CHIEF COMPLAINT: Motor cycle crash with traumatic left leg amputation

PRESENT ILLNESS: 36 year old male status post motorcycle vs Motor vehicle at high
speed with traumatic amputation of Left leg. Patient was found
prone, unresponsive, diaphoretic, and pale with agonal
breathting.  He was found apporxiamately 100 feet from the
motorchycle.  He had a traumatic amputation of this left lower
extremity, with an estimated blood loss of 2 liters at the
scene.  He was helmeted but his helmet was crushed.  He had
decreased breath sounds and oxygen saturations 90%, had a GCS of
3 and the patient was intubated prior to presentation with out
medication.  The patient was med flighted in.

MEDICAL HISTORY: asthma

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival, the patient was awake moving both upper extremities,
but intubated and not following commands.  His eyes were open.
pulse 117, blood pressure 60/palp, bagged with oxygen saturation
of 91%
Head and Neck: trachea midline, in c collar.  no scalp abrasions
or obvious head trauma.
Cardiac: regular rate and rhythm
Lungs: decreased breath sounds on left, small rush of air when
chest tube was placed
Abdomen: soft, non distended
Rectal: No tone (on vecuronium), heme negative
Neuro: moving both upper extremities,
Extremities: Left upper extremity unstable, larg laceration
Left lower extremity: taumatic amputation, approximately 10 cm
from hip joint.  Femur exposed, hamstring muscles, pulsitile
bleeding.
Right lower extremitiy, unstable forefoot
Spine: no stepoffs

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Tree surgeon, recently divorced, many relatives in [**Name (NI) 6171**]
Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, without mention of complication,Traumatic shock,Acute posthemorrhagic anemia,Hemorrhage, unspecified,Injury to other gastrointestinal sites, without mention of open wound into cavity,Pneumonia, organism unspecified,Thrombocytopenia, unspecified,Open unspecified fracture of pelvis,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist
Amput above knee, unilat,Traumatic shock,Ac posthemorrhag anemia,Hemorrhage NOS,GI injury NEC-closed,Pneumonia, organism NOS,Thrombocytopenia NOS,Pelvic fracture NOS-open,Mv collis NOS-motorcycl
Admission Date:  [**2100-9-14**]              Discharge Date:   [**2100-10-15**]

Date of Birth:  [**2066-5-7**]             Sex:   M

Service: [**Last Name (un) **]

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Motor cycle crash with traumatic left leg amputation

Major Surgical or Invasive Procedure:
1.  Left hip disarticulation, operative debridement of Left leg
amputation [**2100-9-14**]
2.  Exploratory laparotomy  with mesenteric tear  [**2100-9-15**]
3.  G-tube placement  [**2100-9-15**]
4.  Left external fixation of forearm fracture [**2100-9-14**]
5.  Revision External fixation of forearm fracture [**2100-9-22**]
6.  External fixation Right foot fracture [**2100-9-22**]
7.  External fixation of pelvic fractue [**2100-9-23**]
8.  Split thickness skin graft to left leg amputation [**2100-10-7**]

History of Present Illness:
36 year old male status post motorcycle vs Motor vehicle at high
speed with traumatic amputation of Left leg. Patient was found
prone, unresponsive, diaphoretic, and pale with agonal
breathting.  He was found apporxiamately 100 feet from the
motorchycle.  He had a traumatic amputation of this left lower
extremity, with an estimated blood loss of 2 liters at the
scene.  He was helmeted but his helmet was crushed.  He had
decreased breath sounds and oxygen saturations 90%, had a GCS of
3 and the patient was intubated prior to presentation with out
medication.  The patient was med flighted in.

Past Medical History:
asthma

Social History:
Tree surgeon, recently divorced, many relatives in [**Name (NI) 6171**]

Family History:
Non contributory

Physical Exam:
On arrival, the patient was awake moving both upper extremities,
but intubated and not following commands.  His eyes were open.
pulse 117, blood pressure 60/palp, bagged with oxygen saturation
of 91%
Head and Neck: trachea midline, in c collar.  no scalp abrasions
or obvious head trauma.
Cardiac: regular rate and rhythm
Lungs: decreased breath sounds on left, small rush of air when
chest tube was placed
Abdomen: soft, non distended
Rectal: No tone (on vecuronium), heme negative
Neuro: moving both upper extremities,
Extremities: Left upper extremity unstable, larg laceration
Left lower extremity: taumatic amputation, approximately 10 cm
from hip joint.  Femur exposed, hamstring muscles, pulsitile
bleeding.
Right lower extremitiy, unstable forefoot
Spine: no stepoffs

Pertinent Results:
XRAY Left upper extremity [**2100-9-14**]:
IMPRESSION:
1. Probable fracture of the coronoid process of the left elbow.
Additonal elbow views or CT is recommended.
2. Comminuted nondisplaced fracture of the left radiostyloid.
3. Oblique fracture of the left third metacarpal base and fifth
metacarpal head.

AP pelvis and Right lower extremity [**2100-9-14**]:
IMPRESSION:

Limited evaluation of the pelvis. Within the limits, there
appears to be a widen left sacroiliac joint. Fractures of the
left superior inferior pubic ramus. CT of the pelvis is
recommended.

Comminuted fracture of the 2nd and 3rd metatarsals with
significant soft tissue swelling.

CT spine [**2100-9-15**]:
IMPRESSION: Unremarkable cervical spine CT scan. Tip of the
spinous process of C7 was not fully imaged; fracture cannot be
excluded in this locale. Otherwise unremarkable cervical spine
CT scan.

CT abdomen/pelvis [**2100-9-15**]:
IMPRESSION:
1) Sternal fracture with bilateral hemothoraces. Status post
left chest tube insertion.
2) Moderate hemoperitoneum. No solid abdominal organ laceration
or contusion identified.
3) Multiple pelvic fractures with diastatic bilateral sacroiliac
joints and amputated left lower extremity.

CT head [**2100-9-15**]:
IMPRESSION:

1) No evidence of intracranial hemorrhage.
2) No definite evidence of fracture, although the facial bones
are not fully imaged.
3) Bilateral air fluid levels in the maxillary sinuses and sinus
mucosal thickening as described.

Spine [**2100-9-15**]:
LUMBAR SPINE, TWO VIEWS:
No fracture. Alignment is normal.

Xray Right foot [**2100-9-20**]:
IMPRESSION: Comminuted fracture of first metatarsal with
displacement. Comminuted of second metatarsal without
displacement. Fracture of distal tibia which is not well
visualized.

XRay Right ankle [**2100-9-21**]:
IMPRESSION: Transverse fracture of medial malleolus.


Brief Hospital Course:
The patient arrived in the trauma bay with an initial Hematocrit
of 14, and a blood gas significant for a pH of 6.91 and a base
deficit of 23.  The trauma panel demonstrated a pelvic fracture.
 He was had pulsitile bleeding coming from his left lower
extremity, that was completely amputated, demonstrating
pulsitile bleeding, exposed femur (approximately 10cm) and
exposed muscles, with complete loss of skin.  The patient was
given a Left chest tube that produced a rush of air.  His
initial fast was negative.  Clamps and packing were used to get
initial hemostasis, while the patient was actively resuscitated
with Lactated ringers and Blood products.  He was rushed to the
operating room for control of the hemorrhage.  After ligating
actively bleeding vessels, performing a hip disarticulation and
performing a debridement, the wound was packed and covered with
sterile materials, and the patient was transfered to the
intensive care unit.  He by that time had recieved over 20 units
of packed red blood cells and greater than 15 units of Fresh
frozen plasma.  Aggressive resucitation was continued, and a
sheet was used to stabilize his pelvis.  He was monitored
closely with serial bladder pressures. His bladder pressures
were initially in in the 30s but trended down.  Once stabilized
he was also brought to the CT Scan for films.  On post op day 1,
the patient was taken back to the operative room for debridement
of the Left stump and for an exploratory laparatomy for fluid
demonstrated on his CT scan.  A Vac drain was placed over the
stump.  He was concurrently treated with antibiotics.  Tube
feeds were started on hospital day 3(post operative days 2 and
1). He was started on a vent wean. On hospital day 6, the
patient was extubated after he bit a hole in the tube.  He also
had some gram negative rods in his sputum that was treated with
antibiotics.  His chest tubes were discontinued on Hosptial day
7.  The patient was stable for transfer to the surgical floor.
His antibiotic regimen included cipro/ceftaz.  He returned to
the operating room on hospital day 9 for revision of his Left
upper extremity fracture and for fixation of his right lower
extremity foot fracture.  The following day he went to the
operating room for placement of an external fixation device on
his pelvis.  He continued to have VAC dressing changes every [**3-9**]
days.  When he was more awake, the patient started complaining
of some vivid "flashback" dreams and requested psyciatric help.
The patient was given a sitter for his saftey until he was
evaluated by psychiatry, who felt that he had an acute stress
reaction, but was not suicidal and did not require a sitter.  he
was placed on zoloft and seroquel, and his work up also included
and EEG to rule out seizures (negative).  His sleep was much
improved with the medication.  He was seen daily by psyciatry.
He was continued on his tube feeds until he was tolerating a
regular diet, and he was doing so by hospital day 13.   He was
also seen by physical therapy and they began working with him
and setting goals.  The patient remained stable on the floor,
his antibiotics were discontinued, his white blood cell count
trended down, was being seen by physical therapy and psychiatry,
while his VAC dressing was changed every three days.  It was
granulating nicely by Hospital day 15, and plastic surgery was
consulted to look at the wound the next vac change to assess the
possibility for a skin graft.  The patient was taken to the OR
by plastic surgery on HD 23 for a split thickness skin graft to
the left leg amputation site. At discharge on HD 31 the patient
was doing well. He will be discharged to [**Hospital 1319**] rehab with
close follow up in the plastic, orthopedic, and trauma clinics.

Medications on Admission:
None

Discharge Medications:
1. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for anxiety/agitation.
6. Methadone HCl 10 mg Tablet Sig: One (1) Tablet PO Q 1800 AND
MIDNIGHT ().
7. Methadone HCl 5 mg Tablet Sig: Three (3) Tablet PO Q 0600 AND
1200 ().
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
10. Nortriptyline HCl 50 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
11. Quetiapine Fumarate 25 mg Tablet Sig: seven Tablet PO at
bedtime: patient to take 175 mg po qHS .
12. Trazodone HCl 50 mg Tablet Sig: 0.5 Tablet PO HS (at
bedtime) as needed for insomnia .
13. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1)  Injection
Q3-4H () as needed for breakthrough pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
1.  Traumatic left leg amputation
2.  Mesenteric tear
3.  right Medial maleolus fracture
4.  bilateral hemothoraces
5.  Sternal fracture
6.  right Third metatarsal fracture
7.  right second metatarsal fracture
8.  right first metatarsal fracture
9.  Multiple pelvic fractures
10.  Left fifth metacarpal fracture
11.  Left third metacarpal fracture
12. Left radiostyloid fracture
13. Acute stress reaction
14. status post chest tube placement
15.  status post Left hip disarticulation, operative debridement
of Left leg amputation [**2100-9-14**]
16.  status post Exploratory laparotomy  with mesenteric tear
[**2100-9-15**]
17.  status post G-tube placement  [**2100-9-15**]
18.  status post Left external fixation of forearm fracture
[**2100-9-14**]
19.  status post Revision External fixation of left forearm
fracture [**2100-9-22**]
20.  status post External fixation Right foot fracture [**2100-9-22**]
21.  status post External fixation of pelvic fractue [**2100-9-23**]
22.  Acute blood loss anemia requiring transfusion
23.  Coagulopathy
24.  Acute hypotension


Discharge Condition:
Good

Discharge Instructions:
Continue pin care, wound care, PT at rehabilitation center.
Continue taking meds as directed.

Followup Instructions:
1.  F/U in plastic surgery clinic next Tuesday, [**10-19**]. Please
call for appt. [**Telephone/Fax (1) **]
2.  F/U in orthopedic surgery clinic in 2 weeks. Please call for
appointment [**Telephone/Fax (1) 52501**].
3. F/U in trauma clinic in 2 weeks. Please call for appointment
[**Telephone/Fax (1) **].
{'Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, without mention of complication,Traumatic shock,Acute posthemorrhagic anemia,Hemorrhage, unspecified,Injury to other gastrointestinal sites, without mention of open wound into cavity,Pneumonia, organism unspecified,Thrombocytopenia, unspecified,Open unspecified fracture of pelvis,Other motor vehicle traffic accident involving collision with motor vehicle 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: Motor cycle crash with traumatic left leg amputation

PRESENT ILLNESS: 36 year old male status post motorcycle vs Motor vehicle at high
speed with traumatic amputation of Left leg. Patient was found
prone, unresponsive, diaphoretic, and pale with agonal
breathting.  He was found apporxiamately 100 feet from the
motorchycle.  He had a traumatic amputation of this left lower
extremity, with an estimated blood loss of 2 liters at the
scene.  He was helmeted but his helmet was crushed.  He had
decreased breath sounds and oxygen saturations 90%, had a GCS of
3 and the patient was intubated prior to presentation with out
medication.  The patient was med flighted in.

MEDICAL HISTORY: asthma

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On arrival, the patient was awake moving both upper extremities,
but intubated and not following commands.  His eyes were open.
pulse 117, blood pressure 60/palp, bagged with oxygen saturation
of 91%
Head and Neck: trachea midline, in c collar.  no scalp abrasions
or obvious head trauma.
Cardiac: regular rate and rhythm
Lungs: decreased breath sounds on left, small rush of air when
chest tube was placed
Abdomen: soft, non distended
Rectal: No tone (on vecuronium), heme negative
Neuro: moving both upper extremities,
Extremities: Left upper extremity unstable, larg laceration
Left lower extremity: taumatic amputation, approximately 10 cm
from hip joint.  Femur exposed, hamstring muscles, pulsitile
bleeding.
Right lower extremitiy, unstable forefoot
Spine: no stepoffs

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Tree surgeon, recently divorced, many relatives in [**Name (NI) 6171**] 

### Response:
{'Traumatic amputation of leg(s) (complete) (partial), unilateral, at or above knee, without mention of complication,Traumatic shock,Acute posthemorrhagic anemia,Hemorrhage, unspecified,Injury to other gastrointestinal sites, without mention of open wound into cavity,Pneumonia, organism unspecified,Thrombocytopenia, unspecified,Open unspecified fracture of pelvis,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist'}
