CHIEF COMPLAINT: s/p fall with right hip pain and fracture

PRESENT ILLNESS: 73 year old woman with past medical history of IDDM, seizure
disorder and breast cancer who lives alone presenting with
right-sided hip, leg and low back pain after slipping off her
toilet this morning. Patient does not remember any other details
at this time. There were no witnesses, and it is not clear how
long she was down for.
.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and
pain was [**9-19**]. Physical exam showed pain with active and
passive R hip rotation. She was given 1g tylenol, 2mg IV
morphine and 2L NS. Evaluated by ortho. Imaging showed
subcapital femoral neck fx. Guaiac negative, cr 1.8 from b/l of
1.3. K+ 5.8->5.6, EKG notable for new T wave inversions in
V1-V4. A CT abdomen and pelvis showed urinary retention and a
foley catheter was placed. Perceived to have a somewhat altered
mental status although unclear baseline.

MEDICAL HISTORY: Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."

MEDICATION ON ADMISSION: Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12.5 mg weekly
Effexor 150 mg Daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on Admission to MICU:
Vitals: T 96.8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not
name of the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal
pulses bilaterally

FAMILY HISTORY: Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

SOCIAL HISTORY: Social History: Lives alone. Ambulatory at baseline.
- Tobacco: none
- Alcohol: none
- Illicits: none
Other closed transcervical fracture of neck of femur,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Accidental fall from commode,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Rheumatoid arthritis,Other nonspecific abnormal serum enzyme levels,Long-term (current) use of insulin,Unspecified glaucoma,Knee joint replacement,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Congestive heart failure, unspecified,Hyperpotassemia,Nontoxic uninodular goiter,Depressive disorder, not elsewhere classified,Leiomyoma of uterus, unspecified,Personal history of malignant neoplasm of breast
Fx femur intrcaps NEC-cl,Acute kidney failure NOS,Acute necrosis of liver,Fall from commode,Epilep NOS w/o intr epil,DMII wo cmp nt st uncntr,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Rheumatoid arthritis,Abn serum enzy level NEC,Long-term use of insulin,Glaucoma NOS,Joint replaced knee,Adv eff antineoplastic,Obstructive sleep apnea,Mental disor NEC oth dis,Other alter consciousnes,CHF NOS,Hyperpotassemia,Nontox uninodular goiter,Depressive disorder NEC,Uterine leiomyoma NOS,Hx of breast malignancy
Admission Date:  [**2128-2-13**]              Discharge Date:   [**2128-2-19**]

Date of Birth:  [**2054-3-20**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
s/p fall with right hip pain and fracture

Major Surgical or Invasive Procedure:
Open reduction internal fixation right valgus impacted femoral
neck fracture with 7.3 mm screws x3.


History of Present Illness:
73 year old woman with past medical history of IDDM, seizure
disorder and breast cancer who lives alone presenting with
right-sided hip, leg and low back pain after slipping off her
toilet this morning. Patient does not remember any other details
at this time. There were no witnesses, and it is not clear how
long she was down for.
.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and
pain was [**9-19**]. Physical exam showed pain with active and
passive R hip rotation. She was given 1g tylenol, 2mg IV
morphine and 2L NS. Evaluated by ortho. Imaging showed
subcapital femoral neck fx. Guaiac negative, cr 1.8 from b/l of
1.3. K+ 5.8->5.6, EKG notable for new T wave inversions in
V1-V4. A CT abdomen and pelvis showed urinary retention and a
foley catheter was placed. Perceived to have a somewhat altered
mental status although unclear baseline.


Past Medical History:
Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."


Social History:
Social History: Lives alone. Ambulatory at baseline.
- Tobacco: none
- Alcohol: none
- Illicits: none


Family History:
Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

Physical Exam:
PE on Admission to MICU:
Vitals: T 96.8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not
name of the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal
pulses bilaterally


Pertinent Results:
ADMISSION LABS:
[**2128-2-14**] 12:40PM BLOOD WBC-3.1* RBC-3.70* Hgb-11.5* Hct-32.8*
MCV-88 MCH-31.1 MCHC-35.2* RDW-19.1* Plt Ct-66*
[**2128-2-13**] 06:45PM BLOOD Neuts-72.0* Lymphs-20.1 Monos-6.4 Eos-0.9
Baso-0.7
[**2128-2-14**] 01:50AM BLOOD PT-12.9 PTT-25.7 INR(PT)-1.1
[**2128-2-14**] 12:40PM BLOOD Glucose-90 UreaN-47* Creat-1.8* Na-143
K-4.6 Cl-112* HCO3-22 AnGap-14
.
DISCHARGE LABS:
[**2128-2-18**] 06:50AM BLOOD WBC-5.5# RBC-4.50 Hgb-14.1 Hct-41.6
MCV-93 MCH-31.3 MCHC-33.8 RDW-18.7* Plt Ct-222
[**2128-2-18**] 06:50AM BLOOD Glucose-155* UreaN-37* Creat-1.3* Na-138
K-4.9 Cl-108 HCO3-21* AnGap-14
[**2128-2-18**] 06:50AM BLOOD ALT-30 AST-31 LD(LDH)-597* AlkPhos-147*
TotBili-0.5
.
CARDIAC ENZYME TREND:
[**2128-2-13**] 12:00PM BLOOD CK 108 CK-MB-10 MB Indx-9.3*
cTropnT-0.16*
[**2128-2-13**] 06:45PM BLOOD CK 147 CK-MB-13* MB Indx-8.8*
cTropnT-0.22*
[**2128-2-14**] 01:50AM BLOOD CK 119 CK-MB-10 MB Indx-8.4*
cTropnT-0.22*
[**2128-2-16**] 06:37PM BLOOD CK 72  CK-MB-NotDone cTropnT-0.18*
[**2128-2-16**] 11:45PM BLOOD CK 49  CK-MB-NotDone cTropnT-0.16*
.
RADIOLOGY:
R Hip Films: [**2128-2-13**]
FINDINGS: There is a nondisplaced, slightly impacted right
subcapital hip
fracture. No other fractures are identified. Mild degenerative
changes
involving the SI joints and lumbar spine are noted. There is a
normal bowel
gas pattern.
IMPRESSION: Right subcapital hip fracture as described above.
.
CT ABD/PELVIS [**2128-2-13**]
IMPRESSION:
1. Right subcapital hip fracture.
2. Fibroid uterus.
3. Distended bladder with mild left pelvic fullness.
4. Bilateral adrenal gland thickening, left greater than right.
.
CT HEAD [**2128-2-13**]
IMPRESSION: No acute intracranial hemorrhage.
.
CT C-SPINE [**2128-2-13**]
IMPRESSION:
1. No evidence of acute fracture.
2. Multilevel degenerative changes as described above.
3. Lung apices suggestive of edema, inflammatory, or small
airways disease, vs infectious process.
4. 6mm peripherally calcified right thyroid nodule for which
further
evaluation with ultrasound.
.
EKG [**2128-2-13**]
Sinus rhythm. The P-R interval is prolonged. There is a late
transition with Q waves and ST-T wave changes in the anterior
leads consistent with probable prior anterior myocardial
infarction. There are tiny R waves in the inferior leads
consistent with possible prior inferior myocardial infarction.
Compared to the previous tracing ST segment changes are new.
.
CXR [**2128-2-13**]
IMPRESSION: No acute cardiopulmonary process.
.
R HIP FILMS [**2128-2-16**]
FINDINGS: In comparison with study of [**2-13**], views from the
operating suite show placement of three metallic screws across
the previously described fracture of the femur.
.
[**2128-2-16**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is markedly dilated with severe global free wall
hypokinesis. There is abnormal diastolic septal motion/position
consistent with right ventricular volume overload. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: Markedly dilated right ventricle with severe global
hypokinesis. At least moderate pulmonary hypertension. Small
left ventricular cavity size with preserved systolic function.
.
[**2038-2-16**] CAROTID ULTRASOUNDS
IMPRESSION: There is less than 40% stenosis within the internal
carotid
arteries bilaterally.
.
[**2128-2-17**] CXR
FINDINGS: In comparison with the study of [**2-16**], there has been a
substantial decrease in the bilateral opacification, which had
been more prominent on the left and could have represented
either asymmetric pulmonary edema or diffuse aspiration. Some
residual areas of opacification are seen at the right base
laterally and at the left base. These most likely represent
residual aspiration or possible atelectasis.
.
[**2128-2-18**] EKG
Normal sinus rhythm with Q waves in the right precordial leads
consistent with anterior wall myocardial infarction. Q waves in
the inferior leads consistent with inferior myocardial
infarction. Compared to tracing #2 there is no change.


Brief Hospital Course:
73F PMHx of DM, seizure disorder and breast cancer, found down
on her floor with R hip fx s/p fall, admitted to the ICU with
hip fx, ARF, NSTEMI, and hypoxia. Hospital course by problem:

# Elevated Cardiac Enzymes and EKG Changes: Had elevated
troponins in the setting of [**Last Name (un) **] and new TWI both in the setting
of anemia. [**Hospital **] medical regimen included ASA 81mg, statin
80mg daily, and beta blocker. ACE-I was held given recent acute
on chronic renal failure and preserved EF as seen on echo (see
below).
.
# Right Hip Fracture s/p Fall.  Pt was evaluated by orthopedics
who planned for
minimally invasive pinning procedure pending medical clearance,
which was provided by daughter, [**Name (NI) 1785**], as pt was delirious.
Went to OR on [**2128-2-16**], no complications intra-op, but did go back
ot the ICU for overnight monitoring as she had some hypoxia
postoperatively (had received a larga amount of morphine). She
commenced PT POD#1, and was significantly limited by pain, but
this improved by POD#3 (ay of d/c). She did receive narcotics
around the time of PT to aid in progress.  Pain was also managed
with tylenol. She was discharged on lovenox 40mg sQ daily for
DVT ppx, and with orthopedic followup.

# Pancyopenia: Presented with acute on chronic anemia with
baseline in low 30s, as well as thrombocytopenia with nadir
platelets in the 40s, and leukopenia to a nadir of 2.1 Felt
likely [**1-13**] methotrexate use with questionable use of folate
(marrow suppressive process).  She was transfused 3 units in the
ICU and on HD#2 had a stable Hct to 32.8.  DDAVP was given for
low platelets. Her methotrexate was held, she received
supplemental folic acid, and all cell lines recovered to normal
by discharge. She will followup with erh rheumatologist for ?
resumption of methotrexate.

# Acute Kidney Injury: Baseline creatinine = 1.3, but she
presented with creatinine 1.8 -> max of 2.2 in setting of fall.
Normal CKs made rhabdo unlikely. Felt likely [**1-13**] hypoperfusion
and prerenal state.  Pt. was given IVF boluses and Cr decreased
to 1.3 by discharge.

# Transaminitis: Had elevations of ALT, AST and Alk Phos without
elevation in bilis. Unclear etiology, felt [**1-13**] mild ischemic
liver in setting of hypotension. Her methotrexate was also held.
LFTs had entirely normalized by discharge.

# IDDM: well-controlled by A1c.  FS were checked every 4 hours
and she was placed on an insuling sliding scale.  Her lisinopril
was held. On discharge,her metformin was continued, but
lisinopril was still held in setting of recent acute renal
failure.

# Fall: unclear etiology in pt with h/o seizure d/o and multiple
CAD risk factors.
Her cardiac enzymes were followed and Trop was trended from
0.16-->0.22-->0.22, so an MI could be the etiology but this
could also have been a conseqeunce of her fall. Further syncope
workup included monitoring on telemetry without significant
arryhtmia, sending a tegretol level (normal), repeating EKGs
(developed signs of MI), and carotid ultrasounds which were
normal. Head CT and Cspine Ct in ED were negative.

# Hypoxia - pt still had minimal O2 requirement on d/c. Has
known OSA per prior sleep evaluations. Also received many liters
of IVF and 3 units of blood during her hospital course, so ?
some element of hypervolemia, but phsical exam did not support
this. Echo performed this admission revealed preserved EF of
60-65% but markedly dilated RV with severe global free wall
hypokinesis. There was abnormal diastolic septal motion/position
consistent with right ventricular volume overload. There was
moderate pulmonary artery systolic hypertension. This was
thought to possible represent sequelae from her MI. Pulmonary
embolism was on the differential but given her acute on chronic
renal failure, a CT-A was deferred, and the patient was allowed
to autodiurese and recover from the imediate postoperative
period and wean off of narcotics. If persistent, this could be
further worked up as an outpatient.

# RA:  methotrexate was held during admission given pancytopenia
above.

# Depression: dx with mild depression - Effexor therapy was
continued

# Dementia/Delerium: unclear circumstances of diagnosis, per
record patient reporting forgetfulness, psych testing showing
mild attention deficits.  She was continued on Aricept. She did
experience significant delirium during her hospitalization which
had improved by her discharge, but was still present in a waxing
and [**Doctor Last Name 688**] nature but easily treated with reorientation and
discontinuation of foley catheter, telemetry, and hydration. She
does have followup scheduled with her cognitive neurologist.

# FEN:
pt was seen by speech and swallow who recommended:
1. Continue current diet of thin liquids and puree.
2. Pills whole or crushed with puree.
3. 1:1 supervision for all POs.
4. Give POs ONLY when patient is most awake and alert.
5. Nutrition consult.
6. Recommend repeat swallowing evaluation at rehab prior to
upgrading diet.

# Prophylaxis: will be on lovenox 40mg sQ daily until ealry
[**Month (only) 547**] for DVT ppx, also d/c'ed on bowel regimen

# Communication: with patient and daughter [**Name (NI) **] HCP
[**Name (NI) 1785**] [**Name (NI) 1356**]
[**PO Box 103136**]
[**Location (un) 2268**], [**Numeric Identifier 103137**]

Home: [**Telephone/Fax (1) 103138**]
Cell: [**Telephone/Fax (1) 103139**]
Work: [**Telephone/Fax (1) 103140**]

# Code: Full

# Dispo:
To [**Hospital3 **]

Medications on Admission:
Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12.5 mg weekly
Effexor 150 mg Daily


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous DAILY (Daily) for 25 days: LAST DAY OF THERAPY IS
[**2128-3-14**].
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Vitamin D 400 unit Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
13. Metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
14. Percocet 2.5-325 mg Tablet Sig: One (1) Tablet PO every [**5-18**]
hours as needed for pain: HOLD for any CNS or respiratory
depression (RR <12). Can be given prior to physical therapy
sessions.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 537**]- [**Location (un) 538**]

Discharge Diagnosis:
Primary:
- Right valgus impacted femoral neck fracture.
- NSTEMI vs. demand ischemia
- shock liver
- Pancytopenia likely due to methotrexate
- Right heart failure

Secondary:
- Rheumatoid arthritis
- Hypertension
- Depression
- Seizure disorder
- Diabetes mellitus type II
- Obstructive sleep apnea
- Dementia
- H/O breast cancer


Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair


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

You were admitted to the hospital after falling at home. You
were found after being down on the floor for a prolonged time.
As a result of the fall, you suffered a fractured right hip, as
well as low blood pressure which caused major stress to your
heart and liver. Your hip fracture was surgically repaired, and
as you were given IV fluids, the damage to your heart and liver
improved substantially. You will need a course of rehabilitation
and aggressive physical therapy to regain your previous level of
function.
.
We also discovered that the right side of your heart is not
working well, which will need to be worked up further by your
PCP. [**Name10 (NameIs) **] the meantime we did discharge you with some supplemental
oxygen to keep your oxygen levels at a healthy level.
.
Some changes were made to your medications, as follows:
1) Your methotrexate was STOPPED, since it might have been
lowering your blood cell counts when you came to the hospital.
The blood counts revcovered nicely when you were taken off
methotrexate. You can determine when to restart this when you
see Dr. [**Last Name (STitle) 6426**] in followup.
2) Your lipitor was increased to 80mg daily
3) You will be receiving daily injections of lovenox, a blood
thinner, to prevent blood clots after your hip surgery, for the
next 25 days
4) START calcium and vitamin D supplements to help with bone
healing
5) START metoprolol 12.5mg [**Hospital1 **] to protect the heart
6) START a baby aspirin every day to protect the heart

Followup Instructions:
Orthopedics:
Tuesday [**3-2**] at 11:20 with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Location (un) 8661**]
Building, [**Location (un) **])
.
Cognitive Neurology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2128-3-2**] 10:30
.
Primary Care:
Thursday, [**2130-4-9**]:20 with Dr. [**First Name (STitle) **]
.
Rheumatology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 14465**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2128-3-4**] 11:30
{'Other closed transcervical fracture of neck of femur,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Accidental fall from commode,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Rheumatoid arthritis,Other nonspecific abnormal serum enzyme levels,Long-term (current) use of insulin,Unspecified glaucoma,Knee joint replacement,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Congestive heart failure, unspecified,Hyperpotassemia,Nontoxic uninodular goiter,Depressive disorder, not elsewhere classified,Leiomyoma of uterus, unspecified,Personal history of malignant neoplasm of breast'}


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: s/p fall with right hip pain and fracture

PRESENT ILLNESS: 73 year old woman with past medical history of IDDM, seizure
disorder and breast cancer who lives alone presenting with
right-sided hip, leg and low back pain after slipping off her
toilet this morning. Patient does not remember any other details
at this time. There were no witnesses, and it is not clear how
long she was down for.
.
In the ED, the intitial VS t 96.6 hr 109 bp 138/83 rr 15 and
pain was [**9-19**]. Physical exam showed pain with active and
passive R hip rotation. She was given 1g tylenol, 2mg IV
morphine and 2L NS. Evaluated by ortho. Imaging showed
subcapital femoral neck fx. Guaiac negative, cr 1.8 from b/l of
1.3. K+ 5.8->5.6, EKG notable for new T wave inversions in
V1-V4. A CT abdomen and pelvis showed urinary retention and a
foley catheter was placed. Perceived to have a somewhat altered
mental status although unclear baseline.

MEDICAL HISTORY: Seizure disorder (developed [**1-13**] DKA in [**2095**])
breast CA s/p mastectomy with prosthetic reconstruction ([**2107**])
IDDM
RA
HTN
glaucoma
bilat TKRs
.
Of note, neuropsych evaluation in [**2125**] commented that "her
marked attentional impairments raises concerns around her
safety, medication compliance, and other areas of functional
vulnerability."

MEDICATION ON ADMISSION: Lipitor 20 mg daily
Tegretol 200 mg TID
Aricept 10 mg daily
Lisinopril 5 mg daily
Meloxicam 15 mg daily
Metformin 500 mg daily
Methotrexate 12.5 mg weekly
Effexor 150 mg Daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE on Admission to MICU:
Vitals: T 96.8 BP 111/50 P 84 RR 16 O2 99ra
General: Alert, oriented to place, year and ethnicity but not
name of the current president; calm but in visible pain
HEENT: Sclera anicteric, dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Chest: right prosthetic breast
GU: foley
Ext: cold and pale bilaterally with weak but palpable distal
pulses bilaterally

FAMILY HISTORY: Family History: mother died at 47 in surgery (possibly during a
hysterectomy). No information was available to her regarding her
birth father. She has several step siblings. Her daughter is
healthy.

SOCIAL HISTORY: Social History: Lives alone. Ambulatory at baseline.
- Tobacco: none
- Alcohol: none
- Illicits: none 

### Response:
{'Other closed transcervical fracture of neck of femur,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Accidental fall from commode,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Rheumatoid arthritis,Other nonspecific abnormal serum enzyme levels,Long-term (current) use of insulin,Unspecified glaucoma,Knee joint replacement,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Obstructive sleep apnea (adult)(pediatric),Other persistent mental disorders due to conditions classified elsewhere,Other alteration of consciousness,Congestive heart failure, unspecified,Hyperpotassemia,Nontoxic uninodular goiter,Depressive disorder, not elsewhere classified,Leiomyoma of uterus, unspecified,Personal history of malignant neoplasm of breast'}
