CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 41-year-old
male who was found down, likely struck by motor vehicle, with
obvious open tibia fibula fracture.  The patient was
intubated at the scene for unresponsiveness and transported
to the [**Hospital6 256**] for further
evaluation.  In the Emergency Department, the patient was
paralyzed for further combativeness, however was noted to be
moving all four extremities.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Open fracture of shaft of fibula with tibia,Closed fracture of scapula, unspecified part,Closed fracture of sixth cervical vertebra,Closed fracture of one rib,Alcohol abuse, unspecified,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian
Fx shaft tibia w fib-opn,Fx scapula NOS-closed,Fx c6 vertebra-closed,Fracture one rib-closed,Alcohol abuse-unspec,Mv coll w pedest-pedest
Admission Date:  [**2132-5-22**]       Discharge Date:  [**2132-6-6**]

Date of Birth:   [**2090-11-28**]       Sex:  M

Service:  Plastic Surgery

HISTORY OF PRESENT ILLNESS:  The patient is a 41-year-old
male who was found down, likely struck by motor vehicle, with
obvious open tibia fibula fracture.  The patient was
intubated at the scene for unresponsiveness and transported
to the [**Hospital6 256**] for further
evaluation.  In the Emergency Department, the patient was
paralyzed for further combativeness, however was noted to be
moving all four extremities.

At time of admission, past medical history, allergies and
medications were unknown, however the patient does not have
any medical history, had no known drug allergies and took no
medications at home.

PHYSICAL EXAMINATION:
GENERAL:  The patient was intubated and sedated.
VITAL SIGNS:  Temperature of 97.4??????, pulse of 100, blood
pressure 127/52, respirations 10 to 14.  He was saturating
100%.
The remainder of the physical exam was significant for some
obvious crepitus of the left upper extremity.  Also
significant for an open tibia fibula fracture with a 12 cm x
9 cm open wound just distal to the left knee with bone
protruding out of the wound.  He had a 1+ probable dorsalis
pedis pulse.  There was no palpable posterior tibial pulse.
Also, it was noted that the patient had poor rectal tone by
report.

SIGNIFICANT LABORATORIES:  White blood cell count 7.6,
hematocrit 38.6, platelets 310.  INR 1.1, sodium 139,
potassium 3.5, chloride 104, bicarbonate 19, BUN 8,
creatinine 0.9, glucose 164, amylase 89, alcohol 439.

IMAGING:  Multiple radiographic studies were obtained and
some of the following were positive:  Trauma series showed
what was thought to be a possible unstable teardrop fracture
of C6.  There was also a comminuted fracture of the left
scapula and left distal clavicle.  Pelvis showed no
fractures.  CT scan of the head showed no acute intracranial
injuries, however it did show an apparent rotatory
subluxation of C1 on C2, question of a teardrop fracture of
C6.  CT scan of the chest showed bilateral first rib
fractures posteriorly, a comminuted fracture of the left
scapula, distal left clavicular fracture and posterior
bibasilar atelectasis.  CT of the abdomen showed no acute
bleeds or organ damage.  Other significant radiographic
findings were a left tibial comminuted fracture, as well as a
left fibular fracture.

HOSPITAL COURSE:  Because of the nature of the patient's
lower extremity injuries, the patient was brought immediately
to the Operating Room for debridement, as well as external
fixation of his left tibia fibula open fractures.  Following
patient's operation, he was admitted to the Surgical
Intensive Care Unit.  While in the Intensive Care Unit, he
remained intubated for several days and required intravenous
antibiotics, including gentamicin and Kefzol.

Following his initial operation, the patient's open wound was
covered with a VAC dressing.  Because of the nature of the
wound, the decision was made to take the patient to the
Operating Room for definitive closure of wound.  However,
because of difficulty obtaining consent from patient as
family members could not be identified at that time, wound
closure had to be delayed and VAC dressing was continued
until definitive closure could be obtained.

On hospital day #4, the patient was brought to the Operating
Room for both irrigation and debridement of his open wound.
The wound was closed with a medial gastrocnemius rotational
flap, as well as hemisoleus rotational flap.  Definitive
coverage was with a split thickness skin graft on the right
thigh.

The patient did well postoperatively.  He was extubated on
hospital day #6.  The patient was continued on leg elevation,
non weightbearing status of left lower extremity and frequent
dressing changes to the left lower extremity flap, as well as
skin graft.  After being cleared by the trauma service for
all other injuries except for the left lower extremity wound,
the patient was transferred from the trauma service to the
plastic surgery team.

On hospital day #13, the patient was brought back to the
Operating Room for revision of the external fixator.  That
surgery was without complication and the patient did well
postoperatively.

Complicating the [**Hospital 228**] hospital course, however, was
persistent agitation during hospitalization, including
pulling his C-collar off, being combative with hospital staff
as well as often times refusing to speak with members of the
clinical team.  The psychiatry consult was obtained for help
with managing such problems and an Ativan taper was begun
which remained for the course of the patient's last five
hospital days.  Additionally, full work up was done for
possible organic causes for patient's mental status.
However, such work up did not find any significant causes for
patient's symptomatology.

At time of discharge, the patient remained hemodynamically
stable, was afebrile for several days, remained on
antibiotics.  He was seen by physical therapy on several
occasions for help with ambulation, as well as general
conditioning.  At time of his discharge, the patient was
still non weightbearing of the left lower extremity, however
could be in the dependant position for up to five minutes per
hour.  His flap was viable, however there was still some area
of questionable viability in the superior lateral aspect of
the flaps.  However, at this time, it is stable and dressing
changes tid were thought to be the best means taking care of
the wound.  It will be further evaluated at a later date to
determine if further intraoperative intervention will be
needed.

DISCHARGE CONDITION:  Stable

DISCHARGE STATUS:  Discharge to rehabilitation

DISCHARGE MEDICATIONS:
1.  Lovenox 30 mg subcutaneous [**Hospital1 **]
2.  Ancef 1 gm q8h
3.  Thiamine 100 mg po q day
4.  Multivitamin 1 tablet po q day
5.  Folate 1 mg po q day
6.  Percocet 1 to 2 tablets po q 4 to 6 hours prn
7.  Ativan 0.5 mg po x1 at 8 p.m. on night of discharge, as
well as afterwards, Ativan 0.5 mg po q8h prn agitation.

DRESSING CHANGES:  Wet-to-dry sterile gauze dressing to the
superolateral aspect of flap and Xeroform gauze to the
remainder of the flap.  Dressing changes will be tid.

DIET:  Regular

Physical therapy will be non weightbearing left lower
extremity, as well as keeping left lower extremity in
dependent position for no more than five minutes per hour.

FOLLOW UP:  Dr. [**First Name (STitle) **] in approximately one week.  Follow up
with orthopedics will be with Dr. [**Last Name (STitle) 363**] in two weeks.

DISCHARGE DIAGNOSES:
1.  Pedestrian struck by vehicle.
2.  Open tibial fracture, grade 3B.
3.  Other fractures include left scapular fracture, right
scapular fracture, first rib fracture, left clavicular
fracture.

The patient will be discharged to [**Hospital 34195**] Rehabilitation.
The patient is on Eight [**Hospital Ward Name 1950**] #[**Numeric Identifier 34196**].




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D.  [**MD Number(1) 8333**]

Dictated By:[**Last Name (NamePattern1) 34142**]
MEDQUIST36

D:  [**2132-6-6**]  10:12
T:  [**2132-6-6**]  11:19
JOB#:  [**Job Number 34197**]
{'Open fracture of shaft of fibula with tibia,Closed fracture of scapula, unspecified part,Closed fracture of sixth cervical vertebra,Closed fracture of one rib,Alcohol abuse, unspecified,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: 

PRESENT ILLNESS: The patient is a 41-year-old
male who was found down, likely struck by motor vehicle, with
obvious open tibia fibula fracture.  The patient was
intubated at the scene for unresponsiveness and transported
to the [**Hospital6 256**] for further
evaluation.  In the Emergency Department, the patient was
paralyzed for further combativeness, however was noted to be
moving all four extremities.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Open fracture of shaft of fibula with tibia,Closed fracture of scapula, unspecified part,Closed fracture of sixth cervical vertebra,Closed fracture of one rib,Alcohol abuse, unspecified,Motor vehicle traffic accident involving collision with pedestrian injuring pedestrian'}
