CHIEF COMPLAINT: Witnessed fall with striking leg

PRESENT ILLNESS: This is an 88 yo F with a past medical history of afib and
frequent falls, recently admitted in [**10-16**] after a mechanical
fall, who was brought to the ED by EMS after a witnessed fall at
home. Her husband said he saw her fall, noting that she only hit
her leg, no head trauma, no LOC, no loss of bowel/bladder
function. When she was picked up by EMS to be brought to [**Hospital1 18**],
she was thought to have an altered mental status and to be
slightly tachypneic, which resolved en route. In the ED, she was
found to have a temp of 101.2. She received 1L IVF and her SBP's
dropped from 100's to 70's. An EJ was placed for another liter
of IVF, and her pressure came up to the 90's. At that point a
RIJ was placed, she was given a dose of vanco, levofloxacin and
flagyl, blood cultures and ua/urine cultures were sent. Her UA
came back with moderate leuks, neg nitrates, large blood and >50
WBC's. She was admitted to the MICU for further management of
urosepsis in the setting of a leukocytosis to 20,000, persistent
fevers to 102.3, lactate of 2 and hypotension.

MEDICAL HISTORY: Past Medical History:
frequent falls
CAD - s/p MI [**00**] years ago
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation, no longer on antiarrhythmic or
anticoagulation
Chronic venous stasis with b/l lower extremity edema
constipation
hernia repair
s/p appy

MEDICATION ON ADMISSION: 1. Atorvastatin 40 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule [**Year (2 digits) **]: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Folic Acid 1 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp: 98.8 (r) BP: 108/58 HR: 68 RR: 25 O2sat 92% RA, CVP 16
GEN: pleasant, comfortable, NAD (able to lay flat with no
respiratory distress)
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, poor
dentition
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules.
RESP: CTA b/l with good air movement throughout, some dependent
dry crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: chronic venous stasis changes in bilateral lower
extremities, 1+ pitting edema to knees, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home with husband (married last year). Previous husband
died 10 [**Name2 (NI) 1686**] ago. Has two children, both of whom live in [**Location (un) 5426**], and three grandchildren. She used to smoke a PPD for 40
[**Location (un) 1686**] stopped roughly 20 [**Location (un) 1686**] ago after her MI. Drinks a glass of
wine a week. No other drugs.
Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Other pulmonary insufficiency, not elsewhere classified,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Severe sepsis,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension
E coli septicemia,Septic shock,Urin tract infection NOS,Other pulmonary insuff,Delirium d/t other cond,Chr diastolic hrt fail,Severe sepsis,Atrial fibrillation,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Hypertension NOS
Admission Date:  [**2188-12-17**]              Discharge Date:   [**2188-12-22**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Witnessed fall with striking leg

Major Surgical or Invasive Procedure:
Central line placement


History of Present Illness:
This is an 88 yo F with a past medical history of afib and
frequent falls, recently admitted in [**10-16**] after a mechanical
fall, who was brought to the ED by EMS after a witnessed fall at
home. Her husband said he saw her fall, noting that she only hit
her leg, no head trauma, no LOC, no loss of bowel/bladder
function. When she was picked up by EMS to be brought to [**Hospital1 18**],
she was thought to have an altered mental status and to be
slightly tachypneic, which resolved en route. In the ED, she was
found to have a temp of 101.2. She received 1L IVF and her SBP's
dropped from 100's to 70's. An EJ was placed for another liter
of IVF, and her pressure came up to the 90's. At that point a
RIJ was placed, she was given a dose of vanco, levofloxacin and
flagyl, blood cultures and ua/urine cultures were sent. Her UA
came back with moderate leuks, neg nitrates, large blood and >50
WBC's. She was admitted to the MICU for further management of
urosepsis in the setting of a leukocytosis to 20,000, persistent
fevers to 102.3, lactate of 2 and hypotension.

Of note, on last admission she was found to have a dirty UA and
was treated for 3 days on ciprofloxacin. Urine culture grew out
E. coli.

On ROS, the patient denies chest or abdominal pain, shortness of
breath, n/v/d. Admits to leg pain, but this is chronic. Denies
dysuria, but admits to 24 hours of polyuria prior to
presentation.


Past Medical History:
Past Medical History:
frequent falls
CAD - s/p MI [**00**] years ago
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation, no longer on antiarrhythmic or
anticoagulation
Chronic venous stasis with b/l lower extremity edema
constipation
hernia repair
s/p appy

Social History:
Lives at home with husband (married last year). Previous husband
died 10 [**Name2 (NI) 1686**] ago. Has two children, both of whom live in [**Location (un) 5426**], and three grandchildren. She used to smoke a PPD for 40
[**Location (un) 1686**] stopped roughly 20 [**Location (un) 1686**] ago after her MI. Drinks a glass of
wine a week. No other drugs.

Family History:
NC

Physical Exam:
Temp: 98.8 (r) BP: 108/58 HR: 68 RR: 25 O2sat 92% RA, CVP 16
GEN: pleasant, comfortable, NAD (able to lay flat with no
respiratory distress)
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, poor
dentition
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules.
RESP: CTA b/l with good air movement throughout, some dependent
dry crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: chronic venous stasis changes in bilateral lower
extremities, 1+ pitting edema to knees, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps


Pertinent Results:
URINE CULTURE (Final [**2188-12-18**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------    16 I
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------    64 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S


Brief Hospital Course:
88 yo female with h/o afib, frequent falls, admitted with
urosepsis.

# Sepsis [**1-10**] UTI: Initially presumed to be secondary to UTI
given UA results.  Was, however, also evaluated for pneumonia,
community acquired or aspiration, but chest film was negative
for infiltrate or consolidation. Upon admission was hypotension
but responded to fluid [**Last Name (LF) 1868**], [**First Name3 (LF) **] patient was not in shock.
APACHE II score was 14 which estimated mortality risk of almost
17%.  She improved rapidly with fluid resuscitation and never
required pressors while in the ICU.  Antibiotic coverage was
started empirically for gram negative rods and gram positive
cocci with cipro and vanco.  Was briefly changed to levofloxacin
for improved pulmonary coverage when she developed a cough for
one day.  This was changed to ceftriaxone given her confusion,
but was ultimately returned to ciprofloxacin.  E.coli was
ciprofloxacin sensitive.
Was discharged with continued antibiotics for 10 day total
course.

# Afib with RVR: Was in normal sinus rhythm upon admission but
the evening of [**2188-12-17**] developed Afib with RVR.  Broken with
diltiazam boluses, then diltiazem gtt, with no response to
metoprolol IV (although had been on metoprolol XL 25mg daily at
home).  Was transition to diltiazam boluses, then to a diltiazam
oral equivalent prior to discharge.

# Altered Mental Status: Initially likely secondary to
sundowning versus infection with plan to treat underlying causes
and monitor.  On [**2188-12-17**] did recieve lorazepam 0.5mg IV and
olanzapine 5mg PO/SL x2 with increased delirium [**12-18**] AM. These
medications were not used further.  Much improved with
conservative treatment.  Continued to keep windows open and
re-orient frequently.  Avoided sedating meds and physical
restraint when possible.  Oral medications were briefly held for
her altered mental status as there was concern for aspiration.
Speech/swallow evaluation was obtained and her diet was adjusted
appropriately.  Upon discharge, had minimal aspiration risk, but
patient consistently tries to eat/drink while lying down.  She
will need to be continually sat up for all oral intake at rehab.
 Will need PT/OT at rehabilitation for further treatment.

# Respiratory distress: SOB initially developed while receiving
fluid resuscitation.  Initial considerations included
bronchospasm [**1-10**] volume overload v. aspiration pneumonitis v.
penumonia.  CXR was unrevealing for these processes beyond mild
fluid overload.  Initially responded to diuresis, but wheezing
recurred intermittently.  Albuterol & ipratroprium nebs were
used as needed and she did experience mild relief.  Aspiration
assessed with speech & swallow and diet adjusted accordingly.

# CAD: STABLE.  CAD s/p MI [**00**] years ago. Continued Atorvastatin.
 BB initially held given hypotension, then restarted for Afib
rate control.  Ultimately was not useful, and was transitioned
to diltiazam.

# Hyperlipidemia: STABLE.  Continued Atorvastatin.

# HTN: Normotensive since admission, and home regimen of
metoprolol XL 25mg daily held.  Started on diltiazam prior to
discharge given atrial fibrillation with RVR.  Discharged on
this medication.
.
# Falls: PT/OT evaluation recommended upon discharge.  Social
work consult was obtained for placement.  Should be monitored
for orthostatic hypotension given prolonged duration in bed
while inpatient.

Medications on Admission:
1. Atorvastatin 40 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule [**Year (2 digits) **]: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Folic Acid 1 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY (Daily).

5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet [**Last Name (STitle) **]: One
(1)Tablet PO Q6H (every 6 hours) as needed: Please hold for
RR<10, SBP<95.
7. Magnesium Hydroxide 1,200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
once a day as needed for low magnesium: Please resume at home
dose.
8. Quinidine Sulfate 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day as needed for for pain: Please resume at home regimen.
9. Ambien 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime as
needed for insomnia: as needed for insomina, resume at home
dosing.
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO once a day:
Please hold for HR<55.

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) mL
Injection Q8H (every 8 hours): [**Month (only) 116**] discontinue as patient
becomes more active.  Should not go home from rehab on this
medication if mobile.
4. Folic Acid 1 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily).

5. Hexavitamin     Tablet [**Month (only) **]: One (1) Cap PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Month (only) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
8. Ipratropium Bromide 0.02 % Solution [**Month (only) **]: One (1) NEB
Inhalation Q6H (every 6 hours) as needed for Wheeze.
9. Diltiazem HCl 30 mg Tablet [**Month (only) **]: One (1) Tablet PO QID (4
times a day): hold for heart rate less than 55, blood pressure
less than 95  .
10. Ciprofloxacin 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Total course of antibiotics 10
days.
11. Aspirin 81 mg Tablet, Chewable [**Month (only) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Outpatient Occupational Therapy
Please evaluate and treat while in rehab.
13. Outpatient Physical Therapy
Please evaluate and treat while in rehab.
14. Outpatient Speech/Swallowing Therapy
Please reassess in 1 week to establish if current diet
modifcations are still appropriate


Discharge Disposition:
Extended Care

Facility:
HEALTH BRIDGE

Discharge Diagnosis:
Primary: Urosepsis
Secondary: Atrial fibrillation with rapid ventricular response,
delirium, respiratory distress, coronary artery disease,
hyperlipidemia, hypertension


Discharge Condition:
Hemodynamically stable and afebrile


Discharge Instructions:
You were admitted for urinary tract infection that effected your
whole body, causing you to have low blood pressure. You were
treated with antibiotics. You should continue the course of
treatment as prescribed for a full 10 day course
.
Your medications have been changed while in the hospital to
control your heart rate and blood pressure.  Take all
medications as prescribed, your rehab facility has been provided
with a new list which you should take.
.
Please return to the hospital or seek medical care if you notice
new fevers, pain with urination, back pain, chills or new
worsening fatigue, as these can be signs of infection. Or, for
any other symptom for which you are concerned.

Followup Instructions:
Provider: [**Name10 (NameIs) **] RM 5 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2188-12-24**]
1:30

Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2189-2-5**] 10:20
{'Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Other pulmonary insufficiency, not elsewhere classified,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Severe sepsis,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension'}


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: Witnessed fall with striking leg

PRESENT ILLNESS: This is an 88 yo F with a past medical history of afib and
frequent falls, recently admitted in [**10-16**] after a mechanical
fall, who was brought to the ED by EMS after a witnessed fall at
home. Her husband said he saw her fall, noting that she only hit
her leg, no head trauma, no LOC, no loss of bowel/bladder
function. When she was picked up by EMS to be brought to [**Hospital1 18**],
she was thought to have an altered mental status and to be
slightly tachypneic, which resolved en route. In the ED, she was
found to have a temp of 101.2. She received 1L IVF and her SBP's
dropped from 100's to 70's. An EJ was placed for another liter
of IVF, and her pressure came up to the 90's. At that point a
RIJ was placed, she was given a dose of vanco, levofloxacin and
flagyl, blood cultures and ua/urine cultures were sent. Her UA
came back with moderate leuks, neg nitrates, large blood and >50
WBC's. She was admitted to the MICU for further management of
urosepsis in the setting of a leukocytosis to 20,000, persistent
fevers to 102.3, lactate of 2 and hypotension.

MEDICAL HISTORY: Past Medical History:
frequent falls
CAD - s/p MI [**00**] years ago
CHF - ? last ECHO [**7-12**] EF 70%
Atrial fibrillation, no longer on antiarrhythmic or
anticoagulation
Chronic venous stasis with b/l lower extremity edema
constipation
hernia repair
s/p appy

MEDICATION ON ADMISSION: 1. Atorvastatin 40 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule [**Year (2 digits) **]: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO BID (2 times a
day) as needed.
4. Folic Acid 1 mg Tablet [**Year (2 digits) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp: 98.8 (r) BP: 108/58 HR: 68 RR: 25 O2sat 92% RA, CVP 16
GEN: pleasant, comfortable, NAD (able to lay flat with no
respiratory distress)
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, poor
dentition
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules.
RESP: CTA b/l with good air movement throughout, some dependent
dry crackles
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: chronic venous stasis changes in bilateral lower
extremities, 1+ pitting edema to knees, warm, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. 2+DTR's-patellar
and biceps

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at home with husband (married last year). Previous husband
died 10 [**Name2 (NI) 1686**] ago. Has two children, both of whom live in [**Location (un) 5426**], and three grandchildren. She used to smoke a PPD for 40
[**Location (un) 1686**] stopped roughly 20 [**Location (un) 1686**] ago after her MI. Drinks a glass of
wine a week. No other drugs. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Septic shock,Urinary tract infection, site not specified,Other pulmonary insufficiency, not elsewhere classified,Delirium due to conditions classified elsewhere,Chronic diastolic heart failure,Severe sepsis,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Unspecified essential hypertension'}
