CHIEF COMPLAINT: s/p stabbing

PRESENT ILLNESS: Mr. [**Known lastname 91910**] is a 28 year old male who was transferred from
[**Hospital6 3105**] on [**2183-12-6**] after being stabbed in the
left flank/axilla with a box cutter during an argument.
According to report from the OSH, he was transferred for left
kidney injury and possible bowel injury. On arrival to [**Hospital1 18**], he
is alert, oriented and cooperative, and complaining of abdominal
pain.

MEDICAL HISTORY: PMH: polysubstance abuse s/p inpatient rehab
PSH: none

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: + ellicit drug, alcohol and tobacco use (+ETOH and cocaine at
time of trauma). Pt reports that he does not drink alcohol daily
but reports binge drinking when he does use. Pt reports using
approx.1 gram of cocaine on weekends, usually with alcohol.
Injury to kidney with open wound into cavity, laceration,Injury to descending [left] colon, with open wound into cavity,Drug withdrawal,Cocaine abuse, unspecified,Tachycardia, unspecified,Acute pain due to trauma,Assault by cutting and piercing instrument,Physical restraints status
Kidney laceration-open,Descending colon inj-opn,Drug withdrawal,Cocaine abuse-unspec,Tachycardia NOS,Acute pain due to trauma,Assault-cutting instr,Physical restrain status
Admission Date:  [**2183-12-6**]              Discharge Date:   [**2183-12-9**]

Date of Birth:  [**2155-4-9**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
s/p stabbing

Major Surgical or Invasive Procedure:
Exploratory laparotomy, Takedown splenic flexure, Repair of
descending colon serosal tear, Evacuation of retroperitoneal
hematoma, Washout of stab wounds.

Exploratory laparotomy, retroperitoneal
exploration, evacuation of the retroperitoneal hematoma,
closure of Gerota's fascia over the left kidney


History of Present Illness:
Mr. [**Known lastname 91910**] is a 28 year old male who was transferred from
[**Hospital6 3105**] on [**2183-12-6**] after being stabbed in the
left flank/axilla with a box cutter during an argument.
According to report from the OSH, he was transferred for left
kidney injury and possible bowel injury. On arrival to [**Hospital1 18**], he
is alert, oriented and cooperative, and complaining of abdominal
pain.

Past Medical History:
PMH: polysubstance abuse s/p inpatient rehab
PSH: none


Social History:
+ ellicit drug, alcohol and tobacco use (+ETOH and cocaine at
time of trauma). Pt reports that he does not drink alcohol daily
but reports binge drinking when he does use. Pt reports using
approx.1 gram of cocaine on weekends, usually with alcohol.

Lives with father and father's girlfriend

Pt reports that he works full time in [**Location (un) 3844**] putting
together cable.

Family History:
noncontributory

Physical Exam:
On admission:

HR: 87 BP: 95/55 Resp: 19 O(2)Sat: 100 Normal

Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: tender, distended abdomen
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: 3cm laceration to L flank and 2x 3cm lacerations to L
posterior shoulder, Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation

On discharge:

HR: 90 BP: 98/62 Resp: 18 O(2)Sat: 96 RA
Constitutional: Comfortable
HEENT: Araumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: abdomen soft, appropriately tender at incision site,
non distended
Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Left flank wound with small to moderate amount serosang
drainage, packed with moist gauze. Abd and left axilla incisions
OTA with staples intact, no errythema or drainage.
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae


Pertinent Results:
[**2183-12-6**] CTA ABD W&W/O C & RECONS:
Patient is status post open laparotomy and evacuation of a
retroperitoneal
hematoma for a grade IV renal laceration. Stable laceration
noted in the
lower pole of the left kidney. However, the kidney demonstrates
normal prompt pelvicaliceal excretion with no evidence for
active contrast extravasation to suggest continued bleeding or
active urine leak.

[**2183-12-6**] 02:55AM   PH-7.28* COMMENTS-GREEN TOP
[**2183-12-6**] 02:55AM   GLUCOSE-125* LACTATE-2.6* NA+-138 K+-4.1
CL--105 TCO2-21
[**2183-12-6**] 02:55AM   HGB-13.7* calcHCT-41 O2 SAT-89 CARBOXYHB-4.5
MET HGB-0.2
[**2183-12-6**] 02:55AM   freeCa-1.06*
[**2183-12-6**] 02:35AM   UREA N-11 CREAT-1.1
[**2183-12-6**] 02:35AM   LIPASE-19
[**2183-12-6**] 02:35AM   ASA-NEG ETHANOL-108* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-12-6**] 02:35AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2183-12-6**] 02:35AM   WBC-21.2* RBC-4.11* HGB-13.0* HCT-37.3*
MCV-91 MCH-31.7 MCHC-34.9 RDW-14.7
[**2183-12-6**] 02:35AM   PLT COUNT-204
[**2183-12-6**] 02:35AM   PT-12.5 PTT-27.0 INR(PT)-1.2*
[**2183-12-6**] 02:35AM   FIBRINOGE-123*
[**2183-12-6**] 02:35AM URINE  COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.042*
[**2183-12-6**] 02:35AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM

[**2183-12-6**] 02:35AM URINE  RBC->182* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2183-12-6**] 02:35AM URINE  MUCOUS-RARE

Brief Hospital Course:
28M transfer from OSH with multiple stab wounds to L
chest/flank.  Trauma protocol activated on arrival to ED.
Received CT torso at OSH which showed L kidney laceration with
RP hematoma though no violation of thoracic cavity.  Following
trauma evaluation, patient was taken to the OR for ex-lap,
evacuation of RP hematoma and repair of serosal tear to L colon.
 Patient tolerated procedure well and was transferred to the
TSICU intubated for further management under ACS service.

Neuro: Post-operatively, the patient was brought to the TSICU
intubated/sedated.  When extubated POD0 dilaudid PCA was
initiated.  Due to refractory pain, patient was acute pain
service was consulted to place an epidural.  Epidural was placed
successfully and patient was concurrently started on
supplementary iv->po pain regimen POD1-2.  When tolerating oral
intake, the patient was transitioned to oral pain medications,
with which he reported adequate pain relief.

CV: Patient admitted with known recent cocaine use.  Patient
demonstrated persistent tachycardia in setting of normotension.
Patient given clonidine patch in setting recent cocaine use,
which was discontinued prior to discharge.

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

Pulmonary: Patient was extubated on POD0 and weaned supplemental
O2 appropriately.  Pulmonary toilet including incentive
spirometry and early ambulation were encouraged.  The patient
was stable from a pulmonary standpoint; vital signs were
routinely monitored.

GI/GU: 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. Foley was removed prior to
discharge, and he was able to void without difficulty. Intake
and output were closely monitored.

ID: Post-operatively, the patient was started on IV cefazolin
perioperatively. The patient's temperature was closely watched
for signs of infection. He remained afebrile without any
evidence of infection and antibiotics were discontinued.

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#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
He was discharged to home with scheduled follow up in [**Hospital 2536**] clinic
on [**2183-12-16**] to have his staples removed. His family was
instructed on how to perform dressing changes, as well as signs
and symptoms of infection.

The patient was also seen by social work during his admission
for drug/etoh use, as well as given the trauma. He was provided
with referal information for resources.

Medications on Admission:
none

Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:
s/p stabbing

1. Left renal laceration.
2. Descending colon serosal tear.


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


Discharge Instructions:
You were admitted to the hospital after be stabbed in the left
chest and flank. You sustained an injury to your left kidney and
a small tear to part of your colon. These injuries were repaired
in the operating room. You are recovering well and are now being
discharged home with the following instructions:

The dressing on your left side needs to be changed twice each
day, as instructed. Remove the dressing in place, including the
gauze packing and replace with a saline-moistened new piece of
gauze. Cover with a dry gauze and secure with tape. If you
notice any signs of infection such as pus/white/yellow drainage
or increased redness around the wound, please call the [**Hospital 2536**]
clinic ([**Telephone/Fax (1) 600**]) or come to the ED.

ACTIVITY:

Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Telephone/Fax (1) 5059**] at your next visit.
Don't lift more than [**10-11**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.

HOW YOU [**Month (only) **] FEEL:

You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time.  If they do not, tell your [**Month (only) 5059**].

YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal. Your staples will be removed at your
follow up appointment.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.

YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].


PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain

MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].

DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound

Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2183-12-16**] at 9:45 AM
With: ACUTE CARE CLINIC/ Dr. [**Last Name (STitle) 853**] [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

It is recommended that you establish care with a Primary Care
Physician. [**Name10 (NameIs) **] you need assistance finding a PCP outside the
[**Name9 (PRE) 86**] area, your local hospital or healthcare center can be a
resource.
If you are looking for a PCP in the [**Name9 (PRE) 86**] area or need further
assistance please call the [**Hospital1 18**] Find-A-Doc line at ([**Telephone/Fax (1) 91202**]. We are able to assist you between the hours of 8:30
AM- 5:00 PM Monday through Friday.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]

Completed by:[**2183-12-9**]
{'Injury to kidney with open wound into cavity, laceration,Injury to descending [left] colon, with open wound into cavity,Drug withdrawal,Cocaine abuse, unspecified,Tachycardia, unspecified,Acute pain due to trauma,Assault by cutting and piercing instrument,Physical restraints status'}


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 stabbing

PRESENT ILLNESS: Mr. [**Known lastname 91910**] is a 28 year old male who was transferred from
[**Hospital6 3105**] on [**2183-12-6**] after being stabbed in the
left flank/axilla with a box cutter during an argument.
According to report from the OSH, he was transferred for left
kidney injury and possible bowel injury. On arrival to [**Hospital1 18**], he
is alert, oriented and cooperative, and complaining of abdominal
pain.

MEDICAL HISTORY: PMH: polysubstance abuse s/p inpatient rehab
PSH: none

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: + ellicit drug, alcohol and tobacco use (+ETOH and cocaine at
time of trauma). Pt reports that he does not drink alcohol daily
but reports binge drinking when he does use. Pt reports using
approx.1 gram of cocaine on weekends, usually with alcohol. 

### Response:
{'Injury to kidney with open wound into cavity, laceration,Injury to descending [left] colon, with open wound into cavity,Drug withdrawal,Cocaine abuse, unspecified,Tachycardia, unspecified,Acute pain due to trauma,Assault by cutting and piercing instrument,Physical restraints status'}
