CHIEF COMPLAINT: Seizures and altered mental status.

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with history of
glioblastoma, staus post resection and VP shunt, who presented
on [**2103-2-6**] with seizures.  He has a history of a prolonged
hospitalization from [**2102-11-14**] to [**2102-12-7**], during which time he
was treated for Pnuemocystis pneumonia.  He also had pulmonary
embolism initially treated with LMWH and then with an IVC filter
following bleeding in his tumor bed, and suffered a PEA arrest
complicated by flail chest and prolonged intubation.  He also
developed C. difficile at [**Hospital1 **] [**Hospital1 **] and
continues on IV metronidazole and PO vancomycin in addition to
an ESBL pneumonia for which he was treated with IV vancomycin
and IV ertapenem (now on meropenem).

MEDICAL HISTORY: Past Oncologic History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital3 9683**] showed right temporal lobe mass.  Started on
dexamethasone. Underwent subtotal resection of the R temporal
lobe mass by Papavassilious on [**2101-12-30**], path positive for GBM
- received temozolamide chemo-radiation, followed by adjuvant
temozolomide (4 cycles)
- ventriculoperitoneal shunt placed [**2102-8-1**]
- started Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
- cycle 2 of PCV on [**2102-10-10**]
- prolonged hospitalization from [**2102-11-14**] to [**2102-12-7**], during
which time he had:
--Pneumoncystis pneumonia
--s/p PEA arrest and flail chest from compression
-- PE s/p IVC filter, was previously on lovenox
- he was discharged to NE [**Hospital1 **], and while there was diagnosed
with C. difficile, ESBL PNA
- plan was to treated with Avastin but this was delayed due to
ICH
Per wife has had 3 IC bleeds post craniectomy and as such has
meant that anticoagulation was contraindicated.
Per C. difficile, had been treated with a prolonged course of
oral antibiotics and had relapsed a few days post
discontinuation of treatment whereupon this was restarted.

MEDICATION ON ADMISSION: Acetaminophen 1000mg PO daily PRN headache
Thiamine 100mg PO daily
Dexamethasone 4mg PO BID
Comapazine 10mg PO daily
Ambien 5mg PO qHS PRN
Oxycodone 5-10mg PO q6PRN pain
Carbidopa-Levodopa 25-100mg PO BID
Miconazole 2% cream, apply to buttock q8 hours
Gabapentin 300mg qAM, 900mg qPM
Valproic Acid 500mg [**Hospital1 **] and 250mg at noon
Mepron oral solution, 1500mg PO daily
Ritalin 5mg PO BID
Zofran 8mg PO q8H PRN nausea
Lidocream 4% 1TP daily
Levofloxacin 500mg PO daily
KCl 20meq PO daily
Esomeprazole 20mg PO daily
Vancomycin 500mg PO TID
Fentanyl Patch 50mcg/hr q72 hours
Ertapenem 1 gram IV daily
Flagyl 500mg PO TID
Vancomycin 1000mg IV BID
Oxymetazoline 0.05% spray nasal [**Hospital1 **]

ALLERGIES: hydromorphone

PHYSICAL EXAM: Admission exam:
VITAL SIGNS:  Temperature 97.4 F, blood pressure 120/77, pulse
87, respiration 20, and oxygen saturation 96% with 4L via nasal
cannula.
GENERAL:  Somulent but arousable, responds to name, NAD
SKIN:  No rashes. did not brusing likely from IV placement;
Portacath intact without signs of infection
HEENT:  PERRLA. MMM. no JVD but exam limited by pt habitus. neck
supple.
CARDIOVASCULAR:  RR S1/S2 normal. no murmurs/gallops/rubs
appreciated.
PULMONARY:  Examination limited by pt ability to comply. No
accessory muscle use. Anteriorly expiratory wheezes but
otherwise CTAB
ABDOMEN:  BS+, soft, NT, rotund abdomen, no rebound/guarding
apparent at this time
EXTREMITIES:  Extremities felt cool to touch, no edema. DPs, PTs
2+.

FAMILY HISTORY: His father had CABG x 3 age 40 and first MI age 42 and died at
age 85 from CAD.
His mother is alive with hypertension.  He has 4 siblings and
one has had recent stent placement for CAD.  His 3 children are
healthy.

SOCIAL HISTORY: He is a semi-retired accountant.  He was transferred from [**Hospital1 15454**] [**Hospital1 **] since [**2102-11-13**] but previously
at home with wife and children
His mobility at rehab was with walker.  There is no history of
tobacco use.  He previously drank socially and with no illicit
drug use.
Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Chronic pulmonary embolism,Other convulsions,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Candidiasis of mouth,Pulmonary collapse,Presence of cerebrospinal fluid drainage device,Hypoxemia,Pain in joint, pelvic region and thigh
Mal neo temporal lobe,Pneumonia, organism NOS,Int inf clstrdium dfcile,Chr pulmonary embolism,Convulsions NEC,Ch DVT/embl prox low ext,Thrush,Pulmonary collapse,Ventricular shunt status,Hypoxemia,Joint pain-pelvis
Admission Date:  [**2103-2-5**]              Discharge Date:   [**2103-2-14**]

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

Service: NEUROLOGY

Allergies:
hydromorphone

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Seizures and altered mental status.

Major Surgical or Invasive Procedure:
Bronchoscopy.

History of Present Illness:
[**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with history of
glioblastoma, staus post resection and VP shunt, who presented
on [**2103-2-6**] with seizures.  He has a history of a prolonged
hospitalization from [**2102-11-14**] to [**2102-12-7**], during which time he
was treated for Pnuemocystis pneumonia.  He also had pulmonary
embolism initially treated with LMWH and then with an IVC filter
following bleeding in his tumor bed, and suffered a PEA arrest
complicated by flail chest and prolonged intubation.  He also
developed C. difficile at [**Hospital1 **] [**Hospital1 **] and
continues on IV metronidazole and PO vancomycin in addition to
an ESBL pneumonia for which he was treated with IV vancomycin
and IV ertapenem (now on meropenem).

Of note, he had no previous generalized tonic-clonic seizures
prior to this admission (although seems he had a temporal lobe
seizure with secondary generalization at the time of his PEA
arrest back in [**Month (only) **]) but did suffer what sounds like
temporal lobe seizures before glioblastoma diagnosis, which
presented as recurrent uinidentifiable but horrible smells.  On
this admission, he suffered a 2.5 min tonic-clonic seizure at
his [**Hospital1 **] [**Hospital1 **] on [**2103-2-5**] and after
transfer to [**Hospital3 417**] Hospital ED on [**2103-2-6**] had a further
2-minute seizure.  At this point he was loaded with 1000 mg IV
phenytoin and 2 mg IV lorazepam and was post-ictal after this.
Head CT showed 4 mm leftward midline shift and a right insular
intraparenchymal hemorrhage (later found to be old) and due to
concern for these CT findings he was transferred to the [**Hospital1 18**].

In the [**Hospital1 18**] ED, he underwent repeat head CT which was unchanged
and chest X-ray showed atelectasis but could not rule out
pneyumonia.  His mental status improved over his ED course.
Neurolgoy was consulted and recommended pursuing an infectious
workup with urinalysis and his valproic acid dose was unchanged
in dose but given via the IV route due to concern for aspiartion
and was admitted to neuro-oncology for further care.  He had no
further seizures and has passed [**Last Name (un) 8692**] Speech and Swallow
evaluation on [**2103-2-6**] a.m.  Per Neurology notes, his valproic
acid dose was seemingly increased but I see no record of this,
an EEG had also been recommended by his neuro-oncologist Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**].
His mental status improved and per oncology has been oriented to
person and place with intermittent communication but now seems
much better and at baseline per his relatives.  [**Name (NI) **] triggered on
[**2103-2-6**] when he desaturated to 80% on 4L and had worsening
problems regarding [**Name2 (NI) 84003**] thick secretions improving with
vigorous suctioning and chest PT and regular nebulizers.  Chest
X-ray was relatively unchanged and indeed has been pretty
unimpressive sice admission with certainly no florid
consolidation to be seen.  He had no WCC response but is
immunosuppressed by long term steroids.  He was transferred to
the [**Hospital Unit Name 153**] for bronchoscopy wich required pre-procedure intubation
and IP noted copious ++ thick secretions on BAL which were sent
for atypical and atypical pathogens.  He was given propofol and
suxamethonium and plan is for transfer back to OMED once
stabilised and if his respiratory status is stable.  On review
post-extubation on the [**Hospital Unit Name 153**], his [**Hospital Unit Name 153**] admission vitals were
temperature 98.2 F, pulse 89, blood pressure 117/90, respiration
24, and O2 saturation at 96% on 6L O2. On review he was on 4L O2
via NC and a shovel mask at 40% maintaining sats at 93%.  He
noted still very troublesome cough with copious secretions
although felt a bit better post bronchoscopy.  He was alert,
oriented and mentating well, wife felt he was at his baseline.
Otherwise patient noted lower sharp abdominal pain since
admission to [**Hospital1 **] (of not previosuly had pain due to his VP shunt)
and a 10-day history of severe right knee pain, neck pain since
admission and 2 weeks of lower back pain.  Of note, he had
limited mobility at rehabiltiation but had managed to use a
walker.

Review of Systems:
CVS - NO CP/SOB
RS - Cough ++ with sputum + no hemoptysis or wheeze
GIS - Nausea no vomiting, diarrhea 3x/day and some lower [**Last Name (un) 103**]
pain as above
[**Male First Name (un) **] - catheterised
CNS - no further fits, no numbness, weakness and reduced
mobility at baseline but not worse
ES - No fevers but does feel cold and no rigors
HS - No bleeding but bruises notable on abdomen but not new

Past Medical History:
Past Oncologic History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital3 9683**] showed right temporal lobe mass.  Started on
dexamethasone. Underwent subtotal resection of the R temporal
lobe mass by Papavassilious on [**2101-12-30**], path positive for GBM
- received temozolamide chemo-radiation, followed by adjuvant
temozolomide (4 cycles)
- ventriculoperitoneal shunt placed [**2102-8-1**]
- started Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
- cycle 2 of PCV on [**2102-10-10**]
- prolonged hospitalization from [**2102-11-14**] to [**2102-12-7**], during
which time he had:
--Pneumoncystis pneumonia
--s/p PEA arrest and flail chest from compression
-- PE s/p IVC filter, was previously on lovenox
- he was discharged to NE [**Hospital1 **], and while there was diagnosed
with C. difficile, ESBL PNA
- plan was to treated with Avastin but this was delayed due to
ICH
Per wife has had 3 IC bleeds post craniectomy and as such has
meant that anticoagulation was contraindicated.
Per C. difficile, had been treated with a prolonged course of
oral antibiotics and had relapsed a few days post
discontinuation of treatment whereupon this was restarted.

Other Past Medical History:
Previous left knee cartilage operation

Social History:
He is a semi-retired accountant.  He was transferred from [**Hospital1 15454**] [**Hospital1 **] since [**2102-11-13**] but previously
at home with wife and children
His mobility at rehab was with walker.  There is no history of
tobacco use.  He previously drank socially and with no illicit
drug use.

Family History:
His father had CABG x 3 age 40 and first MI age 42 and died at
age 85 from CAD.
His mother is alive with hypertension.  He has 4 siblings and
one has had recent stent placement for CAD.  His 3 children are
healthy.

Physical Exam:
Admission exam:
VITAL SIGNS:  Temperature 97.4 F, blood pressure 120/77, pulse
87, respiration 20, and oxygen saturation 96% with 4L via nasal
cannula.
GENERAL:  Somulent but arousable, responds to name, NAD
SKIN:  No rashes. did not brusing likely from IV placement;
Portacath intact without signs of infection
HEENT:  PERRLA. MMM. no JVD but exam limited by pt habitus. neck
supple.
CARDIOVASCULAR:  RR S1/S2 normal. no murmurs/gallops/rubs
appreciated.
PULMONARY:  Examination limited by pt ability to comply. No
accessory muscle use. Anteriorly expiratory wheezes but
otherwise CTAB
ABDOMEN:  BS+, soft, NT, rotund abdomen, no rebound/guarding
apparent at this time
EXTREMITIES:  Extremities felt cool to touch, no edema. DPs, PTs
2+.

NEUROLOGICAL EXAMINATION:  Patient somnolent, responds to name
opens eyes, grunts.  He does not follow commands at this time;
per report this is improvement from when arrived and was
completely non-responsive.

[**Hospital Unit Name 153**] Examination:
VITAL SIGNS:  Temperature 98.2 F, pulse 89, blood pressure
117/90, respiration 24, and oxygen saturation 96% on 6L of O2.
GENERAL:  Alert, oriented and coughing ++ white secretons
requiring suction tube to clear. Appears Cushingoid.
SKIN:  Right Portacath intact without signs of infection.  He
has brusing on abdomen and on feet
HEENT:  PERRL 3.5+/3.5+. MMM. no JVD. Some patchy white exudate
on tongue
CARDIOVASCULAR:  RRR S1/S2 normal. no murmurs/gallops/rubs
appreciated.
PULMONARY:  No accessory muscle use. Rare scattered wheezes abd
decreased breath sounds at bases but no crackles - anterior
exam.
ABDOMEN:  BS+, soft, NT, obese, no rebound/guarding
EXTREMITIES:  Cool extremities with good cap refill, minimal
edema R>L 1+ to mid shin.  Tender posterior right thigh and
anterior right knee withminimal swelling right knee.  Some
tenderness in C5-C& but diffuse and no bony pain.
DPs, PTs 2+.

NEUROLOGICAL EXAMINATION:  His Karnofsky Performance Score is
60.  He is awake, alert, and oriented times 3.  His language is
fluent with good comprehension.  Short-term recall is intact.
He has moderate psychomotor slowing.  Cranial Nerve Examination:
 His pupils are equal and reactive to light, 4 mm to 2 mm
bilaterally.  Extraocular movements are full without nystagmus.
Visual fields
are full to confrontation.  His face is symmetric.  Facial
sensation is intact bilaterally.  His hearing is intact
bilaterally.  His tongue is midline.  Palate goes up in the
midline.  Sternocleidomastoids and upper trapezius are strong.
Motor Examination:  He does not have tremor, pronation, or
drift.
His muscle strengths are [**5-17**] at all muscle groups, except for
proximal lower extremity weakness at 4+/5 strength on both side.
 His muscle tone is normal.  His reflexes are 2- bilaterally.
His ankle jerks are absent.  His toes are
down.  Sensory examination is intact to touch and
proprioception.  He cannot do tandem.  Coordination examination
does not reveal dysmetria.  Gait and stance are deferred.

DISCHARGE EXAM
VITAL SIGNS:  Tm/Tc 97.5 F/97.5 F, blood pressure 122/90
(115-128)/(80-95), pulse 75 (20-88), repsiration 18-22, and
oxygen saturation 93% 2L NC
GENERAL:  Sleeping but easily arousable, NAD, breathing appears
more comfortably
SKIN:  Portacath intact without signs of infection; some
bruising, skin irriation on legs from pneumoboots
HEENT:  PERRLA. MMM. no JVD but exam limited by pt habitus. neck
supple.
CARDIOVASCULAR:  RR S1/S2 normal. no murmurs/gallops/rubs
appreciated.
PULMONARY:  Examination limited by pt ability to comply. No
accessory muscle use.  Still has coarse lung sounds but much
improved from prior exam. diminished expiratory wheezes.
ABDOMEN:  BS+, soft, NT, rotund abdomen, no rebound/guarding
apparent at this time
EXTREMITIES:  +2 LE edema, feet cool

NEUROLOGICAL EXAMINATION:  His Karnofsky Performance Score is
50.  He is awake, alert, and able to follow some commands.  His
language is fluent with fair comprehension.  Short-term recall
is poor.  He has mild psychomotor slowing.  Cranial Nerve
Examination:  His pupils are equal and reactive to light, 4 mm
to
2 mm bilaterally.  Extraocular movements are full without
nystagmus.  Visual fields are full to confrontation.  His face
is symmetric.  Facial sensation is intact bilaterally.  His
hearing is intact bilaterally.  His tongue is midline.  Palate
goes up in the midline.  Sternocleidomastoids and upper
trapezius are strong.  Motor Examination:  He has proximal
weakness at his
upper and lower extremities, at 4/5.  The other muscle groups
have weakness at 4/5.  His muscle tone is normal.  His reflexes
are absent, including the ankle jerks.  His toes are down.
Sensory examination is intact to touch and proprioception.
Coordination examination does not reveal gross dysmetria.  Gait
and stance are deferred.

Pertinent Results:
Admission labs:
[**2103-2-5**] 01:04AM BLOOD WBC-8.1 RBC-4.08* Hgb-13.8* Hct-41.2
MCV-101* MCH-33.9* MCHC-33.5 RDW-16.3* Plt Ct-85*
[**2103-2-5**] 01:04AM BLOOD PT-12.1 PTT-23.1 INR(PT)-1.0
[**2103-2-5**] 01:04AM BLOOD Glucose-231* UreaN-20 Creat-0.3* Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2103-2-5**] 01:04AM BLOOD CK(CPK)-31*
[**2103-2-6**] 05:36AM BLOOD ALT-29 AST-19 LD(LDH)-341* AlkPhos-60
TotBili-0.3
[**2103-2-6**] 05:36AM BLOOD Albumin-2.8* Calcium-8.0* Phos-3.3 Mg-1.9

Other labs:
[**2103-2-5**] 01:04AM BLOOD Phenyto-13.2 Valproa-10*
[**2103-2-5**] 01:04AM BLOOD Vanco-9.0*

Microbiology:
[**2103-2-7**] C. difficile -ve

Radiology:
CT HEAD W/O CONTRAST	Study Date of [**2103-2-5**] 1:06 AM
Overall, this examination is unchanged. Hyperdensity in the
right
insular region compatible with intraparenchymal hematoma is
similar to the
prior examination and demonstrates interval evolution of blood
products from the examination of [**2103-1-25**]. Foci of evolving
blood products are also noted more inferiorly in the right
temporal lobe. No new hyperdense foci to suggest acute
hemorrhage are seen. Extensive edema throughout the right
cerebral hemisphere appears unchanged causing sulcal effacement
and compression of the right lateral ventricle, with enlargement
of the left lateral ventricle. Overall, the degree of midline
shift, 5 mm to the left, is unchanged. The patient is status
post right frontotemporal craniotomy. A ventriculostomy catheter
via a left frontal approach is in unchanged position with tip in
the frontal [**Doctor Last Name 534**] of the right lateral ventricle. Aerosolized
secretions within the bilateral maxillary sinuses appear
similar. Additionally, there is an air-fluid level in the right
sphenoid sinus. The left frontal sinus is underpneumatized.
Opacification of mastoid air cells on the right appears similar.

IMPRESSION:
1. Overall stable examination with interval evolution of blood
products in
the right insula and temporal lobe. No new hemorrhage.
2. Persistent right cerebral hemisphere edema with stable 5-mm
leftward
midline shift.
3. Stable position of ventriculostomy catheter.

XR CHEST (PORTABLE AP)	Study Date of [**2103-2-5**] 3:24 AM
INDINGS/IMPRESSION: Lung volumes are low. There is a vague
opacity
extending from the right hilum, which may be accentuated by
technique and
motion. No pleural effusion or pneumothorax is seen. The heart,
mediastinal
and pleural surface contours appear normal. Prominence of the
azygous region may be accentuated by supine positioning. A
right-sided port is in place with tip obscured on this
radiograph. There is a left-sided VP shunt.
IMPRESSION: Suggest conventional chest radiographs, when
feasible, to
investigate possible right juxtahilar pneumonia and azygos
distension
exaggerated by supine positions or lower paratracheal
adenopathy.

XR CHEST (PORTABLE AP)	Study Date of [**2103-2-6**] 10:10 AM
FINDINGS: In comparison with the study of [**2-5**], there are lower
lung
volumes. Basilar atelectatic changes are seen, especially on the
right. The
possibility of supervening pneumonia cannot be definitely
excluded. Some
prominence of the region of the azygos vein and note is again
seen. This area should be closely checked when the degree of
inspiration improves.

XR HIP 1 VIEW	Study Date of [**2103-2-6**] 5:27 PM
Single AP view of the pelvis and single view of the right hip
were obtained. Evaluation is suboptimal secondary to patient
rotation and limited number of views. Within this limitation,
there is no evidence for fracture or dislocation. No sacroiliac
joint or pubic symphysis diastasis is visualized. No focal lytic
or sclerotic lesion is seen. Right acetabular spurring suggests
osteoarthritis.
IMPRESSION: No acute process or radiographic evidence of AVN.

XR PELVIS (AP ONLY)	Study Date of [**2103-2-6**] 5:27 PM
Single AP view of the pelvis and single view of the right hip
were obtained. Evaluation is suboptimal secondary to patient
rotation and limited number of views. Within this limitation,
there is no evidence for fracture or dislocation. No sacroiliac
joint or pubic symphysis diastasis is visualized. No focal lytic
or sclerotic lesion is seen. Right acetabular spurring suggests
osteoarthritis.
IMPRESSION: No acute process or radiographic evidence of AVN.

XR KNEE (2 VIEWS) RIGHT PORT	Study Date of [**2103-2-6**] 5:29 PM
AP and lateral bedside images of the right knee show minimal
osteophytic
changes in all three compartments. No fracture or bone
destruction. I doubt
the presence of an effusion. Relative widening of the lateral
compartment
raises the question of incidental discoid lateral malleolus.

UNILAT LOWER EXT VEINS RIGHT	Study Date of [**2103-2-7**] 4:37 PM
Normal venous waveformis seen in the bilateral common femoral
veins with normal Valsalva response. The right common femoral
vein compresses normally and has normal wall-to-wall color
Doppler flow. At the junction of the greater saphenous vein
there is nonocclusive thrombus within the proximal, mid and
distal superficial femoral veins demonstrated by lack of
compressibility. Partial color flow is seen through these
portions. The popliteal vein is incompressible and no color or
spectral Doppler tracing is appreciated indicating occlusive
thrombus. The posterior tibial and peroneal veins of the right
calf are noncompressible without color Doppler flow.
IMPRESSION:
Nonocclusive thrombus within the proximal, mid and distal
superficial femoral veins, which becomes occlusive at the level
of the popliteal. There is occlusive thrombus within the
peroneal and posterior tibial veins of the right calf.

Brief Hospital Course:
BRIEF HOSPITAL COURSE
[**Known firstname **] [**Known lastname 13013**] is a 56-year-old man with history of
glioblastoma, status post resection and VP shunt, PE with IVC
filter and C. difficile, ESBL pneumonia who presents with 2x
seizures to the ED and considerable problems with secretion
control and thick secretions necessitating admission to the ICU
for bronchoscopy and BAL.  He was treated for pneumonia in
addition to empiric treatment for C. difficile, and is being
discharged to [**Hospital1 **] Rehabiltiation.

(1) Hypoxia/ESBL PNA (from OSH):  Patient had known ESBL PNA and
was on ertapenem and vanco at OSH.  He presented with problems
with [**Name2 (NI) 84003**] thick secretions and hypoxia.  The decision was
made for pt to undergo therapuetic and diagnostic bronchoscopy
which was performed in the ICU with intubation and was quickly
extubated.  Respiratory status was monitored and pt was
stablized and able to return to the regular oncology floor.  BAL
was sent for Gram stain, culture, fungal culture, AFB (possible
concern for non-tuberculos mycobacteria); infectious workup has
been negative to date (sample contaminated).
Vancomycin/meropenem were continued.  Aggressive chest PT
performed and continued acetylcysteine nebs and
albuterol/ipratropium nebs.  His O2 sat has remained in the high
90's on 4L NC, and his breathing is comfortable.  He will be
treated empirically for pneumonia with Vancomycin IV and
Imipenem IV (his rehab does not have meropenem) for a total of
14 days (last day is [**2103-2-18**]).

(2) Seizures:  Likely due to known GBM with associated cerebral
edema and intraparenchymal hemorrhage and with lower seizure
threshold given IV antibiotics and current infection.  Also
valproate level found to be low (10 on admission) and borderline
phenytoin (13.2) but was not continued on phenytoin maintenance.
Instead  Valproate dose was increased. Continued on gabapentin
w/seizure precautions. EEG was planned but because of logistical
planning issues, it was not performed.  He had no witnessed
seizures during this admission.  He is being discharged on
Valproate 1250mg PO TID (triple the dose that he was on
previously); a Valproate level should be checked on [**2103-2-16**] and
the result should be faxed to the [**Hospital1 18**] Neuro-Oncology office
(ATTN: Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] fax# [**Telephone/Fax (1) 14669**]).  He will follow up
with his Neuro-Oncologist (Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]) on [**2103-2-20**].

(3) Altered Mental Status:  Most likely secondary to GBM with
question of steroids impacting this and intracranial bleeding
post resection and initially due to post-ictal state.  Much
improved by two days after admission.  He still does get
confused after receiving IV Morphine.  His narcotics were held
until mental status cleared and then slowly added back pain meds
as needed.  Decreased his dose of Fentanyl patch.

(4) Glioblastoma:  Bevacizumab is currently on hold due to
recurrent IC bleeding. Tx plan per Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**].  Continued
dexamethasone 4mg IV Q12, isotretinoin (Cilastin),
methylphenidate, atovaquone and fluconazole prophylaxis.
Eventually aiming for bevacizumab treatment but awaiting
clinical stablization and resolution of currently PNA.  He will
follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] on [**2103-2-20**].

(5) C. Difficile Diarrhea:  Though toxin was negative, he is at
high risk and has a history of C. difficile.  He was continued
on treatment (currently on IV Flagyl and PO vancomycin) with
plans to treat until 2 weeks after treatment of his pneumonia
(last day is [**2103-3-4**]).

(6) Right Lower Extremity DVT, with History of PE:  Mild
swelling on exam and has right posterior thigh pain.  He had
doppler U/S whch demonstrated non-occlusive thrombus from
superficial femoral which is non-occlusive and occlusive
thrombus at level of right calf.  He is not a candidate for
anticoagulation per Dr [**Last Name (STitle) 724**] given repeated bleeds into tumor
bed.  He has IVC filter in situ. In house he was on prophylactic
heparin (5000u SC TID) and also pneumoboots were used.  He needs
to continue on DVT prophylaxis.

(7) Speech and Swallow Evaluation:  After patient's mental
status improved, he was advanced to PO diet of thin liquids and
regular consistency solids.  He should swallow medications whole
with water as tolerated, with 1:1 supervision during POs.

(8) Full Code.

(9) Disposition:  Back to [**Hospital1 **] [**Hospital1 **].

Medications on Admission:
Acetaminophen 1000mg PO daily PRN headache
Thiamine 100mg PO daily
Dexamethasone 4mg PO BID
Comapazine 10mg PO daily
Ambien 5mg PO qHS PRN
Oxycodone 5-10mg PO q6PRN pain
Carbidopa-Levodopa 25-100mg PO BID
Miconazole 2% cream, apply to buttock q8 hours
Gabapentin 300mg qAM, 900mg qPM
Valproic Acid 500mg [**Hospital1 **] and 250mg at noon
Mepron oral solution, 1500mg PO daily
Ritalin 5mg PO BID
Zofran 8mg PO q8H PRN nausea
Lidocream 4% 1TP daily
Levofloxacin 500mg PO daily
KCl 20meq PO daily
Esomeprazole 20mg PO daily
Vancomycin 500mg PO TID
Fentanyl Patch 50mcg/hr q72 hours
Ertapenem 1 gram IV daily
Flagyl 500mg PO TID
Vancomycin 1000mg IV BID
Oxymetazoline 0.05% spray nasal [**Hospital1 **]

Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) as needed for headache.
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
once a day.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain not controlled by tylenol.
5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical Q 8H
(Every 8 Hours).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
8. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day.

10. atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
11. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
14. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
15. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
16. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
17. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours): last day is [**2103-3-4**].
18. valproic acid 500 mg Capsule, Delayed Release(E.C.) Sig: Two
(2) Capsule, Delayed Release(E.C.) PO every eight (8) hours:
(total dose 1250mg PO Q8H).
19. valproic acid 250 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO every eight (8) hours:
(total dose 1250mg PO Q8H).
20. oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) spray Nasal
twice a day.
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. Claravis 20 mg Capsule Sig: Five (5) Capsule PO BID (2 times
a day).
24. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezes, sob.
25. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze, sob.
26. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb
Miscellaneous Q2H (every 2 hours) as needed for thick sections,
wheezing.
27. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
28. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
29. Lorazepam 2-4 mg IV Q4H:PRN seizures
30. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
31. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
32. fluconazole 100 mg Tablet Sig: One (1) Tablet PO once a day.

33. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous three times a day: last day is
[**2103-3-4**].
34. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
twice a day: last day is [**2103-2-18**].
35. imipenem-cilastatin 500 mg Recon Soln Sig: Five Hundred
(500) mg Intravenous every six (6) hours: last day is [**2103-2-18**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary:
Seizure, likely related to known GBM
Alter mental status
ESBL pneumonia
C diff infection

Secondary:
DVT
Thrombocytopenia

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Discharge Instructions:
You were admitted to the hospital because you experienced
seizures and had altered mental status in addition to having
known pneumonia and gastrointestinal infection. You mental
status improved with time and supportive treatment however you
continued to have significant difficulty with your secretions
due to your pneumonia. The decision was made to take you to the
intensive care unit were a therapuetic and diagnostic
bronchoscopy could be performed to help clear the secretions and
determine if there was any other infectious process impacting
your breathing. After you were stablized you were able to be
transferred out of the ICU. You were continued on antibiotics
along with chest physical therapy and your condition improved.

The following changes were made you your medications:
-stop Ambien
-change dose of Valproic acid (dose check needed on [**2103-2-16**])
-stop Levofloxacin
-continue Vancomycin IV (last day is [**2103-2-18**])
-start Imipenem (last day is [**2103-2-18**])
-continue Vancomycin PO (last day is [**2103-3-4**])
-continue Flagyl PO (last day is [**2103-3-4**])
-start Fluconazole
-decrease dose of Fentanyl patch
-start Senna and Colace
-start Heparin prophylaxis
-continue Claravis (has own supply)
-start Ipratropium and Albuterol and Acetylcysteine nebs
-start Metoprolol
-start Lorazepam as needed for seizures

Followup Instructions:
Department: NEUROLOGY
When: TUESDAY [**2103-2-20**] at 10:30 AM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Chronic pulmonary embolism,Other convulsions,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Candidiasis of mouth,Pulmonary collapse,Presence of cerebrospinal fluid drainage device,Hypoxemia,Pain in joint, pelvic region and thigh'}


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: Seizures and altered mental status.

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with history of
glioblastoma, staus post resection and VP shunt, who presented
on [**2103-2-6**] with seizures.  He has a history of a prolonged
hospitalization from [**2102-11-14**] to [**2102-12-7**], during which time he
was treated for Pnuemocystis pneumonia.  He also had pulmonary
embolism initially treated with LMWH and then with an IVC filter
following bleeding in his tumor bed, and suffered a PEA arrest
complicated by flail chest and prolonged intubation.  He also
developed C. difficile at [**Hospital1 **] [**Hospital1 **] and
continues on IV metronidazole and PO vancomycin in addition to
an ESBL pneumonia for which he was treated with IV vancomycin
and IV ertapenem (now on meropenem).

MEDICAL HISTORY: Past Oncologic History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital3 9683**] showed right temporal lobe mass.  Started on
dexamethasone. Underwent subtotal resection of the R temporal
lobe mass by Papavassilious on [**2101-12-30**], path positive for GBM
- received temozolamide chemo-radiation, followed by adjuvant
temozolomide (4 cycles)
- ventriculoperitoneal shunt placed [**2102-8-1**]
- started Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
- cycle 2 of PCV on [**2102-10-10**]
- prolonged hospitalization from [**2102-11-14**] to [**2102-12-7**], during
which time he had:
--Pneumoncystis pneumonia
--s/p PEA arrest and flail chest from compression
-- PE s/p IVC filter, was previously on lovenox
- he was discharged to NE [**Hospital1 **], and while there was diagnosed
with C. difficile, ESBL PNA
- plan was to treated with Avastin but this was delayed due to
ICH
Per wife has had 3 IC bleeds post craniectomy and as such has
meant that anticoagulation was contraindicated.
Per C. difficile, had been treated with a prolonged course of
oral antibiotics and had relapsed a few days post
discontinuation of treatment whereupon this was restarted.

MEDICATION ON ADMISSION: Acetaminophen 1000mg PO daily PRN headache
Thiamine 100mg PO daily
Dexamethasone 4mg PO BID
Comapazine 10mg PO daily
Ambien 5mg PO qHS PRN
Oxycodone 5-10mg PO q6PRN pain
Carbidopa-Levodopa 25-100mg PO BID
Miconazole 2% cream, apply to buttock q8 hours
Gabapentin 300mg qAM, 900mg qPM
Valproic Acid 500mg [**Hospital1 **] and 250mg at noon
Mepron oral solution, 1500mg PO daily
Ritalin 5mg PO BID
Zofran 8mg PO q8H PRN nausea
Lidocream 4% 1TP daily
Levofloxacin 500mg PO daily
KCl 20meq PO daily
Esomeprazole 20mg PO daily
Vancomycin 500mg PO TID
Fentanyl Patch 50mcg/hr q72 hours
Ertapenem 1 gram IV daily
Flagyl 500mg PO TID
Vancomycin 1000mg IV BID
Oxymetazoline 0.05% spray nasal [**Hospital1 **]

ALLERGIES: hydromorphone

PHYSICAL EXAM: Admission exam:
VITAL SIGNS:  Temperature 97.4 F, blood pressure 120/77, pulse
87, respiration 20, and oxygen saturation 96% with 4L via nasal
cannula.
GENERAL:  Somulent but arousable, responds to name, NAD
SKIN:  No rashes. did not brusing likely from IV placement;
Portacath intact without signs of infection
HEENT:  PERRLA. MMM. no JVD but exam limited by pt habitus. neck
supple.
CARDIOVASCULAR:  RR S1/S2 normal. no murmurs/gallops/rubs
appreciated.
PULMONARY:  Examination limited by pt ability to comply. No
accessory muscle use. Anteriorly expiratory wheezes but
otherwise CTAB
ABDOMEN:  BS+, soft, NT, rotund abdomen, no rebound/guarding
apparent at this time
EXTREMITIES:  Extremities felt cool to touch, no edema. DPs, PTs
2+.

FAMILY HISTORY: His father had CABG x 3 age 40 and first MI age 42 and died at
age 85 from CAD.
His mother is alive with hypertension.  He has 4 siblings and
one has had recent stent placement for CAD.  His 3 children are
healthy.

SOCIAL HISTORY: He is a semi-retired accountant.  He was transferred from [**Hospital1 15454**] [**Hospital1 **] since [**2102-11-13**] but previously
at home with wife and children
His mobility at rehab was with walker.  There is no history of
tobacco use.  He previously drank socially and with no illicit
drug use. 

### Response:
{'Malignant neoplasm of temporal lobe,Pneumonia, organism unspecified,Intestinal infection due to Clostridium difficile,Chronic pulmonary embolism,Other convulsions,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Candidiasis of mouth,Pulmonary collapse,Presence of cerebrospinal fluid drainage device,Hypoxemia,Pain in joint, pelvic region and thigh'}
