CHIEF COMPLAINT: increasing lethargy s/p fall down several stairs

PRESENT ILLNESS: 69 y/o [**Location 7972**] Female Tx from [**Hospital1 **] s/p fall last
night down ~4 stairs at home with ~15 sec LOC

MEDICAL HISTORY: MR, [**Hospital1 19293**], [**Hospital1 **], Pulm [**Hospital1 **], hypothyroidism, CRI (1.7), mild CHF

MEDICATION ON ADMISSION: Lasix 20mg [**Hospital1 **]
Levoxyl 75mcg daily
Glyburide 2.5mg daliy
Metoprolol 25mg [**Hospital1 **]
ASA 81mg daily

ALLERGIES: Lisinopril

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
Gen: intubated,sedated.
HEENT: Pupils: 2mm minimally reactive,equally round ,
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated,sedated
Propioception intact:UNABLE TO TEST
Toes downgoing bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with family
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Chronic diastolic heart failure,Accidental fall on or from other stairs or steps,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Unspecified acquired hypothyroidism,Oliguria and anuria,Old myocardial infarction,Other chronic pulmonary heart diseases,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Anemia in chronic kidney disease,Hypocalcemia,Mitral valve disorders
Cl skul base fx-coma NOS,Chr diastolic hrt fail,Fall on stair/step NEC,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Hypothyroidism NOS,Oliguria & anuria,Old myocardial infarct,Chr pulmon heart dis NEC,DMII oth nt st uncntrld,Cardiac dysrhythmias NEC,Anemia in chr kidney dis,Hypocalcemia,Mitral valve disorder
Admission Date:  [**2107-5-8**]              Discharge Date:   [**2107-5-13**]

Date of Birth:  [**2038-1-6**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
increasing lethargy s/p fall down several stairs

Major Surgical or Invasive Procedure:
None


History of Present Illness:
69 y/o [**Location 7972**] Female Tx from [**Hospital1 **] s/p fall last
night down ~4 stairs at home with ~15 sec LOC

Past Medical History:
MR, [**Hospital1 19293**], [**Hospital1 **], Pulm [**Hospital1 **], hypothyroidism, CRI (1.7), mild CHF

Social History:
lives with family


Family History:
NC

Physical Exam:
On Admission:
PHYSICAL EXAM:
Gen: intubated,sedated.
HEENT: Pupils: 2mm minimally reactive,equally round ,
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated,sedated
Propioception intact:UNABLE TO TEST
Toes downgoing bilaterally

On dishcharge: Pt more awake, focused, attentive, oriented to
self and "hospital" - unaware of city orname of facility as well
as yr.
follows most commands. No facial, tongue is ML, no drift, all
extremeties antigravity (has difficulty following commands [**1-8**]
language barrier).
Tolerating pureed po intake. Foley in place.

Pertinent Results:
CT Head([**5-8**]):IMPRESSION:
1. Multiple foci of hemorrhagic contusion not significantly
changed. Minimal leftward subfalcine herniation is stable.
2. Small subdural hematoma overlying the frontal convexities
with small amount of subarachnoid hemorrhage. Small subdural
hematoma along the right posterior cerebral convexity.
3. Nondisplaced occipital bone fracture, with associated small
posterior fossa subdural hematoma.
4. Left maxillary mucosal thickening, will a small hyperdense
focus. No discrete fracture is seen. However, if there is
clinical suspicion for a facial fracture, facial CT may be
obtained.

CT Head([**5-9**]):IMPRESSION:
1. Multiple foci of hemorrhagic contusion with intraparenchymal
hemorrhage, associated subarachnoid hemorrhage, and subdural
hematomas, all relatively unchanged. Minimal leftward subfalcine
herniation unchanged. No new intraventricular hemorrhage seen.
2. Nondisplaced occipital bone fracture, unchanged.
3. Left maxillary mucosal thickening with small hyperdense focus
unchanged.

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

[**Known lastname **], [**Known firstname 74752**]       [**Hospital1 18**] [**Numeric Identifier 74753**]TTE (Complete)
Done [**2107-5-10**] at 3:48:02 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] M.
[**Hospital1 **] C
[**Hospital Unit Name 18400**]
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2038-1-6**]
Age (years): 69 F  Hgt (in): 66
BP (mm Hg): 150/50  Wgt (lb): 170
HR (bpm): 46  BSA (m2): 1.87 m2
Indication: Left ventricular function.
ICD-9 Codes: 424.0, 424.2
Test Information
Date/Time: [**2107-5-10**] at 15:48    Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2008W034-1:29 Machine: Vivid [**6-13**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  *4.5 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *5.7 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.3 m/s
Left Atrium - Peak Pulm Vein D:  0.7 m/s
Right Atrium - Four Chamber Length:  *5.6 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.2 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  *1.2 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  4.3 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  2.6 cm
Left Ventricle - Fractional Shortening:  0.40  >= 0.29
Left Ventricle - Ejection Fraction:  >= 60%  >= 55%
Aorta - Sinus Level:  2.7 cm  <= 3.6 cm
Aorta - Ascending:  3.2 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  1.7 m/sec  <= 2.0 m/sec
Mitral Valve - E Wave:  1.6 m/sec
Mitral Valve - A Wave:  0.9 m/sec
Mitral Valve - E/A ratio:  1.78
Mitral Valve - E Wave deceleration time:  *322 ms  140-250 ms
TR Gradient (+ RA = PASP):  *45 mm Hg  <= 25 mm Hg

Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%). [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Abnormal septal motion/position consistent with RV
pressure/volume overload.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mitral
valve annuloplasty ring. Moderate (2+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. A mitral valve annuloplasty
ring is present. Moderate (2+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate to severe pulmonary
artery systolic hypertension.
  Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2107-5-10**] 16:37
Cardiology Report ECG Study Date of [**2107-5-8**]  3:55:44 PM


Sinus rhythm. The P-R interval is 160 milliseconds. Left
bundle-branch block.
Compared to the previous tracing there is no significant change.



Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
41 160 138 536/502 0 60 -85


([**-7/3029**])

Test Name Value Units Reference Range
[**2107-5-10**] 06:55AM
COMPLETE BLOOD COUNT
White Blood Cells 6.2 K/uL 4.0 - 11.0
  PERFORMED AT WEST STAT LAB
Red Blood Cells 3.20* m/uL 4.2 - 5.4
  PERFORMED AT WEST STAT LAB
Hemoglobin 10.2* g/dL 12.0 - 16.0
  PERFORMED AT WEST STAT LAB
Hematocrit 30.9* % 36 - 48
  PERFORMED AT WEST STAT LAB
MCV 97 fL 82 - 98
  PERFORMED AT WEST STAT LAB
MCH 31.8 pg 27 - 32
  PERFORMED AT WEST STAT LAB
MCHC 32.9 % 31 - 35
  PERFORMED AT WEST STAT LAB
RDW 15.0 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 193 K/uL 150 - 440
  PERFORMED AT WEST STAT LAB

Test Name Value Units Reference Range
[**2107-5-10**] 06:55AM
RENAL & GLUCOSE
Glucose 131* mg/dL 70 - 105
  PERFORMED AT WEST STAT LAB
Urea Nitrogen 23* mg/dL 6 - 20
  PERFORMED AT WEST STAT LAB
Creatinine 1.5* mg/dL 0.4 - 1.1
  PERFORMED AT WEST STAT LAB
Sodium 141 mEq/L 133 - 145
  PERFORMED AT WEST STAT LAB
Potassium 4.0 mEq/L 3.3 - 5.1
  PERFORMED AT WEST STAT LAB
Chloride 108 mEq/L 96 - 108
  PERFORMED AT WEST STAT LAB
Bicarbonate 25 mEq/L 22 - 32
  PERFORMED AT WEST STAT LAB
Anion Gap 12 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 8.0* mg/dL 8.4 - 10.2
  PERFORMED AT WEST STAT LAB
Phosphate 4.4 mg/dL 2.7 - 4.5
  PERFORMED AT WEST STAT LAB
Magnesium 2.0 mg/dL 1.6 - 2.6
  PERFORMED AT WEST STAT LAB
NEUROPSYCHIATRIC
Phenytoin 12.5 ug/mL 10.0 - 20.0
  PERFORMED AT WEST STAT LAB

Test Name Value Units Reference Range
[**2107-5-10**] 07:30PM
PITUITARY
Thyroid Stimulating Hormone 77* uIU/mL 0.27 - 4.2


Brief Hospital Course:
Patient was admitted on [**5-8**] after a fall down several stairs and
increased lethargy, and SDH, SAH identified on CT of the Head at
OSH.  Her Repeated head CT's here have been stable for
evaluation of her bleed, without need for surgical intervention.
 Medicine team was consulted on HD#2 for decreased urine output.
She does have a medical history of CRI with a stable creatine of
1.7-1.8 over the last two years.  Upon the medicine team's
recommendation, she was bolused with 500cc NACL and responded
well with adequate urine output.  We were also able to get in
touch with her PCP to further identify her home medication
regimen.  She takes Lasix 20mg [**Hospital1 **] at baseline, and this is also
the likely cause of her decreased urine output.   Since being
started on Lasix, UOP has been substantially improved. Per PCP
report, patient is poor with medication compliance, and
encouraged her follow up

Subsequent CT scans have also been stable, and she went on the
be evaluated by PT.  PT found her to be appropriate for a rehab
placement.

Medications on Admission:
Lasix 20mg [**Hospital1 **]
Levoxyl 75mcg daily
Glyburide 2.5mg daliy
Metoprolol 25mg [**Hospital1 **]
ASA 81mg daily

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Hold for SBP<100 or HR<60.
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.

11. Phenytoin 50 mg Tablet, Chewable Sig: [**12-8**] Tablet, Chewables
PO three times a day: 100mg to be given TID.
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
16. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Potassium Chloride 20 mEq Packet Sig: One (1)  PO once a
day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
SDH/SAH, s/p fall


Discharge Condition:
Stable


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 8 weeks.
??????You will need a CT scan of the brain without contrast.
- You will need to follow up with your Primary Care Physician
and update him or her on your hospitalization.  We did contact
them for your medicine regime.  You need to take your medicine
as previously prescribed by your primary care physician.



Completed by:[**2107-5-11**]

Name:  [**Known lastname 12322**],[**Known firstname 12323**]                 Unit No:   [**Numeric Identifier 12324**]

Admission Date:  [**2107-5-8**]              Discharge Date:   [**2107-5-13**]

Date of Birth:  [**2038-1-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 1455**]
Addendum:
Patient transfered to the medicine service for further
management of hypothroidism after the neurosurgical service
confirmed that patient has stable SDH/SAH s/p fall.

Additional information abou the patient's hypothryoidism is
obtained from her PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient originally seen [**2100**].
Then lost health insurance and did not represent until [**2105**] when
she was noted to have a new heart murmur, poor diabetes contol,
severe hypothyroidism, uncontrolled hypertension requirig
hospitalization, anemia. Complicating her treatment was the
patient's refusal to take any thyroid replacement supplements as
they gave her a cough. Patient despite letters, has declined to
follow-up with Dr. [**First Name (STitle) **] since last [**Month (only) **]. Patient did see
cardiologist in [**10-14**] and that is the most current MD med list
available. Per PCP patient never had normal TSH since diagnosis
of hypothyroidism.


Major Surgical or Invasive Procedure:
None


Physical Exam:
PHYSICAL EXAMINATION on TRANSFER to MEDICINE:
VS: 97.5, 139/53, 53, 19, 95% on RA.
Gen: NAD. Sleeping, arouses to voice.
HEENT: Sclera anicteric. PERRL, MM sl dry, OP clear, EOMI
Neck: Supple, no JVD.
CV: RRR, II/VI systolic murmur USB.
Chest: Few bibasilar crackles, otherwise clear.
Abd: +BS, soft, NTND.
Ext: Warm, 1+ nonpitting edema of feet and arms b/l. right foot
slighty larger than left foot in terms on edema. pneumoboots in
place.

Pertinent Results:
[**2107-5-12**] 07:05AM BLOOD WBC-4.4 RBC-3.31* Hgb-10.9* Hct-31.7*
MCV-96 MCH-33.0* MCHC-34.5 RDW-14.9 Plt Ct-235
[**2107-5-11**] 04:00PM BLOOD Neuts-63.9 Lymphs-27.7 Monos-6.2 Eos-1.9
Baso-0.3
[**2107-5-12**] 07:05AM BLOOD PT-12.4 PTT-32.6 INR(PT)-1.0
[**2107-5-12**] 07:05AM BLOOD Glucose-126* UreaN-19 Creat-1.4* Na-139
K-3.3 Cl-104 HCO3-25 AnGap-13
[**2107-5-12**] 07:05AM BLOOD Calcium-7.7* Phos-3.7 Mg-1.9
[**2107-5-11**] 04:00PM BLOOD ALT-40 AST-76* AlkPhos-71 TotBili-0.4
[**2107-5-10**] 07:30PM BLOOD TSH-77*
[**2107-5-11**] 04:00PM BLOOD TSH-79*
[**2107-5-11**] 04:00PM BLOOD T4-3.4* calcTBG-0.96 TUptake-1.04
T4Index-3.5* Free T4-0.78*
[**2107-5-11**] 04:00PM BLOOD Anti-Tg-LESS THAN  antiTPO-GREATER TH
[**2107-5-12**] 06:19PM BLOOD Type-ART pO2-69* pCO2-45 pH-7.43
calTCO2-31* Base XS-4

Brief Hospital Course:
69 year old female transferred from neurosurgery for evaluation
of profound hypothyroidism. The patient's was treated with IV
and PO levothyroxine at the advice of the endocrinology
consulting team. Patient was not felt to have myxedema coma. Her
antiTPO antibiotics were noted to be greater than 1,000, but
thyroglobulin antibody were within normal limits. Patient was
discharged on 150 mcg of synthroid daily with repeat TFTs in 4
weeks with her PCP.
.
Patient noted to be alert and oriented *2 and often somnulent.
Patient's mental status improving and felt to be due to her
SAH/SDH. Infectious work-up has been negative. Patient not
hypoxic or hypercarbic on ABG. Patient not felt to have myxedema
coma. Patient will follow-up with neurosurgery.
.
Chronic Kidney Disease Stage III: Patient on home lasix and her
kidneys are dependent at this time. Patient lasix dose decreased
given decreased PO intake. Patient remains with FOLEY given she
failed a voiding trial. Patient discharged to rehabiliation with
foley in place. Patient will undergo voiding trials at
rehabilitation.  Patient encouraged to maintain oral intake with
feeding assistance. Patient's volume status will be assessed
daily at rehabiliation in regards to her lasix dose.
.
Hypertension: Patient's home metoprolol stopped due to
hypothyroid bradycardia. Patient is currently on amlodipine 10mg
daily. Patient to avoid nodal blocking agents as patient
recovers from hypothyroidism.
.
Diabetes: Patient off glyburide given variable oral intake.
Patient discharged on insulin sliding scale.
.
Anemia: Patient has chronic anemia likely due in part to her
chronic kidney disease. She was recommended to undergo an
outpatient colonoscopy.
.
Patient discharged to rehabiliation with assistance with eating
while she recovers. Patient is full code. Patient ranitidine was
stopped as it can cause mental confusion. The patient remains on
heparin sc for deep vein thrombosis prophylaxis as she recovers.
The patient was discharged to [**Hospital **] Rehabilitation Center in
[**Location (un) 437**].


Medications on Admission:
Home Medications (per medical record, cardiology appointment
[**2106-10-18**] faxed by PCP [**Name9 (PRE) 12325**] [**Name9 (PRE) **] [**2107-5-11**]):
diovan 160 [**Hospital1 **]
glyburide 2.5 mg daily
bisoprolol 5 mg qhs
norvasc 5 mg [**Hospital1 **]
cardura 4 mg daily
lasix 40 mg [**Hospital1 **]
levothyroxine 100 mcg daily
.
Home Medications (per pill bottles brought from home):
norvasc 5 [**Hospital1 **]
bisoprolol 5 daily
lasix 40 [**Hospital1 **]
vitamin D

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO three times a day.
8. Insulin Regular Human 100 unit/mL Solution Sig: as dir units
Injection QIDAC: Blood Glucose
<121 no insulin
121-160 2 units
161-200 4 units
201-240 6 units
241-280 8 units
>280 call PCP.
9. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO once a
day: pt needs TSH in 4wks, has appt with PCP for this [**6-8**].
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day:
hold SBP <120.
12. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day:
hold SBP <100
.
*** Dr [**Last Name (STitle) 12326**] called [**Hospital **] Rehabilitation Center in
[**Location (un) 437**] within a few hours of discharge and informed them that
the patient should be on Phenytoin chewables only. The phenytoin
extended capsule should not be given (mistakenly written in th
epage 1 that accompanied the patient).

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1174**] [**Hospital **] [**Hospital 2270**] Rehab Unit at
[**Hospital6 2271**] - [**Location (un) 437**]

Discharge Diagnosis:
SDH/SAH, s/p fall
Hypothroidism, untreated
Hypertension
Chronic Kidney Disease, Stage III
Diabetes Mellitus
Anemia


Discharge Condition:
Stable


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.

CALL 911 if you develop fevers, nausea, vomiting, chest pain,
shortness of breath, new seizures or any other concerning
symptoms.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 1702**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 8 weeks.
??????You will need a CT scan of the brain without contrast.
.
You need to follow-up up with your primary care physician about
your recent hospitalization [**2107-6-8**] at 9:30 AM at Dr. [**Name (NI) 12327**] Office. Dr.[**Name (NI) 12328**] address is [**Hospital1 12329**] [**Location (un) 4887**].
MA. Phone [**Telephone/Fax (1) 12330**]. At that visit you will have your thyroid
tested this is very important for your health.


                             [**Name6 (MD) **] [**Last Name (NamePattern4) 1456**] MD [**MD Number(2) 1457**]

Completed by:[**2107-5-23**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Chronic diastolic heart failure,Accidental fall on or from other stairs or steps,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Unspecified acquired hypothyroidism,Oliguria and anuria,Old myocardial infarction,Other chronic pulmonary heart diseases,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Anemia in chronic kidney disease,Hypocalcemia,Mitral valve disorders'}


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: increasing lethargy s/p fall down several stairs

PRESENT ILLNESS: 69 y/o [**Location 7972**] Female Tx from [**Hospital1 **] s/p fall last
night down ~4 stairs at home with ~15 sec LOC

MEDICAL HISTORY: MR, [**Hospital1 19293**], [**Hospital1 **], Pulm [**Hospital1 **], hypothyroidism, CRI (1.7), mild CHF

MEDICATION ON ADMISSION: Lasix 20mg [**Hospital1 **]
Levoxyl 75mcg daily
Glyburide 2.5mg daliy
Metoprolol 25mg [**Hospital1 **]
ASA 81mg daily

ALLERGIES: Lisinopril

PHYSICAL EXAM: On Admission:
PHYSICAL EXAM:
Gen: intubated,sedated.
HEENT: Pupils: 2mm minimally reactive,equally round ,
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated,sedated
Propioception intact:UNABLE TO TEST
Toes downgoing bilaterally

FAMILY HISTORY: NC

SOCIAL HISTORY: lives with family 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with loss of consciousness of unspecified duration,Chronic diastolic heart failure,Accidental fall on or from other stairs or steps,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Unspecified acquired hypothyroidism,Oliguria and anuria,Old myocardial infarction,Other chronic pulmonary heart diseases,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other specified cardiac dysrhythmias,Anemia in chronic kidney disease,Hypocalcemia,Mitral valve disorders'}
