CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 34-year-old man trauma
transferred from [**Hospital **] Hospital on 4 pm on the day of
admission.  The patient tripped in front of a dump truck and
was dragged approximately 20 feet with no loss of
consciousness.  Patient did have alcohol on board.  [**Location (un) 2611**]
coma score is 15, heart rate 114, blood pressure 130/70, and
91% on O2 sat.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Open wound of multiple sites of shoulder and upper arm, complicated,Closed fracture of seven ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Traumatic shock,Alcohol abuse, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta
Mult opn wnd should-comp,Fracture seven ribs-clos,Spleen capsular tear,Traumatic shock,Alcohol abuse-unspec,Hpt B chrn wo cm wo dlta
Name:  [**Known lastname 6212**], [**Known firstname **]                    Unit No:  [**Numeric Identifier 8371**]

Admission Date:  [**2162-9-10**]     Discharge Date:  [**2162-10-14**]

Date of Birth:   [**2128-5-14**]     Sex:  M

Service:

This is an addendum to the dictation.

The condition on discharge is stable.

DISCHARGE MEDICATIONS:  OxyContin 50 mg po bid and oxycodone
5-10 mg q6h prn pain.  The patient was instructed to buy
over-the-counter Colace for stool softener.

DISCHARGE STATUS:  Home with visiting nurses for qod dressing
changes.  The patient will follow up with Trauma Clinic in
one week.

DISCHARGE DIAGNOSES:
1. Status post exlap with splenorrhaphy.
2. Split thickness skin graft to left arm.






                          [**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern1) 3595**], M.D.  [**MD Number(1) 3596**]

Dictated By:[**Name8 (MD) 1561**]

MEDQUIST36

D:  [**2162-10-14**]  08:47
T:  [**2162-10-14**]  09:05
JOB#:  [**Job Number **]


Admission Date:  [**2162-9-10**]     Discharge Date:  [**2162-10-14**]

Date of Birth:   [**2128-5-14**]     Sex:  M

Service:  Trauma

HISTORY OF PRESENT ILLNESS:  This is a 34-year-old man trauma
transferred from [**Hospital **] Hospital on 4 pm on the day of
admission.  The patient tripped in front of a dump truck and
was dragged approximately 20 feet with no loss of
consciousness.  Patient did have alcohol on board.  [**Location (un) 2611**]
coma score is 15, heart rate 114, blood pressure 130/70, and
91% on O2 sat.

He had a head CT scan which showed no bleed and no fracture.
A CT scan of lumbosacral spine which showed no fracture.
Chest x-ray with no pneumothorax and left second through
eighth rib fractures posteriorly.  His hematocrit was stable.
His alcohol level was 129, and he had been given 1 gram of
Ancef.

At that point, patient was deemed stable to be transferred to
[**Hospital1 69**] for management of his
left shoulder laceration.

Patient had a past medical history significant for hepatitis
B and C, IV drug abuse, no past surgical history, no
medications, and no known drug allergies.  He was single, and
smoked one pack per day, and used alcohol occasionally.

On presentation to our Emergency Department, physical
examination was 36.5, heart rate 110, blood pressure 93/58,
sating 90%.  He was in mild distress.  Pupils are equal,
round, and reactive to light and accommodation.  Extraocular
muscles are intact.  Tympanic membranes are clear.
Oropharynx is clear.  Neck was placed in a C collar.  Chest
was clear to auscultation.  Heart was tachycardic, but
regular.  Abdomen was distended and firm.  The FAST
examination was positive.  DPL was also positive.  Patient
also had a left shoulder laceration with 2+ dorsalis pedis
pulses bilaterally, 2+ radial pulses, and no long bone
deformities.

His laboratories were white count 13.9, hematocrit of 39, INR
of 1.3, fibrinogen of 241.  Urinalysis showed [**5-10**] red blood
cells, tox positive for opiates.  Sodium 138, potassium 4.3,
chloride 109, BUN 7, creatinine 0.9, and glucose 130.
Alcohol was 74 in our Emergency Department.

Based on this, the patient was sent to the operating room for
an emergent exploratory laparotomy.  In the operating room,
the patient was found to have a splenic laceration and had a
splenorrhaphy and his left shoulder laceration was closed.
The patient was then admitted to the Surgical Intensive Care
Unit.

Repeat chest x-ray showed a left pneumothorax.  Chest tube
was placed on [**9-11**].  On [**9-15**], patient was
started on Vancomycin and ceftriaxone for temperature spikes.
Chest x-ray showed infiltrates bilaterally and Infectious
Disease was consulted.  Antibiotic coverage was changed from
ceftriaxone to Zosyn.

The patient remained febrile for several days without
identifiable source.  The patient underwent incision and
drainage of the left upper extremity on the 18th to the [**9-19**].  The patient continued to spike on broad-spectrum
antibiotic coverage.  On [**9-28**], the decision was made
to observe the patient off antibiotics.  The patient did
well, was stable, and was transferred to the floor.

On the floor, the patient did well.  Pain was controlled with
Morphine PCA.  Physical therapy was consulted for ambulation.
On [**10-7**], the patient was taken to the operating room
for a split thickness skin graft of the left upper extremity
by Dr. [**Last Name (STitle) 13797**].

On postoperative day five, the dressing was taken down with
100% take of the skin graft.  Pain control was changed from
the Morphine PCA to OxyContin, and on postoperative day seven
from the split thickness skin graft, the wound was again
evaluated with good results on Xeroform dry dressing change.

Please look for addendum to this dictation to follow.






                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D.  [**MD Number(1) 2214**]

Dictated By:[**Last Name (NamePattern1) 13577**]

MEDQUIST36

D:  [**2162-10-14**]  02:22
T:  [**2162-10-15**]  06:17
JOB#:  [**Job Number 45616**]
{'Open wound of multiple sites of shoulder and upper arm, complicated,Closed fracture of seven ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Traumatic shock,Alcohol abuse, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta'}


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: This is a 34-year-old man trauma
transferred from [**Hospital **] Hospital on 4 pm on the day of
admission.  The patient tripped in front of a dump truck and
was dragged approximately 20 feet with no loss of
consciousness.  Patient did have alcohol on board.  [**Location (un) 2611**]
coma score is 15, heart rate 114, blood pressure 130/70, and
91% on O2 sat.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Open wound of multiple sites of shoulder and upper arm, complicated,Closed fracture of seven ribs,Injury to spleen without mention of open wound into cavity, capsular tears, without major disruption of parenchyma,Traumatic shock,Alcohol abuse, unspecified,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta'}
