CHIEF COMPLAINT: weakness and recent fall

PRESENT ILLNESS: 88yo F w/ h/o HTN, lower extremity edema and afib on coumadin
was brought in by family for concern of lethargy and found to be
hyponatremic to 106. Pt had an unwitnessed fall on Friday ([**8-5**])
but denies head strike or LOC. She briefly c/o posterior right
shoulder which resolved shortly afterwards. Family noticed that
pt had increasing fatigue and mild intermittent confusion over
the past week. Her son said that on Wednesday they were able to
complete a 2 block walk, longer than her usual walks, and did
not experience SOB but felt fatigued afterwards. Pt has not had
fever, chills, cough, shortness of breath, dysuria, abdominal
pain or bowel changes. However, family noted decreased appetite,
po intake and urine output during this time. Pt lives alone and
according to her son is normally quite functional and
independently prepares her own food, reliably takes her
medications and walks stably with a cane. Pt had complained of
increased lower extremity edema during this time and in an
effort to decrease edema pt reportedly decreased her fluid
intake. When son stayed with his mother over the weekend and
noticed decreased uop, the family recommended that she drink
free water. Per family report she continued to take her
prescibed doses of her medications, including anti-htn meds
HCTZ, diovan and felodipine. Pt has had chronic lower extremity
edema worsening over the past month and was evaluated by PCP [**Last Name (NamePattern4) **]
[**7-8**] and [**7-19**]. On both visits pt was found to have 3+ pitting
edema in lower extremities with clear lungs and non-elevated
JVP, not clinically determined to by volume overloaded. On [**7-8**]
pt was found to be hyponatremic to 128 (baseline Na 134-138 over
past year). PCP recommended compression stockings which she has
not been compliant with, and discontinuation of felodipine
however pt was hesitant to do so since she felt the CCB was
improving her bp. Also of note, on [**7-8**], pt's weight was 131.5lbs
(59 kilos) and had elevated INR of 4.7 (previously within [**1-8**]
INR goal, on [**2-22**] INR 2.4).

MEDICAL HISTORY: hypertension
hyperlipidemia
atrial fibrillation
glaucoma
cataracts
h/o DCIS, treated with lumpectomy and arimidex tx
old pulmonary nodule
thryoid nodule
s/p left insular cortex stroke and TIAs ([**2158**])

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 10 mg PO HS
2. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
3. Felodipine 2.5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Valsartan 160 mg PO BID
6. Warfarin 0.5 mg PO 2X/WEEK (TU,SA)
Tuesday and Saturday
7. Warfarin 1 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
10. Artificial Tears 1-2 DROP BOTH EYES PRN prn
11. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 97.8, hr 64, bp 147/78, rr 19, Sa02 93% on RA.
Weight 64.7 kilo (59 kilos at PCP's office on [**7-8**])
General: sleepy, drifting in and out of sleep during
interview/exam, oriented, no acute distress, primarily Russian
speaking, hard of hearing, son as well as daughter in law over
phone translated
[**Name (NI) 4459**]: Sclera anicteric, moderately dry mucous membranes,
oropharynx clear, EOMI, PERRL.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse crackles bilaterally, more course in bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley draining clear yellow urine
Ext: Warm, well perfused, 2+ pulses, 2+ lower extremity edema up
to mid shins bilaterally. No clubbing or cyanosis.
Neuro: A+Ox3 although slow to respond, CNII-XII intact, [**4-9**]
strength upper/lower extremities, grossly normal sensation, 2+
reflexes bilaterally, gait deferred.

FAMILY HISTORY: There is family history of strokes (mother and father)

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.   There is family
history of strokes (mother and father, lives alone, has children
that come to see her
Hyposmolality and/or hyponatremia,Acute on chronic diastolic heart failure,Thrombocytopenia, unspecified,Atrial fibrillation,Other and unspecified hyperlipidemia,Other alteration of consciousness,Long-term (current) use of anticoagulants,History of fall,Constipation, unspecified,Unspecified essential hypertension,Monocytosis (symptomatic),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified hearing loss
Hyposmolality,Ac on chr diast hrt fail,Thrombocytopenia NOS,Atrial fibrillation,Hyperlipidemia NEC/NOS,Other alter consciousnes,Long-term use anticoagul,Personal history of fall,Constipation NOS,Hypertension NOS,Monocytosis-symptomatic,Hx TIA/stroke w/o resid,Hearing loss NOS
Name:  [**Known lastname 1570**],[**Known firstname 1571**]                    Unit No:   [**Numeric Identifier 1572**]

Admission Date:  [**2168-8-8**]              Discharge Date:   [**2168-8-16**]

Date of Birth:  [**2080-5-9**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (un) 1573**]
Addendum:
Anticoagulation management plan:
[**Location (un) 382**] Health will manage her warfarin while she is in rehab,
[**Company 112**] Anticoagulation will resume management upon discharge to
home. Our contact information is: phone ?????? [**Telephone/Fax (1) 1574**]; fax
[**Telephone/Fax (1) 1575**]

Adding new follow-up appointment:
Department: [**Hospital3 762**]
When: THURSDAY [**2168-8-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 1216**], MD [**Telephone/Fax (1) 1576**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1577**]
Campus: EAST    Best Parking: [**Hospital Ward Name **] Garage

Your weight on the day of discharge was 52.4 kilograms.  We are
starting a diuretic (medication that makes you pee).  You should
check your weight daily, and if it is less than 51 kg, you
should stop taking the furosemide.


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 10 mg PO HS
2. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
3. Felodipine 2.5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Valsartan 160 mg PO BID
6. Warfarin 0.5 mg PO 2X/WEEK (TU,SA)
Tuesday and Saturday
7. Warfarin 1 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
10. Artificial Tears 1-2 DROP BOTH EYES PRN prn
11. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]


Discharge Medications:
1. Artificial Tears 1-2 DROP BOTH EYES PRN prn
2. Atorvastatin 10 mg PO HS
3. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
4. Warfarin 2.5 mg PO 2X/WEEK (TU,SA)
5. Warfarin 5 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Valsartan 160 mg PO BID
9. Furosemide 20 mg PO DAILY
Hold if weight goes below 51kg and notify PCP (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 690**]).


Discharge Disposition:
Home with Service

Facility:
[**Hospital 382**] Healthcare [**Hospital1 1354**]

Discharge Diagnosis:
Severe multifactorial hyponatremia
Atrial fibrillation on warfarin
Hypertension
Diastolic congestive heart failure
Chronic thrombocytopenia with monocytosis
Severe hearing loss


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted with a very low sodium concentration
(hyponatremia) in your body.  This was likely due to a
combination of factors, and you were treated for these.  To
prevent this from happening again, you need to make sure to not
drink too much fluid and likely you need to avoid certain
medications in the future.  Your weight on the day of discharge
was 52.4 kilograms.  We are starting a diuretic (medication that
makes you pee).  You should check your weight daily, and if it
is less than 51 kg, you should stop taking the furosemide.

Followup Instructions:
Anticoagulation
[**Location (un) 382**] Health will manage her warfarin while she is in rehab,
[**Company 112**] Anticoagulation will resume management upon discharge to
home. Our contact information is: phone ?????? [**Telephone/Fax (1) 1574**]; fax
[**Telephone/Fax (1) 1575**]

Department: [**Hospital3 762**]
When: THURSDAY [**2168-8-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 1216**], MD [**Telephone/Fax (1) 1576**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1577**]
Campus: EAST    Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2168-8-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 337**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2168-10-19**] at 2:15 PM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2168-10-19**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 1365**] [**Last Name (NamePattern4) 1580**], MD [**Telephone/Fax (1) 1581**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2168-12-7**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1582**], MD [**Telephone/Fax (1) 337**]
Building: [**Hospital6 189**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage


                             [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 1583**]

Completed by:[**2168-8-16**]

Admission Date:  [**2168-8-8**]              Discharge Date:   [**2168-8-16**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (un) 11220**]
Chief Complaint:
weakness and recent fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
88yo F w/ h/o HTN, lower extremity edema and afib on coumadin
was brought in by family for concern of lethargy and found to be
hyponatremic to 106. Pt had an unwitnessed fall on Friday ([**8-5**])
but denies head strike or LOC. She briefly c/o posterior right
shoulder which resolved shortly afterwards. Family noticed that
pt had increasing fatigue and mild intermittent confusion over
the past week. Her son said that on Wednesday they were able to
complete a 2 block walk, longer than her usual walks, and did
not experience SOB but felt fatigued afterwards. Pt has not had
fever, chills, cough, shortness of breath, dysuria, abdominal
pain or bowel changes. However, family noted decreased appetite,
po intake and urine output during this time. Pt lives alone and
according to her son is normally quite functional and
independently prepares her own food, reliably takes her
medications and walks stably with a cane. Pt had complained of
increased lower extremity edema during this time and in an
effort to decrease edema pt reportedly decreased her fluid
intake. When son stayed with his mother over the weekend and
noticed decreased uop, the family recommended that she drink
free water. Per family report she continued to take her
prescibed doses of her medications, including anti-htn meds
HCTZ, diovan and felodipine. Pt has had chronic lower extremity
edema worsening over the past month and was evaluated by PCP [**Last Name (NamePattern4) **]
[**7-8**] and [**7-19**]. On both visits pt was found to have 3+ pitting
edema in lower extremities with clear lungs and non-elevated
JVP, not clinically determined to by volume overloaded. On [**7-8**]
pt was found to be hyponatremic to 128 (baseline Na 134-138 over
past year). PCP recommended compression stockings which she has
not been compliant with, and discontinuation of felodipine
however pt was hesitant to do so since she felt the CCB was
improving her bp. Also of note, on [**7-8**], pt's weight was 131.5lbs
(59 kilos) and had elevated INR of 4.7 (previously within [**1-8**]
INR goal, on [**2-22**] INR 2.4).

Last echo (stress) [**5-12**]: normal LVEF >55%, no wall motion
abnormalities, no evidence of inducible ischemia, poor
functional exercise capacity. Mild to moderate mitral
regurgitation at rest. Moderate tricuspid regurgitation. Mild
pulmonary hypertension.

In the ED, initial VS were: 97.9 HR: 60 BP: 143/68 Resp: 22
SaO2Sat: 100. Labs notable for Na 106, K 2.9, Cl 73, Ca 7.9,
Phos 1.3, Mg 1.8.
CXR showed bilateral pleural effusions, pulmonary edema and
possible right lower lobe atelectasis. Pt was started on empiric
antibiotic coverage with ceftriaxone and azithromycin. Pt was
started on NS at 100cc/hr.

On arrival to the MICU, patient's VS were 97.8, hr 64, bp
147/78, rr 19, Sa02 93% on RA. Repeat labs after pt received
~150cc NS showed Na 106, K 3.1. Pt was continued on NS at
100cc/hr and electrolyes repleted with Mg sulfate, K phos and Ca
gluconate. After ~500cc NS repeat Na was still 106. After ~666cc
NS repeat Na was 107 and Ca 8.2, Phos 2.8, Mg 2.5. Renal was
consulted regarding starting hypertonic 3%NS.

Review of systems:
(+) Per HPI. Pt reported poor sleep over thursday and friday
nights for unclear reason and increased Tenderness near iv site
on right forarm that began in ED. Pt has chronic constipation
and has home bowel regimen.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, or wheezing.
Denies chest pain, chest pressure, palpitations. Denies
abdominal pain, diarrhea, dark or bloody stools. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.


Past Medical History:
hypertension
hyperlipidemia
atrial fibrillation
glaucoma
cataracts
h/o DCIS, treated with lumpectomy and arimidex tx
old pulmonary nodule
thryoid nodule
s/p left insular cortex stroke and TIAs ([**2158**])

Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.   There is family
history of strokes (mother and father, lives alone, has children
that come to see her


Family History:
There is family history of strokes (mother and father)

Physical Exam:
Vitals: 97.8, hr 64, bp 147/78, rr 19, Sa02 93% on RA.
Weight 64.7 kilo (59 kilos at PCP's office on [**7-8**])
General: sleepy, drifting in and out of sleep during
interview/exam, oriented, no acute distress, primarily Russian
speaking, hard of hearing, son as well as daughter in law over
phone translated
[**Name (NI) 4459**]: Sclera anicteric, moderately dry mucous membranes,
oropharynx clear, EOMI, PERRL.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse crackles bilaterally, more course in bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley draining clear yellow urine
Ext: Warm, well perfused, 2+ pulses, 2+ lower extremity edema up
to mid shins bilaterally. No clubbing or cyanosis.
Neuro: A+Ox3 although slow to respond, CNII-XII intact, [**4-9**]
strength upper/lower extremities, grossly normal sensation, 2+
reflexes bilaterally, gait deferred.



Pertinent Results:
[**2168-8-8**] 12:40PM   PT-52.3* PTT-48.9* INR(PT)-5.2*
[**2168-8-8**] 12:40PM   PLT SMR-LOW PLT COUNT-83*
[**2168-8-8**] 12:40PM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2168-8-8**] 12:40PM   NEUTS-75* BANDS-0 LYMPHS-12* MONOS-12* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2168-8-8**] 12:40PM   WBC-5.8 RBC-4.39 HGB-13.3 HCT-35.9* MCV-82
MCH-30.2 MCHC-37.0* RDW-12.8
[**2168-8-8**] 12:40PM   ALBUMIN-4.0
[**2168-8-8**] 12:40PM   CK-MB-11* MB INDX-6.6*
[**2168-8-8**] 12:40PM   cTropnT-<0.01
[**2168-8-8**] 12:40PM   LIPASE-54
[**2168-8-8**] 12:40PM   ALT(SGPT)-36 AST(SGOT)-40 CK(CPK)-167 ALK
PHOS-85 TOT BILI-1.4
[**2168-8-8**] 12:40PM   estGFR-Using this
[**2168-8-8**] 12:40PM   GLUCOSE-147* UREA N-15 CREAT-0.4 SODIUM-106*
POTASSIUM-2.9* CHLORIDE-73* TOTAL CO2-22 ANION GAP-14
[**2168-8-8**] 12:50PM URINE  RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2168-8-8**] 12:50PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2168-8-8**] 12:50PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2168-8-8**] 12:50PM URINE  UHOLD-HOLD
[**2168-8-8**] 12:50PM URINE  OSMOLAL-631
[**2168-8-8**] 12:50PM URINE  HOURS-RANDOM UREA N-872 CREAT-73
SODIUM-41 POTASSIUM-80 CHLORIDE-69
[**2168-8-8**] 12:51PM   LACTATE-1.5
[**2168-8-8**] 04:40PM   TSH-2.0
[**2168-8-8**] 04:40PM   OSMOLAL-220*
[**2168-8-8**] 04:40PM   proBNP-916*

On the day of discharge ([**2168-8-16**]), the patient's labs were:
Na 137, K 4.1, Cl 101, HCO3 26, BUN 19, Cr 0.6
INR pending

Brief Hospital Course:
88yo F w/ week of increasing fatigue, confusion and poor po
intake found to be hyponatremic to 106 with altered mental
status.
.
Severe symptomatic hyponatremia of unclear etiology, resolving
- admitted to the ICU for hypertonic saline and furosemide
- Nephrology consulted
- ultimately thought to have been multifactorial, possibly
diuretic related vs. SIADH
- volume status difficult to assess given the issues noted below
- fluid restriction 800mL/day
- stable Na for several days prior to discharge
- felodipine and HCTZ were stopped and should not be restarted
.
Pulmonary edema and lower extremity edema on admission
- found on CXR, and BNP was elevated
- attributed to her history of diastolic CHF (followed by Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 171**])
- repeat TTE this admission showed: EF>55%, right atrial
lengthening and moderate TR, MR, pulmonary hypertension. EKG in
ED did not show evidence of strain or ischemia. First set Tn-T
and CKMB within normal limits. Repeat BNP was similar to prior,
mildy elevated. Improvement in respiratory satus and decreased
O2 requirement with iv lasix suggested some volume over load
- her lower extremity edema was ultimately attributed to her
calcium channel [**Last Name (LF) 7005**], [**First Name3 (LF) **] felodipine was held
.
HTN, diastolic CHF
- anti-HTN management guided by Nephrology with PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) 11221**] and carvedilol were continued (latter at max
dose)
- stopped CCB given confusion about volume status (was it
causing leg swelling?)
- stopped HCTZ given likely contribution to hyponatremia
- restarted valsartan prior to discharge and titrated up to max
dose -- she may require addition of other agents if she remains
hypertensive as an outpatient
- hydralazine and clonidine could be considered (avoid more
B-[**Name10 (NameIs) 7005**], avoid diuretics, avoid CCBs)
.
Afib on warfarin (CHADS2 3 for CHF, HTN, age)
- carvedilol as above
- held warfarin intermittently given elevated INR [**Hospital **]
[**Hospital3 **] will be following post-discharge
.
Thrombocytopenia of unclear etiology with monocytosis
- abdominal ultrasound this admission showed no
hepatosplenomegaly
- fibrinogen normal
- normal platelets the day prior to discharge, but still with
abnormal diff, no sig change
- after d/w PCP plan is for outpt Hematology appointment (in
[**Month (only) **], see f/u section) with recheck of CBC in the interim
.
Other
- continued on her home artificial tears and timolol
.
Recent fall
- PT consult recommend [**Hospital1 1501**]

Day of discharge:
Interval history: There were no events the night prior to
discharge, including no confusion (had been an issue in the
ICU).  She felt ok, had no questions and understood the plan to
d/c to [**Hospital1 1501**].  Her family was involved in explaining this to her
in Russian.  All of their questions were answered.

Discharge day exam:
Vitals: afebrile, BP 150/82, HR 76, RR 16, sat 98% on RA
Gen: elderly woman seated next to bed eating, alert,
cooperative, very hard of hearing esp on L
[**Hospital1 4459**]: MMM
Chest: equal chest rise, no WOB, no cough, CTAB anteriorly
Heart: RRR, no m/r/g
Abd: soft, NTND
Extr: WWP, no sig pitting edema
Skin: no obvious rashes
Neuro: no obvious focal deficits, able to get to and from the
bathroom
Psych: normal affect

Discharge day labs noted above

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. [**Hospital1 **] 10 mg PO HS
2. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
3. Felodipine 2.5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Valsartan 160 mg PO BID
6. Warfarin 0.5 mg PO 2X/WEEK (TU,SA)
Tuesday and Saturday
7. Warfarin 1 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
10. Artificial Tears 1-2 DROP BOTH EYES PRN prn
11. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]


Discharge Medications:
1. Artificial Tears 1-2 DROP BOTH EYES PRN prn
2. [**Hospital1 **] 10 mg PO HS
3. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
4. Warfarin 2.5 mg PO 2X/WEEK (TU,SA)
5. Warfarin 5 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]
8. Valsartan 160 mg PO BID


Discharge Disposition:
Home with Service

Facility:
[**Hospital **] Healthcare [**Hospital1 1501**]

Discharge Diagnosis:
Severe multifactorial hyponatremia
Atrial fibrillation on warfarin
Hypertension
Diastolic congestive heart failure
Chronic thrombocytopenia with monocytosis
Severe hearing loss


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted with a very low sodium concentration
(hyponatremia) in your body.  This was likely due to a
combination of factors, and you were treated for these.  To
prevent this from happening again, you need to make sure to not
drink too much fluid and likely you need to avoid certain
medications in the future.

Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2010**]

Department: CARDIAC SERVICES
When: TUESDAY [**2168-8-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2168-10-19**] at 2:15 PM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2168-10-19**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 11223**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2168-12-7**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Last Name (un) **] MD [**MD Number(2) 11224**]

Completed by:[**2168-8-16**]
{'Hyposmolality and/or hyponatremia,Acute on chronic diastolic heart failure,Thrombocytopenia, unspecified,Atrial fibrillation,Other and unspecified hyperlipidemia,Other alteration of consciousness,Long-term (current) use of anticoagulants,History of fall,Constipation, unspecified,Unspecified essential hypertension,Monocytosis (symptomatic),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified hearing loss'}


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: weakness and recent fall

PRESENT ILLNESS: 88yo F w/ h/o HTN, lower extremity edema and afib on coumadin
was brought in by family for concern of lethargy and found to be
hyponatremic to 106. Pt had an unwitnessed fall on Friday ([**8-5**])
but denies head strike or LOC. She briefly c/o posterior right
shoulder which resolved shortly afterwards. Family noticed that
pt had increasing fatigue and mild intermittent confusion over
the past week. Her son said that on Wednesday they were able to
complete a 2 block walk, longer than her usual walks, and did
not experience SOB but felt fatigued afterwards. Pt has not had
fever, chills, cough, shortness of breath, dysuria, abdominal
pain or bowel changes. However, family noted decreased appetite,
po intake and urine output during this time. Pt lives alone and
according to her son is normally quite functional and
independently prepares her own food, reliably takes her
medications and walks stably with a cane. Pt had complained of
increased lower extremity edema during this time and in an
effort to decrease edema pt reportedly decreased her fluid
intake. When son stayed with his mother over the weekend and
noticed decreased uop, the family recommended that she drink
free water. Per family report she continued to take her
prescibed doses of her medications, including anti-htn meds
HCTZ, diovan and felodipine. Pt has had chronic lower extremity
edema worsening over the past month and was evaluated by PCP [**Last Name (NamePattern4) **]
[**7-8**] and [**7-19**]. On both visits pt was found to have 3+ pitting
edema in lower extremities with clear lungs and non-elevated
JVP, not clinically determined to by volume overloaded. On [**7-8**]
pt was found to be hyponatremic to 128 (baseline Na 134-138 over
past year). PCP recommended compression stockings which she has
not been compliant with, and discontinuation of felodipine
however pt was hesitant to do so since she felt the CCB was
improving her bp. Also of note, on [**7-8**], pt's weight was 131.5lbs
(59 kilos) and had elevated INR of 4.7 (previously within [**1-8**]
INR goal, on [**2-22**] INR 2.4).

MEDICAL HISTORY: hypertension
hyperlipidemia
atrial fibrillation
glaucoma
cataracts
h/o DCIS, treated with lumpectomy and arimidex tx
old pulmonary nodule
thryoid nodule
s/p left insular cortex stroke and TIAs ([**2158**])

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Atorvastatin 10 mg PO HS
2. Carvedilol 25 mg PO Q 8H atrial fibrillation
hold for sbp<100 and hr<60.
3. Felodipine 2.5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Valsartan 160 mg PO BID
6. Warfarin 0.5 mg PO 2X/WEEK (TU,SA)
Tuesday and Saturday
7. Warfarin 1 mg PO 5X/WEEK ([**Doctor First Name **],MO,WE,TH,FR)
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
10. Artificial Tears 1-2 DROP BOTH EYES PRN prn
11. Timolol Maleate 0.25% 1 DROP BOTH EYES [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 97.8, hr 64, bp 147/78, rr 19, Sa02 93% on RA.
Weight 64.7 kilo (59 kilos at PCP's office on [**7-8**])
General: sleepy, drifting in and out of sleep during
interview/exam, oriented, no acute distress, primarily Russian
speaking, hard of hearing, son as well as daughter in law over
phone translated
[**Name (NI) 4459**]: Sclera anicteric, moderately dry mucous membranes,
oropharynx clear, EOMI, PERRL.
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffuse crackles bilaterally, more course in bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley draining clear yellow urine
Ext: Warm, well perfused, 2+ pulses, 2+ lower extremity edema up
to mid shins bilaterally. No clubbing or cyanosis.
Neuro: A+Ox3 although slow to respond, CNII-XII intact, [**4-9**]
strength upper/lower extremities, grossly normal sensation, 2+
reflexes bilaterally, gait deferred.

FAMILY HISTORY: There is family history of strokes (mother and father)

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.   There is family
history of strokes (mother and father, lives alone, has children
that come to see her 

### Response:
{'Hyposmolality and/or hyponatremia,Acute on chronic diastolic heart failure,Thrombocytopenia, unspecified,Atrial fibrillation,Other and unspecified hyperlipidemia,Other alteration of consciousness,Long-term (current) use of anticoagulants,History of fall,Constipation, unspecified,Unspecified essential hypertension,Monocytosis (symptomatic),Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Unspecified hearing loss'}
