CHIEF COMPLAINT: s/p fall from roof

PRESENT ILLNESS: Mr. [**Known lastname 84471**] is a 15 year-old health male who fell off the roof of
a 5 story building while at a party. He does not recall how this
happened. He was BIBA to the emergency department and was
stable. His imaging showed: negative CT head, Left C7 pars
fracture, Right pulmonary contusion, Right 20% pneumothorax, and
some free fluid in the pelvis. A Right chest tube was placed in
the emergency department. A chest xray showed adequate
positioning of the tube. There was a question of possible
pancreatic hematoma/mesenteric hematoma but on repeat imaging
hours later this was not demonstrated.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:98.9 HR:67 BP:112/60 RR:20 SAT: 99% RA

FAMILY HISTORY: None

SOCIAL HISTORY: No ETOH
No Tobacco
No illegal drug use
Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Contusion of lung without mention of open wound into thorax,Contusion of face, scalp, and neck except eye(s),Accidental fall from or out of building or other structure
Traum pneumothorax-close,Fx c7 vertebra-closed,Lung contusion-closed,Contusion face/scalp/nck,Fall from building
Admission Date:  [**2122-10-24**]              Discharge Date:   [**2122-10-28**]

Date of Birth:  [**2107-7-29**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p fall from roof

Major Surgical or Invasive Procedure:
Chest tube placement on Right side.


History of Present Illness:
Mr. [**Known lastname 84471**] is a 15 year-old health male who fell off the roof of
a 5 story building while at a party. He does not recall how this
happened. He was BIBA to the emergency department and was
stable. His imaging showed: negative CT head, Left C7 pars
fracture, Right pulmonary contusion, Right 20% pneumothorax, and
some free fluid in the pelvis. A Right chest tube was placed in
the emergency department. A chest xray showed adequate
positioning of the tube. There was a question of possible
pancreatic hematoma/mesenteric hematoma but on repeat imaging
hours later this was not demonstrated.

Past Medical History:
None

Social History:
No ETOH
No Tobacco
No illegal drug use

Family History:
None

Physical Exam:
T:98.9 HR:67 BP:112/60 RR:20 SAT: 99% RA

GEN: Alert and Oriented x 3
Card: RRR no mrgc
Pulm: CTA B chest tube site clean, dry and intact
Abdomen: soft nontender nondistended +BS


Pertinent Results:
[**2122-10-26**] 02:02AM BLOOD WBC-7.1 RBC-4.08* Hgb-11.9* Hct-33.9*
MCV-83 MCH-29.1 MCHC-35.0 RDW-13.6 Plt Ct-155
[**2122-10-26**] 02:02AM BLOOD Plt Ct-155
[**2122-10-26**] 02:02AM BLOOD Glucose-106 UreaN-7 Creat-0.8 Na-141
K-4.0 Cl-109* HCO3-27 AnGap-9
[**2122-10-25**] 02:36AM BLOOD Glucose-141* UreaN-14 Creat-1.0 Na-142
K-4.3 Cl-111* HCO3-24 AnGap-11
[**2122-10-28**] 05:20AM BLOOD Amylase-55
[**2122-10-26**] 02:02AM BLOOD Amylase-69
[**2122-10-28**] 05:20AM BLOOD Lipase-39
[**2122-10-26**] 02:02AM BLOOD Lipase-51
[**2122-10-26**] 02:02AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
[**2122-10-25**] 02:36AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
[**2122-10-24**] 09:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
Given his pulmonary contusion and questionable abdominal
findings on CT he was admitted to the ICU overnight for
observation. On day two he was transfered to the floor. He
tolerated a regular diet. His pain was well controlled. His
chest tube was put on waterseal and repeat xray showed slight
increase in the pneumothorax. The chest tube was left on
waterseal all day and night and on [**10-27**] the chest tube was
removed after an unchanged chest xr. A post pull film
demonstrated increase in the size of the pneumothorax. He was
put on high flow oxygen and three subsequent chest xrays showed
decrease in the size of the pneumothorax. Since the patient
continued to do well with normal vital signs, normal labs,
tolerating a regular diet and pain well controlled, he was
discharged home on [**10-28**].

Medications on Admission:
none

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain: do not exceed 4g
acetaminophen(tylenol) in 24hours.
Disp:*25 Tablet(s)* Refills:*0*
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: while on narcotics.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Right Pneumothorax with pulmonary contusion
Left pars interarticularis fracture C7


Discharge Condition:
Vital signs stable, ambulating, tolerating a regular diet, pain
well controlled.


Discharge Instructions:
Please call your doctor or return to the ER for 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.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.

*Avoid driving or operating heavy machinery while taking pain
medications.
* 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.
* Continue to ambulate several times per day.

.

Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.

Must wear Ccollar at all times until follow up appointment with
Dr. [**Last Name (STitle) **].

.


Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call for appointment
Follow up with Dr. [**Last Name (STitle) **] in 8 weeks. Call for appointment


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
{'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Contusion of lung without mention of open wound into thorax,Contusion of face, scalp, and neck except eye(s),Accidental fall from or out of building or other structure'}


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 fall from roof

PRESENT ILLNESS: Mr. [**Known lastname 84471**] is a 15 year-old health male who fell off the roof of
a 5 story building while at a party. He does not recall how this
happened. He was BIBA to the emergency department and was
stable. His imaging showed: negative CT head, Left C7 pars
fracture, Right pulmonary contusion, Right 20% pneumothorax, and
some free fluid in the pelvis. A Right chest tube was placed in
the emergency department. A chest xray showed adequate
positioning of the tube. There was a question of possible
pancreatic hematoma/mesenteric hematoma but on repeat imaging
hours later this was not demonstrated.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T:98.9 HR:67 BP:112/60 RR:20 SAT: 99% RA

FAMILY HISTORY: None

SOCIAL HISTORY: No ETOH
No Tobacco
No illegal drug use 

### Response:
{'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of seventh cervical vertebra,Contusion of lung without mention of open wound into thorax,Contusion of face, scalp, and neck except eye(s),Accidental fall from or out of building or other structure'}
