CHIEF COMPLAINT: thoracoabdominal gunshot wound

PRESENT ILLNESS: 52M s/p L ant chest GSW p/w hemoPTX,
diaphragmatic/gastric/splenic injuries.  Pt had hypotension in
ED. Large resusitation with pRBCs and IV fluid

MEDICAL HISTORY: EtOH abuse, unknown liver problem

MEDICATION ON ADMISSION: klonipin, vicodin, paxil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HEENT: no abnormalities noted
CV: RRR, NO MRG
RESP: lungs CTA b/l, BS on L > R at bases
ABD: soft, NT, ND, no masses
EXT: +1 edema b/l

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: tobacco 2 PPD, h/o IV heroin
Injury to diaphragm, with open wound into cavity,Injury to spleen with open wound into cavity, laceration extending into parenchyma,Contusion of lung with open wound into thorax,Traumatic pneumohemothorax with open wound into thorax,Injury to stomach, with open wound into cavity,Assault by handgun,Hematoma complicating a procedure,Bacteremia,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acidosis,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Residual foreign body in soft tissue
Diaphragm injury-open,Spleen parnchym lac-opn,Lung contusion-open,Traum pneumohemothor-opn,Stomach injury-open,Assault-handgun,Hematoma complic proc,Bacteremia,Alcoh dep NEC/NOS-unspec,Alcohol withdrawal,React-oth vasc dev/graft,Acidosis,Tobacco use disorder,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Old FB in soft tissue
Admission Date:  [**2189-2-19**]              Discharge Date:   [**2189-3-9**]

Date of Birth:  [**2136-11-14**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
thoracoabdominal gunshot wound

Major Surgical or Invasive Procedure:
exploratory laparotomy
diaphragmatic repair
gastric repair
splenectomy

History of Present Illness:
52M s/p L ant chest GSW p/w hemoPTX,
diaphragmatic/gastric/splenic injuries.  Pt had hypotension in
ED. Large resusitation with pRBCs and IV fluid

Past Medical History:
 EtOH abuse, unknown liver problem

Social History:
tobacco 2 PPD, h/o IV heroin


Family History:
non-contributory

Physical Exam:
HEENT: no abnormalities noted
CV: RRR, NO MRG
RESP: lungs CTA b/l, BS on L > R at bases
ABD: soft, NT, ND, no masses
EXT: +1 edema b/l

Pertinent Results:
ADMISSION LABS:
[**2189-2-19**] 02:40PM BLOOD WBC-17.9* RBC-4.63 Hgb-15.1 Hct-44.2
MCV-96 MCH-32.6* MCHC-34.1 RDW-16.7* Plt Ct-226
[**2189-2-19**] 02:40PM BLOOD PT-13.1 PTT-25.6 INR(PT)-1.1
[**2189-2-19**] 02:40PM BLOOD Fibrino-126*
[**2189-2-19**] 07:39PM BLOOD Glucose-147* UreaN-10 Creat-0.7 Na-139
K-4.1 Cl-114* HCO3-15* AnGap-14
[**2189-2-19**] 02:40PM BLOOD Amylase-44
[**2189-2-21**] 04:40PM BLOOD Lipase-10
[**2189-2-19**] 07:39PM BLOOD Calcium-6.4* Phos-3.8 Mg-1.3*
[**2189-2-19**] 02:40PM BLOOD ASA-NEG Ethanol-212* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-2-19**] 04:26PM BLOOD Type-ART pO2-260* pCO2-48* pH-7.22*
calTCO2-21 Base XS--8 Intubat-INTUBATED Vent-CONTROLLED
[**2189-2-19**] 02:43PM BLOOD Glucose-148* Lactate-4.0* Na-142 K-6.0*
Cl-113* calHCO3-17*

RADIOLOGY:[**2-19**] Chest CTA: GSW to L chest producing moderate
tension PTX and penetration of the L ant and post hemidiaphragm.
No evidence of vascular injury or trauma to the abdominal
visceral organs. Consolidation along the posterior L lung c/w
contusion and small hematoma. Chronic diverticula w/o evidence
of diverticulitis.
[**2-19**] CXR (post-op): Subsegmental atelectasis of RUL, unchanged
position of bullet.
[**2-25**] CXR: LLL consolidation/contusion is persistent. Left-sided
bowel loops are higher in position compared to R hemidiaphragm;
L hemidiaphragm paresis or possible herniation is suspected
[**2-26**] CT A/P:

MICRO
[**2-22**] blood: MRSA
[**2-22**] catheter tip: MRSA
3/5 blood: MRSA
[**2-24**] sputum: coag + staph and gram + rods
[**2-26**] wound:

Brief Hospital Course:
[**2-19**]: Patient was intubated at the OSH. Chest tube placed in ED,
with 600ml out.  Had hypotension to 70s. 3 units pRBCs given, as
well as 6L IVNS The patient was admitted to the TSICU, and then
taken to the OR for ex-lap, repair of his diaphragm and stomach,
and splenectomy.  He recieved post splenectomy vaccinations.
[**2-20**] POD #1: The patient was extubated. He began to show signs of
alcohol withdrawl, and was placed on a CIWA scale with ativan.
[**2-21**] POD #2: cipro and flagyl (prophylactic abx) were d/ced.
Continued to use large amounts of ativan for control of ETOH
withdrawl.  WBC elevated to 17.9.  NGT was d/ced.
[**2-22**] POD #3: The patient became febrile and had decreased mental
status.  Vancomycin was started.  The site of the patient's
central line looked red, and pus was expressed.  The line was
removed and sent for culture that grew MRSA.  Blood cultures
also grew MRSA.  A new central line was placed.
[**2-23**] POD #4: Left chest tube drained 30ml and was taken out.
[**2-24**] POD #5: The patient was transferred to the floor.
Tolerating PO diet and making good urine output.
[**2-25**] POD 6: The patient ambulated.  There was severe difficulty
with IV access, and an external jugular IV was finally obtained.
 His ativan was decreased.
[**2-26**] POD 7: The patient was noted to have increased erythema
around the wound.  Probing of the wound demonstrated hematoma,
and the skin staples were opened to allow drainage.  The patient
was afebrile, but wbc count increased to 31.3.  A CT scan of his
abdomen and pelvis was preformed to look for signs of
intra-abdominal infection/abscess.  The CT showed a large fluid
collection in the area where the bullet penetrated his
diaphragm.  From the CT, it was difficult to assess if the fluid
collection was in the lung or abdomen.
[**2-27**] POD 8: The fluid collection was drained by radiology under
ultrasound guidence, and a pigtail catheter left in place.
200cc of serosanguinous fluid was removed, and the fluid was
sent for culture.  A wound vac dressing was placed over the
abdominal incision.   wound cultures showed no growth.  Wound
erythema improved greatly.
[**2-28**] POD 9: The patient remained afebrile.  There was 50cc
drainage from the pigtail catheter.  WBC peaked at 31.  The
patient continued to tolerate a regular diet, and his O2
saturation continued to improve.
[**3-1**] POD 10: A cxr showed stable moderate effusion.
[**3-2**] POD 11: TPA was added to the pigtail catheter and the
patient was slowly rotated (every 30 min) to maximize area
involved.  Over the subsequent 24 hours, the patient's Jp drain
put out 350cc of serosanguinous fluid.  The vac dressing was
changed. WBC down to 26.6
[**3-3**] POD 12: A second dose of TPA was inserted into the pigtail
catheter.
The patient remained afebrile, but his wbc again increased to
31.5.  Surveillence blood cultures showed resolution of mrsa
bacteremia.
[**3-4**] POD 13: Repeat CT scan showed:
   1. Persistent small-to-moderate left pleural effusion,
collected posteriorly, might be layering. Persistent subpulmonic
organized hematoma in the region of a left basal pleural drain.
Because of the small size and location of these collections,
respectively, sampling would require imaging guidance.
   2. Persistent consolidation basal segments left lower lobe
without obvious
explanation other than adjacent pleural restriction and
splinting.
   3. Mediastinal adenopathy, probably reactive.
   4. Opened upper abdominal wound. No associated fluid
collection in the levels imaged. Possible cellulitis.
   5. Retained bullet and bone fragments left posterior chest
wall and adjacent pleural or extrapleural space.
- Attending discussion regarding thoracic involvement, and it
was decided that nothing needed to be done at the present time,
however, follow up with Thoracics was advised.
[**3-5**] - vaccuum dressing changed.
[**3-7**] - JP removed at bedside, post pull CXR showed no PTX.
[**3-8**] - last dose of Vancomycin given.  Vaccuum dressing changed.
 Patient cleared for discharge [**3-9**] with services and VAC
changes.


Medications on Admission:
klonipin, vicodin, paxil

Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*8 Patch 72HR(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for breakthrough pain.
Disp:*20 Tablet(s)* Refills:*0*
7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
10 days.
Disp:*10 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Disp:*500 ML(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**First Name8 (NamePattern2) **] [**Doctor First Name **] health care

Discharge Diagnosis:
diaphragmatic injury s/p repair
gastric injury s/p repair
splenic injury s/p splenectomy
thoracoabdominal gunshot wound

Discharge Condition:
good

Discharge Instructions:
It is very important that you rest and take good care of
yourself for the next few weeks.  The wound on your abdomen
needs special care.  The vaccuum dressing will need to be looked
at daily, and changed every three days.  YOU MUST BE CAREFUEL
NOT TO TRIP OVER TEH TUING OR TO ADJUST IT YOURSELF! Visiting
nurses will come to your house to help you with this.

If you develop worsening pain or redness at the wound site,
fevers above 101.5, pus like drainage, nausea or vomiting that
won't stop, difficulty breathing, chest pain, or any other
concerning symptom, please call Dr.[**Name (NI) 15146**] office or come to
the ER right away.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week.  Call 617-
for an appointment
{'Injury to diaphragm, with open wound into cavity,Injury to spleen with open wound into cavity, laceration extending into parenchyma,Contusion of lung with open wound into thorax,Traumatic pneumohemothorax with open wound into thorax,Injury to stomach, with open wound into cavity,Assault by handgun,Hematoma complicating a procedure,Bacteremia,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acidosis,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Residual foreign body in soft tissue'}


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: thoracoabdominal gunshot wound

PRESENT ILLNESS: 52M s/p L ant chest GSW p/w hemoPTX,
diaphragmatic/gastric/splenic injuries.  Pt had hypotension in
ED. Large resusitation with pRBCs and IV fluid

MEDICAL HISTORY: EtOH abuse, unknown liver problem

MEDICATION ON ADMISSION: klonipin, vicodin, paxil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HEENT: no abnormalities noted
CV: RRR, NO MRG
RESP: lungs CTA b/l, BS on L > R at bases
ABD: soft, NT, ND, no masses
EXT: +1 edema b/l

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: tobacco 2 PPD, h/o IV heroin 

### Response:
{'Injury to diaphragm, with open wound into cavity,Injury to spleen with open wound into cavity, laceration extending into parenchyma,Contusion of lung with open wound into thorax,Traumatic pneumohemothorax with open wound into thorax,Injury to stomach, with open wound into cavity,Assault by handgun,Hematoma complicating a procedure,Bacteremia,Other and unspecified alcohol dependence, unspecified,Alcohol withdrawal,Infection and inflammatory reaction due to other vascular device, implant, and graft,Acidosis,Tobacco use disorder,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Residual foreign body in soft tissue'}
