CHIEF COMPLAINT: "I was at [**Hospital3 **] and then came here because I was told I may
have had seizure."

PRESENT ILLNESS: 63yo married white woman with reported h/o multiple
personality disorder, depression, PTSD, and recently documented
h/o bipolar disorder, also with a medical h/o sleep apnea,
ehlers-danlos, and previous seizure due to intracranial
hematoma,
who was transferred form [**Hospital3 417**] hospital at husband of
patient's request for psychiatric evaluation and possible psych
admission.
     Per [**Hospital3 **] notes (sent on transfer), the patient was
recently admitted to [**Hospital3 **] on [**2198-5-12**] for question of
seizure.
Labs, MRI/MRA, Head CT were all negative. EEG was negative for
seizure activity, but showed some generalized slowing. Patient
was also seen by psychiatry while there for expansive affect and
pressured speech. Diagnosed with bipolar disorder with hypomanic
episode, likely secondary to taking antidepressants wrong
(taking
more wellbutrin than she was supposed to). Also had a
subtherapeutic VPA level. Psych planned to taper
antidepressants,
and [**Month (only) **] dose of wellbutrin to 150 daily and celexa 20 daily.
Patient was discharged home [**2198-5-14**] with plan to follow-up with
outpt neuro and psych (though doesn't have any outpt psych
treaters in place).
     Per the husband, the patient continued to have pressured
speech, [**Month (only) **] sleep, only 10minutes at a time for a total of 30
minutes. Was restless in bed. He became concerned about her and
felt he was unable to contain her and called 911. She was taken
back to [**Hospital3 **]. Repeat labs and head imaging was negative.
[**Hospital3 **] recommended inpt psych admit, but the husband wanted
transfer
to [**Hospital1 18**] which the hope that the patient could be admitted if
needed psychiatrically at [**Hospital1 18**] and set up with outpt behavioral
health treaters at [**Hospital1 18**].
     Per the patient, she reports feeling "hyper" meaning that
she has more energy than usual, has a hard time sleeping, and
feels she talks faster than usual. She reports having similar
"hyper" episodes throughout her life. Unable to give an accurate
history about the frequency, length or when the last episode
was.
Denies increased spending, promiscuity or goal directed
behaviors
during these episodes. However her husband endorses that she
will
have [**2-22**] "manic" episodes over a year, then not have any for a
few years since he has known her for 38 years. He endorses that
at her worst, she does have disorganized thoughts, rapid speech,
increased goal directed behavior (such as scrubbing floor in
middle of night) and decreased need for sleep (though would
sleep
some each night). He noticed that this "manic" episode started
about the same time as the potential seizure like activity on
[**2198-5-12**].
     Patient is unable to give a accurate account of her meds,
but she is the one who self administers them. She endorses that
she often changes her meds on her own and endorses needing help
with accurately taking her meds.

MEDICAL HISTORY: PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.

MEDICATION ON ADMISSION: 1. Wellbutrin SR 150mg daily ([**Month (only) **] from 150mg [**Hospital1 **] on [**2198-5-13**])
2. Celexa 20mg daily ([**Month (only) **] from 30mg daily on [**2198-5-13**])
3. Depakote 500mg [**Hospital1 **] (has not been taking accuratly, VPA 22.0
on
[**2198-5-15**])
4. Baclofen 20 TID
5. ASA 81 daily
6. Gabapentin 600 [**Hospital1 **]
7. Metoprolol tartrate 25mg qhs
8. Singulair 10mg qhs
9. Omeprazole 20mg qhs
10. oxybutynin 1mg daily
11. KCL 20mg [**Hospital1 **]
12. Simvastatin 40mg daily
13. Amlodipine 10mg daily
14. Lisinopril 5mg daily

ALLERGIES: Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose

PHYSICAL EXAM: Physical Exam:
VS:  BP: 180/66  HR: 56  temp: 98.6   resp:  O2 sat: 98%
height:
5'3"  weight: 203.8 lbs
Gen: obese Caucasian female, alert and interactive, looking
stated age, dressed in hospital [**Doctor First Name **], grooming fair
HEENT: normocephalic, oropharnyx clear. PERRL, EOMI.
CV: RRR, no M/R/G
Pulm: CTAB
Abd: +BS, NDNT, soft
Ext: mild 1+ pitting edema of right foot
Skin: extensive erythematous scarring of shins bilaterally "pt
attributes to her ehlers-danlos syndrome)

FAMILY HISTORY: FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and SA
when he was 9 years old. Denies any other known psychiatric
family history.

SOCIAL HISTORY: SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes.
Encephalopathy, unspecified,Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Hemoperitoneum (nontraumatic),End stage renal disease,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Ehlers-Danlos syndrome,Bacteremia,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Vascular disorders of kidney,Acute posthemorrhagic anemia,Other and unspecified infection due to central venous catheter,Dissociative identity disorder,Posttraumatic stress disorder,Bipolar disorder, unspecified,Restless legs syndrome (RLS),Narcolepsy, without cataplexy,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Other disorders of muscle, ligament, and fascia,Obstructive sleep apnea (adult)(pediatric),Abnormal involuntary movements,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Iron deficiency anemia secondary to blood loss (chronic),Eosinophilia,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Encephalopathy NOS,Ac kidny fail, tubr necr,Chr duoden ulcer w hem,Hemoperitoneum,End stage renal disease,Acute respiratry failure,Meth sus pneum d/t Staph,Ehlers-danlos syndrome,Bacteremia,Urin tract infection NOS,Int inf clstrdium dfcile,Hyposmolality,Hyp kid NOS w cr kid V,Renal vascular disorder,Ac posthemorrhag anemia,Oth/uns inf-cen ven cath,Dissociatve identity dis,Posttraumatic stress dis,Bipolar disorder NOS,Restless legs syndrome,Narcolepsy w/o cataplexy,Mth sus Stph aur els/NOS,Atrial fibrillation,Muscle/ligament dis NEC,Obstructive sleep apnea,Abn involun movement NEC,Abn react-procedure NEC,Chr blood loss anemia,Eosinophilia,Hyperlipidemia NEC/NOS,Hx TIA/stroke w/o resid
Admission Date:  [**2198-5-15**]              Discharge Date:   [**2198-5-17**]

Date of Birth:  [**2134-6-28**]             Sex:   F

Service: PSYCHIATRY

Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose

Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
"I was at [**Hospital3 **] and then came here because I was told I may
have had seizure."


Major Surgical or Invasive Procedure:
None

History of Present Illness:
63yo married white woman with reported h/o multiple
personality disorder, depression, PTSD, and recently documented
h/o bipolar disorder, also with a medical h/o sleep apnea,
ehlers-danlos, and previous seizure due to intracranial
hematoma,
who was transferred form [**Hospital3 417**] hospital at husband of
patient's request for psychiatric evaluation and possible psych
admission.
     Per [**Hospital3 **] notes (sent on transfer), the patient was
recently admitted to [**Hospital3 **] on [**2198-5-12**] for question of
seizure.
Labs, MRI/MRA, Head CT were all negative. EEG was negative for
seizure activity, but showed some generalized slowing. Patient
was also seen by psychiatry while there for expansive affect and
pressured speech. Diagnosed with bipolar disorder with hypomanic
episode, likely secondary to taking antidepressants wrong
(taking
more wellbutrin than she was supposed to). Also had a
subtherapeutic VPA level. Psych planned to taper
antidepressants,
and [**Month (only) **] dose of wellbutrin to 150 daily and celexa 20 daily.
Patient was discharged home [**2198-5-14**] with plan to follow-up with
outpt neuro and psych (though doesn't have any outpt psych
treaters in place).
     Per the husband, the patient continued to have pressured
speech, [**Month (only) **] sleep, only 10minutes at a time for a total of 30
minutes. Was restless in bed. He became concerned about her and
felt he was unable to contain her and called 911. She was taken
back to [**Hospital3 **]. Repeat labs and head imaging was negative.
[**Hospital3 **] recommended inpt psych admit, but the husband wanted
transfer
to [**Hospital1 18**] which the hope that the patient could be admitted if
needed psychiatrically at [**Hospital1 18**] and set up with outpt behavioral
health treaters at [**Hospital1 18**].
     Per the patient, she reports feeling "hyper" meaning that
she has more energy than usual, has a hard time sleeping, and
feels she talks faster than usual. She reports having similar
"hyper" episodes throughout her life. Unable to give an accurate
history about the frequency, length or when the last episode
was.
Denies increased spending, promiscuity or goal directed
behaviors
during these episodes. However her husband endorses that she
will
have [**2-22**] "manic" episodes over a year, then not have any for a
few years since he has known her for 38 years. He endorses that
at her worst, she does have disorganized thoughts, rapid speech,
increased goal directed behavior (such as scrubbing floor in
middle of night) and decreased need for sleep (though would
sleep
some each night). He noticed that this "manic" episode started
about the same time as the potential seizure like activity on
[**2198-5-12**].
     Patient is unable to give a accurate account of her meds,
but she is the one who self administers them. She endorses that
she often changes her meds on her own and endorses needing help
with accurately taking her meds.

Psych ROS: Patient denies any current depressed mood or
neurovegetative symptoms. Denies any suicidality. Denies any
current or past psychotic symptoms. Denies any dissociate
episodes. Denies any active sx of PTSD except an occasional
trauma related nightmare.

Past Medical History:
PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.

PAST MED HX: Ehlers Danlos syndrome, HTN, ANgina, Sleep apnea
(refuses CPAP), ? h/p TIAs, Cataracts, h/o seizure [**2-21**] to
intracrania hematoma, s/p l5-s1 fusion and laminectomy

Social History:
SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes.

TOB: smoked 2ppd for 40 yrs, quit in [**2195**]
DRUG: none for >20 yrs. Experimented with MJ and "other" drugs
when she was young. Denies any h/o IVDA.

COFFEE: drinks four 32oz glasses of coffee daily. does not want
to cut down.

SOCIAL HX: Raised in [**Location (un) **] and [**Location (un) 686**]. Sexually abused by
father from age [**5-2**]. Went to court for which her father was
sent
to [**Location (un) **] for substance abuse treatment. Then lived with
her
mother, who she reports made her drop out of school in 9th grade
to support the family. She worked in telescope factory. Has 2
sisters and 1 brother, only stays in contact with one sister in
[**Name (NI) 26671**] MA. 1st marriage with 2 children (son and daughter)
who now live in [**Location (un) **] and hullbrook ma. Divorced and
remarried 38 yrs ago to current husband. [**Name (NI) **] children with
current
husband. [**Name (NI) **] now on SSDI for many years due to psych
illness.
Husband works. [**Name2 (NI) **] legal issues in past. Reports DV by husband in
past, hit patient once in [**2167**]'s and pushed patient once. She
does not feel unsafe. He currently calls her names at times, but
she reports they are in couples counseling for this and working
through their issues. Reports she has one friend (with mild
mental retardation) who she is close to and sees almost every
day.

Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and SA
when he was 9 years old. Denies any other known psychiatric
family history.

Physical Exam:
Physical Exam:
VS:  BP: 180/66  HR: 56  temp: 98.6   resp:  O2 sat: 98%
height:
5'3"  weight: 203.8 lbs
Gen: obese Caucasian female, alert and interactive, looking
stated age, dressed in hospital [**Doctor First Name **], grooming fair
HEENT: normocephalic, oropharnyx clear. PERRL, EOMI.
CV: RRR, no M/R/G
Pulm: CTAB
Abd: +BS, NDNT, soft
Ext: mild 1+ pitting edema of right foot
Skin: extensive erythematous scarring of shins bilaterally "pt
attributes to her ehlers-danlos syndrome)

Neurological:
 CN:
  II: PERRLA
  III, IV, VI: EOM intact
  V: facial sensation intact bilat
  VII: facial mvts symmetric bilat
  VIII: finger rub audible bilat
  IX, X: palate raise symmetric bilat
  [**Doctor First Name 81**]: SCM and trapezii [**5-24**] bilat
  XII: tongue midline
 Motor: Normal bulk and tone, strength 4/5 in R leg
(longstanding), [**5-24**] in left leg and right arm; also appears full
strength in left arm but cannot fully test due to pain in left
shoulder
 Sensory: grossly intact to light touch  bilaterally
 Reflexes: 1+ biceps, triceps, brachioradialis and patellar
reflexes. hyporeflexic
 Cerebellar: Intact finger to nose.
 Gait: intact
 Abnormal movements: none noted.

Mental Status:
 Appearance: obese Caucasian female, alert and interactive,
looking stated age, dressed in hospital [**Doctor First Name **], grooming fair,
good eye contact
 Behavior: cooperative with interview, friendly, pleasant,
frequently laughing and joking
 Mood: "great"
 Affect: hyperthymic, pleasant, energetic
 Thought process: tangential, rambling, but logical and
redirectable
 Thought Content: regarding her medical issues (shoulder, rash
on
buttocks); no delusions or bizarre content
 Judgment: fair
 Insight: fair
 SI/HI: denies SI/HI
 Perception: no AVH, delusions, or paranoia

Cognitive Exam:
 Attention: able to recite DOWB
 Orientation: oriented to person, place, and date
 Memory: [**3-22**] registration and recall
 Fund of knowledge: knows president
 Calculations: quarters in $2.25 = 9
 Abstraction: "don't throw stones if you live in a glass house"
=
'how dare you shit on someone else when you're shitting on
yourself'
 Speech: pressured rate, high volume, normal prosody
 Language: used appropriately

Pertinent Results:
LAB DATA: From OSH ([**Hospital3 **]) dated [**2198-5-15**]:
CBC WNL; BMP WNL except GLU 112; LFTS WNL; TSH/T4 WNL; B12 WNL
Serum tox negative
VPA 22.0
U/A: tr bld
UTOX: negative
Head CT: no intracranial abnl
MRI brain/neck & MRA with gad on [**5-12**]: small vessel disease and
mld atrophy.
EKG [**5-15**]: sinus brady at 58, qt/qtc 464/456

LAB DATA: From [**Hospital1 18**]

[**2198-5-15**] 08:10PM   GLUCOSE-93 UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15
[**2198-5-15**] 08:10PM   ALT(SGPT)-20 AST(SGOT)-22 ALK PHOS-99 TOT
BILI-0.3
[**2198-5-15**] 08:10PM   CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-2.2
[**2198-5-15**] 08:10PM   VIT B12-928*
[**2198-5-15**] 08:10PM   TSH-0.86
[**2198-5-15**] 08:10PM   VALPROATE-18*
[**2198-5-15**] 08:10PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2198-5-15**] 08:10PM   WBC-7.3 RBC-4.12* HGB-13.3 HCT-38.3 MCV-93
MCH-32.2* MCHC-34.6 RDW-13.5
[**2198-5-15**] 08:10PM   NEUTS-59.2 LYMPHS-27.8 MONOS-7.9 EOS-3.8
BASOS-1.3
[**2198-5-15**] 08:10PM   PLT COUNT-257

Brief Hospital Course:
Admitted to [**Hospital1 **] 4 for further work-up and management of
?bipolar illness.  On day 1 of hospitalization, pt was continued
on her medication regimen as described in discharge records from
[**Hospital3 417**] Hospital.  She was interactive in the milieu and
was able to participate in conversation with her treatment team.
 She was ambulatory, ate meals, showered, engaged in
conversations, had a visit from her husband.  She did endorse
pain from a recent car accident and received prn doses of
percocet q8h prn.  Her citalopram and bupropion were
discontinued on day 1 of hospital stay due to concern for pt
having bipolar illness and antidepressants worsening risk for
mania.  Her gabapentin was decreased from 600mg [**Hospital1 **] to 300mg
[**Hospital1 **].

During the night after, pt reported rolling out of bed and
hitting her head.  She was evaluated right away by the intern
on-call (see her note in OMR) and did not have any exam findings
or mental status changes after this fall.  Then around 8am on
day 2 of hospitalization she was found in bed to be
hypersomnolent with slowed respirations ([**6-27**]/min).  Her O2sats
were stable around 95%.  Her HR was in the 40s, BP elevated at
190s/160s (some concern as to whether or not this was an
accurate [**Location (un) 1131**] based on machine used and cuff size used).
Medicine was called urgently to see the patient and evaluate.
She received IV access urgently.  She then responded to a very
brisk sternal rub and became more aroused.  Moved all 4
extremities spontaneously in thrashing/writing movements that
were non-rhythmic, non-stereotyped movements.  Her level of
arousal continued to improve such that after several minutes she
could respond to orientation questions, knew she was at [**Hospital1 **] in
[**Apartment Address(1) 105362**], knew month/date/year.  Stat head CT ordered to to
concern for intracranial event s/p fall with altered mental
status.  Meds given for hypertension.  Over the course of the
next half hour or so, pt remained agitated, thrashing all limbs,
writhing in bed, intermittently more responsive to persons at
bedside.  She was unable to participate in a neuro exam due to
not being cooperative.  Medicine consult resident was in to see
pt and agreed with stat head CT and BP management.  Pt had head
CT done and during that again became unarousable with slowed
respirations.  Decision was made due to limited medical support
on psych unit that pt would be transferred to medicine for
ongoing care.

[In [**Location (un) 1131**] through notes from [**Hospital3 417**] Hospital, she was
admitted there prior to transfer to [**Hospital1 **] 4 with what sounds like
nearly identical symptoms to what we're seeing here this morning
(altered mental status, abnormal body movements).  She is listed
in their discharge diagnosis as having seizures as primary
diagnosis.  She received a work-up there including head CT,
brain MRI/MRA and routine EEG which did not demonstrate acute
intracranial abnormality nor active seizure activity on EEG.
She was transferred to [**Hospital1 **] 4 for further psych management, and
now seems to have recurrent symptoms similar to what she
presented with there.]

Medications on Admission:
1. Wellbutrin SR 150mg daily ([**Month (only) **] from 150mg [**Hospital1 **] on [**2198-5-13**])
2. Celexa 20mg daily ([**Month (only) **] from 30mg daily on [**2198-5-13**])
3. Depakote 500mg [**Hospital1 **] (has not been taking accuratly, VPA 22.0
on
[**2198-5-15**])
4. Baclofen 20 TID
5. ASA 81 daily
6. Gabapentin 600 [**Hospital1 **]
7. Metoprolol tartrate 25mg qhs
8. Singulair 10mg qhs
9. Omeprazole 20mg qhs
10. oxybutynin 1mg daily
11. KCL 20mg [**Hospital1 **]
12. Simvastatin 40mg daily
13. Amlodipine 10mg daily
14. Lisinopril 5mg daily

Discharge Medications:
1. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for pain.
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for candidal rash.
6. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day).
7. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
13. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO Q4H (every 4 hours) as needed for stomach
upset.
16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed for stomach upset,
constipation.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain,fever.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Bipolar disorder type II with current hypomanic episode;
reported PTSD, not active; Reported multiple personality
disorder, not active.


Discharge Condition:
Level of Consciousness: Lethargic and not arousable.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.

MSE:
General: somnolent, unarousable except to sternal rub;
previously pleasant, talkative
Speech: none, snoring; previously rambling, easily redirectable
Mood/Affect: unable to assess; previously hypomanic
T. Form: unable to assess. Previously no LOA/TT/TB. Severe FOI
T. Content: unable to assess; previously no
hallucinations/delusions/paranoid ideation. No grandiosity
Cognition : somnolent, previously oriented
J/I: fair

Discharge Instructions:
You were admitted because you were experiencing symptoms of
hypomania, including decreased sleep, pressured speech, and
expansive affect. There was also a concern for seizures and you
had a workup at [**Hospital3 417**] Hospital that was negative. While
on the inpatient psychiatric unit at [**Hospital3 **], you had
another episode of altered mental status, moving your limbs and
were sleepy afterwards. Due to concern for another seizure or
other medical cause for this episode, you were transferred to
medicine for a further workup.

-Please continue all medications as directed.
-Please avoid abusing alcohol and any drugs--whether
prescription drugs or illegal drugs--as this can further worsen
your medical and psychiatric illnesses.
*It was a pleasure to have worked with you, and we wish you the
best of health.*

Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2199-4-25**] 10:30



Completed by:[**2198-5-17**]

Admission Date:  [**2198-5-17**]              Discharge Date:   [**2198-6-20**]

Date of Birth:  [**2134-6-28**]             Sex:   F

Service: MEDICINE

Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose

Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Unresponsive episode

Major Surgical or Invasive Procedure:
Intubation
Initiation of Hemodialysis
EGD [**2198-5-31**], repeat EGD [**2198-6-6**]
Exploratory laparotomy, oversewing of bleeding duodenal ulcer,
four point ligation [**2198-5-31**]

History of Present Illness:
63 yo F with [**Month/Day/Year 72564**] Danlos syndrome, bipolar disorder, multiple
personalities, PTSD, depression, initally admitted [**2198-5-17**] with
mental status changes, with long subsequent hospital course
including acute renal failure from aortic clot, bleeding
duodenal ulcer requiring surgery, RP bleed, now transferred to
MICU for altered mental status.
.
The patient was initially admitted to [**Hospital1 **] 4 on [**2198-5-15**]. On
[**2198-5-17**], she became somnolent and was transferred to the MICU.
She developed acute renal failure, for which MRA was done on
[**2198-5-22**], showing near total occlusive thrombus at the level of
the suprarenal abdominal
aorta. The patient was started on heparin, and her Hct began to
fall. CT abd/pelvis [**2198-5-25**] showed large right retroperitoneal
hemorrhage involving the right iliopsoas muscles, with
dissection throughout the abdomen and pelvis, and large
loculated collection along the right paracolic gutter. The
patient subsequently developed GI bleeding. EGD [**2198-5-31**] showed
diffusely ulcerated duodenal bulb, with active arterial bleeding
from the lateral wall of the apex. For this, the patient
underwent exploratory laparotomy on [**2198-5-31**], with oversewing of
bleeding duodenal ulcer and 4 point ligation. Repeat EGD [**2198-6-6**]
showed multiple oozing ulcers in the duodenal bulb. This was
treated non-operatively. The patient hematocrit remiained
stable.
.
Until [**2198-6-10**], the patient was on the surgical floor, conversing
normally. Then, on the afternoon of [**2198-6-10**], she became
somnolent. CT head [**2198-6-10**] showed no acute intracranial process.
Neurology was called to reassess the patient and found her to be
arousable with prompting and conversant with the examiner,
although she was tangential and has some problems with following
focused examinations, similar to prior assessments. Neurology
concluded that the patient's symtoms were related to renal
failure, medications, and psychiatric problems. Of note, she had
received oxycodone, valproate, and haldol. She received Narcan
with little response.
.
The patient was transferred to the SICU on [**2198-6-10**]. MICU was
requested for altered mental status.

Past Medical History:
- [**Date Range 72564**] Danlos syndrome
- HTN
- Angina
- Sleep apnea (refuses CPAP)
- h/o seizure [**2-21**] to intracranial hematoma (unclear details)
- h/o TIA or stroke (unclear details)
- Cataracts
- bipolar
- multiple personality disorder
- PTSD
- Obesity
.
PAST SURGICAL HISTORY:
L5-S1 fusion and laminectomy
.
Psych history:

PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.

Social History:
< Per OMR >
SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes.

TOB: smoked 2ppd for 40 yrs, quit in [**2195**]
DRUG: none for >20 yrs. Experimented with MJ and "other" drugs
when she was young. Denies any h/o IVDA.

COFFEE: drinks four 32oz glasses of coffee daily. does not want
to cut down.

SOCIAL HX: Raised in [**Location (un) **] and [**Location (un) 686**]. Sexually abused by

father from age [**5-2**]. Went to court for which her father was
sent
to [**Location (un) **] for substance abuse treatment. Then lived with
her
mother, who she reports made her drop out of school in 9th grade

to support the family. She worked in telescope factory. Has 2
sisters and 1 brother, only stays in contact with one sister in
[**Name (NI) 26671**] MA. 1st marriage with 2 children (son and daughter)
who now live in [**Location (un) **] and hullbrook ma. Divorced and
remarried 38 yrs ago to current husband. [**Name (NI) **] children with
current
husband. [**Name (NI) **] now on SSDI for many years due to psych
illness.
Husband works. [**Name2 (NI) **] legal issues in past. Reports DV by husband in

past, hit patient once in [**2167**]'s and pushed patient once. She
does not feel unsafe. He currently calls her names at times, but

she reports they are in couples counseling for this and working
through their issues. Reports she has one friend (with mild
mental retardation) who she is close to and sees almost every
day.


Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and
suicide attempt when he was 9 years old. Denies any other known
psychiatric
family history.

Physical Exam:
On arrival to MICU:
General: Initially somnolent, but subsequently woke up and was
alert, with normal speech but not answering question
appropriately.
HEENT: Anicteric sclerae. Moist mucous membranes.
Neck: Supple.
CV: RRR. Normal s1 and s2. I/VI midsystolic murmur RUSB.
Resp: Normal respiratory effort. CTAB.
Abdomen: Healing surgical scar in midline with staples in place.
Wound C/D/I. +BS. Soft. NT/ND.
Ext: Warm and well-perfused.
Neuro: Mental status as above. Said she was "[**First Name5 (NamePattern1) **] [**Known lastname 105363**]".
Right pupil round and reactive. Left pupil post-surgical. Left
esotropia. Did not cooperate with extraocular movement testing.
Face move symmetrically. Moves all extremities with apparent
full strength but does not cooperate with formal strength
testing. Toes downgoing bilaterally.


Pertinent Results:
ADMISSION LABS
--------------
[**2198-5-17**] 11:57PM   GLUCOSE-88 UREA N-46* CREAT-3.4* SODIUM-143
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2198-5-17**] 11:57PM   CK(CPK)-57
[**2198-5-17**] 11:57PM   CALCIUM-8.0* PHOSPHATE-5.6* MAGNESIUM-2.3
[**2198-5-17**] 11:57PM   VALPROATE-71
[**2198-5-17**] 11:57PM   WBC-6.4 RBC-4.13* HGB-12.7 HCT-38.8 MCV-94
MCH-30.8 MCHC-32.8 RDW-13.6
[**2198-5-17**] 11:57PM   PLT COUNT-203
[**2198-5-17**] 01:59PM   CK-MB-3 cTropnT-<0.01
.
DISCHARGE LABS
--------------
White Blood Cells 4.0
Red Blood Cells 2.80
Hemoglobin 9.0
Hematocrit 26.9
MCV 96
MCH 32.3
MCHC 33.5
RDW 18.4
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 269
.
Glucose 88
Urea Nitrogen 26
Creatinine 3.1
Sodium 132
Potassium 3.9
Chloride 95
Bicarbonate 29
Calcium, Total 7.7
Phosphate 4.5
Magnesium 1.9
.
MICROBIOLOGY
------------
[**2198-6-15**] 4:52 pm STOOL     CONSISTENCY: NOT APPLICABLE

                            **FINAL REPORT [**2198-6-16**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2198-6-16**]):
      Reported to and read back by D. [**Doctor Last Name **] ON [**2198-6-16**] AT
0810.
      CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
.
[**2198-6-14**] 5:29 am SEROLOGY/BLOOD      HELI ADDED TO CHEM#[**Serial Number 105364**]P.

                            **FINAL REPORT [**2198-6-15**]**

   HELICOBACTER PYLORI ANTIBODY TEST (Final [**2198-6-15**]):
      NEGATIVE BY EIA.
           (Reference Range-Negative).
.
[**2198-5-22**] 7:50 am BLOOD CULTURE      RIJ 2 OF 2.

                            **FINAL REPORT [**2198-5-28**]**

   Blood Culture, Routine (Final [**2198-5-28**]):
      STAPH AUREUS COAG +.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------  0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S

   Anaerobic Bottle Gram Stain (Final [**2198-5-23**]):
      Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**] PAGER# [**Serial Number **]
@ 0620 ON
      [**2198-5-23**].
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2198-6-10**] 8:33 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2198-6-13**]**

   URINE CULTURE (Final [**2198-6-13**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.

IMAGING
-------
CT head w/o contrast [**2197-6-10**]:
1. No CT evidence of acute intracranial process such as
hemorrhage.
2. If clinical suspicion for ischemic infarct remains high, MRI
or CTA could be performed for further assessment.
3. Stable mild age-related involution.
.
CT abdomen/pelvis [**2197-6-6**]:
1. New or enlarged 8.2 x 4.7 x 10.2 cm right psoas hematoma,
since the [**2198-5-25**] study. An older right psoas hematoma is
also seen, with decreased fluid along the right paracolic
gutter.
2. Unchanged body wall edema.
.
Bilateral lower extremity venous ultrasound [**2198-6-5**]: No DVT in
the left or right lower extremity.
.
CT abdomen/pelvis [**2198-5-25**]:
1. Large right retroperitoneal hemorrhage involving the right
iliopsoas muscles, with dissection throughout the abdomen and
pelvis, and large loculated collection along the right paracolic
gutter.
2. Severe calcific aortic plaque, with near-complete suprarenal
and moderate infrarenal stenosis.
3. Renal atrophy, right greater than left.
4. Lumbar spine degenerative changes, with lytic L5-S1
anterolisthesis.
5. Body wall edema and small bilateral pleural effusions.
.
Echo (TTE) [**2198-5-23**]: The left atrium is normal in size. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined. The
main pulmonary artery is dilated. There is no pericardial
effusion.
.
IMPRESSION: No cardiac source of embolism seen. Hyperdynamic
biventricular systolic function. No significant valvular
abnormality seen. Dilated main pulmonary artery.
.
MRA Kidney w/o contrast [**2198-5-22**]:
1. Near total occlusive thrombus at the level of the suprarenal
abdominal aorta, most probably the cause of acute kidney injury.

2. High-grade stenosis at the origin of right renal artery and
at the origin of the left renal artery. Normal renal veins.
.
MR [**Name13 (STitle) 430**] w/o constrast [**2198-5-20**]:
1. Periventricular and deep white matter FLAIR hyperintensities
likely to suggest small vessel ischemic change.
2. No evidence of an acute intracranial process or a large
pituitary lesion in this unenhanced study. Pituitary
microadenoma cannot be ruled out in this unenhanced study.
3. MRA brain demonstrates no evidence of aneurysms or vascular
malformation.
4. 14mm x 6mm T2 hyperintense lesion in the left parietal skull
may represent epidermoid cyst as the lesion is mildly bright on
diffusion or possibly a hemangioma.


Brief Hospital Course:
63 y/o female with multiple personality disorder, depression,
PTSD, bipolar disorder, sleep apnea, [**Month/Day/Year **]-danlos, and previous
seizure due to intracranial hematoma, who initially presented to
[**Hospital3 417**] Hospital for questionable seizures (negative
work-up), with subsequent admission to [**Hospital1 18**] for bipolar
disorder treatment, now transferred to MICU for altered mental
status and concern for ? seizures and episodes of apnea.
.
ACTIVE ISSUES
-------------
# Altered mental status: previous work-up at [**Hospital3 417**]
hospital notable for negative non-contrast head CT, MRI, MRA and
neck MRA for stroke. Her head MRA did show some atrophy and
small vessel disease. Patient had a portable EEG on [**5-12**] which
showed moderately abnormal, generalized encephalopathic proces
without lateralizing or epileptogenic abnormalities. Potential
etiologies included post-ictal confusion from unwitnessed
seizure (possible given subtherapeutic depakote level) versus
hypoxemia during night-time from her sleep apnea given her
desaturations. Interestingly, she also appears to have numerous
episodes of apnea and periodic limb movements during the day,
remniscent of restless leg syndrome and narcolepsy, questioning
a sleep disordered breathing pattern. Of note, she had an
unrevealing head CT on [**5-17**]. With regard to toxic metabolic
etiologies, her blood glucose was normal, her CBC and chemistry
10 were normal, her serum toxicology was negative, her liver
enzymes and synthetic function were normal, and her B12 and TSH
were normal. Also, there did not appear to be a withdrawal
syndrome present.  There were no fevers or signs/symptoms of
infection.  There was no evidence for benzodiazepine or narcotic
overuse.  Mental status was improved upon discharge, and patient
had returned to baseline.
.
# Oliguric acute renal failure: Likely ischemic acute tubular
necrosis from thrombus in aorta.  Patient's urine output <100cc
daily initially and gradually improved. Renal was consulted and
the patient started on hemodialysis, which she will continue
upon discharge.  She will follow up with nephrology upon
discharge.  There are pending wound cultures upon discharge from
the site of her hemodialysis line.
.
# Bacteremia: MSSA in one blood culture was isolated during
[**Hospital 228**] hospital course, drawn off a newly placed right-sided
hemodialysis line.  Patient was without fever or white count and
subsequent cultures were without growth.  Infectious disease was
consulted.  All lines were removed at the time and her HD line
was replaced.  As all surveillance cultures are negative to
date, plan was to treat through the infection using nafcillin
(MSSA also in sputum), after she was initially on vancomycin.
TTE was without evidence of vegetation.  Patient remained
afebrile and without leukocytosis throughout remainder of
hospital stay.  During her stay in the SICU, nafcillin was
temporarily discontinued.  During this interim, she was
mom[**Name (NI) 11711**] on ceftriaxone for urinary tract infection.  IV
nafcillin was restarted upon arrival to the medical floor.  Per
ID, she should complete a course of nafcillin to end on [**2198-7-12**].
 She will follow up with infectious disease on [**2198-7-5**].
.
# Atrial fibrillation with rapid ventricular response: Patient
developed atrial fibrillation with rapid ventricular response on
[**6-11**]. She was treated with metoprolol 5 mg IV, then labetalol 20
mg IV, with return of sinus rhythm. With improvement in her
mental status, she was resumed on PO Metoprolol 12.5 twice
daily, which was eventually transitioned to PO labetalol for
added blood pressure control.  She was not anticoagulated given
her gastrointestinal bleeding and retroperitoneal bleed
experienced during hospitalization.
.
# Gastrointestinal bleeding from duodenal ulcer:  On [**5-25**], serial
hematocrits were decreasing and patient had a CTA abdomen
demonstrating a retroperitoneal bleed/psoas bleed/duodenal ulcer
bleed.  On [**5-30**] the patient developed melena and a rapid upper
gastrointestinal bleed.  She received 8 units of pRBC initially
and her hct dropped despite the blood. On [**5-31**], she had an EGD
demonstrating a large duodenal ulcer with evidence of active
bleeding. The patient was taken to the OR for an urgent
exploratory laparotomy and oversew of the duodenal ulcer. The
anticoagulation was stopped and she was monitored closely for
signs of bleeding and serial hematocrits were followed, which
remained stable from then on. The patient was continued on an IV
PPI, and eventually transitioned to PO high dose PPI therapy
upon discharge.  She will follow up with General Surgery upon
discharge.
.
# Retroperitoneal hemorrhage: On [**5-25**], serial hematocrits were
decreasing and patient had a CTA abdomen demonstrating a
retroperitoneal bleed/psoas bleed/duodenal ulcer bleed.  Patient
was transfused as necessary and serial hematocrits were trended.
 The patient remained hemodynamically stable, with stable
hematocrit when she eventually reached the medical floor.
Surgery and Vascular followed the patient during the duration of
the bleed.
.
# Aortic clot: Etiology unclear but the patient has known [**Name (NI) 72564**]
Danlos, ? stasis vs. intimal weakening.  An MRA abdomen was done
to look at renal arteries, which demonstrated an aortic clot
that was straddling the origin of the renal arteries. Renal
arteries still had flow, but this was somewhat diminished.
Vascular was consulted for clot and they recommended a heparin
gtt, which was eventually discontinued due to bleeding episodes.
 Echocardiogram was unremarkable for source of the clot.
Differential diagnosis included an anatomic abnormality of
aorta, hypercoagulability, or intravascular tumor. The patient
could not be continued on anticoagulation given severe bleeding
this hospitalization.  Patient will follow up with Vascular
Surgery upon discharge on [**2198-7-26**].
.
# Clostridium difficile colitis: During hospital course, pt
complained of frequent loose stools. C.diff toxin returned
positive.  Abdominal exam showed slight tenderness during her
hospital stay with no peritoneal signs.  WBC remained within
normal range.  Patient was initially on IV metronidazole, then
transitioned to both IV metronidazole and PO vancomycin when she
developed transient abdominal pain and increased bowel
movements.  She was eventually placed on PO vancomycin upon
discharge, with plan to continue this therapy for two weeks
after she finishes her IV nafcillin therapy on [**2198-7-12**].  This
would mean she would be set to cease PO vancomycin therapy on
[**2198-7-26**].
.
# Hyponatremia: patient was noted to be hyponatremic to the low
130s during her hospitalization.  She was placed on a 1500 ml
fluid restriction.  Etiology was thought to be related to her
kidney failure and need for hemodialysis.
.
# Psychiatric issues: patient was taken off her home dose of
valproic acid, bupropion and citalopram during her
hospitalization due to acute medical issues.  She was eventually
placed back on valproic acid.  She is being discharged on this
medication, but will not resume citalopram or bupropion at this
time.  Psychiatry will see the patient as an outpatient for a
time to be determined.
.
# Hypertension: patient was admitted on metoprolol tartrate and
amlodipine.  During her hospital course, it was determined that
this was not adequate therapy for her elevated blood pressure,
and she was switched from metoprolol to labetalol therapy, which
she will continue as an outpatient.
.
TRANSITION OF CARE
------------------
# Follow-up: patient is scheduled for follow-up appointments
with Vascular Surgery, Infectious Disease, Acute Care Surgery,
Nephrology and her primary care provider upon discharge.  A
psychiatry appointment has not yet been scheduled, but this will
happen after discharge.  There are pending blood cultures and
wound cultures which will need to be followed up after
discharge.  She should have daily complete blood counts and
chemistry panels (Chem7) for at least the first week after
discharge to assure stability.   She should also get weekly
BUN/Creatinine, LFTs, and CBC/differential going forward, with
results to be faxed to the Infectious Disease [**Hospital 4898**] clinic at
[**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Communication: HCP is husband [**Name (NI) 15954**] [**Name (NI) 105363**] [**Telephone/Fax (1) 105365**]
.
# Code status: FULL CODE, confirmed with husband (healthcare
proxy)


Medications on Admission:
Aspirin 81mg qd
Depakote 500mg [**Hospital1 **]
Neurontin 600mg [**Hospital1 **]
Lopressor 25mg qHS
Singulair 10mg qHS
Simvastatin 40mg qd
Omeprazole 20mg qd
Ditropan-XL daily
KCl 20mEq [**Hospital1 **]
Norvasc 10mg qd
Critic-aid clear AF [**Hospital1 **] coccygeal area
Wellbutrin SR 150mg qd
Celexa 20mg qd
Lisinopril 5mg qd

Discharge Medications:
1. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
4. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
5. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
6. Nafcillin 2 g IV Q4H
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Singulair 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-21**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for dyspepsia.
13. Outpatient Lab Work
Please perform weekly BUN/Creatinine, LFTs, and CBC/differential
going forward, with results to be faxed to the Infectious
Disease [**Hospital 4898**] clinic at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].

14. Outpatient Lab Work
Please perform daily CBC and Chem10 for one week until [**2198-6-26**],
or until lab values have stabilized
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
16. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1)
Injection three times a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary diagnosis:

Hypomania/bipolar disorder
Aortic thrombus
MSSA bacteremia
Duodenal ulcer bleed
Retroperitoneal hemorrhage
Hyponatremia
End-stage renal disease on hemodialysis
Clostridium difficile colitis
Hypertension

Secondary diagnosis:

[**Location (un) 72564**]-Danlos syndrome
Obstructive sleep apnea
History of seizures
Bipolar disorder
Multiple personality disorder


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


Discharge Instructions:
Dear Ms. [**Known lastname 105363**],

It was a pleasure taking care of you at the [**Hospital1 18**].  You came for
further evaluation of your bipolar disorder.  While here, there
were many medical issues which occurred, including aortic
thrombus, gastrointestinal bleeding, bleeding into your
retroperitoneal space, blood stream infection, and Clostridium
difficile gastrointestinal infection.  You are now being
discharged to a long term assisted care facility.  It is
important that you continue to take your medications as
prescribed.

The following changes have been made to your medications:

We have STARTED labetalol for control of your blood pressure.
We have STARTED vancomycin for treatment of your C. diff
infection/
We have STARTED naficillin for treatment of your Staph aureus
blood infection.
We have STARTED trazodone to help you sleep.
We have STARTED artificial tears to prevent eye dryness.
We have STARTED simethicone to help with stomach upset.
We have STARTED acetaminophen to help with pain.
We have STARTED calcium carbonate for nutritional
supplementation.
We have STARTED pantoprazole for your reflux and to protect
against gastrointestinal bleeding.
We STOPPED omeprazole in favor of pantoprazole.
We have STOPPED your wellbutrin and Celexa until you are seen by
Psychiatry and they determine what psychiatric medications you
should be on going forward.
We have STOPPED your Baclofen and gabapentin until you follow up
with your primary care doctor and it is determined if you should
resume this therapy.
We have STOPPED your aspirin, since you had numerous bleeding
episodes while hospitalized.
We have STOPPED your metoprolol in favor of labetalol to further
control your blood pressure.
We have STOPPED your lisinopril due to decreased kidney
function.


Followup Instructions:
Department: ORTHOPEDICS
When: THURSDAY [**2199-4-25**] at 10:30 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 14200**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2198-7-26**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: INFECTIOUS DISEASE
When: THURSDAY [**2198-7-5**] at 11:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: VASCULAR SURGERY
When: THURSDAY [**2198-7-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2198-7-5**] at 1:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2198-7-11**] at 9:30 AM
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 Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]



Admission Date:  [**2198-6-23**]              Discharge Date:   [**2198-7-3**]

Date of Birth:  [**2134-6-28**]             Sex:   F

Service: MEDICINE

Allergies:
Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose

Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Frequent dark stools, falling hematocrit

Major Surgical or Invasive Procedure:
EGD

History of Present Illness:
Ms. [**Known lastname 105363**]  is a 36 year old female with a history of an aortic
clot, retroperitoneal bleed, and duodenal ulcer bleed, who
presents with melena and anemia.
.
She presented to [**Hospital3 417**] Hospital today with greater than
20 liquid black bm in 16 hrs. She had hgb 6, hct 18.1, vitals
99.2, hr 93, rr 16, 122/64, 98% RA. Guaiac positive times two.
.
Prior to admission to [**Last Name (LF) **], [**First Name3 (LF) **] [**Hospital1 **] nursing
notes, [**2198-6-22**] at 0700 pt she was incontinent of liquid stool and
urine, hypertensive 190/90, labetalol and nitropaste prior to
dialysis. At 5pm, 3 large loose black BMs, stat hct 22.5 hgb 7,
2 units of blood given. [**6-22**] at 2300 pt continued to have black
liquid stool about 8 per shift. [**6-23**] 0800, 6 liquid black tarry
stools, given 1 unit prbcs and transferred to [**Hospital3 **].
.
She had a recent admission in [**4-30**] for the workup of altered
mental status, which was unrevealing with negative MRI/MRA head,
CT head, MRA neck, EEG.  Ultimately unclear what caused her MS
changes.  She also developed renal failure, MSSA bacteremia,
A-fib with RVR, GI bleed from duodenal ulcer, RP bleed, C. diff,
hyponatremia and aortic clot.  Briefly her previous
hospitalization was significant for the development of an aortic
occlusion for which she was started on heparin.  She then
developed RP hematoma and heparin was stopped.  She then had a
GI bleed.  Endoscopy showed ulcer with stigmata of recent bleed.
 Treated with injectible epi and BICAP.  Unfortuantely she
re-bled and as she has a potential allergy to dye and given her
aortic occlusion she was felt to be a poor candidate for IR
procedure; thus she was taken to the OR for an ex-lap and
oversewing of bleeding duodenal ulcer and 4 point ligation (on
[**5-31**]).  Her hct then improved to her baseline on 38-40.  On [**6-5**]
it dropped again to 31 from 39.  A repeat EGD on [**6-6**] showed
multiple erosions and ulcers in the duodenal bulb with bright
red blood consistent with active recent bleeding.  No
intervention was done at that time.  Her hct then trended down
slowly to 26.
.
In the ED, she was found  to have a hematocrit of 20.4 (from
26.9 on [**2198-6-20**]). She remained hemodynamically stable and without
tachycardia.  Initial vitals there were 99.1, BP 186/94, HR 98,
RR 16, Sat 98% RA.
.
On the floor, she had no new complaints. She mentioned some
non-specific abdominal cramping during her bowel movements.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomitingconstipation. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.


Past Medical History:
h/o alcohol abuse
HTN
Sleep apnea
COPD
s/p ankle fracture repair
h/o TIA
s/p spinal fusion L5-S1 laminectomy [**2170**]
s/p bilateral cataract surgery
?[**Year (4 digits) 72564**] Danlos Syndrome
Aortic thrombus
Mssa bacteremia
Afib
Duodenal cap bleed
PTSD, multiple personalities, bipolar, substance abuse


Social History:
Raised in [**Location (un) **]. History of sexual abuse. History of 1 bottle
of wine daily until 6 months ago. She smoked 2ppd for 40 yrs,
quit in [**2195**]. Denies h/o IVDA.

Family History:
FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and
suicide attempt when he was 9 years old. Denies any other known
psychiatric
family history.

Physical Exam:
On admission:
Tmax: 36.9 ??????C (98.4 ??????F)
Tcurrent: 36.9 ??????C (98.4 ??????F)
HR: 84 (84 - 84) bpm
BP: 159/87(98) {159/87(98) - 159/87(98)} mmHg
RR: 15 (15 - 15) insp/min
SpO2: 98%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: No acute distress
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: 1+ to thready dp bilaterally but lower
extremities warm
Abdominal: Obese Soft, Non-tender, Bowel sounds present,  no
organomegaly
Skin:  Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): times three, Movement: Not assessed,
Tone: Not assessed, moving all extremities


Pertinent Results:
ADMISSION LABS
--------------
[**2198-6-23**] 06:00PM   GLUCOSE-90 UREA N-47* CREAT-2.6* SODIUM-133
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-24 ANION GAP-17
[**2198-6-23**] 06:00PM   estGFR-Using this
[**2198-6-23**] 06:00PM   ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-60 TOT
BILI-0.2
[**2198-6-23**] 06:00PM   LIPASE-65*
[**2198-6-23**] 06:00PM   ALBUMIN-2.8* CALCIUM-8.3*
[**2198-6-23**] 06:00PM   WBC-8.8# RBC-2.08*# HGB-6.8* HCT-20.4* MCV-98
MCH-32.7* MCHC-33.3 RDW-18.9*
[**2198-6-23**] 06:00PM   NEUTS-76.5* LYMPHS-14.7* MONOS-5.4 EOS-2.9
BASOS-0.5
[**2198-6-23**] 06:00PM   PLT COUNT-302
[**2198-6-23**] 06:00PM   PT-12.7 PTT-22.8 INR(PT)-1.1
.
DISCHARGE LABS
--------------
[**2198-7-2**] 05:08AM BLOOD WBC-5.7 RBC-3.05* Hgb-9.7* Hct-29.1*
MCV-96 MCH-31.9 MCHC-33.4 RDW-17.0* Plt Ct-306
[**2198-7-2**] 05:08AM BLOOD Neuts-62.5 Lymphs-11.5* Monos-9.5
Eos-16.0* Baso-0.5
[**2198-7-2**] 05:08AM BLOOD Glucose-84 UreaN-29* Creat-3.7* Na-131*
K-4.3 Cl-97 HCO3-20* AnGap-18
[**2198-7-2**] 05:08AM BLOOD Calcium-8.0* Phos-5.8* Mg-2.3
.
MICROBIOLOGY
------------
MRSA screen: negative
.
IMAGING
-------
CT Abd/Pelvis on admission:
IMPRESSION:
1. Mild decrease in size of two right retroperitoneal/pelvic
hematomas. No
evidence of new bleed.
2. New small amount of simple appearing ascites.
3. Severe suprarenal aortic stenosis, with resulting renal
atrophy.
4. Stable L5-S1 spondylolisthesis.
.
EGD [**2198-6-25**]:
Erythema in the duodenal bulb compatible with mild duodenitis
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum


Brief Hospital Course:
63 yo female with [**Month/Day/Year 72564**] Danlos syndrome, bipolar disorder,
multiple personality disorder, PTSD, and seizure due to
intracranial hematoma and recent hospital course complicated by
suprarenal aortic clot, retroperitoneal bleed, and duodenal
ulcer bleed presents with melena and falling hematocrit.
.
ACTIVE ISSUES
-------------
# Acute on chronic anemia: differential diagnosis included acute
blood loss due to gastrointestinal bleed (with guaiac positive
stools and recent history of duodenal ulcer bleed) versus
retroperitoneal hematomas versus kidney dysfuction.  Patient
received 4 units PRBCs with inappropriate hematocrit response
early in admission.  Gastroenterology was consulted and
performed repeat EGD on [**2198-6-25**] which showed a healing duodenal
ulcer and no direct source of bleed was identified.   Patient
also had CT of the back/abdomen that did not show evidence of an
expanding hematoma, although old hematoma continued to show
signs of resolution.  She was initially on a proton pump
inhibitor drip, then transitioned to intravenous route, and
eventually to oral PPI.  Hematocrit remained stable after EGD,
with numerous guaiac negative stools noted.  Complete blood
counts should be checked daily after the patient leaves the
hospital to trend hematocrit levels, which have remained stable
at 27-30 for days prior to discharge.
.
# Chronic kidney disease: patient was initiated on hemodialysis
during her last admission to [**Hospital1 18**]. Her renal disease was
thought to be due to the large aortic thrombus.  It was noted
over the course of her admission that she was producing more
urine, and 24 hour creatinine measurement was initiated.
However, patient's creatinine uptrended while off hemodialysis,
and it was determined that patient will possibly need to
continue dialysis sessions as need at the outside facility, per
the neprologist's discretion.  Her hemodialysis line will remain
in and Chem10 should be checked [**Hospital1 **].  Patient is scheduled for
follow-up with nephrology, where further determination will be
made of dialysis need.  Patient's dialysis line should be
flushed with heparin at the time of dialysis, if required.
.
# Hypertension: patient was continued on labetalol 200 mg tid
and amlodipine 10 mg daily during her admission for blood
pressure control, which was deemed to be inadequate.  Her
labetalol was increased to 600 mg TID for added control before
discharge, and furosemide was also added, due to concern for
fluid overload.  Twice daily Chem10 should be performed upon
discharge to trend electrolyte levels.  If patient requires
further blood pressure management, further uptitration of
labetalol is recommended.  Recommended systolic blood pressure
range should be 130s-160s due to patient's likely impaired
kidney perfusion from her aortic thrombus.
.
# Eosinophilia: patient was noted to have an eosinophilia of 16%
on labs checked before discharge.  This problem should be
followed up at the discharge facility going forward.
.
INACTIVE ISSUES
---------------
# Retroperitoneal hematoma: per CT abdomen/pelvis, this was
decreasing in size and no new retroperitoneal hematomas were
noted compared to prior.
.
# Aortic thrombus: patient had been on heparin when the clot was
discovered during her admission in [**5-30**]. She was taken off the
heparin after developing retroperitoneal and GI bleeds. She is
not anticoagulated at this time, because anticoagulation is
contraindicated in the setting of a possible GI bleed.  This
should be reevaluated in the future.
.
# Clostridium difficile colitis: patient was toxin positive on
[**2198-6-15**].  She is currently receiving vancomycin 125 mg PO q6hrs
through [**2198-7-26**], two weeks after cessation of nafcillin therapy.
There was noted increased bowel movements prior to admission,
which had slowed considerably on admission.  Patient will remain
on oral vancomycin therapy upon discharge until the date noted
above.  Patient was experiencing loose stools during her
admission, likely due to osmotic mechanism from diet changes,
and possible GI bleed on admission.  There was no noted fever,
leukocytosis or abdominal pain during her hospital course.  At
the time of discharge, she ranged from [**5-27**] soft, loose bowel
movements daily.
.
# MSSA Bacteremia: patient will be continuing nafcillin through
[**2198-7-12**], per Infectious Disease recommendations, which should
continue upon discharge.  She should also get weekly
BUN/Creatinine, LFTs, and CBC/differential going forward, with
results to be faxed to the Infectious Disease [**Hospital 4898**] clinic at
[**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Atrial fibrillation: patient was continued on labetalol 600 mg
TID during admission for rate control, which she will continue
upon discharge.  She is currently not on anticoagulation given
her recent history of gastrointestinal and retroperitoneal
bleed.
.
# Chronic hyponatremia: During her last admission, this was
thought to be secondary to intrinsic renal disease.  During most
of this admission, patient had a normal sodium level.  Level was
trended daily, and should continue to be trended regularly as
noted elsewhere.
.
# Dyslipidemia: patient was continued on simvastatin 40 mg daily
during her admission.
.
# Psychiatric conditions: patient was continued on divalproex
500 mg [**Hospital1 **] during her admission.  Patient will require
Psychiatry follow-up at [**Hospital 14221**] [**Hospital 4189**] Health Center or [**Hospital1 1535**], which has not yet been
scheduled, and should be initiated upon discharge from the LTAC
facility.  The patient's family has been instructed to call and
try to schedule an appointment at one of these two locations.
.
TRANSITION OF CARE
------------------
# Follow-up: patient is scheduled for follow-up appointments
with Vascular Surgery, Infectious Disease, Acute Care Surgery,
Nephrology and her primary care provider upon discharge.  A
psychiatry appointment has not yet been scheduled, but this will

occur after discharge.  There are pending blood cultures and
wound cultures which will need to be followed up after
discharge.  She should have daily complete blood counts and
twice daily chemistry panels (Chem10) for at least the first
week after discharge to assure stability.   She should also get
weekly BUN/Creatinine, LFTs, and CBC/differential going forward,
with results to be faxed to the Infectious Disease [**Hospital 4898**] clinic
at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
.
# Code status: patient is confirmed full code.
.


Medications on Admission:
acetaminophen 325 mg Tablet q6 prn pain
amlodipine 10 mg Tablet daily
calcium carbonate 200 mg calcium (500 mg) Tablet, TID
divalproex 500 mg [**Hospital1 **]
heparin 5,000 unit/mL SC TID
labetalol 300 mg Tablet TID
montelukast 10 mg Tablet qHS
Nafcillin 2 g IV Q4H
pantoprazole 40 mg [**Hospital1 **]
simethicone 80 mg QID
simvastatin 40 mg daily
trazodone 100 mg qHS prn
vancomycin 125 mg Capsule q6
carboxymethylcellulose sodium 1.4-0.6% 1-2 Drops PRN dry eyes.


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
5. montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
6. Nafcillin 2 g IV Q4H
end date [**2198-7-12**]
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
11. Outpatient Lab Work
Please perform CBC daily until [**2198-7-6**], then every other day
after that until hematocrit level stabilizes
12. Outpatient Lab Work
Please perform Chem10 twice a day, until electrolytes stabilize,
specifically potassium and magnesium
13. Outpatient Lab Work
Please perform weekly BUN/Creatinine, LFTs, and CBC/differential
going forward, with results to be faxed to the Infectious
Disease [**Hospital 4898**] clinic at [**Hospital1 18**] at ([**Telephone/Fax (1) 1354**].
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
15. labetalol 300 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
16. Furosemide 40 mg IV BID


Discharge Disposition:
Extended Care

Facility:
[**Hospital 1263**] Hospital Transitional Care Unit - [**Location (un) 686**]

Discharge Diagnosis:
Primary diagnosis:

Acute on chronic anemia
Hypertension
Chronic kidney disease

Secondary diagnosis:

Retroperitoneal hematoma
Aortic thrombus
Clostridium difficile colitis
MSSA bacteremia
Atrial fibrillation
Chronic hyponatremia
Dyslipidemia


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


Discharge Instructions:
Dear Ms. [**Known lastname 105363**],

It was a pleasure taking care of you at [**Hospital1 827**].  You came for further evaluation of anemia and
increased bowel movements.  Tests showed that there was no
evident source of bleeding in your stomach and the first part of
your intestine.  You are now being dischrged to a long-term
acute care facility.  You will also continue dialysis as needed
at the outside facility.  Whether or not you need this in the
future will continue to be determined.  It is important that you
continue to take your medications and follow up with the
appointments that have been arranged for you.

The following changes have been made to your medications:

We INCREASED your labetalol dose for added blood pressure
control
We ADDED furosemide to take extra fluid off of your legs


Followup Instructions:
Please call [**Hospital 14221**] [**Hospital 4189**] Health Center at [**Telephone/Fax (1) **] to
schedule a Psychiatry appointment.

Department: VASCULAR SURGERY
When: THURSDAY [**2198-7-26**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2198-7-26**] at 2:35 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2198-7-5**] at 1:45 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: INFECTIOUS DISEASE
When: THURSDAY [**2198-7-12**] at 8:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2198-7-10**] at 9:30 AM
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
{'Encephalopathy, unspecified,Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Hemoperitoneum (nontraumatic),End stage renal disease,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Ehlers-Danlos syndrome,Bacteremia,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Vascular disorders of kidney,Acute posthemorrhagic anemia,Other and unspecified infection due to central venous catheter,Dissociative identity disorder,Posttraumatic stress disorder,Bipolar disorder, unspecified,Restless legs syndrome (RLS),Narcolepsy, without cataplexy,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Other disorders of muscle, ligament, and fascia,Obstructive sleep apnea (adult)(pediatric),Abnormal involuntary movements,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Iron deficiency anemia secondary to blood loss (chronic),Eosinophilia,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}


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: "I was at [**Hospital3 **] and then came here because I was told I may
have had seizure."

PRESENT ILLNESS: 63yo married white woman with reported h/o multiple
personality disorder, depression, PTSD, and recently documented
h/o bipolar disorder, also with a medical h/o sleep apnea,
ehlers-danlos, and previous seizure due to intracranial
hematoma,
who was transferred form [**Hospital3 417**] hospital at husband of
patient's request for psychiatric evaluation and possible psych
admission.
     Per [**Hospital3 **] notes (sent on transfer), the patient was
recently admitted to [**Hospital3 **] on [**2198-5-12**] for question of
seizure.
Labs, MRI/MRA, Head CT were all negative. EEG was negative for
seizure activity, but showed some generalized slowing. Patient
was also seen by psychiatry while there for expansive affect and
pressured speech. Diagnosed with bipolar disorder with hypomanic
episode, likely secondary to taking antidepressants wrong
(taking
more wellbutrin than she was supposed to). Also had a
subtherapeutic VPA level. Psych planned to taper
antidepressants,
and [**Month (only) **] dose of wellbutrin to 150 daily and celexa 20 daily.
Patient was discharged home [**2198-5-14**] with plan to follow-up with
outpt neuro and psych (though doesn't have any outpt psych
treaters in place).
     Per the husband, the patient continued to have pressured
speech, [**Month (only) **] sleep, only 10minutes at a time for a total of 30
minutes. Was restless in bed. He became concerned about her and
felt he was unable to contain her and called 911. She was taken
back to [**Hospital3 **]. Repeat labs and head imaging was negative.
[**Hospital3 **] recommended inpt psych admit, but the husband wanted
transfer
to [**Hospital1 18**] which the hope that the patient could be admitted if
needed psychiatrically at [**Hospital1 18**] and set up with outpt behavioral
health treaters at [**Hospital1 18**].
     Per the patient, she reports feeling "hyper" meaning that
she has more energy than usual, has a hard time sleeping, and
feels she talks faster than usual. She reports having similar
"hyper" episodes throughout her life. Unable to give an accurate
history about the frequency, length or when the last episode
was.
Denies increased spending, promiscuity or goal directed
behaviors
during these episodes. However her husband endorses that she
will
have [**2-22**] "manic" episodes over a year, then not have any for a
few years since he has known her for 38 years. He endorses that
at her worst, she does have disorganized thoughts, rapid speech,
increased goal directed behavior (such as scrubbing floor in
middle of night) and decreased need for sleep (though would
sleep
some each night). He noticed that this "manic" episode started
about the same time as the potential seizure like activity on
[**2198-5-12**].
     Patient is unable to give a accurate account of her meds,
but she is the one who self administers them. She endorses that
she often changes her meds on her own and endorses needing help
with accurately taking her meds.

MEDICAL HISTORY: PSYCH HX: (per patient, verified with husband)
DX: Multiple personality disorder since teens diagnosed by
counselor at [**Doctor First Name **], due to trauma history. Reports this has not
been active for many years. Reports h/o depressive episodes that
required hospitalization. History of PTSD, not currently active.
Denies Bipolar disorder, however recent psych eval at [**Hospital3 **]
reports diagnosis of Bipolar disorder (hypomanic episodes)
HOSP: multiple (up to 10) at [**Doctor First Name **]. 1st at age 15. Most recent
was [**2188**]. Mostly for depressive episodes.
MED TRIALS: unknown (reports Seroquel once, but caused
significanat inc appetite).
SA/SIB: twice: first age 15 (ASA overdose 85 tablets). Admitted
to hospital. Second (unknown age, but not recent) was by psych
med ingestion.
TREATERS: previously was seen at [**Doctor First Name **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 80749**]
(psychopharm) and Dr. [**First Name8 (NamePattern2) 1258**] [**Last Name (NamePattern1) **] (therapist) for many years
until [**2197-11-20**] (at which time they suggested patient get
treaters at Southbay MHC, closer to her home, bc the patient had
a bad MVA due to her driving and didn't want to put the patient
further at risk by making her drive to [**Location (un) 10059**] from [**Location (un) 701**]).
Currently, the patient is in the intake process at Southbay, but
does not have an actual therapist or psychiatrist.

MEDICATION ON ADMISSION: 1. Wellbutrin SR 150mg daily ([**Month (only) **] from 150mg [**Hospital1 **] on [**2198-5-13**])
2. Celexa 20mg daily ([**Month (only) **] from 30mg daily on [**2198-5-13**])
3. Depakote 500mg [**Hospital1 **] (has not been taking accuratly, VPA 22.0
on
[**2198-5-15**])
4. Baclofen 20 TID
5. ASA 81 daily
6. Gabapentin 600 [**Hospital1 **]
7. Metoprolol tartrate 25mg qhs
8. Singulair 10mg qhs
9. Omeprazole 20mg qhs
10. oxybutynin 1mg daily
11. KCL 20mg [**Hospital1 **]
12. Simvastatin 40mg daily
13. Amlodipine 10mg daily
14. Lisinopril 5mg daily

ALLERGIES: Betadine Viscous Gauze / Iodine Containing Agents Classifier /
Naprosyn / Clindamycin / Lactose

PHYSICAL EXAM: Physical Exam:
VS:  BP: 180/66  HR: 56  temp: 98.6   resp:  O2 sat: 98%
height:
5'3"  weight: 203.8 lbs
Gen: obese Caucasian female, alert and interactive, looking
stated age, dressed in hospital [**Doctor First Name **], grooming fair
HEENT: normocephalic, oropharnyx clear. PERRL, EOMI.
CV: RRR, no M/R/G
Pulm: CTAB
Abd: +BS, NDNT, soft
Ext: mild 1+ pitting edema of right foot
Skin: extensive erythematous scarring of shins bilaterally "pt
attributes to her ehlers-danlos syndrome)

FAMILY HISTORY: FAMILY PSYCH HX: sister with [**Name2 (NI) **]; son with depression and SA
when he was 9 years old. Denies any other known psychiatric
family history.

SOCIAL HISTORY: SUBSTANCE ABUSE HX:
ETOH: h/o etoh abuse drinking 1 bottle wine daily up until 6
months ago, at which time she self tapered with help of her
outpt
psychiatrist. Has not used since. No h/o blackouts or inpt
detoxes. 

### Response:
{'Encephalopathy, unspecified,Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Hemoperitoneum (nontraumatic),End stage renal disease,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Ehlers-Danlos syndrome,Bacteremia,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Vascular disorders of kidney,Acute posthemorrhagic anemia,Other and unspecified infection due to central venous catheter,Dissociative identity disorder,Posttraumatic stress disorder,Bipolar disorder, unspecified,Restless legs syndrome (RLS),Narcolepsy, without cataplexy,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Other disorders of muscle, ligament, and fascia,Obstructive sleep apnea (adult)(pediatric),Abnormal involuntary movements,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Iron deficiency anemia secondary to blood loss (chronic),Eosinophilia,Other and unspecified hyperlipidemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits'}
