CHIEF COMPLAINT: Fall, with gait instability

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is an 84 y.o woman with a history of HTN who
presents with multiple falls, with recent associated
orbital/facial fractures, found to have a small SDH and
hyponatremia following a subsequent fall leading to this
admission.
.
She was first admitted to [**Hospital1 18**] on [**2191-7-28**] after a mechanical
fall down an escalator, approximately 20 feet.  Fall was
unwitnessed but does not recall what happened before the fall;
lost conciousness and woke up in the hospital. CT Max/sinus
obtained during that admission revealed multiple facial
fractures including fractures of the right orbital floor,
lateral wall, lamina papyracea, right zygoma, all walls of the
right maxillary sinus, lateral portion of the right glenoid
fossa, and right lateral pterygoid. She returned for plastic
surgery to repair the fractures on [**2191-8-8**], and had a ORIF Right
Lefort III and closed reduction nasal fracture.
.
She then fell again at home on [**2191-8-15**], when she was walking in
front of her daughter while carrying a plate. Per daughter, the
patient may have caught her foot and fallen, no observed
convulsions. Patient reports no memory of the fall, but denies
any CP, SOB, palpitations, lightheadedness, confusion after the
fall, tongue biting, or urinary incontinence.  No history of
seizures. Daughter reports history of multiple falls over the
past ~2 years, always associated with tripping or instability.
The patient has very little memory of these events and is unable
to explain what she experienced during them. 1.5 years ago she
tripped while alone at home; also tripped while walking up
stairs in 11/[**2190**]. Daughter feels she is having more trouble
lifting up her feet, particularly when she is tired. Currently
does not use walker or cane to ambulate. Daughter reports she is
followed by cardiologist [**First Name9 (NamePattern2) 25495**] [**Last Name (un) 112352**] in [**Location (un) 47**] and had 24
hour monitor (likely Holter), unrevealing.
.
Daughter also reports a history of episodes of "spacing out"
which last a few minutes; have been occuring for the past year
or so. After spacing out, she has an exaggerated yawn and then
"passes out" followed 1-2 minutes later by needing to have a BM.
Reports she had an EEG about 2 years ago at [**Location (un) 47**] [**Hospital1 **]
which was unrevealing.
.
At an OSH she was found to have a small SDH, which has been
stable on serial CT head imaging.  On the floor, the patient is
comfortable, denies any pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.

MEDICAL HISTORY: ORIF Right Lefort III, closed reduction nasal fracture
HTN
GERD
Benign lump removed from neck
Multiple cystic lesions removed from breast in past, told she
has fibrocystic disease
Arthritis of knees, hands, shoulders, and feet

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atenolol 25 mg PO BID
2. Atorvastatin 20 mg PO HS
3. losartan-hydrochlorothiazide *NF* 100-25 mg Oral Daily
4. Omeprazole 20 mg PO DAILY
5. cefaDROXil *NF* 500 mg Oral Q 12 hrs
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
O: T: 97.8 BP: 159/65   HR: 74 R 18 O2Sats 98%
Gen: WD/WN, comfortable
HEENT: Pupils: Right edema with irregular pupil.Left: [**5-3**].
Significant right orbital edema
EOMs no difficulty with left eye
Neck: non tender
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Two children ([**Doctor First Name **] and [**Doctor First Name **]), 2 grandchildren. Lives with
daughter. Denies any smoking history; no EtOH, no illicits.
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other disorders of neurohypophysis,Hypovolemia,Secondary hyperparathyroidism, non-renal,Other and unspecified superficial injuries of eye,Fall from other slipping, tripping, or stumbling,Aftercare for healing traumatic fracture of other bone,Cerebral atherosclerosis,Unspecified vitamin D deficiency,Benign essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Adhesive capsulitis of shoulder,Arthropathy, unspecified, multiple sites,Solitary pulmonary nodule,Lump or mass in breast
Subdural hem w/o coma,Neurohypophysis dis NEC,Hypovolemia,Sec hyprprthyrd nonrenal,Superficial inj eye NEC,Fall from slipping NEC,Aftrce traum fx bone NEC,Cerebral atherosclerosis,Vitamin D deficiency NOS,Benign hypertension,Hyperlipidemia NEC/NOS,Esophageal reflux,Adhesive capsulit shlder,Arthropathy NOS-mult,Solitary pulmonry nodule,Lump or mass in breast
Admission Date:  [**2191-8-15**]              Discharge Date:   [**2191-8-21**]

Date of Birth:  [**2106-12-7**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Fall, with gait instability

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Known firstname **] [**Known lastname **] is an 84 y.o woman with a history of HTN who
presents with multiple falls, with recent associated
orbital/facial fractures, found to have a small SDH and
hyponatremia following a subsequent fall leading to this
admission.
.
She was first admitted to [**Hospital1 18**] on [**2191-7-28**] after a mechanical
fall down an escalator, approximately 20 feet.  Fall was
unwitnessed but does not recall what happened before the fall;
lost conciousness and woke up in the hospital. CT Max/sinus
obtained during that admission revealed multiple facial
fractures including fractures of the right orbital floor,
lateral wall, lamina papyracea, right zygoma, all walls of the
right maxillary sinus, lateral portion of the right glenoid
fossa, and right lateral pterygoid. She returned for plastic
surgery to repair the fractures on [**2191-8-8**], and had a ORIF Right
Lefort III and closed reduction nasal fracture.
.
She then fell again at home on [**2191-8-15**], when she was walking in
front of her daughter while carrying a plate. Per daughter, the
patient may have caught her foot and fallen, no observed
convulsions. Patient reports no memory of the fall, but denies
any CP, SOB, palpitations, lightheadedness, confusion after the
fall, tongue biting, or urinary incontinence.  No history of
seizures. Daughter reports history of multiple falls over the
past ~2 years, always associated with tripping or instability.
The patient has very little memory of these events and is unable
to explain what she experienced during them. 1.5 years ago she
tripped while alone at home; also tripped while walking up
stairs in 11/[**2190**]. Daughter feels she is having more trouble
lifting up her feet, particularly when she is tired. Currently
does not use walker or cane to ambulate. Daughter reports she is
followed by cardiologist [**First Name9 (NamePattern2) 25495**] [**Last Name (un) 112352**] in [**Location (un) 47**] and had 24
hour monitor (likely Holter), unrevealing.
.
Daughter also reports a history of episodes of "spacing out"
which last a few minutes; have been occuring for the past year
or so. After spacing out, she has an exaggerated yawn and then
"passes out" followed 1-2 minutes later by needing to have a BM.
Reports she had an EEG about 2 years ago at [**Location (un) 47**] [**Hospital1 **]
which was unrevealing.
.
At an OSH she was found to have a small SDH, which has been
stable on serial CT head imaging.  On the floor, the patient is
comfortable, denies any pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.

Past Medical History:
ORIF Right Lefort III, closed reduction nasal fracture
HTN
GERD
Benign lump removed from neck
Multiple cystic lesions removed from breast in past, told she
has fibrocystic disease
Arthritis of knees, hands, shoulders, and feet

Social History:
Two children ([**Doctor First Name **] and [**Doctor First Name **]), 2 grandchildren. Lives with
daughter. Denies any smoking history; no EtOH, no illicits.

Family History:
non-contributory

Physical Exam:
On Admission:
O: T: 97.8 BP: 159/65   HR: 74 R 18 O2Sats 98%
Gen: WD/WN, comfortable
HEENT: Pupils: Right edema with irregular pupil.Left: [**5-3**].
Significant right orbital edema
EOMs no difficulty with left eye
Neck: non tender
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

Language: Speech fluent with good comprehension and repetition.

Cranial Nerves:
I: Not tested
II: Pupils: Right edema with steri strips, not assessed.Left:
[**5-3**].
III, IV, VI: Extraocular movements intact left without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Deltoid assessment limited by ROM, [**Hospital1 **]/Tri/Grip and LE's
[**6-4**]. Good sensation. No [**Doctor Last Name 937**] sing, no clonus.

Sensation: Intact to light touch.

Coordination: Exam limited but decreased ROM of L shoulder and
edematous R eye. Dysmetria Bilaterally, L>R. Impaired R rapid
alternating movements, heel to shin

On Discharge:
Vitals: T: 97.4  BP: 132/55  P: 79 R: 18 O2: 97% RA
FSBG: 111, 122, 101, 116, 110
General: Alert, oriented, no acute distress
Skin: No rashes or jaundice
HEENT: Right eye swollen but continuing to improve, eye now more
open, conjunctival injection of right eye; EOM intact
bilaterally; sclera anicteric, MMM, oropharynx clear
Neck: supple, no masses
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no clubbing, cyanosis or edema, right
second toe overlapping first toe
Neuro: A&Ox3, strength 5/5 in upper and lower extremities;
sensation intact; CN grossly intact


Pertinent Results:
CBC:
Admission: [**2191-8-15**] 10:21PM BLOOD WBC-11.5* RBC-3.87*#
Hgb-11.9*# Hct-34.7* MCV-90 MCH-30.8 MCHC-34.3 RDW-14.3 Plt
Ct-428
Diff: [**2191-8-15**] 10:21PM BLOOD Neuts-84.2* Lymphs-10.3* Monos-4.0
Eos-0.7 Baso-0.7
Discharge: [**2191-8-21**] 08:20AM BLOOD WBC-7.3 RBC-3.75* Hgb-11.6*
Hct-34.6* MCV-92 MCH-30.8 MCHC-33.4 RDW-14.0 Plt Ct-385

Coags: [**2191-8-15**] 10:21PM BLOOD PT-11.0 PTT-26.0 INR(PT)-1.0

Electrolytes:
Admission: [**2191-8-15**] 10:21PM BLOOD Glucose-106* UreaN-22*
Creat-0.8 Na-125* K-4.7 Cl-87* HCO3-27 AnGap-16
[**2191-8-16**] 05:30AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.7 Mg-1.8
Discharge: [**2191-8-21**] 08:20AM BLOOD Glucose-109* UreaN-23*
Creat-0.8 Na-134 K-4.7 Cl-99 HCO3-24 AnGap-16
[**2191-8-21**] 08:20AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0

TSH: [**2191-8-17**] 08:04AM BLOOD TSH-4.4*
Cortisol: [**2191-8-17**] 08:04AM BLOOD Cortsol-15.3

PTH: [**2191-8-16**] 05:30AM BLOOD PTH-75*
Vit D: [**2191-8-17**] 02:03AM BLOOD 25VitD-26*

Urine:
[**2191-8-16**] 03:52PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2191-8-16**] 05:04AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-TR
[**2191-8-16**] 03:52PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2191-8-16**] 05:04AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
[**2191-8-16**] 05:04AM URINE Hours-RANDOM Na-41 K-99 Cl-47
[**2191-8-16**] 03:52PM URINE Hours-RANDOM Creat-15 Na-58 K-22 Cl-47
[**2191-8-16**] 05:04AM URINE Osmolal-505
[**2191-8-16**] 03:52PM URINE Osmolal-233

Micro:    MRSA SCREEN (Final [**2191-8-18**]):    No MRSA isolated.

EKG: [**2191-8-18**]: Sinus rhythm, rate 76. Left axis deviation,
likely due to left anterior fascicular block. Compared to the
previous tracing of [**2191-7-30**] the axis is more leftward. The other
findings are similar.

IMAGING:
[**2191-8-16**] Portable CT w/o contrast:
COMPARISON:  CT head without IV contrast performed [**2191-8-15**].

FINDINGS:  Evaluation of the brain tissue is slightly limited
due to the
patient's motion.

There is a 7-mm subdural hematoma in the temporoparietal region
as well as a
right 4-mm subdural hematoma located in the occipital region,
both slightly
decreased in size compared to prior study.

The patient is status post open reduction and internal fixation
of right orbital fractures.  Surgical mesh is seen in the right
orbit.  There is no evidence of herniation of muscle or fat
through the inferior orbital wall.  The multiple fractures
involving the right orbit, axilla and zygomatic process are
better seen and detected on prior studies.  There is persistent
soft
tissue swelling around the right orbit.  The globes are intact
bilaterally.  There is bilateral opacification of the maxillary
sinus.  There is opacification of the ethmoid air cells on the
right.

Normally midline structures are unremarkable.  The basal cistern
appears patent and there is preservation of [**Doctor Last Name 352**]-white
differentiation.  The mastoid air cells and middle ear cavities
are clear.  There is no significant change and no new findings
compared with the prior study.

There is calcification in the basal ganglia bilaterally and in
the dentate nuclei of the cerebellum bilaterally consistent with
possible Fahr's disease or hyperthyroid dysfunction, that is
unchanged compared to prior study.

IMPRESSION:  Multiple fractures including the right orbital
floor, maxilla and zygomatic process, unchanged from prior
studies with persistent soft tissue swelling around the right
orbit.  There is no significant change compared to prior study
and no new findings.


[**2191-8-18**] CT w/o contrast:
FINDINGS:  The right occipital subdural hematoma is now barely
visible and the larger right parietal subdural hematoma has also
decreased in size, with a maximum depth of 7 mm.  There is
persistent minimal mass effect from the subdural hematoma in the
form of regional sulcal effacement.  There is no shift of
normally midline structures.  The ventricles and sulci are
otherwise normal in size and configuration.  Bilateral corona
radiata, basal ganglionic
and cerebellar dentate nuclear mineralization is most consistent
with underlying Fahr disease or, less likely, hyper- or
hypoparathyroidism, as before.  There is no evidence of acute
vascular territorial infarction.  Multiple fractures of the
right orbit, maxilla, and zygomatic process appear stable.  The
mastoid air cells and middle ear cavities are clear.

IMPRESSION:
1.  Interval decrease in size of right convexity subdural
hematoma due to redistribution/resorption.
2.  No new acute intracranial process to explain patient's
clinical decline is identified.
3.  Likely underlying Fahr disease; correlate with clinical
evidence of movement disorder.

EEG: [**2191-8-17**]: FINDINGS:
ABNORMALITY #1: Background activity over the left hemisphere
consists of predominantly mixed [**6-6**] Hz theta with some delta
activity. During the awake state, the maximum alpha rhythm on
the left hemisphere is [**8-7**] Hz.
ABNORMALITY #2: There is absence of posterior rhythm over the
right hemisphere. There is continuous low amplitude slowing on
the right hemisphere with attenuation of faster frequencies.
BACKGROUND: Background activity over the left hemisphere
consists of predominantly mixed [**6-6**] Hz theta with some delta
activity. During the awake state, the maximum alpha rhythm on
the left hemisphere is [**8-7**] Hz. There is absence of posterior
rhythm over the right hemisphere. There is continuous low
amplitude slowing on the right hemisphere with attenuation of
faster frequencies.
HYPERVENTILATION: Is not performed due to portable study.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation is
not performed due to portable study.
SLEEP: Sleep is not recorded.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm with an average rate of 100-120 bpm.
IMPRESSION: This is an abnormal waking EEG because of due to
slow posterior dominant rhythm, continuous focal slowing, absent
alpha rhythm, and attenuation of faster frequencies over the
right hemisphere indicative of focal cortical and subcortical
dysfunction on the right likely secondary to subdural hematoma.
In the left hemisphere, there is mild to moderate diffuse
background slowing indicative of mild to moderate diffuse
cerebral dysfunction which is etiologically non-specific. No
epileptiform discharges or electrographic seizures are present.


Brief Hospital Course:
This is an 84 y.o woman with a history of HTN who presents with
multiple falls of unknown etiology, orbital/facial fractures,
found to have a small SDH and hyponatremia. She is also
confirmed to have bilateral brain calcifications in the basal
ganglia and cerebellum seen on her recent admission, which are
concerning for Fahr's disease and could at least partially
explain the patient's reported gait abnormalities and recurrent
falls. Decreased oral intake in the setting of her recent facial
fracture, as well as now-discontinued HCTZ likely contributed to
the fall leading to this admission, as well.
.
# Falls:  As noted, there is a strong suspicion that the
patient's falls may be related to the calcifications noted on
imaging, and the clarification of the diagnosis will require
close neurology follow-up. We discussed with the patient and her
HCP that we do not yet have a prognosis associated with the
possible diagnosis, but that this should be forthcoming as her
outpatient work-up continues.  Per the patient's and her
daughter's story of the falls, they appear to be due to a
worsening unsteady gait leading to mechanical falls.  The
patient has little recollection of the falls, but per her
daughter she does not lose consciousness prior to falling.  The
unsteady gait may be associated with the significant basal
ganglia and cerebellum calcifications, likely representing
Fahr's disease, as noted below. She was evaluated by neurology
who did not note a clear movement disorder or ataxia. While
inpatient, cardiac causes for falls were ruled out with a normal
EKG and no events on telemetry.  She had an EEG which did not
have evidence of epilepsy; however, given her daughter's
descriptions of "spacing out" seizures remain possible. While
inpatient, she was maintained on [**Month/Day (3) 13401**] largely due to the
subdural hematoma (see below), but will continue this until her
outpatient neurology follow up in a month.  While inpatient she
also worked with physical therapy to build up her strength and
was given a walker to use at home; she will continue with
outpatient physical therapy at home and will be re-evaluated by
neurology in one month to reassess her gait.
.
# Calcifications in basal ganglia and cerebellum: Noted on CT,
likely Fahr's disease.   She had a metabolic work up to
determine other causes of calcification, which revealed a mildly
elevated PTH determined to be due to vitamin D deficiency, but
this was not felt adequate to explain the degree of
calcifications.  She was started on vitamin D repletion, per
below. Per neurology, if the calcifications do represent Fahr's
disease, there may not be a specific treatment to reverse this
condition.
.
# Vitamin D deficiency: Normal Ca and Phos, mildly elevated PTH,
consistent with secondary hyperparathyroidism due to vitamin D
deficiency, will likely resolve with repletion of vitamin D.
Started on vitamin D [**2179**] units daily, to be continued on
discharge.
.
# Hyponatremia: Given urine electrolytes and euvolemia, likely
secondary to SIADH associated with the SDH, in the setting of
recently-started HCTZ. Improved from 125 to 135 with a 1200 cc
fluid restriction, which was then stable on the last day despite
liberalizing the restriction to [**2179**] cc daily.  Her HCTZ was
also held, as this was likely contributing to the hyponatremia,
and we suggested that this [**Doctor Last Name 360**] not be restarted in the future
to the patient and family.
.
# SDH: Right occipital SDH and right parietal SDH initially
visualized at an OSH. Most recent head CT on [**2191-8-18**] showed that
"the right occipital subdural hematoma is now barely visible and
the larger right parietal subdural hematoma has also decreased
in size, with a maximum depth of 7 mm." She had no focal
deficits or evidence of seizure. She was started on [**Date Range 13401**] 750
mg [**Hospital1 **] for seizure ppx and will continue for one month after
discharge.
.
# Right eye injury: The patient had a recent facial/orbital
fracture with repair and plate placement by plastic surgery on
[**2191-8-8**].  She was seen by plastic surgery on this admission, who
noted no new fractures and confirmed that the plate remained in
place. She was also seen by ophthalmology in the ED. She was
continued on dorzolamide eye drops throughout her admission, and
her right eye improved significantly, with improvement both in
swelling and in vision.
.
# HTN: Has been on atenolol and more recently added losartan and
HCTZ at home. In hospital, HCTZ stopped due to hyponatremia.
Losartan was continued on her home dose. Her atenolol was also
decreased to 12.5 mg daily because her blood pressure had been
running low; now with SBP in the 120s-130s on day of discharge.
.
# Hyperlipidemia: Stable, continued home atorvastatin.
.
# GERD: Stable, continued home omeprazole.
.
# RUL pulmonary nodule: Incidental finding on CT at last
admission; patient reminded of this finding and encouraged to
follow up with PCP.
.
# Left breast mass (incidental finding): Incidental finding on
CT at last admission; patient reminded of this finding and
encouraged to follow up with PCP.
.
# Goals of care: Confirmed full code.  Primary contact is
daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 112353**] or cell [**Telephone/Fax (1) 112354**]; second
contact is [**Name (NI) **] [**Name (NI) **] [**0-0-**] (ok to leave messages)
.
# Transitions
1) Sodium to be rechecked outpatient [**2191-8-23**]
2) Home PT, new assistive device (walker)
3) Follow up with neurology in 1 month for further discussion of
potential diagnosis and prognosis.
4) Now on [**Month/Day/Year 13401**], likely will be able to discontinue this
medication in 1 month at neurology follow up
5) Blood pressure medications decreased to continue home
losartan, continue atenolol but at lower dose (12.5 mg daily),
and stop HCTZ given hyponatremia
6) On continued fluid restriction at [**2179**] cc daily; will need to
be monitored by PCP
7) Incidental findings on CT at last admission that need follow
up: left breast mass and RUL pulmonary nodule

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atenolol 25 mg PO BID
2. Atorvastatin 20 mg PO HS
3. losartan-hydrochlorothiazide *NF* 100-25 mg Oral Daily
4. Omeprazole 20 mg PO DAILY
5. cefaDROXil *NF* 500 mg Oral Q 12 hrs
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]


Discharge Medications:
1. Outpatient Lab Work
Please check sodium on [**8-23**] and fax results to [**Telephone/Fax (1) 46473**].
Icd-9 code: hyponatremia
2. Atenolol 12.5 mg PO DAILY
Hold for SBP < 110, HR < 60
3. Atorvastatin 20 mg PO HS
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]
5. Omeprazole 20 mg PO DAILY
6. LeVETiracetam 750 mg PO BID
7. Vitamin D [**2179**] UNIT PO DAILY
8. Losartan Potassium 25 mg PO DAILY
Hold for SBP < 110
9. Senna 1 TAB PO BID:PRN Constipation
10. Docusate Sodium (Liquid) 100 mg PO BID


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Right Acute Subdural Hematoma
Hyponatremia
Bilateral Basal Ganglia Calcifications
Bilateral Cerebellar Calcifications


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

It was a pleasure participating in your care at [**Hospital1 18**].  You were
admitted after a fall in which you hit your right eye.  As you
recently had surgery for repair of a facial fracture in the same
location, you were seen by your plastic surgeon.  You do not
have any new fractures, and the surgical plate is still in the
right place.

As a result of the fall, you were found to have a small bleed in
your brain called a subdural hematoma, which has remained stable
throughout your hospital stay. You were started on [**Last Name (LF) 13401**], [**First Name3 (LF) **]
anti-seizure medication, to prevent seizures that sometimes
occur when people have blood in the brain. You should continue
this medication until you follow up with your neurologist in
about one month. You did have an EEG while you were here which
did not show any evidence of seizures.

As a result of the bleed in your brain, you developed low sodium
in the blood.  This improved with daily fluid restriction to 2
L.  Please continue this when you go home until you see your
primary care physician, [**Name10 (NameIs) 10139**] you should discuss this with them.
We also stopped your HCTZ, which was likely contributing to the
low sodium. You will need to have your sodium rechecked
outpatient on [**2191-8-22**].

You were also found to have calcifications in your brain located
in the basal ganglia and cerebellum, which are areas of the
brain involved with movement and balance. This may be something
called Fahr syndrome, and these may be contributing to your
falls.  The neurology team evaluated you and did not note
significant problems with your ability to walk and no other
movement disorders; however, they would like to follow up with
you in one month to re-evaluate how you are walking.  You will
have home physical therapy to help gain your strength back to
help prevent future falls.

You were also evaluated for other causes of falls, and you did
not have any sign of a cardiac cause for the falls such as an
arrhythmia. You did not drop your blood pressure when standing,
which can be a cause for falls.

Also please remember to follow up with your primary care doctor
about the lung nodule and breast mass that were identified
incidentally on imaging.

General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Use an over the counter stool softener (such as Colace), as
narcotic pain medicine can cause constipation.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.



Completed by:[**2191-8-22**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other disorders of neurohypophysis,Hypovolemia,Secondary hyperparathyroidism, non-renal,Other and unspecified superficial injuries of eye,Fall from other slipping, tripping, or stumbling,Aftercare for healing traumatic fracture of other bone,Cerebral atherosclerosis,Unspecified vitamin D deficiency,Benign essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Adhesive capsulitis of shoulder,Arthropathy, unspecified, multiple sites,Solitary pulmonary nodule,Lump or mass in breast'}


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: Fall, with gait instability

PRESENT ILLNESS: [**Known firstname **] [**Known lastname **] is an 84 y.o woman with a history of HTN who
presents with multiple falls, with recent associated
orbital/facial fractures, found to have a small SDH and
hyponatremia following a subsequent fall leading to this
admission.
.
She was first admitted to [**Hospital1 18**] on [**2191-7-28**] after a mechanical
fall down an escalator, approximately 20 feet.  Fall was
unwitnessed but does not recall what happened before the fall;
lost conciousness and woke up in the hospital. CT Max/sinus
obtained during that admission revealed multiple facial
fractures including fractures of the right orbital floor,
lateral wall, lamina papyracea, right zygoma, all walls of the
right maxillary sinus, lateral portion of the right glenoid
fossa, and right lateral pterygoid. She returned for plastic
surgery to repair the fractures on [**2191-8-8**], and had a ORIF Right
Lefort III and closed reduction nasal fracture.
.
She then fell again at home on [**2191-8-15**], when she was walking in
front of her daughter while carrying a plate. Per daughter, the
patient may have caught her foot and fallen, no observed
convulsions. Patient reports no memory of the fall, but denies
any CP, SOB, palpitations, lightheadedness, confusion after the
fall, tongue biting, or urinary incontinence.  No history of
seizures. Daughter reports history of multiple falls over the
past ~2 years, always associated with tripping or instability.
The patient has very little memory of these events and is unable
to explain what she experienced during them. 1.5 years ago she
tripped while alone at home; also tripped while walking up
stairs in 11/[**2190**]. Daughter feels she is having more trouble
lifting up her feet, particularly when she is tired. Currently
does not use walker or cane to ambulate. Daughter reports she is
followed by cardiologist [**First Name9 (NamePattern2) 25495**] [**Last Name (un) 112352**] in [**Location (un) 47**] and had 24
hour monitor (likely Holter), unrevealing.
.
Daughter also reports a history of episodes of "spacing out"
which last a few minutes; have been occuring for the past year
or so. After spacing out, she has an exaggerated yawn and then
"passes out" followed 1-2 minutes later by needing to have a BM.
Reports she had an EEG about 2 years ago at [**Location (un) 47**] [**Hospital1 **]
which was unrevealing.
.
At an OSH she was found to have a small SDH, which has been
stable on serial CT head imaging.  On the floor, the patient is
comfortable, denies any pain.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, rhinorrhea or congestion. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.

MEDICAL HISTORY: ORIF Right Lefort III, closed reduction nasal fracture
HTN
GERD
Benign lump removed from neck
Multiple cystic lesions removed from breast in past, told she
has fibrocystic disease
Arthritis of knees, hands, shoulders, and feet

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atenolol 25 mg PO BID
2. Atorvastatin 20 mg PO HS
3. losartan-hydrochlorothiazide *NF* 100-25 mg Oral Daily
4. Omeprazole 20 mg PO DAILY
5. cefaDROXil *NF* 500 mg Oral Q 12 hrs
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP RIGHT EYE [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
O: T: 97.8 BP: 159/65   HR: 74 R 18 O2Sats 98%
Gen: WD/WN, comfortable
HEENT: Pupils: Right edema with irregular pupil.Left: [**5-3**].
Significant right orbital edema
EOMs no difficulty with left eye
Neck: non tender
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Two children ([**Doctor First Name **] and [**Doctor First Name **]), 2 grandchildren. Lives with
daughter. Denies any smoking history; no EtOH, no illicits. 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other disorders of neurohypophysis,Hypovolemia,Secondary hyperparathyroidism, non-renal,Other and unspecified superficial injuries of eye,Fall from other slipping, tripping, or stumbling,Aftercare for healing traumatic fracture of other bone,Cerebral atherosclerosis,Unspecified vitamin D deficiency,Benign essential hypertension,Other and unspecified hyperlipidemia,Esophageal reflux,Adhesive capsulitis of shoulder,Arthropathy, unspecified, multiple sites,Solitary pulmonary nodule,Lump or mass in breast'}
