CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: None known.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Injury to liver without mention of open wound into cavity, laceration, moderate,Fall from other slipping, tripping, or stumbling
Liver laceration, mod,Fall from slipping NEC
Admission Date:  [**2125-12-22**]       Discharge Date:  [**2125-12-26**]

Date of Birth:   [**2082-9-21**]       Sex:  F

Service:

The patient is a 43-year-old woman who was sledding down a
[**Doctor Last Name **] and became airborne and landed on top of the sled.  This
occurred about 2 PM on the day of admission.  Denies loss of
consciousness.  The patient remembers the whole event.  She
went home, took a few Aleve and went to the Emergency Room
when she began to have some flank and abdominal pain.  At the
[**Hospital6 5016**] emergency department she had an
abdominal CAT scan which showed a Grade III liver laceration.
 She was transferred to [**Hospital1 69**]
via [**Location (un) **] for further evaluation and treatment.  She was
hemodynamically stable throughout with a GCS of 15.

PAST MEDICAL HISTORY:  None.

MEDICATIONS:  None.

ALLERGIES:  None known.

VITAL SIGNS:  On admission temperature 96.8, heart rate 88,
blood pressure 148/palp, respiratory rate 20 and 97% on room
air.  In general the patient was in no apparent distress.
She was alert and oriented times three, answering questions
appropriately with a GCS of 15.  Her head was normocephalic,
atraumatic with 2 cm pupils bilaterally minimally reactive.
Her TMs are clear.  Her trachea was midline there was no
jugular venous distention.  Heart:  Regular rate and rhythm.
Lungs clear and equal sounding.  Abdomen soft, tender in the
right upper quadrant, no peroneal signs, no ecchymosis over
the flank.  Abdomen was not distended.  Pelvis was stable.
Extremities:  No deformities, 5/5 strength throughout.  Back:
No step-off, no pain on palpation.  Pulses:  There were
palpable dorsalis pedis posterior tibial and femoral pulses
bilaterally.  Rectal exam was normal tone, no stool in rectal
vault.

LABS:  Hematocrit was 41.2, chemistry values were stable.
Her initial blood gas was 7.37/49/41/29/1, this was obviously
a venous gas.  Urinalysis showed moderate blood. Her lactate
was 1.7.

Chest x-ray was negative for pneumothorax and normal
mediastinum.  AP pelvis was negative.  CT scan of the abdomen
from outside hospital showed a Grade III liver laceration
with question extravasation of contrast.  C-spine and
thoracic lumbar spines were unremarkable.

The patient was admitted to the Intensive Care Unit for blood
pressure control and serial crits were followed along with
exams.

On hospital day two the patient underwent an angiogram which
showed no findings in the liver, her cervical spine collar
was discontinued and she was started on Dilaudid PCA for pain
and diet advanced to sips.  She was switched from Hydralazine
to Labetalol for rate and blood pressure control.  On
hospital day five the patient was found to be stable.  She
was discharged home to follow-up with Trauma Clinic as
needed.

Note, the patient was discharged in good condition to home.

DIAGNOSIS:
Grade III liver lacerations.

No discharge medications.  Follow-up p.r.n. with Trauma
Clinic.






                            [**Name6 (MD) 19851**] [**Name8 (MD) 19852**], M.D.  [**MD Number(1) 19853**]

Dictated By:[**Dictator Info **]
MEDQUIST36

D:  [**2126-1-21**]  15:40
T:  [**2126-1-21**]  19:27
JOB#:  [**Job Number 47519**]
{'Injury to liver without mention of open wound into cavity, laceration, moderate,Fall from other slipping, tripping, or stumbling'}


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: 

PRESENT ILLNESS: 

MEDICAL HISTORY: None.

MEDICATION ON ADMISSION: 

ALLERGIES: None known.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Injury to liver without mention of open wound into cavity, laceration, moderate,Fall from other slipping, tripping, or stumbling'}
