CHIEF COMPLAINT: Confusion.

PRESENT ILLNESS: Pt presents from rehab today with headache and increased
confusion at rehab.
Pt recently discharged on [**7-14**] for an admission for headache and
altered mental status.  By the time of his arrival to the floor
during that admission his mental status changes had essentially
resolved and his headache was thought consistent with chronic
headache he has had for at least a month.  He had a CT scan
during that admission, which was stable.
.
Today, Mr [**Known lastname 84008**] neuro-oncologist Dr. [**Last Name (STitle) 724**] got a call from [**Hospital **]
[**Hospital **] Rehab Center reporting confusion.  Apparently the patient
was forgetting the details of his recent hospitalization and
confused as to where he was and where he had been.  Per his
wife, he has not participated in rehab since his recent
admission on [**7-13**] and has been consistently confused at rehab.
He also reported headache, which per the patient was unchanged
from what he has been dealing with for months.  This is
bifrontal and throbbing in character.  It has not improved with
treatment for sinusitis with fluticasone.  The patient also
reports he is unsure of the details of his confusion and feels
like he has been progressively improving.  Further details are
not available at this time.  The physician at rehab did not feel
comfortable managing the patient so he was transferred in to
[**Hospital1 18**].

MEDICAL HISTORY: Glioblastoma Multiforme, with following history
--[**12-21**] headaches and leg weakness, CT at [**Hospital3 **] showed
right temporal lobe mass-->Started on dexamethasone.
--[**2101-12-30**]: Subtotal resection of the R temporal lobe mass by
Papavassilious path positive for GBM
--[**Date range (3) 84009**]: received involved field irradiation as well
as temozolamide followed by four cycles adjuvant temozolomide
--[**2102-8-1**] Ventriculoperitoneal shunt placement
--[**7-/2102**] Diagnosed with PE, started on LMWH
--[**2102-8-23**] Procarbazine, CCNU, and Vincristine (PCV) (received 2
cycles)
--[**Date range (3) 84005**]: Prolonged hospitalization during which time
he had PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
placement of IVC filter for PE; discharged to [**Hospital1 **]
course c/b C. difficile, ESBL PNA
-[**2103-2-28**]: Started bevacizumab
.
Other Past Medical History
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- Steroid induced myopathy

MEDICATION ON ADMISSION: Atovaquone 1500 mg PO daily
Colchicine 0.6 mg PO daily
Gabapentin 900 mg QAM, 400 mg Qafternoon, and 1200 mg QPM
Ibuprofen 600 mg TID PRN
Lidocaine Patch
Nystatin suspension QID
Ondansetron 4 mg Q 8 hrs PRN
Valproic Acid 1250 mg PO Q8hrs
APAP 325-650 PO Q4hrs PRN headache
Ascorbic acid 500 mg PO BID
Ca Carbonate 500 mg PO TID
MVI daily
Senna 1 tab PO BID PRN
Tramadol 50 mg PO Q4hrs PRN
Fluticasone nasal spray
Esomeprazole 40 mg PO daily
Alendronate 70 mg Qweek
Potassium 20 mEq daily
Loperamide 2 mg PO daily PRN
Vit D 400 mg PO TID
Fluconazole 100 mg PO daily
Florastor 250 mg PO TID
HCTZ 25 mg PO daily
Methylphenidate 15 mg PO daily
Heparin 5000 units SC TID
Albuterol nebs TID

ALLERGIES: hydromorphone

PHYSICAL EXAM: ADMISSION EXAM:
VS: T 96.8, BP 118/85, P 93, RR 20, O2 94% on RA
HEENT: Visible shunt under left side of scalp w/o surrounding
redness or erythema, sclerae anicteric, MMM, OP w/o lesions and
no signs thrush
CV: RRR, no M/R/G; no JVD appreciated
Pulm: Poor respiratory effort bilaterally though limited by pt
positioning as pulling to sitting on own, no adventitious sounds
appreciated, respiratory movement equal bilaterally
Abdomen: Mildly TTP diffusely (but less so then on admission 5
days ago), no guarding or rebound, no HSM or mass appreciated,
bowel sounds normoactive
Extrem: W and WP, trace edema bilaterally
Neuro: Alert and oriented *3, 5/5 strength in RUE, 5-/5 in LUE,
4-/5 hip flexors in RLE, [**3-17**] in LLE, EOM full and intact, mild
asterixis?
Skin: Diffuse ecchymoses and skin atrophy

FAMILY HISTORY: Father with CAD in 40's and CABG*3 at 40 (but lived to 85).
Mother still living and has HTN.  One sibling with PTCA for CAD,
other three siblings healthy.

SOCIAL HISTORY: Previously an Accountant.  In rehab recently after prolonged
hospitalization and deconditioning due to steroid myopathy.  No
history of tobacco or illicits.  No history of problem alcohol.
Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Candidiasis of mouth,Acute kidney failure, unspecified,Altered mental status,Epilepsy, unspecified, without mention of intractable epilepsy,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Abdominal pain, other specified site,Headache,Other nonspecific findings on examination of urine,Hypopotassemia,Other myopathies,Osteoporosis, unspecified,Personal history of venous thrombosis and embolism,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Presence of cerebrospinal fluid drainage device,Encounter for palliative care,Do not resuscitate status,Adrenal cortical steroids causing adverse effects in therapeutic use
Mal neo temporal lobe,Pneumonia, organism NOS,Thrush,Acute kidney failure NOS,Altered mental status,Epilep NOS w/o intr epil,Elev transaminase/ldh,Abdmnal pain oth spcf st,Headache,Abn urine findings NEC,Hypopotassemia,Myopathies NEC,Osteoporosis NOS,Hx-ven thrombosis/embols,Hx antineoplastic chemo,Hx of irradiation,Ventricular shunt status,Encountr palliative care,Do not resusctate status,Adv eff corticosteroids
Admission Date:  [**2103-7-17**]              Discharge Date:   [**2103-7-30**]

Date of Birth:  [**2046-10-9**]             Sex:   M

Service: MEDICINE

Allergies:
hydromorphone

Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Confusion.

Major Surgical or Invasive Procedure:
Lumbar puncture [**2103-7-19**].


History of Present Illness:
Pt presents from rehab today with headache and increased
confusion at rehab.
Pt recently discharged on [**7-14**] for an admission for headache and
altered mental status.  By the time of his arrival to the floor
during that admission his mental status changes had essentially
resolved and his headache was thought consistent with chronic
headache he has had for at least a month.  He had a CT scan
during that admission, which was stable.
.
Today, Mr [**Known lastname 84008**] neuro-oncologist Dr. [**Last Name (STitle) 724**] got a call from [**Hospital **]
[**Hospital **] Rehab Center reporting confusion.  Apparently the patient
was forgetting the details of his recent hospitalization and
confused as to where he was and where he had been.  Per his
wife, he has not participated in rehab since his recent
admission on [**7-13**] and has been consistently confused at rehab.
He also reported headache, which per the patient was unchanged
from what he has been dealing with for months.  This is
bifrontal and throbbing in character.  It has not improved with
treatment for sinusitis with fluticasone.  The patient also
reports he is unsure of the details of his confusion and feels
like he has been progressively improving.  Further details are
not available at this time.  The physician at rehab did not feel
comfortable managing the patient so he was transferred in to
[**Hospital1 18**].

In the ED initial VS were T 97.3, P 96, BP 126/85, RR 18, O2 92%
RA.  He complained of chronic headache but had no other
complaints  He had a CT head, which was stable as well as CXR
and UA.  His UA showed very mild pyuria and thus he received PO
ciprofloxacin *1.  He was evaluated by Dr. [**Last Name (STitle) 724**] in the ED who
thought he appeared stable from his previous baseline and was
ready to discharge him back to rehab but when the patient's wife
reported more chronically altered mental status a decision was
made to admit him for further work-up.
.
On the floor the patient cannot remember why he was transferred
to [**Hospital1 18**] but confabulates a story about needing to be brought
here to have a bowel movement (likely due to apparently asking
to defecate in the ambulance and being told he had to wait to
get to [**Hospital Ward Name **]).  He reports persistent headache.  He
reports his abdominal pain, which was an issue during his last
hospitalization has improved.
.
ROS:
+ Per HPI as well as for weakness (chronic) that he thinks is
improving
Denies fevers, chills, night sweats.  Denies change from chronic
intermittent diploplia.  Denies neck pain or stiffness.  Denies
chest pain, shortness of breath, wheezing, or cough.  Denies
acute abdominal pain, nausea, vomiting, or diarrhea.  Denies any
change in baseline weakness. Denies dysuria or foul smelling
urine.  Denies melena or hematochezia.  Denies vertigo.

Past Medical History:
Glioblastoma Multiforme, with following history
--[**12-21**] headaches and leg weakness, CT at [**Hospital3 **] showed
right temporal lobe mass-->Started on dexamethasone.
--[**2101-12-30**]: Subtotal resection of the R temporal lobe mass by
Papavassilious path positive for GBM
--[**Date range (3) 84009**]: received involved field irradiation as well
as temozolamide followed by four cycles adjuvant temozolomide
--[**2102-8-1**] Ventriculoperitoneal shunt placement
--[**7-/2102**] Diagnosed with PE, started on LMWH
--[**2102-8-23**] Procarbazine, CCNU, and Vincristine (PCV) (received 2
cycles)
--[**Date range (3) 84005**]: Prolonged hospitalization during which time
he had PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
placement of IVC filter for PE; discharged to [**Hospital1 **]
course c/b C. difficile, ESBL PNA
-[**2103-2-28**]: Started bevacizumab
.
Other Past Medical History
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- Steroid induced myopathy

Social History:
Previously an Accountant.  In rehab recently after prolonged
hospitalization and deconditioning due to steroid myopathy.  No
history of tobacco or illicits.  No history of problem alcohol.

Family History:
Father with CAD in 40's and CABG*3 at 40 (but lived to 85).
Mother still living and has HTN.  One sibling with PTCA for CAD,
other three siblings healthy.

Physical Exam:
ADMISSION EXAM:
VS: T 96.8, BP 118/85, P 93, RR 20, O2 94% on RA
HEENT: Visible shunt under left side of scalp w/o surrounding
redness or erythema, sclerae anicteric, MMM, OP w/o lesions and
no signs thrush
CV: RRR, no M/R/G; no JVD appreciated
Pulm: Poor respiratory effort bilaterally though limited by pt
positioning as pulling to sitting on own, no adventitious sounds
appreciated, respiratory movement equal bilaterally
Abdomen: Mildly TTP diffusely (but less so then on admission 5
days ago), no guarding or rebound, no HSM or mass appreciated,
bowel sounds normoactive
Extrem: W and WP, trace edema bilaterally
Neuro: Alert and oriented *3, 5/5 strength in RUE, 5-/5 in LUE,
4-/5 hip flexors in RLE, [**3-17**] in LLE, EOM full and intact, mild
asterixis?
Skin: Diffuse ecchymoses and skin atrophy

Pertinent Results:
ADMISSION LABS:
WBC-5.6 RBC-4.16* Hgb-13.8* Hct-41.4 MCV-99* RDW-17.7* Plt
Ct-279
---Neuts-63.1 Lymphs-21.0 Monos-13.7* Eos-1.2 Baso-1.1
Glucose-89 UreaN-24* Creat-0.7 Na-138 K-4.2 Cl-98 HCO3-28
ALT-50* AST-42* LD(LDH)-257* AlkPhos-95 TotBili-0.3
Albumin-4.1 Calcium-9.7 Phos-5.4* Mg-2.2
Valproa-91
UA: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025 Blood-NEG
Nitrite-NEG Protein-TR Glucose-NEG Ketone-40 Bilirub-NEG
Urobiln-NEG pH-5.5 Leuks-SM RBC-2 WBC-4 Bacteri-FEW Yeast-NONE
Epi-0
.
[**2103-7-13**] CT abdomen/pelvis: 1. No evidence of acute abdominal or
pelvic processes. 2. Bilateral common femoral and external iliac
thrombus small amount of thrombus within the infrarenal IVC
filter. New left common iliac vein thrombus is also noted. 3.
Stable bibasilar atelectasis and bilateral 4-mm lower lobe
nodules. 4. Hepatic steatosis.
.
[**2103-7-17**] CT head: 1. No acute intracranial hemorrhage, new mass
effect, or shift of normally midline structures. 2.
Post-treatment changes in the right temporal lobe. 3. Unchanged
left ventriculostomy and slight ventricular enlargement. 4.
Unchanged right sphenoid and mastoid/middle ear sinus disease as
described above.
.
[**2103-7-17**] CXR: Port-A-Cath is unchanged with catheter tip located
in region of the right atrium. Lung volumes are low with stable
elevation of the right hemidiaphragm. VP shunt courses along the
left chest wall into the upper abdomen. No definite signs of
pneumonia or CHF. No large pleural effusion or pneumothorax is
seen. Heart size cannot be assessed fully though appears grossly
stable. Mediastinal contour is unchanged. Bony structures appear
intact.
.
[**2103-7-19**] CXR: No pneumonia, edema or effusion.
.
[**2103-7-20**] 24 hour EEG: IMPRESSION: This is an abnormal continuous
ICU monitoring study because of severe diffuse background
slowing, indicative of severe diffuse cerebral dysfunction.
Background activity over the right hemisphere showed more severe
focal slowing and occasional sharp waves over the right temporal
region. These findings indicate a potentially epileptogenic
focal structural lesion in the right temporal region. Compared
to the prior day's recording, there were no significant change.
.
[**2103-7-22**] CXR: IMPRESSION: Lung volumes remain very low with
marked elevation of the right hemidiaphragm, chronic since at
least [**2103-5-13**]. Small accompanying right pleural effusion or
pleural thickening is also stable. Moderate cardiomegaly
exaggerated by low lung volumes, unchanged. Lungs grossly clear.
Right-sided central venous infusion port ends in the right
atrium close to the tricuspid valve.
.
[**2103-7-25**] MRI BRAIN: IMPRESSION:
1. Increased enhancement demonstrated within the resection
cavity, involving the parenchyma of the residual right temporal
lobe and also extending in a nodular fashion in its lateral
aspect suggestive of subpial involvement and, perhaps,
progressive involvement of the overlying dura. The appearance
suggests progression of disease since [**2103-5-28**].
2. No separate foci of enhancement to suggest new sites of
disease. No evidence of interval infarction.
3. Expected continued evolution of blood products within the
resection cavity, with no evidence of new hemorrhage.
.
DISCHARGE LABS:
[**2103-7-26**]: WBC 8.3, Hb 10.8, HCT 32.4, MCV 98, PLT 185.
[**2103-7-25**]: PT 13.5, INR 1.2, PTT 32.7.
[**2103-7-23**]: Retic 1.5.
[**2103-7-26**]: Na 144, K 3.8, Cl 107, CO2 25, BUN 7, creat 1.1,
glucose 94.
[**2103-7-23**]: Ca 8.4, Phos 4.3, Mg 1.8, Fe 69, TIBC 285, B12 1864,
folate >20, ferritin 549, TSH 4.1.
[**2103-7-24**]: AM cortisol 3.7.
[**2103-7-25**]: ACTH stim test at 0min 4.0, at 30min 17.8, at 60min
19.2.
[**2103-7-25**]: H. pylori Ab negative.
[**2103-7-19**]: CSF protein 178, glucose 42, LDH 56.

Brief Hospital Course:
56yo man with right temporal GBM s/p resection currently on
bevacizumab, steroid-induced myopathy (bed bound), and chronic
issues with delirium admitted for altered mental status and
headache.  Transferred to ICU after found unresponsive on the
floor hypoxic, febrile to 104.0F, and having seizure-like
activity.  Lumbar puncture was negative for infection.  Hypoxia
and fever resolved, so he was transfered out of ICU on IV
valproate and antibiotics possible for aspiration pneumonia,
though CXRs x2 and cultures were negative.  EEGs showed seizure
activity at the site of tumor.  Brain MRI [**2103-7-25**] showed
progression of CNS disease.  Family meeting [**2103-7-26**] with Dr.
[**Last Name (STitle) 724**] confirmed transition to home hospice and comfort measures.
.
# Seizure d/o and altered mental status: Due to progression of
disease.  Minimal improvement with valproate and lorazepam.  TSH
normal.  CSF negative, VDRL pending.  MRI [**2103-7-24**] showed
progression of disease.  Continued valproate, changed to PO
because of IV med shortage and normal swallow eval.  However, he
did not take PO very well because of acute delirium (waxing and
[**Doctor Last Name 688**]), but tolerated the liquid formulation.  EEG [**2103-7-24**]
prelim report showed improvement of the severe diffuse
background slowing seen on the previous EEGs [**2103-7-19**] and [**2103-7-20**],
but the focal slowing and occasional sharp waves over the right
temporal region associated with his tumor remain unchanged.
Modafenil started [**2103-7-24**] without any response and therefore
discontinued.Pt was restarted on dexamethasone and mental status
did improve, therefore pt d/c with dexamethasone and titration
will done at the discretion of neuro-oncology.
.
# Adrenal insufficiency: Low AM cortisol and borderline ACTH
(Cosyntropin) stim test is concerning for adrenal insufficiency.
 Although he was at risk due to the long history of steroids, he
did not require steroids in the recent acute illness in the ICU.
 Dexamethasone was stopped [**2103-7-11**] after very slow taper.  With
little down side to a trial of steroids especially considering
progression of CNS disease, dexamethasone 4mg IV q8hr was
restarted [**2103-7-26**].  Changed to liquid.
.
# Hypoxia/Fever: Due to aspiration pneumonia vs. seizure.
Episode preceded by vomiting.  However, CXRs x2 negative.  LP
negative.  U/A negative.  Cultures negative.  Normal repeat
bed-side swallow eval.  PO resumed, but with recurrence of
vomiting.  Changed vancomycin and pip/tazo to clindamycin for
aspiration pneumonia [**2103-7-24**], avoiding penicillins that may
lower seizure threshold.

# Vomiting: Unclear etiology.  Likely due to CNS progression of
disease.  Started metoclopramide for possible gastroparesis.  H.
pylori Ab negative.On d/c pt able to tolerate po and not
complaining of nausea.
.
# GBM: s/p resection, currently maintained on bevacizumab.
Restaging MRI showed progression of disease.   Neuro-oncology
had a discussion with family and given evidence of both clinical
progression and radiologic progression with poor performance
status plan was to discharge patient to hospice care.
.
# Thrombocytopenia: Possibly drug-related.  Concerning meds
included valproate, pip/tazo, vancomycin, heparin (flushes and
SC).  Stable.  Coags normal, renal function normal.
.
# Anemia: Anemia labs unremarkable.  Stable.
.
# Acute renal failure: Resolved with IV fluids.
.
# Abdominal Pain: Chronic since VP shunt was placed.  CT [**2103-7-13**]
unremarkable.  Continued analgesia prn.
.
.
# FEN: Restarted regular diet with normal swallow eval.
Repleted hypokalemia.
.
# GI Prophylaxis: Continued outpatient PPI and bowel regimen.

.
# Access: Peripherals.
.
# Precautions: Seizure.
.
# Code: DNR/DNI.

Medications on Admission:
Atovaquone 1500 mg PO daily
Colchicine 0.6 mg PO daily
Gabapentin 900 mg QAM, 400 mg Qafternoon, and 1200 mg QPM
Ibuprofen 600 mg TID PRN
Lidocaine Patch
Nystatin suspension QID
Ondansetron 4 mg Q 8 hrs PRN
Valproic Acid 1250 mg PO Q8hrs
APAP 325-650 PO Q4hrs PRN headache
Ascorbic acid 500 mg PO BID
Ca Carbonate 500 mg PO TID
MVI daily
Senna 1 tab PO BID PRN
Tramadol 50 mg PO Q4hrs PRN
Fluticasone nasal spray
Esomeprazole 40 mg PO daily
Alendronate 70 mg Qweek
Potassium 20 mEq daily
Loperamide 2 mg PO daily PRN
Vit D 400 mg PO TID
Fluconazole 100 mg PO daily
Florastor 250 mg PO TID
HCTZ 25 mg PO daily
Methylphenidate 15 mg PO daily
Heparin 5000 units SC TID
Albuterol nebs TID

Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) Neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
Disp:*60 ml* Refills:*0*
3. docusate sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
Disp:*600 mL* Refills:*2*
4. senna 8.6 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. acetaminophen 650 mg/20.3 mL Solution [**Month/Day/Year **]: [**Telephone/Fax (1) 60938**] mg PO Q6H
(every 6 hours) as needed for Pain.
Disp:*1200 mL* Refills:*2*
6. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Telephone/Fax (1) **]: 1500
(1500) mg PO Q8H (every 8 hours).
Disp:*1800 mg* Refills:*0*
7. ondansetron 4 mg Tablet, Rapid Dissolve [**Telephone/Fax (1) **]: [**1-14**] Tablet,
Rapid Dissolves PO Q8H (every 8 hours) as needed for Nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
8. dexamethasone 1 mg/mL Drops [**Month/Day (2) **]: Four (4) mg PO three times a
day.
Disp:*120 ml* Refills:*0*
9. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] daily ().
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
10. vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours).
Disp:*56 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
seasons Hospice

Discharge Diagnosis:
1. Altered mental status.
2. Headache.
3. Glioblastoma multiforme (brain cancer).
4. Nausea/vomiting.
5. Hypoxia (low oxygen).

6. Seizures.
7. Pneumonia.
8. Fever.
9. Steroid-induced myopathy (muscle weakness).


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
Mr [**Known lastname 13013**] was admitted to the hospital for altered mental status
and headache.  In the hospital, he was  found on the floor with
low oxygen and seizure activity. He was transfered to the
intensive care unit (ICU) and started on antibiotics for a
possible aspiration pneumonia.  He also had a lumbar puncture
(spinal tap), which did not show an infection.  Chest x-rays and
cultures have not revealed any infection.The  low oxygen levels
improved, and Mr [**Known lastname 13013**] was transfered out of the ICU.  However,
he  continued to have confusion.  EEGs measuring brain waves
showed chronic seizure activity in the region of the brain
tumor.  A brain MRI showed progression of the tumor, the likely
cause of confusion and seizures.  Because of continued
progression of disease avastin treatment was discontinued and
care now focusing on keeping patient comfortable.Mr [**Known lastname 13013**] did
develop an increase in bowel movements and because of prior
history of clostridium difficile colitis stool cultures were
obtained and patient was started on oral vancomycin empirically.
At the time of discharge stool for c.diff is still pending.Pt
being discharged with home hospice services.
Changes in medications:
Decadron was restarted -please contact Dr [**Name (NI) 724**] for titration of
decadron dose.
valproic acid dose increased
oral vancomycin started
Gabapentin, heparin sq , colchicine, atovaquone,aspirin,
fluconazole -discontinued.
Pending results on d/c:
stools for c.dif
VDRL to evaluate for neuro-syphilis ( although not highly
likely)

Followup Instructions:
Please contact Dr [**First Name8 (NamePattern2) **] [**Name (NI) 724**] for any question or concerns.
{'Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Candidiasis of mouth,Acute kidney failure, unspecified,Altered mental status,Epilepsy, unspecified, without mention of intractable epilepsy,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Abdominal pain, other specified site,Headache,Other nonspecific findings on examination of urine,Hypopotassemia,Other myopathies,Osteoporosis, unspecified,Personal history of venous thrombosis and embolism,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Presence of cerebrospinal fluid drainage device,Encounter for palliative care,Do not resuscitate status,Adrenal cortical steroids causing adverse effects in therapeutic use'}


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: Confusion.

PRESENT ILLNESS: Pt presents from rehab today with headache and increased
confusion at rehab.
Pt recently discharged on [**7-14**] for an admission for headache and
altered mental status.  By the time of his arrival to the floor
during that admission his mental status changes had essentially
resolved and his headache was thought consistent with chronic
headache he has had for at least a month.  He had a CT scan
during that admission, which was stable.
.
Today, Mr [**Known lastname 84008**] neuro-oncologist Dr. [**Last Name (STitle) 724**] got a call from [**Hospital **]
[**Hospital **] Rehab Center reporting confusion.  Apparently the patient
was forgetting the details of his recent hospitalization and
confused as to where he was and where he had been.  Per his
wife, he has not participated in rehab since his recent
admission on [**7-13**] and has been consistently confused at rehab.
He also reported headache, which per the patient was unchanged
from what he has been dealing with for months.  This is
bifrontal and throbbing in character.  It has not improved with
treatment for sinusitis with fluticasone.  The patient also
reports he is unsure of the details of his confusion and feels
like he has been progressively improving.  Further details are
not available at this time.  The physician at rehab did not feel
comfortable managing the patient so he was transferred in to
[**Hospital1 18**].

MEDICAL HISTORY: Glioblastoma Multiforme, with following history
--[**12-21**] headaches and leg weakness, CT at [**Hospital3 **] showed
right temporal lobe mass-->Started on dexamethasone.
--[**2101-12-30**]: Subtotal resection of the R temporal lobe mass by
Papavassilious path positive for GBM
--[**Date range (3) 84009**]: received involved field irradiation as well
as temozolamide followed by four cycles adjuvant temozolomide
--[**2102-8-1**] Ventriculoperitoneal shunt placement
--[**7-/2102**] Diagnosed with PE, started on LMWH
--[**2102-8-23**] Procarbazine, CCNU, and Vincristine (PCV) (received 2
cycles)
--[**Date range (3) 84005**]: Prolonged hospitalization during which time
he had PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
placement of IVC filter for PE; discharged to [**Hospital1 **]
course c/b C. difficile, ESBL PNA
-[**2103-2-28**]: Started bevacizumab
.
Other Past Medical History
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- Steroid induced myopathy

MEDICATION ON ADMISSION: Atovaquone 1500 mg PO daily
Colchicine 0.6 mg PO daily
Gabapentin 900 mg QAM, 400 mg Qafternoon, and 1200 mg QPM
Ibuprofen 600 mg TID PRN
Lidocaine Patch
Nystatin suspension QID
Ondansetron 4 mg Q 8 hrs PRN
Valproic Acid 1250 mg PO Q8hrs
APAP 325-650 PO Q4hrs PRN headache
Ascorbic acid 500 mg PO BID
Ca Carbonate 500 mg PO TID
MVI daily
Senna 1 tab PO BID PRN
Tramadol 50 mg PO Q4hrs PRN
Fluticasone nasal spray
Esomeprazole 40 mg PO daily
Alendronate 70 mg Qweek
Potassium 20 mEq daily
Loperamide 2 mg PO daily PRN
Vit D 400 mg PO TID
Fluconazole 100 mg PO daily
Florastor 250 mg PO TID
HCTZ 25 mg PO daily
Methylphenidate 15 mg PO daily
Heparin 5000 units SC TID
Albuterol nebs TID

ALLERGIES: hydromorphone

PHYSICAL EXAM: ADMISSION EXAM:
VS: T 96.8, BP 118/85, P 93, RR 20, O2 94% on RA
HEENT: Visible shunt under left side of scalp w/o surrounding
redness or erythema, sclerae anicteric, MMM, OP w/o lesions and
no signs thrush
CV: RRR, no M/R/G; no JVD appreciated
Pulm: Poor respiratory effort bilaterally though limited by pt
positioning as pulling to sitting on own, no adventitious sounds
appreciated, respiratory movement equal bilaterally
Abdomen: Mildly TTP diffusely (but less so then on admission 5
days ago), no guarding or rebound, no HSM or mass appreciated,
bowel sounds normoactive
Extrem: W and WP, trace edema bilaterally
Neuro: Alert and oriented *3, 5/5 strength in RUE, 5-/5 in LUE,
4-/5 hip flexors in RLE, [**3-17**] in LLE, EOM full and intact, mild
asterixis?
Skin: Diffuse ecchymoses and skin atrophy

FAMILY HISTORY: Father with CAD in 40's and CABG*3 at 40 (but lived to 85).
Mother still living and has HTN.  One sibling with PTCA for CAD,
other three siblings healthy.

SOCIAL HISTORY: Previously an Accountant.  In rehab recently after prolonged
hospitalization and deconditioning due to steroid myopathy.  No
history of tobacco or illicits.  No history of problem alcohol. 

### Response:
{'Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Candidiasis of mouth,Acute kidney failure, unspecified,Altered mental status,Epilepsy, unspecified, without mention of intractable epilepsy,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Abdominal pain, other specified site,Headache,Other nonspecific findings on examination of urine,Hypopotassemia,Other myopathies,Osteoporosis, unspecified,Personal history of venous thrombosis and embolism,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Presence of cerebrospinal fluid drainage device,Encounter for palliative care,Do not resuscitate status,Adrenal cortical steroids causing adverse effects in therapeutic use'}
