CHIEF COMPLAINT: fall

PRESENT ILLNESS: This is a [**Age over 90 **] year old female with a past medical history of CVA
on coumadin and seizure disorder presenting from OSH for recent
diagnosis of left non-displaced femoral neck fracture with
hypoxemia and moderately sized right sided pleural effusions. Ms
[**Known lastname 16254**] was in her usual state of health last week when she got up
from her sofa and bumped into a coffee table and fell. She had
no presyncopal symptoms, no fevers, no chest pain or shortness
of breath surrounding the event; no loss of consciousness. After
her fall, she crawled to the phone and called EMS. Other than
pain, she had no significant other symptoms. At the OSH, she was
imaged with a CT spine, CT chest, and CT pelvis. Pelvic imaging
revealed a left femoral neck fracture, non-displaced. CT chest
revealed a moderately sized left sided and small right sided
pleural effusions. She was transferred to [**Hospital1 18**] for further
management when these effusions were detected. In the ED at
[**Hospital1 18**], radiology reviewed these films and felt they were
consistent with pleural effusions not hemothorax. She did have
hypoxemia with O2 sats in the high 80s; she was placed on a
non-rebreather with improvement to the high 90s. She did not
endorse significant dyspnea or chest pain. EKG demonstrated
T-wave inversions in inferior leads; a single set of cardiac
enzymes were negative. She received ceftriaxone and azithromycin
given her pleural effusions and fentanyl for her hip pain.
Orthopedics evaluated her and felt her to be an operative
candidate for hemiarthroplasty. Her health care proxy, her son
[**Name (NI) **], declined consent for any surgery and he stated he would
reconsider in the morning after discussing her status with the
attending. At time of transfer to the MICU, she was in mild hip
pain but with no other complaints. She was weaned to 4 L NC with
O2 sats between 97-100, with HRs in the 80s, BPs 120s, and was
afebrile.
.
She has otherwise been healthy other than her chronic seizure
disorder and coumadin therapy for her CVA. She has good exercise
tolerance frequently climbing her [**7-8**] stairs to get to the
[**Location (un) 1773**] of her house without significant dyspnea or
fatigue.

MEDICAL HISTORY: 1. seizure disorder (unclear what type, apparently has had for
several decades)
2. CVA X 2 (unclear what type) dating back a couple of decades
3. hypertension
4. hyperlipidemia
5. paroxysmal afib

MEDICATION ON ADMISSION: - Kepra 500 mg at noon and 1000 mg [**Hospital1 **]
- lisinopril 40 mg qam
- phenytoin ex 100 mg tid
- nifedepine 90 mg qhs
- atenolol 100 mg [**Hospital1 **]
- coumadin 5'
- simvastatin 20'
- depakote 250 mg qam, 500 qhs

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS BP 129/67, HR 74, afebrile, SpO2 98% on 4 L NC
Gen: Sitting up in bed in NAD
Neuro: Alert, cannot tell us year and identifies hospital as
"[**Location (un) **]," however she is able to give us a detailed history of
her fall and converses brightly and intelligently. Moving all
extremities; lower extremity exam limited by pain.
Cardiac: Systolic ejection murmur loudest at left lower sternal
border grade III/VI
Pulm: moderate dullness to percussion over left lung base,
mildly diminished breath sounds at left and right lung base,
exam somewhat limited by inability to sit up secondary to hip
pain
Abd: very soft and nontender, normoactive bowel sounds
Ext: Limited secondary to hip pain, no edema noted

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home by herself in [**Location (un) 14840**], MA; her son, [**Name (NI) **], who
lives at [**Location (un) **] visits her frequently and helps with
groceries, maintenance of house, otherwise she does most of her
ADLs and is very active at home. Denies smoking, alcohol use.
Acute on chronic systolic heart failure,Toxic encephalopathy,Other closed transcervical fracture of neck of femur,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Oliguria and anuria,Hypoxemia,Vascular dementia, uncomplicated,Atrial fibrillation,Dysarthria,Leukocytosis, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Volume depletion, unspecified,Fall from other slipping, tripping, or stumbling,Personal history of Methicillin resistant Staphylococcus aureus,Long-term (current) use of anticoagulants,Do not resuscitate status,Knee joint replacement,History of fall
Ac on chr syst hrt fail,Toxic encephalopathy,Fx femur intrcaps NEC-cl,Urin tract infection NOS,Delirium d/t other cond,Oliguria & anuria,Hypoxemia,Vascular dementia,uncomp,Atrial fibrillation,Dysarthria,Leukocytosis NOS,Epilep NOS w/o intr epil,Hypertension NOS,Hyperlipidemia NEC/NOS,Volume depletion NOS,Fall from slipping NEC,Hx Methicln resist Staph,Long-term use anticoagul,Do not resusctate status,Joint replaced knee,Personal history of fall
Admission Date:  [**2190-10-7**]              Discharge Date:   [**2190-10-14**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
[**10-7**]:  Left femoral neck fracture status post percutaneous
fixation with 7.3 mm screws of nondisplaced valgus impacted
femoral neck fracture.


History of Present Illness:
This is a [**Age over 90 **] year old female with a past medical history of CVA
on coumadin and seizure disorder presenting from OSH for recent
diagnosis of left non-displaced femoral neck fracture with
hypoxemia and moderately sized right sided pleural effusions. Ms
[**Known lastname 16254**] was in her usual state of health last week when she got up
from her sofa and bumped into a coffee table and fell. She had
no presyncopal symptoms, no fevers, no chest pain or shortness
of breath surrounding the event; no loss of consciousness. After
her fall, she crawled to the phone and called EMS. Other than
pain, she had no significant other symptoms. At the OSH, she was
imaged with a CT spine, CT chest, and CT pelvis. Pelvic imaging
revealed a left femoral neck fracture, non-displaced. CT chest
revealed a moderately sized left sided and small right sided
pleural effusions. She was transferred to [**Hospital1 18**] for further
management when these effusions were detected. In the ED at
[**Hospital1 18**], radiology reviewed these films and felt they were
consistent with pleural effusions not hemothorax. She did have
hypoxemia with O2 sats in the high 80s; she was placed on a
non-rebreather with improvement to the high 90s. She did not
endorse significant dyspnea or chest pain. EKG demonstrated
T-wave inversions in inferior leads; a single set of cardiac
enzymes were negative. She received ceftriaxone and azithromycin
given her pleural effusions and fentanyl for her hip pain.
Orthopedics evaluated her and felt her to be an operative
candidate for hemiarthroplasty. Her health care proxy, her son
[**Name (NI) **], declined consent for any surgery and he stated he would
reconsider in the morning after discussing her status with the
attending. At time of transfer to the MICU, she was in mild hip
pain but with no other complaints. She was weaned to 4 L NC with
O2 sats between 97-100, with HRs in the 80s, BPs 120s, and was
afebrile.
.
She has otherwise been healthy other than her chronic seizure
disorder and coumadin therapy for her CVA. She has good exercise
tolerance frequently climbing her [**7-8**] stairs to get to the
[**Location (un) 1773**] of her house without significant dyspnea or
fatigue.


Past Medical History:
1. seizure disorder (unclear what type, apparently has had for
several decades)
2. CVA X 2 (unclear what type) dating back a couple of decades
3. hypertension
4. hyperlipidemia
5. paroxysmal afib


Social History:
Lives at home by herself in [**Location (un) 14840**], MA; her son, [**Name (NI) **], who
lives at [**Location (un) **] visits her frequently and helps with
groceries, maintenance of house, otherwise she does most of her
ADLs and is very active at home. Denies smoking, alcohol use.

Family History:
Non-contributory

Physical Exam:
VS BP 129/67, HR 74, afebrile, SpO2 98% on 4 L NC
Gen: Sitting up in bed in NAD
Neuro: Alert, cannot tell us year and identifies hospital as
"[**Location (un) **]," however she is able to give us a detailed history of
her fall and converses brightly and intelligently. Moving all
extremities; lower extremity exam limited by pain.
Cardiac: Systolic ejection murmur loudest at left lower sternal
border grade III/VI
Pulm: moderate dullness to percussion over left lung base,
mildly diminished breath sounds at left and right lung base,
exam somewhat limited by inability to sit up secondary to hip
pain
Abd: very soft and nontender, normoactive bowel sounds
Ext: Limited secondary to hip pain, no edema noted


Pertinent Results:
I. Labs

A. Admission

[**2190-10-6**] 11:20PM BLOOD WBC-13.5* RBC-4.60 Hgb-12.9 Hct-39.2
MCV-85 MCH-28.1 MCHC-33.0 RDW-15.2 Plt Ct-293
[**2190-10-7**] 05:52AM BLOOD Neuts-89.8* Lymphs-5.2* Monos-4.5 Eos-0.1
Baso-0.4
[**2190-10-6**] 11:20PM BLOOD PT-27.9* PTT-30.9 INR(PT)-2.7*
[**2190-10-6**] 11:20PM BLOOD Plt Ct-293
[**2190-10-6**] 11:20PM BLOOD Fibrino-296
[**2190-10-6**] 11:20PM BLOOD UreaN-23* Creat-0.5
[**2190-10-7**] 05:52AM BLOOD ALT-27 AST-34 LD(LDH)-357* AlkPhos-93
TotBili-0.3
[**2190-10-6**] 11:20PM BLOOD Lipase-41
[**2190-10-6**] 11:20PM BLOOD cTropnT-0.01
[**2190-10-7**] 05:52AM BLOOD Albumin-4.1 Calcium-8.4 Phos-4.0 Mg-2.1
[**2190-10-6**] 11:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-10-6**] 11:28PM BLOOD Glucose-124* Lactate-2.0 Na-140 K-4.1
Cl-103 calHCO3-20*
[**2190-10-6**] 11:28PM BLOOD Hgb-13.4 calcHCT-40

B. Discharge

[**2190-10-14**] 06:55AM BLOOD WBC-8.5 RBC-4.13* Hgb-11.4* Hct-35.9*
MCV-87 MCH-27.6 MCHC-31.8 RDW-16.6* Plt Ct-263
[**2190-10-14**] 06:55AM BLOOD Plt Ct-263
[**2190-10-14**] 06:55AM BLOOD Glucose-108* UreaN-24* Creat-0.4 Na-146*
K-3.7 Cl-110* HCO3-28 AnGap-12
[**2190-10-14**] 06:55AM BLOOD ALT-30 AST-48* AlkPhos-68 TotBili-0.3
[**2190-10-14**] 06:55AM BLOOD Albumin-3.2* Calcium-8.3* Phos-3.4 Mg-2.1

C. Urine

[**2190-10-12**] 09:30AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.028
[**2190-10-12**] 09:30AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2190-10-12**] 09:30AM URINE RBC-64* WBC-13* Bacteri-MANY Yeast-NONE
Epi-6
[**2190-10-12**] 09:30AM URINE Mucous-MANY

II. Microbiology
[**2190-10-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2190-10-11**] URINE ANAEROBIC CULTURE-FINAL INPATIENT
[**2190-10-7**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2190-10-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]
[**2190-10-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY [**Hospital1 **]

III. Radiology

A. Video Swallow ([**2190-10-13**])
INDICATION: Coughing with meals, dysphagia, history of
esophageal dilatation.

VIDEO OROPHARYNGEAL SWALLOW: The study was conducted in
collaboration with
speech pathology. Various consistencies of barium were
administered by mouth including thin, nectar, puree, and ground.
There is a solitary incidence of penetration into the vestibule
with thin consistency. There is no aspiration into the airway.
There is a small amount of nasal regurgitation with thin
consistency. There is a small amount of residue with nectar
consistency.  There is a moderate amount of residue with puree
consistency. This clears with subsequent swallows.

IMPRESSION: No aspiration seen.

B. CXR ([**2190-10-12**])
HISTORY: [**Age over 90 **]-year-old woman with respiratory difficulty and
altered mental
status.

COMPARISON: [**2190-10-7**].

SINGLE UPRIGHT VIEW OF THE CHEST AT 9:15 A.M.: There has been an
increase in size of a layering right pleural effusion, now
moderate, and development of a new left pleural effusion, small.
Bilateral retrocardiac opacities are compatible with associated
compressive atelectasis. There is good aeration of the upper
lungs, without consolidation or pneumothorax. Parenchymal
opacities, particularly in the left upper lung have improved.
There is no new hilar or mediastinal enlargement. Pulmonary
vascularity is near normal in caliber. Aortic arch
calcifications are noted. Degenerative changes are present in
the spine.

A surgical clip at the thoracic inlet is compatible with prior
thyroid
surgery.

IMPRESSION:

Increased pleural effusions (moderate on the right and small on
the left), in combination with improved aeration of the upper
lungs is compatible with improving pulmonary edema.

C. MRI Brain ([**2190-10-11**])
EXAM: MRI of the brain.

CLINICAL INFORMATION: Patient with history of CVA with left
non-displaced
femoral head fracture, has hypoxia and right-sided pleural
effusion, for
further evaluation to exclude intracranial abnormality.

TECHNIQUE: T1 sagittal and FLAIR, T2, susceptibility and
diffusion axial
images of the brain were acquired.

FINDINGS: Diffusion images demonstrate no evidence of acute
infarct. There
is a chronic infarct identified in the left occipital region
with
encephalomalacia and ex vacuo dilatation of the occipital [**Doctor Last Name 534**]
of the left
lateral ventricle. There are diffuse hyperintensities in the
white matter
indicative of small vessel disease. Moderate-to-severe brain
atrophy and
medial temporal atrophy is also seen. No evidence of chronic
microhemorrhages. Suprasellar and craniocervical regions are
normal on the
sagittal images. Incidentally noted are plexus cysts within the
region of
atrium bilaterally.

IMPRESSION: No acute infarct. Chronic left occipital infarct.
Brain atrophy
and small vessel disease. No signs of acute hypoxic injury to
the brain.

D. Hip nailing ([**2190-10-8**])STUDY: LEFT HIP INTRAOPERATIVE STUDY,
[**2190-10-8**].

CLINICAL HISTORY: [**Age over 90 **]-year-old woman with left hip fracture.
Status post
fixation.

FINDINGS: Two views of the left hip from the operating room
demonstrates
interval placement of cannulated screws fixating a femoral neck
fracture in
the left side. There are no signs for hardware-related
complications. Please
refer to the operative note for additional details.

E. Head CT
INDICATION: [**Age over 90 **]-year-old female status post fall.

COMPARISON: No prior study available for comparison.

TECHNIQUE: Contiguous axial images were obtained through the
brain without IV
contrast at [**Hospital3 934**] Hospital. Several initial sections
were degraded
by motion artifact and subsequently repeated. Images are
submitted for formal
second opinion.

FINDINGS: Within limits of motion artifact, there is no acute
intracranial
hemorrhage, major vascular territory infarction, mass effect or
edema.
Hypodensity in the left occipital region may represent an area
of
encephalomalacia related to prior infarct. [**Doctor Last Name **]-white matter
differentiation
is elsewhere preserved. Periventricular white matter hypodensity
is
consistent with chronic small vessel ischemic disease.
Age-appropriate
prominence of ventricles and sulci is compatible with diffuse
parenchymal
volume loss.

Globes and left lens are intact. There has been prior right lens
replacement.
Visualized paranasal sinuses and left mastoid air cells are well
aerated.
There is under pneumatization and opacification of some of the
right mastoid
air cells. No osseous abnormality is identified. There is
calcification of
the bilateral cavernous carotid arteries.

IMPRESSION:

1. No acute intracranial abnormality.

2. Findings compatible with chronic small vessel ischemic
disease and
age-related involutional change.

3. Hypodensity in the left occipital region may represent an
area of
encephalomalacia related to prior infarct.

4. Underpneumatization and partial opacification of some of the
right mastoid
air cells.

F. CT Abdomen
INDICATION: [**Age over 90 **]-year-old female status post fall. Rule out
injury.

COMPARISON: No prior study available for comparison.

TECHNIQUE: MDCT-acquired axial images were obtained through the
abdomen and
pelvis after administration of 130 mL IV Optiray contrast.
Coronal and
sagittal reformats were displayed.

CT ABDOMEN WITH IV CONTRAST: Large right and moderate left
pleural effusions
with associated atelectasis demonstrate simple fluid
attenuation, and are
better evaluated on chest CT performed at the outside hospital
earlier the
same day. There is atherosclerotic calcification of the coronary
arteries,
but the heart is otherwise unremarkable. There is a
small-to-moderate hiatal
hernia. Focal calcification in the left pleural space may be
related to
pleural or diaphragmatic calcifications.

There is a wedge-shaped hyperenhancing perfusion abnormality in
the right lobe
of the liver (segment 8). The gallbladder, pancreas, spleen, and
right
adrenal gland are normal. The left adrenal gland is slightly
full. The kidneys
enhance and excrete contrast symmetrically without evidence of
hydronephrosis
or hydroureter. There are multiple hypodensities in the
bilateral kidneys,
most of which are too small to characterize, but likely simple
cysts. The
largest hypodensity is in the interpolar region of the right
kidney measuring
2.2 x 2.2 cm and with low attenuation, compatible with a simple
cyst. Some
regions of cortical thinning may be from insults related to
prior infection.
The non-opacified stomach and intra-abdominal loops of bowel are
normal.
There is no free air or fluid in the abdomen. No mesenteric or
retroperitoneal lymphadenopathy meeting CT criteria for
pathologic enlargement
is noted.

The aorta is of normal caliber throughout, but with marked
atherosclerotic
calcification and likely stenoses involving the origins of the
celiac axis,
SMA, [**Female First Name (un) 899**] and bilateral renal arteries. Soft plaque in the aorta
is also noted.


CT PELVIS WITH IV CONTRAST: The urinary bladder is collapsed
around a Foley
catheter. The distal ureters, uterus, left adnexa and rectum are
normal.
There is a 2.4 x 2.4 cm cystic structure in the right adnexa.
There is mild
sigmoid diverticulosis without evidence of acute diverticulitis.


BONE WINDOWS: There is an ill-defined lucency through the left
proximal
femoral neck, best seen on the sagittal images (301B:46)
compatible with acute
fracture. In addition, there is a lucency in the left ischium,
which could
also represent an acute fracture (2:70).

There is no suspicious lytic or sclerotic osseous lesion
identified. There is
multilevel degenerative change of the thoracolumbar spine with
endplate
osteophyte formation, loss of disc height and vacuum disc
phenomenon at
multiple levels. There is a grade 1 anterolisthesis of L5 on S1,
likely
chronic given the degenerative change.

IMPRESSION:

1. No evidence of solid organ injury in the abdomen or pelvis.

2. Nondisplaced left femoral neck fracture and possible left
ischial
fracture.

3. Bilateral pleural effusions, better evaluated on CT chest
performed
earlier the same day at an outside hospital.

4. Marked atherosclerotic calcification of the abdominal aorta
and coronary
arteries.

5. Moderate hiatal hernia.

6. Bilateral renal hypodensities, most likely simple cysts.

7. 2.4 cm right adnexal cyst can be further evaluated with
non-emergent
pelvic ultrasound.

8. Marked lumbar degenerative change with L5 on S1
anterolisthesis, likely
chronic given the degenerative changes.

IV. Cardiology
Atrial fibrillation with rapid ventricular response. Possible
left ventricular
hypertrophy. Non-specific ST-T wave changes. Compared to the
previous tracing
of [**2190-10-7**] rapid atrial fibrillation is new.

Intervals Axes
Rate PR QRS QT/QTc P QRS T
113 0 114 348/440 0 57 -80



Brief Hospital Course:
[**Age over 90 **]-year-old female with baseline dementia, prior CVA x 2,
seizure disorder with left femoral neck fracture status post
pinning from mechanical fall on [**2190-10-8**] with course complicated
by hypoxia from pleural effusions and delirium from possible UTI
and metabolic etiologies.

# Femoral neck fracture:  s/p percutaneous fixation with 7.3 mm
screws of
nondisplaced valgus impacted femoral neck fracture on [**2190-10-7**].
The patient had no apparent complications after the operation.
She needs to remain TD weight bearing on the left until she
follows up in ortho clinic in 2 months.

#BILATERAL PLEURAL EFFUSIONS/CHF: Effusions likely related to
acute CHF exacerbation. BNP elevated. CE neg x 1. ECG with TWI
in II and III otherwise no apparent ischemic changes. She should
have an ECHO as an outpt to assess EF as she has no known
history of heart failure.

# Hypoxemia: Hypoxemic on admission with 4L O2 requirement.
Likely related to bilateral effusions. No e/o PNA. O2
requirement now 1-2L. Diuresed initially with IV lasix. No need
for thoracentesis. O2 can likely continue to be weaned off as
tolerated to keep O2 sats>92-93%.
.
# Atrial Fibrillation: New Afib on this admission. TSH normal.
Likely related to longstanding HTN. Her outpt regimen of
atenolol 100 [**Hospital1 **] changed to metoprolol 62.5 [**Hospital1 **]. Systemic
anti-coagulation continued. Given INR became subtherapeutic she
was started on a lovenox bridge which can be stopped when INR
between [**2-3**] for 2 consec days. She will need close outpt follow
up for this new issue and should have an ECHO as outpt.
.
# Altered mental status/Delirium: Developed in MICU. Likely
multifactorial in setting of surgery, pain, hypoxemia, UTI and
hospitalization. Given her h/o prior stroke she had brain MRI
that indicated prior stroke BUT no acute infarct with non-focal.
AMS improved after she was started on ABX for UTI. She is now
oriented to person but remains otherwise disoriented. Per her
family, she is fully oriented at baseline. We anticipate that
her MS will slowly improve.

# Dysarthria with aspiration
Speech and swallow evaluted the patient given clinical suspicion
of aspiration with initial test confirming aspiration. She was
subsequently re-evaluated after her mental status changes
resolved with the following recommendations:

1. Suggest a PO diet of thin liquids and soft consistency solids
2. Strict 1:1 supervision for all PO intake given her current
mental status.
3. Meds crushed with puree.
4. TID oral care
5. Please feed only when most awake and alert.
6. If intake is limited due to her mental status, suggest a
nutrition consult
7. Please page if there are any additional questions or
concerns.

# Urinary tract infection: Problem with initial cx so no
organisms were isolated. We feel she should get a total 7 day
course of cipro 250mg [**Hospital1 **]. Last day [**2190-10-19**].
.
# Seizure disorder - She was continued on her home Keppra,
depakote and phenytoin
.
# Hypertension - The patient's nifedipine and lisinopril were
held given the peri-procedural period and relative volume
depletion. We are restarting lisinopril at 5mg daily and holding
nifedipine for now given BP in normotensive range. Would suggest
titrating up lisinopril to keep normotensive.
.
# Hyperlipidemia - She was continued on simvastatin 20 mg daily
.
# Code: DNR/DNI
.
# Emergency Contacts:
[**Name (NI) **] [**Name (NI) 58397**] (HCP) - [**Telephone/Fax (1) 88428**], [**Telephone/Fax (1) 88429**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58397**] - [**Telephone/Fax (1) 88430**]
[**Name (NI) 11923**] (granddaughter)- [**Telephone/Fax (1) 88431**]

# Imaging Incidentals
- Bilateral renal hypodensities, most likely simple cysts.
- 2.4 cm right adnexal cyst can be further evaluated with
non-emergent
pelvic ultrasound. The team contact[**Name (NI) **] her family to let them
know of this mass too.




Medications on Admission:
- Kepra 500 mg at noon and 1000 mg [**Hospital1 **]
- lisinopril 40 mg qam
- phenytoin ex 100 mg tid
- nifedepine 90 mg qhs
- atenolol 100 mg [**Hospital1 **]
- coumadin 5'
- simvastatin 20'
- depakote 250 mg qam, 500 qhs


Discharge Medications:
1. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days: Stop date: [**2190-10-19**].
2. enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q 12H (Every 12 Hours): Continue until INR [**2-3**] for
two consecutive days and then discontinue.
3. divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO HS (at bedtime).
4. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO q AM.
5. metoprolol tartrate 25 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
8. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please give at noon.
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please monitor INR closely.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 7168**]

Discharge Diagnosis:
Non-displaced left femoral neck fracture
Atrial fibrillation
Delirium
Congestive Heart Failure Exacerbation


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mrs. [**Known lastname 16254**],

You were treated for a hip fracture. During your hospitalization
you also had a new heart arrythmia, urinary tract infection and
delirium.

Medications
================
STOP nifedepine
STOP atenolol
.
START ciprofloxacin 250 mg by mouth twice daily (take until
[**10-19**])
enoxaparin 40 mg subcutaneously twice daily
- continue enoxaparin until INR is [**2-3**] for two consecutive days,
then discontinue
START metoprolol to 62.5 mg
DECREASE warfarin to 2 mg by mouth daily
DECREASE lisinopril from 40 mg to 5 mg


Followup Instructions:
Follow up with [**Doctor Last Name **] Derosiers, Orthopaedics NP, in 2 months.
You can call [**Telephone/Fax (1) 1228**] to make that appointment.

Please follow-up with your primary care doctor after rehab:
[**Last Name (LF) **],[**First Name3 (LF) **] S.
Address: [**Doctor Last Name 87203**], [**Apartment Address(1) 34213**], [**Location (un) **],[**Numeric Identifier 72271**]
Phone: [**Telephone/Fax (1) **]
{'Acute on chronic systolic heart failure,Toxic encephalopathy,Other closed transcervical fracture of neck of femur,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Oliguria and anuria,Hypoxemia,Vascular dementia, uncomplicated,Atrial fibrillation,Dysarthria,Leukocytosis, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Volume depletion, unspecified,Fall from other slipping, tripping, or stumbling,Personal history of Methicillin resistant Staphylococcus aureus,Long-term (current) use of anticoagulants,Do not resuscitate status,Knee joint replacement,History of fall'}


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: This is a [**Age over 90 **] year old female with a past medical history of CVA
on coumadin and seizure disorder presenting from OSH for recent
diagnosis of left non-displaced femoral neck fracture with
hypoxemia and moderately sized right sided pleural effusions. Ms
[**Known lastname 16254**] was in her usual state of health last week when she got up
from her sofa and bumped into a coffee table and fell. She had
no presyncopal symptoms, no fevers, no chest pain or shortness
of breath surrounding the event; no loss of consciousness. After
her fall, she crawled to the phone and called EMS. Other than
pain, she had no significant other symptoms. At the OSH, she was
imaged with a CT spine, CT chest, and CT pelvis. Pelvic imaging
revealed a left femoral neck fracture, non-displaced. CT chest
revealed a moderately sized left sided and small right sided
pleural effusions. She was transferred to [**Hospital1 18**] for further
management when these effusions were detected. In the ED at
[**Hospital1 18**], radiology reviewed these films and felt they were
consistent with pleural effusions not hemothorax. She did have
hypoxemia with O2 sats in the high 80s; she was placed on a
non-rebreather with improvement to the high 90s. She did not
endorse significant dyspnea or chest pain. EKG demonstrated
T-wave inversions in inferior leads; a single set of cardiac
enzymes were negative. She received ceftriaxone and azithromycin
given her pleural effusions and fentanyl for her hip pain.
Orthopedics evaluated her and felt her to be an operative
candidate for hemiarthroplasty. Her health care proxy, her son
[**Name (NI) **], declined consent for any surgery and he stated he would
reconsider in the morning after discussing her status with the
attending. At time of transfer to the MICU, she was in mild hip
pain but with no other complaints. She was weaned to 4 L NC with
O2 sats between 97-100, with HRs in the 80s, BPs 120s, and was
afebrile.
.
She has otherwise been healthy other than her chronic seizure
disorder and coumadin therapy for her CVA. She has good exercise
tolerance frequently climbing her [**7-8**] stairs to get to the
[**Location (un) 1773**] of her house without significant dyspnea or
fatigue.

MEDICAL HISTORY: 1. seizure disorder (unclear what type, apparently has had for
several decades)
2. CVA X 2 (unclear what type) dating back a couple of decades
3. hypertension
4. hyperlipidemia
5. paroxysmal afib

MEDICATION ON ADMISSION: - Kepra 500 mg at noon and 1000 mg [**Hospital1 **]
- lisinopril 40 mg qam
- phenytoin ex 100 mg tid
- nifedepine 90 mg qhs
- atenolol 100 mg [**Hospital1 **]
- coumadin 5'
- simvastatin 20'
- depakote 250 mg qam, 500 qhs

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS BP 129/67, HR 74, afebrile, SpO2 98% on 4 L NC
Gen: Sitting up in bed in NAD
Neuro: Alert, cannot tell us year and identifies hospital as
"[**Location (un) **]," however she is able to give us a detailed history of
her fall and converses brightly and intelligently. Moving all
extremities; lower extremity exam limited by pain.
Cardiac: Systolic ejection murmur loudest at left lower sternal
border grade III/VI
Pulm: moderate dullness to percussion over left lung base,
mildly diminished breath sounds at left and right lung base,
exam somewhat limited by inability to sit up secondary to hip
pain
Abd: very soft and nontender, normoactive bowel sounds
Ext: Limited secondary to hip pain, no edema noted

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home by herself in [**Location (un) 14840**], MA; her son, [**Name (NI) **], who
lives at [**Location (un) **] visits her frequently and helps with
groceries, maintenance of house, otherwise she does most of her
ADLs and is very active at home. Denies smoking, alcohol use. 

### Response:
{'Acute on chronic systolic heart failure,Toxic encephalopathy,Other closed transcervical fracture of neck of femur,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Oliguria and anuria,Hypoxemia,Vascular dementia, uncomplicated,Atrial fibrillation,Dysarthria,Leukocytosis, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Volume depletion, unspecified,Fall from other slipping, tripping, or stumbling,Personal history of Methicillin resistant Staphylococcus aureus,Long-term (current) use of anticoagulants,Do not resuscitate status,Knee joint replacement,History of fall'}
