CHIEF COMPLAINT: multiple traumatic wounds

PRESENT ILLNESS: 29 M presents as an OSH trauma transfer with an open right
clavicular fracture, through and through injury of right upper
arm without radial or ulnar pulses.  Per report, at ~ 3 PM
patient was at work unloading trash and was caught between the
trash truck and a large garbage bin.  The fork-lift portion of
the truck causes a through and through injury of his right upper
arm, left thigh and an open right clavicular fracture.  He was
transferred to [**Hospital1 18**] ED where there was questions of "thready
RUE
pulses".  On trauma evaluation he had no pulses or dopplerable
signals of his radial or ulnar artery.  In addition to his other
injuries, CTA demonstrates Thrombosis of the right subclavian
artery for 2 cm segment with reconstitution in the axillary
portion. No active extravasation.  He has right clavicular and
subscapular fractures as well.  Orthopedic surgery and [**Hospital1 **]
surgery were consulted.

MEDICAL HISTORY: NO PMH or PSH

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VSS, Afebrile

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Works full time on a trash truck - collecting curbside trash
Lives with girlfriend and 4yr old daughter. [**Name (NI) **] another child
but is not in contact with him.
Crushing injury of scapular region,Injury to innominate and subclavian arteries,Traumatic hemothorax without mention of open wound into thorax,Other complications due to other vascular device, implant, and graft,Open fracture of clavicle, unspecified part,Open fracture of scapula, unspecified part,Closed fracture of six ribs,Accidents caused by lifting machines and appliances,Accidents occurring in other specified places,Open wound of hip and thigh, without mention of complication,Other symptoms involving cardiovascular system,Tobacco use disorder
Crush inj scapul region,Inj innomin/subclav art,Traum hemothorax-closed,Comp-oth vasc dev/graft,Fx clavicle NOS-open,Fx scapula NOS-open,Fracture six ribs-closed,Lifting machine accident,Accident in place NEC,Open wound of hip/thigh,Cardiovas sys symp NEC,Tobacco use disorder
Admission Date:  [**2118-4-16**]              Discharge Date:   [**2118-4-29**]

Date of Birth:  [**2088-6-2**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
multiple traumatic wounds

Major Surgical or Invasive Procedure:
[**2118-4-16**]: Polytrauma with closure of open right upper extremity
shoulder wound, closure and washout of posterior right upper
extremity wound, washout and packing of neck wound and washout
and packing of left posterior buttock wound.

[**2118-4-16**]:
1. Right volar forearm compartment release (deep and
superficial).
2. Right mobile wad fasciotomy compartment release.

[**2118-4-16**]: Right subclavian artery to brachial artery bypass with
reverse saphenous vein graft.

[**2118-4-16**]:  Re-exploration of supraclavicular incision, right
arm incision with cutdown at distal bypass anastomosis and
attempted thrombectomy.  Additional cutdown at proximal
anastomosis with attempted thrombectomy.  Bypass anastomosis
repair and right upper extremity angiogram.


History of Present Illness:
29 M presents as an OSH trauma transfer with an open right
clavicular fracture, through and through injury of right upper
arm without radial or ulnar pulses.  Per report, at ~ 3 PM
patient was at work unloading trash and was caught between the
trash truck and a large garbage bin.  The fork-lift portion of
the truck causes a through and through injury of his right upper
arm, left thigh and an open right clavicular fracture.  He was
transferred to [**Hospital1 18**] ED where there was questions of "thready
RUE
pulses".  On trauma evaluation he had no pulses or dopplerable
signals of his radial or ulnar artery.  In addition to his other
injuries, CTA demonstrates Thrombosis of the right subclavian
artery for 2 cm segment with reconstitution in the axillary
portion. No active extravasation.  He has right clavicular and
subscapular fractures as well.  Orthopedic surgery and [**Hospital1 **]
surgery were consulted.


Past Medical History:
NO PMH or PSH

Social History:
Works full time on a trash truck - collecting curbside trash
Lives with girlfriend and 4yr old daughter. [**Name (NI) **] another child
but is not in contact with him.

Smokes cigarettes and marijuana, uses etoh on a regular basis

Family History:
non contributory

Physical Exam:
VSS, Afebrile

Gen: Thin 29yom in no acute distress, alert and oriented x 3
HEENT: Right eye with subconjunctival hemorrhage, PERRLA, neck
supple no jvd
CV: RRR
Lungs: CTA bilat
Abd: Soft no m/t/o
Extremities: Right upper extremity with large puncture wound -
packed with 4x8 wet to dry gauze. Also closed bypass wound,
c/d/i no erythema or drainage. Left thigh with multiple puncture
wounds. Large posterior wound with 2 track, packed wet to dry
kerlex, no erythema or draiange, 2 smaller wounds on lateral
left thigh, packed with wet to dry, no erythema or drainage.

Pertinent Results:
[**2118-4-29**] 07:50AM BLOOD

WBC-11.7* RBC-3.55* Hgb-10.7* Hct-32.1* MCV-90 MCH-30.2
MCHC-33.4 RDW-16.6* Plt Ct-710*

[**2118-4-26**] 07:40AM BLOOD

PT-11.9 PTT-26.7 INR(PT)-1.1

[**2118-4-26**] 07:40AM BLOOD

Glucose-92 UreaN-14 Creat-0.5 Na-133 K-4.3 Cl-100 HCO3-25
AnGap-12

[**2118-4-18**] 08:10PM BLOOD

CK(CPK)-[**Numeric Identifier 66437**]*

[**2118-4-26**] 07:40AM BLOOD

Calcium-7.5* Phos-3.5 Mg-2.1

[**2118-4-27**] 11:34AM URINE

Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010

[**2118-4-27**] 11:34AM URINE

Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG

[**2118-4-22**] 10:31PM

URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
URINE CastGr-7*
URINE AmorphX-OCC CaOxalX-OCC

[**2118-4-24**] 12:45 pm SWAB      Source: posterior R arm.

GRAM STAIN (Final [**2118-4-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2118-4-26**]):    NO GROWTH.
ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

CTA:

[**Known lastname **],[**Known firstname **] [**Medical Record Number 92580**] M  [**6-12**]

Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2118-4-24**] 2:19 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2118-4-24**] 2:19 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD & PELVIS   Clip #
[**Clip Number (Radiology) 92581**]
Reason: please eval bilateral upper extremities, chest, and
include
Contrast: OMNIPAQUE Amt: 130



[**Hospital 93**] MEDICAL CONDITION:
   29 year old man impaled by trash forklift w/ pulseless RUE
s/p R subclavian a.
   jump graft w/ saphenous vein, ORIF Right Clavicle now s/p
bypass exploration,
   and R arm fasciotomies
REASON FOR THIS EXAMINATION:
   please eval bilateral upper extremities, chest, and include
left thigh/buttock,
   eval for abscess, fluid collection, bypass
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Final Report
CTA TORSO WITH CONTRAST

DATE: [**2118-4-24**].

COMPARISON: [**2118-4-15**].

CLINICAL INDICATION: 29-year-old male impaled by trash forklift
with
pulseless right upper extremity, status post right subclavian
artery jump
graft with saphenous vein. ORIF right clavicle. Now status post
bypass
expiration and right arm fasciotomies. Please evaluate bilateral
upper
extremities, chest and include left thigh/buttocks.

TECHNIQUE: MDCT axial images of the chest, right arm, abdomen,
pelvis and
thighs were obtained after the uneventful intravenous
administration of 130 mL
Omnipaque. Images were acquired in the arterial phase. Coronal
and sagittal
reformatted images were constructed.

TOTAL EXAM DLP: 1456.02 mGy-cm.

FINDINGS:

RIGHT UPPER EXTREMITY: There has been interval placement of a
right
subclavian artery jump graft with harvested right saphenous
vein. The graft
is well opacified, as are the upper extremity arteries. Contrast

opacification of the arteries within the hands is slightly
limited secondary
to phase and field of view, however, ulnar and radial arteries
to the level of
the hand are patent. There is mild heterogeneity of medial
aspect of the
biceps muscle in the upper arm, likely related to trauma.
Subcutaneous
stranding is also noted in the upper arm. There is fasciotomy
defect
posteriorly with air tracking into the posterior compartment.

CHEST: Redemonstrated are extensive osseous fractures involving
the right
ribs, clavicle now status post open reduction and internal
fixation and
scapula. The scapula is highly comminuted, with fracture line
extending along
the anterior margin of the glenoid/coracoid junction. The
coracoid is a
complete separate fragment. The clavicular malleable side plate
and screws
appear uncomplicated. Multiple foci of subcutaneous air are
present, although
decreased in number from the prior examination.

Of note, the venous system is non-opacified given the early
arterial phase of
imaging and thus the right axillary vein could not be
reassessed. This was at
least significantly compressed for a long segment in the area of
the
subclavian/axillary artery injury on the prior examination.

There is an increasing right pleural effusion, now small to
moderate size.
This measures higher than simple fluid in Hounsfield units,
although definite
hematocrit level is not identified. There is compressive
atelectasis on the
right lower lobe basilar segments. There is no evidence of
active
extravasation into the pleural fluid, although again, there are
multiple
displaced rib fractures on the right. The lungs are otherwise
clear without
evidence of infection or aspiration. The thyroid gland is within
normal
limits. The aorta and central pulmonary arteries are normal. The
heart is
normal in size. There is no pericardial effusion.

The left arm was not included in the field of view.

ABDOMEN: The liver, pancreas, gallbladder, spleen, adrenal
glands, and
kidneys are within normal limits. The kidneys enhance
symmetrically without
hydronephrosis. The abdominal aorta is normal in caliber with
patent
branches. Bowel loops are within normal limits. There is no
mesenteric or
retroperitoneal adenopathy or free fluid.

PELVIS: The bladder, prostate, seminal vesicles, and rectum are
within normal
limits. Pelvic bowel loops including the appendix are within
normal limits.
There is no inguinal or pelvic adenopathy. There is no free
fluid within the
pelvis. No pneumoperitoneum.

LOWER EXTREMITIES:

LEFT LOWER EXTREMITY: There is a new large upper thigh hematoma
lateral and
posterior to the muscles within the subcutaneous tissues. There
is
high-density material posteriorly, most consistent with active
extravasation
of contrast (2:275-298). Posteriorly and laterally, there are
two large
lacerations. The hematoma is heterogeneous in appearance with
multiple
scattered foci of air throughout. Subcutaneous emphysema tracks
anteriorly
along the anterior compartment. The left thigh hematoma measures

approximately 28 cm in craniocaudal dimension with combined
curvilinear AP and
transverse dimensions of 19.4 cm. There are no large vessels
leading to the
area of active extravasation in the thigh.

There is heterogeneity and enlargement in the quadriceps,
particularly
superolaterally (2:273-300).

RIGHT LOWER EXTREMITY: Surgical skin staples are present,
consistent with
saphenous vein harvesting. There is stranding and fluid within
the underlying
subcutaneous tissues with a small fluid collection measuring
approximately 2.6
x 1.7 cm, likely postoperative seroma given low density in
Hounsfield units.

CTA:

IMPRESSION:

1. New large left thigh hematoma with suspected arterial active
extravasation.
2. Patent right subclavian jump graft with good opacification of
the radial and ulnar arteries.
3. Arterial phase of imaging precludes evaluation of the right
subclavian and axillary veins which appeared at least
significantly compressed at the area of the right subclavian
artery injury on the prior examination.
4. Extensive displaced right rib fractures, comminuted scapular
fracture and comminuted clavicular fracture status post ORIF of
the clavicle.
5. Enlarging right pleural effusion which measures higher than
simple fluid in Hounsfield units, raising concern for an element
of hemothorax. This can be followed with chest radiographs and
serial hematocrits.
6. Post-surgical changes consistent with saphenous vein
harvesting from the right lower extremity with small
postoperative seroma.

CXR:

Cardiomediastinal contours are normal. There is persistent
collapse of the right lower lobe. Right pleural effusion is
unchanged. The left lung is clear. Right upper lobe opacity is
unchanged. This could be atelectasis and/or aspiration. Multiple
right rib fractures are again noted.

CT SCAN HEAD:

FINDINGS: No acute intracranial hemorrhage, large [**Year (4 digits) 1106**]
territory infarct, shift of midline structures or mass effect is
present. The ventricles and sulci are normal in size and
configuration. The visible paranasal sinuses and mastoid air
cells are well aerated.

IMPRESSION: No acute intracranial process.




Brief Hospital Course:
The patient was admitted to the [**Year (4 digits) **] surgery service on
[**2118-4-16**] for a traumatic encounter with Garbage truck. Pt
underwent emergent surgery:

[**2118-4-16**]:
PROCEDURE:
1. Right volar forearm compartment release (deep and
    superficial).
2. Right mobile wad fasciotomy compartment release.

[**2118-4-16**]:
PROCEDURE: R CLavicle repair with fixation

[**2118-4-16**]:
POSTOPERATIVE:  Closure of open right upper extremity shoulder
wound, closure and washout of posterior right upper extremity
wound, washout and packing of
neck wound and washout and packing of left posterior buttock
wound.

[**2118-4-16**]:
PROCEDURE:  Right subclavian artery to brachial artery bypass
with reverse saphenous vein graft.

[**2118-4-16**]: PROCEDURE:  Re-exploration of supraclavicular incision,
right
arm incision with cutdown at distal bypass anastomosis and
attempted thrombectomy.  Additional cutdown at proximal
anastomosis with attempted thrombectomy.  Bypass anastomosis
repair and right upper extremity angiogram.

Pt extubated, transferred to the CVICU in stable condition. See
below for details involving hospital course by systems.

Neuro: Pt initially underwent CT scan which was negative. The
patient received Dilaudid IV/PCA with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications.

CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.

Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Pt with known R
hemothorax. IP was consulted for the hemothorax. Nothing to do
stable. encourage ambulation with IS.

GI: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel regimen
to encourage bowel movement.

GU: Foley was removed on POD#5. Intake and output were closely
monitored. On DC pt is urinating.

ID: The patient was started on Vanco / Cipro / Flagyl. He
remained on this during his hospital course. On DC he will be
swithched to PO Augmentin and PO Flagyl. The patient's
temperature was closely watched for signs of infection. He did
have an increase in WBC's to 20's. This was thought to be
attributed to the lung process or hematoma. On DC he is afebrile
with a 11K WBC.

HEME: Pt Hct was moniterd. Initially pt on Heparin / Coumadin
for his BPG. This was stopped for continous low HCT, his RBC
were repleted multiple of times. Pt had CTA to determine source
of bleed. There was blush of contrast in the left thigh. Because
of this his anticoagulation was stopped. He did recieve FFP and
Vit K for this blush. Once anticoagulation was stopped and pt
was given blood. His HCT remained stable. He is to be discharged
on ASA.

Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.

At the time of discharge on POD#13, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.

Medications on Admission:
none

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dryness,
irritation.
Disp:*30 mL* Refills:*0*
3. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 1 weeks: do not drink alcohol while taking this medication .
Disp:*21 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO four times
a day.
Disp:*100 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take this while on narcotics.
Disp:*60 Capsule(s)* Refills:*0*
7. Shower Chair
To be used for sponge baths until multiple traumatic wounds are
healed
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation .
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Dilaudid 2 mg Tablet Sig: 1-3 Tablets PO q3h as needed for
pain.
Disp:*200 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
1. Polytrauma with multiple puncture wounds
2. Right arm and upper torso crush injury with associated injury
to right subclavian artery.
3. Open right clavicle fracture with right upper extremity crush
injury
4. Multiple right sided rib fractures
5. Left thigh hematoma with large open traumatic wound
6. Left Hemothorax


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery Discharge
Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Do not bear any weight on right upper extremity: you may do
exercises with OT and on your own, but should not push/pull or
use that arm to help you get up
??????	Get up and walk around as much as possible.

2. It is normal to have swelling of the arm you were operated
on:
??????	Elevate your arm above the level of your heart every 2-3 hours
throughout the day and at night

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	Eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	You should get up every day, get dressed and walk
??????	You should gradually increase your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling until your post op visit
??????	You have multiple wounds that will need to be packed by a
visitin nurse.  You may shower when dressings are removed, but
no direct spray on incision, let the soapy water run over
incision, rinse and pat dry
??????	Your Right upper arm wound will be packed with wet to dry 4x8
gauze, your Left posterior thigh wound (the largest wound) is to
be packed with wet to dry kerlex and your other superficial left
thigh wounds can be packed with wet to dry 2x2 gauze.
??????	Take all the medications you are prescribed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Keep follow up appointments

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2118-5-25**]
11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2118-5-25**] 12:20

You have an appointment with DR [**First Name (STitle) 4223**] (Orthopedics) for
suture removal. Monday [**1006-5-2**], [**Hospital Ward Name 23**] Buliding [**Location (un) 1385**].



Completed by:[**2118-4-29**]
{'Crushing injury of scapular region,Injury to innominate and subclavian arteries,Traumatic hemothorax without mention of open wound into thorax,Other complications due to other vascular device, implant, and graft,Open fracture of clavicle, unspecified part,Open fracture of scapula, unspecified part,Closed fracture of six ribs,Accidents caused by lifting machines and appliances,Accidents occurring in other specified places,Open wound of hip and thigh, without mention of complication,Other symptoms involving cardiovascular system,Tobacco use disorder'}


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: multiple traumatic wounds

PRESENT ILLNESS: 29 M presents as an OSH trauma transfer with an open right
clavicular fracture, through and through injury of right upper
arm without radial or ulnar pulses.  Per report, at ~ 3 PM
patient was at work unloading trash and was caught between the
trash truck and a large garbage bin.  The fork-lift portion of
the truck causes a through and through injury of his right upper
arm, left thigh and an open right clavicular fracture.  He was
transferred to [**Hospital1 18**] ED where there was questions of "thready
RUE
pulses".  On trauma evaluation he had no pulses or dopplerable
signals of his radial or ulnar artery.  In addition to his other
injuries, CTA demonstrates Thrombosis of the right subclavian
artery for 2 cm segment with reconstitution in the axillary
portion. No active extravasation.  He has right clavicular and
subscapular fractures as well.  Orthopedic surgery and [**Hospital1 **]
surgery were consulted.

MEDICAL HISTORY: NO PMH or PSH

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VSS, Afebrile

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Works full time on a trash truck - collecting curbside trash
Lives with girlfriend and 4yr old daughter. [**Name (NI) **] another child
but is not in contact with him. 

### Response:
{'Crushing injury of scapular region,Injury to innominate and subclavian arteries,Traumatic hemothorax without mention of open wound into thorax,Other complications due to other vascular device, implant, and graft,Open fracture of clavicle, unspecified part,Open fracture of scapula, unspecified part,Closed fracture of six ribs,Accidents caused by lifting machines and appliances,Accidents occurring in other specified places,Open wound of hip and thigh, without mention of complication,Other symptoms involving cardiovascular system,Tobacco use disorder'}
