CHIEF COMPLAINT: "I'm going to die ..you'll die of old age I just gave you MRSA
because I just shook your hand."

PRESENT ILLNESS: The patient is a 59 yo cauc. female with reported hx of bipolar
do discharged fom [**Hospital **] Hospital psych unit yeserday  brought
to the ED by her husband and twin sister as she continues
delusional.The patient is psychotic, manic and has thoughts that
she and other people are dying and believes she is the last
Catholic alive.
Her husband reports that she was discharged from [**Hospital **]
Hospital
yesterday after a 3 week admission but she continues psychotic,
not sleeping,and arguementative and refusing to take her
medications .He said she is continously hungry , is an insulin
dependent diabetic and last night she ate a huge piece of
cheesecake. This morning he said  "she laid down on the kitchen
floor and refused to get up and said " I'm dying."He said that
she has not slept all night and that he has been up with her as
she is a flight risk.He said before her most recent
hospitalization to Norwooed she cut a hole in the screen door,
crawled out and ran and hid under [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].He said she threw her
suiticase in the [**Doctor Last Name 6641**] and continually tried to run away and he
had to watch her 24 hrs a day.
Her husband [**Name (NI) 68655**] that she was referred to a Dr. [**Last Name (STitle) **] in
[**Location (un) 3320**] after she was discharged  but was told that she could
not have an appointment with him until she was seen by a
therapist for 2-3 times.
The patient has hx of bipolar do first daignosed and
hospitalized
24 years ago and was admitted to [**Hospital3 15986**] twice and has
been apparently relatively stable unitl this past [**Name (NI) **] and has
reportedly had  2 admisssions to [**Hospital **] Hospital.
Recent stressors are her brother in law her twin sister's
husband
died in [**Name (NI) 404**] and [**Month (only) 958**] is the anniversary of her son's death.

MEDICAL HISTORY: * [**Hospital **] Hospital discharged [**2115-7-15**] after a [**2-7**] week
  admission where she was admitted from [**Hospital3 3583**] ED
  manic
* [**Hospital3 15986**] twice 23 years ago manic and diagnosed with
  bipolar do
* no hx of SA or SIB
* [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] CNS, @ Southeast Psychiatric [**First Name9 (NamePattern2) 89027**]
  [**Location (un) 5110**], MA
* Dr. [**Last Name (STitle) 39602**] in [**Location (un) 3320**] has not seen yet was referred to
  him after she was dischzrged from [**Hospital **] Hospital

MEDICATION ON ADMISSION: * Xanax .5mg qid
* Zyprexa 5mg [**Hospital1 **]
* Aricept 5mg @hs
* Avapro 300mg qd
* Toprol XL 50mg extended release 24hr
* Glucophage 1,000mg [**Hospital1 **]
* Zocor 10mg qd
* Vit D 1000 unit qd
* lantus 100 unit/ML s.c. 24u solutions @ 2100
* Novolog unknown strengthI
* Norvasc 5mg qd

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: PE:
General: Thin woman in no distress.  Frequently getting up out
of
chair during interview, lots of fidgeting.
HEENT: head normocephalic & atraumatic, PERRL, EOMI, no
lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops
Abdomen: Soft, nontender, nondistended
Extremities: No clubbing, edema or cyanosis.
Skin: Warm and dry, no rash or significant lesions.

FAMILY HISTORY: paternal cousin with psychiatric illness
father and paternal uncle with [**Name (NI) 2481**]
maernal grandfather with mental illness

SOCIAL HISTORY: alcohol: reported hx of abuse many years ago, sober 9 years
         denies hx of w/d sz or balckouts
drugs: denies illicits
tob: denies
caffeine: drinks a pot of coffee a day
Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Hypotension, unspecified,Syncope and collapse,Unspecified essential hypertension,Alzheimer's disease,Other and unspecified hyperlipidemia,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Essential and other specified forms of tremor,Other psychotropic agents causing adverse effects in therapeutic use,Long-term (current) use of insulin
DMI oth uncntrld,Hyposmolality,Adv eff insulin/antidiab,Hypotension NOS,Syncope and collapse,Hypertension NOS,Alzheimer's disease,Hyperlipidemia NEC/NOS,Adv eff antconvl NEC/NOS,Tremor NEC,Adv eff psychotropic NEC,Long-term use of insulin
Admission Date:  [**2115-7-17**]              Discharge Date:   [**2115-7-22**]

Date of Birth:  [**2056-2-1**]             Sex:   F

Service: PSYCHIATRY

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 12693**]
Chief Complaint:
"I'm going to die ..you'll die of old age I just gave you MRSA
because I just shook your hand."


Major Surgical or Invasive Procedure:
None

History of Present Illness:
The patient is a 59 yo cauc. female with reported hx of bipolar
do discharged fom [**Hospital **] Hospital psych unit yeserday  brought
to the ED by her husband and twin sister as she continues
delusional.The patient is psychotic, manic and has thoughts that
she and other people are dying and believes she is the last
Catholic alive.
Her husband reports that she was discharged from [**Hospital **]
Hospital
yesterday after a 3 week admission but she continues psychotic,
not sleeping,and arguementative and refusing to take her
medications .He said she is continously hungry , is an insulin
dependent diabetic and last night she ate a huge piece of
cheesecake. This morning he said  "she laid down on the kitchen
floor and refused to get up and said " I'm dying."He said that
she has not slept all night and that he has been up with her as
she is a flight risk.He said before her most recent
hospitalization to Norwooed she cut a hole in the screen door,
crawled out and ran and hid under [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].He said she threw her
suiticase in the [**Doctor Last Name 6641**] and continually tried to run away and he
had to watch her 24 hrs a day.
Her husband [**Name (NI) 68655**] that she was referred to a Dr. [**Last Name (STitle) **] in
[**Location (un) 3320**] after she was discharged  but was told that she could
not have an appointment with him until she was seen by a
therapist for 2-3 times.
The patient has hx of bipolar do first daignosed and
hospitalized
24 years ago and was admitted to [**Hospital3 15986**] twice and has
been apparently relatively stable unitl this past [**Name (NI) **] and has
reportedly had  2 admisssions to [**Hospital **] Hospital.
Recent stressors are her brother in law her twin sister's
husband
died in [**Name (NI) 404**] and [**Month (only) 958**] is the anniversary of her son's death.


Past Medical History:
* [**Hospital **] Hospital discharged [**2115-7-15**] after a [**2-7**] week
  admission where she was admitted from [**Hospital3 3583**] ED
  manic
* [**Hospital3 15986**] twice 23 years ago manic and diagnosed with
  bipolar do
* no hx of SA or SIB
* [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] CNS, @ Southeast Psychiatric [**First Name9 (NamePattern2) 89027**]
  [**Location (un) 5110**], MA
* Dr. [**Last Name (STitle) 39602**] in [**Location (un) 3320**] has not seen yet was referred to
  him after she was dischzrged from [**Hospital **] Hospital

PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
* PCP [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] ([**Telephone/Fax (1) 89028**]}
* IDDM hx of insulin pump not connected
* Crohn's Disease

Social History:
alcohol: reported hx of abuse many years ago, sober 9 years
         denies hx of w/d sz or balckouts
drugs: denies illicits
tob: denies
caffeine: drinks a pot of coffee a day

SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
The patient was born and grewup in [**Location (un) 6691**],MA. and has an
identical twin sister and a younger brother was from an intact
family and no hx of abuse.Her [**Last Name (un) 89029**] died at age 59 and her
father
has [**Name (NI) 2481**] and lives in a nsg home.
She graduated from [**Hospital **].[**Location (un) 5169**] with a degree in Mathematics
was working until this past [**Month (only) 116**] for an insurance company as a
Customer Survey Representative.
She is married and had 2 children, her dtr is 23 and works @
[**Hospital1 18**] in accounting and her son died at age 20 in a car fire in
[**2106**] while sitting in his car in the driveway of their home.He
was reportedly working with some type of electrical equipment
and
the car caught on fire and he died of smoke inhalation.


Family History:
paternal cousin with psychiatric illness
father and paternal uncle with [**Name (NI) 2481**]
maernal grandfather with mental illness


Physical Exam:
PE:
General: Thin woman in no distress.  Frequently getting up out
of
chair during interview, lots of fidgeting.
HEENT: head normocephalic & atraumatic, PERRL, EOMI, no
lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops
Abdomen: Soft, nontender, nondistended
Extremities: No clubbing, edema or cyanosis.
Skin: Warm and dry, no rash or significant lesions.

Neuropsychiatric Examination:
*VS:  BP: 155/76  HR: 94  temp: 97.9  resp: 16  O2 sat: 100%
height: 61"  weight: 113.6 lbs
  Neurological:
    *station and gait: gait wnl, but when asked if she is ever
unstable immediatly demonstrated with a self-corrected stumble
    *tone and strength: wnl
    cranial nerves: PERRL, EOMI, face motor & sensation intact &
symmetric, hearing grossly intact & symmetric to finger rub,
symmetric palate raise, symmetric shoulder shrug, tongue
midline.
    abnormal movements: frequent fidgeting
  *Appearance & behavior: unkempt hair, dressed in hospital gown
and wearing bright pink socks with black sandals. Nursing had
given her dinner in the exam room because she had a low CBG
[**Location (un) 1131**]; she frequently got up to fidget with the food and ate
very fast and enthusiastically with mouth open.  Cooperative,
good eye contact.
  *Mood and Affect: "stable" & "a little bit happy"; affect
labile, ranging from tearfulness to happy, occasionally
irritable
  *Thought process: tangential, occasionally loose
  *Thought Content: delusional content as described in HPI;
denies SI, HI, and hallucinations
  *Judgment and Insight: poor
  Cognition:
    *Attention, *orientation, and executive function:  fully
oriented to place, date, time, and season; thought it was
Tuesday
when it is Wednesday.
    *Memory: [**3-7**] registration, [**3-7**] short-term
    Calculations: did serial 7's starting at 30 down to -6, with
one mistake (23-7=15)
    Abstraction: initially interpreted "apple doesn't fall far
from the tree" literally, but able to accurately interpreted
with
the prompt that it is a saying about people.  Accurately
interpreted "birds of a feather."
     Comparisons: pear & [**Location (un) 2452**] are both fruit
    *Speech: rapid, articulate, occasionally bordering on
pressured


Pertinent Results:
[**2115-7-16**] 01:20PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-7-16**] 01:20PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2115-7-16**] 01:20PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2115-7-16**] 01:20PM URINE  HOURS-RANDOM
[**2115-7-16**] 01:55PM   PLT COUNT-271
[**2115-7-16**] 01:55PM   NEUTS-78.0* LYMPHS-14.0* MONOS-6.4 EOS-0.6
BASOS-1.0
[**2115-7-16**] 01:55PM   WBC-6.5 RBC-3.37* HGB-11.2* HCT-31.1* MCV-92
MCH-33.3* MCHC-36.1* RDW-12.8
[**2115-7-16**] 01:55PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-7-16**] 01:55PM   estGFR-Using this
[**2115-7-16**] 01:55PM   GLUCOSE-357* UREA N-27* CREAT-0.8 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-16
[**2115-7-17**] 01:00PM   GLUCOSE-509* UREA N-14 CREAT-0.7 SODIUM-132*
POTASSIUM-5.0 CHLORIDE-93* TOTAL CO2-30 ANION GAP-14
[**2115-7-17**] 01:18PM   freeCa-1.17
[**2115-7-17**] 01:18PM   GLUCOSE-458* LACTATE-2.2* NA+-131* K+-4.8
CL--90* TCO2-30
[**2115-7-17**] 01:18PM   PH-7.38 COMMENTS-GREEN TOP
[**2115-7-17**] 04:21PM   freeCa-1.03*
[**2115-7-17**] 04:21PM   GLUCOSE-300* LACTATE-3.6* NA+-133* K+-3.6
CL--103 TCO2-23
[**2115-7-17**] 04:21PM   PH-7.39
[**2115-7-17**] 05:30PM   PLT COUNT-260
[**2115-7-17**] 05:30PM   NEUTS-80.6* LYMPHS-14.2* MONOS-4.2 EOS-0.7
BASOS-0.4
[**2115-7-17**] 05:30PM   WBC-6.3 RBC-3.20* HGB-10.5* HCT-29.8* MCV-93
MCH-32.8* MCHC-35.1* RDW-12.7
[**2115-7-17**] 05:30PM   CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.7
[**2115-7-17**] 05:30PM   GLUCOSE-228* UREA N-12 CREAT-0.5 SODIUM-133
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-27 ANION GAP-11
[**2115-7-17**] 05:35PM   GLUCOSE-217* LACTATE-2.3*

Brief Hospital Course:
#Bipolar: Per her family, Mrs. [**Known lastname 9464**] was successfully treated
with tegretol as an outpatient for 20 years prior to her recent
decompensation. After being admitted to [**Hospital **] Hospital for
mania the patient was transitioned from tegretol to zyprexa and
risperdal, out of concern that tegretol was causing
hyponatremia. While at [**Hospital1 18**] during this hospitalization the
patient was started on lithium for mania. Her level was 0.6 on a
dose of 300mg [**Hospital1 **], so her dose was increased to 300mg TID. She
was also transitioned from zyprexa 10mg daily to ziprasidone
80mg qhs, as this option is a more weight-neutral atypical
antipsychotic. She demonstrated some improvement in her
symptoms, including improvement of her pressured speech and
impulsivity. However she persistently had delusions of death and
traveling through time. She also frequently lay on the floor,
reporting she was either having seizures or dying. In looking
through old records the patient has exhibited this behavior
throughout each of her hospitalizations. She responds well to
2mg PO ativan and re-direction into bed.

#Diabetes: The patient demonstrated very labile blood sugars
throughout this hospitalization. Her sugars were frequently
elevated in the 300s - 400s, however she frequently
over-corrected into the 30s - 50s overnight. [**Last Name (un) **] has been
following the patient and adjusting her insulin, however she
remains difficult to control. Of note the patient has an insulin
pump which she is not currently using. According to her family
her blood sugar was well-controlled prior to her
hospitalizations at [**Location (un) **] when she was started on Zyprexa.

#Autonomic instability: On the day of transfer ([**2115-7-22**]) the
patient had some autonomic instability which was initially
concerning for NMS, as she had received 3 doses of Geodon over
the weekend. She demonstrated tachycardia (128) and muscle
rigidity this morning, with some concern of rising temperature
(99.7 up from 98.5). The patient was given 2mg PO ativan and a 1
liter bolus of normal saline. She had labs sent which
demonstrated a WBC of 12 without bands, and a CK of 85. This
decreased our suspicion for NMS but the patient was placed on
constant observation and we continued frequent vital sign
checks. The patient's vital signs improved to temp 96.3 and HR
91 in the early afternoon. However, she later demonstrated
somnolence and had a fingerstick which showed a blood sugar of
20. The patient was given glucagon but her blood sugar continued
to drop to 18, then 14. A code was called on the patient. The
ICU team came to evaluate the patient and found her to be
hypotensive with blood pressure in the 90s/50s. She was given
D50 for her low blood sugar and her sugar rose to the 200s. The
patient was given another 1L bolus of NS and the decision was
made to transfer her to the ICU for ongoing monitoring, with
likely transfer to the medicine service after acute
stabilization.

#Hypertension: The patient was continued on her outpatient
regimen of metoprolol 50, amlodipine 5 and irbesartan 300mg
daily.

#Alzheimer's: The patient was continued on her Aricept.
According to her husband she has never had formal neuropsych
testing. We will plan to order a neuropsych consult after she
returns to [**Hospital1 **] 4. We will also obtain a head CT at that time,
unless she has a head CT as part of her workup while on
medicine.

#Legal: The patient signed a CV which was accepted by the house
officer on [**Hospital1 **] 4. She remained her voluntarily

#Safety: The patient frequently had to be placed on 5 minute
checks or constant observation for behavioral problems,
including eating other patients' food and lying on the floor
complaining of seizures. She will be on "constant observation"
while on medicine to try to prevent behavioral problems.

Medications on Admission:
* Xanax .5mg qid
* Zyprexa 5mg [**Hospital1 **]
* Aricept 5mg @hs
* Avapro 300mg qd
* Toprol XL 50mg extended release 24hr
* Glucophage 1,000mg [**Hospital1 **]
* Zocor 10mg qd
* Vit D 1000 unit qd
* lantus 100 unit/ML s.c. 24u solutions @ 2100
* Novolog unknown strengthI
* Norvasc 5mg qd


Discharge Medications:
Ziprasidone Hydrochloride 40 mg PO/NG QAM  [**7-22**] @ 1550 View
Lithium Carbonate 300 mg PO TID  [**7-22**] @ 1550 View
Lorazepam 2 mg PO/NG ONCE Duration: 1 Doses  [**7-22**] @ 1043 View
Insulin SC  (per Insulin Flowsheet) Sliding Scale & Fixed Dose
[**7-20**] @ 0908
Ziprasidone Hydrochloride 80 mg PO/NG HS  [**7-18**] @ 1712 View
Avapro *NF* (irbesartan) 300 mg Oral daily Reason for Ordering:
Wish to maintain preadmission medication while hospitalized, as
there is no acceptable substitute drug product available on
formulary. [**7-17**] @ 2122 View
Alprazolam 0.5 mg PO QID:PRN anxiety, agitation  [**7-17**] @ 2122
View
Amlodipine 5 mg PO DAILY  [**7-17**] @ 2122 View
Donepezil 5 mg PO HS  [**7-17**] @ 2122 View
Metoprolol Succinate XL 50 mg PO DAILY  [**7-17**] @ 2122 View
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol  [**7-17**] @ 2051
View
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol  [**7-17**] @ 2051
View
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN acid
reflux  [**7-17**] @ 2051 View
Milk of Magnesia 30 ml PO Q8H:PRN constipation  [**7-17**] @ 2051
View
Acetaminophen 650 mg PO Q4H:PRN pain, fever  [**7-17**] @ 2051 View


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 18**] CC7

Discharge Diagnosis:
II- defer
III - NIDDM, htn
IV - family tensions, acute hospitalizaiton, recent d/c from
psychiatric unit, failure to comply with medications
V-28


Discharge Condition:
Unstable - being discharged to medicine CC7 for stabilization of
blood sugars and blood pressure

Discharge Instructions:
-Please call psychiatry consult service ([**7-/7896**]) to have
psychiatry continue to follow this patient
-Please have [**Last Name (un) **] continue to follow the patient. They are
aware she has been transferred
-Please have patient return to psychiatry when medically stable

Followup Instructions:
No follow up appointments scheduled at this point




Admission Date:  [**2115-7-22**]              Discharge Date:   [**2115-7-25**]

Date of Birth:  [**2056-2-1**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypotension, hypoglycemia

Major Surgical or Invasive Procedure:
n/a

History of Present Illness:
This is a 59 y/o F with history of T1DM, Hypertension, Bipolar
disorder who was admitted to acute psychiatric [**Hospital1 **] for acute
manic episode. Patient was recently admitted to OSH Psych [**Hospital1 **]
where she was treated for 3 weeks. Upon discharge home, she
continue display manic behavior and was brought back to [**Hospital1 18**] ED
for further evaluation.
.
In [**Hospital1 18**] ED, patient displayed frank manic behavior and was
admitted to [**Hospital1 **] 4 for further evaluation and treatment.
While on the inpatient psych team, pt continued to display manic
behavior and was noted to run up and down hallways eating her
floormates food. Patient was noted to have labile blood sugars.
Hyperglycemia was thought to be [**2-6**] olanzapine and changed to
zisperidone. Of note because of her manic behavior, patient was
placed in the "quiet room."
.
On day of transfer, pt was noted to be tachycardic to 100s and
hypertensive. Patient was given 500cc IV bolus for tachycardia.
She received a total of 25 units of insulin today. At
approximately 330pm, pt was assessed in "quiet room," and was
noted to somnolent and unresponsive. Code was called. FS taken
at that time was noted to be 14. Patient was given PO glucagon
and 1 amp of D50 was given. Patient remained confused and
somnolent. BP was noted to be in SBPs 80s/40s with cool/clammy
extremities. 1L of NS was given and patient SBPs responded to
100s. Pts mental status was improved and patient was transported
to ICU for further monitoring.
.
On the MICU, patient was reported feeling very well. She noted
that during initial event, patient left confused and felt faint.
She denied CP, SOB, N, V. Had similar events in past that she
stated was [**2-6**] "low blood sugar."


Past Medical History:
- Diabetes Mellitus Type 1
- HTN
- celiac disease
- bipolar dx


Social History:
former drinker sober for last 9 yr, denies tobacco and IVD. She
is married, one daughter, son passed away in '[**06**] from accident.


Family History:
non-contributory

Physical Exam:
Admission Physical Exam:
Vitals: 96.1 107/59 63 13 100%RA
General: Alert, oriented, 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
GU: no foley
Ext: cool extremitites, 2+ pulses, no clubbing, cyanosis or
edema

Transfer Physical Exam:
Vitals: T-97.5 110-163/70-86 HR-72-80 RR-18 99-100%RA
General: Alert, oriented, generalized intermittent shaking
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
GU: no foley
Ext: wwp, 2+ pulses, no clubbing, cyanosis or edema


Pertinent Results:
Admission Labs:

[**2115-7-22**] 11:58AM BLOOD WBC-12.2*# RBC-3.69* Hgb-12.0 Hct-34.3*
MCV-93 MCH-32.7* MCHC-35.1* RDW-12.8 Plt Ct-372
[**2115-7-22**] 11:58AM BLOOD Neuts-91.4* Lymphs-5.1* Monos-3.0 Eos-0.2
Baso-0.3
[**2115-7-22**] 04:32PM BLOOD Glucose-172* UreaN-17 Creat-0.8 Na-131*
K-3.8 Cl-99 HCO3-26 AnGap-10
[**2115-7-22**] 11:58AM BLOOD ALT-32 AST-26 LD(LDH)-250 CK(CPK)-85
AlkPhos-89 TotBili-0.3
[**2115-7-22**] 04:32PM BLOOD Lithium-0.7
[**2115-7-23**] 04:03AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.0

[**2115-7-22**] 04:32PM   GLUCOSE-172* UREA N-17 CREAT-0.8 SODIUM-131*
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-10
[**2115-7-22**] 04:32PM   LD(LDH)-227 CK(CPK)-182
[**2115-7-22**] 04:32PM   CK-MB-8 cTropnT-<0.01
[**2115-7-22**] 04:32PM   CALCIUM-8.7
[**2115-7-22**] 04:32PM   LITHIUM-0.7
[**2115-7-22**] 04:32PM   WBC-8.5 RBC-3.11* HGB-10.1* HCT-28.5* MCV-92
MCH-32.5* MCHC-35.4* RDW-12.8
[**2115-7-22**] 04:32PM   NEUTS-83.1* LYMPHS-11.4* MONOS-4.6 EOS-0.5
BASOS-0.4
[**2115-7-22**] 04:32PM   PLT COUNT-274
[**2115-7-22**] 11:58AM   ALT(SGPT)-32 AST(SGOT)-26 LD(LDH)-250
CK(CPK)-85 ALK PHOS-89 TOT BILI-0.3
[**2115-7-22**] 11:58AM   WBC-12.2*# RBC-3.69* HGB-12.0 HCT-34.3*
MCV-93 MCH-32.7* MCHC-35.1* RDW-12.8
[**2115-7-22**] 11:58AM   NEUTS-91.4* LYMPHS-5.1* MONOS-3.0 EOS-0.2
BASOS-0.3
[**2115-7-22**] 11:58AM   PLT COUNT-372
[**2115-7-22**] 06:35AM   UREA N-11 CREAT-0.6
[**2115-7-22**] 06:35AM   TSH-2.9
[**2115-7-22**] 06:35AM   LITHIUM-0.6

Brief Hospital Course:
59 y/o F with type 1 DM, HTN and bipolar disease presented to
MICU after hypoglycemic episode (BS=14) with
hypotension(90/50's), transfered to [**Hospital1 **] bed on [**2115-7-23**], now
stable for transfer to inpatient psychiatry.
.
# HYPOTENSION: Episode Occured in setting of hypoglycemia likely
related to concurrent vagal episode. No evidence of sepsis or
ongoing infectious symptoms. EKG and cardiac enzymes were
normal. Patient remained hemodynamically stable while in MICU
and after when monitored on floor for 48 hours. Oral
antihypertensives were initially held with plan to re-initiate
prior to discharge. The amlodipine was started on [**2115-7-25**].

# HYPOGLYCEMIA/LABILE BLOOD SUGARS: Patient withi history of
type 1 diabetes that was historically treated with insulin pump.
However given psychiatric disorder, insulin pump was
discontinued. Since the discontinuation of pump, patient's blood
sugars have been labile. [**Last Name (un) **] was initially consulted while
patient was on psych [**Hospital1 **]. On day of unresponsive episode,
patient's FS was 14, which recovered with oral glucagon and
ampule of D50. This occured because of aggressive sliding scale
in setting of reduced PO. Glargine was reduced and RISS was
reduced with better control of fingersticks. She has ranged from
186 to 281 over the past 24 hours. Currently the patient is
taking 16units of Glargine QHS and on an ISS based on
post-prandial blood glucose levels. [**Last Name (un) **] is following the
patient and will continue to follow her to provide
recommendations moving forward. They recommend that when she
goes back to psychiatry that she will need close  supervision
and assistance at meal time to make sure that she eats her
meals.  Her premeal insulin should then be dosed AFTER the meal.
If she eats 50% of her meal or less then her short acting meal
insulin should be cut in half.
.
# MANIA: Patient floridly manic and intermittently agitated. Pt
was being stabilized on lithium and geodon for mania, which has
improved but not resolved. Psychiatry continued to follow her on
the medicine floor.
.
# HYPONATREMIA: Patient stable hyponatremia that was thought to
be [**2-6**] tegretol. Her sodium was monitored and remained stable.
.
# TREMOR: Patient developed intermittent upper extremity tremor
with mild rigidity. This was thought to be due to
extra-pyramyidal side effect from her anti-psychotic
medications.  She is currently being uptitrated to benztropine
1mg [**Hospital1 **], currently at 0.5mg [**Hospital1 **].  These shakes could also be
from a conversion disorder after her hypoglycemic episode.  Of
note, she only shakes when medical professional are present, and
does not shake when observed from a far.
.

Medications on Admission:
Medications (on transfer from MICU)
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Docusate Sodium 100 mg PO BID
Heparin 5000 UNIT SC TID
Insulin SC  (per Insulin Flowsheet), Sliding Scale & Fixed Dose
Ziprasidone Hydrochloride 40 mg PO/NG QAM
Lithium Carbonate 300 mg PO TID
Ziprasidone Hydrochloride 80 mg PO/NG HS
Alprazolam 0.5 mg PO QID:PRN anxiety, agitation
Donepezil 5 mg PO HS Glucagon 1 mg IM Q15MIN:PRN hypoglycemia
protocol  Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO Q4H:PRN acid
reflux
Milk of Magnesia 30 ml PO Q8H:PRN constipation
Acetaminophen 650 mg PO Q4H:PRN pain, fever


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q8H (every 8 hours) as needed for constipation.
3. donepezil 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. ziprasidone HCl 40 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ziprasidone HCl 80 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day) as needed for anxiety, agitation.
9. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO Q4H (every 4 hours) as needed for acid reflux.

11. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
12. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. insulin glargine 100 unit/mL Solution Sig: One (1) 16
Subcutaneous at bedtime.
16. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: Please see attached sliding scale
.
17. dextrose 50% in water (D50W)     Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Intensive care unit

Discharge Diagnosis:
bipolar I
Diabetes Mellitus type 1
Hypertension
episode of hypoglycemia


Discharge Condition:
stable
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to [**Hospital1 18**] ICU for manic episodes. You had a
hypoglycemic episode. Your insulin was reduced. Your blood
sugars remained stable. You were followed by [**Last Name (un) **] Diabetes
Specialists. You are being transferred to inpatient psychiatry
for futher management of your mania.

Followup Instructions:
Please follow up with [**Last Name (un) **] Diabetes and your primary care
physician at discharge from inpatient psychiatry
{"Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Hypotension, unspecified,Syncope and collapse,Unspecified essential hypertension,Alzheimer's disease,Other and unspecified hyperlipidemia,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Essential and other specified forms of tremor,Other psychotropic agents causing adverse effects in therapeutic use,Long-term (current) use of insulin"}


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'm going to die ..you'll die of old age I just gave you MRSA
because I just shook your hand."

PRESENT ILLNESS: The patient is a 59 yo cauc. female with reported hx of bipolar
do discharged fom [**Hospital **] Hospital psych unit yeserday  brought
to the ED by her husband and twin sister as she continues
delusional.The patient is psychotic, manic and has thoughts that
she and other people are dying and believes she is the last
Catholic alive.
Her husband reports that she was discharged from [**Hospital **]
Hospital
yesterday after a 3 week admission but she continues psychotic,
not sleeping,and arguementative and refusing to take her
medications .He said she is continously hungry , is an insulin
dependent diabetic and last night she ate a huge piece of
cheesecake. This morning he said  "she laid down on the kitchen
floor and refused to get up and said " I'm dying."He said that
she has not slept all night and that he has been up with her as
she is a flight risk.He said before her most recent
hospitalization to Norwooed she cut a hole in the screen door,
crawled out and ran and hid under [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].He said she threw her
suiticase in the [**Doctor Last Name 6641**] and continually tried to run away and he
had to watch her 24 hrs a day.
Her husband [**Name (NI) 68655**] that she was referred to a Dr. [**Last Name (STitle) **] in
[**Location (un) 3320**] after she was discharged  but was told that she could
not have an appointment with him until she was seen by a
therapist for 2-3 times.
The patient has hx of bipolar do first daignosed and
hospitalized
24 years ago and was admitted to [**Hospital3 15986**] twice and has
been apparently relatively stable unitl this past [**Name (NI) **] and has
reportedly had  2 admisssions to [**Hospital **] Hospital.
Recent stressors are her brother in law her twin sister's
husband
died in [**Name (NI) 404**] and [**Month (only) 958**] is the anniversary of her son's death.

MEDICAL HISTORY: * [**Hospital **] Hospital discharged [**2115-7-15**] after a [**2-7**] week
  admission where she was admitted from [**Hospital3 3583**] ED
  manic
* [**Hospital3 15986**] twice 23 years ago manic and diagnosed with
  bipolar do
* no hx of SA or SIB
* [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) **] CNS, @ Southeast Psychiatric [**First Name9 (NamePattern2) 89027**]
  [**Location (un) 5110**], MA
* Dr. [**Last Name (STitle) 39602**] in [**Location (un) 3320**] has not seen yet was referred to
  him after she was dischzrged from [**Hospital **] Hospital

MEDICATION ON ADMISSION: * Xanax .5mg qid
* Zyprexa 5mg [**Hospital1 **]
* Aricept 5mg @hs
* Avapro 300mg qd
* Toprol XL 50mg extended release 24hr
* Glucophage 1,000mg [**Hospital1 **]
* Zocor 10mg qd
* Vit D 1000 unit qd
* lantus 100 unit/ML s.c. 24u solutions @ 2100
* Novolog unknown strengthI
* Norvasc 5mg qd

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: PE:
General: Thin woman in no distress.  Frequently getting up out
of
chair during interview, lots of fidgeting.
HEENT: head normocephalic & atraumatic, PERRL, EOMI, no
lymphadenopathy, no thyromegaly
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops
Abdomen: Soft, nontender, nondistended
Extremities: No clubbing, edema or cyanosis.
Skin: Warm and dry, no rash or significant lesions.

FAMILY HISTORY: paternal cousin with psychiatric illness
father and paternal uncle with [**Name (NI) 2481**]
maernal grandfather with mental illness

SOCIAL HISTORY: alcohol: reported hx of abuse many years ago, sober 9 years
         denies hx of w/d sz or balckouts
drugs: denies illicits
tob: denies
caffeine: drinks a pot of coffee a day 

### Response:
{"Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Hypotension, unspecified,Syncope and collapse,Unspecified essential hypertension,Alzheimer's disease,Other and unspecified hyperlipidemia,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Essential and other specified forms of tremor,Other psychotropic agents causing adverse effects in therapeutic use,Long-term (current) use of insulin"}
