CHIEF COMPLAINT: right hip pain

PRESENT ILLNESS: Thank you very much for your request for consultation and
treatment of Mr. [**Known firstname 16619**] [**Known lastname **] for advanced osteoarthritis of
the left hip.  He has been seeing Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital1 18**]
musculoskeletal division and [**Doctor Last Name **] has referred the patient to me
as well.  It is his impression that at this point the patient
has
not had an adequate response either to medications or to an
intraarticular cortisone injection earlier this year and that
total hip replacement is his best course of action.  The patient
rates his pain at rest as [**5-21**], with activity [**9-20**].  All
interpretations are done via the Portuguese translator.  The
patient says that the pain has been progressive over the past
year, most intense with walking on uneven ground, ascending or
descending stairs or getting out of a seated position.  He had
very little relief with the cortisone injection even though was
well placed.

MEDICAL HISTORY: 1. Prostate cancer- s/p XRT from [**2170-1-10**] to [**2171-2-4**].
2. Diabetes Type II- controlled with Pioglitazone 15 mg pobid,
Glipizide XL 10mg poqd, and Metformin 1000 mg poqd.
3. HTN- Controlled with Amlodipine 10mg poqd and Valsartan 160
mg poqd.
4. Right hip pain- Pt. takes two alleve daily for pain relief.
5. Benign Prostatic Hypertrophy
6. Gastritis, esophagitis, doudenitis
7. Gastric ulcers in stomach body and antrum.
8. Hemmorrhoids.
9. H pylori
10. h/o GIB.

MEDICATION ON ADMISSION: diovan 160', norvasc 10', glucophage 1000", glucotrol XL 10',
actos 30', simvastatin 20'

ALLERGIES: Lisinopril / Aspirin

PHYSICAL EXAM: see HPI

FAMILY HISTORY: Mother died of ovarian cancer when she was 45. Father died of
prostate cancer when he was 89.

SOCIAL HISTORY: Pt lives at home with wife is now retired and has 7 children.
Pt states that he occasionally drinks 1 small glass of red wine
with dinner
Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Unspecified essential hypertension,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health
Loc osteoarth NOS-pelvis,Hemorrhage complic proc,Ac posthemorrhag anemia,Hypertension NOS,Thrombocytopenia NOS,DMII wo cmp nt st uncntr,BPH w/o urinary obs/LUTS,Hx-prostatic malignancy,Hx of irradiation
Admission Date:  [**2178-5-26**]              Discharge Date:   [**2178-6-3**]

Date of Birth:  [**2100-7-7**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Lisinopril / Aspirin

Attending:[**First Name3 (LF) 64**]
Chief Complaint:
right hip pain

Major Surgical or Invasive Procedure:
right total hip replacement


History of Present Illness:
Thank you very much for your request for consultation and
treatment of Mr. [**Known firstname 16619**] [**Known lastname **] for advanced osteoarthritis of
the left hip.  He has been seeing Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital1 18**]
musculoskeletal division and [**Doctor Last Name **] has referred the patient to me
as well.  It is his impression that at this point the patient
has
not had an adequate response either to medications or to an
intraarticular cortisone injection earlier this year and that
total hip replacement is his best course of action.  The patient
rates his pain at rest as [**5-21**], with activity [**9-20**].  All
interpretations are done via the Portuguese translator.  The
patient says that the pain has been progressive over the past
year, most intense with walking on uneven ground, ascending or
descending stairs or getting out of a seated position.  He had
very little relief with the cortisone injection even though was
well placed.


Past Medical History:
1. Prostate cancer- s/p XRT from [**2170-1-10**] to [**2171-2-4**].
2. Diabetes Type II- controlled with Pioglitazone 15 mg pobid,
Glipizide XL 10mg poqd, and Metformin 1000 mg poqd.
3. HTN- Controlled with Amlodipine 10mg poqd and Valsartan 160
mg poqd.
4. Right hip pain- Pt. takes two alleve daily for pain relief.
5. Benign Prostatic Hypertrophy
6. Gastritis, esophagitis, doudenitis
7. Gastric ulcers in stomach body and antrum.
8. Hemmorrhoids.
9. H pylori
10. h/o GIB.

Social History:
Pt lives at home with wife is now retired and has 7 children.
Pt states that he occasionally drinks 1 small glass of red wine
with dinner


Family History:
Mother died of ovarian cancer when she was 45. Father died of
prostate cancer when he was 89.

Physical Exam:
see HPI

Pertinent Results:
[**2178-5-26**] 10:32AM   freeCa-1.12
[**2178-5-26**] 10:32AM   HGB-9.8* calcHCT-29
[**2178-5-26**] 10:32AM   GLUCOSE-121* LACTATE-2.7* NA+-135 K+-4.3
CL--105 TCO2-27
[**2178-5-26**] 10:32AM   TYPE-[**Last Name (un) **] PH-7.42
[**2178-5-26**] 11:41AM   PLT COUNT-155
[**2178-5-26**] 11:41AM   WBC-9.9 RBC-4.20* HGB-11.5* HCT-34.5* MCV-82
MCH-27.4 MCHC-33.4 RDW-16.0*
[**2178-5-26**] 11:41AM   CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-1.7
[**2178-5-26**] 11:41AM   estGFR-Using this
[**2178-5-26**] 11:41AM   GLUCOSE-113* UREA N-13 CREAT-0.9 SODIUM-141
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2178-5-26**] 08:27PM   PLT COUNT-179
[**2178-5-26**] 08:27PM   WBC-14.1* RBC-3.09*# HGB-8.3*# HCT-26.4*
MCV-85 MCH-26.9* MCHC-31.5 RDW-15.5
[**2178-5-26**] 08:27PM   CALCIUM-7.7* PHOSPHATE-3.7 MAGNESIUM-1.4*
[**2178-5-26**] 08:27PM   GLUCOSE-222* UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14

Brief Hospital Course:
Pt was admitted to the hospital following the above mentioned
procedure - please see op report for details.  Postoperatively,
pt had low urine output and bleeding, and pt was admitted to the
ICU for serial Hcts and monitoring.  On POD1, pt was transfused
2U PRBCs, and on POD2 he received another 2U PRBCs for
persistent bleeding; he was hemodynamically stable during this
period.  While he was in the ICU, he worked some with PT, but
was limited secondary to pain.  Pt's Hct was stable throughout
the remainder of POD2 (following the transfusion) and on POD3,
after 4 stable serial Hcts, he was transferred to the floor, and
lovenox was started on [**5-30**] in the AM.
TLD: Pt's CVL was d/c'd on POD3, foley was d/c'd on POD4, and
his hemovac was d/c'd on POD1.
Pain: Pt's pain was initially trteated with a PCA, but this was
changed to po oxycodone post-operatively, and his pain was
treated with this an tylenol while in-house
ID: pt received perio-op ancef for 24 hrs
Activity: Pt was 50% WB with posterior precautions (for 6 weeks
post-op)



Medications on Admission:
diovan 160', norvasc 10', glucophage 1000", glucotrol XL 10',
actos 30', simvastatin 20'

Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed
for hip pain.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): sliding  scale.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily) for 3 weeks.
12. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
15. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day.

16. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
right hip arthritis


Discharge Condition:
stable


Discharge Instructions:
the following: chest pain, shortness of breath, severe
nausea/vomiting, fever greater than 101F, increasing redness or
drainage from your incision sites, or any other concerning
symptoms.
You should take all medications as prescribed.
You should be 50% WB on your right leg for 6 weeks.

Followup Instructions:
follow-up with Dr. [**Last Name (STitle) **] in 2 weeks - call for appt



Completed by:[**2178-5-31**]

Name:  [**Known lastname 2612**],[**Known firstname 2613**] L.              Unit No:   [**Numeric Identifier 2614**]

Admission Date:  [**2178-5-26**]              Discharge Date:   [**2178-6-3**]

Date of Birth:  [**2100-7-7**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Lisinopril / Aspirin

Attending:[**First Name3 (LF) 370**]
Addendum:
The patient remained in house from [**2178-5-31**] until [**2178-6-3**]
awaiting rehab placement.  There were no incidents or events
during this period of time.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 901**] - [**Location (un) 382**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 372**] MD [**MD Number(2) 373**]

Completed by:[**2178-6-3**]
{'Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Unspecified essential hypertension,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health'}


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: right hip pain

PRESENT ILLNESS: Thank you very much for your request for consultation and
treatment of Mr. [**Known firstname 16619**] [**Known lastname **] for advanced osteoarthritis of
the left hip.  He has been seeing Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the [**Hospital1 18**]
musculoskeletal division and [**Doctor Last Name **] has referred the patient to me
as well.  It is his impression that at this point the patient
has
not had an adequate response either to medications or to an
intraarticular cortisone injection earlier this year and that
total hip replacement is his best course of action.  The patient
rates his pain at rest as [**5-21**], with activity [**9-20**].  All
interpretations are done via the Portuguese translator.  The
patient says that the pain has been progressive over the past
year, most intense with walking on uneven ground, ascending or
descending stairs or getting out of a seated position.  He had
very little relief with the cortisone injection even though was
well placed.

MEDICAL HISTORY: 1. Prostate cancer- s/p XRT from [**2170-1-10**] to [**2171-2-4**].
2. Diabetes Type II- controlled with Pioglitazone 15 mg pobid,
Glipizide XL 10mg poqd, and Metformin 1000 mg poqd.
3. HTN- Controlled with Amlodipine 10mg poqd and Valsartan 160
mg poqd.
4. Right hip pain- Pt. takes two alleve daily for pain relief.
5. Benign Prostatic Hypertrophy
6. Gastritis, esophagitis, doudenitis
7. Gastric ulcers in stomach body and antrum.
8. Hemmorrhoids.
9. H pylori
10. h/o GIB.

MEDICATION ON ADMISSION: diovan 160', norvasc 10', glucophage 1000", glucotrol XL 10',
actos 30', simvastatin 20'

ALLERGIES: Lisinopril / Aspirin

PHYSICAL EXAM: see HPI

FAMILY HISTORY: Mother died of ovarian cancer when she was 45. Father died of
prostate cancer when he was 89.

SOCIAL HISTORY: Pt lives at home with wife is now retired and has 7 children.
Pt states that he occasionally drinks 1 small glass of red wine
with dinner 

### Response:
{'Osteoarthrosis, localized, not specified whether primary or secondary, pelvic region and thigh,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Unspecified essential hypertension,Thrombocytopenia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of prostate,Personal history of irradiation, presenting hazards to health'}
