4. ORIF of left proximal tibia with lateral plating
5. ORIF proximal tibia RLE with transverse 7.3 mm screw.
6. ORIF right segmental shaft fracture with intramedullary
nailing 12x345 SYnthes.

On [**2148-8-19**], the patient was found to have acute bleeding in the
right upper extremity, with frank blood coming from his incision
site.  He underwent:
1. Right arm emergent exploration with Ligation of arterial
bleeder.
2. Median nerve repair with repair of previous neurorrhaphy
.
[**2148-8-27**].  Due to the prognosis that the patient was highly
unlikely to have significant neurologic recovery, the fact that
he could not acquire nutrition voluntarily, and was ventilator
dependent, the following procedures were performed:
1. Percutaneous tracheostomy tube insertion.
2. Percutaneous endoscopic gastrostomy
3. Placement of right femoral vena caval filter
.
Social:
Numerous and extensive family meetings were held with the staff
and the patient's family.  The family understands that the
patient has profound neurologic injury with extremely poor
prognosis for neurologic recovery.  Nonetheless, the family
continued to desire full treatment.
On [**9-9**] the ethic committee was consulted to offer advice on the
patient's dispo and the family's wishes for care.  The family's
wishes were honored and extensive efforts were made to arrange
for the patient to be placed in a rehabilitation facility.  All
of the family's questions and concerns were addressed.

Medications on Admission:
None

Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
3. Levetiracetam 100 mg/mL Solution Sig: [**2-13**]  PO QHS (once a day
(at bedtime)).
4. Levetiracetam 100 mg/mL Solution Sig: [**2-13**]  PO QAM (once a day
(in the morning)).
5. Acetaminophen 160 mg/5 mL Solution Sig: [**2-13**]  PO Q6H (every 6
hours) as needed.
6. Ibuprofen 100 mg/5 mL Suspension Sig: [**2-13**]  PO Q8H (every 8
hours) as needed.
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: [**2-13**]  Subcutaneous Q12H
(every 12 hours).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime) as needed.
9. Phenobarbital 100 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-13**]  PO BID (2 times
a day).
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
12. Topiramate 100 mg Tablet Sig: One (1) Tablet PO 5X/DAY (5
Times a Day).
13. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO
DAILY (Daily).
14. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

15. Ferrous Sulfate 300 mg/5 mL Liquid Sig: [**2-13**]  PO DAILY
(Daily).
16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
17. Phenytoin 100 mg/4 mL Suspension Sig: [**2-13**]  PO Q6H (every 6
hours).
18. Insulin Regular Human 100 unit/mL Solution Sig: [**2-13**]
Injection per ISS as needed.
19. Valproate Sodium 250 mg/5 mL Syrup Sig: [**2-13**]  PO Q3H (every 3
hours).
20. Papain-Urea 830,000-10 unit/g-% Ointment Sig: [**2-13**] Appls
Topical DAILY (Daily).
21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**2-13**]
MLs Intravenous DAILY (Daily) as needed.
22. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: [**2-13**]
Intravenous Q 12H (Every 12 Hours).
23. Ciprofloxacin 400 mg/40 mL Solution Sig: [**2-13**]  Intravenous
Q12H (every 12 hours).
24. Cefepime 2 g Recon Soln Sig: [**2-13**] Recon Solns Injection Q12H
(every 12 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]

Discharge Diagnosis:
1)closed head injury
2)bilateral tibia/fibia fracture
3)Right upper extremity degloving-closed by plastics and VAC
drain placed
4)Bilateral Lower Extemity fasciotomy
5)Right Clavicle fracture
6)Left lower extremity arterial injury
7)Proximal Humerus fracture


Discharge Condition:
Stable to long-term care rehabilitation facility


Discharge Instructions:
Continue mechanical ventilation: assist control (volume
targeted(Tidal volume 600 cc  rr 14, PEEP 5  FIO2 40%  ween to
PSV as tolerated

Continue Tube-feeds: Nutren pulmonary full strength with
Beneprotein 40 gm/day at rate of 65 mL/hr.  Check residual q4hr,
and hold feeding for residual >100 mL. Flush with 200 mL water
q6hr, and follow sodium

Continue wet to dry dressings on bilateral LE, changed [**Hospital1 **]

On coccyx continue accuzyme, and tegaderm dressing

Continue standard trach and peg care, as well as decubitus
prevention.  Keep on air mattress.

Followup Instructions:
1. Please follow with Dr. [**Last Name (STitle) 519**] in trauma surgery.  Please call
to make an appointment: ([**Telephone/Fax (1) 5323**].
2. Please follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 3407**] in
vascular surgery for your leg wounds.  Please call to make an
appointment: ([**Telephone/Fax (1) 18181**].
3. Please follow-up with Dr. [**Last Name (STitle) 2719**] in orthopaedic surgery for
your leg fractures.  Please call to make an appointment: ([**Telephone/Fax (1) 15940**]
4. Please follow-up with Dr. [**First Name (STitle) **] in plastic surgery for your
right arm.  Please call to make an appointment:([**Telephone/Fax (1) 23796**]
5. Please follow-up with neurology service.  Please call to make
an appointment [**Telephone/Fax (1) 44**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
{'Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated,Cardiac arrest,Intracranial injury of other and unspecified nature without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Anoxic brain damage,Other open fracture of upper end of humerus,Open wound of upper arm, with tendon involvement,Closed fracture of upper end of fibula with tibia,Closed fracture of shaft of clavicle,Injury to brachial blood vessels,Injury to popliteal artery,Injury to multiple nerves of shoulder girdle and upper limb,Injury to peroneal nerve,Traumatic compartment syndrome of lower extremity,Closed fracture of one rib,Traumatic pneumothorax without mention of open wound into thorax,Grand mal status,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other tracheostomy complications,Acute posthemorrhagic anemia,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian'}


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: Multitrauma

PRESENT ILLNESS: Patient is a 43M firefighter directing traffic at mvc scene
[**2148-8-10**], hit by high speed passing car.  Had partial amputation
of right arm, and bilateral leg deformity, and bleeding from
head. Arrived to ED in vfib arrest, and was successfully
resuscitated after 28 minutes.  Intubated, bilateral chest tubes
in ED. and taken to the operating room immediately for ex fix of
bilateral LE, bolt placment, and degloving injury of RUE, and
revascularization of LLE with harvest of saphenous vein from
right.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 99.7  HR 96  BP 143/64  RR 14  Spo2 100% on AC FiO2 40 TV 600
PEEP 5

FAMILY HISTORY: no pertinent history

SOCIAL HISTORY: Firefighter 

### Response:
{'Traumatic amputation of arm and hand (complete) (partial), unilateral, level not specified, complicated,Cardiac arrest,Intracranial injury of other and unspecified nature without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level,Anoxic brain damage,Other open fracture of upper end of humerus,Open wound of upper arm, with tendon involvement,Closed fracture of upper end of fibula with tibia,Closed fracture of shaft of clavicle,Injury to brachial blood vessels,Injury to popliteal artery,Injury to multiple nerves of shoulder girdle and upper limb,Injury to peroneal nerve,Traumatic compartment syndrome of lower extremity,Closed fracture of one rib,Traumatic pneumothorax without mention of open wound into thorax,Grand mal status,Pressure ulcer, lower back,Hemorrhage complicating a procedure,Mechanical complication of other vascular device, implant, and graft,Pneumonia, organism unspecified,Urinary tract infection, site not specified,Other tracheostomy complications,Acute posthemorrhagic anemia,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian'}
