CHIEF COMPLAINT: I fell and hurt my arm

PRESENT ILLNESS: 82 y/o M w/ h/o CKD (cr 1.9-2.0), HTN, CHF (most recent ECHO w/
EF 60%), who presented s/p fall, found to have right humerus
fracture.
.
Fell while trying to pull off a safety strap while repairing his
boat. The strap suddenly came loose and he fell 6 feet off a
platform onto his right side. Denies associated lightheadedness,
dizziness, chest pain or palpitations.
.
In the ER, he was found to have right humerus fracture. CT head
and C-spine negative for fracture. Evaluated for surgical
repair, however patient refuses surgical intervention. Plan for
sling with follow-up in 2 weeks. However, overnight developed
decreased urine output (110 cc out over 8 hour period). Given 1L
NS bolus and placed on 80cc/hr LR. However, still w/ low uop
(~10cc/hr), bladder scan showed empty bladder. Given additional
1L NS without response. Subsequently tried 5mg IV lasix to see
if component of CHF, without effect. Creatinine noted to be
elevated from 2.1 to 3.2.

MEDICAL HISTORY: HTN
CRI (baseline cr 1.5-1.8)
Gout
Polycystic kidney disease

MEDICATION ON ADMISSION: Coreg 25 mg twice daily
lisinopril 40 mg daily
allopurinol 300 mg daily
meclizine 12.5 mg daily
aspirin 325 mg daily

ALLERGIES: Digoxin

PHYSICAL EXAM: vitals- T 99.1, BP 100/60, HR 84, RR 16, 92% RA (99% on 2l O2)
gen- sitting up in chair, no labored breathing, NAD
heent- EOMI. MM dry
neck- jvp non-distended
pulm- CTA b/l. good air movement. slight decreased at bases
cv- RRR. no m/r/g
abd- soft, NT/Nd
ext- no edema, distal pulses 2+ ; R arm in sling; grip strength
full b/l
neuro- alert and oriented, follows commands. language fluent

FAMILY HISTORY: No CAD, HTN, or DM

SOCIAL HISTORY: Pt is semi-retired heavy epuipment engineer. Married. No
smoking, EtOH, or drugs.
Closed fracture of surgical neck of humerus,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Mitral valve disorders,Acute kidney failure, unspecified,Hyperpotassemia,Other primary cardiomyopathies,Other fall from one level to another in water transport injuring occupant of other watercraft -- other than crew,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Polycystic kidney, autosomal dominant,Gout, unspecified,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Other drugs and medicinal substances causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nontoxic multinodular goiter
Fx surg nck humerus-clos,CHF NOS,Chronic kidney dis NOS,Mitral valve disorder,Acute kidney failure NOS,Hyperpotassemia,Prim cardiomyopathy NEC,Wtrcraft fall NEC-pasngr,Hy kid NOS w cr kid I-IV,Polycyst kid-autosom dom,Gout NOS,Unilat inguinal hernia,Adv eff medicinal NEC,Anemia in chr kidney dis,Nontox multinodul goiter
Admission Date:  [**2173-8-6**]              Discharge Date:   [**2173-8-12**]


Service: MEDICINE

Allergies:
Digoxin

Attending:[**First Name3 (LF) 678**]
Chief Complaint:
I fell and hurt my arm

Major Surgical or Invasive Procedure:
none

History of Present Illness:
 82 y/o M w/ h/o CKD (cr 1.9-2.0), HTN, CHF (most recent ECHO w/
EF 60%), who presented s/p fall, found to have right humerus
fracture.
.
Fell while trying to pull off a safety strap while repairing his
boat. The strap suddenly came loose and he fell 6 feet off a
platform onto his right side. Denies associated lightheadedness,
dizziness, chest pain or palpitations.
.
In the ER, he was found to have right humerus fracture. CT head
and C-spine negative for fracture. Evaluated for surgical
repair, however patient refuses surgical intervention. Plan for
sling with follow-up in 2 weeks. However, overnight developed
decreased urine output (110 cc out over 8 hour period). Given 1L
NS bolus and placed on 80cc/hr LR. However, still w/ low uop
(~10cc/hr), bladder scan showed empty bladder. Given additional
1L NS without response. Subsequently tried 5mg IV lasix to see
if component of CHF, without effect. Creatinine noted to be
elevated from 2.1 to 3.2.


Past Medical History:
HTN
CRI (baseline cr 1.5-1.8)
Gout
Polycystic kidney disease

Social History:
Pt is semi-retired heavy epuipment engineer. Married. No
smoking, EtOH, or drugs.


Family History:
No CAD, HTN, or DM

Physical Exam:
vitals- T 99.1, BP 100/60, HR 84, RR 16, 92% RA (99% on 2l O2)
gen- sitting up in chair, no labored breathing, NAD
heent- EOMI. MM dry
neck- jvp non-distended
pulm- CTA b/l. good air movement. slight decreased at bases
cv- RRR. no m/r/g
abd- soft, NT/Nd
ext- no edema, distal pulses 2+ ; R arm in sling; grip strength
full b/l
neuro- alert and oriented, follows commands. language fluent


Pertinent Results:
[**2173-8-6**] 10:59AM BLOOD WBC-4.4 RBC-3.87* Hgb-12.8* Hct-37.2*
MCV-96 MCH-33.1* MCHC-34.4 RDW-13.8 Plt Ct-205
[**2173-8-6**] 10:59AM BLOOD PT-13.1 PTT-32.3 INR(PT)-1.1
[**2173-8-6**] 10:59AM BLOOD Plt Ct-205
.
.
[**2173-8-7**]
BLOOD WBC-7.2# RBC-3.18* Hgb-10.2* Hct-31.5* MCV-99* MCH-32.0
MCHC-32.3 RDW-13.8 Plt Ct-197
WBC-7.8 RBC-3.05* Hgb-9.9* Hct-31.6* MCV-104* MCH-32.6*
MCHC-31.4 RDW-13.6 Plt Ct-180
PT-13.2* PTT-30.9 INR(PT)-1.2*
Plt Ct-197
Glucose-112* UreaN-34* Creat-3.2*# Na-142 K-5.3* Cl-110* HCO3-24
AnGap-13
Glucose-110* UreaN-38* Creat-3.7* Na-140 K-5.1 Cl-109* HCO3-21*
AnGap-15
ALT-22 AST-36 LD(LDH)-272* CK(CPK)-2423* AlkPhos-60 TotBili-0.4
CK(CPK)-[**2151**]*
Calcium-7.8* Phos-5.8* Mg-2.2 Iron-12*
Calcium-8.3* Phos-5.8*# Mg-2.2
calTIBC-191* VitB12-685 Folate-10.0 Hapto-127 Ferritn-160
TRF-147*
TSH-1.5
T4-5.5 Free T4-0.95
.
.
([**2173-8-12**])
WBC-5.1 RBC-2.74* Hgb-9.0* Hct-26.6* MCV-97 MCH-32.7* MCHC-33.7
RDW-13.9 Plt Ct-251
Glucose-88 UreaN-35* Creat-2.4* Na-142 K-4.3 Cl-109* HCO3-25
AnGap-12
Calcium-8.6 Phos-2.8 Mg-2.2
.
.
RADIOLOGY:
([**2173-8-6**])
KNEE:
Four radiographs of the right knee demonstrate no effusion.
There is mild narrowing of the medial and lateral compartment
joint space heights on non-weightbearing views. No fracture.
Small marginal osteophytes involve all three joint compartments.
There is evidence of old Osgood-Schlatter's disease. Regional
soft tissues are unremarkable.
IMPRESSION: Mild tricompartmental osteoarthritis
.
.
SHOULDER
Three radiographs of the right shoulder demonstrate a
comminuted, displaced, fracture involving the surgical neck and
head of the right humerus. There is avulsion of the greater
tuberosity. There is impaction of the distal fracture fragments.
Acromioclavicular joint demonstrates mild degenerative change.
Visualized lung and ribs are unremarkable. Regional soft tissues
unremarkable.
IMPRESSION:
Comminuted and impacted fracture through the surgical neck and
head of the right humerus with avulsion of the greater
tuberosity.
.
.
CONTRAST CT ABD/CHEST:
FINDINGS: There is a large multinodular goiter with a dominant
nodule in the left lobe of the thyroid, displacing the airway to
the right. There is no evidence of mediastinal hematoma or
traumatic aortic injury. Pulmonary artery main right and left
branches are enlarged up to 3.3 cm, consistent with pulmonary
hypertension. There is dense calcification of the coronary
arteries, predominantly affecting the LAD. The heart,
pericardium, and great vessels are otherwise unremarkable. No
significant pericardial effusion is detected to account for the
FAST findings. The lungs demonstrate mild basilar atelectasis
and mild emphysematous change in the upper lobe but no
pneumothorax, contusion, or suspicious nodules or masses. No
pathologically enlarged axillary, mediastinal, or hilar
lymphadenopathy.
CT ABDOMEN WITH IV CONTRAST: A large portion of the upper
abdomen is obscured by beam hardening artifact from the
patient's overlying arm which cannot be repositioned.
Specifically, evaluation of the anterior hepatic dome is very
limited, and a laceration could easily be missed in this
location. There is a small geographic hypodense focus in segment
II of the liver and an area obscured by artifact, which appears
atypical for laceration but this is not excluded. No evidence of
active extravasation. There is bilateral polycystic kidney
disease, with a dominant cyst on the right measuring 16.5 x 15.1
x 17.4 cm (transverse, AP, SI). Several of the cysts demonstrate
hyperdense components consistent with hemorrhage or
proteinaceous debris, there appears to be no free fluid or
stranding to suggest traumatic cyst rupture. No evidence of
hematoma or free fluid within the abdomen or mesentery. Given
beam hardening artifact, no definite traumatic injury to the
remainder of the abdominal viscera. No free air.
CT PELVIS WITH IV CONTRAST: Foley catheter in a nondistended
bladder. There is no prominent mesenteric stranding or pelvic
hematoma. Large right scrotal hernia is present. No
pathologically enlarged lymph nodes. No evidence of active
extravasation.
BONE WINDOWS: There is a comminuted fracture of the right
proximal humerus involving the head and surgical neck with
avulsion of the greater tuberosity. Partially imaged, as the
right arm and hand could not be moved to the study, there is the
suggestion of a perilunate dislocation involving the right
wrist, though this may be artifactual due to positioning and
correlation with dedicated wrist x-rays is recommended. There is
extensive thoracic and lumbar spinal spondylosis without
evidence of acute fracture. Patchy ground-glass opacity in the
right ilium may relate either to fibrous dysplasia or Paget's
disease but appears chronic. No acute pelvic fractures or hip
fractures are appreciated. The femoral heads are normally
located in the SI joints and pubic symphysis are congruent.
MULTIPLANAR REFORMATS: Coronal and sagittal reformatted images
confirm the above findings.
IMPRESSION:
1) Comminuted and impacted fracture of the surgical neck and
head of the proximal right humerus with avulsion of the greater
tuberosity.
2) Question of right wrist perilunate dislocation, partially
imaged on this study; while this could be artifactual due to
positioning; if there is clinical concern, this could be
assessed with a dedicated wrist radiograph.
3) Extensive beam hardening artifact from the patient's
overlying arm obscures portions of the right upper abdomen,
specifically the dome of the liver. There is a small ill-defined
hypoechoic focus in segment II of the liver, which appears
atypical for a laceration but this cannot be excluded on this
study. If this is clinical concern, an ultraound may be helpful.
No other definite evidence of traumatic injury throughout the
abdomen and pelvis.
4) Large multinodular goiter.
5) No evidence of pericardial effusion as suggested on FAST.
6) Coronary artery calcification and evidence of pulmonary
hypertension.
7) Polycystic kidney disease with the dominant right cyst,
exerting mass effect on the adjacent organs.
8) Large right scrotal hernia.
9) Question fibrous dysplasia vs Paget's disease in the right
ilium.
.
.
CT SPINE
FINDINGS: There are extensive multilevel degenerative changes,
worse at C2, 3, 4, 5, and 6 respectively. There is
retrolisthesis of C3 in relation to C4 of approximately 3 mm.
There is retrolisthesis of C4 in relation to C5 of approximately
4 mm. There is very mild retrolisthesis of C5 in relation to C6.
There is significant narrowing of the intervertebral disc spaces
at the following levels: C2-3, C3-4, C4-5, C5-6, C6-7, C7-T1.
The vertebral body heights are decreased uniformly at C2, C3,
C4, C5, and C6. There are extensive subchondral cysts and
Schmorl's nodes throughout the cervical spine. No acute fracture
or malalignment is detected. There is mild narrowing of the
neural foramina at the C4-5 level, C5-6, and C6-7 levels
respectively. Non-contrast soft tissue windows demonstrate a
heterogeneous predominantly hypodense mass in the left lobe of
the thyroid which displaces the trachea to the right and has a
significant substernal component. The right lobe of the thyroid
contains an irregular area of hypodensity measuring 1.1 x 0.6
cm. A few areas of calcification are noted throughout the
enlarged left lobe of the thyroid. The visualized portion of the
lung apices is unremarkable.
IMPRESSION:
1. Severe degenerative disease of the cervical spine as noted
above. No acute fracture or malalignment present.
2. Enlarged, asymmetric-appearing thyroid gland. Ultrasound
examination is recommended if clinically warranted
.
.
ECG: (06/
Sinus rhythm with baseline artifact. Borderline prolonged P-R
interval. Left
anterior fascicular block. Probable prior anteroseptal
myocardial infarction.
Anterolateral ST-T wave changes - cannot exclude ischemia.
Clinical correlation
is required. Compared to the previous tracing of [**2173-2-9**]
premature ventricular
beats are no longer present. QTc interval is shorter and
anterolateral
ST-T wave changes are less prominent.

CT HEAD:
FINDINGS: Images are slightly limited secondary to patient
motion. There is no evidence of acute intracranial hemorrhage,
shift of normally midline structures, hydrocephalus or major
vascular territorial infarction. Incidental note is made of
calcification of the dentate nuclei within the cerebellum
bilaterally. There are prominent periventricular white matter
changes consistent with small vessel ischemia. No acute
fractures are identified. There is evidence of bilateral
cataract surgery. The soft tissues, osseous structures,
visualized portions of the paranasal sinuses and mastoid air
cells are unremarkable.
IMPRESSION: No evidence of acute hemorrhage or fracture.
.
.
CHEST X-RAY
Large superior mediastinal mass deviating the trachea towards
the right with associated coronal narrowing of the trachea
appears worse compared to [**2172-2-16**]. Heart remains enlarged
with left ventricular configuration, and aorta is markedly
tortuous. Bibasilar opacities are present with associated volume
loss, involving the lower lobes and right middle lobe, with a
predominantly linear orientation. No pleural effusions are
identified. As compared to the recent radiograph, the right base
is minimally improved and the left base is slightly worse.
IMPRESSION:
1. Bibasilar opacities suggestive of atelectasis.
2. Large left superior mediastinal mass consistent with enlarged
left lobe of thyroid gland on recent CT torso, [**2173-8-6**].
.
.
THYROID ULTRASOUND: Comparison with [**2173-3-10**]. Several
thyroid nodules are seen in both lobes. The largest, in the left
lobe, measures 2.1 x 5.4 x 6.5 cm, and is not appreciably
changed. In the right lobe, dominant nodule with cystic,
measures 1.2 x 1.0 x 1.5 cm, in the inferior lobe. In the
superior lobe, a hypoechoic nodule measuring 5 x 3 x 4 mm is
seen.
IMPRESSION: Bilateral thyroid nodules, without significant
change
.
.
ECG: ([**2173-8-8**])
Sinus rhythm with baseline artifact. Borderline prolonged P-R
interval. Left anterior fascicular block. Probable prior
anteroseptal myocardial infarction. Anterolateral ST-T wave
changes - cannot exclude ischemia. Clinical correlation is
required. Compared to the previous tracing of [**2173-2-9**] premature
ventricular beats are no longer present. QTc interval is shorter
and anterolateral ST-T wave changes are less prominent.
.
.
ECHO ([**2173-8-9**])
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the inferolateral wall and basal half of the
inferior wall. The remaining segments contract well. Right
ventricular chamber size and free wall motion are normal. There
is focal hypokinesis of the apical free wall of the right
ventricle. The aortic root is moderately dilated at the sinus
level. The ascending aorta is moderately dilated. The aortic
arch is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-16**]+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2172-7-6**],
regional left ventricular systolic dysfunction is more apparent
and mild pulmonary artery systolic hypertension is now
identified. The ascending aortic dilation is similar at the
sinus level (on review).
.
.


Brief Hospital Course:
82 y/o male with fractured humerus, acute renal failure
superimpossed on chronic secondary to ADPCKD and congestive
heart failure.

1. Humeral Fracture: Comminuted and impacted fracture of right
humerus affecting surgical neck and head of the right humerus
with avulsion of the greater tuberosity. Patient remained
neurovascularly intact, evaluated by orthopaedic service and
offered surgery which he refused. Trauma CT series performed,
with CTA of arm for vascular assessment. Mr [**Known lastname 94915**] renal
function was severely affected by contrast and he developed ARF.
Aggressive IVF were started to minimize contrast nephropathy,
but due to CHF he became fluid overloaded and symptomatic. He
was transfered to the MICU for closer monitoring and did not
require invasive ventilation to maintain oxygenation. After a
short course in MICU, he was transferred back to the wards where
his UOP gradually continued improving and creatinine returned to
baseline. Renal service was actively involved in patient
management. He was discharged home with outpatient physical
therapy and occupational therapy.
.
2. Acute Renal Failure on CRI: As above, Patient with underlying
polycystic kidney disease and HTN. Creatinine is trended back
towards baseline, down to 2.4 at discharge from 2.6 ([**8-11**]) 3.2
([**8-10**]) and 4.2 ([**8-9**]) with UOP greater than 500ml in 8hrs.
.
3. CHF: History of congestive heart failure, with last
documented EFs before admission of 30% ([**2172-3-20**]) and 60%
([**2172-7-6**]) from medical management. Because of fluid overload,
his clinical condition worsened and a new ECHO was obtained,
which showed a 40% EF ([**8-9**]) with mild pulmonary hypertension.
He was maintained on coreg and had clinical improvement in JVD
and edema with good diuresis and no pulmonary compromise.
.
4. HTN: Longstanding history of hypertension probably secondary
to PCKD. As CHF resolved, hypertension again became an issue to
address. Because of ARF, ACE-I was stopped and BP began to
increase. Felodipine was increased to 10mg and as reneal
function improved, lisinopril was added as per renal rec's.
Patient was discharged with BP ranging from 120's to 140's.
.
5. Anemia: During hospitalization, hematocrit was noted to be
decreased. An iron panel demonstrated normal B12, normal
ferritin, decreased TIBC and Iron level of 12.
Anemia pattern remained normocytic and was initially worse
likely secondary to dilution from fluid overload. Hct stabilized
around 9, and GUIAC by DRE was heme negative. Dr [**First Name (STitle) 216**] is aware
and will follow up on an oupatient basis.
.
6. Multi-nodular Goiter: An incidental fiding of a multinodular
goiter was made during trauma scout film evaluation. Reviewing
patients history, thyroid u/s from [**2-21**] showed increase in size
of a previously existing dominant nodule measuring 10 cm.
Thyroid function tests were obtained and showed no anomalies.
Repeat thyroid ultrasound ([**8-11**]) showed no interval change. F/U
scheduled with Dr [**Last Name (STitle) **], ([**Telephone/Fax (1) 30788**], as requested by PCP.
.
7. FEN: With sporadic nausea but tolerating PO intake in the
last 12hrs without any furhter nausea. Continue senal, cardiac,
low Na diet.
.
8. ACCESS: Only peripheral access was needed during this
hospitalization
.
9. PPx. Heparin SQ, PPI, bowel regimen
.
10. COMMUNICATION: Patient, wife
.
11. CODE STATUS: Patient remained full code througout admission
.


Medications on Admission:
Coreg 25 mg twice daily
lisinopril 40 mg daily
allopurinol 300 mg daily
meclizine 12.5 mg daily
aspirin 325 mg daily


Discharge Medications:
1. Outpatient Physical Therapy
Requires gait and endurance training and right arm
rehabilitation. Follow up for right arm pendulum excercises and
ADL's
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for nausea for 10 days.
Disp:*14 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
1. Humerus fracture
2. Acute renal failure on Chronic renal failure
3. Hypertension
4. Congestive heart failure
5. Anemia
SECONDARY:
1. Scrotal hernia
2. Gout


Discharge Condition:
Stable, strong palpable pulses on right upper extremity,
neurologically intact. Urinating without difficulty and with
resolving kidney function.


Discharge Instructions:
You were admitted to the hospital because you fractured your
right arm when you fell off  your boat. In order to evaluate the
facture and if it affected the nerves and arteries of the arm, a
CT scan was ordered. It showed no compromise to the blood
vessels, and you chose not to have an operation to fix this
broken bone. While you were admitted, you began having worsening
kidney function. The medical team felt this was most likely due
to the contrast used for the CT scan. In order to prevent any
permanent damage to the kidneys, a large amount of fluid was
give through your veins. We were concerned about your breathing
and your heart because of the all the fluid we gave you, so you
were closely monitored in the intensive care unit. You did not
develop any problems and were able to be transfered to the
regular floor, where you continued to improve.
Physical therapy and occupational therapy have been working with
you to improve your strength and teach you how to use your arm.
We have set you up with outpatient physical therapy as well.
.
Please do not take your ALLOPURINOL until your primary care
doctor evaluates you. Also, please arrange for a Nephrologist
(Kidney doctor) to follow you up.
.
If you develop new arm pain, notice excessive swelling, numbness
or tingling in the finger of the right hand, feel chest pain,
shortness or breath, nausea, vomiting or diarrhea, blood in your
stool or black stools or stop making urine, please call your
primary care doctor or come into the Emergency Department.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2173-10-20**] 11:30
DR [**Last Name (STitle) 844**] (THYROID)  ([**Telephone/Fax (1) 30788**]   [**8-23**], 9:15AMProvider:
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2173-8-16**] 12:15. At
this time you should have your kidney function and blood counts
checked and discuss setting an appointment with the kidney
doctors to monitor your condition and adjust your LISINOPRIL.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
{'Closed fracture of surgical neck of humerus,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Mitral valve disorders,Acute kidney failure, unspecified,Hyperpotassemia,Other primary cardiomyopathies,Other fall from one level to another in water transport injuring occupant of other watercraft -- other than crew,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Polycystic kidney, autosomal dominant,Gout, unspecified,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Other drugs and medicinal substances causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nontoxic multinodular goiter'}


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: I fell and hurt my arm

PRESENT ILLNESS: 82 y/o M w/ h/o CKD (cr 1.9-2.0), HTN, CHF (most recent ECHO w/
EF 60%), who presented s/p fall, found to have right humerus
fracture.
.
Fell while trying to pull off a safety strap while repairing his
boat. The strap suddenly came loose and he fell 6 feet off a
platform onto his right side. Denies associated lightheadedness,
dizziness, chest pain or palpitations.
.
In the ER, he was found to have right humerus fracture. CT head
and C-spine negative for fracture. Evaluated for surgical
repair, however patient refuses surgical intervention. Plan for
sling with follow-up in 2 weeks. However, overnight developed
decreased urine output (110 cc out over 8 hour period). Given 1L
NS bolus and placed on 80cc/hr LR. However, still w/ low uop
(~10cc/hr), bladder scan showed empty bladder. Given additional
1L NS without response. Subsequently tried 5mg IV lasix to see
if component of CHF, without effect. Creatinine noted to be
elevated from 2.1 to 3.2.

MEDICAL HISTORY: HTN
CRI (baseline cr 1.5-1.8)
Gout
Polycystic kidney disease

MEDICATION ON ADMISSION: Coreg 25 mg twice daily
lisinopril 40 mg daily
allopurinol 300 mg daily
meclizine 12.5 mg daily
aspirin 325 mg daily

ALLERGIES: Digoxin

PHYSICAL EXAM: vitals- T 99.1, BP 100/60, HR 84, RR 16, 92% RA (99% on 2l O2)
gen- sitting up in chair, no labored breathing, NAD
heent- EOMI. MM dry
neck- jvp non-distended
pulm- CTA b/l. good air movement. slight decreased at bases
cv- RRR. no m/r/g
abd- soft, NT/Nd
ext- no edema, distal pulses 2+ ; R arm in sling; grip strength
full b/l
neuro- alert and oriented, follows commands. language fluent

FAMILY HISTORY: No CAD, HTN, or DM

SOCIAL HISTORY: Pt is semi-retired heavy epuipment engineer. Married. No
smoking, EtOH, or drugs. 

### Response:
{'Closed fracture of surgical neck of humerus,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Mitral valve disorders,Acute kidney failure, unspecified,Hyperpotassemia,Other primary cardiomyopathies,Other fall from one level to another in water transport injuring occupant of other watercraft -- other than crew,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Polycystic kidney, autosomal dominant,Gout, unspecified,Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Other drugs and medicinal substances causing adverse effects in therapeutic use,Anemia in chronic kidney disease,Nontoxic multinodular goiter'}
