CHIEF COMPLAINT: Traumatic injury

PRESENT ILLNESS: The pt is a 57 year-old Eritrean man who presents following
multiple stab wounds to the chest, abdomen and left arm on [**10-11**],
now not waking up off sedation.  On [**10-11**] the patient
came home with multiple stab wounds to his chest, abdomen and
arm, and his brother called 911 and brought him to the ED.  In
the ED he had 2 chest tubes placed, and intubation was attempted
was attempted, but he was reportedly a difficult airway.  An LMA
was initially placed, but the patient reportedly had SaO2s in
the
80s.  An emergent criciotomy was performed in the ED, later
converted to a trach.

MEDICAL HISTORY: PMH: None (per brother)
[**Name (NI) **]: None
[**Last Name (un) 1724**]: None
Soc: Social EtOH, 20pkyr smoking, no drugs

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam upon admission: - Limited, as patient had just
recieved a bolus of
fentanyl and was also on propofol
Vitals: T:101.2  P: 91 R: 18  BP: 109/48 (variable, ranges from
109-180 systolic) SaO2: 100%
General: cric in place, on ventilator, just received fentanyl
bolus, also on propofol drip
HEENT: NC/AT, conjunctival injection, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W.  Bilateral chest
tubes in place transmitting airway sounds
Cardiac: rapid, regular, no murmurs
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, midline incision well healed.
Extremities: No C/C/E bilaterally, L arm bandaged.
Skin: no rashes or lesions noted.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Social Hx: From [**Country 84528**].  Lives with his brother.  ? of possible
substance abuse history based on SW notes.
Traumatic pneumothorax without mention of open wound into thorax,Injury to diaphragm, with open wound into cavity,Traumatic shock,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Anoxic brain damage,Cardiac complications, not elsewhere classified,Unspecified protein-calorie malnutrition,Bacteremia,Urinary tract infection, site not specified,Open wound of forearm, complicated,Other constipation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Assault by cutting and piercing instrument,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Traum pneumothorax-close,Diaphragm injury-open,Traumatic shock,Pseudomonal pneumonia,Food/vomit pneumonitis,Cardiac arrest,Anoxic brain damage,Surg compl-heart,Protein-cal malnutr NOS,Bacteremia,Urin tract infection NOS,Open wound forearm-compl,Constipation NEC,Enterococcus group d,Assault-cutting instr,Abn react-surg proc NEC
Admission Date:  [**2106-10-11**]              Discharge Date:   [**2106-11-6**]

Date of Birth:  [**2049-8-10**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Traumatic injury

Major Surgical or Invasive Procedure:
[**10-11**] 1. Bilateral closed tube thoracostomies.
2. Emergency cricothyroidotomy.
3. Diagnostic laparoscopy.
4. Exploratory laparotomy.
5. Repair of diaphragmatic perforation.
6. Formal tracheostomy.
7. Left forearm fasciotomies.

[**2106-10-13**]
1. Washout of open abdomen with secondary closure.
2. Placement of left chest tube.
3. Repair of multiple abdominal wall wounds and thoracic
    wounds with placement of left anterior chest tube.

[**2106-10-21**]
Percutaneous endoscopic gastrostomy placement

History of Present Illness:
The pt is a 57 year-old Eritrean man who presents following
multiple stab wounds to the chest, abdomen and left arm on [**10-11**],
now not waking up off sedation.  On [**10-11**] the patient
came home with multiple stab wounds to his chest, abdomen and
arm, and his brother called 911 and brought him to the ED.  In
the ED he had 2 chest tubes placed, and intubation was attempted
was attempted, but he was reportedly a difficult airway.  An LMA
was initially placed, but the patient reportedly had SaO2s in
the
80s.  An emergent criciotomy was performed in the ED, later
converted to a trach.

Past Medical History:
PMH: None (per brother)
[**Name (NI) **]: None
[**Last Name (un) 1724**]: None
Soc: Social EtOH, 20pkyr smoking, no drugs


Social History:
Social Hx: From [**Country 84528**].  Lives with his brother.  ? of possible
substance abuse history based on SW notes.

and noted above

Family History:
non contributory

Physical Exam:
Physical Exam upon admission: - Limited, as patient had just
recieved a bolus of
fentanyl and was also on propofol
Vitals: T:101.2  P: 91 R: 18  BP: 109/48 (variable, ranges from
109-180 systolic) SaO2: 100%
General: cric in place, on ventilator, just received fentanyl
bolus, also on propofol drip
HEENT: NC/AT, conjunctival injection, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W.  Bilateral chest
tubes in place transmitting airway sounds
Cardiac: rapid, regular, no murmurs
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, midline incision well healed.
Extremities: No C/C/E bilaterally, L arm bandaged.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Opens eyes briefly in response to voice, but
does
not follow commands, does not grimace or move in response to
sternal rub or painful stimuli.

-Cranial Nerves: Pupils 2->3mm equal.  Disconjugate gaze, with
mild L exotropia.  Dolls eyes, full on left, decreased abduction
to right.  Corneal reflex on right, absent on left.  Intact gag
reflex.

-Motor: Normal bulk, tone throughout. Does not retract from
pain,
does not hold limbs antigravity (per report, however, when less
sedated he has been seen to move his legs and left arm
spontaneously, but not his arm.

-Sensory: Does not retract or grimace to pain (however had just
received 100 of fentanyl)

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  1  1    1    1   1
R  1  1    1    1   1
Plantar response was flexor bilaterally.

-Coordination: Unable to assess
-Gait: Unable to assess

Pertinent Results:
[**2106-11-5**] 02:33AM BLOOD WBC-7.7 RBC-2.39* Hgb-6.8* Hct-21.4*
MCV-90 MCH-28.6 MCHC-32.0 RDW-15.1 Plt Ct-393
[**2106-11-4**] 02:02AM BLOOD WBC-14.1* RBC-2.66* Hgb-7.6* Hct-24.4*
MCV-91 MCH-28.7 MCHC-31.3 RDW-15.2 Plt Ct-515*
[**2106-11-3**] 01:54AM BLOOD WBC-17.6* RBC-3.34*# Hgb-9.5* Hct-30.1*
MCV-90 MCH-28.5 MCHC-31.7 RDW-15.2 Plt Ct-759*
[**2106-11-2**] 02:07AM BLOOD WBC-12.3* RBC-2.65* Hgb-7.8* Hct-24.1*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.9 Plt Ct-552*
[**2106-11-1**] 02:38AM BLOOD WBC-12.0* RBC-2.73* Hgb-7.9* Hct-24.8*
MCV-91 MCH-28.9 MCHC-31.8 RDW-14.9 Plt Ct-570*
[**2106-10-31**] 01:37AM BLOOD WBC-12.2* RBC-2.80*# Hgb-8.0*# Hct-25.7*
MCV-92 MCH-28.4 MCHC-31.0 RDW-15.2 Plt Ct-586*
[**2106-10-30**] 02:44PM BLOOD Hct-25.8*
[**2106-10-30**] 01:12AM BLOOD WBC-13.1* RBC-2.20* Hgb-6.3* Hct-20.7*
MCV-94 MCH-28.7 MCHC-30.5* RDW-14.5 Plt Ct-589*
[**2106-10-29**] 01:16AM BLOOD WBC-19.7* RBC-2.63* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.8 Plt Ct-593*
[**2106-10-30**] 01:12AM BLOOD WBC-13.1* RBC-2.20* Hgb-6.3* Hct-20.7*
MCV-94 MCH-28.7 MCHC-30.5* RDW-14.5 Plt Ct-589*
[**2106-10-29**] 01:16AM BLOOD WBC-19.7* RBC-2.63* Hgb-7.8* Hct-24.3*
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.8 Plt Ct-593*
[**2106-10-28**] 02:00AM BLOOD WBC-19.1* RBC-2.96* Hgb-8.4* Hct-27.3*
MCV-92 MCH-28.4 MCHC-30.8* RDW-14.6 Plt Ct-680*
[**2106-10-27**] 01:49AM BLOOD WBC-12.8* RBC-2.68* Hgb-7.9* Hct-25.0*
MCV-93 MCH-29.6 MCHC-31.6 RDW-14.5 Plt Ct-690*
[**2106-10-26**] 02:01AM BLOOD WBC-14.3* RBC-2.86* Hgb-8.7* Hct-26.6*
MCV-93 MCH-30.5 MCHC-32.8 RDW-14.3 Plt Ct-712*
[**2106-10-25**] 01:53AM BLOOD WBC-12.1* RBC-2.69* Hgb-8.2* Hct-25.1*
MCV-93 MCH-30.3 MCHC-32.5 RDW-14.2 Plt Ct-641*
[**2106-10-24**] 04:01PM BLOOD WBC-11.1* RBC-2.74* Hgb-8.0* Hct-25.5*
MCV-93 MCH-29.4 MCHC-31.5 RDW-14.6 Plt Ct-625*
[**2106-10-24**] 02:17AM BLOOD WBC-10.0 RBC-2.71* Hgb-8.1* Hct-25.3*
MCV-94 MCH-30.0 MCHC-32.1 RDW-13.9 Plt Ct-579*
[**2106-10-23**] 01:54AM BLOOD WBC-8.6 RBC-2.68* Hgb-8.0* Hct-24.8*
MCV-93 MCH-29.8 MCHC-32.2 RDW-14.4 Plt Ct-502*
[**2106-10-12**] 01:00PM BLOOD WBC-10.4# RBC-3.07* Hgb-9.2* Hct-26.4*
MCV-86 MCH-30.1 MCHC-34.9 RDW-13.9 Plt Ct-135*
[**2106-10-12**] 04:43AM BLOOD WBC-5.7# RBC-3.09* Hgb-9.5* Hct-27.4*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.9 Plt Ct-133*
[**2106-10-11**] 07:22PM BLOOD WBC-3.0*# RBC-3.26* Hgb-9.5* Hct-29.0*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.4 Plt Ct-128*
[**2106-10-11**] 02:31PM BLOOD WBC-1.7* RBC-3.59* Hgb-10.5* Hct-32.1*
MCV-89 MCH-29.4 MCHC-32.8 RDW-13.3 Plt Ct-142*
[**2106-10-11**] 09:15AM BLOOD WBC-2.2*# RBC-3.08*# Hgb-9.2*# Hct-28.1*#
MCV-91 MCH-29.8 MCHC-32.7 RDW-13.6 Plt Ct-227
[**2106-10-11**] 02:31AM BLOOD WBC-8.7 RBC-4.56* Hgb-13.6* Hct-39.8*
MCV-87 MCH-29.8 MCHC-34.2 RDW-13.2 Plt Ct-278
[**2106-10-17**] 01:03AM BLOOD Neuts-77.1* Lymphs-16.2* Monos-5.2
Eos-1.1 Baso-0.3
[**2106-10-12**] 01:00PM BLOOD Neuts-90.9* Lymphs-7.3* Monos-1.3*
Eos-0.1 Baso-0.3
[**2106-11-5**] 02:33AM BLOOD Plt Ct-393
[**2106-11-4**] 02:02AM BLOOD Plt Ct-515*
[**2106-11-3**] 01:54AM BLOOD Plt Ct-759*
[**2106-11-2**] 02:07AM BLOOD Plt Ct-552*
[**2106-10-31**] 01:37AM BLOOD Plt Ct-586*
[**2106-10-30**] 01:12AM BLOOD Plt Ct-589*
[**2106-10-29**] 01:16AM BLOOD Plt Ct-593*
[**2106-10-28**] 02:00AM BLOOD Plt Ct-680*
[**2106-10-27**] 01:49AM BLOOD Plt Ct-690*
[**2106-10-25**] 01:53AM BLOOD Plt Ct-641*
[**2106-10-24**] 04:01PM BLOOD Plt Ct-625*
[**2106-10-24**] 02:17AM BLOOD Plt Ct-579*
[**2106-10-23**] 01:54AM BLOOD Plt Ct-502*
[**2106-10-19**] 01:54AM BLOOD PT-13.3 PTT-30.6 INR(PT)-1.1
[**2106-10-18**] 02:12AM BLOOD Plt Ct-234
[**2106-10-14**] 01:45AM BLOOD PT-15.2* PTT-37.4* INR(PT)-1.3*
[**2106-10-13**] 08:05PM BLOOD Plt Ct-153
[**2106-10-13**] 08:05PM BLOOD PT-15.4* PTT-36.4* INR(PT)-1.3*
[**2106-10-11**] 02:31PM BLOOD PT-14.6* PTT-38.0* INR(PT)-1.3*
[**2106-10-11**] 09:15AM BLOOD Plt Ct-227
[**2106-10-11**] 09:15AM BLOOD PT-16.1* PTT-37.9* INR(PT)-1.4*
[**2106-10-11**] 05:43AM BLOOD PT-14.3* PTT-28.7 INR(PT)-1.2*
[**2106-10-11**] 02:31AM BLOOD PT-12.3 PTT-19.6* INR(PT)-1.0
[**2106-10-12**] 04:43AM BLOOD Fibrino-220
[**2106-10-11**] 02:31PM BLOOD Fibrino-155#
[**2106-10-11**] 02:31AM BLOOD Fibrino-311
[**2106-10-31**] 01:37AM BLOOD ESR-112*
[**2106-11-5**] 02:33AM BLOOD Glucose-105 UreaN-11 Creat-0.8 Na-144
K-3.1* Cl-101 HCO3-39* AnGap-7*
[**2106-11-3**] 01:54AM BLOOD Glucose-208* UreaN-28* Creat-1.0 Na-144
K-4.3 Cl-98 HCO3-38* AnGap-12
[**2106-11-2**] 02:07AM BLOOD Glucose-18* UreaN-25* Creat-0.8 Na-146*
K-4.0 Cl-103 HCO3-38* AnGap-9
[**2106-11-1**] 02:38AM BLOOD Glucose-134* UreaN-20 Creat-0.8 Na-145
K-4.9 Cl-102 HCO3-38* AnGap-10
[**2106-10-30**] 01:12AM BLOOD Glucose-125* UreaN-38* Creat-1.1 Na-143
K-4.5 Cl-102 HCO3-35* AnGap-11
[**2106-10-29**] 01:16AM BLOOD Glucose-202* UreaN-30* Creat-0.9 Na-148*
K-4.0 Cl-105 HCO3-34* AnGap-13
[**2106-10-28**] 02:00AM BLOOD Glucose-150* UreaN-29* Creat-1.0 Na-147*
K-4.5 Cl-106 HCO3-33* AnGap-13
[**2106-10-24**] 04:01PM BLOOD Glucose-131* UreaN-22* Creat-0.9 Na-142
K-3.5 Cl-106 HCO3-30 AnGap-10
[**2106-10-23**] 01:54AM BLOOD Glucose-140* UreaN-23* Creat-0.9 Na-147*
K-3.7 Cl-109* HCO3-32 AnGap-10
[**2106-10-22**] 01:29AM BLOOD Glucose-108* UreaN-24* Creat-0.8 Na-147*
K-3.4 Cl-107 HCO3-32 AnGap-11
[**2106-10-21**] 01:02AM BLOOD Glucose-153* UreaN-24* Creat-1.0 Na-142
K-3.2* Cl-106 HCO3-29 AnGap-10
[**2106-10-20**] 02:11AM BLOOD Glucose-160* UreaN-23* Creat-1.0 Na-144
K-3.7 Cl-109* HCO3-28 AnGap-11
[**2106-11-2**] 02:07AM BLOOD estGFR-Using this
[**2106-10-26**] 02:01AM BLOOD estGFR-Using this
[**2106-10-19**] 02:00AM BLOOD estGFR-Using this
[**2106-11-4**] 02:02AM BLOOD ALT-31 AST-35 AlkPhos-100 Amylase-106*
TotBili-0.3
[**2106-10-22**] 01:29AM BLOOD ALT-46* AST-46* LD(LDH)-416* AlkPhos-174*
Amylase-286* TotBili-0.7
[**2106-10-16**] 01:53AM BLOOD ALT-64* AST-108* AlkPhos-110 TotBili-0.6
[**2106-10-12**] 04:43AM BLOOD ALT-31 AST-45* LD(LDH)-256* AlkPhos-26*
Amylase-168* TotBili-0.4
[**2106-10-11**] 02:31PM BLOOD ALT-25 AST-44* LD(LDH)-239 CK(CPK)-461*
AlkPhos-29* TotBili-0.7
[**2106-10-11**] 09:15AM BLOOD ALT-29 AST-38 CK(CPK)-319* AlkPhos-39
TotBili-0.1
[**2106-11-4**] 02:02AM BLOOD Lipase-57
[**2106-10-11**] 02:31AM BLOOD Lipase-58
[**2106-11-5**] 02:33AM BLOOD Calcium-7.4* Phos-2.5* Mg-2.3
[**2106-11-2**] 02:07AM BLOOD Calcium-8.1* Phos-3.8 Mg-3.4*
[**2106-11-1**] 02:38AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.7*
[**2106-10-31**] 01:37AM BLOOD Calcium-8.3* Phos-3.8 Mg-3.2*
[**2106-10-28**] 02:00AM BLOOD Calcium-8.5 Phos-3.4 Mg-3.1*
[**2106-10-28**] 10:22AM BLOOD Albumin-3.2* Iron-9*
[**2106-10-27**] 01:49AM BLOOD Calcium-8.5 Phos-3.6 Mg-3.0*
[**2106-10-26**] 02:01AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.9*
[**2106-10-24**] 02:17AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.6
[**2106-10-21**] 08:06PM BLOOD Calcium-7.9* Phos-5.7*# Mg-2.6
[**2106-10-21**] 11:17AM BLOOD Calcium-7.8* Phos-3.5 Mg-2.4
[**2106-10-20**] 02:11AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.3
[**2106-10-19**] 02:00AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.4
[**2106-10-18**] 02:12AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.3
[**2106-10-15**] 01:48AM BLOOD Calcium-7.9* Phos-7.1*# Mg-1.9
[**2106-10-14**] 01:45AM BLOOD Calcium-8.4 Phos-2.2*# Mg-2.0
[**2106-10-12**] 08:55PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.9
[**2106-10-12**] 08:55PM BLOOD Calcium-8.1* Phos-3.9 Mg-1.9
[**2106-11-4**] 02:02AM BLOOD calTIBC-185* Ferritn-878* TRF-142*
[**2106-10-22**] 01:29AM BLOOD calTIBC-147* Ferritn-1539* TRF-113*
[**2106-10-16**] 01:53AM BLOOD calTIBC-140* Ferritn-739* TRF-108*
[**2106-11-4**] 09:52AM BLOOD Type-ART pO2-125* pCO2-58* pH-7.47*
calTCO2-43* Base XS-16
[**2106-10-30**] 12:50AM BLOOD Type-ART pO2-94 pCO2-64* pH-7.37
calTCO2-38* Base XS-8
[**2106-10-29**] 04:22PM BLOOD Type-ART Rates-/22 Tidal V-500 PEEP-5
FiO2-50 pO2-106* pCO2-67* pH-7.35 calTCO2-39* Base XS-8
Intubat-INTUBATED
[**2106-10-28**] 04:49AM BLOOD Type-ART Rates-/20 FiO2-40 O2 Flow-10
pO2-95 pCO2-48* pH-7.46* calTCO2-35* Base XS-8 Intubat-NOT
INTUBA
[**2106-10-23**] 02:23AM BLOOD Type-ART pO2-108* pCO2-48* pH-7.44
calTCO2-34* Base XS-6
[**2106-10-19**] 05:34PM BLOOD Type-ART pH-7.42
[**2106-10-19**] 09:17AM BLOOD Type-ART pO2-122* pCO2-44 pH-7.40
calTCO2-28 Base XS-2
[**2106-10-19**] 02:09AM BLOOD Type-ART pO2-102 pCO2-45 pH-7.42
calTCO2-30 Base XS-3
[**2106-10-18**] 02:19AM BLOOD Type-ART pO2-89 pCO2-44 pH-7.47*
calTCO2-33* Base XS-7
[**2106-10-17**] 10:06AM BLOOD Type-ART pO2-133* pCO2-46* pH-7.45
calTCO2-33* Base XS-7
[**2106-10-16**] 01:58AM BLOOD Type-ART pO2-128* pCO2-48* pH-7.47*
calTCO2-36* Base XS-10
[**2106-10-11**] 04:59AM BLOOD Type-ART pO2-98 pCO2-89* pH-7.01*
calTCO2-24 Base XS--11 Intubat-INTUBATED
[**2106-11-3**] 02:21AM BLOOD Lactate-1.3
[**2106-10-23**] 01:54PM BLOOD K-3.5
[**2106-10-22**] 02:05PM BLOOD Na-141 K-3.1*
[**2106-10-22**] 02:00AM BLOOD Glucose-100
[**2106-10-21**] 01:10AM BLOOD Glucose-153*
[**2106-10-20**] 11:52AM BLOOD K-3.4*
[**2106-10-19**] 05:34PM BLOOD Na-141 K-3.5
[**2106-10-19**] 10:37AM BLOOD K-3.7
[**2106-10-19**] 02:09AM BLOOD Glucose-142*
[**2106-10-14**] 01:53AM BLOOD Glucose-95 Lactate-1.6
[**2106-10-12**] 09:10PM BLOOD Glucose-105 Lactate-5.2*
[**2106-10-12**] 01:08PM BLOOD Lactate-3.3*
[**2106-10-12**] 03:17AM BLOOD Glucose-182* Lactate-9.8* Na-143 K-3.0*
Cl-104
[**2106-10-11**] 07:09AM BLOOD Glucose-245* Lactate-7.3* Na-141 K-4.0
Cl-111 calHCO3-20*
[**2106-10-11**] 06:23AM BLOOD Glucose-184* Lactate-4.1* Na-140 K-4.5
Cl-110 calHCO3-22
[**2106-10-11**] 04:59AM BLOOD Glucose-183* Lactate-4.0* Na-139 K-3.8
Cl-109 calHCO3-22
[**2106-10-11**] 04:40AM BLOOD Glucose-172* Lactate-6.9* Na-137 K-4.0
calHCO3-19*
[**2106-10-12**] 03:17AM BLOOD Hgb-9.7* calcHCT-29
[**2106-10-12**] 02:17AM BLOOD Hgb-9.2* calcHCT-28
[**2106-10-12**] 12:50AM BLOOD Hgb-10.8* calcHCT-32 O2 Sat-100
[**2106-10-11**] 06:23AM BLOOD Hgb-12.8* calcHCT-38
[**2106-10-11**] 05:37AM BLOOD Hgb-12.1* calcHCT-36
[**2106-10-11**] 04:59AM BLOOD Hgb-11.5* calcHCT-35 O2 Sat-93

Brief Hospital Course:
The pt is a 57 year-old Eritrean man who presents following
multiple stab wounds to the chest, abdomen and left arm on [**10-11**],
now not waking up off sedation.  On [**10-11**] the patient
came home with multiple stab wounds to his chest, abdomen and
arm, and his brother called 911 and brought him to the ED.  In
the ED he had 2 chest tubes placed, and intubation was attempted
was attempted, but he was reportedly a difficult airway.  An LMA
was initially placed, but the patient reportedly had SaO2s in
the
80s.  An emergent criciotomy was performed in the ED, later
converted to a trach.

The details of the initial interactions are in the operative
note
dictated on the first hospital night/day by the attending
physician Dr [**Last Name (STitle) 519**].
This first set of operations included right chest tube
placement,
development of pulseless electrical activity, formal
tracheostomy creation,
intraoperative consultation for hand ischemia and primary repair
of the left
radial artery.

The patient was taken to the Trauma ICU of [**Hospital1 18**] and
resuscitated/recovered.
Given the patient's injuries and open abdomen from the first
series of operations,
he was taken back for fomral abdominal closure and placement of
an additional
chest tube for continued pneumothorax on the left side.  Small
injuries of the initial trauma were then also repaired at that
time ([**2106-10-13**]).

Since that time period the patient was maintained in the ICU.
Given the intensive care of the patient's day-to-day life, the
remaining hospital stay will be summarized
by organ system in appropriate detail.

Neuro:
The patient's metnal status has been slow to improve.  Notably,
the patient makes nonpurposeful movements of all extremities;
the
patient sticks out his tongue to command.
Per our neurology consultation service, "His MRI of the
brain (even the most recent one) is  not characteristic of
anoxic
brain injury, however, the imaging does not have to follow a set
pattern for a patient to have this.  EEG was negative for
seizure
activity, but showed a lot of slow activity which was consistent
with encephalopathy. His stool is being cultured for C. diff,
and
his urine grew Enterococcus. His LP was not suggestive of an
infection (prelim CSF Gram Stain negative, cytology pending).
Neurology has no further recs, and will be signing off
(communicated to TSICU)."

Cardiovascularly:
patient has been hemodynamically stable using a beta blocker and
a clonidine
patch

Pulmonary:
respiratory insufficiency has pervaded the [**Hospital 228**] hospital
course,
notably weaning to CPAP+PS, minimal settings; with Trach mask
trial for 5 mins, which he did not tolerate [**3-15**] tachypnea; chest
tubes were promptly removed and are no
longer in the patient.

GI/Abdominal:
PEG tube placed based on mental status; tolerating tube feeds
but notably at this time the patient appears severely
constipated and is currently undergoing a strong bowel regimen
and enemas to reduce constipation

Renal:
Urine output and electrolytes are being monitored accurately
with a foley catheter in place and daily repletions provided for
electrolytes

HEME:
HCT slowly trending down but notably hemodynamically stable
without a pressor requirement

ENDOCRINE:
Regular insulin sliding scale

ID:
Recently febrile (>38C); managed with an infectious disease
consult who have made the following recommendations based on
current culture data:
[**11-5**] Stable, on 2 weeks of vanc for bacteremia, on 15 days of
cefepime for pseudomonal pneumonia.  LP notably negative; Sputum
with pseudomonas.  Additionally, thoracic surgery was consulted
to rule out the need for a decortication; they felt that there
was no such need given the radiographs and the small size of
effusions seen therein.

Lines / Tubes / Drains: Foley, G-tube, Trach, PICC
Glycemic Control:  Regular insulin sliding scale, Lantus (R)
protocol
Lines:
PICC Line
Prophylaxis:
DVT: Boots, SQ UF Heparin
Stress ulcer: H2 blocker
VAP bundle: HOB elevation, Mouth care, Daily wake up, RSBI
Comments:
Communication: ICU consent signed Comments:
Code status: Full code


Medications on Admission:
none

Discharge Medications:
1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
2. CefePIME 2 g IV Q12H
3. Vancomycin 1000 mg IV Q 12H
4. Potassium Chloride 20 mEq / 50 ml SW IV SLIDING SCALE K < 3.5

Hold for K > 4.5
5. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
6. Senna 8.8 mg/5 mL Syrup Sig: One (1)  PO BID (2 times a day)
as needed for constipation.
7. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical ASDIR (AS DIRECTED) as needed for rash.
8. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1)  Topical
QID (4 times a day) as needed for rash.
9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. PEG-Electrolyte Soln     Recon Soln Sig: Four (4) cc PO
ASDIR (AS DIRECTED).
11. Methadone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  units of 5
cc PO BID (2 times a day).
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
16. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
18. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QWED (every Wednesday).
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000U
Injection TID (3 times a day).
20. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
10-15 Puffs Inhalation Q2H (every 2 hours) as needed for wheeze.

21. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Three (3) ML
Mucous membrane [**Hospital1 **] (2 times a day).
22. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
23. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
24. Acetaminophen 160 mg/5 mL Solution Sig: Fifteen (15) cc PO
Q6H (every 6 hours) as needed for pain/fever.
25. Insulin Regular Human 100 unit/mL Solution Sig: One (1) as
directed by sliding scale Injection as directed by sliding scale
from [**Hospital1 18**] TSICU.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
multiple traumatic injuries including:
B/L pneumothorax
LUE compartment syndrome
Left radial artery tear
Left diaphragm injury


Discharge Condition:
hemodynamically stable, with ventilatory dependence, tube feed
dependence given continued change in mental status


Discharge Instructions:
You have suffered multiple traumatic injuries and are still in
the process of recovery
Come to the Emergency Room if you
have:
* fever above 101.5F
* nausea, vomiting or diarrhea that doesn't stop
* chest pain or pressure
* opening up or drainage from your wound
* any other concerning symptoms

Difficulties with your tracheostomy, gastrostomy tube, wounds,
or sudden new symptoms of concern should prompt your return to
the ER or a call to our offices.

Followup Instructions:
Trauma/Critical Care/General Care issues:
You are to call the Trauma Surgery office at [**Hospital1 18**] in one week
for follow up of these issues and continued care concerns.
Please bring a representative with you who can help guide you in
your care and work with us to best help you.

Plastic Surgery:
Please call the Plastic Surgery Department of Hand Surgery at
[**Hospital1 18**] to set up an appointment on or after [**11-11**] for
removal of fasciotomy sutures and for further evaluation of your
upper extremity function after surgery


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
{'Traumatic pneumothorax without mention of open wound into thorax,Injury to diaphragm, with open wound into cavity,Traumatic shock,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Anoxic brain damage,Cardiac complications, not elsewhere classified,Unspecified protein-calorie malnutrition,Bacteremia,Urinary tract infection, site not specified,Open wound of forearm, complicated,Other constipation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Assault by cutting and piercing instrument,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Traumatic injury

PRESENT ILLNESS: The pt is a 57 year-old Eritrean man who presents following
multiple stab wounds to the chest, abdomen and left arm on [**10-11**],
now not waking up off sedation.  On [**10-11**] the patient
came home with multiple stab wounds to his chest, abdomen and
arm, and his brother called 911 and brought him to the ED.  In
the ED he had 2 chest tubes placed, and intubation was attempted
was attempted, but he was reportedly a difficult airway.  An LMA
was initially placed, but the patient reportedly had SaO2s in
the
80s.  An emergent criciotomy was performed in the ED, later
converted to a trach.

MEDICAL HISTORY: PMH: None (per brother)
[**Name (NI) **]: None
[**Last Name (un) 1724**]: None
Soc: Social EtOH, 20pkyr smoking, no drugs

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam upon admission: - Limited, as patient had just
recieved a bolus of
fentanyl and was also on propofol
Vitals: T:101.2  P: 91 R: 18  BP: 109/48 (variable, ranges from
109-180 systolic) SaO2: 100%
General: cric in place, on ventilator, just received fentanyl
bolus, also on propofol drip
HEENT: NC/AT, conjunctival injection, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W.  Bilateral chest
tubes in place transmitting airway sounds
Cardiac: rapid, regular, no murmurs
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted, midline incision well healed.
Extremities: No C/C/E bilaterally, L arm bandaged.
Skin: no rashes or lesions noted.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: Social Hx: From [**Country 84528**].  Lives with his brother.  ? of possible
substance abuse history based on SW notes. 

### Response:
{'Traumatic pneumothorax without mention of open wound into thorax,Injury to diaphragm, with open wound into cavity,Traumatic shock,Pneumonia due to Pseudomonas,Pneumonitis due to inhalation of food or vomitus,Cardiac arrest,Anoxic brain damage,Cardiac complications, not elsewhere classified,Unspecified protein-calorie malnutrition,Bacteremia,Urinary tract infection, site not specified,Open wound of forearm, complicated,Other constipation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Assault by cutting and piercing instrument,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
