CHIEF COMPLAINT: s/p Stab wound to chest

PRESENT ILLNESS: The patient is an otherwise healthy 23 yo male who presents
immediatley status post sustaining a solitary stab wound to his
right lower anterior
medial torso.  On examination he had no abdominal tenderness;
however, his lactate level was 8.8 and FAST exam in the
emergency room showed a significant amount of free
intraperitoneal fluid.  He was taken to the operating room for
diagnostic laparoscopy.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: Denies

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
HR: 140 BP: 134/64 Resp: 25 O(2)Sat: 97 Normal

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Injury to liver with open wound into cavity, laceration, minor,Injury to other intra-abdominal organs with open wound into cavity, peritoneum,Acute posthemorrhagic anemia,Oliguria and anuria,Assault by cutting and piercing instrument,Elevated blood pressure reading without diagnosis of hypertension,Alcohol abuse, unspecified,Other iatrogenic hypotension
Liver lacerat, minor-opn,Peritoneum injury-open,Ac posthemorrhag anemia,Oliguria & anuria,Assault-cutting instr,Elev bl pres w/o hypertn,Alcohol abuse-unspec,Iatrogenc hypotnsion NEC
Admission Date:  [**2178-9-26**]              Discharge Date:   [**2178-9-28**]

Date of Birth:  [**2155-3-18**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Stab wound to chest

Major Surgical or Invasive Procedure:
[**2178-9-26**] DIAGNOSTIC LAPAROSCOPY


History of Present Illness:
The patient is an otherwise healthy 23 yo male who presents
immediatley status post sustaining a solitary stab wound to his
right lower anterior
medial torso.  On examination he had no abdominal tenderness;
however, his lactate level was 8.8 and FAST exam in the
emergency room showed a significant amount of free
intraperitoneal fluid.  He was taken to the operating room for
diagnostic laparoscopy.


Past Medical History:
Denies

Family History:
Noncontributory

Physical Exam:
Upon presentation to [**Hospital1 18**]:
HR: 140 BP: 134/64 Resp: 25 O(2)Sat: 97 Normal

Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Oropharynx within normal limits
Chest: Clear to auscultation, 4cm R anterior chest wound at
T5 level sternal border
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: MAE, intoxicated
Psych: intoxicated
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae



Pertinent Results:
[**2178-9-26**] 11:30PM   WBC-9.3 RBC-3.11* HGB-9.4* HCT-27.0* MCV-87
MCH-30.3 MCHC-34.9 RDW-13.1
[**2178-9-26**] 11:30PM   PLT COUNT-161
[**2178-9-26**] 04:07AM   GLUCOSE-100 LACTATE-4.5* NA+-142 K+-3.7
CL--112*
[**2178-9-26**] 02:40AM   ASA-NEG ETHANOL-244* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG

Chest xray:
FINDINGS:  The heart size is within normal limits.  The
mediastinal width is also within normal limits.  The lungs are
clear.  There is no pleural effusion or pneumothorax.  No
displaced rib fractures are present.  No unintended radiopaque
foreign bodies are noted.
IMPRESSION:  No evidence of intrathoracic injury.


Brief Hospital Course:
He was admitted to the Acute Care Surgery team and taken to the
operating room immediately for diagnostic laparoscopy. On
laparoscopy, in the upper medial right anterior abdominal wall
there was evidence of an entry stab wound.  This was at the
medial aspect of the dome of the liver; the falciform ligament
was then penetrated with an open stab wounds from right to left.
 On the left side of the falciform on the surface of the liver
there was a visible approximately 2 cm in length stab wound on
the anterior surface of the liver which was not actively
bleeding.  Elevating the liver there was a small half cm stab
wound in the same trajectory visible and it was also not
bleeding. Postoperatively he was taken to the PACU where he was
noted with episodes of tachycardia and elevated blood pressure.
He was given IV Lopressor with improvement in his heart rate and
blood pressure. He was also transfused for a falling hematocrit
felt due to the blood loss associated with his injuries and the
operation. Once hemodynamically stable and was then transferred
to he regular nursing unit where he continued to progress.

He was given a regular diet on the second postoperative day and
was able tot tolerate this without any problems. [**Name (NI) **] was changed
to oral pain medications which were effective in controlling his
pain.

He was seen by Social Work for coping related to his injuries
and also due to the nature of his trauma. A safe discharge plan
was determined to be in place.

He was discharged to home and will follow up in the Acute Care
Surgery Clinic in the next couple of weeks.



Medications on Admission:
Denies

Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 600 mg PO Q8H:PRN pain
Take with food.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*0
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. OxycoDONE (Immediate Release)  5-10 mg PO Q3H:PRN pain
RX *oxycodone 5 mg [**1-19**] tablet(s) by mouth every 4 hours Disp
#*20 Tablet Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Stab wound assault
Liver laceration
Acute blood loss anemia

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 a stabbing assault
requiring that exploratory surgery be performed to identify
internal injuires. You were found to have a laceration to your
liver. You were monitoredclosley in the hospital for signs of
infection and bleeding and have remined stable.

You are being discharged home with the following instructions:

You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST  refrain from such activities while
taking these medications.





Please call your doctor or return to the emergency room if you
have any of the following:


 * You experience new chest pain, pressure, squeezing or
 tightness.

* New or worsening cough or wheezing.

* If you are vomiting and cannot keep in fluids or your
 medications.

* You are getting dehydrated due to continued vomiting,
 diarrhea or other reasons. Signs of dehydration include dry
 mouth, rapid heartbeat or feeling dizzy or faint when standing.

* You see blood or dark/black material when you vomit or have a
 bowel movement.


* You have shaking chills, or a fever greater than 101.5 (F)
 degrees or 38(C) degrees.

* Any serious change in your symptoms, or any new symptoms that
 concern you.

* Please resume all regular home medications and take any new
meds
 as ordered.

Activity:
No heavy lifting of items [**11-2**] pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.

Wound Care:
You may shower, no tub baths or swimming.

If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:


Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
With: [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**], MD
When: TUESDAY [**2178-10-13**] at 2:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Your insurance records are incomplete- please call our
registration department at ([**Telephone/Fax (1) 22161**] before your first
appointment.  We have no address or phone number listed for you
in our system.
{'Injury to liver with open wound into cavity, laceration, minor,Injury to other intra-abdominal organs with open wound into cavity, peritoneum,Acute posthemorrhagic anemia,Oliguria and anuria,Assault by cutting and piercing instrument,Elevated blood pressure reading without diagnosis of hypertension,Alcohol abuse, unspecified,Other iatrogenic hypotension'}


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 Stab wound to chest

PRESENT ILLNESS: The patient is an otherwise healthy 23 yo male who presents
immediatley status post sustaining a solitary stab wound to his
right lower anterior
medial torso.  On examination he had no abdominal tenderness;
however, his lactate level was 8.8 and FAST exam in the
emergency room showed a significant amount of free
intraperitoneal fluid.  He was taken to the operating room for
diagnostic laparoscopy.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: Denies

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
HR: 140 BP: 134/64 Resp: 25 O(2)Sat: 97 Normal

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Injury to liver with open wound into cavity, laceration, minor,Injury to other intra-abdominal organs with open wound into cavity, peritoneum,Acute posthemorrhagic anemia,Oliguria and anuria,Assault by cutting and piercing instrument,Elevated blood pressure reading without diagnosis of hypertension,Alcohol abuse, unspecified,Other iatrogenic hypotension'}
