CHIEF COMPLAINT: abdominal pain, s/p fall

PRESENT ILLNESS: 82yoF with moderate AS (valve area 1.0-1.2), HTN, AFib NOT on
home Coumadin, Alzheimer's dementia who came to the ED with
abdominal pain, s/p unwitnessed fall, unable to ambulate,
vomiting. On presentation, she was hypotensive, hypoxic, and had
bright red blood in her urine. She was found to have
extraperitoneal ruptured bladder and bilateral non-displaced
pubic rami fx's (R inferior and L superior).
.
She was seen by Urology and Surgery on admission for evaluation
of ruptured bladder as well as pelvic fractures. Surgical
intervention was not indicated for either problem. [**Name (NI) 8389**] placed
for decompression.
.
Regarding hypotension/hypoxia, she was given IVF resuscitation
for hypotension and presumably became volume overloaded in the
setting of AS. She then developed hypoxia, initially with poor
sats on facemask. She was not intubated. CXR was notable for RLL
collapse presumed due to mucus plug as well as b/l pleural
effusions secondary to volume overload. She was initially
diuresed with a Lasix gtt with suboptimal effect, transitioned
to Lasix boluses (20mg IV) with good effect (last dose IV dose
was at 8:30am [**2188-7-5**]). At the time of transfer to medicine, she
was 2.5L negative through her LOS and had O2 sats of 94-95% on
4-5L O2.
.
On HD2 she flipped into AFib. It was thought that pulm edema
pushed her back in AFib, so she was bolused and started on po
amiodarone. Flipped back into Afib with RVR twice in SICU, each
time she was bolused with 150 IV Amio and transitioned back into
NS. At time of transfer to medicine was she was 2 days into 5
days of 400mg po amiodarone TID with PO diltiazem 45mg PO QID
per cards recs.
.
There was concern for initial concern for HAP due to initial
CXR. Received Cipro/Cefepime/Vanco for several days which were
stopped on [**7-6**] as probability of infection low. Patient has
been afebrile since admission. Chronic leukocytosis in 20s
thought secondary to underlying PMR and chronic steroid use.
Urine grew pseudomonas in her urine and got 1 dose of
ceftriaxone.
.
She received 1u PRBC's for Hct 35 because her baseline was felt
to be 40's.
.
There was concern about her pain control and concern for
splinting, so had an epidural catheter placed for pain control,
and pain service was following, using Dilaudid and Bupivicaine.
.
She had an NG in for feeding that was removed as she improved,
removed the day of transfer to medicine. PT has been consulted,
needs two person assist, has been OOB to chair qday.  Pain
Service following. Epidural catheter removed prior to transfer
to medicine.
.
Vitals at time of transfer: 98.2 137/55 76 16 93% face tent, 96%
on 3L NC. Per reports, no need further diuresis as patient is
-2.5L through LOS
.
On the medicine floor, pt had no complaints. Saturating well on
RA. Pt denies f/c/ns, difficulty breathing, CP, palpitations,
n/v, abd pain.

MEDICAL HISTORY: Hypertension
Hypercholesterolemia
Aortic stenosis
Dementia- due to Alzheimer's and possible contribution of brain
small-vessel ischemic disease
Depression
Gastrointestinal bleeding
Diverticulosis
Osteopenia
Basal cell carcinoma
Squamous cell carcinoma
Flash pulmonary edema from Takotsubo cardiomyopathy [**2157**],
  catheterization at that time showed no evidence of CAD

MEDICATION ON ADMISSION: -Escitalopram 20 mg
-hydrochlorothiazide 25 mg,
-Fosamax 35mg qSat
-Simvastatin 40 mg Tablet
-Calcium Carbonate 500 mg [**Hospital1 **]
-Tylenol
-Cholecalciferol 400 unit PO BID
-Multivitamin
-Aspirin 325 mg
-Potassium Chloride 20 mEq qMon-Wed-Fri-Sat
-DILT-XR 360mg qhs
-Iron 325 mg
-Colace 100 mg Daily
-Prednisone 11 mg Daily
-Omeprazole 20mg Daily

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 94.7  142/62   96  16 92%RA
Gen: Alert, oriented to place, person, NAD, baseline dementia
HEENT: anicetric sclera, MMM
Neck: Supple, no LAD
CV: RRR, 3/6 systolic murmur radiating to carotid, nl s1,s2, no
peripheral edema
Resp: scant crackles b/l, decreased bs at bases, good aeration
GI: soft, NT, ND, +BS, no guarding, no rebound
Ext: warm, well perfused, several eccyhmosis, no cyanosis
Skin: several eccyhmosis
Neuro: no focal deficits

FAMILY HISTORY: Notable for heart disease, stroke, hypertension, diabetes, skin
cancer, renal cancer.

SOCIAL HISTORY: Born and raised in [**Location (un) 86**]. Has a graduate degree, taught in a
business school for many years, and worked as a librarian.
Widowed with eleven living children. Lives with one of her
daughters. Healthcare proxy is her daughter [**Name (NI) **] [**Name (NI) **]
([**Telephone/Fax (1) 33525**]). Requires assistance for dressing, bathing,
grooming and cooking. Able to participate in activities around
the house, including laundry. Until recently, was able to walk a
couple of miles per day. Mental status is at her baseline
according to her PCP. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] heavy smoker and stopped in [**2161**].
Drinks at only social events.
Closed fracture of pubis,Acute diastolic heart failure,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Pulmonary collapse,Unspecified fall,Aortic valve disorders,Atrial fibrillation,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Polymyalgia rheumatica,Hypoxemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified
Fracture of pubis-closed,Ac diastolic hrt failure,Bladder/urethra inj-clos,Acute kidney failure NOS,Urin tract infection NOS,Pulmonary collapse,Fall NOS,Aortic valve disorder,Atrial fibrillation,Hypertension NOS,Chr airway obstruct NEC,Alzheimer's disease,Dementia w/o behav dist,Polymyalgia rheumatica,Hypoxemia,Pseudomonas infect NOS,Thrombocytopenia NOS
Admission Date:  [**2188-6-29**]              Discharge Date:   [**2188-7-11**]

Date of Birth:  [**2105-8-24**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
abdominal pain, s/p fall

Major Surgical or Invasive Procedure:
none
patient will be d/c with foley in place and urology f/u


History of Present Illness:
82yoF with moderate AS (valve area 1.0-1.2), HTN, AFib NOT on
home Coumadin, Alzheimer's dementia who came to the ED with
abdominal pain, s/p unwitnessed fall, unable to ambulate,
vomiting. On presentation, she was hypotensive, hypoxic, and had
bright red blood in her urine. She was found to have
extraperitoneal ruptured bladder and bilateral non-displaced
pubic rami fx's (R inferior and L superior).
.
She was seen by Urology and Surgery on admission for evaluation
of ruptured bladder as well as pelvic fractures. Surgical
intervention was not indicated for either problem. [**Name (NI) 8389**] placed
for decompression.
.
Regarding hypotension/hypoxia, she was given IVF resuscitation
for hypotension and presumably became volume overloaded in the
setting of AS. She then developed hypoxia, initially with poor
sats on facemask. She was not intubated. CXR was notable for RLL
collapse presumed due to mucus plug as well as b/l pleural
effusions secondary to volume overload. She was initially
diuresed with a Lasix gtt with suboptimal effect, transitioned
to Lasix boluses (20mg IV) with good effect (last dose IV dose
was at 8:30am [**2188-7-5**]). At the time of transfer to medicine, she
was 2.5L negative through her LOS and had O2 sats of 94-95% on
4-5L O2.
.
On HD2 she flipped into AFib. It was thought that pulm edema
pushed her back in AFib, so she was bolused and started on po
amiodarone. Flipped back into Afib with RVR twice in SICU, each
time she was bolused with 150 IV Amio and transitioned back into
NS. At time of transfer to medicine was she was 2 days into 5
days of 400mg po amiodarone TID with PO diltiazem 45mg PO QID
per cards recs.
.
There was concern for initial concern for HAP due to initial
CXR. Received Cipro/Cefepime/Vanco for several days which were
stopped on [**7-6**] as probability of infection low. Patient has
been afebrile since admission. Chronic leukocytosis in 20s
thought secondary to underlying PMR and chronic steroid use.
Urine grew pseudomonas in her urine and got 1 dose of
ceftriaxone.
.
She received 1u PRBC's for Hct 35 because her baseline was felt
to be 40's.
.
There was concern about her pain control and concern for
splinting, so had an epidural catheter placed for pain control,
and pain service was following, using Dilaudid and Bupivicaine.
.
She had an NG in for feeding that was removed as she improved,
removed the day of transfer to medicine. PT has been consulted,
needs two person assist, has been OOB to chair qday.  Pain
Service following. Epidural catheter removed prior to transfer
to medicine.
.
Vitals at time of transfer: 98.2 137/55 76 16 93% face tent, 96%
on 3L NC. Per reports, no need further diuresis as patient is
-2.5L through LOS
.
On the medicine floor, pt had no complaints. Saturating well on
RA. Pt denies f/c/ns, difficulty breathing, CP, palpitations,
n/v, abd pain.

Past Medical History:
Hypertension
Hypercholesterolemia
Aortic stenosis
Dementia- due to Alzheimer's and possible contribution of brain
small-vessel ischemic disease
Depression
Gastrointestinal bleeding
Diverticulosis
Osteopenia
Basal cell carcinoma
Squamous cell carcinoma
Flash pulmonary edema from Takotsubo cardiomyopathy [**2157**],
  catheterization at that time showed no evidence of CAD

Social History:
Born and raised in [**Location (un) 86**]. Has a graduate degree, taught in a
business school for many years, and worked as a librarian.
Widowed with eleven living children. Lives with one of her
daughters. Healthcare proxy is her daughter [**Name (NI) **] [**Name (NI) **]
([**Telephone/Fax (1) 33525**]). Requires assistance for dressing, bathing,
grooming and cooking. Able to participate in activities around
the house, including laundry. Until recently, was able to walk a
couple of miles per day. Mental status is at her baseline
according to her PCP. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] heavy smoker and stopped in [**2161**].
Drinks at only social events.


Family History:
Notable for heart disease, stroke, hypertension, diabetes, skin
cancer, renal cancer.


Physical Exam:
VS: 94.7  142/62   96  16 92%RA
Gen: Alert, oriented to place, person, NAD, baseline dementia
HEENT: anicetric sclera, MMM
Neck: Supple, no LAD
CV: RRR, 3/6 systolic murmur radiating to carotid, nl s1,s2, no
peripheral edema
Resp: scant crackles b/l, decreased bs at bases, good aeration
GI: soft, NT, ND, +BS, no guarding, no rebound
Ext: warm, well perfused, several eccyhmosis, no cyanosis
Skin: several eccyhmosis
Neuro: no focal deficits

Pertinent Results:
Admission Labs:

[**2188-6-29**] 06:50AM BLOOD WBC-18.3* RBC-4.72 Hgb-13.6 Hct-40.6
MCV-86 MCH-28.7 MCHC-33.4 RDW-14.7 Plt Ct-260
[**2188-6-29**] 06:50AM BLOOD Neuts-51 Bands-5 Lymphs-42 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2188-6-29**] 06:50AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2188-6-29**] 06:50AM BLOOD Plt Smr-NORMAL Plt Ct-260
[**2188-6-29**] 06:50AM BLOOD PT-11.6 PTT-20.0* INR(PT)-1.0
[**2188-6-29**] 06:50AM BLOOD Glucose-115* UreaN-47* Creat-1.7* Na-141
K-2.9* Cl-99 HCO3-26 AnGap-19
[**2188-6-29**] 06:50AM BLOOD cTropnT-<0.01
[**2188-6-29**] 12:48PM BLOOD Calcium-7.6* Phos-3.3 Mg-1.3*
[**2188-6-29**] 01:04PM BLOOD Type-ART pO2-214* pCO2-45 pH-7.30*
calTCO2-23 Base XS--3 Intubat-NOT INTUBA

Admission CXR: 1. Left costophrenic angle blunting likely
represents consolidation or effusion.
2. No evidence of rib fractures; if clinical concern for rib
fracture,
dedicated rib series is recommended.

CT CAP [**2188-6-29**]: Extraperitoneal bladder rupture.
No evidence of solid organ injury. No evidence of active
extravasation however limited by presence of extraluminal
contrast from prior cystogram.
Right inferior and left superior pubic rami fractures with
minimal
displacement and small hematoma. Minimal mesenteric stranding in
the right abdomen can be seen in a setting of blunt trauma, CT
is not sensitive in delineation of bowel injury.

CT head [**2188-6-29**]: No acute intracranial process

[**6-29**] UCx with pan sensitive Pseudomonas 10-100k and 10-100k Strep
bovis (presumptive)

Echo [**2188-7-1**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to moderate ([**12-29**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.

Cystogram [**2188-7-9**]:  Persistent small anterolateral bladder leak,
correlating appropriately with the site of extraperitoneal
bladder rupture demonstrated on CT from [**2188-6-29**].

Discharge Labs:
[**2188-7-11**] 06:30AM BLOOD WBC-23.3* RBC-3.98* Hgb-11.4* Hct-34.0*
MCV-85 MCH-28.7 MCHC-33.6 RDW-15.0 Plt Ct-846*
[**2188-7-11**] 06:30AM BLOOD Plt Ct-846*
[**2188-7-11**] 06:30AM BLOOD Glucose-110* UreaN-35* Creat-0.8 Na-139
K-3.9 Cl-104 HCO3-24 AnGap-15
[**2188-7-11**] 06:30AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.1

Brief Hospital Course:
ED Course: Patient presented to ED and after foley catheter
placement bright red blood was drained from the bladder.  The
patient required IVF resuscitation for hypotension.  Imaging was
performed. CT Torso showed extraperitoneal bladder rupture, as
well as R Inf and L Sup Pubic rami fx
Urology and orthopedic surgery were consulted. Orthopedic
surgery recommended non-operative managment of the superior
pubic rami fracture and weight bearing as tolerated. Urology
recommended conservative management of the bladder injury with a
repeat cystogram at HD 10. The patient was admitted to the SICU
given her co-morbidities most notably her history of aortic
stenosis and cardiomyopathy.
.
SICU Events:
[**2188-7-2**] Low thoracic epidural placed for pain management,
bupivicaine 0.05% w/ 10mcg hydromorphone
[**2188-7-1**] TTE completed with mild-mod MR, severe AS, EF 65%.

SICU Course by systems:
Neurologic: alert,arousable, oriented to person. Known history
of alzheimer's dementia with sundowning overnight. Pain
controlled epidural, no boluses; no ortho intervention for now,
weight bearing as tolerated. Epidural for pain control while in
ICU.
Cardiovascular: Started patient on amiodarone for a fib; had
been in sinus but went back into a fib with rate in 120s on [**7-3**]
pm. On [**7-4**] gave repeat amio bolus and increased dose to 400mg
TID. Decreased dilt to 45mg QID. Lasix 20mg x 2 for fluid
mobilization for goal UOP 1L. Started ASA per cards.
Pulmonary: Pt with fluid overload and ? hospital aquire PNA-now
off abx. Pt with significant improvement with O2 requirements.
Patient was gently diuresed ~500 cc negative per day as a goal.
PT/OOB to chair while in ICU.
Gastrointestinal / Abdomen: extraperitoneal bladder rupture;
stable with foley catheter in place. Urology following.
Cystogram planned for HD 10
Nutrition: Patient received TF via NGT. After the patient was
tolerating clears around her feeding tube her tube was removed
and her diet was advanced.
Renal: foley decompression of bladder as bladder injury
non-operative; Continued with lasix bolus goal -500cc/24h. Cr
stable even with diuresis.
Hematology: Hct stable, elevated wbc stable (chronic issue)
Infectious disease: CXR improved and clinical pulmonary function
improved so abx were discontinued. UA positive for PSEUDOMONAS
AERUGINOSA was treated with 3d abx
Endocrine: no issues ISS BG>150.
.
Given that there were no active surgical issues and the patient
significant medical co-morbidities when the patient was stable
from floor transfer she was transferred to the medical service
to continue managing her.  She was planned for a cystogram on HD
10.
.
Medicine course:
1) Hypoxia/SOB: Likely multifactorial (atelectasis, collapse of
RLL [**1-29**] mucus plug: resolved) however primary etiology likely
CHF exacerbation/volume overload after aggressive fluid
rescusitation for hypotension in the midst of trauma evaluation
in ED. CXR's with initial L costophrenic angle blunting later
called as possible epicardial fat pad; however through her
course also then developed R small pleural effusion--small
pleural effusions not likely source of hypoxia but more likely
evidence of volume overload in presence of vascular engorgement.
AS and AFib with resultant loss of atrial kick are likely
etiologies for volume accumulation in her lungs. She was
diuresed with IV Lasix, and then started on 20mg po daily. LOS
negative 3-4L. She initially required supplemental O2, but at
time of d/c has sats of 94-95% on RA. Due to her Hx of COPD, she
was started on Xopenex nebs, and a fluticasone inhaler was
added. Wheezy lung sounds improved. Daily weights and Is&Os were
monitored throughout her hospital course. She will benefit from
chest pt and getting up out of bed as much as possible during
her rehabilitation to mobilize fluids and prevent atelectasis.
Given that her PO intake has been poor she has not required
further lasix and will be discharged without a diuretic. If her
PO intake increases and she begins to show signs of volume
overload she may need to have some PO lasix again.
.
2) AF with RVR: Rate controlled with amiodarone and diltiazem in
the SICU, not on coumadin secondary to PMR and h/o of frequent
falls btu was on ASA 325mg daily. As noted in SICU course,
cardiology was consulted, and patient was amiodorone loaded with
5 days of 400mg TID. At time of d/c she was on day [**3-2**] of 400mg
[**Hospital1 **]. Starting [**7-16**], she will be on 400mg daily. She will follow
up with cardiology as an outpatient. Cardiology also recommended
a full ASA daily. Diltiazem 45mg QID was changed to extended
release form 180mg daily with good BP and HR control for several
days prior to discharge.
.
3) Extraperitoneal bladder rupture: Per urology recs repeat
cystogram performed [**2188-7-9**], which still showed some leakage of
dye. Urology recommend keeping foley in place and getting
another cystogram in one week. Urology will see her and
determine if foley can be d/c after the repeat study.
.
6) Pelvic fractures: Non-operative. Patient continued on Tylenol
1g q8 hrs and oxycodone 5mg PRN pain. She will follow with ortho
as an outpatient. Her pain was well-controlled on this regimen.
She should continue to work with PT to improve functional
status.
.
7) UTI: UCx in SICU showed pseudomonas but patient only recevied
3 days of broad spectrum cephalosporin (they were treating HCAP
not a UTI at the time the cultures were not back). A repeat
urine Cx also grew pan-sensitive Pseudomonas, however, so the
patient was started on Cipro 500mg [**Hospital1 **]. She will get a 14 day
course as outlined in the page one as with foley in place this
is a complicated UTI.
.
8) PMR: Seen by Rheumatology as outpatient. Continue prednisone
10mg daily.
.
9) Chronic Leukocytosis: per old notes from hematology here this
is felt secondary to underlying PMR. WBC count did rise from
baseline of about 20 to 29, but  WBCs trended downward when
Cipro was started for UTI.  Her baseline white count is in the
low-20s range.
.
10) Code: DNR/DNI confirmed with family. Palliative care
consulted at family's request.  Family is interested in pursuing
hospice care if patient does not improve with rehab and may wish
to discuss this more with our palliative care team here as well
as any resources available through the rehab facility.
.
11) Thrombocytopenia: The patient is noted to have platelets
from 600-900 during this hospital stay with previous workup from
hematology (including JAK mutation) negative for other causes
and thought [**1-29**] her PMR. Patient was asymptomatic and platelet
count relatively stable and at baseline throughout her hospital
stay.


Medications on Admission:
-Escitalopram 20 mg
-hydrochlorothiazide 25 mg,
-Fosamax 35mg qSat
-Simvastatin 40 mg Tablet
-Calcium Carbonate 500 mg [**Hospital1 **]
-Tylenol
-Cholecalciferol 400 unit PO BID
-Multivitamin
-Aspirin 325 mg
-Potassium Chloride 20 mEq qMon-Wed-Fri-Sat
-DILT-XR 360mg qhs
-Iron 325 mg
-Colace 100 mg Daily
-Prednisone 11 mg Daily
-Omeprazole 20mg Daily

Discharge Medications:
1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 9 doses: Take 2 times per day until [**7-16**].
Disp:*9 Tablet(s)* Refills:*0*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days: Please finish all of this
medicine. .
Disp:*23 Tablet(s)* Refills:*0*
8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
9. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
11. cystogram
Urology would like you to have a cystogram about 1 week after
discharge so they can decide whether or not it is sfae to remove
the unine catheder.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
16. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
17. Iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once
a day.


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
pelvic fracture
bladder rupture
aortic stenosis
atrial fibrilation
diastolic CHF (acute)


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


Discharge Instructions:
You were admitted to the hospital after you had a fall. The fall
broke your pelvis and damaged your bladder. You did not need
surgery, but the surgeons took care of you in the surgery
intensive care unit (SICU). Your injuries were getting better,
but you were having some trouble breathing, so you were
transferred to the medical floor. We gave you diuretics to help
get rid of extra fluid and inhalers to help open up your lungs.
We also started you on a medicine (amiodarone) for an irregular
heartbeat. You were also found to have a urinary tract infection
(UTI), for which you are receiving antibiotics.

We made the following changes to your medicines:

1) Take Ciprofloxacin 500mg 2xs/day until Tuesday, [**7-22**]
2) Take amiodorone 400 mg 2xs/day until Sunday, [**7-13**]. Then,
start taking it only once a day. When you see your cardiologist,
he may adjust the dose.
3) STOP taking 2 pills of Diltiazem extended release 180mg and
START taking only ONE of these pills daily.
4) Stop taking hydrochlorothiazide (HCTZ).
5) Start using a fluticasone inhaler, 2 puffs daily
6) Start using an albuterol inhaler, 1-2 puffs every 6 hours as
needed for shortness of breath or wheezing
7) Take Tylenol (acetaminophen) 500mg 1 tablets every 8 hours
for pain.
8) You may take oxycodone 5mg every 6 hours as needed for pain
that is not relieved by Tylenol. You will have a limited number
of thses pills, so try to use them sparingly.
9) Continue Alendronate 35 mg 1 tablet weekly. Take this
medication while sitting upright in AM. Do not eat for 30 min
after taking this medicine.
10) Start 325mg Aspirin daily

Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2188-7-24**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: ORTHOPEDICS
When: THURSDAY [**2188-7-17**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Last Name (LF) **],[**Name8 (MD) **] MD
Location: [**Hospital 33526**] Hospital
Address: [**Street Address(2) 33527**], [**Apartment Address(1) 33528**], [**Location (un) 538**]
Phone: [**Telephone/Fax (1) 33529**]
Appointment: Monday, [**7-21**], 8AM

Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2188-7-16**] at 8:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33530**], MD. UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{"Closed fracture of pubis,Acute diastolic heart failure,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Pulmonary collapse,Unspecified fall,Aortic valve disorders,Atrial fibrillation,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Polymyalgia rheumatica,Hypoxemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified"}


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: abdominal pain, s/p fall

PRESENT ILLNESS: 82yoF with moderate AS (valve area 1.0-1.2), HTN, AFib NOT on
home Coumadin, Alzheimer's dementia who came to the ED with
abdominal pain, s/p unwitnessed fall, unable to ambulate,
vomiting. On presentation, she was hypotensive, hypoxic, and had
bright red blood in her urine. She was found to have
extraperitoneal ruptured bladder and bilateral non-displaced
pubic rami fx's (R inferior and L superior).
.
She was seen by Urology and Surgery on admission for evaluation
of ruptured bladder as well as pelvic fractures. Surgical
intervention was not indicated for either problem. [**Name (NI) 8389**] placed
for decompression.
.
Regarding hypotension/hypoxia, she was given IVF resuscitation
for hypotension and presumably became volume overloaded in the
setting of AS. She then developed hypoxia, initially with poor
sats on facemask. She was not intubated. CXR was notable for RLL
collapse presumed due to mucus plug as well as b/l pleural
effusions secondary to volume overload. She was initially
diuresed with a Lasix gtt with suboptimal effect, transitioned
to Lasix boluses (20mg IV) with good effect (last dose IV dose
was at 8:30am [**2188-7-5**]). At the time of transfer to medicine, she
was 2.5L negative through her LOS and had O2 sats of 94-95% on
4-5L O2.
.
On HD2 she flipped into AFib. It was thought that pulm edema
pushed her back in AFib, so she was bolused and started on po
amiodarone. Flipped back into Afib with RVR twice in SICU, each
time she was bolused with 150 IV Amio and transitioned back into
NS. At time of transfer to medicine was she was 2 days into 5
days of 400mg po amiodarone TID with PO diltiazem 45mg PO QID
per cards recs.
.
There was concern for initial concern for HAP due to initial
CXR. Received Cipro/Cefepime/Vanco for several days which were
stopped on [**7-6**] as probability of infection low. Patient has
been afebrile since admission. Chronic leukocytosis in 20s
thought secondary to underlying PMR and chronic steroid use.
Urine grew pseudomonas in her urine and got 1 dose of
ceftriaxone.
.
She received 1u PRBC's for Hct 35 because her baseline was felt
to be 40's.
.
There was concern about her pain control and concern for
splinting, so had an epidural catheter placed for pain control,
and pain service was following, using Dilaudid and Bupivicaine.
.
She had an NG in for feeding that was removed as she improved,
removed the day of transfer to medicine. PT has been consulted,
needs two person assist, has been OOB to chair qday.  Pain
Service following. Epidural catheter removed prior to transfer
to medicine.
.
Vitals at time of transfer: 98.2 137/55 76 16 93% face tent, 96%
on 3L NC. Per reports, no need further diuresis as patient is
-2.5L through LOS
.
On the medicine floor, pt had no complaints. Saturating well on
RA. Pt denies f/c/ns, difficulty breathing, CP, palpitations,
n/v, abd pain.

MEDICAL HISTORY: Hypertension
Hypercholesterolemia
Aortic stenosis
Dementia- due to Alzheimer's and possible contribution of brain
small-vessel ischemic disease
Depression
Gastrointestinal bleeding
Diverticulosis
Osteopenia
Basal cell carcinoma
Squamous cell carcinoma
Flash pulmonary edema from Takotsubo cardiomyopathy [**2157**],
  catheterization at that time showed no evidence of CAD

MEDICATION ON ADMISSION: -Escitalopram 20 mg
-hydrochlorothiazide 25 mg,
-Fosamax 35mg qSat
-Simvastatin 40 mg Tablet
-Calcium Carbonate 500 mg [**Hospital1 **]
-Tylenol
-Cholecalciferol 400 unit PO BID
-Multivitamin
-Aspirin 325 mg
-Potassium Chloride 20 mEq qMon-Wed-Fri-Sat
-DILT-XR 360mg qhs
-Iron 325 mg
-Colace 100 mg Daily
-Prednisone 11 mg Daily
-Omeprazole 20mg Daily

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: 94.7  142/62   96  16 92%RA
Gen: Alert, oriented to place, person, NAD, baseline dementia
HEENT: anicetric sclera, MMM
Neck: Supple, no LAD
CV: RRR, 3/6 systolic murmur radiating to carotid, nl s1,s2, no
peripheral edema
Resp: scant crackles b/l, decreased bs at bases, good aeration
GI: soft, NT, ND, +BS, no guarding, no rebound
Ext: warm, well perfused, several eccyhmosis, no cyanosis
Skin: several eccyhmosis
Neuro: no focal deficits

FAMILY HISTORY: Notable for heart disease, stroke, hypertension, diabetes, skin
cancer, renal cancer.

SOCIAL HISTORY: Born and raised in [**Location (un) 86**]. Has a graduate degree, taught in a
business school for many years, and worked as a librarian.
Widowed with eleven living children. Lives with one of her
daughters. Healthcare proxy is her daughter [**Name (NI) **] [**Name (NI) **]
([**Telephone/Fax (1) 33525**]). Requires assistance for dressing, bathing,
grooming and cooking. Able to participate in activities around
the house, including laundry. Until recently, was able to walk a
couple of miles per day. Mental status is at her baseline
according to her PCP. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] heavy smoker and stopped in [**2161**].
Drinks at only social events. 

### Response:
{"Closed fracture of pubis,Acute diastolic heart failure,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Pulmonary collapse,Unspecified fall,Aortic valve disorders,Atrial fibrillation,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Polymyalgia rheumatica,Hypoxemia,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Thrombocytopenia, unspecified"}
