CHIEF COMPLAINT: Fall

PRESENT ILLNESS: Patient is a 73 year old male with atrial fibrillation, ESRD on
HD, DM type 2, prior CVA, who presents to the ED after falling
in his bathroom at home. His wife reports she heard a thump, and
found the patient on the floor with a large laceration on his
head, awake.
.
He remembers walking to the bathroom and falling over his walker
into the tub. He does not think that he lost consciousness, but
according to his wife he did for about one minute. He remembers
lying in the tub and not being able to move his legs. His wife
called 911.
.
He denies any prodrome before the fall, including
lightheadedness, palpitations, chest pain, SOB.
.
In [**Hospital1 18**] ED, he was noted to have no strength in his lower
bilateral extremities, and poor strength in his upper
extremities. His cranial nerves were intact, and his vitals
remained stable. He had imaging of his neck, which showed an
acute C3 fracture, as well as C4/C5 osteophyte with cord
compression. Neurosurgery was consulted, as well as trauma
surgery. They recommended no surgical treatment at this time,
but decadron and close monitoring. CT chest showed a
non-calcified nodule, and there was a renal mass seen on CT abd.
He was admitted to ICU for monitoring of neuro status, and to
medicine due to multiple co-morbidities.
.
ROS: He recently has been feeling well.

MEDICAL HISTORY: CAD s/p CABG '[**20**]
CHF (LVEF 30-35%)
DM II
Hyperlipidemia
HTN
CKD V due to diabetic nephropathy on HD since [**3-/2122**]
moderate pulm HTN
AF on coumadin, history of stroke (by report) with mild residual
R-sided weakness
PVD s/p L SFA to PT bypass for nonhealing ulcer
tachy-brady s/p PM '[**16**]

MEDICATION ON ADMISSION: EC Aspirin 81mg daily
Folic acid 1mg daily
Glyburide 2.5mg qd
Lipitor 80mg daily
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
Nephrocaps 1 daily
Tegretol XR 200mg [**Hospital1 **]
Tums 500mg [**Hospital1 **]
Vitamin B12 500mcg daily
Vitamin B6 50mg daily
Warfarin 5mg TUES/FRI, 6mg M/W/TH/Sat/Sun, last dose [**2123-7-31**]

ALLERGIES: Methyldopa / Shellfish

PHYSICAL EXAM: T 96.5
BP 136/62
HR 64
RR 20
Oxygen 98% ra
GENERAL: Elderly male lying flat with hard cervical collar,
speaking with garbled voice
HEENT: MMM, large echymsois and significant swelling of left
periorbital area. Large sutured laceration of left anterior
head. Pupils 3mm and reactive. Poor dentition.
NECK: In hard collar.
CARDIAC: Regular, no appreciated murmur or rub.
LUNGS: Coarse BS bilaterally, diminished at left base.
ABDOMEN: soft, flat, NT, ND, pos BS.
EXTREMITIES: no c/c. R 1+ edema. L no edema. Right arm fistula.

FAMILY HISTORY: M: DM2, HTN; F: DM2; MGM: DM2; MGF: DM2.
"Everyone with HTN."

SOCIAL HISTORY: lives at home with wife, + hx smoking quit 30 yrs ago after 10
yrs of smoking [**1-2**] ppd, very rare etoh.
Closed fracture of C1-C4 level with unspecified spinal cord injury,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic systolic heart failure,Other and unspecified open wound of head without mention of complication,Unspecified fall,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia in chronic kidney disease,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Personal history of tobacco use,Family history of diabetes mellitus,Abnormal coagulation profile,Other convulsions,Unspecified disorder of kidney and ureter,Spinal stenosis in cervical region,Fitting and adjustment of cardiac pacemaker
C1-c4 fx-cl/cord inj NOS,End stage renal disease,Hyp kid NOS w cr kid V,Urin tract infection NOS,Late ef-hemplga side NOS,Chr systolic hrt failure,Open wound of head NEC,Fall NOS,DMII renl nt st uncntrld,Atrial fibrillation,Anemia in chr kidney dis,Dysphagia NOS,Hyperlipidemia NEC/NOS,Aortocoronary bypass,History of tobacco use,Fam hx-diabetes mellitus,Abnrml coagultion prfile,Convulsions NEC,Renal & ureteral dis NOS,Cervical spinal stenosis,Ftng cardiac pacemaker
Admission Date:  [**2123-10-8**]              Discharge Date:   [**2123-10-18**]

Date of Birth:  [**2050-8-26**]             Sex:   M

Service: MEDICINE

Allergies:
Methyldopa / Shellfish

Attending:[**First Name3 (LF) 6195**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy C4-C5.
2. Anterior cervical arthrodesis C4-C5.
3. Structural allograft.
4. Anterior plating C4-C5.
5. PEG tube placement


History of Present Illness:
Patient is a 73 year old male with atrial fibrillation, ESRD on
HD, DM type 2, prior CVA, who presents to the ED after falling
in his bathroom at home. His wife reports she heard a thump, and
found the patient on the floor with a large laceration on his
head, awake.
.
He remembers walking to the bathroom and falling over his walker
into the tub. He does not think that he lost consciousness, but
according to his wife he did for about one minute. He remembers
lying in the tub and not being able to move his legs. His wife
called 911.
.
He denies any prodrome before the fall, including
lightheadedness, palpitations, chest pain, SOB.
.
In [**Hospital1 18**] ED, he was noted to have no strength in his lower
bilateral extremities, and poor strength in his upper
extremities. His cranial nerves were intact, and his vitals
remained stable. He had imaging of his neck, which showed an
acute C3 fracture, as well as C4/C5 osteophyte with cord
compression. Neurosurgery was consulted, as well as trauma
surgery. They recommended no surgical treatment at this time,
but decadron and close monitoring. CT chest showed a
non-calcified nodule, and there was a renal mass seen on CT abd.
He was admitted to ICU for monitoring of neuro status, and to
medicine due to multiple co-morbidities.
.
ROS: He recently has been feeling well.


Past Medical History:
CAD s/p CABG '[**20**]
CHF (LVEF 30-35%)
DM II
Hyperlipidemia
HTN
CKD V due to diabetic nephropathy on HD since [**3-/2122**]
moderate pulm HTN
AF on coumadin, history of stroke (by report) with mild residual
R-sided weakness
PVD s/p L SFA to PT bypass for nonhealing ulcer
tachy-brady s/p PM '[**16**]

Social History:
lives at home with wife, + hx smoking quit 30 yrs ago after 10
yrs of smoking [**1-2**] ppd, very rare etoh.


Family History:
M: DM2, HTN; F: DM2; MGM: DM2; MGF: DM2.
"Everyone with HTN."

Physical Exam:
T 96.5
BP 136/62
HR 64
RR 20
Oxygen 98% ra
GENERAL: Elderly male lying flat with hard cervical collar,
speaking with garbled voice
HEENT: MMM, large echymsois and significant swelling of left
periorbital area. Large sutured laceration of left anterior
head. Pupils 3mm and reactive. Poor dentition.
NECK: In hard collar.
CARDIAC: Regular, no appreciated murmur or rub.
LUNGS: Coarse BS bilaterally, diminished at left base.
ABDOMEN: soft, flat, NT, ND, pos BS.
EXTREMITIES: no c/c. R 1+ edema. L no edema. Right arm fistula.

SKIN: laceration on head and knees.
NEURO: AAO x 3. Cranial nerve exam normal. Garbled speech. [**3-4**]
strength in left deltoid and forearm. 4-/5 in right arm deltoid,
[**2-1**] in forearm. Able to lift left leg against gravity, Unable to
move right leg, though does flex as a reflex at times. Equivocal
toes. Could not elicit LE DTR.
PSYCH: Appropriate.


Pertinent Results:
[**2123-10-8**] 01:21PM   WBC-5.4 RBC-3.17* HGB-10.6* HCT-33.0*
MCV-104* MCH-33.4* MCHC-32.1 RDW-14.5
[**2123-10-8**] 01:21PM   NEUTS-74.5* LYMPHS-14.0* MONOS-5.8 EOS-5.7*
BASOS-0.1
[**2123-10-8**] 01:21PM   PLT COUNT-159
[**2123-10-8**] 01:21PM   PT-30.9* PTT-36.1* INR(PT)-3.3*
[**2123-10-8**] 01:21PM   GLUCOSE-205* UREA N-20 CREAT-3.6* SODIUM-133
POTASSIUM-4.1 CHLORIDE-92* TOTAL CO2-31 ANION GAP-14
[**2123-10-8**] 01:21PM   CALCIUM-8.4 PHOSPHATE-2.8 MAGNESIUM-1.8
[**2123-10-18**] 06:11AM BLOOD WBC-9.2# RBC-2.97* Hgb-9.8* Hct-30.8*
MCV-104* MCH-32.9* MCHC-31.7 RDW-16.1* Plt Ct-184
[**2123-10-18**] 06:11AM BLOOD PT-12.0 PTT-24.4 INR(PT)-1.0
[**2123-10-18**] 06:11AM BLOOD Glucose-169* UreaN-67* Creat-4.7* Na-143
K-4.4 Cl-100 HCO3-31 AnGap-16
[**2123-10-18**] 06:11AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.3
[**2123-10-13**] 07:30AM  BLOOD Carbamz-1.4*
[**2123-10-17**] 05:07AM BLOOD Carbamz-3.9*
.
[**2123-10-8**] 01:21PM   CK(CPK)-47
[**2123-10-8**] 01:21PM   CK-MB-NotDone
[**2123-10-8**] 01:21PM   cTropnT-0.20*
[**2123-10-9**] 02:31PM BLOOD CK(CPK)-101
[**2123-10-9**] 02:31PM BLOOD CK-MB-6 cTropnT-0.16*
[**2123-10-9**] 12:05AM BLOOD CK(CPK)-128
[**2123-10-9**] 12:05AM BLOOD CK-MB-6 cTropnT-0.19*
[**2123-10-8**] 01:21PM BLOOD CK(CPK)-47
[**2123-10-8**] 01:21PM BLOOD cTropnT-0.20*
.
[**2123-10-8**] 09:13PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2123-10-8**] 09:13PM URINE  RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0

[**2123-10-14**] 07:59PM BLOOD Type-ART Rates-/12 FiO2-36 pO2-159*
pCO2-40 pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED
Vent-CONTROLLED
[**2123-10-14**] 06:55PM BLOOD pO2-160* pCO2-48* pH-7.35 calTCO2-28 Base
XS-0
[**2123-10-14**] 04:04PM BLOOD Type-ART pO2-310* pCO2-41 pH-7.41
calTCO2-27 Base XS-1 Intubat-NOT INTUBA
[**2123-10-14**] 07:59PM BLOOD Glucose-147* Lactate-1.3 Na-139 K-4.1
Cl-103
[**2123-10-14**] 06:55PM BLOOD Glucose-165* Lactate-1.3 Na-139 K-4.6
Cl-100
[**2123-10-14**] 04:04PM BLOOD Glucose-147* Lactate-0.9 Na-139 K-4.5
Cl-101
[**2123-10-14**] 07:59PM BLOOD freeCa-1.12
[**2123-10-8**] 1:21 pm BLOOD CULTURE  **FINAL REPORT [**2123-10-14**]**
   AEROBIC BOTTLE (Final [**2123-10-14**]):    NO GROWTH.
   ANAEROBIC BOTTLE (Final [**2123-10-14**]):    NO GROWTH.
[**2123-10-10**] 12:21 am URINE      Source: CVS.
                            **FINAL REPORT [**2123-10-12**]**
   URINE CULTURE (Final [**2123-10-12**]):
      ENTEROCOCCUS SP..    >100,000 ORGANISMS/ML..
                              SENSITIVITIES: MIC expressed in
MCG/ML
 ______________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------    16 R
NITROFURANTOIN--------    32 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------   <=1 S

[**2123-10-8**] CT C spine
1. Apparent blockage of the intrathecal contrast especially
ventrally at the C4/5 level due to a large disc osteophyte
complex which appears to be causing severe canal stenosis.
2. At C3/4, there is a disc osteophyte complex which appears to
be causing moderate canal stenosis. At C6/7, there is a disc
osteophyte complex which is causing mild canal stenosis.
3. No high-grade canal stenosis of the thoracic or lumbar spine
although evaluation of the lumbar spine is somewhat limited by
suboptimal filling of the thecal sac by contrast.
4. Again seen is a nondisplaced fracture of the anteroinferior
corner of C3.
5. Multilevel degenerative changes as described above.
Please refer to CT of the abdomen and pelvis for full
description of other significant findings.

[**2123-10-8**] CT Chest/Abdomen/Pelvis
1) Non-calcified 4 mm lung nodules require CT follow up within
six to 12 months. Slightly larger area of ground-glass opacity
in the left upper lobe may represent contusion. Follow up is
advised.
2) Bilateral renal hyperdense and hypodense lesions, which may
represent simple and hemorrhagic cysts though evaluation is
incomplete on this noncontrast study. Further evaluation with
multiphasic CT or MRI is recommended. Cystic structure inferior
to left kidney may represent exophytic cyst.
3) Significantly enlarged prostate measuring approximately 5.5
cm.
4) Extensive calcifications of the aorta and its branches.
5) Degenerative changes with large posterior osteophytes of the
spine as described above.
[**2123-10-8**] CT Head
1. Extensive left frontal scalp and left periorbital and
preseptal soft tissue swelling and hematoma. Within the context
of this severely limited scan, there does not appear to be an
intracranial hemorrhage or acute fracture.
[**2123-10-8**] ECG - Ventricular paced rhythm. Compared to prior
tracing of [**2123-8-4**] atrial pacing is no longer clearly seen.
[**10-14**] intraoperative c-spine 2 views
Two intraoperative portable radiographs of the cervical spine
are submitted for interpretation. The first radiograph
demonstrates a probe positioned at the C4-5 disc space. The
second radiograph demonstrates an anterior fusion plate with
screws at C4 and C5 with an interbody fusion device at the C4-5
disc space. The patient is intubated. There are very large
anterior osteophytes at C5-6. There is diffuse disc space
narrowing at all levels. There is a bridging osteophyte at C6-7.
[**10-15**] CT C-spine w/out contrast: Comparison is made to the
preoperative studies from [**2123-10-8**].
There is a new anterior fixation plate with two screws through
the bodies of C4 and C5. An intervertebral bone graft is seen
within the disc space as well as small bubbles of air. There is
no evidence of hardware breaks. The screws are well placed
within the vertebral bodies. The anterior plate is well apposed
to the vertebral bodies.
There has been partial resection of the posterior corners of the
vertebral bodies adjacent to the C4/5 disc. The previously seen
posterior osteophytes have been largely resected with some
minimal osteophytes remaining at the uncovertebral joints
bilaterally.
The evaluation of the intraspinal contents is somewhat limited
due to streak artifacts from the orthopedic hardware. Bilateral
foraminal stenoses are again seen at this level.
Again seen is a non-displaced corner fracture of the
anteroinferior corner of C3.
Multilevel degenerative changes are again seen as before.
There is new soft tissue emphysema of the anterior neck,
especially extending along the right side of the neck and along
the esophagus.
The visualized lung apices are clear.
IMPRESSION:
1. Since [**2123-10-8**], new ACDF of C4 and C5 with no evidence of
hardware breaks. The previously seen posterior disc osteophyte
complex has been resected with residual osteophytes of the
uncovertebral joints bilaterally remaining.
2. Again visible is a non-displaced fracture of the
anteroinferior corner of C3.
3. Multilevel degenerative changes as previously described.
CHEST (PORTABLE AP)  [**2123-10-18**] 9:00 AM
In comparison with the study of [**10-14**], there is no interval
change. Specifically, no evidence of new pneumonia.


Brief Hospital Course:
73 year old male with multiple medical problems including
coronary artery disease, diabetes mellitus, and ESRD on HD, who
presents after mechanical fall with C3 fracture and cord
compression.
.
1. Fall
Patient was admitted after a fall at home when he was found down
by his wife. According to his wife, she heard a thump and found
him in the bathroom. He reports however that he tripped forward
over his walker and hyperreflexed his neck against the edge of
his bathtub. He denies any complaints of chest pain,
palpitations, and seizure activity. Given that the fall was
unwitnessed, patient underwent a syncope evaluation. Regarding
arrhythmias, EP evaluated the patient and interrogated his
pacer. No events were found. Regarding cardiac ischemia, MI was
ruled out with three sets of negative enzymes.  Regarding
structural heart disease, patient has had an echocardiogram on
[**11-4**] which had no evidence of aortic stenosis or other
structural defect. Regarding neurological event, seizure
remained on the differential given his history.  EP consulted,
pacer functioning normally. No evidence of ischemia/MI, CE's
stable. ECHO [**11-4**] no evidence of AS or other structural defect
that could explain syncope. Infection appeared unlikely given
that patient remained afebrile and no history to suggset
infection. CT showed no evidence of bleed to suggest hemorrhagic
stroke. Cannot get MRI to r/o acute embolic stroke, though pt
was supratherapeutic so less likely. Patient's blood culture was
negative. This was thought to be most likely a mechanical fall.
.
2. Acute fracture of C3 and cord compromise.
Patient was found to have an acute C3 fracture with evidence of
cord compromise. He was evaluated by neurosurgery who
recommended initial treatment with dexamethasone and then
patient went to the OR on [**2123-10-14**]. His procedure was
uncomplicated and he has follow-up imaging and neurosurgery
appointments on [**2123-11-3**]. He has been using standing tylenol and
prn morphine for pain control. He should continue on the hard
collar until he follows up with Dr. [**Last Name (STitle) 548**]. He will need
intensive physical and occupational therapy.
.
3. Coronary Artery Disease
Patient's cardiac enzymes were negative and his ECG remained
unremarkable. Regarding his medication regimen, aspirin was held
during his initial perioperative state but was restarted within
2-3 days of his procedure. His ACEI and beta blocker were
initially held due to the need to maintain an SBP > 120 in the
perioperative state. His ACEI was restarted and his beta blocker
will need to be added back on within his first 3-4 days at rehab
with goal to maintain SBP>90 per neurosurgery. His statin was
continued.
.
4 CHF:
Patient has a history of a depressed ef (~30%) and he remained
stable from that standpoint during his admission. His fluid
status was maintained with HD. His ACEI and beta blocker were
initially held as discussed in #3 CAD. His ACEI was restarted
and his beta blocker will need to be restarted. His fluid status
can continue to be monitored with HD.
.
5. ESRD:
Patient is followed by Dr. [**Last Name (STitle) 118**]. He is normally on a TuThSa HD
regimen. During the [**Holiday 1451**] week, he was dialyzed on Monday
[**10-18**] and will need dialysis on Wednesday [**10-20**] and then return
to his usual schedule on Saturday [**10-23**].  New renal mass in L
kidney. [**Month (only) 116**] need w/u as outpt. Patient was continued on epo and
nephrocaps.
.
6. HTN:
Goal SBP is > 90 to maintain spinal perfusion.  He was restarted
on lisinopril and should be restarted on his beta blocker as his
SBP tolerates.
.
7. Atrial Fibrillation
Patient's coumadin was held perioperatively. He was restarted on
[**10-17**]. His INR and coumadin dose will need to be monitored
daily.
.
# Anemia:
He has anemia associated with CKD and receives EPO.
.
# PPX: pneumoboots, aspiration and fall precautions, bowel
regimen, ppi for steroids
# Code: full.
# Contact: Wife  [**Name (NI) 3508**] [**Name (NI) **] [**Name (NI) 23054**] [**Telephone/Fax (1) 23057**]


Medications on Admission:
EC Aspirin 81mg daily
Folic acid 1mg daily
Glyburide 2.5mg qd
Lipitor 80mg daily
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
Nephrocaps 1 daily
Tegretol XR 200mg [**Hospital1 **]
Tums 500mg [**Hospital1 **]
Vitamin B12 500mcg daily
Vitamin B6 50mg daily
Warfarin 5mg TUES/FRI, 6mg M/W/TH/Sat/Sun, last dose [**2123-7-31**]


Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Carbamazepine 100 mg/5 mL Suspension Sig: One (1)  PO BID (2
times a day).
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Insulin Regular Human 100 unit/mL Solution Sig: Three (3)
Injection ASDIR (AS DIRECTED): Please continue according to the
attached sliding scale. .
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Please continue a dexamethasone taper according to the
following schedule: 4mg on [**10-18**] and [**10-19**]; 3mg on [**10-20**] and
[**10-21**]; 2mg on [**10-22**] and [**10-23**]; 1mg on [**10-24**] and [**10-25**].
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
15. Epo  Sig: 4000 (4000) unit Hemodialysis once a week.
16. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO twice a day.
17. Coumadin 1 mg Tablet Sig: 5-6 Tablets PO at bedtime: Patient
takes 5-6mg of coumadin normally. Please monitor INR daily and
titrate coumadin dosage accordingly. .
18. Morphine 4 mg/mL Syringe Sig: 2-4 mg Injection every four
(4) hours as needed for pain.
19. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. C3 fracture
2. Spinal Cord Compression C4-5; C6-7
3. Urinary Tract Infection
4. End Stage Renal Disease on hemodialysis
5. Diabetes Mellitus
6. Difficulty Swallowing
.
SECONDARY DIAGNOSIS:
1) End stage renal disease on hemodialysis TUES/THURS/SAT at
[**Location (un) 1468**]
Dialysis under the care of Dr. [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] (right arm AV
fistula)
2) Hyperlipidemia
3) Hypertension
4) Possible seizure disorder, none in 15 years
5) Diabetes Type II complicated by retinopathy and neuropathy
6) Atrial fibrillation
7) [**4-4**]: Stroke: (Left MCA embolic stroke) with possible
residual right sided weakness, on chronic anticoagulation
8) [**12-5**]: Hip fracture
9) Depressed Left Ventricular Function, Ejection Fraction 30-35%
[**11-4**], Moderate mitral regurgitation, Coronary Artery Disease
status post silent Myocardial Infarction [**2109**], CABG [**2120**] with
LIMA to LAD, SVG to OM2, SVG to PDA
10) s/p pacemaker placement for tachybrady syndrome in [**2116**] with

generator change [**3-6**]. Considered for ICD upgrade but EP study
negative for inducible VT
11) [**2121**]: Peripheral [**Year (4 digits) **] Disease status post left SFA to PT
bypass
12) Intracranial abscess, treated 50+ years ago with surgery
(patient
reports that he never had an intracranial hemorrhage as noted in

prior records in CCC)
13) History of urinary retention
14) Cataracts, s/p surgery bilaterally
15) Recent thrombocytopenia which has since improved. HIT screen
neg
16) Moderate pulmonary hypertension
.


Discharge Condition:
Stable - Patient continues to be NPO due to poor swallowing
function. He also has limited ability to move his lower
extremities and is able to move his upper extremities (L>R) with
4+/5 strength bilaterally but limited finger extension and
flexion. Patient is alert and oriented to person, place, and
time.


Discharge Instructions:
You were admitted to the hospital for evaluation after your
fall. You were found to have fractured a bone in your neck and
that small fragments of bone were compressing your spinal cord.
You had a procedure called an anterior cervical diskectomy,
arthrodesis, and plating of your C4-C5.
.
While you were hospitalized, you were also found to have a
urinary tract infection and were treated with an antibiotic
called vancomycin for a five day course.
.
Given the difficulty of wearing your collar and your recent
procedure, you are unable to swallow food. We have instead
placed a PEG tube (feeding tube) into your stomach so that you
can continue to receive nutrition and medications. You will need
to have a speech and swallow evaluation repeated during your
stay at rehab.
.
We also held your coumadin in the setting of your recent injury
and surgery. Your neurosurgery team felt comfortable restarting
your coumadin on [**2123-10-17**]. You will need to have your INR and
coumadin dose monitored daily until you are again therapeutic
with an INR between [**1-2**].  Your tegretol was also held for a few
days while you were unable to eat. We have restarted this and
you will need to monitor your tegretol levels every 3 days until
it is considered therapeutic.
.
We continued you on all of your previous medications and
continued your dialysis according to your previous schedule. You
normally receive dialysis on Tuesday - Thursday - Saturday;
however due to the [**Holiday 1451**] holiday, you received dialysis
on Monday [**10-18**], are scheduled to get dialysis on
Wednesday [**10-20**], and then resume your normal schedule
with dialysis on Saturday [**10-23**].
.
Please continue to take all of your medications as prescribed.
Please go to all of your follow up appointments. If you have
fevers, chills, night sweats, abdominal pain, diarrhea, nausea,
vomiting, headache, please seek immediate medical attention.
.
We have made the following changes to your medication list since
your admission:
- dexamethasone - you were added on this medication to improve
swelling around your spinal cord after your fall. We will slowly
decrease your dose of steroids over the next 7-8 days.
- Senna and bisacodyl - we added these medications to maintain
regular bowel movements.
- Tylenol - We added scheduled tylenol to treat post-operative
pain.
- Morphine - We added morphine as needed for pain breakthrough
- Pantoprazole - We added pantoprazole to prevent stress induced
esophagitis or ulcers.

Followup Instructions:
Please follow-up with your primary care doctor Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] within 1-2 weeks of your discharge from rehab. Dr. [**Name (NI) 23058**] office phone number is [**Telephone/Fax (1) 250**].
.
Please also follow-up with your neurosurgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**]
on [**11-3**] at 1:15pm in the [**Hospital **] Medical Building [**Location (un) 3202**] on [**Last Name (NamePattern1) 439**].  You will also need a CT scan of
your neck. Your radiology appointment for your CT scan will be
on [**11-3**] at 11:45am on the [**Hospital Ward Name 517**] on the Clinical
Center [**Location (un) **]. If you need to reschedule, please call his
office at [**Telephone/Fax (1) 1669**]  for your appointment time.
.
You also have an appointment with your podiatrist [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**],
DPM on [**2123-10-28**] 3:30. If you need to cancel or reschedule your
appointment, please call his office at [**Telephone/Fax (1) 543**].
.
You also have a PACEMAKER CALL appointment on [**2123-10-19**] 10:45. If
you need to reschedule, please call them at [**Telephone/Fax (1) 59**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**] MD, [**MD Number(3) 6199**]

Completed by:[**2123-10-18**]
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic systolic heart failure,Other and unspecified open wound of head without mention of complication,Unspecified fall,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia in chronic kidney disease,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Personal history of tobacco use,Family history of diabetes mellitus,Abnormal coagulation profile,Other convulsions,Unspecified disorder of kidney and ureter,Spinal stenosis in cervical region,Fitting and adjustment of cardiac pacemaker'}


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: Fall

PRESENT ILLNESS: Patient is a 73 year old male with atrial fibrillation, ESRD on
HD, DM type 2, prior CVA, who presents to the ED after falling
in his bathroom at home. His wife reports she heard a thump, and
found the patient on the floor with a large laceration on his
head, awake.
.
He remembers walking to the bathroom and falling over his walker
into the tub. He does not think that he lost consciousness, but
according to his wife he did for about one minute. He remembers
lying in the tub and not being able to move his legs. His wife
called 911.
.
He denies any prodrome before the fall, including
lightheadedness, palpitations, chest pain, SOB.
.
In [**Hospital1 18**] ED, he was noted to have no strength in his lower
bilateral extremities, and poor strength in his upper
extremities. His cranial nerves were intact, and his vitals
remained stable. He had imaging of his neck, which showed an
acute C3 fracture, as well as C4/C5 osteophyte with cord
compression. Neurosurgery was consulted, as well as trauma
surgery. They recommended no surgical treatment at this time,
but decadron and close monitoring. CT chest showed a
non-calcified nodule, and there was a renal mass seen on CT abd.
He was admitted to ICU for monitoring of neuro status, and to
medicine due to multiple co-morbidities.
.
ROS: He recently has been feeling well.

MEDICAL HISTORY: CAD s/p CABG '[**20**]
CHF (LVEF 30-35%)
DM II
Hyperlipidemia
HTN
CKD V due to diabetic nephropathy on HD since [**3-/2122**]
moderate pulm HTN
AF on coumadin, history of stroke (by report) with mild residual
R-sided weakness
PVD s/p L SFA to PT bypass for nonhealing ulcer
tachy-brady s/p PM '[**16**]

MEDICATION ON ADMISSION: EC Aspirin 81mg daily
Folic acid 1mg daily
Glyburide 2.5mg qd
Lipitor 80mg daily
Lisinopril 2.5mg daily
Lopressor 25mg [**Hospital1 **]
Nephrocaps 1 daily
Tegretol XR 200mg [**Hospital1 **]
Tums 500mg [**Hospital1 **]
Vitamin B12 500mcg daily
Vitamin B6 50mg daily
Warfarin 5mg TUES/FRI, 6mg M/W/TH/Sat/Sun, last dose [**2123-7-31**]

ALLERGIES: Methyldopa / Shellfish

PHYSICAL EXAM: T 96.5
BP 136/62
HR 64
RR 20
Oxygen 98% ra
GENERAL: Elderly male lying flat with hard cervical collar,
speaking with garbled voice
HEENT: MMM, large echymsois and significant swelling of left
periorbital area. Large sutured laceration of left anterior
head. Pupils 3mm and reactive. Poor dentition.
NECK: In hard collar.
CARDIAC: Regular, no appreciated murmur or rub.
LUNGS: Coarse BS bilaterally, diminished at left base.
ABDOMEN: soft, flat, NT, ND, pos BS.
EXTREMITIES: no c/c. R 1+ edema. L no edema. Right arm fistula.

FAMILY HISTORY: M: DM2, HTN; F: DM2; MGM: DM2; MGF: DM2.
"Everyone with HTN."

SOCIAL HISTORY: lives at home with wife, + hx smoking quit 30 yrs ago after 10
yrs of smoking [**1-2**] ppd, very rare etoh. 

### Response:
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Chronic systolic heart failure,Other and unspecified open wound of head without mention of complication,Unspecified fall,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Anemia in chronic kidney disease,Dysphagia, unspecified,Other and unspecified hyperlipidemia,Aortocoronary bypass status,Personal history of tobacco use,Family history of diabetes mellitus,Abnormal coagulation profile,Other convulsions,Unspecified disorder of kidney and ureter,Spinal stenosis in cervical region,Fitting and adjustment of cardiac pacemaker'}
