CHIEF COMPLAINT: Cough and shortness of breath.

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with
history of glioblastoma of the right temporal lobe, s/p
resection [**2101-12-30**] followed by irradiation and temozolomide, VP
shunt placement on [**2102-8-1**], and now on Procarbazine, CCNU, and
Vincristine (PCV) since [**2102-8-23**].  His most recent cycle was on
[**2102-10-10**].  He presented to the [**Hospital3 **] ED on [**2102-11-14**]
with shortness of breath.  The patient states that his shortness
of breath started 2 days prior to admission but worsened the day
prior to admission so much that he could not move without
becoming short of breath and even at rest was SOB.  He denies
fevers or chills.  He reports a cough which started on the day
of admission which is non-productive.  He states that everyone
in his family has a head cold currently.  He has congestion and
right ear fullness with decreased hearing, and has been using
drops to break up the wax in his ear.  He reports 2 days of
diarrhea last week after eating raw shellfish which as resolved.

MEDICAL HISTORY: Past Oncological History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital1 **] 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**]

MEDICATION ON ADMISSION: Carbidopa-Levodopa 25/100mg PO BID
Dexamethasone 4mg qAM, 2mg qPM
Gabapentin 300mg qAM, 900mg qPM
Nystatin 5ml PO QID PRN
Omeprazole 20mg PO daily
Zofran 8mg PO prior to chemotherapy
Oxycodone 5mg 1-2 tabs q6H PRN pain
Oxycontin 20mg PO q12H
Compazine 10mg PO prior to chemotherapy - pt has been taking
this every morning for nausea
Valproic acid 500mg [**Hospital1 **] and 250mg at noon
Ambien 5mg PO qHS PRN sleep
Acetaminophen 1000mg PO PRN headache

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS:  Temperature is 97.8 F, blood pressure 120/80,
pulse 89, respiration 20, and oxygen saturation 94% with 3 liter
of air.
GENERAL:  AOx3, NAD, ventriculoperitoneal shunt on left side of
scalp visible.
SKIN:  No rashes or bruising
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
CARDIOVASCULAR:  RRR S1/S2 normal. no murmurs/gallops/rubs.
PULMONARY:  No dullness to percussion, Fine crackles scattered
throughout, more in upper lobes bilaterally
ABDOMEN:  Soft, NT, +BS. no rebound/guarding. neg HSM. neg
[**Doctor Last Name 515**] sign.
EXTREMITIES: wwp, no edema. DPs, PTs 2+.

FAMILY HISTORY: His father died of a myocardial infarction at age 60.  His
mother is alive with hypertension.  He has 4 siblings and one
has hypertension.  His 3 children are healthy.

SOCIAL HISTORY: He works as an accountant.  He does not smoke cigarettes.  He
drinks 3 to 6 alcoholic drinks per week.  He does not use
illicit drugs.
Pneumocystosis,Other pulmonary embolism and infarction,Acute respiratory failure,Cardiac arrest,Malignant neoplasm of temporal lobe,Drug-induced delirium,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Injury to bladder and urethra, without mention of open wound into cavity,Other disorders of neurohypophysis,Thrombocytopenia, unspecified,Diarrhea,Spontaneous ecchymoses,Unspecified erythematous condition,Hypotension, unspecified,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Presence of cerebrospinal fluid drainage device,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified accident
Pneumocystosis,Pulm embol/infarct NEC,Acute respiratry failure,Cardiac arrest,Mal neo temporal lobe,Drug-induced delirium,Ac DVT/emb distl low ext,Bladder/urethra inj-clos,Neurohypophysis dis NEC,Thrombocytopenia NOS,Diarrhea,Spontaneous ecchymoses,Erythematous cond NOS,Hypotension NOS,Hx of irradiation,Hx antineoplastic chemo,Ventricular shunt status,Adv eff opiates,Accident NOS
Admission Date:  [**2102-11-14**]              Discharge Date:   [**2102-12-7**]

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

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Cough and shortness of breath.

Major Surgical or Invasive Procedure:
Percutaneous inferior vena cava filter placement.

History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with
history of glioblastoma of the right temporal lobe, s/p
resection [**2101-12-30**] followed by irradiation and temozolomide, VP
shunt placement on [**2102-8-1**], and now on Procarbazine, CCNU, and
Vincristine (PCV) since [**2102-8-23**].  His most recent cycle was on
[**2102-10-10**].  He presented to the [**Hospital3 **] ED on [**2102-11-14**]
with shortness of breath.  The patient states that his shortness
of breath started 2 days prior to admission but worsened the day
prior to admission so much that he could not move without
becoming short of breath and even at rest was SOB.  He denies
fevers or chills.  He reports a cough which started on the day
of admission which is non-productive.  He states that everyone
in his family has a head cold currently.  He has congestion and
right ear fullness with decreased hearing, and has been using
drops to break up the wax in his ear.  He reports 2 days of
diarrhea last week after eating raw shellfish which as resolved.


He initially went to [**Hospital3 4107**] and underwent CTA which
showed no pulmonary embolism but did show bilateral infiltrates
concerning for pneumonia.  He received 750 mg of Levaquin at the
OSH.  He was transferred to [**Hospital1 18**] for further care.  Of note, he
has been on dexamethasone for almost 1 year and has not taken
Bactrim prophylaxis.  He was transferred to the [**Hospital1 18**] ED and
admitted.  The informal read of the CTa was suspicious for
pulmonary embolism.

Past Medical History:
Past Oncological History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital1 **] 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**]

Other Past Medical History:
None.

Social History:
He works as an accountant.  He does not smoke cigarettes.  He
drinks 3 to 6 alcoholic drinks per week.  He does not use
illicit drugs.

Family History:
His father died of a myocardial infarction at age 60.  His
mother is alive with hypertension.  He has 4 siblings and one
has hypertension.  His 3 children are healthy.

Physical Exam:
VITAL SIGNS:  Temperature is 97.8 F, blood pressure 120/80,
pulse 89, respiration 20, and oxygen saturation 94% with 3 liter
of air.
GENERAL:  AOx3, NAD, ventriculoperitoneal shunt on left side of
scalp visible.
SKIN:  No rashes or bruising
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
CARDIOVASCULAR:  RRR S1/S2 normal. no murmurs/gallops/rubs.
PULMONARY:  No dullness to percussion, Fine crackles scattered
throughout, more in upper lobes bilaterally
ABDOMEN:  Soft, NT, +BS. no rebound/guarding. neg HSM. neg
[**Doctor Last Name 515**] sign.
EXTREMITIES: wwp, no edema. 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 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 does not have tremors while working on
[**Hospital Ward Name 23**] eighth floor.  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.  His gait is steady.  He can do tandem.  He does not
have a Romberg.

Pertinent Results:
Labs: per OSH:
Na 141 K 4.6 Cl 100 CO2 28 BUN 26 Creat 0.7 Alb 3.7 T Bili 6.0
Ca 9.2 Alk phos 52 ALT 63 AST 71 Valproic Acid 12.2 (10.6-13.4)
INR 0.96 PTT 23.9 .
WBC 4.3 27%neut 51% bands 12% lymphs HCT 29.2 Plt 104

Imaging:
CT head [**2102-11-16**]: 1. No acute hemorrhage.
2. Large confluent hypodensity involving the right
frontoparietal and
temporal lobes with adjacent vasogenic edema. Increased mass
effect with
compression of the adjacent right lateral ventricle with
leftward shift has
increased since prior study (MRI [**2102-10-2**]).
3. Post-VP shunt terminating in the right frontal [**Doctor Last Name 534**] is
unchanged in
position.

CT head [**2102-11-23**]: Technically limited study by patient motion,
with no evidence of intracranial hemorrhage. Large right
cerebral hypodensity with associated mass effect is
redemonstrated, with decreased right to left subfalcine shift,
though increased mass effect and compression of the right
lateral ventricle.

Echocardiogram [**2102-11-21**]: The left atrium is mildly dilated. No
atrial septal defect is seen by 2D or color Doppler or rest
saline injection. Left ventricular wall thicknesses and cavity
size are normal. There is mild regional left ventricular
systolic dysfunction with mild anterior and anterolateral wall
hypokinesis. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is normal with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
borderline pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a prominent fat pad.

IMPRESSION: Mild regional left ventricular systolic dysfunction
with low normal global systolic function. Mildly right
ventricular dysfunction. No ASD/PFO detected with rest saline
contrast only.

CXR [**2102-11-17**]: (upon admission):  Interval increase in the degree
of the bilateral consolidations within the upper lobes and
appearance of new consolidation in the right mid-lung concerning
for progression of the pneumonia.

CXR [**2102-11-22**]: As compared to the previous radiograph, there is a
minimal increase of the pre-existing opacities at the left lung
base. Otherwise, the distribution and severity of the
pre-existing opacities is unchanged. No evidence of newly
appeared parenchymal opacities. Unchanged low lung volumes with
mild cardiomegaly, minimal overhydration and absence of larger
pleural effusions.

CTA Chest:
1. Motion artifacts, decreased image quality.
2. No definite pulmonary emboli. Borderline cardiomegaly.
3. Bilateral upper and lower lobe reticular and ground glass
density lower lobe opacities, suggesting evolving pneumonia.
Differential diagnosis is lengthy, and may include opportunistic
pathogens.  More linear right upper lobe densities could
represent linear atelectasis.
4. Possible hepatic steatosis.
5. Small zone of lingular region peripheral atelectasis next to
major fissure.

[**2102-11-27**] CT Chest, Abdomen, and Pelvis:
CT THORAX: The patient is intubated with the endotracheal tube
lying approximately 20 mm above the carina.  An NG tube is noted
in situ.
There is a right-sided Port-A-Cath whose tip is seen in the
right ventricle.  There is evidence for coronary artery
calcification.
No pericardial effusion.  There is bibasal consolidation but no
significant effusion.  No lung masses or nodules.
CT ABDOMEN:
No pneumoperitoneum.  Within the confines of non-contrast
examination, no focal liver lesion or intra- or extra-hepatic
biliary dilatation.
Gallbladder, spleen, pancreas, both adrenal glands, and kidneys
are
unremarkable.  There are no retroperitoneal masses or
adenopathy.
Unremarkable IVC filter noted within the IVC with no evidence
for
retroperitoneal hematoma or free intraperitoneal blood.
CT PELVIS: Rectal temperature probe noted within the rectum.
A urinary catheter is noted in the bladder.  Some
high-attenuation material is noted in the right lateral wall of
the bladder (series 2, image 118), most likely representing
intravesical hemorrhage from catheterization.  The rectum,
sigmoid colon, and visualized small bowel loops are
unremarkable.
CT THORAX:
The patient is intubated with the endotracheal tube lying
approximately 20 mm above the carina.  An NG tube is noted in
situ.  There is a right-sided Port-A-Cath whose tip is seen in
the right ventricle. There is evidence for coronary artery
calcification.  No pericardial effusion. There is bibasal
consolidation but no significant effusion.  No lung masses or
nodules.
CT ABDOMEN:
No pneumoperitoneum.  Within the confines of non-contrast
examination, no focal liver lesion or intra- or extra-hepatic
biliary dilatation.
Gallbladder, spleen, pancreas, both adrenal glands, and kidneys
are
unremarkable.  There are no retroperitoneal masses or
adenopathy.
Unremarkable IVC filter noted within the IVC with no evidence
for retroperitoneal hematoma or free intraperitoneal blood.
CT PELVIS:
Rectal temperature probe noted within the rectum.  A urinary
catheter is noted in the bladder.  Some high-attenuation
material is noted in the right lateral wall of the bladder
(series 2, image 118), most likely representing intravesical
hemorrhage from catheterization.  The rectum, sigmoid colon, and
visualized small bowel loops are unremarkable.  No pelvic
adenopathy or free fluid.
CT OSSEOUS SKELETON:
No osseous destructive lesion.
IMPRESSION: No evidence for retroperitoneal bleed.

[**2102-11-30**] CXR:
In comparison with the earlier study of this date, the
nasogastric
tube extends to the distal antrum. The patient has taken a
slightly better
inspiration. Extensive bibasilar atelectatic changes are again
seen. The
endotracheal tube has been removed. Port-A-Cath remains in
place.

[**2102-12-2**] CXR:
Large bands of atelectasis persist at both lung bases. Upper
lungs are clear with no evidence of infections there. Mild
cardiomegaly stable exaggerated by the high diaphragm. Pleural
effusion is small, if any. No pneumothorax.  Nasogastric tube
passes into the duodenum and out of view. Right jugular line
ends in the right atrium.

[**2102-12-6**] MRI HEAD: final read pending

Labs upon admission to [**Hospital1 18**]:
[**2102-11-15**] 06:32AM BLOOD WBC-2.8*# RBC-2.56* Hgb-8.9* Hct-25.6*
MCV-100* MCH-34.9* MCHC-34.8 RDW-19.5* Plt Ct-105*
[**2102-11-15**] 06:32AM BLOOD Neuts-77* Bands-4 Lymphs-11* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-0 NRBC-3*
[**2102-11-15**] 06:32AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2102-11-15**] 06:32AM BLOOD PT-11.7 PTT-23.8 INR(PT)-1.0
[**2102-11-17**] 06:33AM BLOOD Ret Man-8.3*
[**2102-11-15**] 06:32AM BLOOD Glucose-113* UreaN-22* Creat-0.5 Na-139
K-4.0 Cl-100 HCO3-31 AnGap-12
[**2102-11-15**] 06:32AM BLOOD ALT-84* AST-49* LD(LDH)-576* AlkPhos-49
TotBili-0.6 DirBili-0.2 IndBili-0.4
[**2102-11-15**] 06:32AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
[**2102-11-15**] 06:32AM BLOOD Hapto-191
[**2102-11-16**] 06:11AM BLOOD VitB12-757 Folate-16.7
[**2102-11-20**] 03:08AM BLOOD Osmolal-271*
[**2102-11-19**] 03:32AM BLOOD Vanco-9.4*
[**2102-11-17**] 05:46AM BLOOD Type-ART pO2-68* pCO2-32* pH-7.49*
calTCO2-25 Base XS-1
[**2102-11-17**] 05:46AM BLOOD Glucose-109* Lactate-2.3* Na-136 K-4.4
Cl-99*
[**2102-11-17**] 05:46AM BLOOD Hgb-11.2* calcHCT-34 O2 Sat-92
[**2102-11-17**] 05:46AM BLOOD freeCa-1.15
[**2102-11-17**] 06:38AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.2
NEGATIVE
[**2102-11-17**] 06:38AM BLOOD B-GLUCAN- >500 POSITIVE

Labs upon discharge:
[**2102-12-7**] 05:43
COMPLETE BLOOD COUNT
White Blood Cells 4.0 4.0 - 11.0 K/uL
Red Blood Cells 2.82* 4.6 - 6.2 m/uL
Hemoglobin 9.5* 14.0 - 18.0 g/dL
Hematocrit 28.4* 40 - 52 %
MCV 101* 82 - 98 fL
MCH 33.5* 27 - 32 pg
MCHC 33.2 31 - 35 %
RDW 17.8* 10.5 - 15.5 %
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 112* 150 - 440 K/uL
Glucose 113* 70 - 100 mg/dL
Urea Nitrogen 34* 6 - 20 mg/dL
Creatinine 0.7 0.5 - 1.2 mg/dL
Sodium 137 133 - 145 mEq/L
Potassium 4.2 3.3 - 5.1 mEq/L
Chloride 102 96 - 108 mEq/L
Bicarbonate 22 22 - 32 mEq/L
Anion Gap 17 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 8.1* 8.4 - 10.3 mg/dL
Phosphate 3.2 2.7 - 4.5 mg/dL
Magnesium 2.2 1.6 - 2.6 mg/dL
.
Microbiology:
[**2102-12-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B - NEG
[**2102-11-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B - NEG
[**2102-11-28**] BLOOD CULTURE - NEG
[**2102-11-27**] BLOOD CULTURE - NEG
[**2102-11-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B -NEG
[**2102-11-27**] SPUTUM GRAM STAIN-sparse yeast
[**2102-11-26**] URINE CULTURE-NEG
[**2102-11-24**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2102-11-24**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   SQUAMOUS EPITHELIAL CELLS.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2102-11-26**]):
      10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2102-11-24**]):
      Test cancelled by laboratory.
    Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2102-11-24**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Preliminary):
      YEAST.

   ACID FAST SMEAR (Final [**2102-11-27**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      ACIDFAST BACILLI.    MODERATE seen on concentrated smear.

   ACID FAST CULTURE (Preliminary):

   GEN-PROBE AMPLIFIED M. TUBERCULOSIS DIRECT TEST (MTD) (Final
[**2102-11-30**]):
      NEGATIVE FOR M. TUBERCULOSIS BY MTD. AWAIT CULTURE
RESULTS. MTD
      PERFORMED AT [**State **] STATE LABORATORY, [**Location (un) **], MA
[**2102-11-30**].
[**2102-11-23**] BLOOD CULTURE-NEG
[**2102-11-21**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NEG
[**2102-11-21**] SPUTUM Cancelled, contaminated
[**2102-11-19**] SPUTUM GRAM STAIN (Final [**2102-11-19**]):
      <10 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2102-11-21**]):
      MODERATE GROWTH Commensal Respiratory Flora.
      YEAST.    MODERATE GROWTH.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2102-11-20**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..
[**2102-11-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL INPATIENT
[**2102-11-17**] MRSA SCREEN - NEG
[**2102-11-16**] SPUTUM GRAM STAIN (Final [**2102-11-16**]):
      >25 PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions..
      Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2102-11-16**]):
      TEST CANCELLED, PATIENT CREDITED.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2102-11-17**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..
[**2102-11-15**] SPUTUM cancelled, contaminated
[**2102-11-15**] BLOOD CULTURE -NEG
[**2102-11-15**] SPUTUM cancelled, contaminated
[**2102-11-15**] URINE CULTURE-<10,000 organisms/ml.
[**2102-11-15**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-NEG
[**2102-11-15**] URINE Legionella Urinary Antigen -NEG

Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with
history of glioblastoma who initially presented with cough,
shortness of breath, and bilateral infiltrates on CXR, treated
for PCP pneumonia, and [**Name Initial (PRE) **]/p PEA arrest.

(1) PEA Arrest [**2102-11-23**]:  Flail chest resulted from CPR, pt
continues to occasionally complain of pleuritic left sided chest
pain.

(2) Hypoxemic Respiratory Failure:  Patient was admitted to the
ICU with a very tenuous respiratory status.  His Beta-Glucan was
overwhelmingly positive at 500, which was very suggestive of
PCP.  [**Name10 (NameIs) 15255**], physical and CT and CXR findings were also very
suggestive of PCP, [**Name10 (NameIs) **], no definitive diagnosis could be
made at the time of admission.  He was started on treatment for
HAP with Vancomycin, levo, zosyn.  He was also started on
Bactrim 3DS tabs TID and prednisone 40mg PO BID.  ID was
consulted.  Although suspicion for PCP was high, he was
continued on Abx for HAP for 6 days prior to ID recommending
discontinuing the Abx as likely PCP [**Name Initial (PRE) 1064**].  The patient's
respiratory status remained tenuous during the first 5 days of
his admission, but then it began to improve with his treatment
and he is currently on NC 4L with an oxygen saturation of 100%.
The plan is to continue Bactrim DS 3 tabs 4 times a day for 21
days (D1, [**2102-11-14**]). The patient is being discharged on
prophylactic Bactrim DS 1 daily.

However, patient had a PEA arrest requiring intubation on
[**2102-11-23**].  He was bronchoscoped after intubation, and BAL showed
growth of AFB.  Therefore, he was placed on isolation room.
Initially, he was maintained on high PEEP.  Upon a trial of
lowered sedation, it was noted that patient also had paradoxical
respiration likely [**2-14**] rib fractures from the CPR on [**2102-11-23**].
 Therefore, he was kept on mechanical ventilator for respiratory
support until [**2102-11-30**] after a day tolerating pressure
support.  Very shortly after extubation, patient had a witnessed
aspiration of vomitus with initial ABG showing hypoxemia pH 7.49
pCO2 37 pO2 74 HCO3 29 but with improved O2Sat with face mask
and repeat ABG shows pH 7.51 pCO2 39 pO2 91 HCO3 32.  The
alkalosis was likely from aggressive diuresis.  At time of
transfer pt was satting well with Nasal Cannula 3L and on Day
19/21 for PCP [**Name Initial (PRE) 31304**].  He will be continued on prednisone
20mg PO Daily after completion of PCP [**Name Initial (PRE) 31304**].

(3) Delirium:  The patient had an episode of delirium on
[**2102-11-22**] that resolved the following morning.  It occurred after
administration of oxycodone and after his family left and he
became disoriented.  Delerium was likely secondary to opiate
administration as well as disorientation and his underlying
disease.  [**Month (only) 116**] also have some confusion secondary to steroid
administration and underlying encephalopathy from PEA arrest.

(4) Subsegmental Pulmonary Embolism:  [**Hospital1 18**] radiology says clot
is stable (initially found to have a subsegmental PE on CTA done
to rule out causes of hypoxia).  He was started on a heparin
drip for a few days.  As his respiratory status began to
stabilize, he was converted to Lovenox.  However, he was
switched back to heparin gtt after the PEA arrest.  As part of
the work up for the PEA arrest, a LENIS was obtained which found
bilateral DVT.  Therefore, patient underwent placement of IVC
filter.  Heparin drip was held briefly also because of
pancytopenia (including dropping platelet counts).  However, it
was restarted given the risk outweighs the benefit and
stabilized anemia and platelets counts.  Pt was switched to
lovenox on day of ICU transfer. Lovenox dosage was reduced by
10% (90 mcg to 80 mcg q12H) due to continued hematuria after
traumatic Foley insertion or self discontinuation of Foley
catheter.

(5) Hematuria:  Initially, this was felt to be due to traumatic
Foley insertion in ICU; continued after patient self
discontinued consistent pulling on Foley catheter. Hematocrit
started to trend down, but remains stable on day of discharge.
Urinalysis otherwise negative.  Lovenox decreased by 10%, expect
hematuria to improve as thrombocytopenia continues to improve.

(6) Multiple Loose Stools:  Patient had flexiseal placed
secondary to multiple watery stools.  C. difficile toxin tests
were negative 3 times.  Currently secretory diarrhea of unknown
cause, possibly from disrupted normal flora given long term on
antibiotics.  Started on banana flakes for stool bulking and
given imodium as c. dificile very unlikely.  This was resolved
by time of discharge, flexiseal removed 3 days prior to
discharge.  Loperamide prescribed at time of discharge as needed
for continued loose stools.

(7) Positive AFB on BAL:  Patient had positive AFB from BAL and
was placed on respiratory isolation.  Gene probe amplification
was negative for TB so was taken off of respiratory precautions.
 TB culture from negative from state laboratory.

(8) SIADH:  Likely secondary to intracranial malignancy.  His
sodium remained stable with free water restriction.  It was
initially thought that he had a reset osmostat.  After the PEA
arrest and cooling/rewarming protocol, patient's hyponatremia
improved and resolved on continued free water restriction even
prior to initiation of Lasix on [**2102-11-28**].  Hyponatremia
resolved, Na 137 at time of discharge.

(9) Glioblastoma Multiforme:  Neurological status stable, he has
been continued on his home doses of carbidopa-levodopa, valproic
acid, gabapentin and has been given stress dose steroids as
described above.  He was followed by our neurooncology team
while in the ICU.  Patient will be readmitted in 2 weeks time
after pt regains strength at [**Date Range **] for treatment with
Avastin per Dr. [**Last Name (STitle) 724**].  Patient started on ritalin during
admission for improved energy and alertness.  Patient also
started on thiamine during admission.

(10) Thrombocytopenia:  Patient presented thrombocytopenic, but
platelets trended up and then began to trend down, now trending
up.  It was unclear whether it was medication induced, increased
destruction or sequestration.  TTP and DIC labs were negative.
bactrim was not stopped because of need to treat PCP.  [**Name10 (NameIs) 2772**],
as patient's condition improved his platelets began to trend up.
 Possibly secondary to underlying infectious process as it is
now trending up and still on Bactrim and other antiepileptic
meds that can cause thrombocytopenia, however, underlying cause
still unclear.  Platelet count 112 at time of discharge.

(11) Erythroderma:  After artic cooling patient developed
diffuse erythroderma.  It was unclear whether this was secondary
to medication or artic cooling because also happened in the
setting of thrombocytopenia and petechiae.  Bactrim was not
discontinued and rash now significantly improved, likely
secondary to artic sun cooling, it began after use of the
cooling pads and has since resolved with no changes in
medications. Improving, not significantly noticable on exam
currently.

(12) Petechiae:  After the artic sun cooling it was noticed the
patient had petechiae around the border of the cooling blankets.
 It was unclear whether in the setting of the rash and
thrombocytopenia this was related to bactrim treatment.  pt was
continued on Bactrim and petechiae resolved.  Likely secondary
to arctic sun cooling pads as petechiae are in distrubtion of
borders of pads.  Low suspicion for emboli.  There was no
evidence of DIC as hemolysis labs negative.  He is improving,
but not significantly noticable on examination currently.

(13) Code Statuis:  The patient was full code for this
admission.

Medications on Admission:
Carbidopa-Levodopa 25/100mg PO BID
Dexamethasone 4mg qAM, 2mg qPM
Gabapentin 300mg qAM, 900mg qPM
Nystatin 5ml PO QID PRN
Omeprazole 20mg PO daily
Zofran 8mg PO prior to chemotherapy
Oxycodone 5mg 1-2 tabs q6H PRN pain
Oxycontin 20mg PO q12H
Compazine 10mg PO prior to chemotherapy - pt has been taking
this every morning for nausea
Valproic acid 500mg [**Hospital1 **] and 250mg at noon
Ambien 5mg PO qHS PRN sleep
Acetaminophen 1000mg PO PRN headache

Discharge Medications:
1. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
3. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QPM.
4. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush, mouth pain.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain, headache.
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. valproic acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
9. valproic acid 250 mg Capsule Sig: One (1) Capsule PO NOON (At
Noon).
10. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, headache.
11. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea: and
prior to chemotherapy
13. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
once a day.
14. bisacodyl 5 mg Tablet Sig: One (1) Tablet, Delayed Release
(E.C.) PO DAILY (Daily) as needed for constipation.
15. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for loose stools.
16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
18. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Pneumonia, pulmonary embolism, glioblastoma multiforme

Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
Dear Mr. [**Known lastname 13013**],
You were admitted to [**Hospital1 **] for
shortness of breath.  You a lung infection on chest xray and
were treated with anitbiotics. Also, you were noted to have
blood clots in your lungs, so were started on blood thinners.
You also had a MRI of your brain and the preliminary report
showed that the tumor is unchanged, but it is more dense. So Dr.
[**Last Name (STitle) 724**] recommended you going to [**Last Name (STitle) **] facility to gain
strength and for you to return in 2 weeks for chemotherapy
treatment.

Please make the following changes to your medications:
-START prednisone 20mg by mouth daily to help with brain
swelling
-START Ritalin 5mg by mouth daily for increased energy/alertness
-START thiamine 100 mg by mouth daily
-START Sulfameth/Trimethoprim (Bactrim) DS 1 tablet by mouth
daily to prevent future lung infections
-START Lovenox (Enoxaparin) 80 mg subcutaneously twice daily for
pulmonary embolism/blood clot in your lungs
-START loperamide 2mg by mouth four times daily as needed for
loose stools
-START bisacodyl 10 mg by mouth daily as needed for
constipation;
please hold if having loose bowel movements

-STOP dexamethasone
-STOP oxycontin
-STOP ambien

Please continue all other medications as prescribed.

Followup Instructions:
The following appointments have been made for you:

Department: NEUROLOGY
When: TUESDAY [**2102-12-19**] at 11:30 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

Please arrive to the infusion center 30 minutes before your
appointment
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2102-12-19**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2102-12-19**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumocystosis,Other pulmonary embolism and infarction,Acute respiratory failure,Cardiac arrest,Malignant neoplasm of temporal lobe,Drug-induced delirium,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Injury to bladder and urethra, without mention of open wound into cavity,Other disorders of neurohypophysis,Thrombocytopenia, unspecified,Diarrhea,Spontaneous ecchymoses,Unspecified erythematous condition,Hypotension, unspecified,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Presence of cerebrospinal fluid drainage device,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified accident'}


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: Cough and shortness of breath.

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 13013**] is a 56-year-old right-handed man with
history of glioblastoma of the right temporal lobe, s/p
resection [**2101-12-30**] followed by irradiation and temozolomide, VP
shunt placement on [**2102-8-1**], and now on Procarbazine, CCNU, and
Vincristine (PCV) since [**2102-8-23**].  His most recent cycle was on
[**2102-10-10**].  He presented to the [**Hospital3 **] ED on [**2102-11-14**]
with shortness of breath.  The patient states that his shortness
of breath started 2 days prior to admission but worsened the day
prior to admission so much that he could not move without
becoming short of breath and even at rest was SOB.  He denies
fevers or chills.  He reports a cough which started on the day
of admission which is non-productive.  He states that everyone
in his family has a head cold currently.  He has congestion and
right ear fullness with decreased hearing, and has been using
drops to break up the wax in his ear.  He reports 2 days of
diarrhea last week after eating raw shellfish which as resolved.

MEDICAL HISTORY: Past Oncological History:
- [**12-21**] developed headaches and leg weakness and CT at [**Hospital1 **] 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**]

MEDICATION ON ADMISSION: Carbidopa-Levodopa 25/100mg PO BID
Dexamethasone 4mg qAM, 2mg qPM
Gabapentin 300mg qAM, 900mg qPM
Nystatin 5ml PO QID PRN
Omeprazole 20mg PO daily
Zofran 8mg PO prior to chemotherapy
Oxycodone 5mg 1-2 tabs q6H PRN pain
Oxycontin 20mg PO q12H
Compazine 10mg PO prior to chemotherapy - pt has been taking
this every morning for nausea
Valproic acid 500mg [**Hospital1 **] and 250mg at noon
Ambien 5mg PO qHS PRN sleep
Acetaminophen 1000mg PO PRN headache

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS:  Temperature is 97.8 F, blood pressure 120/80,
pulse 89, respiration 20, and oxygen saturation 94% with 3 liter
of air.
GENERAL:  AOx3, NAD, ventriculoperitoneal shunt on left side of
scalp visible.
SKIN:  No rashes or bruising
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
CARDIOVASCULAR:  RRR S1/S2 normal. no murmurs/gallops/rubs.
PULMONARY:  No dullness to percussion, Fine crackles scattered
throughout, more in upper lobes bilaterally
ABDOMEN:  Soft, NT, +BS. no rebound/guarding. neg HSM. neg
[**Doctor Last Name 515**] sign.
EXTREMITIES: wwp, no edema. DPs, PTs 2+.

FAMILY HISTORY: His father died of a myocardial infarction at age 60.  His
mother is alive with hypertension.  He has 4 siblings and one
has hypertension.  His 3 children are healthy.

SOCIAL HISTORY: He works as an accountant.  He does not smoke cigarettes.  He
drinks 3 to 6 alcoholic drinks per week.  He does not use
illicit drugs. 

### Response:
{'Pneumocystosis,Other pulmonary embolism and infarction,Acute respiratory failure,Cardiac arrest,Malignant neoplasm of temporal lobe,Drug-induced delirium,Acute venous embolism and thrombosis of deep vessels of distal lower extremity,Injury to bladder and urethra, without mention of open wound into cavity,Other disorders of neurohypophysis,Thrombocytopenia, unspecified,Diarrhea,Spontaneous ecchymoses,Unspecified erythematous condition,Hypotension, unspecified,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Presence of cerebrospinal fluid drainage device,Other opiates and related narcotics causing adverse effects in therapeutic use,Unspecified accident'}
