CHIEF COMPLAINT: worsening speech difficulties and decreased movement of the
right arm

PRESENT ILLNESS: The pt is a 50 year-old right-handed man with a recent
history of HSV encephalitis who presents with worsening speech
difficulties and decreased movement of the right arm.  He was
initially diagnosed with HSV 1 meningitis on [**2190-4-23**].  He
presented after he was in an accident while driving from RI to
VT, rented a second car, and was in a second accident, at which
point he was brought to an outside hospital and eventually
diagnosed with HSV meningitis.  He was started on a course of IV
acyclovir, and discharged to [**Hospital 38**] rehab.  His rehab course
was complicated by a lower extremity DVT, for which he was
started on Coumadin, however on [**5-15**] there was concern that the
clot was mobile, and on [**2190-5-16**] he had an IVC filter placed.
Around this time he became febrile to 102.6, and on [**5-18**] was
transferred to [**Hospital1 18**] for fever and worsening confusion.  He was
admitted from [**Date range (1) 66375**], during which time he underwent a repeat
LP, which showed 56 WBCs and a protein of 83, but was HSV
negative.  He had blood and urine cultures that were also
negative.  His fevers resolved with restarting acyclovir, though
his mental status continued to fluctuate, and he was sent back
to
rehab on [**5-21**].  His sister continued to visit him, and reports
that even as recently as two days ago he was actually starting
to
improve.  At his best he was reported to be communicative, with
a
slightly strange affect, and mild short term memory and
executive
function impairment.  However, on [**5-26**] he was noted to be very
unsteady with PT, and was found to be orthostatic as low of SBP
of 60 when standing, and it was recommended that he start both
fludrocortisone and midodrine.  On [**5-27**] the patient was noted to
be forcibly keeping his right eye closed, and also was felt to
be
more apraxic with worsening coordination.  He was also felt to
not be moving his right arm as frequently.  For all of this he
was transferred to [**Hospital1 18**] for further evaluation.

MEDICAL HISTORY: - Lyme disease, per sister s/p treatment years ago
- Malaria, per sister s/p treatment years ago
- Lumbar laminectomy

MEDICATION ON ADMISSION: - Colace 100mg [**Hospital1 **]
- Finasteride 5mg daily
- Fludrocortisone 0.1mg daily
- Keppra 500mg [**Hospital1 **]
- Midodrine 5mg daily
- Mirtazapine 15mg QHS
- Pantoprazole 40mg daily
- Senna 2 tablets daily
- Tamsulosin 0.4mg daily
- Coumadin
- Acyclovir 500mg Q8hr

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.6 P: 77 R: 16  BP: 108/94 SaO2: 94% on RA
General: Awake, cooperative, NAD.  Intermittent twitching of the
right cheek, biting of the lip, sharp intakes of breath, and
automotisms of the left hand throughout the exam.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Mild stiffness and nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Blood clots in sister (unprovoked PE age 33) and father
(multiple DVT post-op). Sister has also had 3 miscarriages.

SOCIAL HISTORY: Divorced, has a girlfriend. Previously worked as a fundraiser
and ?park ranger equivalent in [**Doctor Last Name **], in excellent
physical health. No T/E/D that sister knows of.
Herpetic meningoencephalitis,Cerebral edema,Epilepsia partialis continua, with intractable epilepsy,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Personal history of malaria,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dehydration,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Anemia of other chronic disease,Long-term (current) use of anticoagulants
Herpetic encephalitis,Cerebral edema,Epil par cont w intr epi,Ac kidny fail, tubr necr,Acute respiratry failure,K. pneumoniae pneumonia,Ch DVT/embl prox low ext,Protein-cal malnutr NOS,Urin tract infection NOS,Oth/uns inf-cen ven cath,Personal histry malaria,Abn react-procedure NEC,Dehydration,Adv eff antconvl NEC/NOS,Anemia-other chronic dis,Long-term use anticoagul
Admission Date:  [**2190-5-27**]              Discharge Date:   [**2190-7-23**]

Date of Birth:  [**2139-6-11**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
worsening speech difficulties and decreased movement of the
right arm

Major Surgical or Invasive Procedure:
lumbar puncture
tracheostomy
PEG tube

History of Present Illness:
The pt is a 50 year-old right-handed man with a recent
history of HSV encephalitis who presents with worsening speech
difficulties and decreased movement of the right arm.  He was
initially diagnosed with HSV 1 meningitis on [**2190-4-23**].  He
presented after he was in an accident while driving from RI to
VT, rented a second car, and was in a second accident, at which
point he was brought to an outside hospital and eventually
diagnosed with HSV meningitis.  He was started on a course of IV
acyclovir, and discharged to [**Hospital 38**] rehab.  His rehab course
was complicated by a lower extremity DVT, for which he was
started on Coumadin, however on [**5-15**] there was concern that the
clot was mobile, and on [**2190-5-16**] he had an IVC filter placed.
Around this time he became febrile to 102.6, and on [**5-18**] was
transferred to [**Hospital1 18**] for fever and worsening confusion.  He was
admitted from [**Date range (1) 66375**], during which time he underwent a repeat
LP, which showed 56 WBCs and a protein of 83, but was HSV
negative.  He had blood and urine cultures that were also
negative.  His fevers resolved with restarting acyclovir, though
his mental status continued to fluctuate, and he was sent back
to
rehab on [**5-21**].  His sister continued to visit him, and reports
that even as recently as two days ago he was actually starting
to
improve.  At his best he was reported to be communicative, with
a
slightly strange affect, and mild short term memory and
executive
function impairment.  However, on [**5-26**] he was noted to be very
unsteady with PT, and was found to be orthostatic as low of SBP
of 60 when standing, and it was recommended that he start both
fludrocortisone and midodrine.  On [**5-27**] the patient was noted to
be forcibly keeping his right eye closed, and also was felt to
be
more apraxic with worsening coordination.  He was also felt to
not be moving his right arm as frequently.  For all of this he
was transferred to [**Hospital1 18**] for further evaluation.


Past Medical History:
- Lyme disease, per sister s/p treatment years ago
- Malaria, per sister s/p treatment years ago
- Lumbar laminectomy


Social History:
Divorced, has a girlfriend. Previously worked as a fundraiser
and ?park ranger equivalent in [**Doctor Last Name **], in excellent
physical health. No T/E/D that sister knows of.


Family History:
Blood clots in sister (unprovoked PE age 33) and father
(multiple DVT post-op). Sister has also had 3 miscarriages.


Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.6 P: 77 R: 16  BP: 108/94 SaO2: 94% on RA
General: Awake, cooperative, NAD.  Intermittent twitching of the
right cheek, biting of the lip, sharp intakes of breath, and
automotisms of the left hand throughout the exam.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Mild stiffness and nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Exam fluctuates significantly throughout.
Alert,
oriented to self but states it is [**Month (only) 956**], then starts reciting
[**2184**]..[**2185**]..[**2186**] when asked the year.  Later can state [**2190**] and
that the president is [**Last Name (un) 2753**].  States he is at [**Hospital 38**] Rehab.
Has intermittent dysarthria, most notable with '[**Name Prefix (Prefixes) **]' '[**Last Name (Prefixes) **]' and
'ka'
sounds, but this fluctuates.  Can follow simple midline and
appendicular commands, though with two step commands, such as
'take your left hand and touch your right ear' looks at his left
hand, picks it up, then holds it over his head.  When asked what
he is supposed to be doing states 'I'm supposed to touch my
right
ear' but never actually does it, and when asked a minute later
what he is supposed to be doing states 'picking my nose' (still
with his left arm held suspended above his head).  Able to read,
though periodically adds the word 'hospital' into sentences (e.g
'near the table in the hospital dining room').  Can name the
key,
glove and feather on the stroke card, but says 'tetanus with a
shower in between' for the cactus, a nonsensical word for the
chair and 'nice...a mattress' for the hammock.  Able to count to
20 forwards, but when counting backwards makes it to 12, then
repeats 12, 13, 12, 11, 12, 13.... When asked to repeat a second
time does the exact same thing.  Unable to register even 1 of 3
objects.  Is able to register my name, but when asked to produce
it ~3 minutes later, pauses, and then names a friend of his, who
he states looks like me.  Has difficulty describing the events
of
his recent hospitalization, but is able to provide appropriate
history prior to his illness (information about his life in
[**Location (un) 7188**], his sister's family and his nephew, all confirmed by
his
sister).

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  Keeps right eye squinted shut.
Able to grossly count fingers in all quadrants with the left
eye,
and will look towards a moving finger in all fields, though will
not fully cooperate with more formal testing.
III, IV, VI: Will track objects to the right without difficulty,
though takes significant prompting, including a $5 [**Doctor First Name **] to look
over to the left, and even then does not fully bury the sclera
of
the left eye.
V: Facial sensation intact to light touch.
VII: Left sided facial droop, and right eye slightly squinted at
rest, though can open it volitionally.  Intermittent twitching
of
the right check
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Will not fully open mouth to assess palate.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Significant paratonia throughout, with limited
cooperation for testing all muscle groups.  When attempts are
made to assess for pronator drift, holds both arms up over his
head, and will not allow them to be repositioned.
  Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L  5    5   5   5   5  5  5   5    5  5     5
R  4+   4+  5   5   5  5  5   5    5  5     5

-Sensory: Reports vibration feels slightly less on the right
knee
compared to the left.  Otherwise no reported deficits to light
touch, pinprick, cold sensation, proprioception throughout.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: Poor cooperation with attempts at FNF.
Eventually
able to coerce him into giving 'high 5' on either side with no
clear dysmetria.  Also able to reach his toe to my hand on
either
side with no dysmetria.

-Gait: Deferred given significant confusion, poor cooperation
and
impulsivity, with concern for fall risk.
DISCHARGE EXAM: deceased

Pertinent Results:
ADMISSION LABS:

[**2190-5-27**] 01:30PM BLOOD WBC-7.9 RBC-3.94* Hgb-12.3* Hct-33.4*
MCV-85 MCH-31.1 MCHC-36.7* RDW-16.7* Plt Ct-289
[**2190-5-27**] 01:30PM BLOOD Neuts-73.8* Lymphs-18.4 Monos-5.2 Eos-1.8
Baso-0.8
[**2190-5-27**] 01:30PM BLOOD PT-34.5* PTT-32.0 INR(PT)-3.4*

[**2190-6-1**] 06:23AM BLOOD  WBC-6.7 Lymph-24 Abs [**Last Name (un) **]-1608 CD3%-71
Abs CD3-1139 CD4%-44 Abs CD4-709 CD8%-27 Abs CD8-427 CD4/CD8-1.7
[**2190-7-5**] 09:34AM BLOOD  WBC-4.9 Lymph-10* Abs [**Last Name (un) **]-490 CD3%-85
Abs CD3-419* CD4%-43 Abs CD4-212* CD8%-42 Abs CD8-207
CD4/CD8-1.0
[**2190-5-27**] 01:30PM BLOOD Glucose-87 UreaN-20 Creat-1.2 Na-137
K-4.2 Cl-100 HCO3-27 AnGap-14
[**2190-5-27**] 01:30PM BLOOD ALT-40 AST-22 AlkPhos-42 TotBili-0.6
[**2190-6-2**] 10:40AM BLOOD TSH-4.9*
[**2190-6-30**] 05:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2190-6-1**] 06:23AM BLOOD IgG-805 IgA-125 IgM-126
[**2190-7-6**] 08:00PM BLOOD HIV Ab-NEGATIVE
[**2190-6-30**] 05:30AM BLOOD HCV Ab-NEGATIVE

HTLV I/II ANTIBODY, WITH      Nonreactive
QUANTIFERON(R)-TB GOLD        NEGATIVE
TETANUS ANTITOXOID AB         2.32

CSF STUDIES:
[**2190-6-1**] 08:57AM CEREBROSPINAL FLUID (CSF) WBC-13 RBC-3* Polys-1
Lymphs-96 Monos-0 Macroph-3
[**2190-6-24**] 12:56PM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-10* Polys-0
Lymphs-97 Monos-3
[**2190-6-1**] 08:57AM CEREBROSPINAL FLUID (CSF) TotProt-88*
Glucose-55
[**2190-6-24**] 12:56PM CEREBROSPINAL FLUID (CSF) TotProt-68*
Glucose-76

Herpes Virus 6 DNA, Qualitative Real-Time PCR
  HHV-6 DNA          Not Detected

[**Male First Name (un) 2326**] Virus DNA Ultrasensitive Quantitative Real-Time PCR
  [**Male First Name (un) 2326**] Virus DNA, Ultra QN PCR  Negative

Herpes Simplex Virus PCR
   Specimen Source: Cerebrospinal Fluid
Result ------  Negative on both [**6-1**] and [**6-24**]

VARICELLA ZOSTER VIRUS (VZV)  Not Detected
 Not Detected DNA, QL RT PCR

CMV DNA, QL PCR               NOT DETECTED

[**Doctor Last Name 3271**] [**Doctor Last Name **] Virus, Qualitative Real Time PCR
  EBV DNA, QL PCR         Not Detected

IMAGING:
MRI/A BRAIN [**2190-6-1**]
Bilateral temporal lobe enhancing signal abnormality with also
extension into the bilateral insula and right cingulate gyrus.
Encephalomalacic changes in the right temporal lobe suggest that
this represents an acute on chronic infectious process, on the
left, this appears to be acute.
No evidence for acute ischemia or hydrocephalus.
Unremarkable MRA of the head and neck.

MRI C-SPINE
1. No abnormal spinal cord signal or enhancement to suggest an
inflammatory process within the spinal cord. No evidence of
osteomyelitis, discitis or epidural abscess.
2. Degenerative changes, particularly at C5-C6, where there is
high-grade
spinal canal narrowing.

MRI BRAIN [**2190-6-20**]
Substantial progression of brain abnormalities, which remain
compatible with the stated clinical diagnosis of herpes simplex
encephalitis.

MRI BRAIN [**2190-7-8**]
Unchanged encephalomalacia of the right temporal lobe with
interval decrease in the extent of white matter edema in the
brain. No areas of enhancement.

MRI BRAIN [**2190-7-12**]
Stable appearances of the diffuse white matter FLAIR
hyperintensities since [**2190-7-8**], however, improved signal
changes since [**2190-6-20**]. White matter signal changes could
reflect two seizure episodes. Stable
encephalomalacia in the right temporal lobe and enhancement
along the right mesial temporal lobes and right frontal [**Doctor Last Name 352**]
matter. No new intracranial abnormality.


Brief Hospital Course:
NEURO:
SEIZURES:
On initial EEG, he was thought to be in complex partial status,
and was
given a trial of ativan with electrographic and clinical
improvement. He was increased on his Keppra from 500 mg [**Hospital1 **] to
1500 mg [**Hospital1 **]. He continued to have frequent R temporal
complex partial seizures, characterized by focal rhythmic theta
activity.  Clinically, the seizures were characterized by L hand
twitching movements, R facial twitching, and confusion.
On [**5-29**], He was loaded on phosphenytoin and started on
maintenance
dosing with improvement in seizure frequency.  On [**6-1**], he was
loaded on vimpat 200 mg IV, and started on maintenance of 100 mg
[**Hospital1 **].

Patient had a very complicated course with many antiepileptic
medications trialed.

He was initially transferred to the ICU for hypotension and
respiratory distress.
His seizures were controlled with midazolam, then he was
switched to propofol because midazolam was not providing
sufficient sedation, and this was also effective in suppressing
seizures. He then began having frequent nonconvulsive seizures,
and was started on phenobarbital [**6-6**], and Depakote on [**6-9**]. He
underwent trach and PEG [**6-11**]. Zonisamide and Topamax were also
tried. He temporarily was able to be transferred to the
neurology step down unit, but returned to the ICU for midazolam
drip on [**2190-7-4**].

Nonconvulsive status epilepticus remained refractory.  The
seizures continued to originate from bilateral temporal lobes
despite increasing serum levels of Dilantin (corrected 20-25)
and phenobarbital (90-100) and midazolam drip.

HSV ENCEPHALITIS:
Patient had severe HSV encephalitis resulting in necrosis and
cystic changes in bilateral temporal lobes. Serial MRIs also
showed development of extensive vasogenic edema in bilateral
cortices. There was concern for ADEM process, and patient was
treated with 5 days high dose steroids. Repeat MRI did show
improvement in the diffuse edema after steroids. Another repeat
MRI done several days after stopping steroids appeared stable
with no further improvement but no worsening. It was impossible
to determine if the steroids would have improved his mental
status, this the timing coincided with worsening of his seizures
and starting midazolam drip. On [**2190-7-21**], a family meeting
was held with the epilepsy team, palliative care, and the SICU
team. It was decided that the patient would not want to go on
with his current quality of life. It was then decided to make
the patient comfort-measures-only with continuation of the
antiepileptics and to pursue extubation on Friday [**7-23**]. The
patient maintained off of intubation for several hours but
ultimately passed away Friday night.

ID:
1. HSV ENCEPHALITIS- ID was consulted on admission. Patient has
completed 2 21 day courses of acyclovir. Repeat CSF HSV PCR was
negative x 2. He underwent thorough workup for other coexisting
viral infections which was negative (HIV, CMV, EBV, VZV, HTLV1,
[**Male First Name (un) 2326**] virus). HIV viral load was also negative, so patient could
not possibly be in the "window period" of acute infection. HSV
culture was also negative from the CSF, so there was no evidence
that the type of HSV was resistant to acyclovir, and thus no
additional antiviral treatment was warranted. Brain biopsy was
discussed several times throughout his course, but ultimately
decided that there would be no diagnostic or therapeutic
advantage from this.

2. FEVER OF UNKNOWN ORIGIN-
Patient developed fever to 102 daily. He was initially treated
with empiric course of vanco/zosyn but fevers persisted with no
clear source and all cultures negative. ID ultimately thought
this was either drug or central fever. He did also develop a
mild maculopapular rash and elevated eosinophil count, which
point toward drug fever. His seizure medications were likely
culprit, but could not be stopped due to nonconvulsive status.
The rash improved on its own and the fevers continued until
discharge.

3. LYMPHOPENIA/LOW CD4 COUNT
Patient developed lymphopenia and low CD 4 count (212 on [**7-5**]).
This caused concern for HIV, but HIV antibodies and viral load
were negative. Other possible causes such as CMV and HTLV1 were
also negative. This may be due to chronic illness and bone
marrow suppression from HSV infection.

4. UTI
Urine culture from [**7-9**] grew >100,000 E coli, treated with
ceftriaxone.

5. PNA
Sputum culture from [**7-9**] grew Klebsiella, treated with
ceftriaxone.

GI:
TRANAMINITIS- Patient had normal LFTs on admission but developed
elevation in AST/ALT to 300-400 with no elevated bilirubin but
with elevated ammonia. This was likely a medication side effect,
and improved with stopping Depakote.
There was then a second episode of LFT elevation that resolved
with stopping zonisamide.

HEME:
1. DVT-
 His prior rehab course was complicated by a lower extremity DVT
and he was started on Coumadin. However, on [**5-15**] there was
concern that the clot was mobile, and on [**2190-5-16**] he had an IVC
filter placed. He was treated with therapeutic doses of Lovenox
during this hospitalization, since coumadin was interacting with
AEDs.

2. Anemia
Hematocrit gradually trended down during admission from 33 at
admission to 25. Hematology was consulted. There was no evidence
of hemolysis or any other acute concerning process on peripheral
smear. Iron studies were consistent with iron deficiency so he
was started on ferrous sulfate daily. There was also likely
contribution of bone marrow suppression from medications.

RENAL:
Acute kidney injury- likely due to acyclovir and hypotension on
sedation and AEDs. Resolved.

Medications on Admission:
- Colace 100mg [**Hospital1 **]
- Finasteride 5mg daily
- Fludrocortisone 0.1mg daily
- Keppra 500mg [**Hospital1 **]
- Midodrine 5mg daily
- Mirtazapine 15mg QHS
- Pantoprazole 40mg daily
- Senna 2 tablets daily
- Tamsulosin 0.4mg daily
- Coumadin
- Acyclovir 500mg Q8hr


Discharge Medications:
Deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
refractory status epilepticus from HSV encephalitis

Discharge Condition:
deceased

Discharge Instructions:
NA

Followup Instructions:
NA
{'Herpetic meningoencephalitis,Cerebral edema,Epilepsia partialis continua, with intractable epilepsy,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Personal history of malaria,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dehydration,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Anemia of other chronic disease,Long-term (current) use of anticoagulants'}


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: worsening speech difficulties and decreased movement of the
right arm

PRESENT ILLNESS: The pt is a 50 year-old right-handed man with a recent
history of HSV encephalitis who presents with worsening speech
difficulties and decreased movement of the right arm.  He was
initially diagnosed with HSV 1 meningitis on [**2190-4-23**].  He
presented after he was in an accident while driving from RI to
VT, rented a second car, and was in a second accident, at which
point he was brought to an outside hospital and eventually
diagnosed with HSV meningitis.  He was started on a course of IV
acyclovir, and discharged to [**Hospital 38**] rehab.  His rehab course
was complicated by a lower extremity DVT, for which he was
started on Coumadin, however on [**5-15**] there was concern that the
clot was mobile, and on [**2190-5-16**] he had an IVC filter placed.
Around this time he became febrile to 102.6, and on [**5-18**] was
transferred to [**Hospital1 18**] for fever and worsening confusion.  He was
admitted from [**Date range (1) 66375**], during which time he underwent a repeat
LP, which showed 56 WBCs and a protein of 83, but was HSV
negative.  He had blood and urine cultures that were also
negative.  His fevers resolved with restarting acyclovir, though
his mental status continued to fluctuate, and he was sent back
to
rehab on [**5-21**].  His sister continued to visit him, and reports
that even as recently as two days ago he was actually starting
to
improve.  At his best he was reported to be communicative, with
a
slightly strange affect, and mild short term memory and
executive
function impairment.  However, on [**5-26**] he was noted to be very
unsteady with PT, and was found to be orthostatic as low of SBP
of 60 when standing, and it was recommended that he start both
fludrocortisone and midodrine.  On [**5-27**] the patient was noted to
be forcibly keeping his right eye closed, and also was felt to
be
more apraxic with worsening coordination.  He was also felt to
not be moving his right arm as frequently.  For all of this he
was transferred to [**Hospital1 18**] for further evaluation.

MEDICAL HISTORY: - Lyme disease, per sister s/p treatment years ago
- Malaria, per sister s/p treatment years ago
- Lumbar laminectomy

MEDICATION ON ADMISSION: - Colace 100mg [**Hospital1 **]
- Finasteride 5mg daily
- Fludrocortisone 0.1mg daily
- Keppra 500mg [**Hospital1 **]
- Midodrine 5mg daily
- Mirtazapine 15mg QHS
- Pantoprazole 40mg daily
- Senna 2 tablets daily
- Tamsulosin 0.4mg daily
- Coumadin
- Acyclovir 500mg Q8hr

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.6 P: 77 R: 16  BP: 108/94 SaO2: 94% on RA
General: Awake, cooperative, NAD.  Intermittent twitching of the
right cheek, biting of the lip, sharp intakes of breath, and
automotisms of the left hand throughout the exam.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Mild stiffness and nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Blood clots in sister (unprovoked PE age 33) and father
(multiple DVT post-op). Sister has also had 3 miscarriages.

SOCIAL HISTORY: Divorced, has a girlfriend. Previously worked as a fundraiser
and ?park ranger equivalent in [**Doctor Last Name **], in excellent
physical health. No T/E/D that sister knows of. 

### Response:
{'Herpetic meningoencephalitis,Cerebral edema,Epilepsia partialis continua, with intractable epilepsy,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Other and unspecified infection due to central venous catheter,Personal history of malaria,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dehydration,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Anemia of other chronic disease,Long-term (current) use of anticoagulants'}
