DATE OF ADMISSION:  MM/DD/YYYY
DATE OF DISCHARGE:  MM/DD/YYYY  

DISCHARGE DIAGNOSES:

1.  Vasovagal syncope, status post fall.
2.  Traumatic arthritis, right knee.
3.  Hypertension.
4.  History of recurrent urinary tract infection.
5.  History of renal carcinoma, stable.
6.  History of chronic obstructive pulmonary disease.

CONSULTANTS:  None.

PROCEDURES:  None.

BRIEF HISTORY:  The patient is an (XX)-year-old female with history of previous stroke; hypertension; COPD, stable; renal carcinoma; presenting after a fall and possible syncope.  While walking, she accidentally fell to her knees and did hit her head on the ground, near her left eye.  Her fall was not observed, but the patient does not profess any loss of consciousness, recalling the entire event.  The patient does have a history of previous falls, one of which resulted in a hip fracture.  She has had physical therapy and recovered completely from that.  Initial examination showed bruising around the left eye, normal lung examination, normal heart examination, normal neurologic function with a baseline decreased mobility of her left arm.  The patient was admitted for evaluation of her fall and to rule out syncope and possible stroke with her positive histories.

DIAGNOSTIC STUDIES:  All x-rays including left foot, right knee, left shoulder and cervical spine showed no acute fractures.  The left shoulder did show old healed left humeral head and neck fracture with baseline anterior dislocation.  CT of the brain showed no acute changes, left periorbital soft tissue swelling.  CT of the maxillofacial area showed no facial bone fracture.  Echocardiogram showed normal left ventricular function, ejection fraction estimated greater than 65%.

HOSPITAL COURSE:

1.  Fall:  The patient was admitted and ruled out for syncopal episode.  Echocardiogram was normal, and when the patient was able, her orthostatic blood pressures were within normal limits.  Any serious conditions were quickly ruled out.
2.  Status post fall with trauma:  The patient was unable to walk normally secondary to traumatic injury of her knee, causing significant pain and swelling.  Although a scan showed no acute fractures, the patient's frail status and previous use of cane prevented her regular abilities.  She was set up with a skilled nursing facility, which took several days to arrange, where she was to be given daily physical therapy and rehabilitation until appropriate for her previous residence.

DISCHARGE DISPOSITION:  Discharged to skilled nursing facility.

ACTIVITY:  Per physical therapy and rehabilitation.

DIET:  General cardiac.

MEDICATIONS:  Darvocet-N 100 one tablet p.o. q.4-6 h. p.r.n. and Colace 100 mg p.o. b.i.d.  Medications at Home:  Zestril 40 mg p.o. daily, Plavix 75 mg p.o. daily, Norvasc 5 mg p.o. daily, hydrochlorothiazide 50 mg p.o. daily, potassium chloride 40 mEq p.o. daily, Atrovent inhaler 2 puffs q.i.d., albuterol inhaler 2 puffs q.4-6 h. p.r.n., clonidine 0.1 mg p.o. b.i.d., Cardura 2 mg p.o. daily, and Macrobid for prophylaxis, 100 mg p.o. daily.

FOLLOWUP:

1.  Follow up per skilled nursing facility until discharged to regular residence.
2.  Follow up with primary provider within 2-3 weeks on arriving to home.