CHIEF COMPLAINT: Left open tibial shaft fracture s/p mechanical fall

PRESENT ILLNESS: 88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.

MEDICAL HISTORY: -HTN
-COPD
-Hypercholesterolemia
-Aortic insufficiency
-Rheumatoid arthritis
-TIA
-Thrombophlebitis of LE, on coumadin
-Diverticulosis
-Spinal stenosis
-GERD
-Hiatal hernia
-Acute gastritis
-Osteoporosis
-Urinary incontinence
-Appendectomy
-Cholecystectomy
-L breast biopsy
-Urinary incontinence
-Lactose intolerance

MEDICATION ON ADMISSION: *cyanocobalamin (vitamin B-12) 1,000 mcg daily
*aspirin 81 mg Tab Oral
*Boniva 150mg q 30 days
*hydrochlorothiazide 25 daily
*lisinopril 10 daily
*Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Inhalation
2 puffs Aerosol(s) Four times daily
*Prilosec 20 mg q AM
*Remeron 7.5 q HS
*Coumadin 1.25ng x 2d (w,sa); 2.5mg x 5d
*meclizine -- 25 mg PRN vertigo
*folic acid 1mg daily
*Calcium 600 mg q TID
*prednisone 10 mg daily
*methotrexate sodium-not filled since novemember-12.5 mg weekly

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / Tetracycline /
Neurontin / IV Dye, Iodine Containing Contrast Media

PHYSICAL EXAM: AVSS, NAD, AOx3
CV: RRR
PULM: Non-labored breathing

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives alone, walks with a walker. Smokes [**11-21**] ppd x10 yrs, no
etoh, illicits.
Open fracture of shaft of fibula with tibia,Acute posthemorrhagic anemia,Contusion of foot,Overexertion from sudden strenuous movement,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Thrombocytopenia, unspecified,Hypopotassemia,Hypocalcemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Aortic valve disorders,Rheumatoid arthritis,Tobacco use disorder,Long-term (current) use of steroids,Personal history of venous thrombosis and embolism,Pure hypercholesterolemia,Spinal stenosis, unspecified region,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteoporosis, unspecified,Urinary incontinence, unspecified,Intestinal disaccharidase deficiencies and disaccharide malabsorption
Fx shaft tibia w fib-opn,Ac posthemorrhag anemia,Contusion of foot,Overxrt-sudn stren mvmt,Abnrml coagultion prfile,Adv eff anticoagulants,Iatrogenc hypotnsion NEC,Thrombocytopenia NOS,Hypopotassemia,Hypocalcemia,Hypertension NOS,Chr airway obstruct NEC,Aortic valve disorder,Rheumatoid arthritis,Tobacco use disorder,Long-term use steroids,Hx-ven thrombosis/embols,Pure hypercholesterolem,Spinal stenosis NOS,Esophageal reflux,Diaphragmatic hernia,Gstr/ddnts NOS w/o hmrhg,Osteoporosis NOS,Urinary incontinence NOS,Disaccharidase def/malab
Admission Date:  [**2102-3-22**]              Discharge Date:   [**2102-3-28**]


Service: ORTHOPAEDICS

Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / Tetracycline /
Neurontin / IV Dye, Iodine Containing Contrast Media

Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Left open tibial shaft fracture s/p mechanical fall

Major Surgical or Invasive Procedure:
Washout and debridement of the open fracture, operative
treatment of left tibia shaft fracture with intramedullary nail,
and closed treatment of the left fibula fracture without
manipulation.


History of Present Illness:
88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.


Past Medical History:
-HTN
-COPD
-Hypercholesterolemia
-Aortic insufficiency
-Rheumatoid arthritis
-TIA
-Thrombophlebitis of LE, on coumadin
-Diverticulosis
-Spinal stenosis
-GERD
-Hiatal hernia
-Acute gastritis
-Osteoporosis
-Urinary incontinence
-Appendectomy
-Cholecystectomy
-L breast biopsy
-Urinary incontinence
-Lactose intolerance


Social History:
Pt lives alone, walks with a walker. Smokes [**11-21**] ppd x10 yrs, no
etoh, illicits.

Family History:
NC

Physical Exam:
AVSS, NAD, AOx3
CV: RRR
PULM: Non-labored breathing

MSK:
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U [**Month/Day (2) 2189**]
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses

LLE with bivalve cast in place
Incision is clean/dry/intact with mild erythema and ecchymosis,
No edema, drainage, or fluctuance
Peri-incisional tenderness appropriate to post-op exam, no
induration or ecchymosis
Thighs and legs are soft
No pain with passive motion at knee or ankle
Saph Sural DPN SPN MPN LPN [**First Name9 (NamePattern2) 2189**]
[**Last Name (un) 938**] FHL GS TA PP Fire
1+ PT and DP pulses

Contralateral extremity examined with good range of motion,
SILT, motors intact and no pain or edema


Pertinent Results:
[**2102-3-28**] 05:47AM BLOOD WBC-7.0 RBC-3.45* Hgb-10.0* Hct-31.5*
MCV-91 MCH-29.0 MCHC-31.8 RDW-15.2 Plt Ct-165
[**2102-3-28**] 05:47AM BLOOD Glucose-78 UreaN-19 Creat-0.8 Na-142
K-3.9 Cl-106 HCO3-28 AnGap-12
[**2102-3-28**] 05:47AM BLOOD Calcium-8.5 Phos-2.4* Mg-1.7

Brief Hospital Course:
88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.

She was admitted to the Orthopaedic Trauma Service for repair of
an open mid-shaft spiral tibia fracture .  The patient was taken
to the OR and underwent an uncomplicated washout and debridement
of the open fracture, operative treatment of left tibia shaft
fracture with intramedullary nail, and closed treatment of the
left fibula fracture without manipulation.

The patient tolerated the procedure without complications, was
extubated without difficulty and was transferred to the PACU in
stable condition.  Please refer to the operative report for
details of the case.  However while in the PACU she became
hypotensive with a pressor requirement and was transferred to
the ICU post op for management.  She responded well to PRBC
transfusion and to pressor and her BP had improved on arrival to
the ICU. Pressors were turned off at 3 PM on the day of surgery
([**2102-3-24**]) and she remained stable for the remainder of her
hospitalization. During her hospitalization she was also noted
to have a decrease in platelet count, workup revealed that she
was HIT antibody NEGATIVE and her platelet count stabilized and
slowly began to increase.

Post operatively pain was controlled with IV pain medication
with a transition to PO pain meds once tolerating POs.  The
patient tolerated diet advancement without difficulty and made
steady progress with PT, however was found to benefit most from
discharge to rehab.


Weight bearing status: Weight bearing as tolerated in bivalve
cast .

The patient received peri-operative antibiotics as well as
Lovenox for DVT prophylaxis.  The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout.  The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care.  The patient will be continued on chemical DVT
prophylaxis for 4 weeks post-operatively.  All questions were
answered prior to discharge and the patient expressed readiness
for discharge.

The patient's PCP was informed of this admission and the need to
restart coumadin as an outpatient. [**First Name4 (NamePattern1) 501**] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] at the
[**Hospital3 **] associated with the patient's PCP (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]) has been informed of her admission and treatment
course. She can be reached at [**Telephone/Fax (1) 110522**] regarding management
of the patient's coumadin.


Medications on Admission:
*cyanocobalamin (vitamin B-12) 1,000 mcg daily
*aspirin 81 mg Tab Oral
*Boniva 150mg q 30 days
*hydrochlorothiazide 25 daily
*lisinopril 10 daily
*Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Inhalation
2 puffs Aerosol(s) Four times daily
*Prilosec 20 mg q AM
*Remeron 7.5 q HS
*Coumadin 1.25ng x 2d (w,sa); 2.5mg x 5d
*meclizine -- 25 mg PRN vertigo
*folic acid 1mg daily
*Calcium 600 mg q TID
*prednisone 10 mg daily
*methotrexate sodium-not filled since novemember-12.5 mg weekly



Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours).
10. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Syringe
Subcutaneous QPM (once a day (in the evening)) for 4 weeks.
Disp:*28 Syringe* Refills:*0*
11. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]

Discharge Diagnosis:
Left open midshaft spiral tibia fracture

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


Discharge Instructions:
******SIGNS OF INFECTION**********

should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.

-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.

******WEIGHT-BEARING*******

Left lower extremity: Weight bearing as tolerated in bivalve
cast

******MEDICATIONS***********

- Resume your pre-hospital medications.

- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink 8-8oz glasses of water daily and take a stool
softener (colace) to prevent this side effect.

-Medication refills cannot be written after 12 noon on Fridays.

*****ANTICOAGULATION******

- Take Lovenox for DVT prophylaxis for 4 weeks post-operatively.


******FOLLOW-UP**********

Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-3**] days
post-operation for evaluation and staple/suture removal. Call
[**Telephone/Fax (1) 1228**] to schedule appointment upon discharge.

Please follow up with your PCP regarding this admission and any
new medications/refills.
Physical Therapy:
Left lower extremity: Weight bearing as tolerated in bivalve
cast
Treatments Frequency:
Site: bilat arms
Description: ecchymosis over entire arm, weaping serous fluid.
*skin tear to Right upper arm dressed with adaptik and DSD
wrapped in Kerlix**
Care: Kerlix wraps prn

Site: Coccyx
Description: stage 2 pressure ulcer
Care: Mepilex q3days and prn

Site: LLE
Description: ORIF
Care: [**Hospital1 **]-valve cast in place, wound beneath to be dressed with
xeroform, ABD pads and loosely placed ace wrap.

Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**9-3**] days
post-operation for evaluation and staple/suture removal. Call
[**Telephone/Fax (1) 1228**] to schedule appointment upon discharge.

Please follow up with your PCP regarding this admission and the
need to restart coumadin as an outpatient.


Completed by:[**2102-3-28**]
{'Open fracture of shaft of fibula with tibia,Acute posthemorrhagic anemia,Contusion of foot,Overexertion from sudden strenuous movement,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Thrombocytopenia, unspecified,Hypopotassemia,Hypocalcemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Aortic valve disorders,Rheumatoid arthritis,Tobacco use disorder,Long-term (current) use of steroids,Personal history of venous thrombosis and embolism,Pure hypercholesterolemia,Spinal stenosis, unspecified region,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteoporosis, unspecified,Urinary incontinence, unspecified,Intestinal disaccharidase deficiencies and disaccharide malabsorption'}


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: Left open tibial shaft fracture s/p mechanical fall

PRESENT ILLNESS: 88F with aortic insufficiency, COPD, RA on
prednisone/methotrexate, on coumadin for DVT who was admitted at
2 AM on [**3-22**] for an open mid-shaft spiral tibia fracture
sustained after twisting her ankle while getting into bed. The
patient does not recall the exact mechanism of injury but states
that had no head strike and no LOC.

MEDICAL HISTORY: -HTN
-COPD
-Hypercholesterolemia
-Aortic insufficiency
-Rheumatoid arthritis
-TIA
-Thrombophlebitis of LE, on coumadin
-Diverticulosis
-Spinal stenosis
-GERD
-Hiatal hernia
-Acute gastritis
-Osteoporosis
-Urinary incontinence
-Appendectomy
-Cholecystectomy
-L breast biopsy
-Urinary incontinence
-Lactose intolerance

MEDICATION ON ADMISSION: *cyanocobalamin (vitamin B-12) 1,000 mcg daily
*aspirin 81 mg Tab Oral
*Boniva 150mg q 30 days
*hydrochlorothiazide 25 daily
*lisinopril 10 daily
*Combivent 18 mcg-103 mcg/actuation Aerosol Inhaler Inhalation
2 puffs Aerosol(s) Four times daily
*Prilosec 20 mg q AM
*Remeron 7.5 q HS
*Coumadin 1.25ng x 2d (w,sa); 2.5mg x 5d
*meclizine -- 25 mg PRN vertigo
*folic acid 1mg daily
*Calcium 600 mg q TID
*prednisone 10 mg daily
*methotrexate sodium-not filled since novemember-12.5 mg weekly

ALLERGIES: Penicillins / Sulfa(Sulfonamide Antibiotics) / Tetracycline /
Neurontin / IV Dye, Iodine Containing Contrast Media

PHYSICAL EXAM: AVSS, NAD, AOx3
CV: RRR
PULM: Non-labored breathing

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives alone, walks with a walker. Smokes [**11-21**] ppd x10 yrs, no
etoh, illicits. 

### Response:
{'Open fracture of shaft of fibula with tibia,Acute posthemorrhagic anemia,Contusion of foot,Overexertion from sudden strenuous movement,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Other iatrogenic hypotension,Thrombocytopenia, unspecified,Hypopotassemia,Hypocalcemia,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Aortic valve disorders,Rheumatoid arthritis,Tobacco use disorder,Long-term (current) use of steroids,Personal history of venous thrombosis and embolism,Pure hypercholesterolemia,Spinal stenosis, unspecified region,Esophageal reflux,Diaphragmatic hernia without mention of obstruction or gangrene,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteoporosis, unspecified,Urinary incontinence, unspecified,Intestinal disaccharidase deficiencies and disaccharide malabsorption'}
