CHIEF COMPLAINT: traumatic fall

PRESENT ILLNESS: The patient is an 82 year old man who was admitted in the
afternoon of [**2164-11-15**] with a fall at home complicated by rib
pain and found to have multiple rib fractures now transfered to
the ICU for hypoxic and hypercarbic respiratory distress.
.
He is an 82 M with hx of CAD s/p DES x4, CABG, CHF with EF55%,
hx of renal cell carcinoma, COPD, and CKD presents with severe L
rib pain, SOB, and vomiting with exertion. On the morning of
presentation (~9am)the patient slipped on ice landing on his R
flank. He took an unknown amount of tylenol #3 prior to coming
to hospital. HE denied LOC. Denies striking head. EMS called and
pt refused transport. Denies neck, back pain but has noted
severe, [**9-12**] pain with any inspiration over L flank. Large
ecchymosis over area. Son reports pt s/p 2 episodes vomiting
with exertion this pm, initially yellow. No hematemesis. Denies
abd pain. Has chronic urinary incontinence. Per ED patient
recently increased his furosemide dose.
.
In the ED he had a CXR that showed no infiltrate, edema, or
pneumothorax. He had rib films that showed multiple rib
fractures ([**5-12**]). He was admitted for pain control and evaluation
of acute on chronic renal failure.
On arrival to the medicine floor he was "lethargic and sleepy"
was afebrile with repirations of 16 and O2sat 93%2L. He had
received no pain medications since arrival to the medicine
floor. At ~2:45 am he was found to be hypoxic with O2sat 71% on
2L. He received nebs and was able to wean his supplemental O2 to
2-3L. However at ~4am, he desatted again requiring a NRB and ICU
transfer.
Also he was found to have a bladder scan of ~500cc and a foley
catheter was placed.
.
ROS: no nausea. no vomiting. no leg pain. no increase in leg
swelling. left chest pain.

MEDICAL HISTORY: Hyperlipidemia
hypertension
CAD: (Outpatient cardiologist is Dr. [**Last Name (STitle) **]
- s/p CABG status post coronary artery bypass graft in [**2138**]
SVG--> OM1 (last stented in [**2162**] x 3), SVG-->LAD (last stented
in [**2162**]), SVG-->RCA (occluded)
- MI [**2151**], multiple cardiac catherizations and stent placements.

MEDICATION ON ADMISSION: ASA 325 mg QD
Plavix 75 mg daily
captopril 100 mg [**Hospital1 **]
atenolol 100 mg daily
Lipitor 40 mg QD
Norvasc 10 mg QD
Lasix 40 mg [**Hospital1 **]
Imdur 120 mg
doxazosin 8mg
levothyroxine 50mg
Spirva
Zaroxolyn 5 mg daily
albuterol prn
epogen 3x/week

ALLERGIES: Inderal

PHYSICAL EXAM: Vitals: 98.3 82 142/66 15 99%NRB
Gen: ill appearing. moaning in pain
HEENT: dry MM. PERRL. EOMI. no battle sign or racoon eyes. no
head bruising
Neck: supple. no JVD seen
Chest: ecchymotic patch to left flank
CV: regular. S1/S2 w/o murmur or gallop
Abd: adipose. soft. active bowel sounds
Ext: venous harvest on right. chronic venous stasis bilat
Skin: ecchymosis to left upper flank
Neuro:
-MS: alert. oriented to self, "[**Hospital3 **]" "[**2113**]"
-CN: pupils reactive. EOMI. face [**Last Name (un) 36**] intact. head turn intact
-Motor: moving
-DTR:
-[**Last Name (un) **]: light touch intact to face, arms, legs

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: retired furniture salesman. Married, has children, one daughter
is a nurse and works at [**Hospital1 18**]. He currently lives with his son
and grandson. They are very involved and very supportive. He has
an extensive smoking history (stopped 25yrs ago) and admits to
minimal EtOH. He denies use of illicit substances.
Closed fracture of four ribs,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Chronic combined systolic and diastolic heart failure,Myoclonus,Altered mental status,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dehydration,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Pernicious anemia,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Encounter for palliative care,Personal history of malignant neoplasm of kidney,Personal history of malignant neoplasm of prostate,Cardiac pacemaker in situ
Fracture four ribs-close,Acute kidney failure NOS,Secondary malig neo lung,Chr syst/diastl hrt fail,Myoclonus,Altered mental status,Fall from slipping NEC,Chr airway obstruct NEC,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Dehydration,Status-post ptca,Cor ath unsp vsl ntv/gft,Pernicious anemia,Abdom aortic aneurysm,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Encountr palliative care,Hx of kidney malignancy,Hx-prostatic malignancy,Status cardiac pacemaker
Admission Date:  [**2164-11-15**]              Discharge Date:   [**2164-11-18**]

Date of Birth:  [**2082-10-9**]             Sex:   M

Service: MEDICINE

Allergies:
Inderal

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
traumatic fall

Major Surgical or Invasive Procedure:
arterial line

History of Present Illness:
The patient is an 82 year old man who was admitted in the
afternoon of [**2164-11-15**] with a fall at home complicated by rib
pain and found to have multiple rib fractures now transfered to
the ICU for hypoxic and hypercarbic respiratory distress.
.
He is an 82 M with hx of CAD s/p DES x4, CABG, CHF with EF55%,
hx of renal cell carcinoma, COPD, and CKD presents with severe L
rib pain, SOB, and vomiting with exertion. On the morning of
presentation (~9am)the patient slipped on ice landing on his R
flank. He took an unknown amount of tylenol #3 prior to coming
to hospital. HE denied LOC. Denies striking head. EMS called and
pt refused transport. Denies neck, back pain but has noted
severe, [**9-12**] pain with any inspiration over L flank. Large
ecchymosis over area. Son reports pt s/p 2 episodes vomiting
with exertion this pm, initially yellow. No hematemesis. Denies
abd pain. Has chronic urinary incontinence. Per ED patient
recently increased his furosemide dose.
.
In the ED he had a CXR that showed no infiltrate, edema, or
pneumothorax. He had rib films that showed multiple rib
fractures ([**5-12**]). He was admitted for pain control and evaluation
of acute on chronic renal failure.
On arrival to the medicine floor he was "lethargic and sleepy"
was afebrile with repirations of 16 and O2sat 93%2L. He had
received no pain medications since arrival to the medicine
floor. At ~2:45 am he was found to be hypoxic with O2sat 71% on
2L. He received nebs and was able to wean his supplemental O2 to
2-3L. However at ~4am, he desatted again requiring a NRB and ICU
transfer.
Also he was found to have a bladder scan of ~500cc and a foley
catheter was placed.
.
ROS: no nausea. no vomiting. no leg pain. no increase in leg
swelling. left chest pain.


Past Medical History:
Hyperlipidemia
hypertension
CAD: (Outpatient cardiologist is Dr. [**Last Name (STitle) **]
- s/p CABG status post coronary artery bypass graft in [**2138**]
SVG--> OM1 (last stented in [**2162**] x 3), SVG-->LAD (last stented
in [**2162**]), SVG-->RCA (occluded)
- MI [**2151**], multiple cardiac catherizations and stent placements.

AV delay:
- [**Company 1543**] pacer AV placed for AV delay/conduction disease in
[**2159**]- interrogated last [**10-10**]
CHF (diastolic dysfunction, LVH, EF 40-45%)
COPD
History renal cell carcinoma s/p nephrectomy [**2149**]
Chronic Renal failure (baseline 2.4-3)
Pernicious anemia
AAA
Diabetes
Prostate cancer
Lung nodules potentially from lung cancer vs mets (seen 2 years
ago)


Social History:
retired furniture salesman. Married, has children, one daughter
is a nurse and works at [**Hospital1 18**]. He currently lives with his son
and grandson. They are very involved and very supportive. He has
an extensive smoking history (stopped 25yrs ago) and admits to
minimal EtOH. He denies use of illicit substances.

Family History:
noncontributory

Physical Exam:
Vitals: 98.3 82 142/66 15 99%NRB
Gen: ill appearing. moaning in pain
HEENT: dry MM. PERRL. EOMI. no battle sign or racoon eyes. no
head bruising
Neck: supple. no JVD seen
Chest: ecchymotic patch to left flank
CV: regular. S1/S2 w/o murmur or gallop
Abd: adipose. soft. active bowel sounds
Ext: venous harvest on right. chronic venous stasis bilat
Skin: ecchymosis to left upper flank
Neuro:
-MS: alert. oriented to self, "[**Hospital3 **]" "[**2113**]"
-CN: pupils reactive. EOMI. face [**Last Name (un) 36**] intact. head turn intact
-Motor: moving
-DTR:
-[**Last Name (un) **]: light touch intact to face, arms, legs


Pertinent Results:
EKG: sinus. PR prolongation (stable from priors). right axis
deviation. RBBB. slow R wave progression. no ST-T changes from
prior
.
Studies:
[**2164-11-15**] CXR Cardiomediastinal silhouette is grossly unchanged.
Patient is status post median sternotomy with wires intact. A
left basal nodule measures 13 mm. Right basal nodule is not well
seen on today's study. There is no pneumothorax or focal
consolidations. Pulmonary vascularity is normal. Left pleural
thickening is stable since [**2164-5-4**]. Osseous structures are
diffusely demineralized. There is no displaced fracture.
.
[**2164-11-15**] rib xray - There are nondisplaced and mildly displaced
fractures of four contiguous left-sided ribs (the sixth through
ninth ribs). There is increased pleural density in this region
which could reflect associated hematoma. No pneumothorax is
seen. Chest is unchanged in appearance with a [**Month/Day/Year 4448**] seen in
the left anterior chest wall and prominent cardiomegaly.
Subsegmental
atelectasis is seen at the bases bilaterally. Osseous structures
are
otherwise unremarkable.
.
[**2164-11-16**] CXR - (unofficial) patchy rounded opacities in right
mid lung field and left base potentially atelectasis vs
infiltrate

[**2164-11-15**] 04:36PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2164-11-15**] 04:36PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2164-11-15**] 04:36PM URINE  RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2164-11-15**] 04:33PM   GLUCOSE-140* UREA N-91* CREAT-3.4* SODIUM-141
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2164-11-15**] 04:33PM   CK(CPK)-66
[**2164-11-15**] 04:33PM   CK-MB-NotDone cTropnT-0.02*
[**2164-11-15**] 04:33PM   CALCIUM-8.8 PHOSPHATE-7.6*# MAGNESIUM-2.7*
[**2164-11-15**] 02:23AM   GLUCOSE-179* UREA N-85* CREAT-3.4* SODIUM-141
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-29 ANION GAP-16
[**2164-11-15**] 02:23AM   estGFR-Using this
[**2164-11-15**] 02:23AM   CK(CPK)-77
[**2164-11-15**] 02:23AM   cTropnT-0.02*
[**2164-11-15**] 02:23AM   CK-MB-NotDone proBNP-4228*
[**2164-11-15**] 02:23AM   WBC-8.7 RBC-4.71# HGB-13.0*# HCT-41.4# MCV-88
MCH-27.6 MCHC-31.5# RDW-15.1
[**2164-11-15**] 02:23AM   NEUTS-91.1* LYMPHS-5.0* MONOS-3.6 EOS-0.3
BASOS-0.1
[**2164-11-15**] 02:23AM   PLT COUNT-231
[**2164-11-15**] 02:23AM   PT-12.4 PTT-26.4 INR(PT)-1.1

Brief Hospital Course:
The patient is an 82 year old man with history of extensive CAD,
CHF, DM2, COPD, RCC now presenting with rib fractures following
a fall complicated by respiratory distress. The patient's
daughter confirmed that he was DNR/DNI.  He was placed on bipap
to help with his breathing which was particularly difficult
given the need to balance treatment of his fracture pain with
adequate mentation and respiratory effort.  An epidural could
not be placed as the patient was taking clopidogrel.  The
patient remained significantly acidemic with pH 7.1 and elevated
CO2.  Family members concluded that he would want comfort care
only and did not want to continue with invasive interventions.
The patient was made CMO status and appeared comfortable. He
received morphine boluses prior to moving him but otherwise did
not require additional therapeutics.
.
HOSPITAL COURSE BY PROBLEM PRIOR TO CMO STATUS:
# Respiratory Distress: likely secondary to pain with splinting
from rib pain resulting in ventilation and oxygenation deficits.
given normal or near normal serum bicarb likely not a
significant CO2 retainer at baseline. no fever or evidence for
infection however with vomiting and altered mental status could
have aspirated. likely dehydrated as opposed to in CHF. no
pneumothorax on imaging. other potentials could be PE however
seems early in course for this and has no hemodynamic or ECG
evidence for PE.
- cycle cardiac enzymes: peaked at 0.04
- serial ABG: most recent 7.21/77/101
- Chest CT yesterday noted as above
- NIPPV yesterday without signif improvement in PCo2. Still with
myoclonus. Will re-attempt with higher PS today.
- A-line for BP monitor and frequent ABG
- CXR this am as above. Limit fluid today
.
# Altered mental status/myoclonus: non-focal neuro exam and
altered mental status has waxed and waned with the respiratory
distress (i.e. CO2 narcosis) which supports this as the primary
disorder. however with recent trauma, SDH also possible.
- serial ABG as above
- CT head: negative
- Mental status improved yesterday. Will target improving Co2
status to improve mental status and myoclonus.
-DC'd lidoderm patch yesterday without change in myoclonus.
.
# Acute on chronic renal failure: likely pre-renal with
component or post-renal given large bladder scan.
- UA, urine lytes showing likely pre-renal etiology with high
osmol and low urine Na.
- renally dose meds
- UOP improved this am.
- Limit further fluids now that uOP increasing.
.
# Fall: likely mechanical secondary to slipping on ice at home.
no evidence of head trauma per history or exam.
- monitor as above
- low dose dilaudid for pain given renal impairment if needed
- Acute pain service: no epidural due to plavix. Recs tylenol,
neurontin, prn dilaudid.
.
#DM: Sliding scale insulin with good coverage yesterday.
.
# CAD: no ischemic changes on EKG and negative enzymes x 2.
however with new respiratory changes reasonable to re-cycle
enzymes
- cycle enzymes. Peaked at 0.04
- repeat EKG
- continue aspirin/plavix/statin
.
# CHF: appears dehydrated as shown in Hct, Cr, and mucous
membranes.
- hold home diuretics
- received gentle IVF on [**11-16**]. Limit further IVF [**11-17**].
- hold ACE for now
- continue BB
.
#Lung mets from unknown primary, possible renal given history
RCC.
- no further eval at this time. Will discuss with daughter.
.
# FEN: Limit further IVF. Replace as needed. NPO for now.
.
# Prophy: hep sc, bowel regimen
# Access: PIV
# Code: DNR/DNI confirmed with daughter who corroborated with
her 2 siblings. Will discuss DNI with daughter regarding
possible temporary intubation for Co2 reduction.
# Contact Info: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27320**] (daughter) cell: [**Telephone/Fax (1) 103116**]
# Dispo: ICU


Medications on Admission:
ASA 325 mg QD
Plavix 75 mg daily
captopril 100 mg [**Hospital1 **]
atenolol 100 mg daily
Lipitor 40 mg QD
Norvasc 10 mg QD
Lasix 40 mg [**Hospital1 **]
Imdur 120 mg
doxazosin 8mg
levothyroxine 50mg
Spirva
Zaroxolyn 5 mg daily
albuterol prn
epogen 3x/week


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
s/p fall
hypoxic and hypercarbic respiratory distress

Secondary:
hyperlipidemia
hypertension
CAD
s/p PPM
CHF
COPD
chronic renal failure
pernicious anemia
AAA
diabetes
prostate cancer
lung nodules

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Closed fracture of four ribs,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Chronic combined systolic and diastolic heart failure,Myoclonus,Altered mental status,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dehydration,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Pernicious anemia,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Encounter for palliative care,Personal history of malignant neoplasm of kidney,Personal history of malignant neoplasm of prostate,Cardiac pacemaker in situ'}


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: traumatic fall

PRESENT ILLNESS: The patient is an 82 year old man who was admitted in the
afternoon of [**2164-11-15**] with a fall at home complicated by rib
pain and found to have multiple rib fractures now transfered to
the ICU for hypoxic and hypercarbic respiratory distress.
.
He is an 82 M with hx of CAD s/p DES x4, CABG, CHF with EF55%,
hx of renal cell carcinoma, COPD, and CKD presents with severe L
rib pain, SOB, and vomiting with exertion. On the morning of
presentation (~9am)the patient slipped on ice landing on his R
flank. He took an unknown amount of tylenol #3 prior to coming
to hospital. HE denied LOC. Denies striking head. EMS called and
pt refused transport. Denies neck, back pain but has noted
severe, [**9-12**] pain with any inspiration over L flank. Large
ecchymosis over area. Son reports pt s/p 2 episodes vomiting
with exertion this pm, initially yellow. No hematemesis. Denies
abd pain. Has chronic urinary incontinence. Per ED patient
recently increased his furosemide dose.
.
In the ED he had a CXR that showed no infiltrate, edema, or
pneumothorax. He had rib films that showed multiple rib
fractures ([**5-12**]). He was admitted for pain control and evaluation
of acute on chronic renal failure.
On arrival to the medicine floor he was "lethargic and sleepy"
was afebrile with repirations of 16 and O2sat 93%2L. He had
received no pain medications since arrival to the medicine
floor. At ~2:45 am he was found to be hypoxic with O2sat 71% on
2L. He received nebs and was able to wean his supplemental O2 to
2-3L. However at ~4am, he desatted again requiring a NRB and ICU
transfer.
Also he was found to have a bladder scan of ~500cc and a foley
catheter was placed.
.
ROS: no nausea. no vomiting. no leg pain. no increase in leg
swelling. left chest pain.

MEDICAL HISTORY: Hyperlipidemia
hypertension
CAD: (Outpatient cardiologist is Dr. [**Last Name (STitle) **]
- s/p CABG status post coronary artery bypass graft in [**2138**]
SVG--> OM1 (last stented in [**2162**] x 3), SVG-->LAD (last stented
in [**2162**]), SVG-->RCA (occluded)
- MI [**2151**], multiple cardiac catherizations and stent placements.

MEDICATION ON ADMISSION: ASA 325 mg QD
Plavix 75 mg daily
captopril 100 mg [**Hospital1 **]
atenolol 100 mg daily
Lipitor 40 mg QD
Norvasc 10 mg QD
Lasix 40 mg [**Hospital1 **]
Imdur 120 mg
doxazosin 8mg
levothyroxine 50mg
Spirva
Zaroxolyn 5 mg daily
albuterol prn
epogen 3x/week

ALLERGIES: Inderal

PHYSICAL EXAM: Vitals: 98.3 82 142/66 15 99%NRB
Gen: ill appearing. moaning in pain
HEENT: dry MM. PERRL. EOMI. no battle sign or racoon eyes. no
head bruising
Neck: supple. no JVD seen
Chest: ecchymotic patch to left flank
CV: regular. S1/S2 w/o murmur or gallop
Abd: adipose. soft. active bowel sounds
Ext: venous harvest on right. chronic venous stasis bilat
Skin: ecchymosis to left upper flank
Neuro:
-MS: alert. oriented to self, "[**Hospital3 **]" "[**2113**]"
-CN: pupils reactive. EOMI. face [**Last Name (un) 36**] intact. head turn intact
-Motor: moving
-DTR:
-[**Last Name (un) **]: light touch intact to face, arms, legs

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: retired furniture salesman. Married, has children, one daughter
is a nurse and works at [**Hospital1 18**]. He currently lives with his son
and grandson. They are very involved and very supportive. He has
an extensive smoking history (stopped 25yrs ago) and admits to
minimal EtOH. He denies use of illicit substances. 

### Response:
{'Closed fracture of four ribs,Acute kidney failure, unspecified,Secondary malignant neoplasm of lung,Chronic combined systolic and diastolic heart failure,Myoclonus,Altered mental status,Fall from other slipping, tripping, or stumbling,Chronic airway obstruction, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dehydration,Percutaneous transluminal coronary angioplasty status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Pernicious anemia,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Encounter for palliative care,Personal history of malignant neoplasm of kidney,Personal history of malignant neoplasm of prostate,Cardiac pacemaker in situ'}
