CHIEF COMPLAINT: hip pain

PRESENT ILLNESS: The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presented to the ED with left thigh pain after
a fall [**9-22**] in the afternoon. The patient states she went to the
refrigerator using her walker when her knee gave out and she
fell on her butt.  Her legs were twisted under her.  She denies
LOC or head injury.  She was unable to weight bear on her left
leg and after one of pain day decided to come to the ED.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

MEDICATION ON ADMISSION: Nexium 40mg PO daily
Fluticasone/salmeterol 250/50mcg 1 INH [**Hospital1 **]
Senna
Aranes
ASA 81mg PO daily
Hydralazine 25mg PO q6hours (hold on dialysis days)
Simvastatin 20mg PO daily
Amiodarone 200mg PO daily
Ambien 5mg qHS PRN
Metoprolol 50mg PO bid.(hold on dialysis days)
Lactulose PRN
Colace 50mg PRN
Levthyroxine 88mcg tab PO daily
Warfarin
Nephrocaps 1mg PO daily
Sevelamer 2400 mg PO TID W/MEALS

ALLERGIES: Protamine / Lovenox

PHYSICAL EXAM: VS: Afebrile BP 115/46 HR 52 100% on 2L NC
GEN: African American female in NAD, sitting up in bed
HEENT: EOMI, PERRL, oropharynx clear
NECK: Supple, no [**Doctor First Name **]
CHEST: CTABL, no w/r/r
CV: Bradycardic, S1S2, no m/r/g
ABD: Soft/NT/ND; colostomy with associated herniation at site
EXT: no c/c/e
SKIN: no rashes
NEURO: AAOx 3; no focal deficits; gait deferred; answers
questions appropriately
.

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not

SOCIAL HISTORY: Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager Her son [**Name (NI) **] lives her on the [**Location (un) 19201**] of their two family home.
Closed fracture of trochanteric section of neck of femur,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Disorder of bone and cartilage, unspecified,Atrial fibrillation,Anemia in chronic kidney disease,Renal dialysis status,Acquired absence of intestine (large) (small),Heart valve replaced by other means,Personal history of Methicillin resistant Staphylococcus aureus,Knee joint replacement,Infection with microorganisms resistant to penicillins,Fall from other slipping, tripping, or stumbling,Colostomy status
Trochanteric fx NOS-clos,End stage renal disease,Chr diastolic hrt fail,Hyp kid NOS w cr kid V,Hypotension NOS,Hypothyroidism NOS,Pure hypercholesterolem,DMII wo cmp nt st uncntr,Bone & cartilage dis NOS,Atrial fibrillation,Anemia in chr kidney dis,Renal dialysis status,Acquire absnce intestine,Heart valve replac NEC,Hx Methicln resist Staph,Joint replaced knee,Inf mcrg rstn pncllins,Fall from slipping NEC,Colostomy status
Admission Date:  [**2166-9-23**]              Discharge Date:   [**2166-9-26**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: MEDICINE

Allergies:
Protamine / Lovenox

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hip pain

Major Surgical or Invasive Procedure:
Dialysis

History of Present Illness:
The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presented to the ED with left thigh pain after
a fall [**9-22**] in the afternoon. The patient states she went to the
refrigerator using her walker when her knee gave out and she
fell on her butt.  Her legs were twisted under her.  She denies
LOC or head injury.  She was unable to weight bear on her left
leg and after one of pain day decided to come to the ED.

Past Medical History:
1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

in ICU (at time of colectomy) - removed
5. Severe AS s/p mechanical AVR, [**Hospital3 **], goal INR [**2-11**]
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF (via LUE AVF)
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery

12. Hypothyroidism
13. Presumptive history of atrial fibrillation; on amiodarone
14. revision of LUE AVF [**2165-11-21**] -->functioning and started HD
[**12-20**]


Social History:
Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager Her son [**Name (NI) **] lives her on the [**Location (un) 19201**] of their two family home.

Family History:
She is an only child. Grandfather died of cancer but son is not

sure of what type. Three sons with htn.


Physical Exam:
VS: Afebrile BP 115/46 HR 52 100% on 2L NC
GEN: African American female in NAD, sitting up in bed
HEENT: EOMI, PERRL, oropharynx clear
NECK: Supple, no [**Doctor First Name **]
CHEST: CTABL, no w/r/r
CV: Bradycardic, S1S2, no m/r/g
ABD: Soft/NT/ND; colostomy with associated herniation at site
EXT: no c/c/e
SKIN: no rashes
NEURO: AAOx 3; no focal deficits; gait deferred; answers
questions appropriately
.


Pertinent Results:
Admission labs-

[**2166-9-22**] 10:44PM BLOOD WBC-3.7* RBC-3.90* Hgb-12.4 Hct-37.7#
MCV-97 MCH-31.7 MCHC-32.8 RDW-15.1 Plt Ct-169
[**2166-9-22**] 10:44PM BLOOD Neuts-59.4 Lymphs-31.0 Monos-5.8 Eos-3.2
Baso-0.6
[**2166-9-22**] 10:44PM BLOOD PT-26.5* PTT-30.9 INR(PT)-2.6*
[**2166-9-22**] 10:44PM BLOOD Glucose-86 UreaN-44* Creat-6.3*# Na-139
K-4.5 Cl-99 HCO3-29 AnGap-16
[**2166-9-24**] 06:15AM BLOOD Calcium-6.9* Phos-5.7*# Mg-1.9

Images-

xray
RIGHT FEMUR: Diffuse osteopenia. Suboptimal radiograph for
evaluation of a
fracture. No definite fracture or dislocation seen; however
subtle fracture could be missed. On one of the images, there is
overlapping hand with ring, which is limiting the evaluation of
that area.

RIGHT KNEE: Status post total knee arthroplasty. No evidence of
lucency at
the total hip prosthesis. No evidence of fracture or
dislocation. Vascular
calcifications are seen. There is a large calcified fibroid.

IMPRESSION
1. Suboptimal radiograph; however, no definite fracture or
dislocation seen. 2. Vascular calcifications.
3. Calcified fibroid.

CT pelvis
IMPRESSION:
No evidence of free fluid or hematoma.

CT lower ext
PRELIMINARY READ-
non displaced fracture of the left lesser trochanter. No
hematoma.

Brief Hospital Course:
The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presents with left hip pain.

In the ED, VS were : T98.4 BP 104/48 HR 58 RR18 100%RA. She
received tramadol and toradol for pain but was still unable to
ambulate given severe pain. The next morning in the ED her blood
pressure was found to be in the 84/31 -> 78/32. She also had a
Hct drop from 37 to 31 and there was concern that she was
bleeding.  She was given 2L NS while in the ED with some
improvement in pressure and her AM BP meds were held. Hip films
showed osteopenia but no fractures.  CT abdomen and CT thigh
were done to further evaluate her hypotension and the CT thigh
showed nondisplaced fracture of her left lesser trochanter.
Ortho was consulted and felt she did not need surgery and
recommended PT consult and partial weight bearing as tolerated.
She was transferred to the ICU for further management of her
hypotension.

# Hypotension: Her BP improved with 2L of fluid bolus. The
hypotension was thought to be realated to fluid depletion
initially. Her BP meds were stopped. She had several low BPs
into the 80s while asleep, and was given small fluid boluses
without great effect. She went for HD the day after admisison,
she was 7kg above her dry wt, had 1.5 liters removed and BP
actually improved. Therefore, she was likely not fluid depleted,
but more likely was fluid overloaded. Her hct was stable and a
CT of the extremity and abd/pelvis showed no evidence of
bleeding as an explaination. Her amiodarone was restarted but
her metoprolol and hydralazine were held.  When she was
transfered to the medicine floor, her BP meds continued to be
held and her blood pressure remained in the low 100s.  She
should continue to not take her metoprolol as long as her blood
pressures remains low, but this medication can be restarted as
an outpatient if her BP increases.

# Trochanteric fracture: She had a new stable, non-displaced
fracture. Pt was seen by ortho who recommended partial weight
bearing as tolerated and PT, and surgical repair was not needed
at this time. She was treated for her pain with tylenol and IV
morphine with her turning. She continued to improve and did well
on tylenol alone.

# ESRD: Continued on HD M/W/F. Continued on nephrocaps and
sevelamir. Renal followed the pt while admited. She should be
discharged on a new medication:  Sevelamer Carbonate 2400 mg
three times a day with meals.

# Anemia of chronic disease: Iron studdies showed ferretin 1295,
TIBC 161, trasnferin 124.  Pt received EPO at hemodialysis.

# Hypothyroidism: stable. Continued on levothyroxine.  TSH = 3.5

# Atrial fibrillation: She was in sinus rhythm and her
metoprolol was initially was held due to low BP. She was
continued on her amiodarone. She was continued on
anticoagulation.

# Hyperlipidemia: She was continued on her statin


Medications on Admission:
Nexium 40mg PO daily
Fluticasone/salmeterol 250/50mcg 1 INH [**Hospital1 **]
Senna
Aranes
ASA 81mg PO daily
Hydralazine 25mg PO q6hours (hold on dialysis days)
Simvastatin 20mg PO daily
Amiodarone 200mg PO daily
Ambien 5mg qHS PRN
Metoprolol 50mg PO bid.(hold on dialysis days)
Lactulose PRN
Colace 50mg PRN
Levthyroxine 88mcg tab PO daily
Warfarin
Nephrocaps 1mg PO daily
Sevelamer 2400 mg PO TID W/MEALS

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Lactulose 10 gram/15 mL Solution Oral
8. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for fever/pain.
Disp:*60 Tablet(s)* Refills:*0*
13. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*qs Tablet(s)* Refills:*2*
14. Aranesp (Polysorbate)  Injection
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
Primary diagnosis:
Trochanteric fracture
Hypotension
End stage renal disease

Secondary diagnosis:
hypothyroidism
atrial fibrillation
anemia of chronic disease


Discharge Condition:
Good. Afebrile, hemodynamically stable. Pain well controlled.


Discharge Instructions:
You came to the hospital because you fell and hurt your leg.
You had a CT scan which showed you have a nondisplaced fracture
of your thigh bone and the orthopedic surgeons thought that you
did not need surgery.  They said that you can bear weight on
your leg as tollerated.  You were transfered to the ICU because
you were found to have low blood pressure.  There you received
IV fluids and pain medications.  You did well and were
transfered back to the medicine floor.  During your
hospitalization you continued to have your hemodialysis.  You
tollerated this well.  You were also evaluated by the physical
therapists who recommended that you go to rehab until your leg
heals a little more.

The following changes have been made to your medications:
Start: Sevelamer Carbonate 2400 mg three times a day with meals
Stop: metoprolol
Stop: hydralazine

Please go to all follow up appointments (see below)

Please call your doctor or return to the hosptial if you have
fever above 103, chest pain, shortness of breath, increased
weight gain over 5 lbs, increased pain in your leg, or any other
symptoms of concern.

Followup Instructions:
Please go to the following appointments:
You have an appointment in Orthopedics with [**Name6 (MD) 2191**] [**Name8 (MD) 97510**], NP on [**10-9**] at 9:20 am.  The phone number is
[**Telephone/Fax (1) 1228**]

You will need to go the [**Location (un) 1773**] of the [**Hospital Ward Name **] building at
9 am the day of your appointment ([**2166-10-9**]) so that you can have
an x ray done

You should also make an appointment with your nurse
practitioner, [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**].  Her phone number is ([**Telephone/Fax (1) 30577**].
She has asked that you call her as soon as you are discharged
from rehab so that she can make a house call to check on you.

Provider [**Name9 (PRE) **],[**Name9 (PRE) **] AV CARE AV CARE [**Location (un) **] (NHB)
Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2166-12-8**] 8:00
{'Closed fracture of trochanteric section of neck of femur,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Disorder of bone and cartilage, unspecified,Atrial fibrillation,Anemia in chronic kidney disease,Renal dialysis status,Acquired absence of intestine (large) (small),Heart valve replaced by other means,Personal history of Methicillin resistant Staphylococcus aureus,Knee joint replacement,Infection with microorganisms resistant to penicillins,Fall from other slipping, tripping, or stumbling,Colostomy status'}


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: hip pain

PRESENT ILLNESS: The patient is an 81 year old female with past medical history
of coronary artery disease, aortic stenosis status post Aortic
valve repair, diastolic congestive heart failure, End stage
renal disease on hemodialysis (MWF [**Location (un) **]), diabetes , and
hypertension who presented to the ED with left thigh pain after
a fall [**9-22**] in the afternoon. The patient states she went to the
refrigerator using her walker when her knee gave out and she
fell on her butt.  Her legs were twisted under her.  She denies
LOC or head injury.  She was unable to weight bear on her left
leg and after one of pain day decided to come to the ED.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%) on 2L O2
4. Status post tracheostomy placement after prolonged intubation

MEDICATION ON ADMISSION: Nexium 40mg PO daily
Fluticasone/salmeterol 250/50mcg 1 INH [**Hospital1 **]
Senna
Aranes
ASA 81mg PO daily
Hydralazine 25mg PO q6hours (hold on dialysis days)
Simvastatin 20mg PO daily
Amiodarone 200mg PO daily
Ambien 5mg qHS PRN
Metoprolol 50mg PO bid.(hold on dialysis days)
Lactulose PRN
Colace 50mg PRN
Levthyroxine 88mcg tab PO daily
Warfarin
Nephrocaps 1mg PO daily
Sevelamer 2400 mg PO TID W/MEALS

ALLERGIES: Protamine / Lovenox

PHYSICAL EXAM: VS: Afebrile BP 115/46 HR 52 100% on 2L NC
GEN: African American female in NAD, sitting up in bed
HEENT: EOMI, PERRL, oropharynx clear
NECK: Supple, no [**Doctor First Name **]
CHEST: CTABL, no w/r/r
CV: Bradycardic, S1S2, no m/r/g
ABD: Soft/NT/ND; colostomy with associated herniation at site
EXT: no c/c/e
SKIN: no rashes
NEURO: AAOx 3; no focal deficits; gait deferred; answers
questions appropriately
.

FAMILY HISTORY: She is an only child. Grandfather died of cancer but son is not

SOCIAL HISTORY: Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager Her son [**Name (NI) **] lives her on the [**Location (un) 19201**] of their two family home. 

### Response:
{'Closed fracture of trochanteric section of neck of femur,End stage renal disease,Chronic diastolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Hypotension, unspecified,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Disorder of bone and cartilage, unspecified,Atrial fibrillation,Anemia in chronic kidney disease,Renal dialysis status,Acquired absence of intestine (large) (small),Heart valve replaced by other means,Personal history of Methicillin resistant Staphylococcus aureus,Knee joint replacement,Infection with microorganisms resistant to penicillins,Fall from other slipping, tripping, or stumbling,Colostomy status'}
