CHIEF COMPLAINT: Splenic rupture

PRESENT ILLNESS: 57 yo male recently hospitalized following a motor vehicle crash
where he sustained a splenic laceration. He was hospitalized for
several days for close monitoring. He was discharged to home and
reportedly went to the dentist the following day when he began
to fell very lightheaded. He returned to the ED here at [**Hospital1 18**],
underwent abdominal CT scan which revealed a moderate amount of
fluid in the abdomen.

MEDICAL HISTORY: DM
HTN
Chronic low back pain
PTSD

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Other injury into spleen without mention of open wound into cavity,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Other, mixed, or unspecified drug abuse, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Posttraumatic stress disorder,Anxiety state, unspecified,Lumbago
Spleen injury NEC-closed,Traffic acc NOS-pers NOS,Drug abuse NEC-unspec,Anemia NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Posttraumatic stress dis,Anxiety state NOS,Lumbago
Admission Date:  [**2184-6-3**]              Discharge Date:   [**2184-6-8**]

Date of Birth:  [**2127-3-4**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Splenic rupture

Major Surgical or Invasive Procedure:
[**2184-6-4**] Splenectomy


History of Present Illness:
57 yo male recently hospitalized following a motor vehicle crash
where he sustained a splenic laceration. He was hospitalized for
several days for close monitoring. He was discharged to home and
reportedly went to the dentist the following day when he began
to fell very lightheaded. He returned to the ED here at [**Hospital1 18**],
underwent abdominal CT scan which revealed a moderate amount of
fluid in the abdomen.

Past Medical History:
DM
HTN
Chronic low back pain
PTSD

Family History:
Noncontributory

Pertinent Results:
[**2184-6-3**] 09:21PM   HCT-22.6*
[**2184-6-3**] 11:30AM   GLUCOSE-316* UREA N-17 CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2184-6-3**] 11:30AM   CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.1
[**2184-6-3**] 11:30AM   WBC-6.1 RBC-3.11* HGB-10.1* HCT-29.0* MCV-93
MCH-32.5* MCHC-34.7 RDW-13.4
[**2184-6-3**] 11:30AM   PLT COUNT-236
[**2184-6-3**] 11:30AM   PT-10.6 PTT-19.2* INR(PT)-0.9

CT ABD W&W/O C; CT PELVIS W/CONTRAST

Reason: bleed- IV contrast ONLY
Field of view: 50 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
57 year old man with L abd pain s/p MVC 4 days ago with splenic
lac
REASON FOR THIS EXAMINATION:
bleed- IV contrast ONLY
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 57-year-old man with lower abdominal pain status
post MVC four days ago with apparently known splenic laceration.

No prior studies are available for comparison.

TECHNIQUE: MDCT axial images through the abdomen and pelvis
without and with IV contrast. 3' delayed images were also
obtained. Coronal and sagittal reformatted views were displayed.

CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: The lung bases
are clear. The liver is diffusely hypodense consistent with
fatty infiltration. The gallbladder is normal. The spleen
demonstrates a 9.7 x 3.8 cm hypodense lesion in the lateral
aspect consistent with subcapsular hematoma. 3.7 x 2.8 cm
hypodense lesion in the anterior aspect of the spleen could
represent a cyst. There is an irregular linear hypodensity
transversing the inferior pole of the spleen consistent with
laceration. Moderate amount of hyperdense fluid within the
abdomen is seen. No evidence of active contrast extravasation.

The pancreas and adrenal glands are normal. There is no evidence
of free air. No oral contrast was given which limits the
evaluation for loops of bowel, however, no gross abnormality is
identified. The kidneys demonstrate symmetrical enhancement and
excretion without evidence of hydronephrosis. The right kidney
demonstrates a simple cyst in the upper pole measuring 3.1 x 3.3
cm. A tiny cortical density in the lower pole of the left kidney
is noted, too small to characterize.

CT OF THE PELVIS WITH IV CONTRAST: The rectum, prostate, seminal
vesicles, and sigmoid are unremarkable. Free hyperdense fluid in
the pelvis is seen. No evidence of pelvic or inguinal
lymphadenopathy.

BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. No evidence of fracture.

IMPRESSION:
1. Findings are consistent with spleen laceration, spleen
hematoma and hemoperitoneum.

2. Fatty liver.

3. 3.3 x 3.1 cm right renal cyst.

Findings were discussed with Dr. [**Last Name (STitle) **] at the time of the
dictation.

NOTE ADDED IN ATTENDING REVIEW: As above, there is a large
splenic subcapsular hematoma, indenting virtually the entire
lateral margin of the spleen. There is a complex laceration, or
series of discrete lacerations, involving its lower pole,
reaching the surface of the spleen in several places, but not
involving its hilum or those vessels (Grade II). The arterial
phase images (3:39) raise the possibility of a small focus of
extravasation in the lower pole; the delayed phase demonstrates
no pooling of contrast at this site, or elsewhere. There is a
moderately large amount of complex fluid (up to 45HU) gathered
around the spleen and in the low pelvis, as well as over the
dome of the liver; no hepatic or other visceral injury is seen.
According to Dr. [**Last Name (STitle) 33863**] (Trauma [**Doctor First Name **]), the pelvic blood is new
from the OSH study (not scanned into PACS, and therefore, not
available or review). The well-defined non-enhancing 3.5cm
cystic (7 [**Doctor Last Name **], pre-contrast) structure, at the medial aspect of
the splenic dome (3:20), likely represents an acquired cyst,
related to more remote trauma.


Brief Hospital Course:
He was admitted to the Surgery Service and was taken to the
operating room for splenectomy. There were no intraoperative
complications. Postoperatively he has done well, his hematocrits
have been stable. His pain is being controlled with prn Dilaudid
and his home dose of Methadone 80 mg daily was resumed. He was
given the recommended immunizations because of his splenectomy
and was given instructions to follow up with Dr. [**Last Name (STitle) **] next
week.

Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO DAILY (Daily).
Disp:*60 Tablet, Soluble(s)* Refills:*0*
2. Clonazepam 1 mg Tablet Sig: Four (4) Tablet PO BID (2 times a
day).
3. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*qs Patch 24 hr(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:
Splenic rupture


Discharge Condition:
Stable


Discharge Instructions:
Return to the Emergency room if you develop any fevers, chest
pain, dizziness, lightheadedness, weakness, abdominal pain and
any other symptoms that are concerning to you.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] next week, call [**Telephone/Fax (1) 600**] for an
appointment.



Completed by:[**2184-6-8**]
{'Other injury into spleen without mention of open wound into cavity,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Other, mixed, or unspecified drug abuse, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Posttraumatic stress disorder,Anxiety state, unspecified,Lumbago'}


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: Splenic rupture

PRESENT ILLNESS: 57 yo male recently hospitalized following a motor vehicle crash
where he sustained a splenic laceration. He was hospitalized for
several days for close monitoring. He was discharged to home and
reportedly went to the dentist the following day when he began
to fell very lightheaded. He returned to the ED here at [**Hospital1 18**],
underwent abdominal CT scan which revealed a moderate amount of
fluid in the abdomen.

MEDICAL HISTORY: DM
HTN
Chronic low back pain
PTSD

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Other injury into spleen without mention of open wound into cavity,Motor vehicle traffic accident of unspecified nature injuring unspecified person,Other, mixed, or unspecified drug abuse, unspecified,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Posttraumatic stress disorder,Anxiety state, unspecified,Lumbago'}
