CHIEF COMPLAINT: left parietal mass

PRESENT ILLNESS: 53 yo female with a history of non-Hodgkin's lymphoma, s/p BMT
([**2118**]), [**Year (4 digits) 1291**], atrial fibrillation not on coumadin, cardiomyopathy
(EF 45%) who was transferred to [**Hospital1 18**] on [**2143-8-30**] for further
management of left parietal mass. Patient initially presented to
an OSH on [**8-29**] after nearly a week of left frontal headaches,
right sided arm and leg weakness and progressive aphasia. At the
OSH neuroimaging revealed a ring enhancing left parietal mass
with extensive surrounding edema.

MEDICAL HISTORY: Gastric bypass [**2135**] per husband (outside records not available
to confirm date/exact procedure)
Roux-en-Y gastrojejunostomy [**2140**] for "perforated ulcers" per
husband (outside records not available to confirm date/exact
procedure)
-Atrial fibrillation s/p successful cardioversion [**1-9**], taken
off coumadin given h/o UGIB [**2140**]
-Bovine [**Year (4 digits) 1291**] for AS [**3-8**]
-Hypertension
-Non-Hodgkin's lymphoma, status post chemotherapy [**2138**], s/p
partial splenectomy [**2139**], in remission since [**2139**]
CAD
Cardiomyopathy (EF 45%)

MEDICATION ON ADMISSION: Home Meds
-Sotalol 40 mg [**Hospital1 **]
-Ativan 1mg qhs
-Protonix 20 qd
-Hydromorphone 0.5mg IV PRN
-Acetaminophen 325-650 mg PRN

ALLERGIES: Penicillins / Codeine / Keflex

PHYSICAL EXAM: Discharge Exam:
VS: 97.7  113/71  69  20  100% on RA with ambulation
Gen: Pleasant female in no acute distress
HEENT: Healing surgical wound, not erythematous or
infected-appearing. Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior lung exam clear, no wheezes or crackles
appreciated
CV: S1 & S2 regular without murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, 4+/5 RUE strength, 5/5 strength all other
extremities

FAMILY HISTORY: Two brothers with neoplasms.
Mother with lung Ca
No CNS tumors. No seizures. No early strokes or CNS bleeds

SOCIAL HISTORY: She lives with her husband.
Social ETOH.
Denies drugs in the present or the past.
She quit smoking 20 years ago - 37 pack year history
Intracranial abscess,Acute respiratory failure,Other primary cardiomyopathies,Bone marrow replaced by transplant,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Epilepsia partialis continua, without mention of intractable epilepsy,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Leukocytopenia, unspecified,Other diseases of spleen,Unspecified essential hypertension,Anemia, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Anxiety state, unspecified,Personal history of other lymphatic and hematopoietic neoplasms,Heart valve replaced by other means,Heart valve replaced by transplant,Aortocoronary bypass status,Old myocardial infarction
Intracranial abscess,Acute respiratry failure,Prim cardiomyopathy NEC,Trnspl status-bne marrow,Ac DVT/emb prox low ext,Epil par cont w/o int ep,Streptococcus group b,Atrial fibrillation,Leukocytopenia NOS,Spleen disease NEC,Hypertension NOS,Anemia NOS,Cor ath unsp vsl ntv/gft,Anxiety state NOS,Hx-lymphatic malign NEC,Heart valve replac NEC,Heart valve transplant,Aortocoronary bypass,Old myocardial infarct
Admission Date:  [**2143-8-30**]              Discharge Date:   [**2143-10-15**]

Date of Birth:  [**2090-5-5**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Codeine / Keflex

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
left parietal mass

Major Surgical or Invasive Procedure:
Craniotomy and empyema evacuation
Stereotactic evacuation of abscess and burr hole drainage of
subdural empyema
PICC Placement


History of Present Illness:
53 yo female with a history of non-Hodgkin's lymphoma, s/p BMT
([**2118**]), [**Year (4 digits) 1291**], atrial fibrillation not on coumadin, cardiomyopathy
(EF 45%) who was transferred to [**Hospital1 18**] on [**2143-8-30**] for further
management of left parietal mass. Patient initially presented to
an OSH on [**8-29**] after nearly a week of left frontal headaches,
right sided arm and leg weakness and progressive aphasia. At the
OSH neuroimaging revealed a ring enhancing left parietal mass
with extensive surrounding edema.

Following transfer to [**Hospital1 18**] and admission to the neurosurgery
service patient developed worsening aphasia and right
hemiparesis. On [**8-30**] brain MRI demonstrated a rim-enhancing left
parietal lesion measuring approximately 5 mm,suggestive of
abscess with subdural empyema. On [**8-31**] she underwent L sided
stereotactic evacuation of abscess and bur hole drainage of
subdural empyema. An MRI from [**9-2**] showed interval decrease in
size of the left parietal abscess status post surgical
evacuation. Notably, there was a small new multiloculated
subdural collection in the left parieto-occipital region. Wound
cx from evacuation growing strep, unspeciated at time of
transfer to medicine. Since pt has PCN and cephalosporin allergy
she was started on vancomycin for strep coverage. The consulting
ID team stongly recommended PCN desensitization so pt would be
able to receive a beta lactam antibiotic.

Notably, CT torso done given patient's presenting complaint of
LUQ abd pain. Study on [**8-30**] showed air and fluid in the splenic
hilum,
suggesting recent leakage vs stump carcinoma. Patient was
started on cipro/flagyl for concern of infection. IR felt this
was likely a more chronic collection.

Course to date also c/b refractory seizure activity on
continuous EEG monitoring.

Past Medical History:
Gastric bypass [**2135**] per husband (outside records not available
to confirm date/exact procedure)
Roux-en-Y gastrojejunostomy [**2140**] for "perforated ulcers" per
husband (outside records not available to confirm date/exact
procedure)
-Atrial fibrillation s/p successful cardioversion [**1-9**], taken
off coumadin given h/o UGIB [**2140**]
-Bovine [**Year (4 digits) 1291**] for AS [**3-8**]
-Hypertension
-Non-Hodgkin's lymphoma, status post chemotherapy [**2138**], s/p
partial splenectomy [**2139**], in remission since [**2139**]
CAD
Cardiomyopathy (EF 45%)


Social History:
She lives with her husband.
Social ETOH.
Denies drugs in the present or the past.
She quit smoking 20 years ago - 37 pack year history

Family History:
Two brothers with neoplasms.
Mother with lung Ca
No CNS tumors. No seizures. No early strokes or CNS bleeds

Physical Exam:
Discharge Exam:
VS: 97.7  113/71  69  20  100% on RA with ambulation
Gen: Pleasant female in no acute distress
HEENT: Healing surgical wound, not erythematous or
infected-appearing. Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior lung exam clear, no wheezes or crackles
appreciated
CV: S1 & S2 regular without murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, 4+/5 RUE strength, 5/5 strength all other
extremities

Pertinent Results:
Discharge Labs:
WBC 2.5, Hct 26.6 (stable), plts 277
INR: 1.7
ALT 17, AST 30
Valproate: 38

Pertinent Labs:
[**2143-8-30**] 09:20AM   SED RATE-135* CRP-GREATER THAN ASSAY
[**2143-8-30**] 09:20AM   PT-12.7 PTT-26.1 INR(PT)-1.1
[**2143-8-29**] 11:55PM   LACTATE-0.9
[**2143-8-29**] 11:45PM   WBC-9.3 RBC-3.54* HGB-9.8* HCT-30.7* MCV-87
MCH-27.6 MCHC-31.8 RDW-14.7
[**2143-8-29**] 11:45PM   NEUTS-81.6* LYMPHS-14.6* MONOS-3.3 EOS-0.4
BASOS-0.1
[**2143-8-29**] 11:45PM   GLUCOSE-126* UREA N-12 CREAT-0.6 SODIUM-137
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-22 ANION GAP-20

Imaging:
[**2143-8-30**]: CT C/A/P: Air-fluid collection centered in splenic
hilum near an apparent site of gastrojejunostomy

[**2143-8-30**]: CT Head: Left parieto-occipital vasogenic edema with
the suggestion of a central lesion within that area.

[**2143-8-30**]: MR [**Name13 (STitle) 430**]: Rim-enhancing left parietal lesion with
surrounding edema with enhancement of the adjacent leptomeninges
and pachymeninges with subdural collection in the left
frontoparietal region measuring approximately 5 mm. Suspicious
for an abscess with a
question of subdural empyema. No midline shift is seen. Mild
mass effect on the left lateral ventricle

[**2143-8-31**]: CXR no infiltrates, line OK, no PTX

[**2143-9-2**]: TTE no vegetations, EF 50%, trivial MR. [**First Name (Titles) **] [**Last Name (Titles) 1291**].

[**2143-9-6**]: CT Interval increase size of L prefrontal subdural
collection, 1.6 x 5.6 cm in widest dimensions. Unchanged L
posterior frontal cerebral abscess 1.6 x 0.7 cm. Mass effect
from left prefrontal subdural empyema w/4 mm rightward deviation
of falx.

[**2143-9-8**]: The small air-fluid collection at splenic hilum,
slightly
decreased in size. Still tracks through spleen an unusual
wedge-shaped configuration to subcapsular region associated
with small pleural effusion and LLL atelectasis. ? cause of
collection. Wedge-shaped low-attenuation abnormalities in
periphery of spleen could represent prior infarcts. Collection
would be difficult to access percutaneously, probably
require trans-splenic approach. New RLL centrilobular nodules w/
tree-in-[**Male First Name (un) 239**] configuration and atelectasis suggests recent
infection or inflammation d/t ?aspiration. L adnexal ovoid
homogeneous cystic abnormality f/u by U/s.

[**2143-9-8**]: CXR NG tip in stomach. RIJ tip at cavoatrial junction.
There LLL volume loss and RLL volume loss w/obscuration of
hemidiaphragms. ?underlying infectious infiltrate.

[**2143-9-8**]: CXR L PIC catheter terminates in the lower superior vena
cava.

[**2143-9-11**]: CT new hypodense lesion w/hyperdense rim L frontal
region,highly suspicious for evolving abscess vs. postop change.
Interval increase in L centrum semiovale edema, w/ 2mm shift of
midline structures.

[**2143-9-11**]: MRI prelim no interval change in dominant ring-enhancing
intraparenchymal fluid collection in L parietal lobe and
associated subdural fluid, slightly increased parenchymal edema
w mass effect and meningial enhancement

[**2143-9-12**] Sinus CT: Heterogeneous opacification of multiple
paranasal sinuses and mastoid air cells and right middle ear
cavity,with no evidence of bony erosions. [**2-4**] sinusitis or h/o
intubation.

[**2143-9-12**]: TEE
IMPRESSION: No valvular vegetation or abscess seen

[**2143-9-7**]: EEG: This telemetry captured no pushbutton activations
but it
did capture several events of rhythmic activity seen
predominantly in
the right frontal area and suggestive, although not clearly so,
of a
seizure activity. There were no clear interictal spikes seen in
this
recording. The background activity was slow suggestive of a
moderate
encephalopathy with slower frequencies seen in the left
posterior
quadrant suggestive of functional and probably structural
abnormality in
that area.

[**10-9**] Lower Extremity U/S:
IMPRESSION: Occlusive thrombus from the proximal right SFV to at
least the
level of the popliteal vein.

[**10-9**] CT Ab/Pelvis:
IMPRESSION:
1. No change in size of perisplenic fluid collection. A small
amount of oral contrast and air tracking from anastomotic site
to splenic hilum is most compatible with contained leak,
unchanged since prior examination from [**2143-10-1**].
2. Asymmetric enlargement with hypodensity in the right versus
left femoral veins that could indicate right venous thrombus.
Recommend correlation with ultrasound.
3. Stable appearance of left adnexal cystic lesion since
earliest available examination of [**2143-8-30**]. Recommend pelvic
ultrasound be performed within six weeks in outpatient setting
or when clinically feasible for further evaluation.
4. Slight decrease in size of right obturator internus muscle
with 15-mm area of hyperdensity suggestive of calcification.
This is likely related to resolving hematoma or myositis
ossificans. No fluid collection in this area to suggest abscess
formation.
5. Transverse colonic [**Doctor Last Name **] hernia with no evidence of
obstruction.

[**10-4**] Head MRI:
Interval resolution of previously seen abscess cavities. A small
amount of
enhancement in the left parietal lobe is noted which has
decreased
considerably compared to the prior examination. Previously noted
subdural
collections have resolved. There is decreased mass effect.

Microbiology:
MRSA screen: positive

Blood Cultures:
[**Date range (1) 84706**] Negative

Urine Cultures: Negative

Abscess Culture [**8-31**]:
Strep species x 2
Wound swab- strep milleri
Repeat Wound Cultures: Negative

HELICOBACTER PYLORI ANTIBODY TEST (Final [**2143-9-9**]):
      NEGATIVE BY EIA.


Brief Hospital Course:
53 YO F with a history of non-Hodgkin's lymphoma s/p BMT ([**2138**]),
Aortic valve replacement (biological), atrial fibrillation not
previously on coumadin, prior report of cardiomyopathy (EF 45%)
who was transferred to [**Hospital1 18**] on [**2143-8-30**] for management of left
parietal mass found to have a parietal Strep Milleri abscess c/b
subdural empyema s/p craniotomy with evacuation.

1. Brain Abscesses (Seizures): The patient initially presented
to an OSH on [**8-29**] after nearly a week of left frontal headaches,
right sided arm and leg weakness and progressive aphasia. At the
OSH neuroimaging revealed a ring enhancing left parietal mass
with extensive surrounding edema.  On [**8-31**] morning rounds,
patient was witnessed to have ongoing seizures characterized
with right arm tremor despite Keppra loading.  Respiratory
status was marginal with acute tachypnea and so she was
transferred to the ICU at this time. MRI read came back
indicating a intracranial abscess with a subdural empyema.  The
patient was taken emergently to the OR for drainage.  She was
left intubated post operatively and maintained on a midazolam
gtt, which was slowly weaned and the patient was transitioned to
Keppra and dilantin. An MRI from [**9-2**] showed interval decrease
in size of the left parietal abscess status post surgical
evacuation. There was also a small new multiloculated subdural
collection in the left parieto-occipital region which worsened
and repeat craniotomy was performed on [**2143-9-6**].  She has been
without seizure activity since [**2143-9-4**].  Her motor exam improved
slightly in UE and significantly in LE on the Right.

On transfer to the internal medicine service, the patient left
sided strength continued to improve.  She is to continue
Pencillin, Cipro and Flagyl for at least 3 more weeks as
directed by Infectious disease.  Her recent repeat head MRI
showed significant interval improvement.  The patient has
Neurology & Neurosurgical follow-up in the next several weeks
with a repeat MRI scheduled.  She will continue on Keppra,
Phenytoin taper and Divalproex with levels followed by
Neurology.

The patient continues to have head pain which is currently
controlled on a Fentanyl Patch and Dilaudid PO prn.  It is
expected that her need for these medicines will diminish over
the coming weeks.

2. Anastamotic Leak/Splenic Abscess: Patient was noted to have
multiple abscesses on head imaging.  Ciprofloxacin 400 mg IV
Q12H, MetRONIDAZOLE 500 mg IV Q8H and Fluconazole 400 mg IV Q24H
were started empirically as was vancomycin.  The cultures from
burhole surgical site on [**8-31**] grew STREPTOCOCCUS ANGINOSUS
(MILLERI) for which she was desensitized and started on
Penicillin G on [**2143-9-3**], vancomycin was discontinued as was
fluconazole.  She has remained afebrile since [**2143-9-6**].  She
underwent infectious work up which revealed negative UCx, CXR,
[**2143-9-12**] TEE showed no vegetations.  Her CT abdomen showed a
small air-fluid collection at the splenic hilum, tracking
through the spleen in a wedge-shaped configuration, w/ small
pleural effusion and left lower lobe atelectasis as well as a
possible ulceration at the old roux en y site. She was also
noted to have opacities in her sinuses (maxillary, sphenoid, but
not frontal). It was felt that the source for the infection was
either splenic abscess, a possible ulceration vs. extension from
the sinuses (unlikely based on ENT evaluation).  Given difficult
approach, it was felt that she could not undergo drainage by IR.
 The obturator abscess was ruled a hematoma and the splenic
abscess was ruled a remant of the leak.  The patient will
continue Cipro/Flagyl for 3 more weeks under the guidance of
Infectious Disease.

Surgery was consulted for a thorough evaluation of her
anastamotic leak.  After a period of NPO with repeat studies by
CT and X-ray, as well as consultation with bariatric surgery, it
was decided that this leak was likely chronic, and although
possibly the source of the abscesses, did not pose an active
risk with regards to nutrition.  The patient was maintained on
TPN while this was under evaluation, but ultimately was able to
be discharged on a regular diet without issue.

3. R Iliac Deep Vein Thrombosis:  The patient developed a DVT
discovered on CT and confirmed with ultrasound.  Given her
recent brain surgery and history of GI bleeds, the pros and cons
of anticoagulation were weighed with her neuro- and general
surgeons.  Based on obtained old records and a discussion with
the above parties, it was determined that the benefits of
anticoagulation outweighed the risks.  The patient has been
briefed on concerning signs of GI Bleed and pulmonary embolism.
Her PCP agreed to manage her coumadin as an outpatient.  The
patient tolerated 48 hours of a heparin drip and was
transitioned to Lovenox/Coumadin which she will continue until
therapeutic at 2-3.

4. Atrial fibrillation s/p cardioversion:  The patient was
admitted on Sotalol but converted to metoprolol on this
hospitalization.  She was rate controlled in the 60s-80s and
will continue 12.5mg PO BID on discharge.  Anticoagulation per
problem DVT above.

5. Leukopenia/Anemia: The patient developed a stable and
non-hemodynamically significant leukopenia and anemia while
admitted.  These problems have been variously attributed to
Dilantin, Penicillin and her underlying history of lymphoma s/p
BMT.  She was repleted with Vitamin B while admitted.  We have
left the patient instructions to follow up with her PCP &
Oncologist to monitor these values.  Infectious disease will
also monitor her blood counts weekly.

6. Hypertension: The patient had no signs of hypertension and
will continue on Metoprolol.

7. CAD, s/p MI, CABG. The patient was not continued on Aspirin
due to risk of GI bleed and anticoagulation.  She will follow
with her PCP on this issue.

8. Anxiety: The patient was continued on Ativan.

Medications on Admission:
Home Meds
-Sotalol 40 mg [**Hospital1 **]
-Ativan 1mg qhs
-Protonix 20 qd
-Hydromorphone 0.5mg IV PRN
-Acetaminophen 325-650 mg PRN


Discharge Medications:
1. Outpatient Lab Work
Please draw weekly on Wednesdays CBC with diff, BUN, Cr, AST,
ALT, Alk Phos, T bili and forward results to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 6313**] ATTN Dr. [**Name (NI) 1420**] & [**Last Name (LF) 84707**],[**First Name3 (LF) **] C
Address: 128 STATE RT 27, [**Location (un) **],[**Numeric Identifier 84708**]
Phone: [**Telephone/Fax (1) 84709**] Fax: [**Telephone/Fax (1) 84710**]
2. Outpatient Lab Work
Please draw a Depatoke level Wed [**10-16**] and forward to Dr. [**First Name (STitle) **]
Phone ([**Telephone/Fax (1) 35413**] Fax ([**Telephone/Fax (1) 67774**] and Dr. [**Last Name (STitle) 84707**],[**First Name3 (LF) **] C
Address: 128 STATE RT 27, [**Location (un) **],[**Numeric Identifier 84708**] Phone: [**Telephone/Fax (1) 84709**]
Fax: [**Telephone/Fax (1) 84710**]
3. Outpatient Lab Work
Please draw PTs (first draw Wed [**10-16**]) as directed by Dr.
[**Last Name (STitle) 84707**],[**First Name3 (LF) **] C Address: 128 STATE RT 27, [**Location (un) **],[**Numeric Identifier 84708**]
Phone: [**Telephone/Fax (1) 84709**] Fax: [**Telephone/Fax (1) 84710**]
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for skin folds.
[**Telephone/Fax (1) **]:*1 Bottle* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation every six (6) hours as needed for
wheezing.
[**Telephone/Fax (1) **]:*1 HFA* Refills:*0*
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
[**Telephone/Fax (1) **]:*1 Aerosol* Refills:*0*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
[**Telephone/Fax (1) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: 0.5-1 Tablet PO every eight (8)
hours as needed for anxiety.
[**Telephone/Fax (1) **]:*42 Tablet(s)* Refills:*0*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for headache.
10. Levetiracetam 500 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
[**Telephone/Fax (1) **]:*240 Tablet(s)* Refills:*0*
11. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 3 weeks.
[**Telephone/Fax (1) **]:*84 Tablet(s)* Refills:*0*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 3 weeks.
[**Telephone/Fax (1) **]:*63 Tablet(s)* Refills:*0*
13. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
[**Telephone/Fax (1) **]:*10 Patch 72 hr(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*0*
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*0*
16. Enoxaparin 100 mg/mL Syringe Sig: One (1) Syringe
Subcutaneous Q12H (every 12 hours): Please take until stopped by
your Primary Care Physician.
[**Name Initial (NameIs) **]:*14 Syringe* Refills:*0*
17. Penicillin G Potassium 20,000,000 unit Recon Soln Sig:
4,000,000 (4 Million) Units Injection Q4H (every 4 hours) for 3
weeks: Until [**11-1**].
[**Month/Year (2) **]:*26 Units* Refills:*0*
18. PICC Care
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
19. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
[**Month/Year (2) **]:*30 Tablet(s)* Refills:*0*
20. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 Aerosol* Refills:*0*
21. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
[**Hospital1 **]:*168 Tablet(s)* Refills:*0*
22. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day: Total
divalproex dose 1250mg twice daily. .
[**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
23. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO BID (2 times a day): Total
divalproex dose 1250mg twice daily. .
[**Hospital1 **]:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
24. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO BID (2 times a day).
[**Hospital1 **]:*180 Tablet, Chewable(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 8300**] VNA

Discharge Diagnosis:
Primary Diagnoses:
1. Brain Abscess
2. s/p Roux-en-y Bypass with anastamotic leak
3. R femoral deep vein thrombosis
4. Simple partial seizures

Secondary Diagnoses:
Atrial Fibrillation
Aortic Stenosis s/p Aortic valve replacement
Hypertension
Coronary artery disease
Non-hodgkin lymphoma


Discharge Condition:
Hemodynamically stable with normal vital signs. Ambulating
without difficulty.


Discharge Instructions:
You have been admitted to the hospital for evaluation of a brain
abscess.  While you were here, our Neurosurgical team was
successful in draining these abscesses.  Our Infectious Disease
and Surgical teams evaluated you for a source of infection and
found that your old bypass surgery had a small but stable leak,
and this was likely the cause of your infection.  Unfortunately
while you were here you also developed a blood clot which
obligates you to 6 months of anticoagulation therapy.

It has been a long and difficult hospital course and I commend
you on your continued positive spirits.  It has been a true
pleasure caring for you during this difficult time.

There have been many changes to your medications including
antibiotics.  Please ask the nurse for a full print out of your
medications as the most accurate and up to date list.
Of note:
Please stop Sotalol, you will not need this medication at this
time
Please take your Cipro & Flagyl (antibiotics) every day as
directed
Please take your Warfarin (Coumadin, blood thinner) as directed
and follow with Dr. [**Last Name (STitle) **] to guide you on dose. Please continue
enoxaparin until Dr. [**Last Name (STitle) **] tells you otherwise.
Please take valproate, levatiracetem, and fosphenytoin at the
currently prescribed doses until you are told otherwise by your
seizure doctor. While on these medications, you should have your
liver function, platelet count and drug levels drawn and
monitored by either Dr [**Last Name (STitle) **] or your seizure doctor.

Please make all appointments as directed.  For many of our
specialists, we have made appointments for you but you can find
a specialist closer to home.

Please make all appointments as scheduled and recommended:
1. Primary Care: [**Last Name (LF) 84707**],[**First Name3 (LF) **] C [**Telephone/Fax (1) 84709**], Monday [**10-21**] @
11am
Please tell your Primary care doctor that you need a pelvic
ultrasound 6 weeks post discharge to evaluate an adnexal cyst

2. Infectious Disease: [**2143-10-24**] @ 10:00a  with Dr.
[**Last Name (STitle) **] at the:  LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)

3. Neurology (Epileptology): [**2143-11-1**]  01:00p   [**Last Name (LF) **],[**First Name3 (LF) **] T.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  NEUROLOGY UNIT CC8 (SB) (This appointment can be made with
your own neurologist/epileptologist)

4. Neurosurgery: On [**2143-11-26**] at 1:40pm you are scheduled for a
brain MRI, at 2:30pm on the same day you will see Dr [**Last Name (STitle) **]. The
MRI is located on the [**Hospital Ward Name **] basement of the clinical
center. Dr [**Last Name (STitle) **] is located on the [**Location (un) 9998**] of the [**Hospital Unit Name **] behind the clinical center [**Last Name (NamePattern1) 51019**]. Dr [**Name (NI) 28838**] office can be reached at ([**Telephone/Fax (1) 88**].

We recommend the following appointments:
1. Hematologist/Oncologist: Your blood counts were low on this
admission and this should be followed.

2. Gastroenterologist/Bariatric Surgeon: Our surgeons have no
operative recommendations regarding your bypass leak, but your
surgeons may care to re-evaluate you.

Please call your doctor or 911 if you experience worsening or
uncontrolled head pain, confusion, chest pain, difficulty
breathing, nausea, vomiting, abdominal pain, black or bloody
stools or any other concerning medical symptom.

Neurosurgical Instructions:
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Please make all appointments as scheduled and recommended:
1. Primary Care: [**Last Name (LF) 84707**],[**First Name3 (LF) **] C [**Telephone/Fax (1) 84709**], Monday [**10-21**] @
11am
Please tell your Primary care doctor that you need a pelvic
ultrasound 6 weeks post discharge to evaluate an adnexal cyst

2. Infectious Disease: [**2143-10-24**] @ 10:00a  with Dr.
[**Last Name (STitle) **] at the:  LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
ID WEST (SB)

3. Neurology (Epileptology): [**2143-11-1**]  01:00p   [**Last Name (LF) **],[**First Name3 (LF) **] T.
  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  NEUROLOGY UNIT CC8 (SB) (This appointment can be made with
your own neurologist/epileptologist)

4. Neurosurgery: On [**2143-11-26**] at 1:40pm you are scheduled for a
brain MRI, at 2:30pm on the same day you will see Dr [**Last Name (STitle) **]. The
MRI is located on the [**Hospital Ward Name **] basement of the clinical
center. Dr [**Last Name (STitle) **] is located on the [**Location (un) 9998**] of the [**Hospital Unit Name **] behind the clinical center [**Last Name (NamePattern1) 51019**].

We recommend the following appointments:
1. Hematologist/Oncologist: Your blood counts were low on this
admission and this should be followed.

2. Gastroenterologist/Bariatric Surgeon: Our surgeons have no
operative recommendations regarding your bypass leak, but your
surgeons may care to re-evaluate you.
{'Intracranial abscess,Acute respiratory failure,Other primary cardiomyopathies,Bone marrow replaced by transplant,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Epilepsia partialis continua, without mention of intractable epilepsy,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Leukocytopenia, unspecified,Other diseases of spleen,Unspecified essential hypertension,Anemia, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Anxiety state, unspecified,Personal history of other lymphatic and hematopoietic neoplasms,Heart valve replaced by other means,Heart valve replaced by transplant,Aortocoronary bypass status,Old myocardial infarction'}


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: left parietal mass

PRESENT ILLNESS: 53 yo female with a history of non-Hodgkin's lymphoma, s/p BMT
([**2118**]), [**Year (4 digits) 1291**], atrial fibrillation not on coumadin, cardiomyopathy
(EF 45%) who was transferred to [**Hospital1 18**] on [**2143-8-30**] for further
management of left parietal mass. Patient initially presented to
an OSH on [**8-29**] after nearly a week of left frontal headaches,
right sided arm and leg weakness and progressive aphasia. At the
OSH neuroimaging revealed a ring enhancing left parietal mass
with extensive surrounding edema.

MEDICAL HISTORY: Gastric bypass [**2135**] per husband (outside records not available
to confirm date/exact procedure)
Roux-en-Y gastrojejunostomy [**2140**] for "perforated ulcers" per
husband (outside records not available to confirm date/exact
procedure)
-Atrial fibrillation s/p successful cardioversion [**1-9**], taken
off coumadin given h/o UGIB [**2140**]
-Bovine [**Year (4 digits) 1291**] for AS [**3-8**]
-Hypertension
-Non-Hodgkin's lymphoma, status post chemotherapy [**2138**], s/p
partial splenectomy [**2139**], in remission since [**2139**]
CAD
Cardiomyopathy (EF 45%)

MEDICATION ON ADMISSION: Home Meds
-Sotalol 40 mg [**Hospital1 **]
-Ativan 1mg qhs
-Protonix 20 qd
-Hydromorphone 0.5mg IV PRN
-Acetaminophen 325-650 mg PRN

ALLERGIES: Penicillins / Codeine / Keflex

PHYSICAL EXAM: Discharge Exam:
VS: 97.7  113/71  69  20  100% on RA with ambulation
Gen: Pleasant female in no acute distress
HEENT: Healing surgical wound, not erythematous or
infected-appearing. Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Anterior lung exam clear, no wheezes or crackles
appreciated
CV: S1 & S2 regular without murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, 4+/5 RUE strength, 5/5 strength all other
extremities

FAMILY HISTORY: Two brothers with neoplasms.
Mother with lung Ca
No CNS tumors. No seizures. No early strokes or CNS bleeds

SOCIAL HISTORY: She lives with her husband.
Social ETOH.
Denies drugs in the present or the past.
She quit smoking 20 years ago - 37 pack year history 

### Response:
{'Intracranial abscess,Acute respiratory failure,Other primary cardiomyopathies,Bone marrow replaced by transplant,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Epilepsia partialis continua, without mention of intractable epilepsy,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group B,Atrial fibrillation,Leukocytopenia, unspecified,Other diseases of spleen,Unspecified essential hypertension,Anemia, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Anxiety state, unspecified,Personal history of other lymphatic and hematopoietic neoplasms,Heart valve replaced by other means,Heart valve replaced by transplant,Aortocoronary bypass status,Old myocardial infarction'}
