CHIEF COMPLAINT: s/p Motor vehicle crash

PRESENT ILLNESS: 70 year old female involved in a motor vehicle crash; intubated
at scene because of mental status changes; also was found to be
in shock with a distended abdomen. She had both a positive FAST
and DPL and was taken to the operating room directly from the
trauma bay for exploratory.

MEDICAL HISTORY: Hypertension
GERD
Bilateral knee replacements with post-op GI bleed

MEDICATION ON ADMISSION: HCTZ 25'
Toprol XL 100'
Accupril 20'

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Tm/c: 100.2/100.2  HR: 97  BP: 160/80  RR: 18  O2sat: 97%RA

FAMILY HISTORY: Nonconttibutory

SOCIAL HISTORY: 
Injury to other gastrointestinal sites, without mention of open wound into cavity,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Traumatic shock,Injury to multiple blood vessels of abdomen and pelvis,Closed fracture of T7-T12 level with unspecified spinal cord injury,Closed fracture of lumbar vertebra without mention of spinal cord injury,Urinary tract infection, site not specified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Closed fracture of one rib,Third or oculomotor nerve palsy, partial,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Ptosis of eyelid, unspecified,Hypertensive retinopathy,Esophageal reflux,Knee joint replacement
GI injury NEC-closed,Subdural hem-brief coma,Traumatic shock,Inj mult abd/pelv vessel,T7-t12 fx-cl/crd inj NOS,Fx lumbar vertebra-close,Urin tract infection NOS,Traum pneumothorax-close,Oth coll stndng obj-driv,Fracture one rib-closed,Partial third nerv palsy,Open wound of jaw,Hypertension NOS,Ptosis of eyelid NOS,Hypertensive retinopathy,Esophageal reflux,Joint replaced knee
Admission Date:  [**2197-8-28**]              Discharge Date:   [**2197-9-11**]

Date of Birth:  [**2126-10-12**]             Sex:   F

Service: SURGERY

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motor vehicle crash

Major Surgical or Invasive Procedure:
[**2197-8-28**] Exploratory Lap
[**2197-8-29**] Closure of Abdominal wound


History of Present Illness:
70 year old female involved in a motor vehicle crash; intubated
at scene because of mental status changes; also was found to be
in shock with a distended abdomen. She had both a positive FAST
and DPL and was taken to the operating room directly from the
trauma bay for exploratory.

Past Medical History:
Hypertension
GERD
Bilateral knee replacements with post-op GI bleed

Family History:
Nonconttibutory

Physical Exam:
Tm/c: 100.2/100.2  HR: 97  BP: 160/80  RR: 18  O2sat: 97%RA

Gen: AAOx3, NAD, TLSO on
HEENT: Left eye: EOMI, PERRL; Right eye: ptosis, CN IV and VI
intact
With TLSO off and patient lying flat in bed:
CV: RRR, no murmurs
Lungs: CTAB
Abd: NA BS present, soft, NT, ND, steri-strips intact, distal
wound opened, packed, bandaged - clean and intact
Extr: venodynes, no C/C/E

Pertinent Results:
IMAGING
.
CT PELVIS W/CONTRAST  [**2197-8-28**] 6:16 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST

IMPRESSION:
1. Free air within the anterior mediastinum, and air anterior to
the epicardium, of indeterminate etiology.
2. Edema within the lungs.
3. Small right pleural effusion.
4. Post-surgical changes of the abdomen, with an open abdominal
wound and stomach, small and large bowel protruding through the
wound defect. Free air and free fluid in the abdomen. Per the
operative note, there was a tear at the root of the mesentery
with vascular injury.
5. Multiple fractures, including the T11 vertebral body with
retropulsion of fragments into the central spinal canal. The
acuity of this finding is uncertain, as there are no priors for
comparison. There is a fracture of some transverse processes of
the lumbar spine, and a fracture of the right posterior eleventh
rib.
6. Enhancement of the small bowel mucosa suggesting shock.
.
.
CT C-SPINE W/O CONTRAST  [**2197-8-28**] 6:16 PM
CT C-SPINE W/O CONTRAST

IMPRESSION:
1. No evidence of cervical spine fracture.
2. Grade I anterolisthesis of C3 on C4.
3. Edema at the lung apices.

.
.
CT HEAD W/O CONTRAST  [**2197-8-28**] 6:15 PM
INDICATION: Status post MVC. Intubated.

There are no prior studies for comparison.

NONCONTRAST HEAD CT SCAN: There is a very small amount of
subdural blood along the falx cerebri on the left side near the
vertex (series 2 images 22 through 27). No other definite areas
of hemorrhage are appreciated. The ventricles and cisterns are
normal. The density values of the brain parenchyma are normal,
with preservation of the [**Doctor Last Name 352**]-white matter differentiation.
There are widened bifrontal extra-axial spaces, which may be
related to involutional change. There is a small amount of fluid
layering posteriorly within each maxillary sinus. There is
partial opacification of the ethmoid air cells. The mastoid air
cells are clear. Osseous and soft tissue structures are
unremarkable.

IMPRESSION: Small subdural hematoma along the left side of the
falx cerebri. No shift of the normally midline structures.

The finding was discussed with Dr. [**Last Name (STitle) 69770**] at the conclusion
of the exam.

.
.
TRAUMA #2 (AP CXR & PELVIS PORT)  [**2197-8-28**] 6:08 PM
INDICATION: Trauma.

CHEST: Trauma supine chest and pelvis reviewed. There is diffuse
opacification of both lungs. The left diaphragmatic border is
obscured. The pleura are grossly clear without large effusions
or pneumothoraces. No displaced rib fractures are identified.
The patient is intubated with the ET tube located 1.5 cm above
the carina. NG tube is present in the stomach. The heart and
mediastinal contours are within normal limits given the supine
projection.

IMPRESSION: Diffuse opacification of both lungs likely secondary
to pulmonary edema versus contusion. ET tube 1.5 cm above the
carina, some withdrawal may provide more optimal position is
possible.

PELVIS: No displaced pelvic fractures are identified. Evaluation
of the proximal femur is limited secondary to rotation. There is
lumbar scoliosis with convexity to the left with associated
osteophytes and degenerative changes. Bowel gas is unremarkable.

IMPRESSION: No gross injury.

.
.
CT HEAD W/O CONTRAST  [**2197-8-29**] 10:57 AM
INDICATION: Evaluation for interval change in a 70-year-old
lady, status post motor vehicle accident. Assessment for
intracranial hemorrhage.

TECHNIQUE: Axial images of CT of the head.

COMPARISON: [**2197-8-28**].

FINDINGS: There is left subdural hematoma on the free edge of
falx that is unchanged in comparison to prior study. There is no
new acute extra- or intraaxial hemorrhage. There is no major or
minor territorial infarct. There is no mass effect or shift of
normal midline structures. There is no fracture line or soft
tissue density abnormality identified. There is normal soft
tissue density of the brain parenchyma. There are widened stable
bifrontal extra-axial spaces which are related to atrophic
changes . There are air fluid levels within the maxillary
sinuses and sphenoid sinuses that are unchanged in comparison to
prior study. Mastoid air cells are clear.

IMPRESSION: Unchanged small left subdural hematoma along the
falx. No new change.
.
.
CHEST (PORTABLE AP)  [**2197-8-30**] 4:54 AM
INDICATION: Status post MVC and exploratory laparotomy. Evaluate
for interval change.

FINDINGS: Compared with [**2197-8-28**], lines and tubes are unchanged in
position. There has been considerable partial interval clearing
of the diffuse patchy pulmonary densities, with mild residual
atelectasis at the left base.
.
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST  [**2197-8-31**] 9:16 AM
INDICATION: Trauma, evaluate for facial fractures.

COMPARISON: Head CT, [**2197-8-29**].

TECHNIQUE: MDCT-acquired contiguous axial images of the facial
bones were obtained without intravenous contrast.
Three-dimensional reconstructed images were obtained.

CT OF THE FACIAL BONES WITHOUT INTRAVENOUS CONTRAST: No facial
fracture is identified. Mild-to-moderate mucosal thickening is
seen involving all of the paranasal sinuses, with air-fluid
levels demonstrated in the maxillary, sphenoid, and ethmoid
sinuses. All of these findings are likely secondary to patient's
intubated state. Tiny hyperdensity within a right sphenoid sinus
air cell likely represents a minute osteoma. Visualized portions
of the mastoid air cells are clear. Surrounding soft tissue
structures appear unremarkable. There is extensive
atherosclerotic calcification of the cavernous portion of both
internal carotid arteries.

At C2-3 and C3-4, facet degenerative changes are present, more
pronounced on the right leading to mild-to-moderate neural
foraminal narrowing.

An endotracheal tube and nasogastric tube are partially imaged
within the airway and esophagus respectively.

IMPRESSION:
1. No facial fracture identified.
2. Air-fluid levels within the paranasal sinuses consistent with
the patient's intubated state.

.
.
CHEST (PORTABLE AP)  [**2197-9-1**] 9:19 PM
CLINICAL INDICATION: Evaluate lung integrity.

TECHNIQUE: AP semierect portable examination is compared with
prior examination dated [**2197-8-30**].

FINDINGS: A left-sided chest tube is visualized with side port
projecting over the subcutaneous soft tissues outside of the
hemithorax. Recommend advancement.

Left-sided subclavian line terminates in the proximal SVC. NG
tube projects over the body of the stomach.

Cardiomediastinal silhouette is within normal limits. There is
increased left lower lung hazy opacity. Right-sided pleural
effusion again seen. Small left apical pneumothorax again
appreciated. New surgical staples seen over the upper abdomen.

IMPRESSION:
1. Recommend advancement of left-sided chest tube with side port
seen projecting outside of the left hemithorax.
2. Interval increase in left lower lung hazy opacification.

.
.
CHEST (PORTABLE AP); CHEST, SINGLE VIEW ON [**9-2**] at 2100.
REASON FOR THIS EXAMINATION: s/p removal chest tube

HISTORY: Left chest tube to waterseal, status post removal of
chest tube.

FINDINGS: There has been interval removal of the left chest
tube. There is a small left pneumothorax that is similar in size
to that seen on the film from the prior day. There continue to
be bibasilar opacities and patchy areas of volume loss.

.
.
CHEST (PORTABLE AP)  [**2197-9-2**] 5:16 AM
REASON FOR THIS EXAMINATION: eval for interval change
CLINICAL INDICATION: 50-year-old woman status post MVC, evaluate
for chest tube placement.

IMPRESSION: Interval advancement of left-sided chest tube, small
residual left apical pneumothorax. Interval increase in
bibasilar opacities.

.
.
CTA NECK W&W/OC & RECONS; CTA HEAD W&W/O C & RECONS  [**2197-9-6**]
6:19 PM
REASON FOR THIS EXAMINATION: ? aneurysm in carotid system in
setting of CNIII palsy
CLINICAL INFORMATION: Cranial nerve III palsy, question carotid
aneurysm.

NON-CONTRAST HEAD CT

Exam shows near complete resolution of the left parafalcine
subdural hematoma posteriorly seen on prior study of [**2197-8-29**]. The
low-density extra-axial fluid collections over the frontal
aspects of both hemispheres are again noted and unchanged.
Ventricular dimension is unchanged.

IMPRESSION: Some resorption of the left parafalcine subdural
hematoma. No other new findings.

CT ANGIOGRAM OF THE CERVICAL VESSELS WITH MULTIPLANAR
REFORMATTED IMAGES AND 3-DIMENSIONAL RECONSTRUCTED IMAGES

IMPRESSION: No evidence of significant internal carotid artery
stenosis. See above comment regarding the appearance of C4-5 on
the left.

CT ANGIOGRAM OF THE INTRACRANIAL CIRCULATION

There is no evidence of aneurysm or flow abnormality. The
cavernous portions are always difficult to assess on CT
angiography for technical reasons. If there remains a clinical
question regarding a small aneurysm in either cavernous portion,
formal catheter angiography may be considered for further
evaluation.

IMPRESSION: No definite evidence of aneurysm. See above comment
regarding the appearance of the cavernous portions of the
internal carotid arteries.

.
.
ABDOMEN (SUPINE ONLY)  [**2197-9-6**] 3:18 PM
REASON FOR THIS EXAMINATION: r/o obstruction or other processes

INDICATION: 70-year-old woman status post motor vehicle
accident, status post exploratory laparotomy, now with
increasing nausea and vomiting. Rule out obstruction.

COMPARISON: Abdominal radiograph [**2197-8-29**].

FINDINGS: There is unremarkable bowel gas pattern. There is air
in the rectum. Multiple surgical clips are projecting over the
midline. Interval removal of the nasogastric tube. Fractures of
11th posterior, ninth lateral ribs. Levoconvex scoliosis,
centered at L3-L4.

IMPRESSION: No evidence of obstruction.
.
.
PROCEDURES
.
OPERATIVE REPORT

[**Last Name (LF) **],[**First Name3 (LF) **] J.
Name:  [**Known lastname **],[**Known firstname **] T
Unit No:  [**Numeric Identifier 69771**]
Service:  MED
Date:  [**2197-8-28**]
Date of Birth:  [**2139-12-26**]
Sex:  F
Surgeon:  [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], MD 2211

INDICATIONS:  This woman has been in a motor vehicle accident.
She was found to be in shock and her abdomen was distended. I
should mention that 1 of her pupils was also wide.

PROCEDURE:  She was taken to the operating room and placed in a
supine position, given a general anesthetic. The abdomen was
prepped and draped using Betadine. A vertical incision was made
taking it down to the level of the fascia. The fascia was
opened. The abdomen was opened and the following findings were
noted. Considerable bleeding was noted within the abdomen. There
was a large rent in the mesentery of the small bowel that
extended into the right lower quadrant. There was bleeding from
vessels at the root of the mesentery and we managed to control
the bleeding with several sutures of 3-0 silk and 2-0 silk up
through the mesentery. The
patient, at this point, was extremely hypothermic and we needed
to get control of this and we had transected the bowel both on
the ileum and also on the ascending colon. We removed the
intestine by clamping with [**Doctor Last Name 1356**] clamps and then ligating with
2-0 silk sutures. Once this was done, we carried out a very fast
anastomosis using the linear cutting stapler and a
TA stapler across the remaining part. The anastomotic line was
inverted using interrupted 3-0 silk sutures. At this point,
after making sure that we controlled the blood vessel in the
mesentery with the silk sutures, we decided to leave the
mesenteric defect open. I should mention that we carried out a
look at the spleen. The spleen was not bleeding. There was an
adhesion to the lower end of the spleen which was divided. The
liver was similarly not bleeding. We did not open the lesser
sac. We placed a [**Location (un) 5701**] bag in place and then used warm saline
to irrigate. We then closed the abdomen using 0 Prolene suture
in continuous fashion to the skin and
thus the abdomen was left open, the [**Location (un) 5701**] bag being used to
hold the abdominal contents in place. Two [**Location (un) 1661**]-[**Location (un) 1662**] drains
were left in place and a superficial dressing was placed. There
were 2 liters of blood within the abdomen. This was suctioned
out with the autotransfusor and got the bloodback from the cell
[**Doctor Last Name 10105**].
ESTIMATED BLOOD LOSS:  500 cc.
                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5732**], [**MD Number(1) 5733**]
.
.
OPERATIVE REPORT

PREOPERATIVE DIAGNOSIS:  Motor vehicle crash resulting in
open abdomen mesenteric vein avulsion.

POSTOPERATIVE DIAGNOSIS:  Motor vehicle crash resulting in
open abdomen mesenteric vein avulsion.

PROCEDURE:
1.  Closure of mesenteric defect.
2.  Closure of abdomen.

INDICATIONS FOR SURGERY:  The patient is a 70-year-old female
who sustained a motor vehicle crash that required an exploratory
laparotomy the day prior. She was noted to have a mesenteric
avulsion with profuse bleeding from the venous system. These
were suture ligated, and hemostasis was achieved; however, the
abdomen was left open due to the necessity for a second look to
assess the viability of the bowel, thus the patient was taken
back to the operating room for closure.

PROCEDURE IN DETAIL:  The patient was brought to the operating
room in stable condition. She was already intubated in the
intensive care unit prior to presentation to the operating room.
The abdomen was prepped and draped with sterile Betadine. The
previously-placed [**Location (un) 5701**] bag was removed from the
circumferential surrounding skin, and the abdomen was explored.

There was noted to be adequate hemostasis at the mesenteric
rent. The bowel seemed adequately viable. Four laparotomy pads
were removed from the abdomen which had been placed as packing
the day before.

The mesenteric defect was then closed with interrupted 3-0 silk
sutures at the previously performed ileocolostomy anastomosis.
An NG tube was placed with adequate positioning in the stomach.
The wound was then closed with looped #1 PDS sutures. It was
noted to come together nicely without undue
tension. The peak inspiratory pressures on the ventilator did
not increase substantially at all during this procedure.

The subcutaneous tissue was then copiously irrigated, and the
skin was closed with skin staples. The patient was transferred
back to the ICU in stable condition. All sponge and needle
counts were correct at the end of the case x 2. The patient did
undergo an abdominal x-ray, as the previous
sponge count had not been counted. There was no evidence of any
retained instruments or sponge counts in the abdomen.
Dr. [**Last Name (STitle) **] was present and scrubbed during the entire procedure.

                        [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 67332**]
.
.
URINE
[**2197-9-8**]  URINE CULTURE (Preliminary):
   GRAM NEGATIVE ROD(S).  >100,000 ORGANISMS/ML - FURTHER
IDENTIFICATION TO FOLLOW

LABS:
[**2197-8-28**] 06:17PM   FIBRINOGEN-146*
[**2197-8-28**] 06:17PM   PT-14.2* PTT-31.8 INR(PT)-1.3*
[**2197-8-28**] 06:17PM   PLT COUNT-143*
[**2197-8-28**] 06:17PM   WBC-12.9* RBC-2.88* HGB-9.8* HCT-27.0* MCV-94
MCH-34.1* MCHC-36.3* RDW-12.9
[**2197-8-28**] 06:17PM   UREA N-18 CREAT-1.1
[**2197-8-28**] 06:24PM   freeCa-0.99*
[**2197-8-28**] 06:17PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-8-28**] 06:24PM   HGB-10.3* calcHCT-31 O2 SAT-82 CARBOXYHB-1.6
MET HGB-0.1
[**2197-8-28**] 06:24PM   GLUCOSE-173* LACTATE-3.2* NA+-132* K+-3.3*
CL--105 TCO2-23

[**2197-8-28**] 07:32PM   HGB-8.6* calcHCT-26
[**2197-8-28**] 09:11PM   OSMOLAL-286
[**2197-8-28**] 09:11PM   CALCIUM-6.4* PHOSPHATE-3.5 MAGNESIUM-1.2*
[**2197-8-28**] 09:11PM   CK-MB-45* MB INDX-3.1 cTropnT-0.20*
[**2197-8-28**] 09:11PM   ALT(SGPT)-25 AST(SGOT)-49* CK(CPK)-1455* ALK
PHOS-29* TOT BILI-0.4
[**2197-8-28**] 09:11PM   GLUCOSE-209* UREA N-15 CREAT-0.7 SODIUM-133
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-20* ANION GAP-12

[**2197-8-29**]:
Glucose 205*, Urea Nitrogen 15, Creatinine 0.8, Sodium 133,
Potassium 3.1*, Chloride 105, Bicarbonate 21*, Anion Gap 10,
Creatine Kinase (CK)3864*, Creatine Kinase, MB Isoenzyme 118*,
CK-MB Index 3.1 % 0 - 6

Calcium, Total 6.8*  Phosphate 2.5*  Magnesium 2.2

Creatine Kinase (CK) 4314*   Creatine Kinase, MB Isoenzyme 99
CK-MB Index 2.3 %

[**2197-9-1**]:
Phenytoin 9.4* ug/mL

[**2197-9-5**]:
White Blood Cells 10.8
Red Blood Cells 3.29*
Hemoglobin 10.3*
Hematocrit 30.4* %
MCV 92 fL 82 - 98
MCH 31.4 pg 27 - 32
MCHC 34.0 % 31 - 35
RDW 15.0 % 10.5 - 15.5
Platelet Count 172 K/uL 150 - 440

[**2197-9-8**]:
Glucose 119*
Urea Nitrogen 13
Creatinine 0.6
Sodium 133
Potassium 3.4
Chloride 100
Bicarbonate 25
Anion Gap 11

Calcium, Total 7.9*
Phosphate 3.2
Magnesium 1.9

Hemoglobin A1c 6.1* %

Urine Color Yellow, Urine Appearance Clear
Specific Gravity 1.005
DIPSTICK URINALYSIS
Blood SM, Nitrite NEG, Protein NEG, Glucose NEG, Ketone NEG,
Bilirubin NEG, Urobilinogen NEG, pH 7.0, Leukocytes SM
MICROSCOPIC URINE EXAMINATION
RBC [**2-26**]*, WBC [**11-13**]*, Bacteria MANY, Yeast NONE, Epithelial
Cells <1, Transitional Epithelial Cells 0-2


Brief Hospital Course:
She was admitted to the trauma service; because of a positive
DPL and FAST exams she was immediately taken to the operating
room for exploratory laparotomy (see Pertinent results).
.
Neurosurgery was consulted because of the subdural hematoma;
this injury was nonoperative; serial head CT scans were
performed and were stable; neurologically she has remained
intact. She was fitted for a TLSO brace because of her L1
transverse process fracture. This will need to be worn at all
times while out of bed; while in bed if not worn she will need
to be log rolled. She will follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks
for repeat imaging.
.
Ophthalmology was consulted for ptosis of her right eye
following the crash; ?post traumatic CN III palsy; this was
nonoperative. She underwent CTA of her head and neck, no acute
processes were identified (see Pertinent results).
.
Her finger sticks were somewhat elevated throughout her hospital
stay 200's; she was placed on a sliding scale. There was no
documented history of Diabetes. She also experienced vertigo
during this admission; she was started on Meclizine which
improved the dizziness that she was experiencing. Physical
therapy worked with patient to assess for BPPV; the vertigo was
not reproducible with maneuvers.
.
She also experienced 2 days of nausea and vomiting; KUB did not
reveal any obstruction. She was placed on Reglan which was
eventually stopped; the Meclizine seemed to improve these
symptoms.  It was later discovered that she had a UTI and that
she has had frequent UTI's in the past and was planning on
having bladder suspension surgery in the future prior to her
admission.  This could be the reason for her elevated finger
sticks.  Ciprofloxacin for 10 days was started.
.
She tolerated a regular diet and her staples were removed and
steri-strips with benzoin were applied prior to her discharge to
her rehabilitation facility.

Medications on Admission:
HCTZ 25'
Toprol XL 100'
Accupril 20'

Discharge Medications:


1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
twice a day as needed for constipation.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose
Injection four times a day as needed for based on fingersticks
per sliding scale.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for SBP <110.
6. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for SBP <110.
7. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic  [**Hospital1 **] (2 times a day): Apply OD.
8. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) as needed for UTI for 10 days.
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO
DAILY (Daily) for 5 days.
13. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily):
hold for HR <60 and/or SBP <110.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
s/p Motor vehicle crash
Left subdural hematoma
Right 11th rib fracture
L1 transverse body fracture
Post traumatic CN III palsy


Discharge Condition:
Stable


Discharge Instructions:
Please take your medications as directed.  Please always have
your brace on unless you are lying flat in bed.  Please ask for
assistance in putting on your brace.  Please call for your
follow-up appointments as detailed.  Please call/return to [**Hospital1 18**]
if you have persistent pain, fever, nausea/vomit,
bleeding/drainage from your wound, dizziness and/or difficulty
breathing.

Followup Instructions:
Follow-up with plastic surgery clinic the Friday after
discharge. Call [**Telephone/Fax (1) 5343**] to schedule the appointment.

Follow up with Opthamology Resident Clinic in 1 week, call
[**Telephone/Fax (1) 253**] for an appointment.

Follow-up with Dr. [**Last Name (STitle) 548**], Neurosurgery in 5 weeks; call
[**Telephone/Fax (1) 1669**] to schedule the appointment. Inform the office that
you will also need A/P & Lateral Thoracic/Lumbar spine films for
this appointment.

Please follow-up with Trauma clinic, please call [**Telephone/Fax (1) 6429**]



Completed by:[**2197-9-11**]
{'Injury to other gastrointestinal sites, without mention of open wound into cavity,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Traumatic shock,Injury to multiple blood vessels of abdomen and pelvis,Closed fracture of T7-T12 level with unspecified spinal cord injury,Closed fracture of lumbar vertebra without mention of spinal cord injury,Urinary tract infection, site not specified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Closed fracture of one rib,Third or oculomotor nerve palsy, partial,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Ptosis of eyelid, unspecified,Hypertensive retinopathy,Esophageal reflux,Knee joint replacement'}


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: 70 year old female involved in a motor vehicle crash; intubated
at scene because of mental status changes; also was found to be
in shock with a distended abdomen. She had both a positive FAST
and DPL and was taken to the operating room directly from the
trauma bay for exploratory.

MEDICAL HISTORY: Hypertension
GERD
Bilateral knee replacements with post-op GI bleed

MEDICATION ON ADMISSION: HCTZ 25'
Toprol XL 100'
Accupril 20'

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: Tm/c: 100.2/100.2  HR: 97  BP: 160/80  RR: 18  O2sat: 97%RA

FAMILY HISTORY: Nonconttibutory

SOCIAL HISTORY:  

### Response:
{'Injury to other gastrointestinal sites, without mention of open wound into cavity,Subdural hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Traumatic shock,Injury to multiple blood vessels of abdomen and pelvis,Closed fracture of T7-T12 level with unspecified spinal cord injury,Closed fracture of lumbar vertebra without mention of spinal cord injury,Urinary tract infection, site not specified,Traumatic pneumothorax without mention of open wound into thorax,Other motor vehicle nontraffic accident involving collision with stationary object injuring driver of motor vehicle other than motorcycle,Closed fracture of one rib,Third or oculomotor nerve palsy, partial,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Ptosis of eyelid, unspecified,Hypertensive retinopathy,Esophageal reflux,Knee joint replacement'}
