CHIEF COMPLAINT: Cognitive decline

PRESENT ILLNESS: 60 yo F h/o Hodgkin's disease, ITP, hypothyrodisim p/w cognitive
decline. The patient's care has been at outside institutions
prior to this month. She has had a progressive decline in
cognition and general health beginning in [**7-12**], at which point
she had recurrent ITP. In [**9-11**] she was treated with rituximab
and her ITP seemed to respond. However, she felt fatigued, had
night sweats, and experienced weight loss, all of an unclear
etiology. She was thought to perhaps have URIs but eventually
went to her PCP who found that her LFTs were elevated. Imaging
revealed multiple small nodules in her liver worrisome for
metastatic malignancy. However, CT guided biopsy in [**2-11**] was w/o
evidence of malignancy.
.
At this point, she was transfused due to worsening anemia. This
temporarily improved her symptoms. Then in [**3-13**], she began to
notice a decline in her cognitive function. This was marked to
the patient at her work in human resources. She found that she
was having difficulty "connecting" with people and completeing
tasks.
.
She was admitted to [**Hospital1 498**] for an extensive workup. Initial
thought was that she had MS, given white matter changes on an
MRI in [**Month (only) 116**], but the diagnosis was not definite. She continued to
decline and presented to [**Hospital1 **] in early [**5-13**] for a second opinion
by Dr. [**Last Name (STitle) 8760**].
.
Dr. [**Last Name (STitle) 8760**] felt at that time that her exam and history were most
consistent with PML. Also on the differential were tertiary
syphilis, B12 deficiency, and Hashimoto encephalopathy.
Evaluation at that time was notable for: WBC of 15.5, 93%
neutrophils, Hct 28.7, MCV 91, plts of 448, Cr of 0.7, TSH of
0.50, neg HIV, neg EBV and [**Male First Name (un) 2326**] virus PCR in CSF, negative
viral/fungal/cryptococcal Ag in CSF. LP: cell count 1 WBC, 4
RBC, 3% polys, 70% lymphs, 27% monos, TP 28, glu 68. [**Male First Name (un) 2326**] virus
was re-checked by Dr. [**Last Name (STitle) 2340**] in neurology and found her test
to again be negative.
.
Over the past 2 days the patient has become more confused at
home. She has also had difficulty coordinating her swallow with
new-onset hiccups. The patient's neurologists were contact[**Name (NI) **] and
it was decided to admit the patient electively to the neuro
service for brain biopsy. The patient was seen in the ED and
admitted to neurology. The patient had a number of abnormalities
on her ED labwork further complicating her presentation. She was
transferred to medicine for further management.

MEDICAL HISTORY: # h/o recurrent Hodgkin's disease
- initially presented as stage II
- tx w/ XRT in [**2083**]
- recurred then treated w/ ABVD
- followed by splenectomy and autoBMT in [**2092**]
- disease free since
# recurrent ITP
- first dx in [**2105**]
- recurred in [**9-11**]
- tx w/ IVIG, prednisone, rituximab (last given [**10-12**])
# h/o hypothyroidism since XRT
# h/o SVT in [**2105**] - now on beta-blocker
# asymptomatic carotid bruit
# chronic anemia since [**7-/2107**]
- required transfusion on at least 1 occassion

MEDICATION ON ADMISSION: MEDS:
tylenol 325-650 PO Q6 prn
FeSO4 325mg PO BID
levothyroxine 88mcg PO QD
metoprolol XL 25mg PO QD
pantoprazole 40mg PO QD
prednisone 5mg PO QD
sertraline 50mg PO QD
vitamin D 400u PO QD
colace 100mg PO BID
ciprofloxacin 250mg PO Q12 - started on [**5-29**], for total 7 days

ALLERGIES: Penicillins

PHYSICAL EXAM: Temp 99
BP 104/62
Pulse 103
Resp 18
O2 sat 99% ra
Gen - Alert, oriented x3, no acute distress
HEENT - anicteric, mucous membranes slightly dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, systolic murmur heard best at the LLSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro -
[**12-8**] words at 5 minutes, unable to spell world backwards
cranial nerves [**1-17**] intact
4+/5 in [**Hospital1 **]/triceps b/l, o/w full strength throughout
reflexes intact and symmetric
sensation grossly intact
Skin - No rash

FAMILY HISTORY: Father with parkinson's otherwise no neuro history.

SOCIAL HISTORY: Former HR manager, had to leave due to her present illness.
Denies etoh/tob/illicits.
Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Hematoma complicating a procedure,Pneumonitis due to inhalation of food or vomitus,Unspecified pleural effusion,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other specified aplastic anemias,Other convulsions,Encephalopathy, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Orthostatic hypotension,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Mononeuritis of unspecified site
Hdgk dis unsp xtrndl org,Acute respiratry failure,Hematoma complic proc,Food/vomit pneumonitis,Pleural effusion NOS,Protein-cal malnutr NOS,Urin tract infection NOS,Hyposmolality,Aplastic anemias NEC,Convulsions NEC,Encephalopathy NOS,Mental disor NEC oth dis,Orthostatic hypotension,Anemia NOS,Adv eff antineoplastic,Mononeuritis NOS
Admission Date:  [**2108-6-1**]              Discharge Date:   [**2108-7-14**]

Date of Birth:  [**2047-6-9**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Cognitive decline

Major Surgical or Invasive Procedure:
Frontal Brain biopsy with Right craniotomy [**2108-6-16**]
PICC line placement [**2108-6-19**]
Percutaneous JG tube placement [**2108-6-13**]
Ultra Sound guided liver biopsy [**2108-6-5**]
Lumbar puncture [**2108-6-4**]


History of Present Illness:
60 yo F h/o Hodgkin's disease, ITP, hypothyrodisim p/w cognitive
decline. The patient's care has been at outside institutions
prior to this month. She has had a progressive decline in
cognition and general health beginning in [**7-12**], at which point
she had recurrent ITP. In [**9-11**] she was treated with rituximab
and her ITP seemed to respond. However, she felt fatigued, had
night sweats, and experienced weight loss, all of an unclear
etiology. She was thought to perhaps have URIs but eventually
went to her PCP who found that her LFTs were elevated. Imaging
revealed multiple small nodules in her liver worrisome for
metastatic malignancy. However, CT guided biopsy in [**2-11**] was w/o
evidence of malignancy.
.
At this point, she was transfused due to worsening anemia. This
temporarily improved her symptoms. Then in [**3-13**], she began to
notice a decline in her cognitive function. This was marked to
the patient at her work in human resources. She found that she
was having difficulty "connecting" with people and completeing
tasks.
.
She was admitted to [**Hospital1 498**] for an extensive workup. Initial
thought was that she had MS, given white matter changes on an
MRI in [**Month (only) 116**], but the diagnosis was not definite. She continued to
decline and presented to [**Hospital1 **] in early [**5-13**] for a second opinion
by Dr. [**Last Name (STitle) 8760**].
.
Dr. [**Last Name (STitle) 8760**] felt at that time that her exam and history were most
consistent with PML. Also on the differential were tertiary
syphilis, B12 deficiency, and Hashimoto encephalopathy.
Evaluation at that time was notable for: WBC of 15.5, 93%
neutrophils, Hct 28.7, MCV 91, plts of 448, Cr of 0.7, TSH of
0.50, neg HIV, neg EBV and [**Male First Name (un) 2326**] virus PCR in CSF, negative
viral/fungal/cryptococcal Ag in CSF. LP: cell count 1 WBC, 4
RBC, 3% polys, 70% lymphs, 27% monos, TP 28, glu 68. [**Male First Name (un) 2326**] virus
was re-checked by Dr. [**Last Name (STitle) 2340**] in neurology and found her test
to again be negative.
.
Over the past 2 days the patient has become more confused at
home. She has also had difficulty coordinating her swallow with
new-onset hiccups. The patient's neurologists were contact[**Name (NI) **] and
it was decided to admit the patient electively to the neuro
service for brain biopsy. The patient was seen in the ED and
admitted to neurology. The patient had a number of abnormalities
on her ED labwork further complicating her presentation. She was
transferred to medicine for further management.


Past Medical History:
# h/o recurrent Hodgkin's disease
- initially presented as stage II
- tx w/ XRT in [**2083**]
- recurred then treated w/ ABVD
- followed by splenectomy and autoBMT in [**2092**]
- disease free since
# recurrent ITP
- first dx in [**2105**]
- recurred in [**9-11**]
- tx w/ IVIG, prednisone, rituximab (last given [**10-12**])
# h/o hypothyroidism since XRT
# h/o SVT in [**2105**] - now on beta-blocker
# asymptomatic carotid bruit
# chronic anemia since [**7-/2107**]
- required transfusion on at least 1 occassion

Social History:
Former HR manager, had to leave due to her present illness.
Denies etoh/tob/illicits.

Family History:
Father with parkinson's otherwise no neuro history.

Physical Exam:
Temp 99
BP 104/62
Pulse 103
Resp 18
O2 sat 99% ra
Gen - Alert, oriented x3, no acute distress
HEENT - anicteric, mucous membranes slightly dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, systolic murmur heard best at the LLSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro -
[**12-8**] words at 5 minutes, unable to spell world backwards
cranial nerves [**1-17**] intact
4+/5 in [**Hospital1 **]/triceps b/l, o/w full strength throughout
reflexes intact and symmetric
sensation grossly intact
Skin - No rash


Pertinent Results:
[**2108-6-1**] 10:46PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2108-6-1**] 10:46PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2108-6-1**] 10:46PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2108-6-1**] 10:46PM URINE  RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-[**2-8**]
[**2108-6-1**] 09:03PM URINE  HOURS-RANDOM CREAT-113 SODIUM-57
[**2108-6-1**] 09:03PM URINE  OSMOLAL-608
[**2108-6-1**] 08:25PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2108-6-1**] 08:25PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2108-6-1**] 08:25PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-8.0 LEUK-NEG
[**2108-6-1**] 08:25PM URINE  RBC-[**2-8**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2108-6-1**] 06:49PM   PT-14.5* PTT-28.8 INR(PT)-1.3*
[**2108-6-1**] 06:20PM   GLUCOSE-158* UREA N-14 CREAT-0.7 SODIUM-127*
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-20* ANION GAP-17
[**2108-6-1**] 06:20PM   estGFR-Using this
[**2108-6-1**] 06:20PM   ALT(SGPT)-50* AST(SGOT)-92* LD(LDH)-248 ALK
PHOS-297* TOT BILI-1.4 DIR BILI-0.7* INDIR BIL-0.7
[**2108-6-1**] 06:20PM   ALBUMIN-2.4* IRON-17*
[**2108-6-1**] 06:20PM   calTIBC-135 VIT B12-502 FOLATE-7.9
HAPTOGLOB-590* FERRITIN-GREATER TH TRF-104*
[**2108-6-1**] 06:20PM   OSMOLAL-262*
[**2108-6-1**] 06:20PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2108-6-1**] 06:20PM   WBC-18.3* RBC-2.85* HGB-7.6* HCT-23.7*
MCV-83# MCH-26.7* MCHC-32.0 RDW-17.5*
[**2108-6-1**] 06:20PM   NEUTS-84* BANDS-3 LYMPHS-6* MONOS-5 EOS-1
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2108-6-1**] 06:20PM   HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-2+ POLYCHROM-2+ TARGET-1+ SCHISTOCY-1+
BURR-1+
[**2108-6-1**] 06:20PM   PLT SMR-NORMAL PLT COUNT-351 PLTCLM-1+
ANC nadir of 1312 on [**2108-7-5**]
WBC nadir of 1.1 on [**2108-7-1**]

Discharge labs-
                    Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2108-7-14**] 03:26AM    253* 16 0.4 139 4.8 109* 23 12

                       WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2108-7-14**] 03:26AM    10.5 3.26* 10.3* 30.7* 94 31.5 33.5 19.9*
417
[**2110-7-13**].0        28.7
385

PT 12.9 INR 1.1 (from 1.2) PTT 26.4

AST 15 ALT 20 LDH 186 (from 138) AP 166 (from 144)

.
IMAGING:
OLD IMAGING (per OMR note of Dr. [**Last Name (STitle) 8760**] [**2108-5-21**]):
1. MRI scan of the head [**2108-4-15**] reviewed today. There are
bihemispheric confluent areas of increased signal within the
centrum semiovale extending into the white matter of the
cortical
gyri without involvement of the cortex. In addition, there are
extensive paraventricular white matter changes. Many of the
extensive confluent white matter changes are oriented parallel
to
the long axis of the ventricle. There is a solitary 9-mm round
oval area of increased signal within the right deep cerebellar
white matter with feathery edges and no mass effect. There is no

enhancement and only mild atrophy. There is no significant
evidence of leukomalacia at this time. Diffusion weighted
studies appear normal with no evidence of hemorrhage.
2. MRI scan of the spine [**2108-4-15**] shows no intramedullary
signal changes. There are degenerative changes at C5-C6 with
some impingement of the thecal sac on the left side. There is
mention of submandibular and subclavicular lymph node
enlargement
on this study.

[**2108-6-2**]
Final Report
EXAM: MRI brain.

IMPRESSION:
1. Mild-to-moderate hyperintense signal in the subcortical and
periventricular white matter could be due to small vessel
disease and/or
associated therapy-related changes.
2. Mild brain atrophy.
3. No evidence of abnormal brain parenchymal enhancement or
acute infarcts.
4. Mild diffuse pachymeningeal enhancement is a nonspecific
finding and could
be related to previous lumbar punctures.
.
CT torso [**2108-6-2**]
INDICATION: History of cognitive decline, history of liver
nodules concerning for metastatic disease on outside hospital
imaging.

TECHNIQUE: Axial volumetric images have been obtained through
the abdomen and pelvis without IV contrast. Arterial, portal
venous, and delayed venous phases were also obtained after
administration of IV contrast. Coronal and sagittal reformats
were also obtained.

FINDINGS: There are multiple innumerable hypoechoic nodules. The
largest is in segment VI measuring 5 cm. Overall, there is
enhancement of these nodules that appear to be more conspicuous
on the portal venous phase. The background liver parenchyma
appears unremarkable. No evidence of intra-hepatic biliary duct
dilatation. The pancreas appears unremarkable. The stomach
appears within normal limits. There are multiple retroperitoneal
lymph nodes, all of which measure subcentimeter except for three
portal lymph nodes measuring 1 cm in short axis. There has been
previous splenectomy with surgical clips seen in the left upper
quadrant. Bilateral adrenal glands are within normal limits. The
bilateral kidneys appear unremarkable with no evidence of
hydronephrosis or nephrolithiasis. No evidence of free fluid or
free air in the abdomen. No evidence of abnormality.

There is an 8 mm pericardial lymph node.

There is basal atelectasis within the bilateral lower lobes.
There are
bilateral small pleural effusions. No evidence of suspicious
bony lesions.

There is a 2 mm lung nodule in the right lower lobe.

IMPRESSION:
1. Innumerable hepatic nodules with an appearance mostly in
keeping with
multiple metastases with the largest in segment VI measuring 5
mm.

2. Multiple subcentimeter retroperitoneal lymph nodes with 1
periportal lymph node measuring 1 cm. No evidence of gastric,
colonic, or pancreatic visible tumors.

-----------------
[**2108-6-3**] MR of thoracic and cervical spine
MRI SCAN OF THE CERVICAL AND THORACIC SPINE

CONCLUSION:

Relatively minor changes of cervical spondylosis, and a small
T2-3 disc
protrusion. Multiple nerve root diverticula as described.
Moderate-size
pleural effusions. Heterogeneous marrow signal pattern. Please
see above
report for additional discussion regarding the latter
observation.
[**2108-6-5**]
Liver, needle core biopsies:

Classical Hodgkin Lymphoma, see note:

Note:  Tissue cores reveal predominantly a
lymphohistiocytic/granulomatoid background with scattered large,
atypical [**Doctor Last Name **]-Sternberg cells and variants (monolobated Hodgkin
cells) with a small fragment of residual intact hepatic tissue
at the edges.  By immunohistochemistry neoplastic cells express
CD30, CD15 (dim/partial) and PAX5; CD20 and CD45 is negative
(Block A).  The CD30 and CD15 expression is confirmed in block
B. Overall morphologic and immunohistochemical stains are in
keeping with recurrence of patient's know classical Hodgkin
lymphoma. The findings were communicated with the care providing
team.

ADDENDUM: [**Last Name (un) **] was performed: this revealed an increased number
of EBV incorporated large cells. This is consistent with the
above diagnosis. The overall impression remains unchanged.
[**2108-6-5**] CXR
HISTORY: Dyspnea, possibly related to aspiration.

FINDINGS: In comparison with the earlier study of this date, the
medial
aspect of the left hemidiaphragm is not well seen. This raises
the
possibility of left basilar opacification consistent with
atelectasis or, in view of the clinical history, possibly
aspiration.
ultra sound liver biopsy [**2108-6-5**]
TARGETED ULTRASOUND-GUIDED LIVER BIOPSY: A limited ultrasound
examination of the liver was performed, demonstrating numerous
lobulated hypoechoic masses within the liver, consistent with
lymphoma. A lobulated lesion in the left lobe measuring 3.7 cm
was deemed most amenable to biopsy.

IMPRESSION: Successful ultrasound-guided targeted liver biopsy
of one lesion in the left lobe as described.
CT chest [**2108-6-5**]
INDICATION: Mental status change and liver nodules. Evaluate for
aspiration.

TECHNIQUE: MDCT axial images through the chest were obtained
without
intravenous contrast and displayed at 5 and 1.25 mm of
collimation. A set of sagittal and coronal images were
reformatted for review.

COMPARISON: None.

CT CHEST WITHOUT INTRAVENOUS CONTRAST: When compared to the
prior CT abdomen of [**2108-6-2**], small bilateral pleural
effusions, left greater than right, have increased in size.
There is no evidence of aspiration or focal parenchymal
consolidation. Microscopic apical subpleural nodules are too
small to characterize. There is right apical scarring. Subtle
nodular
thickening of the right major fissure and right lower lobe
intersitium could suggest lymphangitic tumor spread. Scattered
mediastinal lymph nodes do not meet CT criteria for enlargement.
The largest is a precarinal lymph node measuring 8 mm. There is
a 6-mm pericardial lymph node.

The airways are patent to the level of the subsegmental bronchi
bilaterally, although there is generalized bronchial wall
abnormality.

While not tailored for infradiaphragmatic evaluation, multiple
liver
hypodensities concerning for metastases are best characterized
on the recent CT abdomen scan. The patient is status post
splenectomy.

A 16 x 14 mm lytic lesion within the right humeral head disrupts
the cortex.
LP [**2108-6-6**]
Cerebrospinal fluid:
  NEGATIVE FOR MALIGNANT CELLS.
Shoulder xray [**2108-6-6**]
HISTORY: Lytic humeral lesion seen on CT showing liver disease.

IMPRESSION: Nonspecific lytic lesion humeral head is consistent
with
metastasis.
Bone Scan [**2108-6-7**]
IMPRESSION:
No definite osseous metastases. Symmetrically increased tracer
uptake in both shoulders is likely degenerative. No definite
photopenia in the right humeral head to correspond to the
patient's known lytic lesion.
Video swallow [**2108-6-11**]
HISTORY: Lymphoma recurrence, concern for aspiration.

Comparison is made to report from prior examination dated
[**2108-6-4**].

OROPHARYNGEAL SWALLOW STUDY

Prior to the initiation of the study, the patient had an episode
of seizure beginning with tonic stiffening of the upper
extremities and slight rightward deviation of the head for
approximately 30 seconds followed by generalized clonic activity
of both upper and lower extremities, which lasted approximately
1-1/2 minutes. The patient was kept in an upright position to
minimize aspiration risk and 2 mg of IV Ativan were administered
just after termination of the clonic activity. Patient's
hemodynamic parameters remained stable, and a blood sugar of
over 100 was noted. The primary ordering team was contact[**Name (NI) **] and
came to the department to further manage the patient's care. The
findings were discussed with the caring resident, Dr. [**Last Name (STitle) **],
immediately after the episode.

IMPRESSION:

Unsuccessful swallow study due to seizure.
[**2108-6-11**] cxr
HISTORY: Aspiration pneumonia.

FINDINGS: In comparison with the study of [**6-9**], there is
increased
opacification at the right base silhouetting the hemidiaphragm,
consistent
with aspiration involving the right middle lobe. The area of
opacification in the right upper zone is again seen though not
as clearly. There is also some increased opacification in the
left perihilar region and possibly at the left base.
[**2108-6-12**]
HISTORY: Aspiration pneumonia.

FINDINGS: In comparison with the study of [**6-9**], there is
increased
opacification at the right base silhouetting the hemidiaphragm,
consistent
with aspiration involving the right middle lobe. The area of
opacification in the right upper zone is again seen though not
as clearly. There is also some increased opacification in the
left perihilar region and possibly at the left base.
CXR [**2108-6-13**]
FRONTAL CHEST RADIOGRAPH: There has been interval placement of a
nasogastric tube, which is appropriately positioned. Right
perihilar and right upper lobe opacities are resolving. There
remains left retrocardiac atelectasis and a small left-sided
pleural effusion.
 [**2108-6-13**]
IMPRESSION: Successful percutaneous transgastric jejunal tube
placement. The tube is ready for use. The T-fastener skin
sutures can be cut and released in seven to ten days.
[**2108-6-15**] MR of HEAD with and without contrast
IMPRESSION:

1. No interval change in degree of mild diffuse pachymeningeal
enhancement, which is a non-specific finding and may be related
to previous lumbar punctures, this appearance is not typical of
lymphoma or PML.

2. Mild-to-moderate hyperintense signal in the subcortical and
periventricular white matter is non-specific and could be due to
small vessel ischemia and/or post-treatment changes.
brain bx [**2108-6-16**]
I. Dura, biopsy (A):

Focal perivascular cuff of macrophages, see note.

II. Right frontal lobe, biopsy (B):

Cortical [**Doctor Last Name 352**] and white matter with minimal changes, see note.

Note: Special stains on the dura (block A) reveal no organisms
(gram stain, PAS, GMS, and AFB). By immunohistochemistry, the
perivascular macrophages demonstrate positive staining with
CD68, CD3, CD4, and CD8 highlight scattered T-lymphocytes.
Special stains on the frontal lobe section (block B) show no
organisms (gram stain, PAS, GMS, and AFB). Immunohistochemical
stains show that CD68 highlights scattered macrophages and CD3,
CD4, and CD5 stains rare T-lymphocytes. No microglial nodules
are observed. No viral inclusions are detected. The inflammatory
cell infiltrate is minimal and does not suffice for a diagnosis
of meningoencephalitis.

--------------------
[**2108-6-16**]
Sinus tachycardia. Compared to the previous tracing of [**2108-6-9**]
the rate has
increased.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 104 94 374/458 73 23 13
Head CT without Contrast [**2108-6-17**]
INDICATION: 61-year-old female status post right frontal biopsy.
Please
evaluate for postoperative bleed, edema, and pneumocephalus.

COMPARISON: MRI from [**2108-6-15**] and CT from [**2108-6-11**].

TECHNIQUE: Non-contrast head CT.

IMPRESSION: Minimal, likely hemorrhage within right frontal
cortex and
pneumocephalus in the right frontal lobe, consistent with post-
surgical
change.
ECHO [**2108-6-18**]
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal to mid inferior and inferolateral
segments. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets (3) are mildly thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.

IMPRESSION: Mild focal LV systolic dysfunction. Probable
diastolic dysfunction. Mild aortic stenosis. Moderate mitral
regurgitation.

[**2108-6-19**]
PICC replacement by IR
IMPRESSION: Uncomplicated fluoroscopically guided PICC line
exchange for a new double lumen PICC line. Final internal length
is 51 cm, with the tip
positioned in the SVC. The line is ready to use.
[**2108-6-21**] cxr
FINDINGS: In comparison with the study of [**6-20**], there is again a
diffuse
infiltrate of pulmonary process presenting as marked prominence
of the
interstitial markings. Moderate bilateral pleural effusions are
again seen.  The cardiac silhouette remains within normal limits
and the right subclavian catheter again extends to the lower
portion of the SVC.
[**2108-6-28**] chest CT with contrast
IMPRESSION:
1. Increased, almost complete left lower lobe atelectasis with
mucus filling
multiple segmental and subsegmental bronchi without visible
focal lesion.
2. Right PICC line installed in good position.
3. Scattered non-enlarged mediastinal lymph nodes except for one
11 mm
precarinal lymph node.
4. Left small pleural effusion improved. No residual right
pleural effusion.
5. Multiple liver hypodensities worrisome for metastases from
lymphoma or
other primary should be compared with same technique of prior
abdominal CT.
6. Post-splenectomy.
7. Stable lytic lesion of the right humeral head disrupting the
cortex.
8. Unchanged biapical scarring and right lateral meningoceles or
dural
diverticula.

[**2108-6-29**] echo
IMPRESSION: Suboptimal image quality. Mild aortic stenosis. Low
normal global left ventricular systolic function. Technically
limited to exclude regional wall motion abnormality. Mild mitral
regurgitation.

Compared to prior study (images reviewed) of [**2108-6-18**], the
regional left ventricular dysfunction cannot be assessed on the
current study. The mitral regurgitation appears less prominent
[**2108-6-29**] MR head with and without contrast
IMPRESSION:

1. Subacute hematoma in the right frontal lobe at the biopsy
site, with
moderate surrounding edema. Superimposed infection within the
hematoma cannot be excluded by imaging if the patient has
infectious symptoms.

2. Diffuse pachymeningeal enhancement, unchanged compared to the
preoperative study of [**2108-6-15**], which is of uncertain etiology
but unlikely to be related to lymphoma.

3. Persistent fluid in the sphenoid sinus. Opacification of the
right
lateral mastoid air cells.
CT Head with contrast [**2108-7-3**]
IMPRESSION:
1. Rim-enhancing area in the right frontal cortex in the site of
previous
biopsy. This may be an evolving hematoma; however, an abscess is
not entirely excluded. MRI is recommended to document evolution
of blood products and to aid in the discrimination of an abscess

MR head with contrast [**2108-7-4**]
IMPRESSION:
1. Essentially unchanged appearance of the abnormality in the
right frontal cortex. This may still be an evolving hematoma.
Underlying infectious process is not excluded as suggested
before in the appropriate setting.

2. Unchanged mild pachymeningeal enhancement.

3. New area of susceptibility in the left globe causing adjacent
artifact.
This may be secondary to metal overlying the left eye, and
clinical
correlation is recommended.
[**2108-7-5**] EEG
FINDINGS:
IMPRESSION: Abnormal EEG due to the persistently slow background
and
due to the mixed frequency slowing in the left temporal region.
The
first abnormality signifies a widespread encephalopathy.
Medications,
metabolic disturbances, and infection are among the most common
causes.
The focal slowing indicates a focal subcortical dysfunction in
the left
hemisphere, but the tracing cannot specify the etiology. There
were no
epileptiform features.
[**2108-7-5**] CT torso with constrast

IMPRESSION:

1. Unchanged appearance of innumerable hepatic nodules in
keeping with
multiple metastases, grossly unchanged.

2. Marked increase in left pleural effusion and slight increase
in the right pleural effusion.

3. Increased number of peribronchial ground-glass and
consolidative opacities suggests more prominent multifocal
airspace disease.

4. No evidence of pathologically enlarged nodes.

The study and the report were reviewed by the staff radiologist.

Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2108-7-11**]  10:59 AM


SPIROMETRY 10:59 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred %chg
FVC   1.94 3.39 57
FEV1   1.56 2.50 63
MMF   1.52 2.74 55
FEV1/FVC   81 74 109

LUNG VOLUMES 10:59 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   3.56 5.49 65
FRC   2.67 3.13 85
RV   1.77 2.10 85
VC   1.88 3.39 55
IC   0.89 2.36 38
ERV   0.90 1.04 87
RV/TLC   50 38 131
He Mix Time   0.00

DLCO 10:59 AM
    Actual Pred %Pred
DSB   10.85 19.61 55
VA(sb)   3.38 5.49 61
HB   10.00
DSB(HB)   12.37 19.61 63
DL/VA   3.66 3.57 103

[**2108-7-12**] CXR
Small left pleural effusion is comparable in volume to [**7-3**].
Opacification of the base of the left lung could represent
either pneumonia or residual atelectasis. An intervening chest
CT, on [**7-5**], when there was more left lower lobe
consolidation was equivocal in this regard. Peribronchial
opacification in the right mid lung is another candidate for
pneumonia, unchanged since [**7-3**], and alternatively could be
residual edema improved since [**7-1**]. Upper lungs are clear.
There is no right pleural effusion. Heart size is normal. No
pneumothorax. Right PICC line ends in the lower SVC.
Mirco reports
[**2108-7-12**] 9:40 pm STOOL     CONSISTENCY: FORMED      Source:
Stool.

                            **FINAL REPORT [**2108-7-13**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2108-7-13**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

[**2108-7-8**] 5:17 pm SPUTUM      Source: Induced.

                            **FINAL REPORT [**2108-7-9**]**

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2108-7-9**]):    NEGATIVE for Pneumocystis jirvovecii
(carinii).

[**2108-7-5**] 4:45 pm BLOOD CULTURE      Source: Line-picc #2.

                            **FINAL REPORT [**2108-7-11**]**

   Blood Culture, Routine (Final [**2108-7-11**]):    NO GROWTH.

[**2108-7-5**] 4:45 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2108-7-6**]**

   URINE CULTURE (Final [**2108-7-6**]):    NO GROWTH.

[**2108-6-27**] 8:06 am URINE      Source: Catheter.

                            **FINAL REPORT [**2108-6-29**]**

   URINE CULTURE (Final [**2108-6-28**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    >100,000
ORGANISMS/ML..
[**2108-6-16**] 9:00 pm TISSUE      DURA  ALSO R/O CMV AND HSV.

   VIRAL CULTURE (Preliminary):    No Virus isolated so far.

   CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2108-6-20**]):
      NEGATIVE FOR CYTOMEGALOVIRUS EARLY ANTIGEN.
      REFER TO CULTURE RESULTS.

[**2108-6-16**] 9:00 pm TISSUE     Site: BRAIN      DURA MIDDLE LOBE.
      FUNGAL, TISSUE, [**Doctor First Name **] AND GRAM STAIN REQUESTED BY
DR.[**First Name (STitle) **],[**First Name3 (LF) **]
      ([**Numeric Identifier 78639**]), [**2108-6-18**].

   GRAM STAIN (Final [**2108-6-18**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2108-6-18**]):
      NO FUNGAL ELEMENTS SEEN.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   TISSUE (Final [**2108-6-21**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2108-6-24**]):    NO GROWTH.

[**2108-6-6**] 2:00 pm CSF;SPINAL FLUID      TUBE 3.

                            **FINAL REPORT [**2108-6-9**]**

   GRAM STAIN (Final [**2108-6-6**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2108-6-9**]):    NO GROWTH.

Time Taken Not Noted     Log-In Date/Time: [**2108-6-4**] 5:14 am
      Blood (EBV)

                            **FINAL REPORT [**2108-6-4**]**

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2108-6-4**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2108-6-4**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2108-6-4**]):
      NEGATIVE <1:10 BY IFA.
      INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
      In most populations, 90% of adults have been infected at
sometime
      with EBV and will have measurable VCA IgG and EBNA
antibodies.
      Antibodies to EBNA develop 6-8 weeks after primary
infection and
      remain present for life. Presence of VCA IgM antibodies
indicates
      recent primary infection.

Time Taken Not Noted     Log-In Date/Time: [**2108-6-4**] 5:14 am
      Blood (CMV AB)

                            **FINAL REPORT [**2108-6-5**]**

   CMV IgG ANTIBODY (Final [**2108-6-5**]):
      NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
      < 4 AU/ML.
      Reference Range:  Negative < 4 AU/ml, Positive >= 6 AU/ml.


   CMV IgM ANTIBODY (Final [**2108-6-5**]):
      NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
      INTERPRETATION:  NO ANTIBODY DETECTED.
      Greatly elevated serum protein with IgG levels >[**2099**] mg/dl
may cause
      interference with CMV IgM results.










Brief Hospital Course:
60yo female with a very prolonged and complicated hospital
course. She has a past history of Hodgkin's' lymphoma in [**2092**]
now with recurrence and was admitted for diagnostic work-up of
cognitive decline.  She initially has seen by the neurology
service and there was concern for PML or other brain pathology.
She had a liver bx that diagnosed Hodgkin's disease. She then
had a brain bx which did not show any pathology. During her
admission she developed dysphagia and problems speaking. She has
a swallow study with a seizure. And then was treated for
aspiration pneumonia. She then began treatment for her cancer.
She developed orthostatic hypotension with syncope. She had ICU
stays on [**8-7**] for hypoxia and syncope and [**Date range (1) 5489**] for
aspiration PNA. Her mental status improved and she was able to
receive additional chemotherapy before discharge.

# Hodgkin's lymphoma - on [**6-2**] she had a abdominal CT that
showed innumerable liver nodules. She has a ultra sound guided
liver biopsy on [**6-5**], and the patient was found to have a
recurrence of HD.  She was then transferred to the BMT service.
Her LP on [**6-6**] and brain bx on [**6-16**] was negative for CNS
involvement. It was thought her mental decline was due to a
paraneoplastic syndrome, since other causes were ruled out. Her
dysphagia was also likely to neuropathy secondary to her
disease. After she was stable, she received a PICC line and had
treatment on [**6-21**] with gemcitabine 1400mg, vinorelbine 26mg, and
Decadron 20mg. Then on [**6-17**] she received the same tx plus
liposomal doxorubicin 20mg. Her WBC nadir was on [**7-1**] at 1.1 and
her ANC nadir was on [**7-5**] at 1312. She had G-CSF treatment on
[**8-1**] and [**Date range (1) 20550**]. She had a follow up torso CT with
contrast on [**2108-7-5**] that did not show significant change in her
disease, however, her mental status had improved. Therefore, she
was restarted on chemotherapy with Doxil 17mg, Vinorelbine 26mg,
and Gemcitabine 1400mg, Decadron 20mg on [**2108-7-13**], and will need
her next treatment in [**5-15**] days after discharge depending on her
nadir. She will also likely need treatment with G-CSF as her ANC
falls on [**7-16**] and [**7-17**]. Her out patient Oncologist Dr. [**Last Name (STitle) 78640**]
at [**Hospital3 15054**] will be contact[**Name (NI) **] and informed about her
hospitalization and will likely administer her next dose of
chemotherapy. If her oncologist is unable to be contact[**Name (NI) **] she
will need her next treatment as an outpatient at the [**Hospital3 **]
clinic.

# Seizure - Just prior to a video swallowing exam on [**2108-6-11**], the
patient was observed to have a tonic clonic seizure lasting
approximately 30 seconds to 1 minute.  She had post-ictal
confusion, no fecal or urinary incontinence, and her vital signs
were stable during and after her seizure. She was evaluated by
neurology and she was started on levetiracetam 1500 mg daily,
this was later changed on 500mg TID. She had an EEG on [**7-5**] that
only showed diffuse slowing consistent with encephalopathy
consistent with her paraneoplastic syndrome.
.
# Aspiration pneumonia - The [**Hospital 228**] hospital course was
complicated transient hypoxemia that was believed to be
aspiration PNA she was treated with levofloxacin and Flagyl
initially. She went to the ICU in setting of hypoxia from
714/-[**6-20**] after her brain bx.  Aspiration PNA and pulmonary
edema were the leading diagnoses.  She was diuresed with Lasix
20 IV with brisk response.  She was net neg 3.7 L during ICU
stay.  Her resp status improved and she was on 2L. She was
transferred back to the oncology floor for chemo if indicated
per heme/onc. Then again after chemo on [**6-30**] that pt had
orthostatic hypotension with syncope and temporary hypoxia
believed to be a mucus plug. Her resp status improved with
nebulizers and she was treated with levofloxacin. Then after her
last CT scan on [**7-5**] showed bilateral increased pleural
effusions (worse on left) and bilaterally lower lobe
consolidations she was switched to vancomycin and aztreonam. She
is on day 9 of both, she will need treatment for 6 more days, or
until her cell counts recover. She has had no resp sx since her
last ICU stay.

# Cognitive decline: After full neurology work up including
brain bx, her mental decline was likely secondary to
paraneoplastic syndrome from her Hodgkin's causing
encephalopathy. Pt has had evidence of memory difficulties and
hallucinations on multiple exams here at [**Hospital1 **]. Her decline has
been rapid. She has had gait changes, but otherwise minimal
disordered movement before admission. She had a seizure on
[**2108-6-11**], however, her EEG later during admission did not show
continued seizure activity. The brain biopsy was on [**6-16**] and was
inconsistent with lymphoma or PML. While in the ICU, head
imaging showed edema around her biopsy site that was concerning
for infection, but MRI was not consistent with this. Neuro felt
that the amount of edema was consistent with post-biopsy.
Cultures, EBV PCR, and [**Male First Name (un) 2326**] Virus PCR from CSF were all negative.
HSV PCR was negative. Her mental status slowly improved after
her chemotherapy which reenforced the diagnosis of a
paraneoplastic syndrome.

# Dysphagia: Daughter gives history of difficulty swallowing
liquids and solids.  Had a during this hospitalization of
aspiration pneumonia. She was evaluated multiple times by speech
and swallow, and was determined to be at serious aspiration
risk. On [**2108-6-13**] she was refluxing tube feeds through her
nasogastric tube, and thus had a gastric-jejunostomy tube placed
and tube feeds were initiated. Then after improvement in her
mental status, she had another video swallow test on [**2108-7-13**],
which did not show aspiration. Therefore she was restarted on
pureeded solids and thickened liquids, she will need follow up
swallow study with video in [**12-7**] weeks. She should slowly
increase her PO intake and decrease her tube feeds.

# Hypotension: patient was transiently hypotensive to the 80's
on [**2108-6-30**] when she stood up and had brief syncope, she had not
been taking good PO's in prior 24 hours, secondary to nausea.
She has since had multiple episodes of orthostatic hypotension,
always responsive to fluids. These episodes have decreased since
starting on fludrocortisone.

# Tachycardia: History of SVT, baseline HR appears to be 90-110
for last several days. Sinus tachy on EKG. Tachycardia may also
be worsening her diastolic dysfunction leading to increased
pulmonary congestion. Her home Lopressor was held due to
orthostatic hypotension. Once her BP has improved would benefit
from restarting anti nodal [**Doctor Last Name 360**].

# Anemia: Low MCV anemia, suggesting either chronic blood loss
or iron deficiency. Of note, patient must get irradiated blood
due to previous stem cell transplant. Goal HCT is >25, now 30.7.


# h/o ITP: Has been on a long taper of home prednisone. Steroid
therapy was discontinued per oncology recommendations at the
beginning of her hospital stay and her platelets progressively
fell to below 100,000. Platelets are now 417.

# hypothyroidism: Was continued on home dose of Synthroid.

Patient will have follow up with Dr. [**Last Name (STitle) 78640**] at [**Hospital3 15054**], if she
can not follow the patient she will be seen at [**Hospital1 18**]. She will
need more chemotherapy in [**5-15**] days. She will be transferred to
rehab for more physical therapy and treatment. Her CBC, ANC,
electrolytes, coags, and LFT's should be followed. She will need
a follow up video swallow test in [**12-7**] weeks.


Medications on Admission:
MEDS:
tylenol 325-650 PO Q6 prn
FeSO4 325mg PO BID
levothyroxine 88mcg PO QD
metoprolol XL 25mg PO QD
pantoprazole 40mg PO QD
prednisone 5mg PO QD
sertraline 50mg PO QD
vitamin D 400u PO QD
colace 100mg PO BID
ciprofloxacin 250mg PO Q12 - started on [**5-29**], for total 7 days

Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Year (2) **]: 3-5 MLs
Intravenous PRN (as needed) as needed for line flush: Flush with
10mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
.
2. Aztreonam 1 gram Recon Soln [**Month/Year (2) **]: 500mg Recon Solns Injection
Q8H (every 8 hours) for 6 days: started on [**2108-7-6**]. Recon Soln(s)

3. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Date Range **]: One (1)
Intravenous Q 12H (Every 12 Hours) for 6 days: Started on
[**2108-7-6**].
4. Levothyroxine 88 mcg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
5. Thiamine HCl 100 mg/mL Solution [**Date Range **]: One (1)  Injection DAILY
(Daily).
6. Levetiracetam 100 mg/mL Solution [**Date Range **]: Five (5)  PO Q 8H
(Every 8 Hours).
7. Ipratropium Bromide 0.02 % Solution [**Date Range **]: One (1)  Inhalation
Q6H (every 6 hours) as needed.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Date Range **]: One (1)  Inhalation Q6H (every 6 hours) as
needed.
9. Fluconazole 200 mg Tablet [**Date Range **]: One (1) Tablet PO Q24H (every
24 hours) as needed for yeast on culture.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] every twelve (12) hours: give in G
TUBE .
11. Fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
12. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea for 7 days.
13. Filgrastim 300 mcg/0.5 mL Syringe [**Last Name (STitle) **]: One (1)  Injection
once a day for 2 days: Please give on [**7-16**] and [**7-17**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]

Discharge Diagnosis:
-recurrent hodgkin's disease
-orthostatic hypotension
-paraneoplastic syndrome causing neuropathy and encephalopathy
-bilateral pleural effusions
-bilateral pneumonia
-tonic clonic seizure
-dysphagia secondary to neuropathy


Discharge Condition:
Hemodynamically stable, can ambulate a few steps with
assistance, afebrile.


Discharge Instructions:
You were admitted to [**Hospital1 69**] due to
mental decline and peumonia. You were found to have recurrent
Hodgkin's Disease, this was found on a liver biopsy. You were
treated with chemotherapy, you will need more chemotherapy after
discharge in [**5-15**] days since you still have significant disease.
You also had a brain biopsy which did not show cancer in your
brain. You have complications that required going to the ICU for
pneumonia and having a feeding tube since for a time you could
not swallow properly. Before discharge your swallowing improved
and you were restarted on foods. You are still being treated for
a pneumonia with antibiotics. You also had problems with your
blood pressure dropping when you stood up, this has been
improved with medication. You will require more physical therapy
after your discharge. Your swallowing will also be retested in
[**12-7**] weeks. You will be going to a rehab center for more
treatment.

Please keep your follow up appointments.

Please take your medications as perscribed.

If you have shortness of breath, chest pain, increased
confusion, rash, fever, chills, diarrhea or any other concerning
symptom please seek medical attention or go to the ER.

Followup Instructions:
You will need to call your hemetologist/oncologist Dr. [**Last Name (STitle) 78640**]
on Monday to set up an appointment in the next week. She will
determine your next chemotherapy cycle. You will also need
treatment with GCSF as your white blood drops.

Video Swallow study in [**12-7**] weeks, should be arranged by rehab
facility.



Completed by:[**2108-7-14**]
{"Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Hematoma complicating a procedure,Pneumonitis due to inhalation of food or vomitus,Unspecified pleural effusion,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other specified aplastic anemias,Other convulsions,Encephalopathy, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Orthostatic hypotension,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Mononeuritis of unspecified site"}


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: Cognitive decline

PRESENT ILLNESS: 60 yo F h/o Hodgkin's disease, ITP, hypothyrodisim p/w cognitive
decline. The patient's care has been at outside institutions
prior to this month. She has had a progressive decline in
cognition and general health beginning in [**7-12**], at which point
she had recurrent ITP. In [**9-11**] she was treated with rituximab
and her ITP seemed to respond. However, she felt fatigued, had
night sweats, and experienced weight loss, all of an unclear
etiology. She was thought to perhaps have URIs but eventually
went to her PCP who found that her LFTs were elevated. Imaging
revealed multiple small nodules in her liver worrisome for
metastatic malignancy. However, CT guided biopsy in [**2-11**] was w/o
evidence of malignancy.
.
At this point, she was transfused due to worsening anemia. This
temporarily improved her symptoms. Then in [**3-13**], she began to
notice a decline in her cognitive function. This was marked to
the patient at her work in human resources. She found that she
was having difficulty "connecting" with people and completeing
tasks.
.
She was admitted to [**Hospital1 498**] for an extensive workup. Initial
thought was that she had MS, given white matter changes on an
MRI in [**Month (only) 116**], but the diagnosis was not definite. She continued to
decline and presented to [**Hospital1 **] in early [**5-13**] for a second opinion
by Dr. [**Last Name (STitle) 8760**].
.
Dr. [**Last Name (STitle) 8760**] felt at that time that her exam and history were most
consistent with PML. Also on the differential were tertiary
syphilis, B12 deficiency, and Hashimoto encephalopathy.
Evaluation at that time was notable for: WBC of 15.5, 93%
neutrophils, Hct 28.7, MCV 91, plts of 448, Cr of 0.7, TSH of
0.50, neg HIV, neg EBV and [**Male First Name (un) 2326**] virus PCR in CSF, negative
viral/fungal/cryptococcal Ag in CSF. LP: cell count 1 WBC, 4
RBC, 3% polys, 70% lymphs, 27% monos, TP 28, glu 68. [**Male First Name (un) 2326**] virus
was re-checked by Dr. [**Last Name (STitle) 2340**] in neurology and found her test
to again be negative.
.
Over the past 2 days the patient has become more confused at
home. She has also had difficulty coordinating her swallow with
new-onset hiccups. The patient's neurologists were contact[**Name (NI) **] and
it was decided to admit the patient electively to the neuro
service for brain biopsy. The patient was seen in the ED and
admitted to neurology. The patient had a number of abnormalities
on her ED labwork further complicating her presentation. She was
transferred to medicine for further management.

MEDICAL HISTORY: # h/o recurrent Hodgkin's disease
- initially presented as stage II
- tx w/ XRT in [**2083**]
- recurred then treated w/ ABVD
- followed by splenectomy and autoBMT in [**2092**]
- disease free since
# recurrent ITP
- first dx in [**2105**]
- recurred in [**9-11**]
- tx w/ IVIG, prednisone, rituximab (last given [**10-12**])
# h/o hypothyroidism since XRT
# h/o SVT in [**2105**] - now on beta-blocker
# asymptomatic carotid bruit
# chronic anemia since [**7-/2107**]
- required transfusion on at least 1 occassion

MEDICATION ON ADMISSION: MEDS:
tylenol 325-650 PO Q6 prn
FeSO4 325mg PO BID
levothyroxine 88mcg PO QD
metoprolol XL 25mg PO QD
pantoprazole 40mg PO QD
prednisone 5mg PO QD
sertraline 50mg PO QD
vitamin D 400u PO QD
colace 100mg PO BID
ciprofloxacin 250mg PO Q12 - started on [**5-29**], for total 7 days

ALLERGIES: Penicillins

PHYSICAL EXAM: Temp 99
BP 104/62
Pulse 103
Resp 18
O2 sat 99% ra
Gen - Alert, oriented x3, no acute distress
HEENT - anicteric, mucous membranes slightly dry
Neck - no JVD, no cervical lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, systolic murmur heard best at the LLSB
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No edema. 2+ DP pulses bilaterally
Neuro -
[**12-8**] words at 5 minutes, unable to spell world backwards
cranial nerves [**1-17**] intact
4+/5 in [**Hospital1 **]/triceps b/l, o/w full strength throughout
reflexes intact and symmetric
sensation grossly intact
Skin - No rash

FAMILY HISTORY: Father with parkinson's otherwise no neuro history.

SOCIAL HISTORY: Former HR manager, had to leave due to her present illness.
Denies etoh/tob/illicits. 

### Response:
{"Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Hematoma complicating a procedure,Pneumonitis due to inhalation of food or vomitus,Unspecified pleural effusion,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Other specified aplastic anemias,Other convulsions,Encephalopathy, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Orthostatic hypotension,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Mononeuritis of unspecified site"}
