CHIEF COMPLAINT: On presentation to ICU: Hypotension after right THA

PRESENT ILLNESS: 67 yo M with complicated past medical history who had an
elective total right hip arthroplasty earlier today. During the
surgery he received 3500 mL of crystalloid and had 965 mL of
UOP. He was reported to have an EBL of 600 mL. He was noted to
be hypotensive in the PACU following the operation and was given
a single unit of PRBC with little effect on blood pressure. His
HCT was measured as 30.4 after that unit of blood (down from
baseline HCT of 33.8 pre-op). Additionally, patient had very low
urine output of < 5 mL/hr. He was placed on phenylephrine
peripherally to support his blood pressure and a transfer to the
ICU was requested. The PACU anesthesia attending was concerned
about fluid status and possibility of volume overload given that
patient is an extremely difficult intubation and has required
fiberoptic intubation in the past.

MEDICAL HISTORY: 1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy

MEDICATION ON ADMISSION: 1) Calcitriol 0.5 mg
2) Cozaar 50 mg daily
3) Finasteride 5 mg daily
4) Tamsulosin 0.8 mg at supper daily
5) Furosemide 80 mg TID
6) Lamotrigine 225 mg daily
7) Metolazone 2.5 mg PRN
8) Pantoprazole 40 mg daily
9) Simvastatin 10 mg QHS
10) Pramipexole 0.125 mg QHS
11) Oxycodone 5/325 1-2 tabs Q8H:PRN pain
12) Insulin glargine 18 units QHS
13) Insulin lispro sliding scale
14) Ipratropium bromide 1 spray each nostril TID:PRN rhinorrea
15) Ketoconazole 2% cream
16) Lactulose 1 tsp [**Hospital1 **]:PRN constipation
17) Aspirin 325 daily
18) Iron 65 mg daily
19) Omega 3 1200 mg TID
20) Miralax 1 tsp PRN constipation

ALLERGIES: Vicodin / Ms Contin / Gabapentin

PHYSICAL EXAM: Exam on presentation to ICU:
VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC
GENERAL: NAD aside from occasional right groin pain
HEENT:  PERRL, EOMI, no conjunctival pallor, no scleral icterus,
oral mucosa and lips extremely dry
NECK: Supple, No LAD, No thyromegaly, no JVP elevation
CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G
LUNGS: attenuated and decreased anterior breath sounds with
basilar crackles noted at midaxillary line bilaterally and
anterior, unable to obtain posterior exam due to patient
positioning
ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic
EXTREMITIES: Trace bipedal edema, compression stockings and
pneumoboots in place, right hip with large C/D/I bandage
overlying, right thigh soft though tender in right groin area,
bilateral radial pulses and hand cap refill preserved
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Brother-[**Name (NI) 2320**], h/o several strokes. Mother-dead in 70's from
breast cancer. Father-dead at 61 from complications of
emphysema, CHF. All children in good health.

SOCIAL HISTORY: Patient is a retired manager from the Polaroid companyx26 years,
referee in four sportsx40yrs (recently had to give up due to
health issues), lives in [**Hospital1 **] with wife. [**Name (NI) **] 3 children, in
good health, 4 grandchildren. EtOH use: occasional beer, no
smoking, no illicit drug use. Patient uses walker to get around
or electronic wheelchair.
Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Chronic kidney disease, unspecified,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Osteoarthros NOS-pelvis,Acute kidney failure NOS,Chr diastolic hrt fail,Ac posthemorrhag anemia,DMII neuro nt st uncntrl,Neuropathy in diabetes,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Chronic kidney dis NOS,Iatrogenc hypotnsion NEC,Obstructive sleep apnea,Ath ext ntv at w claudct,Depressive disorder NEC,Abn react-artif implant
Admission Date:  [**2145-11-2**]              Discharge Date:   [**2145-11-7**]

Date of Birth:  [**2078-1-6**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Vicodin / Ms Contin / Gabapentin

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
On presentation to ICU: Hypotension after right THA

Major Surgical or Invasive Procedure:
Right total hip arthroplasty

History of Present Illness:
67 yo M with complicated past medical history who had an
elective total right hip arthroplasty earlier today. During the
surgery he received 3500 mL of crystalloid and had 965 mL of
UOP. He was reported to have an EBL of 600 mL. He was noted to
be hypotensive in the PACU following the operation and was given
a single unit of PRBC with little effect on blood pressure. His
HCT was measured as 30.4 after that unit of blood (down from
baseline HCT of 33.8 pre-op). Additionally, patient had very low
urine output of < 5 mL/hr. He was placed on phenylephrine
peripherally to support his blood pressure and a transfer to the
ICU was requested. The PACU anesthesia attending was concerned
about fluid status and possibility of volume overload given that
patient is an extremely difficult intubation and has required
fiberoptic intubation in the past.

ROS:
(+)ve: fatigue, right groin pain, dry mouth, hunger
(-)ve: fever, chills, sweats, chest pain, palpitations,
orthopnea, paroxysmal nocturnal dyspnea, constipation, diarrhea,
sore throat, myalgias, nausea, vomiting

Past Medical History:
1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy

2) Chronic diastolic CHF
3) Chronic kidney disease (baseline Cr 2.4 - 2.8)
4) OSA (Mask Choice: Swift II NV, DME Ordered: BiPAP 14/11; EERS

100, 4L O2)
5) Polyneuropathy (hand and feet)
6) Spinal stenosis
7) Severe degenerative arthritis
8) Anemia of chronic disease
9) Chronic restrictive ventilatory disease secondary to a bile
duct
10) Leak with pulmonary fibrosis requiring decortication
11) PVD w/ ower extremity claudication
12) Benign prostatic hyperplasia
13) Glaucoma; on carbonic anhydrase inhibitor
14) Bilateral cataracts s/p surgical removal
15) Depression
16) Erectile dysfunction s/p penile implant [**11-6**]
.
PAST SURGICAL HISTORY:
1) [**2138**] Roux-en-y reconstruction after laparoscopic
cholecystectomy c/b damage to CBD
2) [**2139**] Decortication for fibrothorax complicated by respiratory

failure requiring tracheostomy.
3) Appendectomy.
4) Left knee/hip replacement
5) L shoulder AC recection


Social History:
Patient is a retired manager from the Polaroid companyx26 years,
referee in four sportsx40yrs (recently had to give up due to
health issues), lives in [**Hospital1 **] with wife. [**Name (NI) **] 3 children, in
good health, 4 grandchildren. EtOH use: occasional beer, no
smoking, no illicit drug use. Patient uses walker to get around
or electronic wheelchair.


Family History:
Brother-[**Name (NI) 2320**], h/o several strokes. Mother-dead in 70's from
breast cancer. Father-dead at 61 from complications of
emphysema, CHF. All children in good health.

Physical Exam:
Exam on presentation to ICU:
VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC
GENERAL: NAD aside from occasional right groin pain
HEENT:  PERRL, EOMI, no conjunctival pallor, no scleral icterus,
oral mucosa and lips extremely dry
NECK: Supple, No LAD, No thyromegaly, no JVP elevation
CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G
LUNGS: attenuated and decreased anterior breath sounds with
basilar crackles noted at midaxillary line bilaterally and
anterior, unable to obtain posterior exam due to patient
positioning
ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic
EXTREMITIES: Trace bipedal edema, compression stockings and
pneumoboots in place, right hip with large C/D/I bandage
overlying, right thigh soft though tender in right groin area,
bilateral radial pulses and hand cap refill preserved
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant


Pertinent Results:
[**2145-11-2**] 01:22PM   WBC-18.4*# RBC-3.40* HGB-10.7* HCT-30.4*
MCV-89 MCH-31.4 MCHC-35.2* RDW-13.7
[**2145-11-2**] 01:22PM   PLT COUNT-220
[**2145-11-2**] 01:22PM   GLUCOSE-230* UREA N-92* CREAT-2.8* SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
[**2145-11-2**] 01:22PM   CALCIUM-8.2* PHOSPHATE-5.4*# MAGNESIUM-2.2
[**2145-11-2**] 10:36PM   HCT-28.9*

[**2145-11-2**]: Right hip film:
Since the study of [**2145-3-10**], the patient has undergone a
total hip
arthroplasty. The current films are somewhat limited by
exposure. The
metallic components are in expected position. There is a
cerclage wire at the level of the lesser trochanter. The penile
prosthesis is partially
visualized. IMPRESSION: There has been a total hip arthroplasty.


[**2145-11-5**] 07:00AM BLOOD Hct-26.2*
[**2145-11-4**] 12:35PM BLOOD Hct-28.5*
[**2145-11-3**] 11:43AM BLOOD Hct-28.3*
[**2145-11-3**] 03:50AM BLOOD WBC-23.0* RBC-3.00* Hgb-9.4* Hct-27.0*
MCV-90 MCH-31.3 MCHC-34.8 RDW-14.3 Plt Ct-199
[**2145-11-2**] 10:36PM BLOOD Hct-28.9*

Brief Hospital Course:
MICU course:

67 year old male with complicated past medical history who had
an elective total right hip arthroplasty on [**2145-11-2**].

#. Post Operative Hypotension:  He had post-operative
hypotension requiring phenylephrine to keep mean blood pressure
in the 60s. His hypotension was associated with urine output
less than 5 mL/hr.  He was felt to be hypovolemic and was fluid
resuscitated with approximately 2 liters of LR.  It was felt
that he was likely third spacing after his hip surgery.
Post-operatively his hematocrit dropped slightly and he was also
given 1 unit of blood.

#. Hip fracture: His pain was relatively well-controlled,
initially with a Dilaudid PCA and then with oral Dilaudid prn.
He was also given Valium for anxiety and muscle spasms.  He was
given two doses of Vancomycin post-operatively.  His JP drain
was pulled on POD 1.

#. Acute on chronic renal failure: His creatinine increased
slightly from baseline (2.8 to 3.5) after admission, most likely
of prerenal etiology due to volume depletion. It trended down
with IV fluids.

#. Code Status: Full Code

Floor course
The patient
was initially treated with a PCA followed by PO pain medications
on POD#1.  The
patient received IV antibiotics for 24 hours postoperatively, as
well as lovenox
for DVT prophylaxis starting on the morning of POD#1.   The
drain was removed
without incident on POD#1. The Foley catheter was removed
without incident on POD 4 after a voiding trial. The
surgical dressing was removed on POD#2 and the surgical incision
was found to be
clean, dry, and intact without erythema or purulent drainage.

While in the hospital, the patient was seen daily by physical
therapy. Labs were
checked throughout the hospital course and repleted accordingly.
At the time of
discharge the patient was tolerating a regular diet and feeling
well.  The
patient was afebrile with stable vital signs.
The patient's hematocrit was stable, and the patient's pain was
adequately
controlled on a PO regimen. The operative extremity was
neurovascularly intact
and the wound was benign. The patient was discharged to home
with services or
rehabilitation in a stable condition.  The patient's
weight-bearing status was
weight bearing as tolerated with posterior precautions.


Medications on Admission:
1) Calcitriol 0.5 mg
2) Cozaar 50 mg daily
3) Finasteride 5 mg daily
4) Tamsulosin 0.8 mg at supper daily
5) Furosemide 80 mg TID
6) Lamotrigine 225 mg daily
7) Metolazone 2.5 mg PRN
8) Pantoprazole 40 mg daily
9) Simvastatin 10 mg QHS
10) Pramipexole 0.125 mg QHS
11) Oxycodone 5/325 1-2 tabs Q8H:PRN pain
12) Insulin glargine 18 units QHS
13) Insulin lispro sliding scale
14) Ipratropium bromide 1 spray each nostril TID:PRN rhinorrea
15) Ketoconazole 2% cream
16) Lactulose 1 tsp [**Hospital1 **]:PRN constipation
17) Aspirin 325 daily
18) Iron 65 mg daily
19) Omega 3 1200 mg TID
20) Miralax 1 tsp PRN constipation

Allergies: Vicodin/MSContin/Gabapentin

Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) vial Subcutaneous
once a day for 21 days.
Disp:*21 vials* Refills:*0*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain.
3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q 8H (Every 8 Hours).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
6. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO QD () for
5 days.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for edema.
8. Lamotrigine  Oral
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for dyspnea
or wheezing.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
Right hip OA


Discharge Condition:
good


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

experience
severe pain not relieved by medication, increased swelling,
decreased sensation,
difficulty with movement, fevers >101.5, shaking chills, redness
or drainage
from the incision site, chest pain, shortness of breath or any
other concerns.
2. Please follow up with your PCP regarding this admission and
any new
medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not operate heavy
machinery or drink alcohol when taking these medications. As
your pain improves,
please decrease the amount of pain medication. This medication
can cause
constipation, so you should drink plenty of water daily and take
a stool
softener (e.g., colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your
primary physician.
6. Please keep your wounds clean. You may get the wound wet or
take a shower
starting 5 days after surgery, but no baths or swimming for at
least 4 weeks. No
dressing is needed if wound continues to be non-draining. Any
stitches or
staples that need to be removed will be taken out by a visiting
nurse at 2 weeks
after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up
appointment at 4 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).

9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to
prevent deep
vein thrombosis (blood clots). Thrn take aspirin 325mg teice a
day for 3 weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower
after POD#5 but do not take a tub-bath or submerge your incision
until 4 weeks
after surgery. Please place a dry sterile dressing on the wound
each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be
removed by VNA in 2 weeks. If you are going to rehab, the rehab
facility can
remove the staples at 2 weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound
checks, and staple removal at 2 weeks after surgery.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous
exercise or heavy lifting until follow up appointment.

Physical Therapy:
weight bearing as tolerated with posterior precautions
Treatments Frequency:
WOUND CARE: Please keep your incision clean and dry. It is okay
to shower after
POD#5 but do not take a tub-bath or submerge your incision until
4 weeks after
surgery. Please place a dry sterile dressing on the wound each
day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of
infection such as redness or thick yellow drainage. Staples will
be removed by
VNA in 2 weeks. If you are going to rehab, the rehab facility
can remove the
staples at 2 weeks.
VNA (once at home): Home PT/OT, dressing changes as instructed,
wound checks,
and staple removal at 2 weeks after surgery.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2145-12-10**] 12:00



Completed by:[**2145-11-7**]
{'Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Chronic kidney disease, unspecified,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: On presentation to ICU: Hypotension after right THA

PRESENT ILLNESS: 67 yo M with complicated past medical history who had an
elective total right hip arthroplasty earlier today. During the
surgery he received 3500 mL of crystalloid and had 965 mL of
UOP. He was reported to have an EBL of 600 mL. He was noted to
be hypotensive in the PACU following the operation and was given
a single unit of PRBC with little effect on blood pressure. His
HCT was measured as 30.4 after that unit of blood (down from
baseline HCT of 33.8 pre-op). Additionally, patient had very low
urine output of < 5 mL/hr. He was placed on phenylephrine
peripherally to support his blood pressure and a transfer to the
ICU was requested. The PACU anesthesia attending was concerned
about fluid status and possibility of volume overload given that
patient is an extremely difficult intubation and has required
fiberoptic intubation in the past.

MEDICAL HISTORY: 1) Diabetes mellitus II c/b neuropathy, nephropathy, retinopathy

MEDICATION ON ADMISSION: 1) Calcitriol 0.5 mg
2) Cozaar 50 mg daily
3) Finasteride 5 mg daily
4) Tamsulosin 0.8 mg at supper daily
5) Furosemide 80 mg TID
6) Lamotrigine 225 mg daily
7) Metolazone 2.5 mg PRN
8) Pantoprazole 40 mg daily
9) Simvastatin 10 mg QHS
10) Pramipexole 0.125 mg QHS
11) Oxycodone 5/325 1-2 tabs Q8H:PRN pain
12) Insulin glargine 18 units QHS
13) Insulin lispro sliding scale
14) Ipratropium bromide 1 spray each nostril TID:PRN rhinorrea
15) Ketoconazole 2% cream
16) Lactulose 1 tsp [**Hospital1 **]:PRN constipation
17) Aspirin 325 daily
18) Iron 65 mg daily
19) Omega 3 1200 mg TID
20) Miralax 1 tsp PRN constipation

ALLERGIES: Vicodin / Ms Contin / Gabapentin

PHYSICAL EXAM: Exam on presentation to ICU:
VS: T 97.8, HR 87, BP 91/56, RR 12, O2Sat 100% 2L NC
GENERAL: NAD aside from occasional right groin pain
HEENT:  PERRL, EOMI, no conjunctival pallor, no scleral icterus,
oral mucosa and lips extremely dry
NECK: Supple, No LAD, No thyromegaly, no JVP elevation
CARDIAC: RR, distant heart sounds, nl S1, nl S2, no M/R/G
LUNGS: attenuated and decreased anterior breath sounds with
basilar crackles noted at midaxillary line bilaterally and
anterior, unable to obtain posterior exam due to patient
positioning
ABDOMEN: Obese, BS+, soft, NT, distended, tympanitic
EXTREMITIES: Trace bipedal edema, compression stockings and
pneumoboots in place, right hip with large C/D/I bandage
overlying, right thigh soft though tender in right groin area,
bilateral radial pulses and hand cap refill preserved
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Brother-[**Name (NI) 2320**], h/o several strokes. Mother-dead in 70's from
breast cancer. Father-dead at 61 from complications of
emphysema, CHF. All children in good health.

SOCIAL HISTORY: Patient is a retired manager from the Polaroid companyx26 years,
referee in four sportsx40yrs (recently had to give up due to
health issues), lives in [**Hospital1 **] with wife. [**Name (NI) **] 3 children, in
good health, 4 grandchildren. EtOH use: occasional beer, no
smoking, no illicit drug use. Patient uses walker to get around
or electronic wheelchair. 

### Response:
{'Osteoarthrosis, unspecified whether generalized or localized, pelvic region and thigh,Acute kidney failure, unspecified,Chronic diastolic heart failure,Acute posthemorrhagic anemia,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Chronic kidney disease, unspecified,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Atherosclerosis of native arteries of the extremities with intermittent claudication,Depressive disorder, not elsewhere classified,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
