CHIEF COMPLAINT: fever, lethargy

PRESENT ILLNESS: 66 year old female, history of large B cell lymhoma s/p 6 cycles
R-CHOP, auto SCT in [**Month (only) 958**], h/o C diff, traumatic SDH s/p
evacuations, presents with one day of fevers, lethargy. Patient
has expressive aphasia at baseline but per family she is much
more lethargic than normal. No localizing symptoms except for
increasing diarrhea. Per patient's family, she had recent CDiff
infection (last documented here at end of [**Month (only) 205**]) and po
vancomycin was stopped on [**2158-10-5**].
.
She is followed in [**Hospital **] clinic by Dr. [**Last Name (STitle) 724**] for SDH,
seizures and encephalopathy. Recent EEG on [**10-9**] showed cortical
irritability but not electrographic epileptogenic activity seen.

MEDICAL HISTORY: 1. High-grade large B cell non-Hodgkin's lymphoma diagnosed
[**10-14**]. She was treated with 6 cycles of R-CHOP [**2157-11-2**] through
[**2158-1-17**]. Treatment course complicated by fever and neutropenia.
Supportive care with Neulasta and Aranesp given. PET at the end
of treatment showed no FDG-avid disease. Stem cell mobilization
performed [**2158-2-16**]. Anutologous stem cell transplant with BEAM
chemotherapy was done in [**2158-3-9**].
2. Intra-parenchymal hemorrhage and sub-dural hematoma s/p
evacuation x 4 following fall.
3. Bilateral pulmonary emboli and LLE DVT in [**10-14**]
4. Heparin-induced thrombocytopenia in [**11-14**]
5. Suprarenal IVC filter placed on [**2158-2-10**] (large infrarenal
IVC clot and thrombosis of left common iliac and left femoral
veins seen at that time)
6. C. difficile colitis [**2-15**] and [**3-15**]
7. Staphylococcus hand infection treated with incision and
drainage and subsequent antibiotics
8. Right toe Staphylococcus infection
9. Hypertension
10. Osteoarthritis
11. Peripheral neuropathy (attributed to her chemotherapy)
12. Tonsillectomy
13. Cholecystectomy
[**65**]. Excision of a benign abdominal tumor

MEDICATION ON ADMISSION: Acetazolamide 250 mg po q6hrs
Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 750mg PO Q 8H prn szs; 7.5
ml
(750 mg) PO/Gtube every 8 hours.
Prednisone 15mg daily ??
Acetaminophen 160 mg/5 mL Solution po q6hrs prn
Docusate Sodium 50 mg/5 mL 10ml po bid
Thiamine HCl 100 mg po daily/folate 1mg po daily
Metoprolol Tartrate 75mg po bid
Vancomycin 125 mg po q6hrs (recently stopped)
Miconazole Nitrate 2 % Powder Topical TID prn

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: V: HR 99 BP 115/49 RR 32 100%/4Ln.c.
GEN: awake, ill-appearing female, tachypneic
HEENT: PERRL, opens eyes to command but does not track,
anicteric sclera, OP with some white coating on tongue
Neck: no LAD
CV: regular, tachycardic, no murmurs appreciated
Pulm: coarse breath sounds bilaterally
Abd: (+) bowel sounds, soft, nondistended, mild TTP LLQ and mod
TTP LUQ, j tube in place, mild erythema around a suture but not
at J tube site
Ext: warm, trace edema
Neuro: awake, aphasic at baseline, able to open eyes and mouth
to command, grunts yes/no at times or slight nod, not moving
extremitites to me.

FAMILY HISTORY: Mother: [**Name (NI) **] cancer
Father: Prostate [**Name (NI) 3730**]

SOCIAL HISTORY: She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability.  She is also caring for her grandchild.  She has
been married for 41 years.  She has two children, one son and
one daughter, and four grandchildren.  She is a nonsmoker and
does
not drink alcohol.
Pneumocystosis,Other pulmonary embolism and infarction,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Bone marrow replaced by transplant,Pulmonary collapse,Other and unspecified infection due to central venous catheter,Other specified septicemias,Unspecified essential hypertension,Unspecified hereditary and idiopathic peripheral neuropathy,Infection with microorganisms without mention of resistance to multiple drugs,Status of other artificial opening of gastrointestinal tract,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Pneumocystosis,Pulm embol/infarct NEC,Int inf clstrdium dfcile,Oth lymp unsp xtrndl org,Trnspl status-bne marrow,Pulmonary collapse,Oth/uns inf-cen ven cath,Septicemia NEC,Hypertension NOS,Idio periph neurpthy NOS,Inf mcr rst ot drg nt ml,Enterostomy status NEC,Adv eff anticoagulants,Accident in place NEC,Abn react-procedure NEC
Admission Date:  [**2158-10-15**]              Discharge Date:   [**2158-11-10**]

Date of Birth:  [**2092-3-5**]             Sex:   F

Service: MEDICINE

Allergies:
Heparin Agents / Motrin / Phenobarbital / Vancomycin

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
fever, lethargy

Major Surgical or Invasive Procedure:
flexible bronchoscopy


History of Present Illness:
66 year old female, history of large B cell lymhoma s/p 6 cycles
R-CHOP, auto SCT in [**Month (only) 958**], h/o C diff, traumatic SDH s/p
evacuations, presents with one day of fevers, lethargy. Patient
has expressive aphasia at baseline but per family she is much
more lethargic than normal. No localizing symptoms except for
increasing diarrhea. Per patient's family, she had recent CDiff
infection (last documented here at end of [**Month (only) 205**]) and po
vancomycin was stopped on [**2158-10-5**].
.
She is followed in [**Hospital **] clinic by Dr. [**Last Name (STitle) 724**] for SDH,
seizures and encephalopathy. Recent EEG on [**10-9**] showed cortical
irritability but not electrographic epileptogenic activity seen.

.
ED: Febrile to 103F. tachy 110-120s, BP stable, tachypneic 40s,
97%4L. Initially hypertensive then bp dropped to 100's systolic.
Given tylenol x 1, ondansetron x 1, vancomycin, flagyl,
levofloxacin. Given benadryl x 1. Oncology was notifed and
empiric solumedrol 50mg iv 1 given for stress dose (was on
prednisone as outpt so no [**Last Name (un) 104**] stim). EKG - < 1mm ST depressions
in V4-V6. CXR - no acute process. Diarrhea persisted in ED.


Past Medical History:
1. High-grade large B cell non-Hodgkin's lymphoma diagnosed
[**10-14**]. She was treated with 6 cycles of R-CHOP [**2157-11-2**] through
[**2158-1-17**]. Treatment course complicated by fever and neutropenia.
Supportive care with Neulasta and Aranesp given. PET at the end
of treatment showed no FDG-avid disease. Stem cell mobilization
performed [**2158-2-16**]. Anutologous stem cell transplant with BEAM
chemotherapy was done in [**2158-3-9**].
2. Intra-parenchymal hemorrhage and sub-dural hematoma s/p
evacuation x 4 following fall.
3. Bilateral pulmonary emboli and LLE DVT in [**10-14**]
4. Heparin-induced thrombocytopenia in [**11-14**]
5. Suprarenal IVC filter placed on [**2158-2-10**] (large infrarenal
IVC clot and thrombosis of left common iliac and left femoral
veins seen at that time)
6. C. difficile colitis [**2-15**] and [**3-15**]
7. Staphylococcus hand infection treated with incision and
drainage and subsequent antibiotics
8. Right toe Staphylococcus infection
9. Hypertension
10. Osteoarthritis
11. Peripheral neuropathy (attributed to her chemotherapy)
12. Tonsillectomy
13. Cholecystectomy
[**65**]. Excision of a benign abdominal tumor

Social History:
She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability.  She is also caring for her grandchild.  She has
been married for 41 years.  She has two children, one son and
one daughter, and four grandchildren.  She is a nonsmoker and
does
not drink alcohol.


Family History:
Mother: [**Name (NI) **] cancer
Father: Prostate [**Name (NI) 3730**]

Physical Exam:
V: HR 99 BP 115/49 RR 32 100%/4Ln.c.
GEN: awake, ill-appearing female, tachypneic
HEENT: PERRL, opens eyes to command but does not track,
anicteric sclera, OP with some white coating on tongue
Neck: no LAD
CV: regular, tachycardic, no murmurs appreciated
Pulm: coarse breath sounds bilaterally
Abd: (+) bowel sounds, soft, nondistended, mild TTP LLQ and mod
TTP LUQ, j tube in place, mild erythema around a suture but not
at J tube site
Ext: warm, trace edema
Neuro: awake, aphasic at baseline, able to open eyes and mouth
to command, grunts yes/no at times or slight nod, not moving
extremitites to me.


Pertinent Results:
ADMISSION LABS:
[**2158-10-14**] 08:25PM   WBC-8.9# RBC-3.31* HGB-12.5 HCT-36.2 MCV-110*
MCH-37.9* MCHC-34.6 RDW-16.8*
[**2158-10-14**] 08:25PM   NEUTS-83.3* BANDS-0 LYMPHS-13.4* MONOS-2.7
EOS-0.3 BASOS-0.2
[**2158-10-14**] 08:25PM   PT-12.7 PTT-22.9 INR(PT)-1.1
[**2158-10-14**] 08:25PM   RET AUT-1.4
[**2158-10-14**] 08:25PM   FIBRINOGE-356
[**2158-10-14**] 08:20PM   LACTATE-2.7* K+-4.0
[**2158-10-14**] 08:25PM   HAPTOGLOB-297*
[**2158-10-14**] 08:25PM   GLUCOSE-144* UREA N-32* CREAT-0.9 SODIUM-141
POTASSIUM-5.0 CHLORIDE-111* TOTAL CO2-16* ANION GAP-19
[**2158-10-14**] 08:25PM   ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-3.0
MAGNESIUM-1.6
[**2158-10-14**] 08:25PM   ALT(SGPT)-55* AST(SGOT)-71* LD(LDH)-720* ALK
PHOS-56 AMYLASE-36 TOT BILI-0.5
[**2158-10-14**] 08:25PM   DIR BILI-0.1
[**2158-10-14**] 08:25PM   LIPASE-33
.
ECG ([**10-14**]): Sinus tachycardia. Diffuse non-specific ST-T wave
changes.
CXR ([**10-14**]): No evidence of focal consolidation.
AXR ([**10-15**]): Limited examination. Non-obstructive bowel gas
pattern.
AXR ([**10-28**]): Unremarkable bowel gas pattern.
.
CT-abd/pelvis ([**10-15**]): 1.Pancolitis. 2.Unchanged IVC filter at
the level of the renal veins.
.
CT-chest ([**10-18**]): 1.New right apical area of ground glass
opacity as well as new right middle and right lower lobe areas
of peribronchial opacities and centrilobular nodules most likely
due to an acute infection. The nondependent location of some
opacities is atypical aspiration.  2.New small pericardial
effusion with questionable pericardial thickening. Correlation
with echocardiography may be helpful. 3.New tiny left pleural
effusion. 4.Unchanged multiple liver and renal cysts.
5.Unchanged appearance of IVC filter.
.
CT-head ([**10-18**]): No new intracranial hemorrhage is seen compared
to the prior examination.
.
Echocardiogram ([**10-19**]): The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The left ventricular inflow pattern
suggests impaired relaxation. The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade. Compared with the prior study (images reviewed) of
[**2158-5-26**], the findings are similar. Pulmonary artery systoic
pressure could not be estimated on the current study.
.
EEG ([**10-21**]): This is an abnormal portable EEG in the waking and
drowsy
states due to high voltage multifocal sharp waves arising
broadly over
the left hemisphere, but most notably over the left anterior
quadrant.
Some of the increased voltage amplitude over the left hemisphere
may be
due to breech rhythm, given the patient's history of craniotomy
and
skull defect in that region. The sharp wave discharges suggest
areas of
ongoing cortical irritability with potential for
epileptogenesis. No
rhythmic or repetitive discharges were noted. In addition, there
was
prominent and persistent mixed frequency slowing on the left
side,
consistent with ongoing subcortical dysfunction. No
electrographic
seizures were noted.
.
CT-chest ([**10-23**]): New diffuse ground-glass opacities with upper
lobe predominance, accompanied by septal and bronchovascular
thickening. In the setting of cough and fever, opportunistic
infection such as PCP should be considered. Differential
diagnosis includes hydrostatic pulmonary edema, pulmonary
hemorrhage, and drug reaction.
.
EEG ([**10-29**]): This is an abnormal portable EEG due to high
voltage
multifocal sharp wave discharges arising broadly over the left
hemisphere, suggestive of ongoing cortical irritability with
potential for epileptogenesis. No sustained or repetitive
discharges
were noted. The persistent mixed frequency slowing evident
on the left side is consistent with subcortical dysfunction on
the left,
while the more generalized delta frequency slowing, in the
setting of
the slow and disorganized background, suggests a mild to
moderate global
encephalopathy. The finding of an encephalopathic pattern
suggests
bilateral or deep midline dysfunction. Medications, metabolic
disturbance, and infection are the most common causes of
encephalopathy.
No electrographic seizures were noted.
.

Brief Hospital Course:
66 year old female h/o large B cell lymhoma s/p 6 cycles R-CHOP,
auto SCT in [**2-15**], h/o of recurrent C diff, SDH s/p 4 evacuations
c/b global aphasia presents with fevers, diarrhea. In the ED,
patient was febrile to 103F, tachycardic, tachypneic, satting
97%on 4l and initially hypertensive but bp then dropped to 100's
systolic. Patient was given tylenol x 1, ondansetron x 1, and
started on vancomycin, flagyl, levofloxacin. Given benadryl x 1.
Per oncology fellow, patient was given solumedrol 50mg iv 1
given for stress dose. EKG - < 1mm ST depressions in V4-V6. CXR
- no acute process. Diarrhea persisted in the ED. Patient wa
initially treated in the ICU for hypotension. Her metoprolol was
held and she was fluid resuscitated.
.
# Hypotension - Patient was initially hypotensive and admitted
to the unit. Stress dose steroids were given in the ED.
Patient's neurooncologist was concerned about adrenal
insufficiency and started patient on prednisone, increasing from
2.5 to 10mg on [**2158-9-15**] and then to 15mg daily on [**2158-9-22**]. SBP was
responsive to fluid bolus, c/w with presumed
prerenal/hypovolemia status. Upon discharge from the ICU, her
metoprolol was resumed at a lower dose, with good control of her
blood pressures. Her prednisone was continued at stress dose of
15mg daily until she was appropriately treated for her
infections, at which point she was decreased down to 7mg daily
([**2158-11-10**]).
.
# C.diff colitis: Patient recently stopped course of PO Vanc on
[**10-5**] for CDiff. She had been on long course of antibiotics since
[**7-15**]. At home she had a change in mental status as well as loose
stools. On admission,CT abdomen showed thickened colonic mucosa
c/w colitis. Stools were C.diff positive and patient was started
back on course of PO vancomycin. Flagyl was avoided as drug can
lower seizure threshold. ID was consulted and felt that since
patient has had recurrent C diff colitis, she will warrant a
long course of PO vanco, of at least 6months after discharge.
.
#. VRE bacteremia: Blood cultures drawn in ED were positive for
Vancomycin resistant Enterococcus (1/2 bottles, [**1-10**] sets).
Culture was sensitive to daptomycin and patient completed a 12
day course on [**2158-10-28**].
.
#. PCP [**Name Initial (PRE) 1064**]: Pt was diagnosed with PCP pneumonia based on
bronchoalveolar lavage results from the flexible bronchoscopy
done on [**2158-10-24**]. She was noted to also have an elevated
beta-glucan level but not galactomannan. She was initially
started on Bactrim for treatment of PCP pneumonia, but was noted
to have increasing LFTs, so her Bactrim was changed to
Atovaquone on day 7 of treatment. Atovaquone should be continued
for a full 21-day course of treatment, to end on [**2158-11-12**]. LFTs
have continued to trend back down to baseline. Her Atovaquone
should be continued at prophylactic dosing at 1500mg daily after
[**2158-11-12**].
.
#. Altered Mental Status: Followed by Dr. [**Last Name (STitle) 724**] in Neuro [**Hospital **]
clinic. Patient was seen on admission. EEGs were done for her
altered mental status, on [**2158-10-21**] and [**2158-10-29**]. These showed
sharp spikes indicative of encephalopathy, and per neuro-onc,
also consistent with underlying seizure disorder. Adjustments
were made to her medications, including adjusting the doses of
Keppra and Ativan, and adding Lamictal, Seroquel, and PRN Zydis
Zyprexa. Her mental status greatly improved during her
hospitalization, and she was considered to be close to baseline
upon discharge. She will benefit greatly from rehabilitation at
this point.
.
# Thrombocytopenia: decreased production vs. sequestration vs.
consumption, now worsening from 61 ---> 54. DIC labs negative.
Per BMT, have kept plts > 50 given prior ICH. Transfused on
admit for low plts, BRBPR. Now with only mild decrease c/w fluid
resuscitation. The patient continued to have dropping platelets,
requiring platelet infusions approximately every other day. It
was decided that the platelet transfusion threshold should be 30
given that her last intra-cranial hemorrhage was over 6 months
prior. She will need to continue to have her platelet level
checked every Monday and Thursday at rehab, and she should be
transfused 1unit of platelets for a platelet level < 30.
.


Medications on Admission:
Acetazolamide 250 mg po q6hrs
Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 750mg PO Q 8H prn szs; 7.5
ml
(750 mg) PO/Gtube every 8 hours.
Prednisone 15mg daily ??
Acetaminophen 160 mg/5 mL Solution po q6hrs prn
Docusate Sodium 50 mg/5 mL 10ml po bid
Thiamine HCl 100 mg po daily/folate 1mg po daily
Metoprolol Tartrate 75mg po bid
Vancomycin 125 mg po q6hrs (recently stopped)
Miconazole Nitrate 2 % Powder Topical TID prn


Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day/Year **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Carbamide Peroxide 6.5 % Drops [**Month/Day/Year **]: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days: day 1 = [**2158-11-9**].
3. Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 1000 (1000) mg PO Q8H
(every 8 hours).
4. Acetaminophen 650 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H (every
6 hours) as needed for Pain or fever.
5. Docusate Sodium 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO twice a
day. Tablet(s)
6. Thiamine HCl 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.

7. Leucovorin Calcium 15 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a
day.
8. Metoprolol Tartrate 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO TID
(3 times a day).
9. Vancomycin 250 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO Q6H (every
6 hours).
10. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: SLIDING SCALE
Subcutaneous ASDIR (AS DIRECTED).
11. Nystatin 100,000 unit/mL Suspension [**Month/Day/Year **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
12. Atovaquone 750 mg/5 mL Suspension [**Month/Day/Year **]: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day) for 3 days: Last day [**2158-11-12**].
13. Oxycodone 5 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO Q4H (every 4
hours) as needed.
14. Lamotrigine 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times
a day).
15. Quetiapine 25 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
16. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)) as needed.
17. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
18. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4H (every 4
hours) as needed.
19. Prednisone 2.5 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO once a
day.
20. Outpatient Lab Work
Please check the patient's CBC/diff, Chem 10, LFTs, and ANC
every Monday and Thursday until her next appointment with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Heme-Onc, at [**Hospital1 18**]. Please forward all laboratory
results to Dr. [**First Name (STitle) **].
21. Transfusion Order
Please transfuse 1unit platelets for platelet count < 30.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
1. Pneumocystis pneumonia
2. C.difficile colitis
3. VRE septicemia
4. Altered mental status
Secondary Diagnosis:
- high-grade large B-cell non-Hodgkin's lymphoma
- sub-dural hematoma / intra-parenchymal hemorrhage s/p
evacuation x4 after fall
- heparin-induced thrombocytopenic thromboses
- bilateral pulmonary emboli, LLE DVT s/p suprarenal IVC filter
placement
- hypertension
- osteoarthritis
- peripheral neuropathy


Discharge Condition:
afebrile, vital signs stable, asymptomatic, infections treated,
mental status improved


Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2158-10-15**], with fevers and lethargy,
and diarrhea. You were first admitted to the Intensive Care Unit
for stabilization due to low blood pressures, and you were
transferred out to the Bone Marrow Transplant unit once your
pressures were stabilized. An abdominal CT showed findings
consistent with colitis, and your stools were positive for
C.diff, so you were started on oral Vancomycin for treatment,
with a plan to continue this medication for at least 6 months
after discharge. Blood cultures drawn in the emergency room also
grew Vancomycin-Resistant Enterococcus, so you were started on a
12-day course of Daptomycin, which you completed on [**2158-10-28**].
Bronchoalveloar Lavage was done on [**2158-10-24**], which showed
evidence of Pneumocystis pneumonia, so you were started on
treatment with Bactrim. This was changed to Atovaquone when it
was noted that your liver function tests were increasing while
on the Bactrim. Finally, your altered mental status was
addressed while your were an inpatient. An EEG was done which
showed continued sharp spikes, consistent with an
encephalopathy, and the neuro-oncologists believed that you had
continued underlying seizures, so you were started on Lamictal
with a plan to uptitrate this dose. You were also started on
Seroquel nightly. These medications greatly improved your mental
status. You were medically cleared for discharge.
.
You should continue to take your medications as prescribed
below. You should continue on the Atovaquone until Sunday,
[**2158-11-12**], to complete the full 21-day course, after
which your Atovaquone should be continued at prophylactic dosing
of 1500mg once daily. You should also continue the oral
Vancomycin for six months after discharge. You should not
discontinue this medication without first discussing it with
your primary care physician.
.
You should also continue your Keppra, Lamictal, and Seroquel at
the current dosing. These medications should not be adjusted
without first discussing with your Primary Oncologist and your
Neuro-Oncologist. You may continue to take the Zydis Zyprexa as
needed at nighttime. You should continue your Ativan at 0.25mg
daily, with more doses available as needed, until you see your
Neuro-Oncologist. You will probably be able to stop the Ativan
at that time, but do not do this without first discussing with
your Neuro-Oncologist.

Followup Instructions:
Primary Hematologist/Oncologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD - please call
Dr.[**Name (NI) 14047**] office at [**Telephone/Fax (1) 3237**] to schedule an appointment to
see her in one month's time.
Neuro-Oncologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], MD - Monday, [**2158-11-27**], at
3:30pm.
{'Pneumocystosis,Other pulmonary embolism and infarction,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Bone marrow replaced by transplant,Pulmonary collapse,Other and unspecified infection due to central venous catheter,Other specified septicemias,Unspecified essential hypertension,Unspecified hereditary and idiopathic peripheral neuropathy,Infection with microorganisms without mention of resistance to multiple drugs,Status of other artificial opening of gastrointestinal tract,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: fever, lethargy

PRESENT ILLNESS: 66 year old female, history of large B cell lymhoma s/p 6 cycles
R-CHOP, auto SCT in [**Month (only) 958**], h/o C diff, traumatic SDH s/p
evacuations, presents with one day of fevers, lethargy. Patient
has expressive aphasia at baseline but per family she is much
more lethargic than normal. No localizing symptoms except for
increasing diarrhea. Per patient's family, she had recent CDiff
infection (last documented here at end of [**Month (only) 205**]) and po
vancomycin was stopped on [**2158-10-5**].
.
She is followed in [**Hospital **] clinic by Dr. [**Last Name (STitle) 724**] for SDH,
seizures and encephalopathy. Recent EEG on [**10-9**] showed cortical
irritability but not electrographic epileptogenic activity seen.

MEDICAL HISTORY: 1. High-grade large B cell non-Hodgkin's lymphoma diagnosed
[**10-14**]. She was treated with 6 cycles of R-CHOP [**2157-11-2**] through
[**2158-1-17**]. Treatment course complicated by fever and neutropenia.
Supportive care with Neulasta and Aranesp given. PET at the end
of treatment showed no FDG-avid disease. Stem cell mobilization
performed [**2158-2-16**]. Anutologous stem cell transplant with BEAM
chemotherapy was done in [**2158-3-9**].
2. Intra-parenchymal hemorrhage and sub-dural hematoma s/p
evacuation x 4 following fall.
3. Bilateral pulmonary emboli and LLE DVT in [**10-14**]
4. Heparin-induced thrombocytopenia in [**11-14**]
5. Suprarenal IVC filter placed on [**2158-2-10**] (large infrarenal
IVC clot and thrombosis of left common iliac and left femoral
veins seen at that time)
6. C. difficile colitis [**2-15**] and [**3-15**]
7. Staphylococcus hand infection treated with incision and
drainage and subsequent antibiotics
8. Right toe Staphylococcus infection
9. Hypertension
10. Osteoarthritis
11. Peripheral neuropathy (attributed to her chemotherapy)
12. Tonsillectomy
13. Cholecystectomy
[**65**]. Excision of a benign abdominal tumor

MEDICATION ON ADMISSION: Acetazolamide 250 mg po q6hrs
Levetiracetam 100 mg/mL Solution [**Month/Day/Year **]: 750mg PO Q 8H prn szs; 7.5
ml
(750 mg) PO/Gtube every 8 hours.
Prednisone 15mg daily ??
Acetaminophen 160 mg/5 mL Solution po q6hrs prn
Docusate Sodium 50 mg/5 mL 10ml po bid
Thiamine HCl 100 mg po daily/folate 1mg po daily
Metoprolol Tartrate 75mg po bid
Vancomycin 125 mg po q6hrs (recently stopped)
Miconazole Nitrate 2 % Powder Topical TID prn

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: V: HR 99 BP 115/49 RR 32 100%/4Ln.c.
GEN: awake, ill-appearing female, tachypneic
HEENT: PERRL, opens eyes to command but does not track,
anicteric sclera, OP with some white coating on tongue
Neck: no LAD
CV: regular, tachycardic, no murmurs appreciated
Pulm: coarse breath sounds bilaterally
Abd: (+) bowel sounds, soft, nondistended, mild TTP LLQ and mod
TTP LUQ, j tube in place, mild erythema around a suture but not
at J tube site
Ext: warm, trace edema
Neuro: awake, aphasic at baseline, able to open eyes and mouth
to command, grunts yes/no at times or slight nod, not moving
extremitites to me.

FAMILY HISTORY: Mother: [**Name (NI) **] cancer
Father: Prostate [**Name (NI) 3730**]

SOCIAL HISTORY: She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability.  She is also caring for her grandchild.  She has
been married for 41 years.  She has two children, one son and
one daughter, and four grandchildren.  She is a nonsmoker and
does
not drink alcohol. 

### Response:
{'Pneumocystosis,Other pulmonary embolism and infarction,Intestinal infection due to Clostridium difficile,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Bone marrow replaced by transplant,Pulmonary collapse,Other and unspecified infection due to central venous catheter,Other specified septicemias,Unspecified essential hypertension,Unspecified hereditary and idiopathic peripheral neuropathy,Infection with microorganisms without mention of resistance to multiple drugs,Status of other artificial opening of gastrointestinal tract,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
