CHIEF COMPLAINT: Fall

PRESENT ILLNESS: History of Present Illness: 53 yo M with hx of bipolar d/o,
baseline mild dementia, was found down at [**Hospital3 **] in her
bathroom. She states that she did hit her head however she
states that she did not lose conciousness. The patient states
that she remembers everything. She said that she fell while she
was getting up from the toilet and using the handicap handles,
she slipped and did not grab the handles and fell backwards and
hit her lower back and her posterior.
.
In ED, expressed LBP, mild headache, no neck pain.
.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
After the patient was transferred to the floor she continued to
complain of lower back pain however no other symptoms. She did
not have any neck pain, weakness, paralysis, loss of sensation,
chest pain, shortness of breath, or abdominal pain.

MEDICAL HISTORY: - CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.

MEDICATION ON ADMISSION: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
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, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII intact, 5/5 strength in 4 ext, normal gait,
negative romberg

FAMILY HISTORY: Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.

SOCIAL HISTORY: Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.
Unspecified septicemia,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior,Diabetes insipidus,Other specified hemiplegia and hemiparesis affecting unspecified side,Muscle weakness (generalized),Drug-induced delirium,Severe sepsis,Secondary hyperparathyroidism (of renal origin),Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Other chronic nonalcoholic liver disease,Other psychotropic agents causing adverse effects in therapeutic use,Sprain of neck,Contusion of back,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Brachial plexus lesions,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Accidental fall from commode
Septicemia NOS,Acute necrosis of liver,Ac kidny fail, tubr necr,Pneumonia, organism NOS,Bipol I manic-sev w psy,Diabetes insipidus,Ot sp hmiplga unspf side,Muscle weakness-general,Drug-induced delirium,Severe sepsis,Sec hyperparathyrd-renal,Other pulmonary insuff,Atrial fibrillation,Chronic liver dis NEC,Adv eff psychotropic NEC,Sprain of neck,Back contusion,Obstructive sleep apnea,Morbid obesity,Brachial plexus lesions,Hypothyroidism NOS,Anemia in chr kidney dis,Fall from commode
Admission Date:  [**2196-12-3**]              Discharge Date:   [**2196-12-4**]

Date of Birth:  [**2143-2-1**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 20128**]
Chief Complaint:
Fall

Major Surgical or Invasive Procedure:
None


History of Present Illness:
History of Present Illness: 53 yo M with hx of bipolar d/o,
baseline mild dementia, was found down at [**Hospital3 **] in her
bathroom. She states that she did hit her head however she
states that she did not lose conciousness. The patient states
that she remembers everything. She said that she fell while she
was getting up from the toilet and using the handicap handles,
she slipped and did not grab the handles and fell backwards and
hit her lower back and her posterior.
.
In ED, expressed LBP, mild headache, no neck pain.
.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
After the patient was transferred to the floor she continued to
complain of lower back pain however no other symptoms. She did
not have any neck pain, weakness, paralysis, loss of sensation,
chest pain, shortness of breath, or abdominal pain.


Past Medical History:
- CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.

Social History:
Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.


Family History:
Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.

Physical Exam:
General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
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, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII intact, 5/5 strength in 4 ext, normal gait,
negative romberg

Pertinent Results:
[**2196-12-3**] 11:36PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2196-12-3**] 11:36PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 11:36PM URINE  RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2196-12-3**] 11:36PM URINE  MUCOUS-RARE
[**2196-12-3**] 04:00AM URINE  HOURS-RANDOM
[**2196-12-3**] 04:00AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-12-3**] 02:00AM   GLUCOSE-120* UREA N-50* CREAT-2.8*
SODIUM-132* POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-21* ANION
GAP-17
[**2196-12-3**] 02:00AM   estGFR-Using this
[**2196-12-3**] 02:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM URINE  HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE  HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE  UHOLD-HOLD
[**2196-12-3**] 02:00AM URINE  GR HOLD-HOLD
[**2196-12-3**] 02:00AM   WBC-6.8 RBC-3.04* HGB-10.7* HCT-31.9*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.7
[**2196-12-3**] 02:00AM   NEUTS-71.1* BANDS-0 LYMPHS-17.7* MONOS-6.7
EOS-3.9 BASOS-0.6
[**2196-12-3**] 02:00AM   PLT COUNT-156
[**2196-12-3**] 02:00AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2196-12-3**] 02:00AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 02:00AM URINE  RBC-0-2 WBC-[**3-4**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2

Brief Hospital Course:
# Fall: The patient had a head CT which was negative. Otherwise
the patient also had a c-spine CT which did not reveal any
fractures or dislocations. The patient was assessed for her
mental status which was determined to be able to produce a
reliable history. She stated that at the time the only other
place of injury was [**4-9**] back pain. She was evaluated to not
have any distracting injuries. Her c-spine was palpated which
did not have any tenderness. She had her collar taken off and
her neck ranged without any pain or neurologic deficits. The
patient had plain films done of her T-L-S spine which were all
negative for fractures or malalignments. Otherwise the patient
gives very clear history that this was not a syncopal episode
and that she never lost conciousness. She states that she
grabbed the handlebars on her toilet incorrectly which is what
caused her to fall. Given this the patient did not have a
syncope work up but was rather cleared from a fall perspective.
The patient was evaluated by physical therapy which determined
that the patient was safe to be discharged home and would
require a visit from outpatient physical therapy to evaluate for
how well she ambulates with her walker. The patient was
monitored on tele without any evidence of any arrhythmias.
Otherwise the patient was discharged with follow up to her
primary care doctor
.
# Acute Renal Failure: The patient had a minor elevation of her
kidney function from 2.8 to 3.1. Given this she had a CK checked
which was in the normal range and therefore made rhabdomyolysis
less likely. She was given IV fluid hydration and discharged
again with follow up to her primary care doctor.
.
#. Fever: The patient had one isolated episode of a temperature.
She spiked a temp to 101.8 which subsequently was evaluated for
with blood cultures which were negative, urine analysis which
was negative and a chest x-ray which was negative. The patient
did not have any other temperatures above 100.

Medications on Admission:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day

(at bedtime)).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO THREE
TIMES WEEKLY (). Capsule(s)
5. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day). Tablet(s)
6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
13. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
14. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed


Discharge Medications:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO QMOWEFR
(Monday -Wednesday-Friday). Capsule(s)
5. sodium bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
10. quetiapine 200 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
16. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO HS (at bedtime).
17. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Fall


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
How to Prevent Falling: Recommendations for Patients and Their
Caregivers

1. Make your environment safe:
??????  Make sure that you have good lighting in your home. A well
lit home will help you avoid tripping over objects that are not
easy to see. Put night lights in your bedroom, hallways, stairs
and bathrooms.
??????  Rugs should be firmly fastened to the floor or have nonskid
backing. Loose ends should be tacked down.
??????  Electrical cords should not be lying on the floor in walking
areas.
??????  Put hand rails in your bathroom for bath, shower and toilet
use.
??????  Have rails on both sides of your stairs for support.
??????  In the kitchen, make sure items are within easy reach. Don't
store things too high or too low. Then you won't have to use a
stepladder or a stool to reach them. It's also a good idea to
avoid storing things too low, so you won't have to bend down to
get them.
??????  Wear shoes with firm nonskid soles. Avoid wearing
loose-fitting slippers that could cause you to trip.

2. Avoid dangerous medications and alcohol:
??????  Sedatives and sleeping pills, including Alprazolam (Xanax),
Chlordiazepoxide (Librium), Diazepam (Valium), Oxazepam (Serax),
Triazolam (Halcion), Flurazepam (Dalmane), and Meprobamate
(Miltown, Equanil).
??????  Over-the-counter medications for sleep or colds that contain
Diphenhydramine (Benadryl), like Tylenol PM, Benylin, or Nytol.
??????  Tricyclic Antidepressants, including Amitriptyline (Elavil)
and Imipramine (Tofranil)
??????  Bring all of your medications to your Doctor and carefully
review them to be sure they are safe.
??????  Avoid drinking alcohol.

3. Take 1200-1500 mg Calcium and 800 Units of Vitamin D every
day.
??????  Look for a generic brand that contains 600 mg calcium
(carbonate or citrate) and 400 Units of Vitamin D3, and take one
twice a day.
??????  Examples: Caltrate 600 + Vitamin D3 (contains calcium
citrate, better absorbed, less constipating), or Calcarb 600 +
400 D (contains calcium carbonate, less expensive, take with
meals).
??????  There are chewable options for calcium, but take an 800 or
1000 Unit Vitamin D3 pill in addition every day. These options
include: Tums 600 (take [**2-3**] daily) and Viactiv or Adora
(chocolate-flavored, take 3 daily).

4. Exercise:  Three types of exercise are important:
??????  Aerobic:  Daily walking, swimming, or biking.  Work up to
20-30 minutes daily, to the point that you break a sweat. Use
every opportunity to walk or climb stairs.
??????  Strengthening: Do leg-lifts at least 3 days a week.  Start
with no weight or a small velcro weight wrapped around your
ankles. While sitting in a straight-backed chair, lift each leg
until it is straight at the knee. Keep it extended for a count
of 3.  Do this at least 10 times for each leg. Repeat each set
of 10 leg- lifts two to three times at each session.
??????  Balance: Practice balance daily by standing with feet
together, one in front and to the side of the other, and one
directly in front of the other until you can hold each position
for 1 minute. Then, practice standing on one foot until you can
remain that way for at least 1 minute without holding on to
something. Be sure to do this next to something you can grab on
to if you lose your balance.
	
5. Assistive Devices and other interventions:
??????  Canes and walkers can prevent falls if they are used
properly.  They should be prescribed, measured, and adjusted by
a physical therapist or physician.  [**Name10 (NameIs) **] [**Name Initial (NameIs) **] cane on the good
(stronger) side. [**Male First Name (un) **]??????t be embarrassed about using these. It is
more embarrassing to fall, break a hip, and lose your
independence.
??????  Hearing aides, glasses, and cataract operations can also help
prevent falls by improving your sensory function.  Ask your
Doctor if you should have your hearing or vision checked.
??????  Get a Life-Line Device or other emergency system, so you can
call for help by simply pressing a button if you fall and can
not reach a phone.
??????  Drink plenty of fluids (at least [**1-2**] quarts a day) to prevent
dehydration.
??????  Take care of your feet. Wash them daily and inspect them for
lesions. If you have sores or foot pain, see your Doctor.
??????  Have your Doctor check your blood pressure while you are
standing up to be sure it doesn??????t fall too low. Get out of bed
slowly and pump your feet before standing up in the morning to
avoid sudden drops in blood pressure.

6. Resources for more information:
??????  National Safety Council:
[**URL 37657**]
Click on the Falls Prevention Resources and Safe Steps Video.
This provides a useful guide to preventing injuries in your
home.
??????  National Center for Injury Prevention and Control:
[**URL 37658**]  There is a good home safety
checklist at this site.
??????  National Institute on Aging:
[**Female First Name (un) 37659**]
This provides information in Spanish.


Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-1-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-4-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**]



Admission Date:  [**2196-12-4**]              Discharge Date:   [**2196-12-21**]

Date of Birth:  [**2143-2-1**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 832**]
Chief Complaint:
weakness

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Ms. [**Known lastname **] is a 53 yo female with hx of bipolar d/o, baseline
mild dementia, who was recently admitted because she was found
down at [**Hospital3 **] in her bathroom. She states that she did
hit her head however she states that she did not lose
conciousness. The patient states that she remembers everything.
She said that she fell while she was getting up from the toilet
and using the handicap handles, she slipped and did not grab the
handles and fell backwards and hit her lower back and her
posterior. She was discharged on [**12-4**] however when she arrived
to the [**Hospital3 **] she was unable to stand up due to
weakness and was sent back.
.
In ED, expressed LBP, mild headache, no neck pain.

In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
On the floor she was noted to be febrile to 101 and rigoring.
She was able to answer questions appropriately but did note
having fevers and trembling for 2 days. She denied any cough,
abdominal pain, dysuria or neck stiffness.


Past Medical History:
- CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.


Social History:
Born in [**Location (un) 86**], lived here all her life. Worked in limited care

and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.


Family History:
Patient denies family history of psychiatric illness. Denies any

family suicide attempts or completed suicides.


Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 101.6 BP: 160/100 P: 96 O2: 98RA
General: Patient looked sick/diaphoretic, rigoring
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
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, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Labs on Admission:

[**2196-12-3**] 02:00AM URINE  RBC-0-2 WBC-[**3-4**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2196-12-3**] 02:00AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 02:00AM   WBC-6.8 RBC-3.04* HGB-10.7* HCT-31.9*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.7
[**2196-12-3**] 02:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-4**] 07:15AM   WBC-5.1 RBC-3.08* HGB-11.2* HCT-32.7*
MCV-106* MCH-36.2* MCHC-34.1 RDW-12.9
[**2196-12-4**] 07:15AM   GLUCOSE-90 UREA N-49* CREAT-3.1* SODIUM-141
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2196-12-4**] 07:15AM   CALCIUM-8.4 PHOSPHATE-5.4* MAGNESIUM-3.1*

[**2196-12-20**] 06:15    6.2 2.71* 9.2* 28.8* 106* 34.0* 32.1 14.6
411
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2196-12-20**] 06:15    6.2 2.71* 9.2* 28.8* 106* 34.0* 32.1 14.6
411
[**2196-12-19**] 05:40    7.4 2.67* 8.9* 28.2* 106* 33.3* 31.5 14.7
424
[**2196-12-18**] 04:28    9.7 2.82* 9.6* 29.9* 106* 34.0* 32.2 14.5
474*
[**2196-12-17**] 05:02    10.2 2.75* 9.3* 29.1* 106* 33.9* 32.0 14.2
517*
[**2196-12-16**] 02:53    10.7 2.52* 8.7* 26.4* 105* 34.6* 33.0 13.5
516*
[**2196-12-15**] 01:31    11.3* 2.73* 9.2* 28.4* 104* 33.8* 32.4 13.0
515*
ADDED DIFF 9:49AM
[**2196-12-14**] 03:43    9.7 2.58* 8.8* 26.8* 104* 34.2* 32.9 13.1
489*
Source: Line-piv
[**2196-12-13**] 03:49    9.5 2.50* 8.4* 25.8* 104* 33.7* 32.6 13.2
385
[**2196-12-12**] 13:50    9.4 2.52* 8.5* 26.0* 103* 33.9* 32.8 13.1
305
Random
[**2196-12-12**] 02:52    9.2 2.49* 8.3* 25.9* 104* 33.3* 32.0 13.0
300
Random
[**2196-12-11**] 03:11    8.6 2.30* 8.3* 24.2* 105* 35.9* 34.1 12.8
254
Source: Line-aline
[**2196-12-10**] 02:40    7.8 2.30* 8.0* 24.5* 107* 34.6* 32.5 12.8
211
Source: Line-a-line
[**2196-12-9**] 17:14    7.0 2.22* 7.7* 23.8* 108* 34.9* 32.5 13.0
185
Source: Line-aline
[**2196-12-9**] 03:51    6.7 2.26* 8.1* 24.0* 106* 35.8* 33.7 13.0
173
Source: Line-A-line
[**2196-12-8**] 22:52          23.9*
[**2196-12-8**] 16:35    7.8 2.25* 8.0* 23.9* 106* 35.7* 33.7 12.9
153
[**2196-12-8**] 11:03    9.4 2.41* 8.3* 25.1* 104* 34.5* 33.0 13.0
159
[**2196-12-8**] 05:50    11.1* 2.44* 8.9* 25.9* 106* 36.6* 34.6 12.9
176
[**2196-12-7**] 05:55    13.6* 2.78* 10.2* 28.8*1 104* 36.5* 35.3*
13.0 1802
[**2196-12-6**] 13:07    9.3 2.75* 9.7* 28.3* 103* 35.2* 34.1 12.2
129*
CAD ADDED 5:03PM
[**2196-12-6**] 07:15    8.63 2.80* 9.7* 30.0*4 105* 34.6* 35.1* 12.8
1673
ESR ADDED 11:33AM,SPECIMEN QNS FOR SED RATE, NOTIFIED [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 37660**] ON [**2196-12-6**] @ 12:47PM
[**2196-12-5**] 09:10    6.9 2.86* 10.2* 30.2* 106* 35.6* 33.7 12.6
144*
[**2196-12-4**] 07:15    5.1 3.08* 11.2* 32.7* 106* 36.2* 34.1 12.9
153
[**2196-12-3**] 02:00    6.8 3.04* 10.7* 31.9* 105* 35.2* 33.5 12.7
156

.
Imaging:
[**12-15**] ECG  Atrial fibrillation with rapid ventricular response.
Probable left anterior fascicular block. Delayed R wave
progression with late precordial QRS transition is
non-diagnostic but cannot exclude possible prior anterior wall
myocardial infarction. Modest lateral lead ST-T wave changes are
non-specific. Since the previous tracing of [**2196-12-11**] the
ventricular rate is faster and axis appears more leftward but
there may be no significant change.

[**12-11**] CT Chest/Abd/pelvis 1. Extensive multifocal airspace
opacities in the lungs as described along with small bilateral
pleural effusions. Findings are suggestive of a multifocal
pneumonia. 2. Multiple enlarged mediastinal lymph nodes, likely
reactive. 3. Indeterminate 7 mm calculus in the abdomen, which
may be within the right renal pelvis or represent a vascular
calcification. Of note, there is no hydronephrosis.

[**12-11**] MRI L-spine  1. Multilevel lumbar spine spondylosis
without severe spinal canal or neural foraminal narrowing.  2. A
broad-based disc protrusion is present at the L4-L5 level with
minimal inferior migration resulting in mild spinal canal
narrowing and bilateral subarticular zone narrowing with
deformity on the L5 nerves. 3. Moderate bilateral neural
foraminal narrowing is present at the L5-S1 level due to facet
arthrosis with impingement on the L5 nerves.  Study is limited
for abnormal enhancement due to lack of post Gado imaging, gado
could not eb given due to low eGFR.

[**12-7**] abd u/s This is a technically limited study showing a
normal size of the liver and spleen. No focal abnormality is
seen. Limited views of the kidneys show no hydronephrosis, but
assessment for focal renal lesions is suboptimal.

Date   6  Lab #  Specimen  Tests  Ordered By
 All [**2196-12-3**] [**2196-12-5**] [**2196-12-6**] [**2196-12-7**] [**2196-12-8**]
[**2196-12-9**] [**2196-12-10**] [**2196-12-11**] [**2196-12-12**] [**2196-12-13**]    All
BLOOD CULTURE Blood (EBV) IMMUNOLOGY Immunology (CMV) Influenza
A/B by DFA MRSA SCREEN SEROLOGY/BLOOD STOOL THROAT FOR STREP
URINE    All INPATIENT
[**2196-12-13**] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT
[**2196-12-13**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2196-12-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2196-12-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2196-12-13**] Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
[**2196-12-13**] SEROLOGY/BLOOD MONOSPOT-FINAL INPATIENT
[**2196-12-12**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2196-12-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2196-12-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL


Brief Hospital Course:
53 year old female with a PMH significant for bipolar d/o,
baseline mild dementia, CKD stage IV, HTN and DM who was
recently admitted ([**2196-12-3**]) after a fall and discharged on
[**2196-12-4**], readmitted w/ weakness, now w/ hypotension to 70's
systolic and altered mental status, as well as daily fevers
since admission.
For several days she had fevers as high as 103. Infectious work
up and extensive imaging was negative for cause of fever. On
[**12-7**] the patient developed hypotension with SBP in the 70s and
hypoxic to the 90s on 4L, a rapidly increasing creatinine and a
new transaminities so was transferred to the MICU.
.
In the MICU, patient continued to have daily fevers but further
infectious work up all negative. Patient's ABX initially held as
no source identified, however she spiked fever to 103 on [**12-10**]
and was re-started on vanc/cefepime. LENIs negative for DVT.
ECHO without evidence of endocarditis. She did have a CT Chest
that showed ground glass opacities that could have been
consistent with pneumonia, so it was felt that she should be
treated for HAP. Of note, despite the patient's fever and mental
status changes as well as complaint of neck pain, she did not
get an LP.
.
Given the negative infectious work up, a rheumatologic process
was considered. Labs were notable for ESR 142 Ferritin 3170, TRF
102, TIBC 133, negative [**Doctor First Name **] and ANCA. Rheumatology was consulted
and felt that her this was unlikely to be HLH or Adult still's
given her lack of constellation of symptoms, nor did they think
this was a vasculitis (more likely infectious pna).
.
The patient's altered mental status attributed to psych meds in
the setting of acute renal failure and transaminitis leading to
poor metabolism of meds. Her mental status rapidly improved
after holding her psych medications. Malignant hyperthermia and
seratonin syndrome were considered but CK was 97 on [**12-6**] (height
of temperature curve) and the patient had no clinical exam
findings consistent with seratonin syndome. However, after
holding the patient's psych medications she started to become
more aggitated. Psychiatry was consulted and the patient was
restarted on aripiprazole with PRN lorazepam and risperdal and
has since remained calm.
.
The patient's hypoxemia felt likely to be due to OSA and fluid
overload as well as possible pneumonia. The patient autodiuresed
and was treated with ABX and her hypoxia resolved resolved even
though patient did not wear her CPAP (refused). Of note, she was
briefly on Bipap but did not require intubation.
.
The patient's creatinine peaked at 4 on [**12-9**] and has since
trended down to 2.4. Nephrology was consuled and spun her urine
and saw a few hyaline casts, few muddy brown casts consistent
with hypoperfusion. Renal U/S showed chronic disease, no acute
changes so it was felt this was most likely due to poor renal
perfusion as it has been slowly improving.
.
The patient's AST/ALT/ALP peakined on [**12-12**] at [**Telephone/Fax (3) 37661**] and
has since been trending down slowly. Her lipase and LDH were
also mildly elevated. Hepatitis serologies were negative. Liver
was consulted who felt that her LFT abnormalities were due to
hypotension/sepsis on the background of a fatty liver.
.
Finally, the patient developed A fib with RVR that was very
difficult to control. She was given IV Dilt, IV metoprolol and
even started on digoxin at one point (though stopped given her
rapidly changing renal function). Cardiology was consulted who
was considering a TEE cardioversion. However, this morning the
patient converted back into sinus rhythm. She is currently on PO
Dilt and PO Metoprolol.

Problem [**Name (NI) **]:
.
#Altered mental status: The patient had altered mental status
and was intermittently somnolent, but oriented x 2. We suspected
this was mostly due to multiple psychiatric medications in the
context of decreased clearance due to acute on chronic renal
failure. Her psychiatric and anti-hypertensive meds were held
until her mental status improved.
.
#Fevers: She originally presented with low back pain/neck
pain/HA, and upon arrival to floor fever to 101. Pt had daily
fevers from time of admission.  Pt was started initially on
Vancomycin, cefepime and flagyl. An extensive infectious work-up
including monospot, influenza, full rapid respiratory panel,
hepatitis serologies, blood cx, urine cx and echo to r/o
endocarditis were all negative. She had MRI L-spine given fever
w/ back pain, which showed no abscess. She defervesced and
remained afebrile at time of discharge
.
#Hypotension: On admission she was hypotensive to 70's systolic
for unclear reason.  As noted above, infectious unremarkable.
Blood pressure stablized with volume resucitation.
.
#Hypoxic Respiratory Distress: Likely related to volume
overload. Improved with diuresis.
.
#Atrial Fibrillation: New onset Afib on [**12-11**]. Etiology likely
longstanding HTN. TSH normal. HR difficult to control. She
intially was continued on her home regimen of metoprolol 12.5
[**Hospital1 **]. When this did not control rate he was changed to diltiazem
90mg QID. Metoprolol was restarted along with the diltiazem and
titrated up to 25 TID. Possible that if this regimen does not
achieve rate control than she may require DCCV in the future.
.
# Neck pain: Likely strain [**2-2**] fall. The patient sustained a
fall after trying to arise from the toilet. CT of the c-spine
did not reveal any fractures or malalignments. Neck pain
improved throughout admission.
.
.
#Acute on chronic renal failure: Her creatinine on admission was
3.1 but climbed to 4 on [**12-9**]. This was likely due to prerenal
source as patient was quite dry on exam. Unclear etiology of the
ARF however thought likely to be from ATN. Her creatinine
improved back to 2.5 over the following few days which is her
baseline.
 .
#Transaminitis: Etiology unclear though may have been related to
transient hypotension. Hepatitis serolgies negative, [**Doctor First Name **], AMA
all negative. CT abdomen unremarkable for any liver related
pathology. LFTs trending down at time of discharge.
.
# Bipolar Disorder: Her psych medications of seroquel,
risperidone, clozaril, lamotrigine, depakote and lorazepam were
held due to concern for elevated LFT's. Psych was consulted and
we spoke to her outpatient psychiatrist Dr [**First Name (STitle) **]. Per their
recommendations, she was initially started at 1mg Risperidone.
This was then increased. On [**12-14**] the patient became more
aggitated with evidence of psychosis and mania. Psychiatry
recommended starting abilify 30mg QHS w/ lorazepam 1-2mg MRx1
QHS + risperdal 1mg TID PRN which helped patient and helped her
sleep. Pt noted to acutely decompensate with manic episode;
section 12'ed; admitted to [**Hospital1 **] 4 for further psychiatric
evaluation/stabilization.
.
# Hypothyroidism - The patients TSH was 1.2. Her home med of
levothyroxine was continued.
.
# Elevated inflammatory markers: Unclear cause, Noted to have
ferritin >3000 and extremely high ESR/CRP's >100, but again
trended down. Rheumatology did not feel it was rheumatological.
No splenomegaly or cytopenias to imply HLH. Heme looked at smear
and no abnormalities.


Medications on Admission:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day

(at bedtime)).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a

day (at bedtime)).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO THREE
TIMES WEEKLY (). Capsule(s)
5. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID

(2 times a day). Tablet(s)
6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a

day (in the morning)).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times

a day) as needed for anxiety/agitation.
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once

a day (at bedtime)).
13. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
14. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a

day (in the morning)).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed


Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceeed 2g/day given
recent transaminitis.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for straining with stooling.
9. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath/wheezing.
10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. risperidone 1 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
12. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) unit Subcutaneous four times a day: See attached sliding
scale. Adjust as needed.
13. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).

14. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

16. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for aggitation or insomnia.
17. aripiprazole 10 mg Tablet Sig: Three(3) Tablet PO QHS (once
a day (at bedtime)).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] 4

Discharge Diagnosis:
Systemic Inflammatory Response Syndrome (SIRS)
Atrial fib - paroxysmal in setting of SIRS and volume overload
with reversible cause

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
How to Prevent Falling: Recommendations for Patients and Their
Caregivers

1. Make your environment safe:
??????  Make sure that you have good lighting in your home. A well
lit home will help you avoid tripping over objects that are not
easy to see. Put night lights in your bedroom, hallways, stairs
and bathrooms.
??????  Rugs should be firmly fastened to the floor or have nonskid
backing. Loose ends should be tacked down.
??????  Electrical cords should not be lying on the floor in walking
areas.
??????  Put hand rails in your bathroom for bath, shower and toilet
use.
??????  Have rails on both sides of your stairs for support.
??????  In the kitchen, make sure items are within easy reach. Don't
store things too high or too low. Then you won't have to use a
stepladder or a stool to reach them. It's also a good idea to
avoid storing things too low, so you won't have to bend down to
get them.
??????  Wear shoes with firm nonskid soles. Avoid wearing
loose-fitting slippers that could cause you to trip.

2. Avoid dangerous medications and alcohol:
??????  Sedatives and sleeping pills, including Alprazolam (Xanax),
Chlordiazepoxide (Librium), Diazepam (Valium), Oxazepam (Serax),

Triazolam (Halcion), Flurazepam (Dalmane), and Meprobamate
(Miltown, Equanil).
??????  Over-the-counter medications for sleep or colds that contain
Diphenhydramine (Benadryl), like Tylenol PM, Benylin, or Nytol.
??????  Tricyclic Antidepressants, including Amitriptyline (Elavil)
and Imipramine (Tofranil)
??????  Bring all of your medications to your Doctor and carefully
review them to be sure they are safe.
??????  Avoid drinking alcohol.

3. Take 1200-1500 mg Calcium and 800 Units of Vitamin D every
day.
??????  Look for a generic brand that contains 600 mg calcium
(carbonate or citrate) and 400 Units of Vitamin D3, and take one

twice a day.
??????  Examples: Caltrate 600 + Vitamin D3 (contains calcium
citrate, better absorbed, less constipating), or Calcarb 600 +
400 D (contains calcium carbonate, less expensive, take with
meals).
??????  There are chewable options for calcium, but take an 800 or
1000 Unit Vitamin D3 pill in addition every day. These options
include: Tums 600 (take [**2-3**] daily) and Viactiv or Adora
(chocolate-flavored, take 3 daily).

4. Exercise:  Three types of exercise are important:
??????  Aerobic:  Daily walking, swimming, or biking.  Work up to
20-30 minutes daily, to the point that you break a sweat. Use
every opportunity to walk or climb stairs.
??????  Strengthening: Do leg-lifts at least 3 days a week.  Start
with no weight or a small velcro weight wrapped around your
ankles. While sitting in a straight-backed chair, lift each leg
until it is straight at the knee. Keep it extended for a count
of 3.  Do this at least 10 times for each leg. Repeat each set
of 10 leg- lifts two to three times at each session.
??????  Balance: Practice balance daily by standing with feet
together, one in front and to the side of the other, and one
directly in front of the other until you can hold each position
for 1 minute. Then, practice standing on one foot until you can
remain that way for at least 1 minute without holding on to
something. Be sure to do this next to something you can grab on
to if you lose your balance.
	
5. Assistive Devices and other interventions:
??????  Canes and walkers can prevent falls if they are used
properly.  They should be prescribed, measured, and adjusted by
a physical therapist or physician.  [**Name10 (NameIs) **] [**Name Initial (NameIs) **] cane on the good
(stronger) side. [**Male First Name (un) **]??????t be embarrassed about using these. It is
more embarrassing to fall, break a hip, and lose your
independence.
??????  Hearing aides, glasses, and cataract operations can also help

prevent falls by improving your sensory function.  Ask your
Doctor if you should have your hearing or vision checked.
??????  Get a Life-Line Device or other emergency system, so you can
call for help by simply pressing a button if you fall and can
not reach a phone.
??????  Drink plenty of fluids (at least [**1-2**] quarts a day) to prevent

dehydration.
??????  Take care of your feet. Wash them daily and inspect them for
lesions. If you have sores or foot pain, see your Doctor.
??????  Have your Doctor check your blood pressure while you are
standing up to be sure it doesn??????t fall too low. Get out of bed
slowly and pump your feet before standing up in the morning to
avoid sudden drops in blood pressure.

6. Resources for more information:
??????  National Safety Council:
[**URL 37657**]
Click on the Falls Prevention Resources and Safe Steps Video.
This provides a useful guide to preventing injuries in your
home.
??????  National Center for Injury Prevention and Control:
[**URL 37658**]  There is a good home safety

checklist at this site.
??????  National Institute on Aging:
[**Female First Name (un) 37659**]

This provides information in Spanish.


Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-1-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-4-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage
{'Unspecified septicemia,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior,Diabetes insipidus,Other specified hemiplegia and hemiparesis affecting unspecified side,Muscle weakness (generalized),Drug-induced delirium,Severe sepsis,Secondary hyperparathyroidism (of renal origin),Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Other chronic nonalcoholic liver disease,Other psychotropic agents causing adverse effects in therapeutic use,Sprain of neck,Contusion of back,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Brachial plexus lesions,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Accidental fall from commode'}


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

PRESENT ILLNESS: History of Present Illness: 53 yo M with hx of bipolar d/o,
baseline mild dementia, was found down at [**Hospital3 **] in her
bathroom. She states that she did hit her head however she
states that she did not lose conciousness. The patient states
that she remembers everything. She said that she fell while she
was getting up from the toilet and using the handicap handles,
she slipped and did not grab the handles and fell backwards and
hit her lower back and her posterior.
.
In ED, expressed LBP, mild headache, no neck pain.
.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
After the patient was transferred to the floor she continued to
complain of lower back pain however no other symptoms. She did
not have any neck pain, weakness, paralysis, loss of sensation,
chest pain, shortness of breath, or abdominal pain.

MEDICAL HISTORY: - CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.

MEDICATION ON ADMISSION: 1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: Alert, orientedx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
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, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII intact, 5/5 strength in 4 ext, normal gait,
negative romberg

FAMILY HISTORY: Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.

SOCIAL HISTORY: Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married. 

### Response:
{'Unspecified septicemia,Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Bipolar I disorder, most recent episode (or current) manic, severe, specified as with psychotic behavior,Diabetes insipidus,Other specified hemiplegia and hemiparesis affecting unspecified side,Muscle weakness (generalized),Drug-induced delirium,Severe sepsis,Secondary hyperparathyroidism (of renal origin),Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Other chronic nonalcoholic liver disease,Other psychotropic agents causing adverse effects in therapeutic use,Sprain of neck,Contusion of back,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Brachial plexus lesions,Unspecified acquired hypothyroidism,Anemia in chronic kidney disease,Accidental fall from commode'}
