CHIEF COMPLAINT: Fall

PRESENT ILLNESS: 88 year old male s/p fall resulting in a left hip fracture
requiring surgical management.

MEDICAL HISTORY: Alzhiemers
Hypertension
Hypercholexterolemia
BPH

MEDICATION ON ADMISSION: OUTPATIENT MEDICATIONS:
1. amlodipine 5mg PO
2. finasteride 5mg PO
3. lovastatin 40mg PO
4. terazosin 2mg PO

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp:96.3 HR:97 BP:138/78 Resp:16 O(2)Sat:94

FAMILY HISTORY: n/a

SOCIAL HISTORY: Nursing home patient, no alcohol, tobacco or drug use
Closed fracture of intertrochanteric section of neck of femur,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Other respiratory complications,Atrial flutter,Hyperosmolality and/or hypernatremia,Unspecified transient mental disorder in conditions classified elsewhere,Unspecified fall,Retention of urine, unspecified,Alzheimer's disease,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)
Intertrochanteric fx-cl,Food/vomit pneumonitis,Nutritional marasmus,Respiratory comp NEC,Atrial flutter,Hyperosmolality,Transient mental dis NOS,Fall NOS,Retention urine NOS,Alzheimer's disease,Hypertension NOS,Pure hypercholesterolem,BPH w/o urinary obs/LUTS
Admission Date:  [**2107-7-19**]              Discharge Date:   [**2107-7-30**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8961**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
[**2107-7-20**]: s/p Open reduction internal fixation, left hip.


History of Present Illness:
88 year old male s/p fall resulting in a left hip fracture
requiring surgical management.

Past Medical History:
Alzhiemers
Hypertension
Hypercholexterolemia
BPH

Social History:
Nursing home patient, no alcohol, tobacco or drug use

Family History:
n/a

Physical Exam:
Temp:96.3 HR:97 BP:138/78 Resp:16 O(2)Sat:94

Constitutional: Awake, agitated
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact
Oropharynx within normal limits
C-collar in place
Chest: Clear to auscultation
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Neuro: Unable to answer basic questions. Moves all
extremities


Pertinent Results:
[**2107-7-19**] 06:00PM   GLUCOSE-134* UREA N-18 CREAT-0.6 SODIUM-144
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-13
[**2107-7-19**] 06:00PM   estGFR-Using this
[**2107-7-19**] 06:00PM   WBC-5.5 RBC-3.44* HGB-10.6* HCT-31.8* MCV-92
MCH-30.8 MCHC-33.4 RDW-14.3
[**2107-7-19**] 06:00PM   NEUTS-69.4 LYMPHS-19.4 MONOS-9.9 EOS-0.6
BASOS-0.8
[**2107-7-19**] 06:00PM   PLT COUNT-177
[**2107-7-19**] 06:00PM   PT-13.2 PTT-21.4* INR(PT)-1.1

Brief Hospital Course:
SUMMARY:  Mr. [**Known lastname **] is an 88 year old gentleman with a past
medical history significant for hyperlipidemia, hypertension,
and dementia admitted for a fall with a left hip fracture on
[**7-19**] s/p ORIF on [**2107-7-20**] with hospital course complicated by
tachycardia, hypotension, and hypoxia.
.
Hip Fracture s/p ORIF: Pt. tolerated the procedure well after
[**7-20**] with no major complications from the surgery. Orthopedic
surgery followed him during his admission and they recommended
weight-bearing activity on the left leg. His dressings on his
left leg were changed twice a day to reduce the risk of
infection to the joint. In addition, they recommended follow-up
in 2 weeks post-operatively.
.
Hypoxia: Post-operatively, the patient had one episode of
aspiration. His O2 saturations were persitently low after this
event and he was unreposnsive to neublizer treatments. He was
transferred to the MICU on [**7-23**] due to persistently low O2
saturations. After transfer to the MICU, the patient was found
to have a bibasilar infiltrates that were concerning for an
aspiration event. He was started on vancomycin and cefepime in
the unit for concern for possible hospital-acquired pneumonia in
addition to his recent aspiration event. Once his O2 saturations
were stable, he was transferred back to the medicine floor. His
antibiotics were changed from Cefepime to Zosyn because this
antibiotic had better anaerobic coverage. He was continued on
the Vancomycin and Zosyn and he remained afebrile during his
time out of the intensive care unit. He should continue
vancomycin (day 7) and zosyn (day 5). for a 10 day course.
.
Tachycardia: Had intermitent atrial flutter in setting of his
recent ORIF and his aspiration pneumonia. He was started on
telemetry when he was transferred to the MICU. We discontinued
his home dose of amlodipine and started AV nodal blockade with
metoprolol 10mg IV q6h in the MICU. His heart rate declined into
the after he was started on IV metoprolol. There were no acute
changes on telemetry after his transfer to the unit. He can be
switched to metoprolol by mouth twice a day once he is able to
tolerate PO intake.
.
Urinary retention: Pt. had distended bladder after he was
transferred from the MICU. He had a bladder scan that showed
greater than 1L in his bladder. Pt. was noted to have hyospadias
on examination and a small urethra. He was maintained on his
home dose of terazosin. A 14 coude catheter was placed with some
difficulty into the urethra and his urine output has been
adequate since the Foley was placed. He should follow-up with
urology as an outpatient.
.
Delirium: Likely multifactorial, with contributing factors
including aspiration pneumonitis/HCAP, recent surgery, hearing
loss, and hospital admission. Geriatrics was consulted and they
recommeded zydis to control his delirium. We started with low
doses of zydis and his medication was adjust so that he takes
Zydis at 10mg qHS and increased to 5mg in the mornings yesterday
and Zydis 2.5mg q6h prn agitation.
.
Nutrition: Was unable to take food by mouth post-operatively d/t
risk of aspiration. Speech and swallow evaluated the patient and
agreed after his aspiration event that it was safer to keep the
patient NPO than to give him food. He was started on PPN on [**7-28**].
Nutrition recommended switching over to TPN until his mental
status improved. A PICC line was placed on [**7-30**] to deliver
antibiotics. The PICC line will also be his main access for
nutrition with TPN.
.
Neck pain: Pt. currently in soft collar. There was concern about
injury to the cervical spine on admission. An MRI was ordered,
but was not completed during the admission because the patient
developed worsening shortness of breath and was sent to the
intensive care unit. Neurosurgery followed the patient and there
were no signs of fracture/misalignment based on CT scan on
admission. They recommended continuing with a soft collar and
having the patient follow-up in 1 to 2 weeks. On CT scan, there
was a large hypodense right thyroid lobe lesion, measuring 3.0 x

1.3 cm. You should see your primary care physician to discuss
this finding further.
.
HTN: Amlodipine was discontinued during hospitalization.
Metoprolol was started for better rate control and some blood
pressure control.
.
BPH: Continued home dose of finasteride and terazosin. A Foley
catheter was placed and continues to drain clear urine.
.
Hyperlipidemia: Continued atorvastatin throughout admission.
.
PPx: Enoxaparin. Will continue for 4 weeks post-operatively from
[**7-19**].
Access: PICC line placed on [**2107-7-30**]
Code: Full


Medications on Admission:
OUTPATIENT MEDICATIONS:
1. amlodipine 5mg PO
2. finasteride 5mg PO
3. lovastatin 40mg PO
4. terazosin 2mg PO


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily).
5. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
7. Calcium Carbonate 200 mg (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. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed for Pain.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
15. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
16. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO Q6H (every 6 hours) as needed for agitation.
20. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QAM (once a day (in the morning)).
21. Metoprolol Tartrate 10 mg IV Q6H
hold for sbp < 100 or HR < 60
22. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours): Please give 1250mg IV
q12hrs.
23. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1)  Intravenous Q8H (every 8 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 8**] Nursing Home - [**Hospital1 8**]

Discharge Diagnosis:
Left hip fracture s/p ORIF
Delirium
Aspiration Pneumonia


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname **],

     You were admitted for hip fracture on [**7-18**]. During
your hospitalization, you had an open reduction internal
fixation of your hip on [**7-20**]. After your surgery,
however, your hospital course was complicated by persistently
low oxygen levels in your blood and low blood pressure. You were
transferred to the medical intensive care unit for further
management and you were found have an aspiration pneumonia. You
were started on two antibiotics known as Vancomycin and Zosyn.
You should complete a full antibiotic course for 14 days. You
are currently on day 8 of Vancomycin and day 6 of Zosyn.
.
You were evaluated by speech and swallow and they believe that
you are at high risk of aspiration when you ingest food.
Therefore, we kept you without food during your hospital
admission. We ordered a nutrition consult and they recommended
starting total parenteral nutrition. Nutrition has made several
recommendations and these recommendations are available for
review on page 1 of the discharge paperwork.
.
In addition, a geriatrics consult was ordered to evaluate your
delirium post-operatively and they made several additions to
your home medication that will help to control the delirium more
effectively. The medication recommended was Zydis and the
dosages can be found on the attached medication list.
.
During your hospitalization, the orthopedic surgeons followed
you post-operatively and they recommended keeping your incision
clean and dry with daily dressings. They also encouraged
physical therapy to work with you in the post-operative period
and you are encouraged to be full weight-bearing on the left
leg.
.
Please follow-up to see your orthopedic surgery in 2 weeks. In
addition, you should also continue to wear a soft collar until
you complete an MRI of your cervical spine as an outpatient.

Followup Instructions:
You should follow up in 2 weeks in the [**Hospital **] clinic with
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this
appointment.


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 8965**]
{"Closed fracture of intertrochanteric section of neck of femur,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Other respiratory complications,Atrial flutter,Hyperosmolality and/or hypernatremia,Unspecified transient mental disorder in conditions classified elsewhere,Unspecified fall,Retention of urine, unspecified,Alzheimer's disease,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)"}


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: 88 year old male s/p fall resulting in a left hip fracture
requiring surgical management.

MEDICAL HISTORY: Alzhiemers
Hypertension
Hypercholexterolemia
BPH

MEDICATION ON ADMISSION: OUTPATIENT MEDICATIONS:
1. amlodipine 5mg PO
2. finasteride 5mg PO
3. lovastatin 40mg PO
4. terazosin 2mg PO

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp:96.3 HR:97 BP:138/78 Resp:16 O(2)Sat:94

FAMILY HISTORY: n/a

SOCIAL HISTORY: Nursing home patient, no alcohol, tobacco or drug use 

### Response:
{"Closed fracture of intertrochanteric section of neck of femur,Pneumonitis due to inhalation of food or vomitus,Nutritional marasmus,Other respiratory complications,Atrial flutter,Hyperosmolality and/or hypernatremia,Unspecified transient mental disorder in conditions classified elsewhere,Unspecified fall,Retention of urine, unspecified,Alzheimer's disease,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS)"}
