CHIEF COMPLAINT: Femur fracture s/p fall

PRESENT ILLNESS: 86 year-old male who presented to the ED s/p mechanical fall
with left hip Fx. Was at his daughters house walking from
bathroom and fell as he walked through the door. Landed on left
Hip. No LOC, no CP , No SOB. + Headstrike against the floor.
Underwent uncomplciated ORIF on [**12-23**]. Extubated in PACU without
complciation. While on floor, found to be in respiratory
distress with SaO2 85% on NRB. ABG done showed 7.09/94/91 with a
lactate of 1.8. He was intubated and transferred to MICU for
management of hypercarbic respiratory failure. He was
tachycardic and had a negative CTA on [**12-24**]. He steadily
improved with normal ABGs by MICU day #1 and was extubated on
[**12-25**] with room air O2 sats 95%. The patient has fluctuating MS
and sundowns frequently at night. He does not report pain but,
according to his family, this is easily assessed by watching his
face. He has been covered with very small doses of Dilauded
(0.25mg) which, according to the patient and his family, has
well controlled his pain. He is being transferred to the floor
for further inpatient medical care.

MEDICAL HISTORY: R TKR in [**2117**]
L TKR in [**2127-4-27**] (c/b post-op confusion and AF-RVR)
[**11-30**] to OR for L hip repair
CAD s/p CABG times two with sternal ostia as a complication.
PM
Right inguinal hernia repair
Pilonidal cyst I&D.
Parkinson's with [**Last Name (un) 309**] Body Dementia c/b Visual Hallucinations.

MEDICATION ON ADMISSION: Coumadin 5mg q.day; Lopressor 25mg po bid; Lanoxin 0.125 q.day;
Allopurinol 100 q.day; Zoloft 100mg po qd, Protonix 40mg po qd,
lasix 10mg po qd

ALLERGIES: Penicillins / Sulfonamides / Morphine

PHYSICAL EXAM: Vitals: 99.8 137/73 89 17 96% RA
General: Intubated
HEENT: PERRL, no scleral icterus noted, ETT
Neck: supple
Pulmonary: Lungs CTA bilaterally anteriorlaterally without R/R/W

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Social Hx: The patient lives with his wife in a 1 story
apartment. He has difficulty walking [**1-29**] leg stiffness due to
Parkinsons. His wife takes care of him. He is able to eat and
dress by himself. His daughter lives down the street. He quit
smoking in [**2094**]. He has occassional sips of wine.
Closed fracture of intertrochanteric section of neck of femur,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Hypotension, unspecified,Iron deficiency anemia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Pain in joint, upper arm,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Cardiac pacemaker in situ,Knee joint replacement,Fall from other slipping, tripping, or stumbling,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use
Intertrochanteric fx-cl,Atrial fibrillation,Hyperosmolality,Hypotension NOS,Iron defic anemia NOS,Dementia w Lewy bodies,Dementia w/o behav dist,Joint pain-up/arm,Depressive disorder NEC,Aortocoronary bypass,Status cardiac pacemaker,Joint replaced knee,Fall from slipping NEC,Adv eff sedat/hypnot NOS
Admission Date:  [**2127-12-21**]              Discharge Date:   [**2127-12-31**]


Service: MEDICINE

Allergies:
Penicillins / Sulfonamides / Morphine

Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Femur fracture s/p fall

Major Surgical or Invasive Procedure:
ORIF for left inter/sub troc. fracture
Intubation
Central Line placement


History of Present Illness:
86 year-old male who presented to the ED s/p mechanical fall
with left hip Fx. Was at his daughters house walking from
bathroom and fell as he walked through the door. Landed on left
Hip. No LOC, no CP , No SOB. + Headstrike against the floor.
Underwent uncomplciated ORIF on [**12-23**]. Extubated in PACU without
complciation. While on floor, found to be in respiratory
distress with SaO2 85% on NRB. ABG done showed 7.09/94/91 with a
lactate of 1.8. He was intubated and transferred to MICU for
management of hypercarbic respiratory failure. He was
tachycardic and had a negative CTA on [**12-24**]. He steadily
improved with normal ABGs by MICU day #1 and was extubated on
[**12-25**] with room air O2 sats 95%. The patient has fluctuating MS
and sundowns frequently at night. He does not report pain but,
according to his family, this is easily assessed by watching his
face. He has been covered with very small doses of Dilauded
(0.25mg) which, according to the patient and his family, has
well controlled his pain. He is being transferred to the floor
for further inpatient medical care.

Past Medical History:
R TKR in [**2117**]
L TKR in [**2127-4-27**] (c/b post-op confusion and AF-RVR)
[**11-30**] to OR for L hip repair
CAD s/p CABG times two with sternal ostia as a complication.
PM
Right inguinal hernia repair
Pilonidal cyst I&D.
Parkinson's with [**Last Name (un) 309**] Body Dementia c/b Visual Hallucinations.


Social History:
Social Hx: The patient lives with his wife in a 1 story
apartment. He has difficulty walking [**1-29**] leg stiffness due to
Parkinsons. His wife takes care of him. He is able to eat and
dress by himself. His daughter lives down the street. He quit
smoking in [**2094**]. He has occassional sips of wine.


Family History:
Noncontributory.


Physical Exam:
Vitals: 99.8 137/73 89 17 96% RA
General: Intubated
HEENT: PERRL, no scleral icterus noted, ETT
Neck: supple
Pulmonary: Lungs CTA bilaterally anteriorlaterally without R/R/W

Cardiac: Irregularly irregular rhythm, S1, S2, [**2-2**] HSM heard
best at apex.
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
neuro: CN II-XII intact


Pertinent Results:
[**2127-12-21**] 09:46PM URINE  HOURS-RANDOM
[**2127-12-21**] 09:46PM URINE  GR HOLD-HOLD
[**2127-12-21**] 09:46PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2127-12-21**] 09:46PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2127-12-21**] 09:46PM URINE  RBC-[**2-29**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2127-12-21**] 02:10PM   GLUCOSE-109* UREA N-34* CREAT-1.3* SODIUM-140
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
[**2127-12-21**] 02:10PM   CK(CPK)-24*
[**2127-12-21**] 02:10PM   CK-MB-NotDone cTropnT-<0.01
[**2127-12-21**] 02:10PM   CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2127-12-21**] 02:10PM   DIGOXIN-1.1
[**2127-12-21**] 02:10PM   WBC-7.1 RBC-3.76* HGB-9.8*# HCT-30.4*
MCV-81*# MCH-26.0*# MCHC-32.1 RDW-17.3*
[**2127-12-21**] 02:10PM   NEUTS-65.3 LYMPHS-27.4 MONOS-3.9 EOS-2.3
BASOS-1.2
[**2127-12-21**] 02:10PM   HYPOCHROM-2+ ANISOCYT-1+ MICROCYT-1+
[**2127-12-21**] 02:10PM   PLT COUNT-150
[**2127-12-21**] 02:10PM   PT-22.0* PTT-38.5* INR(PT)-3.5
.
ECHO [**12-24**]    1. The left atrium is mildly dilated. The right
atrium is markedly dilated.  2. The left ventricular cavity size
is normal. Due to suboptimal technical  quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is difficult to assess but is
probably low normal. Overall left ventricular systolic function
(EF) cannot be reliably assessed.
3. The right ventricular cavity is dilated. Right ventricular
systolic function appears depressed. 4. The aortic root is
mildly dilated. The ascending aorta is mildly dilated. 5. The
aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. 6. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. 7. At least
moderate [2+] tricuspid regurgitation is seen.
.
EKG: AF with VR 130's and evidence of right hrt strain
.
Radiologic Data:
1. Hip xray ([**12-20**])- Comminuted fracture, left proximal femur
with intertrochanteric and subtrochanteric components.
Moderately severe to severe diffuse osteopenia.
.
2. Head CT ([**12-20**])- no acute intracranial findings -prelim.
.
3. C-spine CT ([**12-20**])- no fractures or prevertebral soft tissue
swelling. DJD of spine, but relatively normal vertebral body
alignment.
.
4. CXR([**12-24**]) - Status post sternotomy. Cardiomegaly and
probable COPD. A right-sided single lead pacemaker with lead tip
over right ventricle.  No change from preop.
.
5. CTA [**12-24**] MPRESSION: 1.  No evidence of pulmonary embolism.
2.  Bilateral lower lobe atelectasis with small effusion. 3.
Patchy ground glass opacities in bilateral lungs, probably
representing
pulmonary edema. 4.  Marked enlargement of right atrium, IVC and
hepatic veins, representing right-sided heart failure. 5.  Small
low-density area in the left lobe of the liver, which cannot be
further characterized on this chest CT. 6.  Low-density areas in
the right kidney, which is only partially imaged.
.
6. CXR for NG placement [**12-26**] (wet read). Some evidence of
atalectasis and fluid in lungs.  ? R sided opacity mid-lung.
.
7. CXR [**12-26**]  There is a nasogastric tube whose distal tip and
side port are not included on the study and are below the
inferior margin of the film.  However, they are likely below the
gastroesophageal junction and within the stomach.  There is a
single lead right-sided pacemaker and a left-sided IJ central
line, which are unchanged in position.  Median sternotomy wires
are seen.  There is cardiomegaly.  There is again seen an
opacity at the left base most consistent with subsegmental
atelectasis as seen on the recent chest CT.  There is no
evidence for overt pulmonary edema or focal infiltrate.
.
8. Elbow x rays [**12-28**] FINDINGS:  Three views of the right elbow
are limited secondary to difficulty in positioning the patient.
No true lateral radiograph has been provided, thus assessment
for joint effusion cannot be performed.  There are several
densities seen in the joint space suspicious for loose bodies.
One density is seen just volar to the distal humerus and a
second density is seen adjacent to
the radial head. Smaller densities are seen within the
adiocapitellar joint, which may represent chondrocalcinosis.  No
clear fracture is identified. Dedicated films with a true
lateral radiograph would be helpful to exclude occult fracture.
.
[**12-31**] CXR, official read pending but no gross evidence of opacity
(wet read)

Brief Hospital Course:
The patient is a 86 yo male with AF on Coumadin, CAD s/p CABG,
s/p ORIF for left hip fracture [**2127-12-24**] after a fall on
[**2127-12-21**].
.
#. Hip Fracture s/p fall: In the ED, CTA was negative for PE,
and showed some pulm edema, RLL opacity read as likely
atelectasis. The patient was followed by ortho throughout his
hospitalization.  He was kept non-weight bearing and went for
ORIF of his fracture on [**12-23**].  The operation went well and he
was transeferred to the floor. The patient was transfered to the
MICU on [**12-24**] after his post-op course was complicated by
hypercarbic respiratory failure (ABG 7.09/94/91), thought to be
secondary to obstruction vs. aspiration vs. sedation on meds.
Also on arrival to the MICU gross blood was seen from NGT but
this quickly changed to billious output over the day.  He was
started on Levo/Flagyl and intubated. His hypercarbic
respiratory failure resolved within a day, and he was extubated
without event. He was subsequently transferred to the floor and
followed by ortho and PT who were pleased with his progress
despite some persistent edema in the surgical leg and oozing at
the wound site.  Ortho recommended Cefazolin 1gm IV Q8H for 1
week course and this was switched to PO Keflex to be completed
at rehab.  He will need ongoing PT and rehabilitation of his
recently fractured hip.
.
#. Elbow pain:  The patient developled elbow pain after transfer
to the floor.  Concern was for previously undiagnosed fracture
from his fall.  Elbow films were negative for fracture and ortho
considered this a frozen elbow.  PT worked with him and he had
marked improvement in ROM and pain prior to discharge.
.
#. Cardiovascular: He has a PMH significant for CAD s/p CABG
times two with sternal ostia as a complication which was stable
without active ischemia.  Surveillance cardiac enzymes from
[**12-24**] were negative.  Throughout hospitalization he was
intermittently in AF with RVR, as in the past. His beta blocker
and digoxin were continued, and anticoagulation was accomplished
with Heparin gtt until the patient was therapeutic on Coumadin.
He is being discharged on his home dose of 5mg Warfarin daily
PO.  Pt currently off ACE and statin and this can be addressed
with his PCP.  [**Name10 (NameIs) **] also has an aspirin allergy, so his health
care providers may consider plavix as outpatient once his
fracture heals.
.
# Labile WBC count: Four days prior to discharge the patient's
WBC began to trend upwards in the absence of fever. Work-up
revealed negative urinalysis, although CXR showed RLL opacity
read as likely atelectasis. His Levo/Flagyl was continued for 5
days and then discontinued in the absence of symptoms (had been
started [**12-24**] for presumed aspiration pneumonia).  He was
treated with lasix for fluid overload daily at 20mg (home dose
10mg) and will continue on this 20mg dose upon discharge.  On
the day of discharge, WBC count was elevated at 14.  CXR was
done and negative for PNA.  U/A was sent and negative.  He did
not have diarrhea.  Urine cultures are pending at time of
discharge.
.
#Anemia - Baseline low 30s per old records.  This is probably
anemia of chronic disease with superimposed iron defficiency
anemia.  Has been worked up as outpatient by PCP.  [**Name10 (NameIs) **] was guaiac
positive on [**12-29**].  This was communicated to his PCP and he can
have an outpatient colonoscopy at a later date.  Otherwise, his
HCT was stable throughout admission.
.
#[**Last Name (un) 309**] Body Dementia: No antipsychotics.  Followed as outpatient
for this by a specialist. He was pleasantly demented but able to
converse well throughout admission.
.
#Depression: Restart Zoloft down NG.
.
#Prophylaxis: PPI, bowel regimen, hep gtt throughout admission
.
#FEN: NG tube was placed after extubation with tubefeeds for
several days. Pt passed a speech and swallow eval on [**12-29**] with
recommended soft diet with nectar thickened liquids.
.
#Access: PIVs, Left IJ was in place s/p transfer to unit and
discontinued one day prior to discharge.
.
#Communication: With pt and family.  He has a PCP at the [**Name9 (PRE) 42986**]
Clinic: Dr. [**Last Name (STitle) 108319**] [**Telephone/Fax (1) 108320**]
.
#Code Status: Full
.
#Dispo: to rehab
.

Medications on Admission:
Coumadin 5mg q.day; Lopressor 25mg po bid; Lanoxin 0.125 q.day;
Allopurinol 100 q.day; Zoloft 100mg po qd, Protonix 40mg po qd,
lasix 10mg po qd

Discharge Medications:
1. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1)  PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO Q 8H (Every 8 Hours).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
15. Lasix 20 mg Tablet Sig: 0.5 Tablet PO once a day.
16. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Femur fracture s/p fall
Hypercarbic respiratory failure
CAD
AF
Anemia
Dementia


Discharge Condition:
Stable


Discharge Instructions:
Please take all meds as prescribed.

Seek medical attention immediately if you experience new
symptoms including leg pain, shortness of breath, bleeding,
lightheadedness, fainting, falls, etc.

Please follow up as per below

Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1941**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 1942**]
Date/Time:[**2128-1-26**] 8:30

Have your staples removed in 2 weeks per Ortho

Follow-up with your PCP as soon as possible (or with rehab MD)


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
{'Closed fracture of intertrochanteric section of neck of femur,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Hypotension, unspecified,Iron deficiency anemia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Pain in joint, upper arm,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Cardiac pacemaker in situ,Knee joint replacement,Fall from other slipping, tripping, or stumbling,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use'}


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: Femur fracture s/p fall

PRESENT ILLNESS: 86 year-old male who presented to the ED s/p mechanical fall
with left hip Fx. Was at his daughters house walking from
bathroom and fell as he walked through the door. Landed on left
Hip. No LOC, no CP , No SOB. + Headstrike against the floor.
Underwent uncomplciated ORIF on [**12-23**]. Extubated in PACU without
complciation. While on floor, found to be in respiratory
distress with SaO2 85% on NRB. ABG done showed 7.09/94/91 with a
lactate of 1.8. He was intubated and transferred to MICU for
management of hypercarbic respiratory failure. He was
tachycardic and had a negative CTA on [**12-24**]. He steadily
improved with normal ABGs by MICU day #1 and was extubated on
[**12-25**] with room air O2 sats 95%. The patient has fluctuating MS
and sundowns frequently at night. He does not report pain but,
according to his family, this is easily assessed by watching his
face. He has been covered with very small doses of Dilauded
(0.25mg) which, according to the patient and his family, has
well controlled his pain. He is being transferred to the floor
for further inpatient medical care.

MEDICAL HISTORY: R TKR in [**2117**]
L TKR in [**2127-4-27**] (c/b post-op confusion and AF-RVR)
[**11-30**] to OR for L hip repair
CAD s/p CABG times two with sternal ostia as a complication.
PM
Right inguinal hernia repair
Pilonidal cyst I&D.
Parkinson's with [**Last Name (un) 309**] Body Dementia c/b Visual Hallucinations.

MEDICATION ON ADMISSION: Coumadin 5mg q.day; Lopressor 25mg po bid; Lanoxin 0.125 q.day;
Allopurinol 100 q.day; Zoloft 100mg po qd, Protonix 40mg po qd,
lasix 10mg po qd

ALLERGIES: Penicillins / Sulfonamides / Morphine

PHYSICAL EXAM: Vitals: 99.8 137/73 89 17 96% RA
General: Intubated
HEENT: PERRL, no scleral icterus noted, ETT
Neck: supple
Pulmonary: Lungs CTA bilaterally anteriorlaterally without R/R/W

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Social Hx: The patient lives with his wife in a 1 story
apartment. He has difficulty walking [**1-29**] leg stiffness due to
Parkinsons. His wife takes care of him. He is able to eat and
dress by himself. His daughter lives down the street. He quit
smoking in [**2094**]. He has occassional sips of wine. 

### Response:
{'Closed fracture of intertrochanteric section of neck of femur,Atrial fibrillation,Hyperosmolality and/or hypernatremia,Hypotension, unspecified,Iron deficiency anemia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Pain in joint, upper arm,Depressive disorder, not elsewhere classified,Aortocoronary bypass status,Cardiac pacemaker in situ,Knee joint replacement,Fall from other slipping, tripping, or stumbling,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use'}
