CHIEF COMPLAINT: MVC

PRESENT ILLNESS: 42M car vs pole, ejected ~30ft, garbled speech at scene, +[**Hospital 76954**]
transfer from OSH with C6 fracture, free fluid in abd/pelvis,
hypotension peri-RSI. Per EMS was moving all 4 extremities at
OSH. Taken to OR upon admission, found liver lacs and performed
ileocecectomy. Brought to TICU intubated. Taken to OR for
re-exploration on [**5-31**], evacuated ~1L old blood.

MEDICAL HISTORY: s/p Left ankle ORIF
s/p removal of adenoids

MEDICATION ON ADMISSION: Multivitamin, Vitamin D

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
Constitutional: Intubated and sedated
HEENT: Pupils equal, round and reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Moves all extremities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Supportive wife, works in construction building houses
+ETOH, unknown tobacco/IVDU
Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum,Traumatic shock,Injury to liver without mention of open wound into cavity, hematoma and contusion,Acute and subacute necrosis of liver,Acute vascular insufficiency of intestine,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure following trauma and surgery,Acute kidney failure with lesion of tubular necrosis,Closed fracture of four ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Rhabdomyolysis,Acidosis,Cardiac complications, not elsewhere classified,Right bundle branch block,Tachycardia, unspecified,Other iatrogenic hypotension,Traumatic hemothorax without mention of open wound into thorax,Closed dislocation, multiple cervical vertebrae,Other chronic nonalcoholic liver disease,Unspecified injury of heart without mention of open wound into thorax,Injury to other gastrointestinal sites, without mention of open wound into cavity,Edema of male genital organs,Contact dermatitis and other eczema due to plants [except food],Accidental poisoning from other specified plants,Alcohol abuse, unspecified,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Personal history of allergy to penicillin
Peritoneum injury-closed,Traumatic shock,Liver hematoma/contusion,Acute necrosis of liver,Ac vasc insuff intestine,Meth sus pneum d/t Staph,Ac resp flr fol trma/srg,Ac kidny fail, tubr necr,Fracture four ribs-close,Fx dorsal vertebra-close,Rhabdomyolysis,Acidosis,Surg compl-heart,Rt bundle branch block,Tachycardia NOS,Iatrogenc hypotnsion NEC,Traum hemothorax-closed,Disloc mult cerv vert-cl,Chronic liver dis NEC,Heart injury NOS-closed,GI injury NEC-closed,Edema, male genital orgn,Dermatitis due to plant,Acc poison-plants NEC,Alcohol abuse-unspec,Mv coll w oth obj-driver,Hx-penicillin allergy
Admission Date:  [**2198-5-31**]              Discharge Date:   [**2198-6-25**]

Date of Birth:  [**2155-4-24**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
MVC

Major Surgical or Invasive Procedure:
[**2198-5-31**]:  Exploratory laparotomy, washout of
hemoperitoneum, debridement of laceration of the liver,
ileocecectomy, ileocolostomy.

[**2198-5-31**]: Take back for Exploratory laparotomy, ileocectomy

[**2198-6-8**]: IR-guided drainage of subhepatic/ right paracolic
gutter collection


History of Present Illness:
42M car vs pole, ejected ~30ft, garbled speech at scene, +[**Hospital 76954**]
transfer from OSH with C6 fracture, free fluid in abd/pelvis,
hypotension peri-RSI. Per EMS was moving all 4 extremities at
OSH. Taken to OR upon admission, found liver lacs and performed
ileocecectomy. Brought to TICU intubated. Taken to OR for
re-exploration on [**5-31**], evacuated ~1L old blood.

Past Medical History:
s/p Left ankle ORIF
s/p removal of adenoids

Social History:
Supportive wife, works in construction building houses
+ETOH, unknown tobacco/IVDU


Family History:
Noncontributory

Physical Exam:
On admission:
Constitutional: Intubated and sedated
HEENT: Pupils equal, round and reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Moves all extremities


Pertinent Results:
[**2198-5-31**] 12:00AM BLOOD WBC-10.8 RBC-4.50* Hgb-13.5* Hct-41.0
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.1 Plt Ct-214
[**2198-5-31**] 12:00AM BLOOD PT-11.4 PTT-24.9* INR(PT)-1.1
[**2198-5-31**] 01:16AM BLOOD Glucose-138* UreaN-14 Creat-1.2 Na-136
K-4.8 Cl-106 HCO3-16* AnGap-19

CT Head: No acute intracranial process with small left subgaleal
hematoma.

CT Cspine:
1.  Comminuted fracture of the left facet of the C6 vertebral
body with
extension into the lamina, pedicle and posterosuperior
left-sided aspect of the C6 vertebral body.
2.  Right-sided C6 pedicular fracture extending into the facet
and right
lateral C6 vertebral body.
3.  Assessment of fracture extension into the transverse
foramina is limited and as a result cannot fully be excluded.
Thus, need for CTA to assess vertebral arteries is unclear.
These findings were discussed with Dr. [**First Name (STitle) **] by phone at 01:40.
Initial findings were also discussed with Dr. [**Last Name (STitle) 54156**] and [**Doctor Last Name 2819**]
at 23:45 on [**2198-5-30**].

CT Sinus: Limited study due to motion without evidence of
fracture.

CT Torso:
1.  Subcapsular hepatic hematoma with 1 or 2 segment VI, 4-5 cm
lacerations, though others may be masked due to fatty liver and
bolus timing
2.  3.2 cm right adrenal hematoma and stranding about the left
adrenal gland.
3.  Stranding and free fluid in the mesentery as well as
dependently in the pelvis suspicious for mesenteric and/or bowel
injury, though no additional CT signs of bowel injury are
identified.
4.  Non-specific stranding about the aorta and IVC without
evidence of frank extravasation.
5.  Right sixth and seventh lateral rib fractures, right fifth
rib anterior chondral fracture, left fifth through eighth
anterolateral costochondral fracture-dislocations, and
transverse process fractures at T6 and T12 through L5 as
described above.
6.  No evidence pulmonary contusion with atelectasis felt more
likely.
7.  Right axillary soft tissue contusion.

MRI Cspine:
1. Mild STIR hyperintensity in bilateral C6 pedicles and facets.
There is
mal-alignment of bilateral C5-C6 facet joints, left more than
right which is likely secondary to rotatory subluxation. The
fractures of C6 facets are better seen on the CT cervical spine.
No evidence of ligamentous injury. Increased mobility at this
level can be assessed by flexion/extension views when patient is
stable if clinically indicated.
2. A T1 and T2 hypointense soft tissue in the anterior epidural
space
extending from C6-C7 disc posterior to C7 body. This likely
represents an
extruded disc with inferior migration. This causes deformity of
the ventral surface of the spinal cord.
3. No focal signal abnormality in the spinal cord.
4. Degenerative changes in the cervical spine with multilevel
neural foraminal stenosis.

Brief Hospital Course:
Mr. [**Known lastname 9450**] was admitted to the trauma ICU on [**2198-5-31**] with the
following injuries:
Bilateral pulmonary contusions
Right rib fractures [**6-21**]
Left rib fractures [**5-22**]
Fracture of C-spine at C6
Transverse process fracture T12-L5
Subcapsular liver hematoma
Segment 6 liver laceration (4cm)
Ileal mesenteric tear with small bowel ischemia
Blunt cardiac injury
Adrenal hematoma

In brief, he was taken to the operating room on admission from
the ED.  There was a large mesenteric tear and associated small
bowel ischemia.  This was resected; he had a ileo cecectomy with
primary anastomosis.  He also was noted to have a liver
laceration with associated liver ischemia, this was debrided.
Post-op he was monitored in the ICU and was noted to be
persistently tachycardic with an increasing pressor requirement.
His lactate was elevated and rising and he was taken back to the
OR for a 2nd look laparotomy, also on [**2198-5-31**].  Approximately 1
liter of blood was found and an internal hernia. He was
hemostatic at the end of the case and he was returned to the
ICU.  The rest of his hospital course by systems below, but in
brief was characterized by a prolonged wean from the ventilator,
finally extubated on [**2198-6-14**] and liver necrosis and eventual
fluid collection which was drained by IR. His course is
described below by system:

Neuro:  He was initially sedated while intubated with a
combination of propofol, fentanyl and versed but this was weaned
as appropriate and after extubation he was treated with Dilaudid
for pain. Orthopedic Spine evaluation was requested for the
cervical spine fracture- this was treated non operatively with a
cervical collar. He will follow up in approx 4 weeks with Dr.
[**Last Name (STitle) 363**] where he will have repeat spine films done. He was alert
and oriented x 3 and neurologically intact with some bilateral
upper extremity weakness that had improved during his admission.

Cardiac: Patient was hypotensive during the initial days postop
and required pressors. He was weaned off Levophed on POD#3. Echo
was performed to evaluate for blunt cardiac injury and the heart
appeared hyperdynamic with no wall motion abnormalities. Patient
was resuscitated with PRBC and albumin.  He remained
hemodynamically stable throughout the rest of his hospital
course.

Resp:  He was intubated initially on scene then remained
intubated post-operatively through two trips to the OR.
Initially requiring high PEEPs this was eventually weaned though
he continued to struggle with poor oxygenation and inability to
wean from the vent, likely due to a combination of [**Last Name (STitle) 1064**]
(noted on CXR, BAL after bronch on [**2198-6-6**] grew MSSA) and fluid
overload.  He was placed on a Lasix drip to remove excess fluid
and treated with levofloxacin (started on [**6-7**]) for the
[**Month/Year (2) 1064**]; he was eventually weaned to extubation on [**2198-6-14**]. He
remained on 40mg PO Lasix daily while on the floor and continued
to diurese well. He was changed to diamox on [**6-21**] to avoid
hypercarbia. His supplemental oxygen was weaned and his oxygen
saturation remained stable on room air. Continued pulmonary
toileting and incentive spirometry were encouraged.  On [**6-24**] he
underwent diagnostic and therapeutic thoracentesis for 1.5L and
he symptomatically improved with saturations remaining in the
mid to high 90's. Follow up CXR showed interval decrease in
right pleural effusion with no evidence of pneumothorax after
thoracentesis.

GI: Patient was taken for emergent laparotomy on the night of
admission. Postop, patient had persistent lactic acidosis and
hypotension. Patient was taken back to OR for re-exploration,
also on [**5-31**], as noted above.  He started to spike temperatures
on [**4-19**].  In combination with his downtrending Hct (to 24),
a CT scan was obtained on [**6-7**]; it showed a fluid collection
near a necrotic portion of the liver with fluid in the right
paracolic gutter.  Hepatobiliary surgery was consulted and
recommended a triple phase CT to assess progression of the liver
ischemia/necrosis one week later (this was done on [**6-14**]) to aid
in surgical planning regarding debridement.  He was taken by IR
on [**6-8**] for drainage of the fluid collection near the drain.
Cultures grew mixed bacteria as well as b. fragilis (he was
started on Flagyl on [**6-7**] along with levofloxacin).

He had a triple phase CT on [**6-14**] which demonstrated progression
of necrosis with expected walling off/organization of the liver
necrosis.  Also of note on [**6-14**], the drainage from his liver
collection drain (placed [**6-8**] by IR) changed from
serosanguinous/yellow to thicker brown.  There was concern that
this was stool from a leak in his anastomosis, so he was sent
down urgently for a CT scan with contrast injected through the
drain.  The contrast did not enter the bowel which was
reassuring.  The drainage color change was attributed to
additional necrosis of the liver which was now sloughing off and
draining through the drain.

On transfer to the floor on [**6-15**] his tube feeds were discontinued
and he was started on a regular diet. Nutritional supplements
were added. He tolerated a regular diet and was started on a
bowel regimen.

He was discharged to home with the drainage catheter in place,
teaching was provided to patient and his wife on the care and
monitoring of the drainage catheter system.

GU: On admission, patient was in acute renal failure with
rhabdomyolysis. He was aggressively hydrated and his creatinine
improved with downtrend in his CK from 12,0000 to 700 after
which the level was no longer checked as his urine output was
excellent and his creatinine normalized.  His urine output was
normal throughout his stay. On the floor he was diuresed as
discussed above under respiratory. A Foley catheter remained in
place for urine output monitoring until [**6-16**], at which time it
was removed and he voided without difficulty. He was noted with
scrotal edema primarily related to fluid overload; this did
eventually improve significantly with intermittent diuresis
using Lasix which was later changed to Diamox.

ID: Patient began to spike fevers on POD#4.  He was started on
levofloxacin, as noted above, for an MSSA [**Month/Day (2) 1064**] and
completed a 7 day course that was dc'd on [**6-14**].  The Flagyl was
also started on [**6-7**] due to the cultures from the drain growing
bacteroides.  This was continued until [**2198-6-21**]. At time of
discharge he was afebrile with a normal white count of 8.2.

MSK: He was evaluated by Physical ad Occupational therapy and at
time of discharge he was supervision level with the walker.

Dispo: He was discharged home with his wife and was provided
with follow up appointments with his PCP, [**Name10 (NameIs) 4289**] [**Name11 (NameIs) **] surgery and
Orthopedic Spine.


Medications on Admission:
Multivitamin, Vitamin D


Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. multivitamin     Capsule Sig: One (1) Capsule PO once a day.

5. Vitamin D3 4,000 unit Capsule Sig: One (1) Capsule PO once a
day.
6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
7. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*30 GM* Refills:*2*
8. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Polytrauma s/p motor vehicle crash:

Bilateral pulmonary contusions
Right rib fractures [**6-21**]
Left rib fractures [**5-22**]
Fracture of C-spine at C6
Transverse process fracture T12-L5
Subcapsular liver hematoma
Segment 6 liver laceration (4cm)
Ileal mesenteric tear with small bowel ischemia
Blunt cardiac injury
Adrenal hematoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
You were admitted to the hospital after a motor vehicle crash.
You sustained multiple injuries including fractures in your
neck, spine, ribs and an injury to your bowel and liver. You
required an operation to repair your abdominal injury. You
required a stay in the intensive care unit and were transferred
to the surgical floor when stable. You are continuing to recover
well from your accident and are now being discharged home with
the following instructions:

You should remain in the cervical collar until follow up with
Orthopedic Spine Surgery. Please follow up with Dr. [**Last Name (STitle) 363**] at
the appointment scheduled below.

You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedating, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
If your doctor allows, non steriodal anti-inflammatory drugs are
very effective in controlling pain (i.e. Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.

General Drain Care:

*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).

*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor if the amount increases significantly or changes in
character. Be sure to empty the drain frequently. Record the
output, if instructed to do so.

*Measure and record the output from the draiange catheter every
day and be sure to bring a log/diary of this information with
you to your Acute Care Surgery Clinic follow up.

*Wash the area gently with warm, soapy water.

*Keep the insertion site clean and dry otherwise.

*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.

*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.

You sustained rib fractures which can cause severe pain and
subsequently cause you to take shallow breaths because of the
pain.
You should take your pain medicine as as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths.
If the pain medication is too sedating, take half the dose and
notify your physician.
[**Name10 (NameIs) **] is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
Do NOT smoke.
Return to the ED right away for any acute shortness of breath,
increased pain or crackling sensation around your rips
(crepitus).
Narcotic pain medication can cause constipation. Thefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.

ACTIVITY:

Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Name10 (NameIs) 5059**] at your next visit.
Don't lift more than 20-25 lbs for 4-6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.

HOW YOU [**Month (only) **] FEEL:

You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time.  If they do not, tell your [**Month (only) 5059**].

YOUR INCISION:
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that that's okay.
Your incision may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next 6-12 months, your incision will fade and become
less prominent.

YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].


PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain

DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound

Followup Instructions:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 111789**] NP
Location: [**Hospital1 **]-[**Location (un) **]
When: Wednesday [**7-4**] at 12pm
Address: [**Street Address(2) 87814**], [**Location (un) **],[**Numeric Identifier 76341**]
Phone: [**Telephone/Fax (1) 30738**]

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2198-7-12**] at 1:15 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
*You will need a chest x-ray prior to this appointment. Please
go to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment.

Name: [**Last Name (LF) 363**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
When: Friday [**7-20**] at 11 am
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name 23**] [**Location (un) 551**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3573**]


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

Completed by:[**2198-6-25**]
{'Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum,Traumatic shock,Injury to liver without mention of open wound into cavity, hematoma and contusion,Acute and subacute necrosis of liver,Acute vascular insufficiency of intestine,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure following trauma and surgery,Acute kidney failure with lesion of tubular necrosis,Closed fracture of four ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Rhabdomyolysis,Acidosis,Cardiac complications, not elsewhere classified,Right bundle branch block,Tachycardia, unspecified,Other iatrogenic hypotension,Traumatic hemothorax without mention of open wound into thorax,Closed dislocation, multiple cervical vertebrae,Other chronic nonalcoholic liver disease,Unspecified injury of heart without mention of open wound into thorax,Injury to other gastrointestinal sites, without mention of open wound into cavity,Edema of male genital organs,Contact dermatitis and other eczema due to plants [except food],Accidental poisoning from other specified plants,Alcohol abuse, unspecified,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Personal history of allergy to penicillin'}


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: MVC

PRESENT ILLNESS: 42M car vs pole, ejected ~30ft, garbled speech at scene, +[**Hospital 76954**]
transfer from OSH with C6 fracture, free fluid in abd/pelvis,
hypotension peri-RSI. Per EMS was moving all 4 extremities at
OSH. Taken to OR upon admission, found liver lacs and performed
ileocecectomy. Brought to TICU intubated. Taken to OR for
re-exploration on [**5-31**], evacuated ~1L old blood.

MEDICAL HISTORY: s/p Left ankle ORIF
s/p removal of adenoids

MEDICATION ON ADMISSION: Multivitamin, Vitamin D

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:
Constitutional: Intubated and sedated
HEENT: Pupils equal, round and reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nondistended, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: Moves all extremities

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Supportive wife, works in construction building houses
+ETOH, unknown tobacco/IVDU 

### Response:
{'Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum,Traumatic shock,Injury to liver without mention of open wound into cavity, hematoma and contusion,Acute and subacute necrosis of liver,Acute vascular insufficiency of intestine,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acute respiratory failure following trauma and surgery,Acute kidney failure with lesion of tubular necrosis,Closed fracture of four ribs,Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Rhabdomyolysis,Acidosis,Cardiac complications, not elsewhere classified,Right bundle branch block,Tachycardia, unspecified,Other iatrogenic hypotension,Traumatic hemothorax without mention of open wound into thorax,Closed dislocation, multiple cervical vertebrae,Other chronic nonalcoholic liver disease,Unspecified injury of heart without mention of open wound into thorax,Injury to other gastrointestinal sites, without mention of open wound into cavity,Edema of male genital organs,Contact dermatitis and other eczema due to plants [except food],Accidental poisoning from other specified plants,Alcohol abuse, unspecified,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Personal history of allergy to penicillin'}
