CHIEF COMPLAINT: hip fracture

PRESENT ILLNESS: 70yo man with ESRD not yet on HD, DM, PVD who initially
presented s/p fall while getting out of bed in setting of
hypoglycemia and poor appetite. He landed on his R hip and
sustained a displaced femoral neck fracture. He was found by his
son on the floor next to his bed, who called EMS. On arrival to
an OSH he was found to have FS 36 and the above fracture and he
was sent to [**Hospital1 18**] for further management. He was recently
treated at an outside hospital from [**Date range (1) 61322**] for a R great toe
cellulitis and was discharged to home on IV antibiotics
(imipenem and zyvox). He was found to have a necrotic R great
toe on arrival. He was medically cleared for the OR and had a
hemiarthroplasty of the R hip, immediate post op period was
complicated by DKA and the patient was sent to the micu, where
he was kept on an insulin drip for one day. Since then he has
had very volatile FS, running between very elevated and quite
low. [**Last Name (un) **] has been following and with their recs the pt's FS
have been stable off D5 for the last 24 hours.
.
[**Hospital 1094**] hospital course has also been complicated by hospital
acquired LLL pneumonia for which he is being treated with
vanco/zosyn, MS changes believed to be due to
narcotics/psychotropic meds, development of a coccygeal
decubitus pressure ulcer, and elevated INR in setting of
coumadin use s/p femoral fracture (avoiding lovenox given CRI).
He has been followed by renal, ID, [**Last Name (un) **], [**Last Name (un) 1106**] surgery and
orthopedic surgery throughout his stay.
.
ROS: pt reports mild pain in his r hip and r toe. no cp, no sob,
no other complaints. eating well.

MEDICAL HISTORY: CRI
DM
PVD with R great toe cellulitis/necrosis
HTN

MEDICATION ON ADMISSION: ASA
lantus 35, HISS
Iron sulfate qday
mag oxide 400mg po qday
sodium bicarb 650po [**Hospital1 **]
norvasc 10 qday
toprol 25 po qday
allopurinol 100 po qday
was on 6wk course of imipenem 250mg [**Hospital1 **], zyvox 600mg [**Hospital1 **]

ALLERGIES: Aleve

PHYSICAL EXAM: 99.1, 155/52, 63, 13, 98% RA, FS 74-123
Gen: confused man, NAD, oriented x 3 with much effort, answers
questions but very circuitously
HEENT: PERRL, OP not injected, MMM, CM II-XII intact
Neck: no JVD, no LAD
Pulm: decreased BS and inspiratory rhonchi at bilateral bases
anteriorly
Cor: rrr, s1s2, no r/g/m
Abd: soft, NT, ND, +bs, no hsm
Ext: R great toe black and necrotic, R hip wound c/d/i, staples
in place, nontender, nonerythematous, trace edema bilaterally,
small 2x2cm coccygeal decub stage II, bilateral PT and DP not
palpable
GU: yellow urine in foley, scrotum erythematous with fungal skin
infection around scrotal skin and inguinal folds

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with son and daughter-in-law, usually I in ADLs; 100+ py
tobacco hx, quit [**2129**] ([**4-12**] ppd x 40y); no etoh or other drugs
Other closed transcervical fracture of neck of femur,Atherosclerosis of native arteries of the extremities with gangrene,Accidental fall from bed,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Arterial embolism and thrombosis of lower extremity,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Drug-induced delirium,Peripheral vascular complications, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to genitourinary device, implant, and graft,Chronic kidney disease, Stage IV (severe),Hypovolemia,Thrombocytopenia, unspecified,Cellulitis and abscess of toe, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Diarrhea,Dermatophytosis of groin and perianal area,Long-term (current) use of insulin,Redundant prepuce and phimosis,Vascular disorders of penis
Fx femur intrcaps NEC-cl,Ath ext ntv art gngrene,Fall from bed,Cellulitis of leg,Acute kidney failure NOS,Pneumonia, organism NOS,Pressure ulcer, low back,Coagulat defect NEC/NOS,Lower extremity embolism,DMII ketoacd uncontrold,Drug-induced delirium,Surg comp-peri vasc syst,Hyp kid NOS w cr kid V,Comp-genitourin dev/grft,Chr kidney dis stage IV,Hypovolemia,Thrombocytopenia NOS,Cellulitis, toe NOS,Adv eff analgesics NEC,Diarrhea,Dermatophytosis of groin,Long-term use of insulin,Redun prepuce & phimosis,Vascular disorder, penis
Admission Date:  [**2147-4-26**]              Discharge Date:   [**2147-5-25**]

Date of Birth:  [**2076-6-19**]             Sex:   M

Service: MEDICINE

Allergies:
Aleve

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
hip fracture

Major Surgical or Invasive Procedure:
R hip ORIF [**2147-4-27**]
Cental line (R IJ, R subclavian dialyisis line)
R PICC line placed [**2147-5-12**]


History of Present Illness:
70yo man with ESRD not yet on HD, DM, PVD who initially
presented s/p fall while getting out of bed in setting of
hypoglycemia and poor appetite. He landed on his R hip and
sustained a displaced femoral neck fracture. He was found by his
son on the floor next to his bed, who called EMS. On arrival to
an OSH he was found to have FS 36 and the above fracture and he
was sent to [**Hospital1 18**] for further management. He was recently
treated at an outside hospital from [**Date range (1) 61322**] for a R great toe
cellulitis and was discharged to home on IV antibiotics
(imipenem and zyvox). He was found to have a necrotic R great
toe on arrival. He was medically cleared for the OR and had a
hemiarthroplasty of the R hip, immediate post op period was
complicated by DKA and the patient was sent to the micu, where
he was kept on an insulin drip for one day. Since then he has
had very volatile FS, running between very elevated and quite
low. [**Last Name (un) **] has been following and with their recs the pt's FS
have been stable off D5 for the last 24 hours.
.
[**Hospital 1094**] hospital course has also been complicated by hospital
acquired LLL pneumonia for which he is being treated with
vanco/zosyn, MS changes believed to be due to
narcotics/psychotropic meds, development of a coccygeal
decubitus pressure ulcer, and elevated INR in setting of
coumadin use s/p femoral fracture (avoiding lovenox given CRI).
He has been followed by renal, ID, [**Last Name (un) **], [**Last Name (un) 1106**] surgery and
orthopedic surgery throughout his stay.
.
ROS: pt reports mild pain in his r hip and r toe. no cp, no sob,
no other complaints. eating well.


Past Medical History:
CRI
DM
PVD with R great toe cellulitis/necrosis
HTN


Social History:
lives with son and daughter-in-law, usually I in ADLs; 100+ py
tobacco hx, quit [**2129**] ([**4-12**] ppd x 40y); no etoh or other drugs

Family History:
NC

Physical Exam:
 99.1, 155/52, 63, 13, 98% RA, FS 74-123
Gen: confused man, NAD, oriented x 3 with much effort, answers
questions but very circuitously
HEENT: PERRL, OP not injected, MMM, CM II-XII intact
Neck: no JVD, no LAD
Pulm: decreased BS and inspiratory rhonchi at bilateral bases
anteriorly
Cor: rrr, s1s2, no r/g/m
Abd: soft, NT, ND, +bs, no hsm
Ext: R great toe black and necrotic, R hip wound c/d/i, staples
in place, nontender, nonerythematous, trace edema bilaterally,
small 2x2cm coccygeal decub stage II, bilateral PT and DP not
palpable
GU: yellow urine in foley, scrotum erythematous with fungal skin
infection around scrotal skin and inguinal folds


Pertinent Results:
Labs:
141 110 56 83 AGap=13
4.6 18 4.7
.
Ca: 7.4 Mg: 2.1 P: 4.8
Other Blood Chemistry:
Vanco: 21.2 (last dose on [**5-3**])
.
....7.6 87
15.3>---<191
...**23.5**
.
PT: 26.6 *PTT: 112.3* INR: 2.7
.
ColorYellow AppearClear SpecGr1.012 pH 5.0 UrobilNeg BiliNeg
LeukNeg BldLg NitrNeg Prot100 Glu100 KetNeg
.
Mg: 2.1
Acetone:Negative
Comments: Detects Acetone + Acetoacetate Not Beta-Hydroxy
Butyrate
_
_
_
_
_
_
_
_
_
________________________________________________________________
FEMUR (AP & LAT) RIGHT  [**2147-4-26**] 1:17 AM
PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS RIGHT
AP PELVIS AND AP AND LATERAL VIEWS OF THE RIGHT FEMUR. There is
a right subcapital/transcervical femoral fracture with superior
displacement of the distal fracture with limb shortening. There
is varus angulation of the fragments. The femoral head
articulates with the acetabulum appropriately. The left femoral
neck appears intact. No fractures are detected involving the
right femur or knee. The soft tissues are unremarkable.
IMPRESSION:
1. Right femoral subcapital/transcervical fracture with
impaction and varus angulation of the distal fragment.
2. Extensive [**Month/Day/Year 1106**] calcifications.
_
_
_
_
_
_
_
_
_
________________________________________________________________

CHEST (PRE-OP AP ONLY)  [**2147-4-26**] 1:23 AM
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs clear. Heart size top normal, exaggerated by low lung
volumes and supine positioning. No pleural effusion or evidence
of central adenopathy. No pneumothorax. Tip of a right-sided
central venous catheter projects over the junction of the
brachiocephalic veins.
_
_
_
_
_
_
_
_
_
________________________________________________________________

CT HEAD W/O CONTRAST  [**2147-4-30**] 11:35 AM
NON-CONTRAST HEAD CT: No priors for comparison. No
hydrocephalus, shift of normally midline structures, hemorrhage,
or infarct is identified. Calcified internal carotid arteries
are noted. No fracture. Retention cyst vs polyp in left
maxillary sinus; other imaged sinuses are clear. There is
cavernous carotid artery calcification.
_
_
_
_
_
_
_
_
________________________________________________________________
CHEST (PA & LAT)
AP AND LATERAL CHEST RADIOGRAPHS:
Dating back to [**2147-4-26**], there has been interval
development of left lower lobe consolidation obscuring the left
hemidiaphragm consistent with pneumonia. Cardiac, mediastinal,
and hilar contours are stable. Right internal jugular catheter
tip is seen within the mid SVC. No evidence of pneumothorax or
pleural effusions. Osseous and soft tissue structures are
unremarkable.
_
_
_
_
_
_
_
_
_
________________________________________________________________
   RADIOLOGY  Final Report

AORTA AND BRANCHES
AORTA AND BRANCHES U/S [**2147-5-8**] 1:15 PM

The abdominal aorta is normal in caliber measuring 2.3 cm in
maximal diameter and showing no focal aneurysmal dilatation.
There is some elevated atherosclerotic plaque in the distal
abdominal aorta and at the iliac bifurcation. These plaques do
not compromise flow, however. The possibility of the plaques
being a source for peripheral emboli cannot be assessed by this
technique. Iliac arteries are normal in caliber bilaterally.
_
_
_
_
_
_
_
_
_
________________________________________________________________
Cardiology Report ECHO Study Date of [**2147-5-10**]

MEASUREMENTS:
Left Ventricle - Ejection Fraction: 60% (nl >=55%)

INTERPRETATION:

Findings:

LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the  RA/RAA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD or PFO by  2D, color Doppler or saline contrast with
maneuvers.

LEFT VENTRICLE: Overall normal LVEF (>55%).

RIGHT VENTRICLE: Normal RV systolic function.

AORTA: No atheroma in aortic arch. Simple atheroma in descending
aorta.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or
vegetations on aortic valve. No AR.

MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral  valve. Physiologic MR (within normal
limits).

TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on  tricuspid valve. Physiologic TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No
vegetation/mass on pulmonic valve.

Conclusions:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers.
2.Overall left ventricular systolic function is probably normal
(LVEF>55%),
however, the probe was not passed beyond the GE junction and
transgastric
views were not obtained.
3.Right ventricular systolic function is normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened. No masses
or vegetations
are seen on the aortic valve. No aortic regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mass or
vegetation is
seen on the mitral valve. Physiologic mitral regurgitation is
seen (within
normal limits).
7. No vegetation/mass is seen on the pulmonic valve.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________

VIDEO OROPHARYNGEAL SWALLOW  [**2147-5-16**] 2:49 PM

OROPHARYNGEAL VIDEO FLUOROSCOPIC STUDY:

Oropharyngeal video fluoroscopic swallowing evaluation was
performed with speech and swallow therapist, and demonstrates
mild oral and pharyngeal dysphasia, mild swallowing delay. Mild
silent aspiration was noted. No significant improvement in mild
aspiration. For further details please refer to speech and
swallow report.
_
_
_
_
_
_
_
_
_
________________________________________________________________

FOOT AP,LAT & OBL BILAT  [**2147-5-17**] 3:26 PM

BILATERAL FEET, SIX VIEWS: No cortical destruction or
irregularity is identified to indicate osteomyelitis. The
mineralization is normal. There are diffuse [**Year/Month/Day 1106**]
calcifications. The joint spaces are preserved. There is a
posterior and plantar calcaneal spur on the left.

IMPRESSION: No radiographic evidence of osteomyelitis.








Brief Hospital Course:
# R great toe  and left [**2-10**] toe necrosis: Likely embolic. TEE,
aorta MRA and lower extremity angiogram did not show any source
of emboli. Pt was on anticoagulation for right hip
orif..completed several weeks of heparin gtt..and currently on
aspirin for prophylaxis. Also started on statin for possiblity
of cholesterol emboli. Xray do not show sign of osteomylelitis.
No signs of active infection.  Followed by vasuclar surgery
while in house who plan for amputation  after discharge at outpt
follow up.
.
# R femoral neck fracture s/p hemiarthroplasty- Repaired on [**4-27**]
- Pt to f/u with Dr. [**Last Name (STitle) 1005**] in ortho clinic 1-2w after
discharge [**Telephone/Fax (1) 1228**].
- WBAT for pt.
- staples removed [**2147-5-11**]
.
# DM/DKA: Initially developed DKA in setting of orthopedic
surgery around [**2147-4-27**]. Treated with insulin drip in the ICU.
Sent to floor with closed gap. Developed DKA again on [**2147-5-1**] in
setting of fever and hospital aquired PNA/ Again treated in teh
ICU with insulin drip. Transferred back to floor on [**5-7**].
GLucose has been stable and lantus dose titrated up as diet
increased. Has been difficult to follow GAP with renal acidosis.
Have been following urine ketones which are negative at the time
of discharge.
.
# CRI: pt with ESRD but not yet on HD. renal following during
hospitalization and pt requiring frequent adjustments to
phosphate binders, lytes, etc. Never required HD despite dye
load from angiogram. Renal care will needs to be continued,
unclear when pt will need hemodialysis.
.
# LLL pneumonia: likely hospital acquired, Treated with 14d
course of zosyn and vanco for broad coverage. afebrile. cultures
negative.
.
# MS change: Confused in the settin gof high INR (up to 13).
Head ct negative. Likely delerium secondray to illness and
medication (narcotics and benzodiazepines). Mental status is now
back to baseline.
.
#Hypotension/Hypoxia/Bradycardia - On[**2147-5-11**], pt was found
unresponsive at 9am. The previous night he had been getting
hydration for renal ppx prior to dye load. Initial assement - RR
5, BP 50/pal, sinus brady at 34. Given 200 mg IV lasix push, 1
amp atropine, and narcan. Pt responed with increased HR and RR.
CT scan done showed no bleed. Likely volume overload, leading to
hypoxia and and bradycardia. Resolved quickly and never
recurred.
# HTN: fairly well controlled at present. continue BB, norvasc,
hydralazine. titrate as tolerated.
.
# diarrhea; c diff negative x 3. continue to follow for
frequency.
.
# coccygeal decubitus ulcer and penile ulcer- continue wound
care as previously. turn q2 hours as tolerated. coccygeal swab +
for pseudomonas which was more likely a colonization rather than
infection. coccygeal ulcer had an overlying fungal infection
that improved with local care.
.
# penile necrosis - secondary to foley trauma from pt pulling on
it in setting of altered mental status.  Seen by urology who
recommend leaving foley in place, securing it tightly to leg,
and local wound care with bacitracin and silvadeine.

# access: PICC placed [**2147-5-12**].
.
#Aspiration risk - pt failed speech and swallow eval. recommend
thin liquids and observation.

Medications on Admission:
ASA
lantus 35, HISS
Iron sulfate qday
mag oxide 400mg po qday
sodium bicarb 650po [**Hospital1 **]
norvasc 10 qday
toprol 25 po qday
allopurinol 100 po qday
was on 6wk course of imipenem 250mg [**Hospital1 **], zyvox 600mg [**Hospital1 **]


Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
 QID (4 times a day): apply to penis.
4. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane  PRN
(as needed).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical  QID
(4 times a day): apply to penis.
10. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
18. Insulin Glargine 100 unit/mL Cartridge Sig: Seven (7) units
Subcutaneous once a day.
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous  DAILY (Daily) as needed.
24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
25. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]

Discharge Diagnosis:
hip fracture
renal failure
peripheral [**Location (un) 1106**] disease
diabetic ketoacidosis
pneumonia


Discharge Condition:
Stable


Discharge Instructions:
Please follow up as directed.

Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2147-6-13**] 11:15
.
Please see the Urology department at the first available
appointment on [**2147-6-7**] 3pm with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10426**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2147-6-6**] 3:00
.
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2147-6-6**] 2:40
.
Please make a follow up appointment with your renal (kidney)
doctor.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

Completed by:[**2147-5-25**]
{'Other closed transcervical fracture of neck of femur,Atherosclerosis of native arteries of the extremities with gangrene,Accidental fall from bed,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Arterial embolism and thrombosis of lower extremity,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Drug-induced delirium,Peripheral vascular complications, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to genitourinary device, implant, and graft,Chronic kidney disease, Stage IV (severe),Hypovolemia,Thrombocytopenia, unspecified,Cellulitis and abscess of toe, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Diarrhea,Dermatophytosis of groin and perianal area,Long-term (current) use of insulin,Redundant prepuce and phimosis,Vascular disorders of penis'}


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: hip fracture

PRESENT ILLNESS: 70yo man with ESRD not yet on HD, DM, PVD who initially
presented s/p fall while getting out of bed in setting of
hypoglycemia and poor appetite. He landed on his R hip and
sustained a displaced femoral neck fracture. He was found by his
son on the floor next to his bed, who called EMS. On arrival to
an OSH he was found to have FS 36 and the above fracture and he
was sent to [**Hospital1 18**] for further management. He was recently
treated at an outside hospital from [**Date range (1) 61322**] for a R great toe
cellulitis and was discharged to home on IV antibiotics
(imipenem and zyvox). He was found to have a necrotic R great
toe on arrival. He was medically cleared for the OR and had a
hemiarthroplasty of the R hip, immediate post op period was
complicated by DKA and the patient was sent to the micu, where
he was kept on an insulin drip for one day. Since then he has
had very volatile FS, running between very elevated and quite
low. [**Last Name (un) **] has been following and with their recs the pt's FS
have been stable off D5 for the last 24 hours.
.
[**Hospital 1094**] hospital course has also been complicated by hospital
acquired LLL pneumonia for which he is being treated with
vanco/zosyn, MS changes believed to be due to
narcotics/psychotropic meds, development of a coccygeal
decubitus pressure ulcer, and elevated INR in setting of
coumadin use s/p femoral fracture (avoiding lovenox given CRI).
He has been followed by renal, ID, [**Last Name (un) **], [**Last Name (un) 1106**] surgery and
orthopedic surgery throughout his stay.
.
ROS: pt reports mild pain in his r hip and r toe. no cp, no sob,
no other complaints. eating well.

MEDICAL HISTORY: CRI
DM
PVD with R great toe cellulitis/necrosis
HTN

MEDICATION ON ADMISSION: ASA
lantus 35, HISS
Iron sulfate qday
mag oxide 400mg po qday
sodium bicarb 650po [**Hospital1 **]
norvasc 10 qday
toprol 25 po qday
allopurinol 100 po qday
was on 6wk course of imipenem 250mg [**Hospital1 **], zyvox 600mg [**Hospital1 **]

ALLERGIES: Aleve

PHYSICAL EXAM: 99.1, 155/52, 63, 13, 98% RA, FS 74-123
Gen: confused man, NAD, oriented x 3 with much effort, answers
questions but very circuitously
HEENT: PERRL, OP not injected, MMM, CM II-XII intact
Neck: no JVD, no LAD
Pulm: decreased BS and inspiratory rhonchi at bilateral bases
anteriorly
Cor: rrr, s1s2, no r/g/m
Abd: soft, NT, ND, +bs, no hsm
Ext: R great toe black and necrotic, R hip wound c/d/i, staples
in place, nontender, nonerythematous, trace edema bilaterally,
small 2x2cm coccygeal decub stage II, bilateral PT and DP not
palpable
GU: yellow urine in foley, scrotum erythematous with fungal skin
infection around scrotal skin and inguinal folds

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with son and daughter-in-law, usually I in ADLs; 100+ py
tobacco hx, quit [**2129**] ([**4-12**] ppd x 40y); no etoh or other drugs 

### Response:
{'Other closed transcervical fracture of neck of femur,Atherosclerosis of native arteries of the extremities with gangrene,Accidental fall from bed,Cellulitis and abscess of leg, except foot,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Pressure ulcer, lower back,Other and unspecified coagulation defects,Arterial embolism and thrombosis of lower extremity,Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Drug-induced delirium,Peripheral vascular complications, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to genitourinary device, implant, and graft,Chronic kidney disease, Stage IV (severe),Hypovolemia,Thrombocytopenia, unspecified,Cellulitis and abscess of toe, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Diarrhea,Dermatophytosis of groin and perianal area,Long-term (current) use of insulin,Redundant prepuce and phimosis,Vascular disorders of penis'}
