CHIEF COMPLAINT: s/p 18 ft fall

PRESENT ILLNESS: 45 year-old gentleman s/p fall approx 18 ft onto a large post
which snapped in half who broke several left sided ribs and also
ruptured his spleen. +EtOH He was transported to [**Hospital1 18**] where he
was takne to the operating and underwent a splenectomy.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH
Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of four ribs,Alcohol abuse, unspecified,Injury to other specified intrathoracic organs without mention of open wound into cavity,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Empyema without mention of fistula,Accidental fall from or out of building or other structure,Other specified anomalies of kidney,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Delirium due to conditions classified elsewhere
Spleen parenchyma lacer,Traum pneumohemothor-cl,Fracture four ribs-close,Alcohol abuse-unspec,Intrathoracic inj NEC-cl,Adrenal gland injury-cl,Bact pleur/effus not TB,Meth sus pneum d/t Staph,Bacteremia,Empyema w/o fistula,Fall from building,Kidney anomaly NEC,Mth sus Stph aur els/NOS,Delirium d/t other cond
Admission Date:  [**2170-8-1**]              Discharge Date:   [**2170-8-14**]

Date of Birth:  [**2125-3-16**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p 18 ft fall

Major Surgical or Invasive Procedure:
Splenectomy
VATS procedure with empyema tube placement


History of Present Illness:
45 year-old gentleman s/p fall approx 18 ft onto a large post
which snapped in half who broke several left sided ribs and also
ruptured his spleen. +EtOH He was transported to [**Hospital1 18**] where he
was takne to the operating and underwent a splenectomy.

Social History:
+EtOH

Family History:
Noncontributory

Pertinent Results:
[**2170-8-1**] 11:58PM   GLUCOSE-159* LACTATE-2.4* NA+-137 K+-4.6
CL--105
[**2170-8-1**] 03:22AM   GLUCOSE-116* UREA N-19 CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-20* ANION GAP-17
[**2170-8-1**] 03:22AM   CALCIUM-7.9* PHOSPHATE-3.3 MAGNESIUM-2.1
[**2170-8-1**] 03:22AM   WBC-10.8 RBC-4.19* HGB-14.0 HCT-40.4 MCV-97
MCH-33.5* MCHC-34.7 RDW-13.2
[**2170-8-1**] 03:22AM   PLT COUNT-230
[**2170-8-1**] 12:30AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG

CT CHEST W/CONTRAST
IMPRESSION:
1. Resolving contusion in right apex and basal segment of right
lower lobe.
2. Interval resolution of loculated effusion in left apex
anteriorly.
3. Chest tube in situ with left pleural effusion noted.
4. The patient is status post splenectomy.
5. Multiple rib fractures on the left.
6. Small fluid collection in intercostal muscles on the left
side at the site of a rib fracture.

CT HEAD W/O CONTRAST
IMPRESSION: No intracranial hemorrhage or fracture.

CT C-SPINE W/O CONTRAST
IMPRESSION:
1. No acute alignment abnormality or fracture.
2. Partial demonstration of patient's left pneumothorax.


Brief Hospital Course:
He was admitted to the Trauma service. Once stabilized in the
trauma bay he was taken to the operating room for an exploratory
laparotomy and splenectomy. There were no intraoperative
complications. He remained in the Trauma ICU for several days
for close monitoring given his injuries. He was noted to have
dyspnea and increased oxygen requirements; chest imaging
revealed a loculated left sided effusion. Thoracic surgery was
consulted and he was taken to the operating room on [**8-6**] for left
VATS decortication.

Cultures of the pleural fluid and of his chest wound were sent
which revealed a staphylococcal infection. It was recommended by
Infectious Disease that he be treated with a 6 week course of
Nafcillin. A PICC line was placed and plans were made or
discharge home with IV antibiotics.

He was given the appropriate vaccinations due to the splenectomy
prior to his discharge. Follow up is needed in both Trauma and
Thoracic clinic.




Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) GM
Intravenous Q6H (every 6 hours) for 6 weeks.
Disp:*qs GM* Refills:*0*
6. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML
Injection DAILY (Daily): Flush PICC line before and after use
and PRN.
Disp:*qs ML(s)* Refills:*2*
7. Central line dressing kit
Change PICC line dressing as directed


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
s/p 18 ft fall
Left pneumothorax
Multiple left sided rib fractures
Grade III splenic laceration
Wound staphylococcal infection


Discharge Condition:
Stable


Discharge Instructions:
You will need to continue with the IV antibiotics for a total of
6 weeks.

Return to the Emergency room if you develop any fevers, chills,
shortness of breath, chest discomfort, redness or thick drainage
from PICC lie site, abdominal pain, nausea, vomiting, diarrhea
and/or any other symptoms that are concerning to you.

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

Follow up in [**Hospital 16814**] clinic in [**2-6**] weeks, call [**Telephone/Fax (1) 170**]
for an appointment.



Completed by:[**2170-8-14**]
{'Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of four ribs,Alcohol abuse, unspecified,Injury to other specified intrathoracic organs without mention of open wound into cavity,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Empyema without mention of fistula,Accidental fall from or out of building or other structure,Other specified anomalies of kidney,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Delirium due to conditions classified elsewhere'}


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 18 ft fall

PRESENT ILLNESS: 45 year-old gentleman s/p fall approx 18 ft onto a large post
which snapped in half who broke several left sided ribs and also
ruptured his spleen. +EtOH He was transported to [**Hospital1 18**] where he
was takne to the operating and underwent a splenectomy.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH 

### Response:
{'Injury to spleen without mention of open wound into cavity, laceration extending into parenchyma,Traumatic pneumohemothorax without mention of open wound into thorax,Closed fracture of four ribs,Alcohol abuse, unspecified,Injury to other specified intrathoracic organs without mention of open wound into cavity,Injury to other intra-abdominal organs without mention of open wound into cavity, adrenal gland,Pleurisy with effusion, with mention of a bacterial cause other than tuberculosis,Methicillin susceptible pneumonia due to Staphylococcus aureus,Bacteremia,Empyema without mention of fistula,Accidental fall from or out of building or other structure,Other specified anomalies of kidney,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Delirium due to conditions classified elsewhere'}
