CHIEF COMPLAINT: S/p fall

PRESENT ILLNESS: Ms. [**Known lastname 15011**] is an 87 year old woman with past medical history of
HTN, glaucoma, OA, and recently diagnosed pancreatic/[**Known lastname 499**] CA
with ?liver mets who presented s/p unwitnessed fall at her
[**Hospital3 **] facility. She was found on the ground by her
aide complaining of severe right hip pain.

MEDICAL HISTORY: -newly discovered likely pancreatic, [**Month/Day (2) 499**] ca with liver mets
(pt unaware)
-HTN
-glaucoma
-OA
-?Rheum dx
-LBP

MEDICATION ON ADMISSION: Lorazepam 0.5 mg Tab QID
Aciphex 20mg [**Hospital1 **]
Ibuprofen 800 mg Tab Oral daily
Duloxetine 60 mg daily
Metoprolol Tartrate 25 mg Tab Oral [**Hospital1 **]
Prednisone 5 mg daily
Ultram 50 mg Tab Oral QID

ALLERGIES: Amoxicillin / Sulfonamides / Penicillins

PHYSICAL EXAM: (Per Admitting Resident)
Vitals:T.98.2, BP 150/83, HR 108, RR 16, sat 97% on RA.

FAMILY HISTORY: No history of [**Hospital3 499**] cancer, IBD, breast cancer, CAD, diabetes,
rheumatic diseases, asthma.

SOCIAL HISTORY: Pt lives at [**Hospital3 **], aide helps with all ADLs. No
smoking, ETOH, drug use.
Closed fracture of intertrochanteric section of neck of femur,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Malignant neoplasm of colon, unspecified site,Malignant neoplasm of liver, secondary,Malignant neoplasm of head of pancreas,Urinary tract infection, site not specified,Other closed fractures of distal end of radius (alone),Fall from other slipping, tripping, or stumbling,Polymyalgia rheumatica,Unspecified glaucoma,Unspecified essential hypertension,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Disorder of bone and cartilage, unspecified,Other alteration of consciousness,Other chronic pulmonary heart diseases
Intertrochanteric fx-cl,Acute respiratry failure,Food/vomit pneumonitis,Ac posthemorrhag anemia,Malignant neo colon NOS,Second malig neo liver,Mal neo pancreas head,Urin tract infection NOS,Fx distal radius NEC-cl,Fall from slipping NEC,Polymyalgia rheumatica,Glaucoma NOS,Hypertension NOS,Osteoarthros NOS-unspec,Bone & cartilage dis NOS,Other alter consciousnes,Chr pulmon heart dis NEC
Admission Date:  [**2194-10-27**]              Discharge Date:   [**2194-11-12**]


Service: MEDICINE

Allergies:
Amoxicillin / Sulfonamides / Penicillins

Attending:[**First Name3 (LF) 800**]
Chief Complaint:
S/p fall

Major Surgical or Invasive Procedure:
-Open reduction internal fixation of right hip
-Closed reduction of right distal radius with manipulation.
-Endotracheal Intubation
-Placement of a Right Internal Jugular Central Venous Line


History of Present Illness:
Ms. [**Known lastname 15011**] is an 87 year old woman with past medical history of
HTN, glaucoma, OA, and recently diagnosed pancreatic/[**Known lastname 499**] CA
with ?liver mets who presented s/p unwitnessed fall at her
[**Hospital3 **] facility. She was found on the ground by her
aide complaining of severe right hip pain.

In the ED, the patient was found to have low HCT 23.6. She was
crossmatched 4 units and consented. She was placed in a C-collar
and had a CT C-spine. Xray showed right hip fracture. She was
given IV Morphine for pain control.

Overnight, the patient was transfused 2 units of pRBCs. She was
unable to answer questions appropriately [**1-13**] to pain. She does
not remember anything from the fall. The daughter reports that
the patient is ambulatory at baseline and relies on her aide for
all ADLs.

Past Medical History:
-newly discovered likely pancreatic, [**Month/Day (2) 499**] ca with liver mets
(pt unaware)
-HTN
-glaucoma
-OA
-?Rheum dx
-LBP

Social History:
Pt lives at [**Hospital3 **], aide helps with all ADLs. No
smoking, ETOH, drug use.

Family History:
No history of [**Hospital3 499**] cancer, IBD, breast cancer, CAD, diabetes,
rheumatic diseases, asthma.

Physical Exam:
(Per Admitting Resident)
Vitals:T.98.2, BP 150/83, HR 108, RR 16, sat 97% on RA.

General: sleeping comfortable, C-collar in place. Family
requests no distruptions.
HEENT:nc/at, MMM,
Neck: C-collar in place.
Lungs: Clear to auscultation anteriorly.
CV: Regular rate and rhythm, normal S1 + S2, +3/6 systolic
crescendo/decrescendo murmur loudest in aortic area.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, 1+pitting edema.
neuro: unable to assess.

Pertinent Results:
ADMISSION LABS [**2194-10-27**]:
BLOOD
[**2194-10-27**] 09:00PM WBC-13.1* Hgb-6.9* Hct-23.6* Plt Ct-468*
[**2194-10-27**] 09:00PM Neuts-81.9* Lymphs-11.2* Monos-3.9 Eos-2.8
Baso-0.2
[**2194-10-27**] 09:00PM PT-11.5 PTT-19.5* INR(PT)-1.0
[**2194-10-27**] 09:00PM Glucose-187* UreaN-29* Creat-1.2* Na-136 K-4.4
Cl-102 HCO3-26 AnGap-12
[**2194-10-27**] 09:00PM CK(CPK)-49
[**2194-10-27**] 09:00PM CK-MB-3 cTropnT-0.07*

U/A
[**2194-10-28**] 02:33AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2194-10-28**] 02:33AM Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2194-10-28**] 02:33AM RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-<1
[**2194-10-28**] 02:33AM Mucous-RARE

MICROBIOLOGY:
[**2194-10-28**], [**2194-10-29**] 2 Urine Cx grew e. coli
[**2194-10-30**], [**2194-11-3**] 2 Urine Cx Negative
[**2194-11-6**], [**2194-11-8**] 2 Urine Cx grew yeast
C.Diff negative x 2
Blood Cx negative x 5 (2 pending at d/c)
BAL Respiratory Viral Cx Negative; BAL Gram Stain Negative
Sputum Cx ([**2194-10-30**]): 3+ GRAM NEGATIVE DIPLOCOCCI.; 1+ MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.; Resp Cx grew out
yeast (sparse growth)

RADIOLOGY:
CT C-Spine ([**2194-10-27**]) -IMPRESSION:
1. No acute fracture of the cervical spine.
2. Minimal anterolisthesis of C4 over C5 and C7 over T1 and
minimal retrolisthesis of C5 over C6 of indeterminate age, but
could be degenerative.  Clinical correlation advised. Severe
osteopenia and degenerative changes.  MRI is a more sensitive
modality to evaluate for ligamentous or spinal cord injury.
3. Sub-cm right thyroid nodule. 1.3 x 0.9 cm nodule posterior to
the right lobe of the thyroid may represent a parathyroid
adenoma versus a thyroid nodule. Correlation with thyroid
ultrasound on a non-emergent basis suggested.

CT Head ([**2194-10-27**]) - IMPRESSION: No acute intracranial
abnormality.

Hip X-Ray ([**2194-10-27**]) - IMPRESSION:
1. Intertrochanteric-subtrochanteric fracture of the femur
extending to the lesser trochanter with varus angulation.
2. Severe osteopenia.

Wrist X-Ray ([**2194-10-28**]) - IMPRESSION:
1. Right wrist -- Colles fracture with dorsal angulation of the
distal radial articular surface. Question acute or subacute.
2. Left wrist -- findings essentially representing SLAC wrist
(scapholunate advanced collapse), unlikely to be acute. No acute
fracture identified. No chondrocalcinosis.
3. Bilateral severe osteopenia and osteoarthritis.

CXR ([**2194-10-29**]) - IMPRESSION: New left lower lobe atelectasis
with pleural effusion could be due to aspiration. Early followup
chest radiograph recommended.

CXR ([**2194-10-29**]; at time of MICU transfer) - As compared to the
previous radiograph, there is no relevant change. Borderline
size of the cardiac silhouette, moderate retrocardiac
atelectasis. Presence of minimal left-sided pleural effusion
cannot be excluded. No evidence of overhydration. No focal
parenchymal opacity suggesting pneumonia. No pneumothorax.

CXR ([**2194-11-3**]; at time of MICU callout) - IMPRESSION:
Significant interval improvement in multifocal airspace
opacities.

Echo ([**2194-10-30**]) - The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis
(valve area 1.2 -1.9cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is severe pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.

DISCHARGE LABS ([**2194-11-11**]):

[**2194-11-11**] 05:30AM BLOOD WBC-16.9* RBC-3.34* Hgb-9.3* Hct-29.7*
MCV-89 MCH-27.8 MCHC-31.2 RDW-18.1* Plt Ct-771*
[**2194-11-11**] 05:30AM BLOOD Glucose-98 UreaN-17 Creat-0.8 Na-141
K-4.2 Cl-109* HCO3-25 AnGap-11
[**2194-11-11**] 05:30AM BLOOD ALT-36 AST-38 LD(LDH)-332* AlkPhos-256*
TotBili-0.7
[**2194-11-11**] 05:30AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2194-11-11**] 05:30AM BLOOD CRP-37.0*
[**2194-11-11**] 05:30AM BLOOD ESR-24*

Brief Hospital Course:
87 year old female with recently diagnosed pancreatic/[**Month/Day/Year 499**]
cancer with liver metastases, hypertension, osteoarthritis who
presented on [**2194-10-27**] with right hip and wrist fractures after
an unwitnessed fall.

# Unwitnessed Fall, Right Hip and Wrist Fractures - The patient
presented with right hip and wrist fractures after an
unwitnessed fall.  On arrival to [**Hospital1 18**], she received one liter
of normal saline and morpine 4 mg IV x 2. CT-c-spine was without
fracture. CT head was without acute process. Hip xray showed a
right intertrochanteric-subtrochanteric fracture of the femur
extending to the lesser trochanter with varus angulation. She
was admitted to the medical service for further management. She
underwent open reduction and internal fixation of right hip
fracture and closed reduction or right distal radius fracture.
She tolerated the procedure well but had agitation
post-operatively which was treated with IV haldol. On POD#1 she
was noted to have acute hypoxia, tachypnea and tachycardia.  She
was ultimately transferred to the MICU for further management
(see below).  While in the MICU, she had an echo which showed
mild atrial stenosis, mild mitral regurgitation, severe
pulmonary artery hypertension, and an EF of 75%.  After she was
called out to the floor, PT and OT were consulted.  At the time
of discharge, PT recommendations included transfer training,
balance training, and bed mobility.  The patient was ultimately
discharged to a rehabilitation facility.

# Hypoxia, respiratory distress - At approximately 2 PM on POD#1
she was noted to have acute hypoxia, tachypnea and tachycardia.
She was initially 80% on RA and this improved to low 90s on
facemask and high 90s on a non-rebreather. Repeat CXR showed no
acute cardiopulmonary process. ABG on a non-breather was
7.34/34/170. EKG showed sinus tachycardia but no other changes
compared to priors. She was transferred to the MICU for further
management.  CTA did not show evidence of pulmonary embolism.
Also, bilateral lower extremity ultrasounds showed no evidence
of DVT.  While in the MICU, the patient was intubated.  She was
also found to have a pneumonia (in addition to a previously
known UTI, which was being treated with ciprofloxacin).  She was
started on vancomycin and cefepime.  She was ultimately
extubated on [**2194-11-2**].  She was called out to the floor on
[**2194-11-3**].  The patient also had some episodes of delirium /
agitation upon transfer to the MICU and while she was in the
MICU.  By the time the patient was transferred to the floor,
this had improved.  Sedating medications were avoided after she
was called out to the medicine floor.  A right internal jugular
CVL was also place while the patient was in the MICU.  This was
removed after the patient was called out to the floor.

# Anemia - On admission, the patient's hematocrit was 23.6 with
iron studies notable for low iron and ferritin.  It was felt
that this could be related to the patient's colonic malignancy
(see below).  She received three units of PRBCs.  Her hematocrit
was trended.  She was also kept on pantoprazole.  At the time of
her call out from the MICU on [**2194-11-4**], the patient's hematocrit
was stable.  After she was called out to the floor, the
patient's family requested that she receive no more blood
transfusions.

# Leukocytosis / Thrombocytosis - On [**2194-11-8**], as the patient
was approaching discharge, she was noted to have rising white
blood cell and platelet counts.  At that time, she had already
completed a 7 day course of vancomycin and cefepime for a
pneumonia.  Her mental status was noted to be improving, and she
remained afebrile despite her rising white count.  A urinalysis
showed bacteriuria; however, two urine cultures grew out yeast
alone.  She was started on ciprofloxacin again for possible UTI,
and she was started on fluconazole for the yeast in her urine.
Her Foley [**Last Name (un) **] was discontinued but restarted secondary to
urinary retention.  Two stool cultures were negative for c.diff.
 Blood cultures also were drawn and did not grow out anything by
the time of discharge.  A chest x-ray did not show signs of
infection.  LFT's showed elevated LDH and alkaline phosphatase,
which could be consistent with her underlying malignancy.  This
was discussed with the heme/onc fellow, and it was felt that
that the patient's leukocytosis and thrombocytosis were
consistent with an inflammatory state secondary to her recent
PNA and UTI as well as her mailgnancy.  It was discussed with
the patient's family that the next step in the workup of her
leukocytosis would include bone marrow biopsy.  This was not
consistent with their goals of care (see below).  At the time of
discharge, the patient's WBC was trending down.

# Pancreatic/[**Name (NI) **] Cancer - Pt had recently been diagnosed with
adenocarcinoma of the [**Name (NI) 499**] on biopsy.  She has suspicious liver
lesions as well as a mass in the head of the pancreas concerning
for second primary.  At the time of admission, she had not been
told yet, as her family wanted to withhold the information until
after the [**Holiday 1451**] holiday.  Social work and palliative
worked with the patient's family throughout her hospitalization.
 As explained above, the patient had leukocytosis and
thrombocytosis towards the end of her hospitalization with a
negative infectious work-up.  It was discussed with the
patient's family that further work-up of this would include a
bone marrow biopsy.  Furthermore, if any abnormalities were
found on bone marrow biopsy, treatment of the patient's [**Holiday 499**]
and pancreatic cancer would need to be addressed first.  This
was not consistent with the family's goals of care.  At the time
of discharge, the family's goal of care were to move the patient
to a rehab facility, where she could build her strength.
Telling the patient of her diagnosis can also be addressed
during that time.  As the patient's disease progresses, the
family plans to progress towards hospice care.

# Hypertension - The patient did have some episodes of
hypertension.  While in the MICU, she was on IV metoprolol QID.
This was switched to PO metoprolol [**Hospital1 **].  After the transition to
PO metoprolol, the patient's blood pressure was better
controlled.

# Polymyalgia Rheumatica - The patient's home regimen of
prednisone was not entirely clear.  While in the MICU, she was
on stress doses of steroids.  However, after call out to the
floor, she was transitioned to a regimen of 5 mg prednisone
daily.

# Of note, a speech and swallow evaluation on [**2194-11-4**]
recommended nectar thick liquids and pureed foods, with the
patient's meds being crushed in puree.  Repeat speech and
swallow done on the day prior to discharge cleared the patient
for a regular diet.

Medications on Admission:
Lorazepam 0.5 mg Tab QID
Aciphex 20mg [**Hospital1 **]
Ibuprofen 800 mg Tab Oral daily
Duloxetine 60 mg daily
Metoprolol Tartrate 25 mg Tab Oral [**Hospital1 **]
Prednisone 5 mg daily
Ultram 50 mg Tab Oral QID

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Right hip and wrist fractures s/p unwitnessed falls
Pneumonia
Urinary Tract Infection


Discharge Condition:
afebrile, hemodynamically stable


Discharge Instructions:
You were admitted to the hospital after you had an unwitnessed
fall at your [**Hospital3 **] facility.  You were found to have
fractures in both your right hip and your right wrist.  You were
admitted and taken to the OR to repair these fractures.  You
post-operative course was complicated by respiratory distress,
ultimately requiring transfer to the ICU and intubation.  You
were ultimately extubated and transferred back to the medical
floor.

Also, during your hospital course, you were found to have a
urinary tract infection as well as a pneumonia.  These were
treated with antibiotics. We also tried removing your foley
catheter but you had difficulty urinating after. This will be
removed as possible at your rehab facility.

MEDICATION CHANGES:
-CHANGE Lorazepam to 0.5 mg at night as needed for anxiety
-STOP Aciphex; START Pantoprazole 40 mg twice a day
-STOP Ibuprofen
-STOP Lexapro; START Duloxetine 40 mg daily
-CHANGE Metoprolol Tartrate to 50 mg twice a day
-CHANGE Prednisone to 5 mg daily
-STOP Ultram

THE FOLLOWING MEDICATIONS WERE ADDED:
-Milk of Magnesia 30 mL twice a day as needed for upset stomach
-Bisacodyl 10 mg PO/PR daily as needed for constipation
-Docusate Sodium 100 mg twice a day
-Enoxaparin Sodium 40 mg injection daily
-Acetaminophen 650 mg every 6 hours as needed for pain
-Miconazole Powder 2% three times a day
-Fluconazole 200 mg daily (to complete a 7 day course, ending on
[**11-14**])
-Senna 1 tab twice a day
-Lidocaine 5% Patch daily (apply for 12 hours and then keep off
for 12 hours)
-Amlodipine 5 mg daily

Please return to the emergency room or call 911 if you
experience any further falls, chest pain, shortness of breath,
fevers greater than 101.5, severe nausea with inability to
tolerate food or liquids by mouth, confusion, or any other
concerning symptoms.

It was a pleasure taking part in your medical care.

Followup Instructions:
You should call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **], and make a
follow-up appointment with her within 2 weeks of discharge.  The
telephone number for Dr.[**Name (NI) 15012**] office is [**Telephone/Fax (1) 133**].

You also need to follow-up with orthopedic surgery in 4 weeks.
To set up this appointment, please call [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 15013**] at
[**Telephone/Fax (1) 1228**].


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
{'Closed fracture of intertrochanteric section of neck of femur,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Malignant neoplasm of colon, unspecified site,Malignant neoplasm of liver, secondary,Malignant neoplasm of head of pancreas,Urinary tract infection, site not specified,Other closed fractures of distal end of radius (alone),Fall from other slipping, tripping, or stumbling,Polymyalgia rheumatica,Unspecified glaucoma,Unspecified essential hypertension,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Disorder of bone and cartilage, unspecified,Other alteration of consciousness,Other chronic pulmonary heart diseases'}


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: S/p fall

PRESENT ILLNESS: Ms. [**Known lastname 15011**] is an 87 year old woman with past medical history of
HTN, glaucoma, OA, and recently diagnosed pancreatic/[**Known lastname 499**] CA
with ?liver mets who presented s/p unwitnessed fall at her
[**Hospital3 **] facility. She was found on the ground by her
aide complaining of severe right hip pain.

MEDICAL HISTORY: -newly discovered likely pancreatic, [**Month/Day (2) 499**] ca with liver mets
(pt unaware)
-HTN
-glaucoma
-OA
-?Rheum dx
-LBP

MEDICATION ON ADMISSION: Lorazepam 0.5 mg Tab QID
Aciphex 20mg [**Hospital1 **]
Ibuprofen 800 mg Tab Oral daily
Duloxetine 60 mg daily
Metoprolol Tartrate 25 mg Tab Oral [**Hospital1 **]
Prednisone 5 mg daily
Ultram 50 mg Tab Oral QID

ALLERGIES: Amoxicillin / Sulfonamides / Penicillins

PHYSICAL EXAM: (Per Admitting Resident)
Vitals:T.98.2, BP 150/83, HR 108, RR 16, sat 97% on RA.

FAMILY HISTORY: No history of [**Hospital3 499**] cancer, IBD, breast cancer, CAD, diabetes,
rheumatic diseases, asthma.

SOCIAL HISTORY: Pt lives at [**Hospital3 **], aide helps with all ADLs. No
smoking, ETOH, drug use. 

### Response:
{'Closed fracture of intertrochanteric section of neck of femur,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Acute posthemorrhagic anemia,Malignant neoplasm of colon, unspecified site,Malignant neoplasm of liver, secondary,Malignant neoplasm of head of pancreas,Urinary tract infection, site not specified,Other closed fractures of distal end of radius (alone),Fall from other slipping, tripping, or stumbling,Polymyalgia rheumatica,Unspecified glaucoma,Unspecified essential hypertension,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Disorder of bone and cartilage, unspecified,Other alteration of consciousness,Other chronic pulmonary heart diseases'}
