CHIEF COMPLAINT: Status post fall.
Reason for MICU admission: tachycardia, falling hematocrit.

PRESENT ILLNESS: [**Age over 90 **] year old female with history of hypertension, asthma, CVA in
[**2140**] on anticoagulation, MRSA left hip infection in [**2142**] (on
life long doxycycline), transferred status post fall in commode
at OSH on [**2144-9-19**], while being treated for a UTI.  At the OSH,
patient found to have a right humeral and left distal femur
fracture.  There was no venous insufficiency, distally.
Preliminary reads at the OSH revealed no abnormalities on head
CT or cervical spine.  Patient's abdomen/pelvis were reported as
normal.
.
On presentation, found to have HR 120 BP 120's and O2 sat 100%
on 2L.  EKG revealed sinus tachycardia.  Pain was controlled
with morphine and tachycardia treated with metoprolol.
Ceftriaxone was continued for patient's UTI.  Shortly after
admission to orthopedics service, for impending surgery,
patient's hematocrit decreased from 31 to 25.6 in 6 hours.  Ct
was negative for hip bleed.  Right groin line was placed.  As
patient's blood pressure decreased to the 70's, responding to 2
liters IVF to the 90's, and O2 saturations that were in the
80's, but only returned to [**Location 213**] with 10L supplemental oxygen,
she was transferred to the medical ICU.  She spiked a fever to
100.0F, so vancomycin 1gm given for presumed line infection.
Her blood pressure remained tenuous, so she received a total of
4 units of packed red blood cells and 2 units of fresh frozen
plasma during these first several days.
While in the MICU, patient was noted to have NSTEMI, with
cardiac ECHO noted to reveal new global hypokinesis.  Troponins
elevated to 1.28, but subsequently trended downwards.  Following
surgery, she was noted to develop new-onset atrial fibrillation,
but she remained hemodynamically stable.  Patient was started on
metoprolol and lovenox and transferred to medicine floor for
medical management.

MEDICAL HISTORY: 1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]:
complicated by infected prosthesis with enterobacter and MRSA.
Removal of Hardware  in [**1-9**].
5) Hypothyroidism
6) Asthma
7) Vertebral compression
8) hysterectomy
9) appendectomy
10) vertebroplasty: L1 and T12
11) MRSA/diskitis/epidural abscess

MEDICATION ON ADMISSION: 1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents /
Shellfish

PHYSICAL EXAM: On admission:
VS Tc 99.0, P 100-115, BP 105/46, resp 18, 95% on 10 L face
tent.
Gen: elderly, chronically-ill appearing female, collar in place.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: No Tob/EtOH. Independent prior to 1st hip fracture.
Daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **] and son.
Closed fracture of shaft of femur,Closed fracture of unspecified part of lower end of humerus,Accidental fall from commode,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute posthemorrhagic anemia,Bacteremia,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Other postoperative infection,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter,Esophageal reflux
Fx femur shaft-closed,Fx lower humerus NOS-cl,Fall from commode,Subendo infarct, initial,Atrial fibrillation,Ac posthemorrhag anemia,Bacteremia,Urin tract infection NOS,Hyposmolality,Cellulitis of leg,CHF NOS,Other postop infection,Hypertension NOS,Hypothyroidism NOS,Renal & ureteral dis NOS,Esophageal reflux
Admission Date:  [**2144-9-19**]              Discharge Date:   [**2144-10-9**]


Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents /
Shellfish

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Status post fall.
Reason for MICU admission: tachycardia, falling hematocrit.


Major Surgical or Invasive Procedure:
Left femur intramedullary nail.


History of Present Illness:
[**Age over 90 **] year old female with history of hypertension, asthma, CVA in
[**2140**] on anticoagulation, MRSA left hip infection in [**2142**] (on
life long doxycycline), transferred status post fall in commode
at OSH on [**2144-9-19**], while being treated for a UTI.  At the OSH,
patient found to have a right humeral and left distal femur
fracture.  There was no venous insufficiency, distally.
Preliminary reads at the OSH revealed no abnormalities on head
CT or cervical spine.  Patient's abdomen/pelvis were reported as
normal.
.
On presentation, found to have HR 120 BP 120's and O2 sat 100%
on 2L.  EKG revealed sinus tachycardia.  Pain was controlled
with morphine and tachycardia treated with metoprolol.
Ceftriaxone was continued for patient's UTI.  Shortly after
admission to orthopedics service, for impending surgery,
patient's hematocrit decreased from 31 to 25.6 in 6 hours.  Ct
was negative for hip bleed.  Right groin line was placed.  As
patient's blood pressure decreased to the 70's, responding to 2
liters IVF to the 90's, and O2 saturations that were in the
80's, but only returned to [**Location 213**] with 10L supplemental oxygen,
she was transferred to the medical ICU.  She spiked a fever to
100.0F, so vancomycin 1gm given for presumed line infection.
Her blood pressure remained tenuous, so she received a total of
4 units of packed red blood cells and 2 units of fresh frozen
plasma during these first several days.
While in the MICU, patient was noted to have NSTEMI, with
cardiac ECHO noted to reveal new global hypokinesis.  Troponins
elevated to 1.28, but subsequently trended downwards.  Following
surgery, she was noted to develop new-onset atrial fibrillation,
but she remained hemodynamically stable.  Patient was started on
metoprolol and lovenox and transferred to medicine floor for
medical management.




Past Medical History:
1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]:
complicated by infected prosthesis with enterobacter and MRSA.
Removal of Hardware  in [**1-9**].
5) Hypothyroidism
6) Asthma
7) Vertebral compression
8) hysterectomy
9) appendectomy
10) vertebroplasty: L1 and T12
11) MRSA/diskitis/epidural abscess

Social History:
No Tob/EtOH. Independent prior to 1st hip fracture.
Daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **] and son.


Family History:
Non-contributory.

Physical Exam:
On admission:
VS Tc 99.0, P 100-115, BP 105/46, resp 18, 95% on 10 L face
tent.
Gen: elderly, chronically-ill appearing female, collar in place.

Head: NCAT
Mouth: MM dry
Cardiac: Tachycardic, regular no M/R/G
Pulm: Diffuse expiratory wheezes and scattered rhonchi
Abd: NABS, soft, NT/ND
Ext: In traction L hip, cast in place at R arm.
Pulses dopplerable on L, palpable on R no edema.


Pertinent Results:
Chest Xray ([**10-4**]): Allowing for the differences in rotation and
technique, there likely has been no major change in the
appearance of the bilateral pleural effusions, left basilar
atelectasis/airspace disease and mild pulmonary vascular
congestion.
.
Chest Xray ([**9-19**]):  Slightly more pronounced perihilar markings
and hazy opacity right upper zone most likely reflects early
CHF.
.
CT head ([**9-30**]): 1. No acute intracranial hemorrhage identified.
2. Multiple chronic large and small vessel infarctions.
.
Cardiac ECHO ([**9-22**]):  Symmetric LVH with mild regional left
ventricular systolic dysfunction. Mild aortic stenosis. Moderate
mitral regurgitation. Moderate pulmonary hypertension.  Compared
with the prior study (images reviewed on tape) of [**2142-8-3**],
septal hypokinesis is new, and mild aortic stenosis is now
identified. The other findings appear similar.
.
Xray ([**9-19**]):  Humerus fracture. No evidence of associated elbow
dislocation.  There is a fracture of the distal left femur,
which is not completely imaged on this study. There has been
placement of a traction pin through the distal left femur, with
slight posterior displacement and minimal anterior angulation of
the distal fracture fragment.
.
Speech and Swallow ([**10-6**]):  PO diet of nectar thick liquids and
pureed solids when fully awake and seated upright.  Continue
with tube feeds for supplemental nutrition and hydration.
.
.

[**2144-10-7**] 06:01AM BLOOD WBC-11.3* RBC-3.14* Hgb-9.9* Hct-29.4*
MCV-94 MCH-31.6 MCHC-33.8 RDW-17.6* Plt Ct-282
[**2144-10-2**] 07:15AM BLOOD WBC-20.0*# RBC-3.47* Hgb-10.9* Hct-32.4*
MCV-94 MCH-31.4 MCHC-33.5 RDW-16.5* Plt Ct-354
[**2144-9-24**] 04:22AM BLOOD WBC-20.7* RBC-3.46* Hgb-10.8* Hct-31.5*
MCV-91 MCH-31.2 MCHC-34.2 RDW-16.3* Plt Ct-237
[**2144-9-20**] 05:36PM BLOOD WBC-15.0* RBC-3.46* Hgb-10.9* Hct-31.5*
MCV-91 MCH-31.6 MCHC-34.7 RDW-14.4 Plt Ct-172
[**2144-9-19**] 05:10AM BLOOD WBC-11.1* RBC-3.13* Hgb-9.7* Hct-28.6*
MCV-91 MCH-31.0 MCHC-34.0 RDW-13.7 Plt Ct-265
[**2144-10-7**] 06:01AM BLOOD PT-12.9 PTT-43.4* INR(PT)-1.1
[**2144-9-19**] 05:10AM BLOOD PT-25.5* PTT-53.8* INR(PT)-2.6*
[**2144-10-7**] 06:01AM BLOOD Glucose-112* UreaN-23* Creat-0.6 Na-132*
K-3.8 Cl-93* HCO3-34* AnGap-9
[**2144-9-19**] 05:10AM BLOOD Glucose-148* UreaN-23* Creat-0.8 Na-140
K-3.5 Cl-104 HCO3-27 AnGap-13
[**2144-10-6**] 05:57AM BLOOD CK-MB-3 cTropnT-<0.01
[**2144-9-23**] 04:52PM BLOOD CK-MB-NotDone cTropnT-1.28*
[**2144-9-21**] 11:21AM BLOOD CK-MB-NotDone cTropnT-1.12*
[**2144-9-20**] 03:17PM BLOOD CK-MB-21* MB Indx-11.2* cTropnT-1.13*
[**2144-10-7**] 06:01AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.7
[**2144-9-19**] 09:46PM BLOOD Calcium-8.2* Phos-2.9 Mg-1.5*
[**2144-10-5**] 08:16AM BLOOD %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2144-9-22**] 04:40PM BLOOD Type-ART pO2-98 pCO2-35 pH-7.38
calTCO2-22 Base XS--3 Intubat-INTUBATED Vent-CONTROLLED
[**2144-10-9**] 06:22AM BLOOD WBC-9.9 RBC-2.77* Hgb-9.0* Hct-26.0*
MCV-94 MCH-32.5* MCHC-34.7 RDW-18.5* Plt Ct-286
[**2144-10-9**] 06:22AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-133
K-3.9 Cl-95* HCO3-32 AnGap-10
[**2144-10-9**] 06:22AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.9

Brief Hospital Course:
A/P:
[**Age over 90 **] year old woman with HTN, asthma, osteoarthritis, and GERD who
presented with L femur and R humeral fracture status post fall.
Admitted to MICU for tachycardia, periods of hypotension and
hypoxemia, and falling hematocrit. Tachycardia improved with
volume resuscitation and with pain control.  On hospital day 3,
the patient underwent ORIF of her L femur fracture and reduction
of R humeral fracture.  Her post-operative course was
complicated by new onset atrial fibrillation which was
controlled with diltiazem and for which prophylaxis was started
with lovenox.  In addition, the patient had an NSTEMI with
evidence of new septal hypokinesis on cardiac ECHO.  Her MICU
course was also complicated by [**Age over 90 **] UTI.
Transferred to the medical service for medical management of
pulmonary edema.  Developed a pseudomonas bacteremia, for which
patient was treated with vancomycin, gentamicin, and
ciprofloxacin.
.
1)  Humeral and femur fracture:
  Right humeral and left humeral fracture. Right humerus in cast
and left intramedullary nail in place.  Pain managed with
hydromorphone.  As patient developed transient decreases in
blood pressure when administered IV, better results achived when
administered SC.  Previous enterobacter (necessitating hardware
removal in [**1-9**]) and MRSA required lifelong doxycycline
treatment.  Enoxaparin 60mg q12hr used for DVT prophylaxis and
to anticoagulate.  Lower extremity pulses auscultated by
Doppler, with right greater than left dorsalis pedis pulses.
  Left upper thigh wound slightly erythematous during
hospitalization.  Culture revealed pseudomonas.  Orthopedics
team opted to not remove hardware.  Will treat with life-long
antibiotics course of doxycycline and ciprofloxacin.  A two week
course of IV gentamicin will continue following discharge.
   Encourage patient out of bed with assistance.  Patient able
to sit in chair without pain.
.
2) Bacteremia/Lower extremity  cellulitis:
  Blood cultures on [**10-1**] positive for pseudomonas.  History of
blood infections (MRSA and enterobacter) in [**2142**].  On [**10-2**],
elevated white count to 20 and fever to 100.3.  Infectious
disease team consulted and recommended changing linezolid to
vancomycin on [**10-2**], but then switched to ceftazidime and
levofloxacin.  Once sensitivites achieved, switched to
ciprofloxacin 400 IV q12, as ceftaz resistant.  Continued
vancomycin.  Added gentamicin 90 IV qd on [**10-4**].  Lower extremity
cellulitis improving.
  White count has continued to trend downwards since [**10-2**].
Doses for vancomycin and gentamicin adjusted for therapeutic
goals.  At no point did sputum cultures reveal pseudomonas.
On discharge, patient will remain on gentamycin for 2 weeks,
until [**10-18**].  She will remain on doxycycline and
ciprofloxacin for the remainder of her life.  If she develops a
temperature when discharged, she will need to have blood
cultures drawn immediately.  In there are gram negative rods
found in the culture, she will need to be transported
IMMEDIATELY back to [**Hospital1 69**] for IV
antibiotic treatment.
.
3) Hypoxemia:
  Upon transfer from MICU, patient required supplemental oxygen.
 Evidence of edema on previous chest films.  Following surgery,
patient probably developed stunned myocardium and her net fluid
balance had been positive for several days.  Initially goal was
to gently diurese patient, with IV lasix doses given on PRN
basis.  On [**10-4**], she developed flash pulmonary edema, that was
relieved with lasix 20mg IV x2 and one dose of 40mg IVx1.
Subsequent to event, patient was continued on IV lasix with
diuresis continued.  On [**10-6**], patient able to achieve 93% oxygen
saturation on ambient air. Will continue PO lasix upon
discharge.
.
4)  UTI:
  On admission, patient's UTI treated with ceftriaxone.
Sensitivities revealed [**Last Name (LF) **], [**First Name3 (LF) **] patient started on linezolid, but
changed to vancomycin on [**10-2**].  Foley was changed on [**10-2**], and
urine cultures from [**10-2**] negative to date.
.
5) NSTEMI/Atrial Fibrillation:
  Following surgical repair of fracture, post-operatively,
patient developed new onset of atrial fibrillation.  Thought to
be likely to increased intravascular volume.  Also, during
surgery, patient may have developed demand ischemia, as
manifested by new septal hypokinesis on ECHO.  The ischemia was
most likely transient.  Rate control achieved through metoprolol
and diltiazem.  Anticoagulation achieved through enoxaparin.
Will be discharged on atenolol and lisinopril, in place of
metoprolol and captopril.
  On [**10-4**], patient developed ten beats of polymorphic VT.  Blood
pressure remained stable.  Troponin was 0.02, but returned to
<0.01.  No acute EKG changes noted.  Monitored electrolytes to
ensure that K>4.0 and Mg>2.0.
.
6) Mental Status:
  Patient has history of CVA in [**2140**] that resulted in short term
memory loss.  During admission, patient oriented only to self
and place.  As hospital stay lengthened, patient became more
interactive.  The team tried to continually find a  balance
between pain relief and decreased mentation from pain
medications.
  As there was concern, initially, that mental status was not
improving, head CT performed on [**9-30**].  It revealed no
intracranial hemorrhage, but multiple chronic large and small
vessel infarctions.  An MRI of the head was not obtained.
.
7) Hypotension:
  Initially etiology for hypotension unclear.  Considered
potential infectious, versus acute bleeding episode.  Patient
responded well to fluid and blood transfusions after initial
episode of hypotension.  Bleeding resolved following hematocrit
drop before surgery.  Antibiotics started.  No further episodes
of hypotension during hospitalization.
.
8)  Hypertension:
  Continued patient on lisinopril, atenolol, and diltiazem.
.
9) Anemia:
  Following surgery on [**9-22**], patient required 2 units of packed
red blood cells.  Hematocrit has remained stable in the low 30's
since this event.
.
10) Hypothyroid:
  Patient was continued on levothyroxine during hospitalization.
.
11)  FEN:
  NGT placed during recovery from surgery.  With altered mental
status, patient aspiration risk.  On [**10-6**], patient passed speech
and swallow test to drink nectars and dysphagia solids.  Will
remove NGT once PICC line placed.  Discharged taking adequate PO
intake.
.
12)  Asthma:
  During admission, continued ibratropium nebulizers, as needed.
.
13) Prophylaxis:
  Patient placed on enoxaparin SC and a proton pump inhibitor
for GERD.
.
14) Access:
  Difficult to achieve access in patient.  Peripheral IVs were
tenuous.  Central IJ removed once PICC in place.
.
15) Dispo:
  DNR/DNI.
  Daughters actively involved in care.  [**Doctor Last Name **] is healthcare proxy
([**Telephone/Fax (1) **]).  Will be placed in rehabilitation facility
following hospital stay.


Medications on Admission:
1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:

One (1) Disk with Device Inhalation DAILY (Daily).
3. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY

(Daily).
6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID

(3 times a day).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic daily

14. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID

(2 times a day).
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed.
18. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
21. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
All: PCN/Sulfa/ASA/Heparin/Shellfish


Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1)  Nasal DAILY (Daily).
2. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
8. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
11. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
12. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).
13. Hydromorphone 2 mg/mL Syringe Sig: One (1)  Injection Q6H
(every 6 hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO TID (3 times a day).
16. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO ONCE
(Once) for 1 doses.
17. Gentamicin 90 mg IV Q24H
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day: Please alternate each day with 60 mg PO lasix.
19. Lasix 20 mg Tablet Sig: Three (3) Tablet PO every other day:
Please alternate with 40 mg every other day.
20. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
21. Atenolol 100 mg Tablet Sig: Three (3) Tablet PO once a day.

22. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
23. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
24. Outpatient Lab Work
Please draw weekly CBC, BUN, Cr, Gentamicin trough and peak
values and fax to Dr. [**Last Name (STitle) 3394**] at [**Telephone/Fax (1) 41334**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]

Discharge Diagnosis:
Primary:
-Left femur fracture
-Bacteremia
-Hypertension
-Atrial Fibrillation
.
Secondary:
-GERD
-CVA in [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
-Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]
-Hypothyroidism
-Asthma


Discharge Condition:
Stable.


Discharge Instructions:
**You were admitted for a femur and humeral fracture.  You
developed atrial fibrillation and then developed difficulty
breathing without supplemental oxygen.  In addition, you
developed an infection in your blood.
**During your stay, your leg fracture was operated upon and you
were treated for your blood and urine infections.
**You will be discharged home on a variety of medications, some
of which are new.  You should continue to take all your
medications that are ordered at discharge.
**You will need to remain on gentamycin for 2 weeks, until
[**10-18**].  You will remain on doxycycline and ciprofloxacin
for the remainder of your life.  If you develop a temperature,
you need to have blood cultures drawn immediately.  In there are
gram negative rods found in the culture, you need to be
transported IMMEDIATELY back to [**Hospital1 1170**] for IV antibiotic treatment.
**You no longer will take coumadin.
**If you develop chest pain, shortness of breath, or any other
concerning symptoms, you need to call your doctor or go to the
ED immediately.
**You will need to have weekly blood work faxed to Dr. [**Last Name (STitle) 3394**] at
[**Telephone/Fax (1) **] (CBC, Cr, BUN, gentamicin peak and trough).

Followup Instructions:
**You need to follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) 30642**] [**Name (STitle) **] ([**Telephone/Fax (1) **]) on Friday [**2144-10-23**] at 2:00pm.  [**Street Address(2) 41335**], [**Location (un) 620**], MA.
**You need to follow-up with your orthopedic surgeon, Dr.
[**Last Name (STitle) **] on [**2144-11-5**] at 10:00am ([**Location (un) **], [**Location (un) 551**]
[**Hospital Ward Name 23**] Building).  Phone number is [**Telephone/Fax (1) **].
**You need to follow-up with Dr. [**Last Name (STitle) 3394**] in the Infectious Disease
Clinic on [**10-27**] at 11am.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Closed fracture of shaft of femur,Closed fracture of unspecified part of lower end of humerus,Accidental fall from commode,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute posthemorrhagic anemia,Bacteremia,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Other postoperative infection,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter,Esophageal reflux'}


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: Status post fall.
Reason for MICU admission: tachycardia, falling hematocrit.

PRESENT ILLNESS: [**Age over 90 **] year old female with history of hypertension, asthma, CVA in
[**2140**] on anticoagulation, MRSA left hip infection in [**2142**] (on
life long doxycycline), transferred status post fall in commode
at OSH on [**2144-9-19**], while being treated for a UTI.  At the OSH,
patient found to have a right humeral and left distal femur
fracture.  There was no venous insufficiency, distally.
Preliminary reads at the OSH revealed no abnormalities on head
CT or cervical spine.  Patient's abdomen/pelvis were reported as
normal.
.
On presentation, found to have HR 120 BP 120's and O2 sat 100%
on 2L.  EKG revealed sinus tachycardia.  Pain was controlled
with morphine and tachycardia treated with metoprolol.
Ceftriaxone was continued for patient's UTI.  Shortly after
admission to orthopedics service, for impending surgery,
patient's hematocrit decreased from 31 to 25.6 in 6 hours.  Ct
was negative for hip bleed.  Right groin line was placed.  As
patient's blood pressure decreased to the 70's, responding to 2
liters IVF to the 90's, and O2 saturations that were in the
80's, but only returned to [**Location 213**] with 10L supplemental oxygen,
she was transferred to the medical ICU.  She spiked a fever to
100.0F, so vancomycin 1gm given for presumed line infection.
Her blood pressure remained tenuous, so she received a total of
4 units of packed red blood cells and 2 units of fresh frozen
plasma during these first several days.
While in the MICU, patient was noted to have NSTEMI, with
cardiac ECHO noted to reveal new global hypokinesis.  Troponins
elevated to 1.28, but subsequently trended downwards.  Following
surgery, she was noted to develop new-onset atrial fibrillation,
but she remained hemodynamically stable.  Patient was started on
metoprolol and lovenox and transferred to medicine floor for
medical management.

MEDICAL HISTORY: 1) Hypertension
2) GERD
3) CVA [**2140**] (residual short-term memory loss and diminished
vision bilaterally)
4) Right Hip Fracture s/p ORIF by Dr. [**Last Name (STitle) 28272**] in [**2-8**]:
complicated by infected prosthesis with enterobacter and MRSA.
Removal of Hardware  in [**1-9**].
5) Hypothyroidism
6) Asthma
7) Vertebral compression
8) hysterectomy
9) appendectomy
10) vertebroplasty: L1 and T12
11) MRSA/diskitis/epidural abscess

MEDICATION ON ADMISSION: 1. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Aspirin / Heparin Agents /
Shellfish

PHYSICAL EXAM: On admission:
VS Tc 99.0, P 100-115, BP 105/46, resp 18, 95% on 10 L face
tent.
Gen: elderly, chronically-ill appearing female, collar in place.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: No Tob/EtOH. Independent prior to 1st hip fracture.
Daughters [**Name (NI) **] (Healthcare proxy) and [**Name (NI) **] and son. 

### Response:
{'Closed fracture of shaft of femur,Closed fracture of unspecified part of lower end of humerus,Accidental fall from commode,Subendocardial infarction, initial episode of care,Atrial fibrillation,Acute posthemorrhagic anemia,Bacteremia,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Cellulitis and abscess of leg, except foot,Congestive heart failure, unspecified,Other postoperative infection,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Unspecified disorder of kidney and ureter,Esophageal reflux'}
