CHIEF COMPLAINT: Femur fracture

PRESENT ILLNESS: The patient is a 89 yo woman with h/o CAD, CHF, and depression
with psychosis, who presented from her [**Hospital3 **] facility
to [**Hospital6 204**] with left leg pain. The patient was
reportedly in her normal state of health until approximately 1
PM yesterday when she started to complain of left knee pain. On
further questioning, it appears that the patient fell when she
was in the bathroom earlier this morning, but she is unable to
provide details surrounding the event and it was an unwitnessed
fall. Given her knee pain, she was sent to [**Hospital3 **] for further evaluation.

MEDICAL HISTORY: Past Medical History:
Anemia
Depression with psychosis
Back pain
Osteoarthritis
Schitzoaffective disorder
CAD
CHF

MEDICATION ON ADMISSION: Lorazepam 1 mg PO BID
Miralax prn for constipation
Cholecalciferol 800 U PO daily
Ferrous sulfate 325 mg PO daily
ASA 81 mg PO daily
Abilify 5 mg PO daily
Lorazepam 0.5 mg PO q6h prn for anxiety
Fentanyl 12 mcg/h patch q72h
Mirtazapine 45 mg PO qhs
Omeprazole 20 mg PO BID
Olanzapine 20 mg PO BID
Olanzapine 2.5 mg PO BID
Docusate 100 mg PO BID
Olanzapine 10 mg PO daily prn for anxiety

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 98.9, BP: 114/85, P: 84, R: 12 O2: 99% on 2L
General: AAO x 1 (to person only. She thought she was in a
"place of business," and thought it was [**2055**]). NAD
HEENT: Sclera anicteric, dry mucous membranes, poor dentition,
oropharynx clear
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
Ext: Erythema and effusion present in the left knee. 2+ bounding
DP and PT pulses bilaterally. No edema.
Neuro: oriented x1, patient unable to cooperate with neuro exam

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unable to obtain due to congition
Closed supracondylar fracture of femur,Acute respiratory failure,Cardiac arrest,Cardiac complications, not elsewhere classified,Unspecified fall,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Depressive disorder, not elsewhere classified
Supracondyl fx femur-cl,Acute respiratry failure,Cardiac arrest,Surg compl-heart,Fall NOS,Anemia NOS,Crnry athrscl natve vssl,Depressive disorder NEC
Admission Date:  [**2145-1-16**]              Discharge Date:   [**2145-1-29**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Femur fracture

Major Surgical or Invasive Procedure:
[**2145-1-19**] L distal femur [**Last Name (un) 101**] - Dr. [**Last Name (STitle) **]
[**2145-1-16**] Cardiac resuscitation [**2-3**] cardiac arrest

History of Present Illness:
The patient is a 89 yo woman with h/o CAD, CHF, and depression
with psychosis, who presented from her [**Hospital3 **] facility
to [**Hospital6 204**] with left leg pain. The patient was
reportedly in her normal state of health until approximately 1
PM yesterday when she started to complain of left knee pain. On
further questioning, it appears that the patient fell when she
was in the bathroom earlier this morning, but she is unable to
provide details surrounding the event and it was an unwitnessed
fall. Given her knee pain, she was sent to [**Hospital3 **] for further evaluation.

At [**Hospital3 **], she had an XRay, which demonstrated a closed
fracture of the femur. Basic labs were sent, which revealed
baseline anemia. Given the extent of the fracture, she was
transferred to [**Hospital1 18**] for further evaluation. In our ED, her
initial VS were T 99.5, P 74, BP 108/52, R 18, O2 92% on RA. She
had a hip XRay in the ED, which was unremarkable. Ortho was
consulted, and she will likely go to the OR tomorrow. EKG showed
LBBB and she was given one dose of Morphine. Given her hypoxia
and anemia, she was admitted to medicine for further evaluation.
Her VS at the time of transfer were T 99.0, P 67, BP 120/53, R
21, O2 98% on 2L.

On the floor, the patient is a AAOx1 and is unable to give any
history as to what occurred yesterday morning. She does say that
she is currently having left knee pain, and she denies chest
pain, shortness of breath, or abdominal pain. She states that
she does not want pain medications, and she continuously asks,
"where is my mint green dress?"

Review of systems: Unable to obtain
(+) Per HPI
(-) Denies fever, headache, cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain.

Past Medical History:
Past Medical History:
Anemia
Depression with psychosis
Back pain
Osteoarthritis
Schitzoaffective disorder
CAD
CHF

Social History:
Unable to obtain due to congition

Family History:
Unable to obtain

Physical Exam:
Vitals: T: 98.9, BP: 114/85, P: 84, R: 12 O2: 99% on 2L
General: AAO x 1 (to person only. She thought she was in a
"place of business," and thought it was [**2055**]). NAD
HEENT: Sclera anicteric, dry mucous membranes, poor dentition,
oropharynx clear
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
Ext: Erythema and effusion present in the left knee. 2+ bounding
DP and PT pulses bilaterally. No edema.
Neuro: oriented x1, patient unable to cooperate with neuro exam

Pertinent Results:
Admission:

[**2145-1-16**] 04:50PM   GLUCOSE-152* UREA N-23* CREAT-0.9 SODIUM-142
POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-26 ANION GAP-11
[**2145-1-16**] 04:50PM   ALT(SGPT)-182* AST(SGOT)-192* LD(LDH)-473*
CK(CPK)-328* ALK PHOS-72 TOT BILI-0.7
[**2145-1-16**] 04:50PM   CK-MB-6 cTropnT-0.05*
[**2145-1-16**] 04:50PM   CALCIUM-8.4 PHOSPHATE-2.7 MAGNESIUM-1.6
[**2145-1-16**] 04:50PM   WBC-7.6 RBC-3.05* HGB-9.0* HCT-26.1* MCV-86
MCH-29.3 MCHC-34.3 RDW-13.9
[**2145-1-16**] 04:50PM   PLT COUNT-148*
[**2145-1-16**] 04:50PM   PT-11.5 PTT-22.8 INR(PT)-1.0
[**2145-1-16**] 02:55PM   WBC-7.4 RBC-2.80* HGB-8.2* HCT-24.4* MCV-87
MCH-29.4 MCHC-33.7 RDW-14.4
[**2145-1-16**] 02:55PM   PLT COUNT-144*
[**2145-1-16**] 02:55PM   PT-12.2 PTT-29.6 INR(PT)-1.0
[**2145-1-16**] 02:55PM   FIBRINOGE-428*
[**2145-1-16**] 02:51PM   TYPE-ART RATES-/12 O2-100 O2 FLOW-12 PO2-370*
PCO2-48* PH-7.28* TOTAL CO2-24 BASE XS--4 AADO2-319 REQ O2-57
INTUBATED-INTUBATED VENT-CONTROLLED COMMENTS-ETT TUBE
[**2145-1-16**] 02:51PM   GLUCOSE-169* LACTATE-2.4* NA+-141 K+-3.2*
CL--112
[**2145-1-16**] 02:51PM   HGB-8.1* calcHCT-24 O2 SAT-98 CARBOXYHB-2 MET
HGB-0
[**2145-1-16**] 02:51PM   freeCa-1.08*
[**2145-1-16**] 07:40AM   GLUCOSE-129* UREA N-30* CREAT-0.9 SODIUM-143
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-27 ANION GAP-10
[**2145-1-16**] 07:40AM   CK-MB-3
[**2145-1-16**] 07:40AM   CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-1.9
[**2145-1-16**] 07:40AM   WBC-6.7 RBC-2.87* HGB-8.2* HCT-24.5* MCV-85
MCH-28.5 MCHC-33.5 RDW-14.3
[**2145-1-16**] 07:40AM   PT-12.0 PTT-25.5 INR(PT)-1.0
[**2145-1-16**] 07:40AM   PLT COUNT-177
[**2145-1-16**] 02:50AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2145-1-16**] 02:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2145-1-16**] 02:50AM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2 RENAL EPI-0-2
[**2145-1-16**] 01:50AM   GLUCOSE-131* UREA N-32* CREAT-1.0 SODIUM-144
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-28 ANION GAP-11
[**2145-1-16**] 01:50AM   estGFR-Using this
[**2145-1-16**] 01:50AM   CK(CPK)-219*
[**2145-1-16**] 01:50AM   cTropnT-<0.01
[**2145-1-16**] 01:50AM   cTropnT-<0.01
[**2145-1-16**] 01:50AM   PHOSPHATE-3.2 MAGNESIUM-2.0
[**2145-1-16**] 01:50AM   WBC-7.1 RBC-3.12* HGB-8.8* HCT-26.4* MCV-85
MCH-28.3 MCHC-33.4 RDW-14.4
[**2145-1-16**] 01:50AM   NEUTS-82.3* LYMPHS-11.7* MONOS-5.3 EOS-0.3
BASOS-0.4
[**2145-1-16**] 01:50AM   PLT COUNT-196
[**2145-1-16**] 01:50AM   PT-12.3 PTT-27.2 INR(PT)-1.0
.
Pertinent Reports
Knee films ([**2145-1-16**]): Comminuted fracture of distal femur, with
posterior displacement of distal fragments, and associated joint
effusion.

Femur films ([**2145-1-16**]): Comminuted fracture of distal femur,
with posterior displacement of distal fragments, and associated
joint effusion.

CT head ([**2145-1-17**]): No evidence of acute intracranial hemorrhage
or mass effect.

NOTE ON ATTENDING REVIEW:
There is slightly hypodense appearance of the caudate nuclei on
both sides. As there are no priors, and given the history, MR
[**Name13 (STitle) 430**] can be considered if necessary and not CI to evaluate for
infarction; otherwise followup CT.

CTA Chest ([**2145-1-17**]):
1. No evidence of pulmonary embolism.
2. Small pericardial effusion.
3. Bibasilar atelectasis, small bilateral pleural effusions and
emphysematous changes.
4. Multiple rib fractures, may be related to resuscitation
efforts.
5. Subcarnial soft tissue density may be related to hiatal
hernia, however a soft tissue mass is not entirely excluded.
When the patient is stable, repeat examination with Esophotrast
or endoscopy may be performed.

Post-OR femur films ([**2145-1-19**]): FOUR INTRAOPERATIVE RADIOGRAPHS
OF THE DISTAL LEFT FEMUR. Since preoperative exam [**2145-1-17**] the comminuted displaced supracondylar fracture of the
distal left femur has been fixated with a lateral plate and
multiple screws. There is marked improvement in the positioning
of the major fragments.

TTE ([**2145-1-20**]): Right ventricular dilation with moderate global
hypokinesis. Preserved left ventricular systolic function. Small
circumferential pericardial effusion.

CXR ([**2145-1-20**]): Left lower lobe atelectasis has improved. Small
left pleural effusion is new or newly apparent. Right lung is
clear. ET tube in standard placement. Right jugular line ends in
the mid SVC. No pneumothorax.

Brief Hospital Course:
Assessment and Plan: The patient is a 89 yo woman with h/o
dementia, depression with paranoia, CAD, and CHF, who presented
s/p fall at her [**Hospital3 **] with a left-sided impacted
femoral fracture, who had a PEA arrest after receiving
anesthesia in the OR.

# CODE STATUS - After discussions with the nephew, primary team,
and palliative care, it was decided that hospice care was the
most appropriate decision and in line with what the patient
would have wanted.

#. Left Femoral fracture: The patient has a distal supracondylar
fracture of the femur with angulation and displacement. Her
pre-operative assessment was completed and she went to the
operating room on [**1-16**] to undergo open reduction, internal
fixation. As she was being intubated prior to surgery, she had
pulseless electrical activity. A code blue was called with
return of spontaneous circulation with CPR.  She was transferred
to the MICU. She was taken back to the OR on [**2145-1-19**] and
underwent successful open reduction and internal fixation by Dr.
[**Last Name (STitle) **].  She is maintained on Lovenox for DVT prophylaxis and
pain controlled with fentanyl as she is intubated.  She was
evaluated by PT starting on [**1-25**].  Her pain was controlled with
fentanyl patch and dilaudid, which was able to be weaned down to
oxycodone and lidocaine patches on both knees.

#. Pulseless electrical activity: Immediately following the
induction of
general endotracheal anesthesia on [**2145-1-16**], she was noted to be
in
asystole.  Cardiopulmonary resuscitation was started with return
of spontaneous circulation. There were no lab abnormalities to
explain her arrest; CTA showed no PE.  PEA arrest possibly
secondary to fluid shift vs anesthesia.

#. Respiratory failure: Intubated in the setting of pulse
electrical arrest.  She was continued on mechanical ventilation
due to her concern for her mental status (agitation), sedation
required for pain control.  She was extubated on [**1-20**] and did
well for several hours, then required re-intubation for
increased secretions and respiratory distress.  Extubated again
on [**1-24**].  After discussion with her nephew [**Name (NI) 382**] it was decided
that she would not be reintubated (patient was originally a
DNR/DNI, but had been reversed for the OR).  Patient did well on
nasal cannula oxygen, she did have episodes of tachypnea and
shortness of breath which responeded well to morphine 2.5mg PO.

#. Hypotension: She has required intermittent norepineprhine gtt
throughout her MICU stay for MAP < 65 likely from drop in blood
pressure from versed gtt for sedation in setting of volume
depletion due to loss of blood into her femur fracuture.

#. Anemia: The patient has a history of anemia, for which she
takes iron daily. Her Hct on admission was 26.4, which is
decreased from her baseline of 29. Given the IVFs she received
in the ED, this may be dilutional; however, she may also have
bled into her fracture site.  She was given 2 units of PRBC on
admission on [**2145-1-16**].  She was given 3 more units on [**2145-1-18**]
as she continued to have drop in her hematocrit thought to be
likely bleeding into her femur fracture.  Hct stabilized after
surgery, and she has not required further transfusions.

#. Depression: The patient has a history of depression with
psychosis, for which she takes multiple psychiatric medications.
 Continued on Olanzapine, lorazepam, Abilify, and Mirtazapine,
per outpatient list.

#  Nutrition: pt started on tube feeds while intubated.
Evaluated by speech and swallow after extubation on [**1-25**], but
failed.  Re-evaluation showed that patient can tolerate very
small amount ([**1-5**] teaspoon) of nectar thickened liquids and
pureed food. Per discussion with the HCP and team, the decision
was made to allow the patient to eat for comfort.

Medications on Admission:
Lorazepam 1 mg PO BID
Miralax prn for constipation
Cholecalciferol 800 U PO daily
Ferrous sulfate 325 mg PO daily
ASA 81 mg PO daily
Abilify 5 mg PO daily
Lorazepam 0.5 mg PO q6h prn for anxiety
Fentanyl 12 mcg/h patch q72h
Mirtazapine 45 mg PO qhs
Omeprazole 20 mg PO BID
Olanzapine 20 mg PO BID
Olanzapine 2.5 mg PO BID
Docusate 100 mg PO BID
Olanzapine 10 mg PO daily prn for anxiety

Discharge Medications:
1. olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
2. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours) as needed for pain, sob.
7. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
Q8H (every 8 hours).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] House

Discharge Diagnosis:
Primary: left femur fracture s/p repair, pulseless electrical
activity x2, respiratory failure

Secondary: Anemia


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


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

 It was a pleasure taking care of you during your
hospitalization.  You were admitted with a left femur fracture.
During the initial attempt to repair your leg, your heart
stopped beating.  This occurred twice, although each time we
were able to start your heart again.  You were hooked up to a
ventilator that breathed for you for a few days, then we were
able to remove the breathing tube and you were able to breathe
on your own.  You had a feeding tube placed down your nose,
however you did not like this in and pulled it out.  You also
had periodic difficulty breathing that responded well to
morphine.  After speaking to your nephew and our palliative care
team, we thought it would be in your best interest to focus on
comfort care.  We will focus on symptom management to make you
as comfortable as possible.


Followup Instructions:
As per Hospice Care.



Completed by:[**2145-2-1**]
{'Closed supracondylar fracture of femur,Acute respiratory failure,Cardiac arrest,Cardiac complications, not elsewhere classified,Unspecified fall,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Depressive disorder, not elsewhere classified'}


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

PRESENT ILLNESS: The patient is a 89 yo woman with h/o CAD, CHF, and depression
with psychosis, who presented from her [**Hospital3 **] facility
to [**Hospital6 204**] with left leg pain. The patient was
reportedly in her normal state of health until approximately 1
PM yesterday when she started to complain of left knee pain. On
further questioning, it appears that the patient fell when she
was in the bathroom earlier this morning, but she is unable to
provide details surrounding the event and it was an unwitnessed
fall. Given her knee pain, she was sent to [**Hospital3 **] for further evaluation.

MEDICAL HISTORY: Past Medical History:
Anemia
Depression with psychosis
Back pain
Osteoarthritis
Schitzoaffective disorder
CAD
CHF

MEDICATION ON ADMISSION: Lorazepam 1 mg PO BID
Miralax prn for constipation
Cholecalciferol 800 U PO daily
Ferrous sulfate 325 mg PO daily
ASA 81 mg PO daily
Abilify 5 mg PO daily
Lorazepam 0.5 mg PO q6h prn for anxiety
Fentanyl 12 mcg/h patch q72h
Mirtazapine 45 mg PO qhs
Omeprazole 20 mg PO BID
Olanzapine 20 mg PO BID
Olanzapine 2.5 mg PO BID
Docusate 100 mg PO BID
Olanzapine 10 mg PO daily prn for anxiety

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: T: 98.9, BP: 114/85, P: 84, R: 12 O2: 99% on 2L
General: AAO x 1 (to person only. She thought she was in a
"place of business," and thought it was [**2055**]). NAD
HEENT: Sclera anicteric, dry mucous membranes, poor dentition,
oropharynx clear
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
Ext: Erythema and effusion present in the left knee. 2+ bounding
DP and PT pulses bilaterally. No edema.
Neuro: oriented x1, patient unable to cooperate with neuro exam

FAMILY HISTORY: Unable to obtain

SOCIAL HISTORY: Unable to obtain due to congition 

### Response:
{'Closed supracondylar fracture of femur,Acute respiratory failure,Cardiac arrest,Cardiac complications, not elsewhere classified,Unspecified fall,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Depressive disorder, not elsewhere classified'}
