CHIEF COMPLAINT: Polytrauma/Motor vehicle collision

PRESENT ILLNESS: Patient is a 21F pedestrian struck transferred from OSH via
[**Location (un) **] with multiple traumatic injuries.  She was in usual
state of good health prior to being struck by motor vehicle and
reportedly dragged a distance of 100 feet.  Patient required
intubation in the field prior to transport to OSH.  At OSH
patient was resuscitated with 4L crystalloid and transferred to
[**Hospital1 18**] for further management after plain films obtained.
Reported injuries on arrival include multiple C spine fractures,
L humerous fxs, pelvic fx, liver
lacerations and degloving of her L foot.

MEDICAL HISTORY: PMH: None
PSH: None
[**Last Name (un) 1724**]: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: HR: 95 BP: 105/76 Resp: 18 O(2)Sat: 100 Normal
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B/L radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient is from [**Location (un) 2848**] and recently graduated from NYU.  Tobacco:
Denies.  EtOH: Social.  Drugs: Denies.
Multiple closed pelvic fractures with disruption of pelvic circle,Dissection of vertebral artery,Contusion of lung without mention of open wound into thorax,Closed fracture of C5-C7 level with unspecified spinal cord injury,Injury to liver without mention of open wound into cavity laceration, unspecified,Traumatic pneumohemothorax without mention of open wound into thorax,Acute posthemorrhagic anemia,Closed fracture of multiple cervical vertebrae,Acidosis,Closed fracture of unspecified part of upper end of humerus,Closed dislocation, sternum,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian,Street and highway accidents,Open wound of foot except toe(s) alone, complicated,Open wound of abdominal wall, anterior, without mention of complication,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection
Pelv fx-clos/pelv disrup,Dissect vertebral artery,Lung contusion-closed,C5-c7 fx-cl/cord inj NOS,Liver lacerat unspcf cls,Traum pneumohemothor-cl,Ac posthemorrhag anemia,Fx mult cervical vert-cl,Acidosis,Fx up end humerus NOS-cl,Dislocat sternum-closed,Mv coll w pedest-pedest,Accid on street/highway,Open wound foot-compl,Opn wnd anterior abdomen,Open wnd knee/leg/ankle,Abrasion NEC
Admission Date:  [**2112-8-14**]              Discharge Date:   [**2112-9-2**]

Date of Birth:  [**2090-8-30**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Polytrauma/Motor vehicle collision

Major Surgical or Invasive Procedure:
[**2112-8-15**]:
1. Open reduction internal fixation posterior pelvic ring
    with bilateral sacroiliac screws.
2. Anterior fixation pelvic ring with external fixator with
    closed reduction manipulation.
3. Open reduction internal fixation of right
    sternoclavicular joint.
4. Manipulation with manually applied stress under fluorosocopy
for assessment of pelvis joint stability

[**2112-8-17**]:
1. Posterolateral arthrodesis C3-C6.
2. Posterolateral instrumentation C3-C6.
3. Open treatment of fracture of C4, C5, C3.
4. Application of allograft and local autograft.
5. IVC filter placement

[**2112-8-20**]:
1. Open reduction internal fixation left humerus
fracture with 3.5 mm proximal humerus locking plate.
[**2112-8-24**]
1. Surgical preparation and irrigation and debridement of
    left dorsal foot wound area, 16 x 8 cm.
2. Partial closure of the distal foot wound over an area of
    4 cm.
3. Placement of vacuum-assistant closure device, 16 x 6 cm.

[**2112-8-25**]
1. Wide tangential debridement of left leg and left foot
    (greater than 400 cm2).
2. Local flap to left foot.
3. Split-thickness skin graft to left foot (20.0 cm x 8.0
    cm).
4. Split-thickness skin graft to left leg (40.0 cm x 10. 0
    cm).
5. Debridement and delayed primary closure of right lower
    quadrant of abdomen (15.0 cm).


History of Present Illness:
Patient is a 21F pedestrian struck transferred from OSH via
[**Location (un) **] with multiple traumatic injuries.  She was in usual
state of good health prior to being struck by motor vehicle and
reportedly dragged a distance of 100 feet.  Patient required
intubation in the field prior to transport to OSH.  At OSH
patient was resuscitated with 4L crystalloid and transferred to
[**Hospital1 18**] for further management after plain films obtained.
Reported injuries on arrival include multiple C spine fractures,
L humerous fxs, pelvic fx, liver
lacerations and degloving of her L foot.

Past Medical History:
PMH: None
PSH: None
[**Last Name (un) 1724**]: None

Social History:
Patient is from [**Location (un) 2848**] and recently graduated from NYU.  Tobacco:
Denies.  EtOH: Social.  Drugs: Denies.

Family History:
Non-contributory

Physical Exam:
HR: 95 BP: 105/76 Resp: 18 O(2)Sat: 100 Normal
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B/L radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect


Pertinent Results:
LABORATORIES:
(Admission)
[**2112-8-14**] 12:50AM BLOOD WBC-12.0* RBC-2.89* Hgb-9.3* Hct-27.3*
MCV-94 MCH-32.2* MCHC-34.1 RDW-12.7 Plt Ct-272
[**2112-8-14**] 12:50AM BLOOD PT-13.9* PTT-28.8 INR(PT)-1.2*
[**2112-8-14**] 04:19AM BLOOD Glucose-130* UreaN-18 Creat-0.5 Na-142
K-4.3 Cl-114* HCO3-18* AnGap-14
[**2112-8-14**] 04:19AM BLOOD Calcium-6.8* Phos-3.6 Mg-1.7
[**2112-8-14**] 05:09AM BLOOD Type-ART Temp-35.6 Rates-/24 Tidal V-350
PEEP-5 FiO2-50 pO2-218* pCO2-41 pH-7.26* calTCO2-19* Base XS--8
-ASSIST/CON Intubat-INTUBATED
[**2112-8-14**] 12:59AM BLOOD Glucose-115* Lactate-2.0 Na-139 K-3.6
Cl-114* calHCO3-17*

MICROBIOLOGY:
MRSA Screen - Negative

IMAGING:
CT Head [**8-14**]: Cephalohematoma. No evidence of intracranial
injury

CT C/A/P [**8-14**]: 1. Mult fxs involving sternoclavicular joints, L
humerus,
chest wall, spine, and pelvis. 2. Severe pulmonary injury, w mod
L and trace R pneumothoraces. 3. Severe liver injury, w
loculated surrounding hematoma 4. No evidence active vascular
extravasation.

CT C-spine [**8-14**]: 1. C3-C5 R lamina and pedicle fxs. 2. Bony
fragment C4 transverse foramen w ? vertebral artery injury 3.
C6-T2 spinous process fxs. Epidural high attenuation was
demonstrated to be artifactual on subsequent MR. 4. B/L
pulmonary hemorrhage, w moderate L and trace R
pneumothoraces.

CTA Neck [**8-16**]: 1. Complete occlusion nondominant R vertebral
artery at C4-C6 levels, spanning 4.1 cm, and irregularity of R
vertebral artery at C7,
likely [**3-9**] intramural hematoma/dissection, given cervical fxs at
involved levels.  2. Upper mediastinal hematoma

B/L LE US [**8-16**]: No evidence of lower extremity DVT.

PATHOLOGY: None

Brief Hospital Course:
The patient was admitted to the acute care surgery service on
[**2112-8-14**] for management of multiple traumatic injuries associated
with motor vehicle collision.  Patient arrived via [**Location (un) **] as
transfer from OSH intubated.  ATLS protocol initiated and
patient had clinical course as follows:
Admitted to the Trauma ICU.
Neuro: Patient arrived intubated/sedated from OSH.  Sedation
regimen adjusted over course of intubation to minimize
hypotension secondary to sedation.  Remained intubated for
multiple orthopedic procedures and was extubated without
incident [**8-18**].  Chronic pain service was consulted [**8-19**] who made
recommendations regarding patient's analgesic regimen.  Regimen
consisted of long/short acting narcotics as well as topical
anesthetic creams for road rash.  Regimen was effective and well
tolerated.

Noted to have multiple cervical fractures as noted above though
no focal neurologic deficits.  Patient was kept on logroll
precautions related to this.  Patient was brought to OR by [**Month/Year (2) **]
spine [**8-17**] for cervical fusion which was tolerated well.  Given
c-spine injuries vascular imaging of neck was pursued that
showed dissection of R vertebral artery with occlusion over 4cm
segment at level of C4.  Logroll was discontinued following
surgical stabilization.  A soft collar was recommended until she
is evaluated at her follow up appointment.  Neuro-stroke and
neurosurgery were consulted regarding management of this who
recommended ASA 325 daily for six months with a follow up MRA in
three months time.

CV: On arrival the patient was hypovolemic with hypotension and
oliguria.  Patient was resuscitated with multiple boluses of
crystalloid IVF over first 48 hours of admission.  Four units
pRBCs (2 in ED, 2 in TSICU) were transfused on HD#1 with
stabilization of Hct following this.  Three additional units
pRBC were transfused [**8-17**] as hct drifted down from 32 ([**8-15**]) to
23([**8-17**]).  Hct bumped appropriately and hct remained stable
throughout remainder of admission.  The patient was persistently
in sinus tachycardia throughout admission with pulse ranging
from 100s to 110s.  The patient was stable from a cardiovascular
standpoint; vital signs were routinely monitored.

Pulmonary: On arrival patient was intubated and noted to have a
L pneumothorax and B/L pulmonary contusions.  Left chest tube
was placed in the ED.  ET tube was upsized [**8-16**] as 6.5 tube was
placed in field.  Chest tube was removed [**8-18**] upon extubation.
Pulmonary toilet including incentive spirometry.  The patient
was stable from a pulmonary standpoint; vital signs were
routinely monitored.

GI/GU: On arrival patient was resuscitated as above.  Patient
was given IV fluids until tolerating oral intake.  Tube feeds
via OGT were initiated [**8-16**].  These were tolerated well.  OGT
was removed [**8-17**].  Regular diet was started [**8-18**] following
extubation and patient tolerated this without issue.  Extensive
bowel regimen was given secondary to narcotic usage and passed
bowel movements without issue.

Liver laceration was sustained at time of injury though no
active extravasation was seen on CT scan.  Serial hcts were
monitored as above.  Transfusions administered though unlikely
that blood loss was related to hepatic injury.  LFTs were noted
to be elevated [**2115-8-17**] though this was as expected given known
injury.

Foley was placed at OSH and maintained until [**2112-8-24**].  Currently
she is voiding without difficulty.  Lasix was given [**8-17**] to
assist in diuresis and this had good effect.  Patient
auto-diuresed following this.  Intake and output were closely
monitored.

MSK: Patient had injuries as listed above including c-spine
fractures (see neuro), sternoclavicular dislocations
bilaterally, pelvic fractures and degloving of L LE.  Patient
was taken to OR by [**Month/Year (2) **] for anterior pelvic ex fix and
posterior ORIF [**8-15**] and this was tolerated well.  Displaced
right sternoclavicular joint was reduced as well secondary to
compression of adjacent subclavian artery and vein.  Mediastinal
hematoma was stable both pre and post procedure.  Weight bearing
status at that time was non-weight bearing in B/L lower
extremities.  Returned to OR [**8-20**] for repair of proximal L
humerus fracture and patient was kept non-weight bearing in
upper extremities as well. She is however able to feed herself
with her right hand.

She developed a thrombocytosis over the last 12-12 days likely a
reaction to her multiple trauma and operations.  Currently her
platelet count is in the 1200 range and she is on 325 mg aspirin
daily which will continue.

Podiatry initially followed patient for superficial injuries to
left foot.  Their recommendations for wound management were
followed.  Plastic surgery was also consulted for management of
exposed tendon and have recommended operative managment. Care of
this was then assumed by Plastics. She was taken to the
Operating Room on [**8-24**] and [**8-25**] for debridement, closure then
skin grafting to the dorsum of the left foot. See formal op note
for details.  She tolerated the procedures well with minimal
pain.  The donor site is clean and healing well and the left
foot is healing well with the graft pink without drainage.

Physical therapy and Occupational therapy services were
consulted and followed her closely during her stay to maintain
some functional mobility,and review transfers.  she will need
vigorous therapy once she is able to increase her weight bearing
status.

ID: Perioperative antibiotics were administered as appropriate
for patient's procedures.  No signs of infection were present
during this admission.  The patient's temperature was closely
watched for signs of infection.

Prophylaxis: Given mediastinal hematoma and concern for bleed
the patient was maintained with SCDs only until [**8-16**].  LENIs
performed B/L LE [**8-17**] and these were negative for DVT.  They
were performed again on [**2112-9-1**] to the left leg as she
complained of left calf pain however they were again negative.
Given concern for immobility during recovery period an IVC
filter was placed [**8-17**].  GI prophylaxis was given until
tolerating regular diet.

At the time of discharge on [**2112-9-2**], the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet and
her pain was well controlled.


Medications on Admission:
None

Discharge Medications:
1. lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical DAILY
(Daily): Mix w/ silver sulfadiazine and apply to left buttock.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO at bedtime as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
7. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for deep skin excoriation: apply to
excoriated areas on legs, bck and buttock.
8. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 10 days.
11. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
12. multivitamin,tx-minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
14. morphine 15 mg Tablet Extended Release Sig: Three (3) Tablet
Extended Release PO Q8H (every 8 hours).
15. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for break-through pain.
16. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pains.
19. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
S/P Motor vehicle crash
Injuries:
1. Cervical spine fractures (a-Fracture with floating mass C4;
b-Fracture with floating mass C5; c-Laminar fracture C3;
d-Spinous process fracture of C6 and C7)
2. Right vertebral artery dissection with associated thrombotic
occlusion
3. Bilateral sternoclavicular dislocations
4. Left pneumothorax
5. Grade 3 segment VII liver laceration
6. Windswept pelvic fracture (Bilateral pelvic ring fracture
with sacroiliac dissociation and anterior bilateral rami
fractures)
7. Proximal left humerus fracture
8. Extensive abrasions/road rash to back/buttocks, bilateral
lower extremities
9. Full thickness laceration/skin defect dorsal aspect left foot
with extensor tendon exposure
10.Acute blood loss anemia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the acute care surgery service for
management of multiple traumatic injuries sustained in setting
of motor vehicle collision. You required several operations to
fix your spine and extremity fractures. Becasue of the severity
of your injuries it is being recommended that you not bear any
weight on any of your extremtiies for at least the next [**5-13**]
weeks. Upgrade of your activity status will be determined by the
Orthopedic doctors. A device called and IVC filter was placed
into the major vein in your abdomen; this device is used to
catch any blood clots that may come from your lower extremties
as a result of your limited mobility.



Followup Instructions:
Call Dr. [**Last Name (STitle) 5385**] at from Plastic Surgery at [**0-0-**] for a
follow up appointment in 1 week.

Also, follow up with the providers below:

[**Year (4 digits) **] SPINE:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2112-9-5**] 12:20
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2112-9-5**] 12:40

ORTHOPEDICS: Call [**Telephone/Fax (1) 1228**] for an appointment in 2 weeks.

NEURO-STROKE:
Please arrange for MRA Neck in 3 months ([**2112-11-5**]) and
follow up with Neuro-stroke team regarding right vertebral
artery occlusion/dissection.  [**Doctor First Name **] [**Doctor Last Name **] (attending) You
can call [**Telephone/Fax (1) 44**] to arrange this.

Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] upon discharge to
arrange a follow up appointment in [**4-8**] months. Office is located
at [**Hospital1 18**], [**Hospital 2577**] Medical Office Building, [**Location (un) **].



Completed by:[**2112-9-2**]
{'Multiple closed pelvic fractures with disruption of pelvic circle,Dissection of vertebral artery,Contusion of lung without mention of open wound into thorax,Closed fracture of C5-C7 level with unspecified spinal cord injury,Injury to liver without mention of open wound into cavity laceration, unspecified,Traumatic pneumohemothorax without mention of open wound into thorax,Acute posthemorrhagic anemia,Closed fracture of multiple cervical vertebrae,Acidosis,Closed fracture of unspecified part of upper end of humerus,Closed dislocation, sternum,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian,Street and highway accidents,Open wound of foot except toe(s) alone, complicated,Open wound of abdominal wall, anterior, without mention of complication,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection'}


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: Polytrauma/Motor vehicle collision

PRESENT ILLNESS: Patient is a 21F pedestrian struck transferred from OSH via
[**Location (un) **] with multiple traumatic injuries.  She was in usual
state of good health prior to being struck by motor vehicle and
reportedly dragged a distance of 100 feet.  Patient required
intubation in the field prior to transport to OSH.  At OSH
patient was resuscitated with 4L crystalloid and transferred to
[**Hospital1 18**] for further management after plain films obtained.
Reported injuries on arrival include multiple C spine fractures,
L humerous fxs, pelvic fx, liver
lacerations and degloving of her L foot.

MEDICAL HISTORY: PMH: None
PSH: None
[**Last Name (un) 1724**]: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: HR: 95 BP: 105/76 Resp: 18 O(2)Sat: 100 Normal
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B/L radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers
PSYCH: normal judgment/insight, normal memory, normal
mood/affect

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient is from [**Location (un) 2848**] and recently graduated from NYU.  Tobacco:
Denies.  EtOH: Social.  Drugs: Denies. 

### Response:
{'Multiple closed pelvic fractures with disruption of pelvic circle,Dissection of vertebral artery,Contusion of lung without mention of open wound into thorax,Closed fracture of C5-C7 level with unspecified spinal cord injury,Injury to liver without mention of open wound into cavity laceration, unspecified,Traumatic pneumohemothorax without mention of open wound into thorax,Acute posthemorrhagic anemia,Closed fracture of multiple cervical vertebrae,Acidosis,Closed fracture of unspecified part of upper end of humerus,Closed dislocation, sternum,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian,Street and highway accidents,Open wound of foot except toe(s) alone, complicated,Open wound of abdominal wall, anterior, without mention of complication,Open wound of knee, leg [except thigh], and ankle, without mention of complication,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection'}
