CHIEF COMPLAINT: [**4-12**] rib fractures, left hemopneumothorax, grade II-III splenic
laceration

PRESENT ILLNESS: 19M brought to the ED by ambulance after colliding into a road
rail on his motorcycle.  He had decreased breath sounds on his
left side on auscultation and decreasing O2 Saturation to the
low 90's in the ER.  Hemopneumothorax was seen on CXR.  He
underwent CT torso which demonstrated a grade II-III splenic
laceration and a T11 vertebral body chip fracture.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives with parents. Non smoker, no EtOH, no recreational drug
use.
Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of six ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Street and highway accidents,Traumatic subcutaneous emphysema
Traum pneumohemothor-cl,Fracture six ribs-closed,Spleen capsular tear,Fx dorsal vertebra-close,Mv collis NOS-motorcycl,Accid on street/highway,Traum subcutan emphysema
Admission Date:  [**2155-3-22**]              Discharge Date:   [**2155-4-3**]

Date of Birth:  [**2135-4-3**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
[**4-12**] rib fractures, left hemopneumothorax, grade II-III splenic
laceration

Major Surgical or Invasive Procedure:
left tube thoracostomy

History of Present Illness:
19M brought to the ED by ambulance after colliding into a road
rail on his motorcycle.  He had decreased breath sounds on his
left side on auscultation and decreasing O2 Saturation to the
low 90's in the ER.  Hemopneumothorax was seen on CXR.  He
underwent CT torso which demonstrated a grade II-III splenic
laceration and a T11 vertebral body chip fracture.

Past Medical History:
None

Social History:
Lives with parents. Non smoker, no EtOH, no recreational drug
use.

Family History:
Non-contributory.

Pertinent Results:
[**2155-4-3**] WBC-17.6* RBC-3.52* Hgb-10.5* Hct-30.3 Plt Ct-835*
[**2155-4-2**] WBC-19.0* RBC-3.74* Hgb-11.0* Hct-32.7  Plt Ct-627*
[**2155-4-1**] WBC-21.0*# RBC-3.83* Hgb-11.8* Hct-32.6 Plt Ct-648*
[**2155-3-22**] WBC-22.2* RBC-4.67 Hgb-13.8* Hct-39.7 Plt Ct-244
[**2155-3-30**] Neuts-76* Bands-0 Lymphs-8* Monos-12* Eos-2 Baso-0
Atyps-0 Metas-2* Myelos-0
[**2155-4-1**] Glucose-128* UreaN-6 Creat-0.9 Na-134 K-4.8 Cl-97
HCO3-28
[**2155-3-23**] Glucose-120* UreaN-12 Creat-0.9 Na-135 K-5.3* Cl-104
HCO3-25
[**2155-3-28**] ALT-45* AST-31 LD(LDH)-227 AlkPhos-76 TotBili-0.8
[**2155-4-1**] Calcium-8.4 Phos-5.3*# Mg-2.2

Micros
[**2155-3-28**] L chest tissue 2+ PMN, 1+ GPC pair/clusters; sparse
GPs, suggestive of staph; neg AFB
[**2155-3-28**] L effusion 4+ PMN, no organisms; rare GPCs MSSA
[**2155-3-28**] L fibrous 4+ PMN, no organisms; sparse GPs, suggestive
of staph; neg AFB
[**2155-3-28**] UCx NEG

CXR
[**2155-4-3**]: Right PICC tip is in the mid SVC. Left chest tube
remains in place. There is no evident pneumothorax. Elevation of
the left hemidiaphragm is unchanged.  Cardiomediastinal contours
are normal. Left lower lobe atelectasis has increased. A
combination of left pleural thickening and small left pleural
effusion has minimally increased. Rib plates are in place.

CCT [**2155-3-27**]
1. Four different compartments of fluid in the left thoracic
cavity. The
posterior one likely a freely layering pleural effusion. The
anterior one
likely a loculated effusion. The medial and lateral collections
are
concerning for a combination of lung contusion/laceration and
hematoma with superimposed infection such as empyemas.
2. Small left pneumothorax. Left chest tube terminates in the
apex,
unchanged.
3. Grossly unchanged multilevel displaced left lateral rib
fractures,
constituting a flail chest. No acute spinal injury.
4. Interval decrease of left lateral chest/abdominal wall
subcutaneous gas.
[**2155-3-22**]: IMPRESSION:
1. Left hemopneumothorax, as above. Left chest tube,
kink/coiled, and
extending distally posteriorly along the left mediastinum, as
above.
Recommend repositioning. Left pulmonary contusions. Dependent
left pulmonary consolidation may be due to contusion,
aspiration, and/or atelectasis.
2. Multiple left-sided rib fractures involving ribs 4 through 9
with at least 6 through 8 displaced. Extensive left chest wall
subcutaneous edema extending superiorly into the left neck and
inferiorly along the left flank and back to just above the left
iliac crest. Evidence of intramuscular emphysema with air
extending to the left flank abdominal wall, difficult to exclude
focus of intra-abdominal air.
3. Mild dependent right pulmonary consolidation may be due to
atelectasis,
aspiration, cannot exclude contusion.
4. Grade III splenic laceration, measuring approximately 3.9 cm
in length,
with small amount of perisplenic hemoperitoneum, without
definite active
extravasation. Trace hemoperitoneum at the inferior edge of the
right lobe of the liver and in the pelvis.
5. Markedly distended stomach containing gastric contents,
consider
nasogastric tube placement.
6. Foley catheter within a partially decompressed bladder;
diffusely
thickened bladder wall, most likely related to underdistension,
clinical
correlation suggested.
7. 0.5 cm calcific/ossific structure just posterior to the
inferior aspect of T11 vertebral body, at T11/T12, may represent
focal calcification of the posterior longitundinal ligament, a
tiny chip fracture can not be entirely excluded, although would
be atypical in appearance.


Brief Hospital Course:
He was admitted to the ACS service. A left chest tube was placed
urgently in the ED with a return of breath sounds on his left
side and improving O2 saturation.  Chest tube position and
re-expansion of the lung was confirmed with CXR.  He was
transferred to the ICU for close hemodynamic monitoring. His
splenic laceration was managed non-operatively; serial Hct's
were followed and remained stable ranging between 34-36.  Final
radiological read of his CT torso revealed a possible T11 chip
fracture of his vertebral body. Neuro Spine were consulted but
no further interventions were warranted per their
recommendation. His activity was liberalized and he was
independent with ambulation.

On HD 2 while in the ICU he was transition ed to a regular diet
for which he has tolerated. Incentive spirometry was encouraged.
Subcutaneous heparin for prophylaxis was started. He was
subsequently transferred out of the ICU to the regular nursing
unit. His chest tube remained in place; on HD 4 the CT was
placed to water seal and the chest xray that was obtained
several hours later  showing a small left apical pneumothorax.
The CT was placed back to suction and repositioned on the
following day.

He did have pain control issues requiring IV narcotics
initially, he was later changed to an oral narcotic regimen.
Toradol was added for 3 days which seemed to improve comfort.

His chest tube output decreased and the chest tube removed on HD
6 with purulent drainage noted at time removal.  He was spiking
fevers.  A Chest CT showed hematoma and possible empyema.
Thoracic surgery was consulted.  He was taken to the operating
room on [**2155-3-28**] for Left video-assisted  thoracic surgery
(VATS)
decortication and freeing of trapped lung from rib fragments.
He was extubated in the operating room monitored in the PACU
prior transfer to the floor in stable condition with 2 chest
tubes, Foley and Dilaudid PCA for pain.  He was monitored
closely.  He was taken back to the operating room on [**2155-3-31**]
for  Open reduction and internal fixation (rib plating) of 4 rib
fractures, left.  He was extubated in the operating room,
monitored in the PACU prior transfer to the floor with a Foley
right chest tube and Dilaudid PCA for pain.

Respiratory: incentive spirometer, good pain control he titrated
off oxygen with saturations of 97% room air.

Chest-tube: right once drainage decreased and intraoperative
pleural cultures were final the chest tube was removed on
[**2155-4-2**].

ID: intra-operative cultures grew MSSA.  He was continued on
Nafcillin 2 gm and will be continued for a 4 week course.

PICC line was placed [**2155-4-2**] right basilic, 50 cm placement
confirmed terminates  mid SVC

Pain: Dilaudid PCA was converted to PO Dilaudid, Motrin and
acetaminophen were given with good pain control.

Disposition: he was discharged to home [**2155-4-3**] with his mother,
home solutions care team for IV antibiotics.  He will follow-up
with Dr. [**Last Name (STitle) **] as an outpatient.


Medications on Admission:
None

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
5. Advil 200 mg Tablet Sig: Three (3) Tablet PO every 6-8 hours
as needed for pain.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
7. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gm
Intravenous Q6H (every 6 hours) for 4 weeks.
Disp:*224 gm* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Home Solutions Infusion therapy

Discharge Diagnosis:
s/p Motorcycle crash
Injuries:
1. Left [**4-12**] rib fractures
2. Left hemopneumothorax
3. Grade II-III splenic laceration
4. T11 vertebral body chip fracture


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


Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incisions develops drainage
-Should chest tube site drain cover with a clean dressing and
change as needed
-Cover chest tube site with a bandaid until healed
-Shower daily. Wash incision with soap & water, rinse, pat dry
-No tub bathing, swimming or hot tubs until incision healed

Antibiotics: Nafcillin 2 gm every 6 hrs: complete course

Pain
-Take motrin 600 mg 3 x day with food and water for pain
-Take prontonix's while taking motrin
-Take Dilaudid as needed for severe pain.  Taper off narcotics
-Warm packs on left side for muscle spams

Activity:
-AVOID all contact sports for the next 6 weeks to allow for
proper healing of your spleen injury.
-No lifting anything greater than 10 pounds
-Walk frequently




Followup Instructions:
Follow up in [**Hospital 2536**] clinic in [**2-6**] weeks, call [**Telephone/Fax (1) 600**] for an
appoinment.

Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2155-4-15**]
2:30 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 mintues before your
appointment

Chest Suture removal on Monday [**4-7**].

Weekly CBC w/diff & BMP weekly. Fax to [**Telephone/Fax (1) 89999**] [**First Name9 (NamePattern2) **] [**Location (un) 1439**]



Completed by:[**2155-4-3**]
{'Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of six ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Street and highway accidents,Traumatic subcutaneous emphysema'}


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: [**4-12**] rib fractures, left hemopneumothorax, grade II-III splenic
laceration

PRESENT ILLNESS: 19M brought to the ED by ambulance after colliding into a road
rail on his motorcycle.  He had decreased breath sounds on his
left side on auscultation and decreasing O2 Saturation to the
low 90's in the ER.  Hemopneumothorax was seen on CXR.  He
underwent CT torso which demonstrated a grade II-III splenic
laceration and a T11 vertebral body chip fracture.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: 

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives with parents. Non smoker, no EtOH, no recreational drug
use. 

### Response:
{'Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of six ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist,Street and highway accidents,Traumatic subcutaneous emphysema'}
