CHIEF COMPLAINT: Transfer for management of pneumonia and all oncology care.

PRESENT ILLNESS: The patient is a 56-year-old man with history of right temporal
lobe glioblastoma, s/p resection and XRT, currently on
bevacizumab and dexamethasone followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] as
outpatient, who was sent to [**Hospital3 417**] hospital from [**Hospital1 15454**] [**Hospital1 **] in [**Location (un) 701**], MA on [**2103-5-19**] with
SOB and fevers.  CTA revealed posterior consolidations
bilaterally most consistent with pneumonia.  He was started on
imipenem/tigacycline, defervesced, requiring 3-4L of oxygen via
nasal cannula. Per ICU attending there, his imaging/presentation
did not seem consistent with PCP and serum LDH was normal at
230.  He was transfered to [**Hospital1 18**] for further management and
since all of his oncology care has been coordinated by Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**].  Of note, his nasal swabs at [**Hospital3 417**] tested
positive for MRSA and VRE.

MEDICAL 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 intracranial temozolamide chemo-radiation, followed
by adjuvant temozolomide (4 cycles) [**2102-1-23**] to [**2102-3-7**]
- Ventriculoperitoneal shunt placement [**2102-8-1**]
- Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
and had 1 cycle so far
- Hospitalization from [**Date range (3) 84005**], during which time he
had:  PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
PE s/p IVC filter, was previously on lovenox
- Discharged to [**Hospital1 **] course c/b C. difficile, ESBL
PNA
- plan was to treated with bevacizumab but this was delayed due
to ICH Per wife has had 3 IC bleeds post craniectomy and as such
has meant that anticoagulation was contraindicated
- start bevacizumab treatment on [**2103-2-28**] and had 1 cycle so
far at 5 mg/kg.
- C. difficile:  First diagnosed during [**11/2102**] hospitalization
with relapse on [**2103-3-26**], for which patient has completed an
extended course of po vancomycin on [**2103-5-3**].
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- PE/bilateral DVTs (s/p IVC filter placement [**11/2102**])

MEDICATION ON ADMISSION: Medication on Transfer
alendronate 70mg q week
ascorbic acid 1000mg TID
Valcium vitamin d 1 tab
Carbidopa/levodopa 1 dab daily
Methylphenidate 5mg daily
Colchicine 0.6mg daily
fluconazole 100mg daily
furosemide 20mg daily
gabapentin 300mg QAM 1200mg QPM
Potassium chloride 20meq daily
Thiamine 100mg
Valproate 1250mg
Heparin sub q 500units TID
fluticasone 2 sprays Q24
nystatin 500,000 units QID
ipratropium 0.5mg UINH Q6H
Levalbuterol 1.25mg Q6H
Dexamethasone 2mg IV Q6H
Pantoprazole 40mg IV daily
Acetaminophen 650 Q4h PRN
[**Doctor Last Name **]/hydrox/mg hydrox/simethicone 30ml Q4H PRN
Guaifenesin 200mg Q6H PRN
Mag hydroxide 10mL QHS PRN
Docusate 100mg [**Hospital1 **] PRN
Ondansetron 4mg Q6H PRN
Ibuprofen 400mg Q8H PRN
Tramadol 50mg Q4H PRN
acetaminophen 650mg PR PRN
albuterol sulgate 2.5 mg INH Q4H PRN
Ipratropium 0.5mg INH Q4H PRN
Pertolatum/zinc oxide 1 appl daily prn
miconazole nitrate 1 appl [**Hospital1 **] PRN
.
Home meds
accutane 20 mg 1 capsule [**Hospital1 **] x 3 weeks ([**2103-1-30**])
accutane 40 mg 2 caps po BID x 3 weeks ([**2103-1-30**])
acetylcysteine 20% (200 mg/mL) solution nebs q2hrs prn
albuterol sulfate 90 mcg HFA inhaler 90 mcg nasal q4h prn
alendronate 70 mg 1 po weekly
atovaquone 750 mg/5 ml suspension 10 ml po daily
carbidopa-levodopa 25 mg-100 mg 1 tab po BID
colchicine 0.6 mg 1 tab po daily
dexamethasone 0.75 mg 1 tab po daily
esomeprazole magnesium (nexium) 40 mg E.C. 1 cap po daily
gabapentin 300 mg 1 cap po qam and 4 qhs
heparin 5,000 units/mL cartridge 500 units sub-Q q6 hours
ibuprofen 600 mg 1 tab po q8h prn
methylphenidate 5 mg 1 tab po qam
nystatin 100,000 unit/mL suspensi9on 10 mL po daily
ondansetron 4 mg tab 1 po q8h prn
potassium chloride 20 mEq ER 1 tab po daily
sodium chloride 2.5 mEq/nL parenteral solution 20 mg daily
valproic acid 250 mg 7 caps po TIC
OTC:
acetaminophen 325 mg 2 tabs po q6h prn
acetaminophen extra strength 500 mg 2 tabs po qhs prn headache
ascorbic acid 500 mg 1 tab po BID
calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400 unit
[**Unit Number **] tab po TID
diphenhydramine HCL 25 mg [**1-14**] caps po QHS prn insomnia
docusate sodium 100 mg 1 cap po BID
multivitamin 1 po daily
thiamine HCL 100 mg 1 po daily

ALLERGIES: hydromorphone

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 96.6 F, blood pressure 139/101, pulse
94, respiration 16, and oxygen saturation 96% on 3L NC; pain
[**7-22**] in abdomen.
GENERAL:  No apparent distress; slow response time to questions,
but normal verbal fluency
HEENT:  No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CARDIOVASCULAR:  Regular rate and rhythm, no
murmurs/gallops/rubs
PULMONARY:  Clear to auscultation bilaterally, but inspirtory
effort is poor.  He has no rales/crackles/rhonchi
ABDOMEN:  Soft, non-tender, non-distended; no guarding/rebound
EXTREMITIES:  No clubbing/cyanosis; 2+ pitting edema L>R, 2+
distal pulses; peripheral IV present

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

SOCIAL HISTORY: Semi-retired accountant.  He was transfered from [**Year (4 digits) **]
but previously at home with wife and children.  Mobility at
[**Year (4 digits) **] was only standing for a few seconds while holding
onto walker.  He has no history of tobacco use.  He previously
drank socially, but without drug use.
Pneumonia, organism unspecified,Toxic encephalopathy,Acute kidney failure, unspecified,Toxic myopathy,Pressure ulcer, lower back,Malignant neoplasm of temporal lobe,Other convulsions,Personal history of venous thrombosis and embolism,Anemia, unspecified,Presence of cerebrospinal fluid drainage device,Osteoporosis, unspecified,Diarrhea,Adrenal cortical steroids causing adverse effects in therapeutic use,Do not resuscitate status
Pneumonia, organism NOS,Toxic encephalopathy,Acute kidney failure NOS,Toxic myopathy,Pressure ulcer, low back,Mal neo temporal lobe,Convulsions NEC,Hx-ven thrombosis/embols,Anemia NOS,Ventricular shunt status,Osteoporosis NOS,Diarrhea,Adv eff corticosteroids,Do not resusctate status
Admission Date:  [**2103-5-22**]              Discharge Date:   [**2103-6-7**]

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

Service: NEUROLOGY

Allergies:
hydromorphone

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Transfer for management of pneumonia and all oncology care.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
The patient is a 56-year-old man with history of right temporal
lobe glioblastoma, s/p resection and XRT, currently on
bevacizumab and dexamethasone followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] as
outpatient, who was sent to [**Hospital3 417**] hospital from [**Hospital1 15454**] [**Hospital1 **] in [**Location (un) 701**], MA on [**2103-5-19**] with
SOB and fevers.  CTA revealed posterior consolidations
bilaterally most consistent with pneumonia.  He was started on
imipenem/tigacycline, defervesced, requiring 3-4L of oxygen via
nasal cannula. Per ICU attending there, his imaging/presentation
did not seem consistent with PCP and serum LDH was normal at
230.  He was transfered to [**Hospital1 18**] for further management and
since all of his oncology care has been coordinated by Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**].  Of note, his nasal swabs at [**Hospital3 417**] tested
positive for MRSA and VRE.

Upon review of OMR, he was admitted to [**Hospital1 18**] from [**2103-4-13**] to
[**2103-4-18**] for AMS and a positive blood culture.  He was found to
have a UTI had his urinary catheter exchanged on arrival.  Urine
cultures from [**Year/Month/Day **] was positive for ESBL Klebsiella
and pseudomonas resistant to meropenem.  Repeat urine culture
showed no growth.  Blood cultures showed no growth at the time
of discharge.  Portable chest X-ray showed no evidence of
pneumonia.  The patient was started on vancomycin, meropenem,
and ciprofloxacin, renally dosed.  His mental status and
clinical condition improved with antibiotics and fluids in the
ICU.  Vancomycin was discontinued (given patient had only 1 out
of 4 bottles positive for coag-positive staph at [**Year/Month/Day **],
with negative blood culture here).  He was discharged with
meropenem/ciprofloxacin for a goal 14 day course to be completed
on [**2103-4-26**].

On the floor here, he reports "a lot" of abdominal pain over the
past four days and continued pain in both of his legs.  He also
states that his shortness of breath is improved compared to a
few days ago.

Review of Systems:
(+) Per HPI
(-) He denies fever, chills, night sweats, recent weight loss or
gain.  He denies visual changes, headache, dizziness, sinus
tenderness, neck stiffness, rhinorrhea, congestion, sore throat
or dysphagia.  He denies chest pain, palpitations, orthopnea,
dyspnea on exertion.  He denies nausea, vomiting, heartburn,
diarrhea, constipation, BRBPR, melena.  There is no dysuria,
urinary frequency.  He denies arthralgias or myalgias.  He
denies rashes.  There is no increasing lower extremity swelling.
 There is no numbness/tingling or muscle weakness in
extremities.  There is no feelings of depression or anxiety.
All other review of systems negative.

Past Medical 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 intracranial temozolamide chemo-radiation, followed
by adjuvant temozolomide (4 cycles) [**2102-1-23**] to [**2102-3-7**]
- Ventriculoperitoneal shunt placement [**2102-8-1**]
- Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
and had 1 cycle so far
- Hospitalization from [**Date range (3) 84005**], during which time he
had:  PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
PE s/p IVC filter, was previously on lovenox
- Discharged to [**Hospital1 **] course c/b C. difficile, ESBL
PNA
- plan was to treated with bevacizumab but this was delayed due
to ICH Per wife has had 3 IC bleeds post craniectomy and as such
has meant that anticoagulation was contraindicated
- start bevacizumab treatment on [**2103-2-28**] and had 1 cycle so
far at 5 mg/kg.
- C. difficile:  First diagnosed during [**11/2102**] hospitalization
with relapse on [**2103-3-26**], for which patient has completed an
extended course of po vancomycin on [**2103-5-3**].
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- PE/bilateral DVTs (s/p IVC filter placement [**11/2102**])

Social History:
Semi-retired accountant.  He was transfered from [**Year (4 digits) **]
but previously at home with wife and children.  Mobility at
[**Year (4 digits) **] was only standing for a few seconds while holding
onto walker.  He has no history of tobacco use.  He previously
drank socially, but without drug use.

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

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 96.6 F, blood pressure 139/101, pulse
94, respiration 16, and oxygen saturation 96% on 3L NC; pain
[**7-22**] in abdomen.
GENERAL:  No apparent distress; slow response time to questions,
but normal verbal fluency
HEENT:  No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CARDIOVASCULAR:  Regular rate and rhythm, no
murmurs/gallops/rubs
PULMONARY:  Clear to auscultation bilaterally, but inspirtory
effort is poor.  He has no rales/crackles/rhonchi
ABDOMEN:  Soft, non-tender, non-distended; no guarding/rebound
EXTREMITIES:  No clubbing/cyanosis; 2+ pitting edema L>R, 2+
distal pulses; peripheral IV present

NEUROLOGICAL EXAMINATION:  His Karnofsky Performance Score is
50.  He is awake, alert, and able to follow commands.  His
language is fluent with good comprehension.  Short-term recall
is intact.  He has moderate psychomotor slowing.  Cranial Nerve
Examination:  His pupils are equal and reactive to light, 4 mm
to 2 mm bilaterally.  Extraocular movements are full without
nystagmus.  Visual fields are full to confrontation.  His face
is symmetric.
Facial sensation is intact bilaterally.  His hearing is intact
bilaterally.  His tongue is midline.  Palate goes up in the
midline.  Sternocleidomastoids and upper trapezius are strong.
Motor Examination:  He has postural tremors, but no pronation or
drift.  He can move his upper extremities with good strength at
4+/5.  But in the lower extremities, he has proximal lower
extremity weakness at 3/5 on the right and [**2-17**] on the left (this
is somewhat limited by low back pain).  His muscle tone is
normal.  His reflexes are 0-1 bilaterally.  His ankle jerks are
absent.  His toes are down.  Sensory examination is intact to
touch and proprioception.  He cannot walk.

DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 96.5 F, blood pressure 126/82, pulse
65, respiration 18, and oxygen saturation 96% in room air.
GENERAL:  Middle aged male appearing comfortable, Alert,
conversant Place: [**Hospital1 18**] Year: [**2103**]
SKIN:  Stage II sacral decubitis with dressing in place
HEENT:  Left sided VP shunt, well healed surgical scar. PERRLA.
MMM.
CHEST:  Right sided porta cath in place with mild erythemia and
skin break down surrounding port.
CARDIOVASCULAR:  RRR S1/S2 normal. no murmurs/gallops/rubs.
PULMONARY:  Poor inspiratory effort. Clear to ascultation BL.
ABDOMEN:  Overweight, LUQ mild TTP. BS+, soft, no
rebound/guarding,
EXTREMITIES:  Warm to the touch, BL ecchymoses in upper
extremities. L>R peripheral edema to the mid calf.

NEUROLOGICAL EXAMINATION:  His Karnofsky Performance Score is
50.  He is awake, alert, and able to respond to most commands
readily.  His language is fluent with fair comprehension.
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 threat.  His face
is
symmetric.  Facial sensation is intact bilaterally.  His hearing
is grossly intact.  His tongue is midline.  Palate goes up in
the midline.  Sternocleidomastoids and upper trapezius are
strong.  Motor Examination:  He has postural tremors.  His motor
strength is [**4-17**] at proximal and 4+/5 at distal upper
extremities.  In the lower extremities, the strength is [**3-17**] at
proximal and distal lower extremities.  His reflexes are 0-1
bilaterally.  His
ankle jerks are absent.  His toes are down.  Sensory examination
is intact to pinch.  He cannot walk.

Pertinent Results:
ADMISSION LABS
[**2103-5-22**] 10:38PM   GLUCOSE-108* UREA N-26* CREAT-0.4* SODIUM-141
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-28 ANION GAP-14
[**2103-5-22**] 10:38PM   ALT(SGPT)-27 AST(SGOT)-17 LD(LDH)-269* ALK
PHOS-109 TOT BILI-0.2
[**2103-5-22**] 10:38PM   ALBUMIN-3.1* CALCIUM-8.5 PHOSPHATE-3.5
MAGNESIUM-2.2
[**2103-5-22**] 10:38PM   WBC-8.9# RBC-3.81* HGB-12.8* HCT-38.6*
MCV-101* MCH-33.6* MCHC-33.2 RDW-16.7*
[**2103-5-22**] 10:38PM   NEUTS-70 BANDS-0 LYMPHS-8* MONOS-19* EOS-0
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
[**2103-5-22**] 10:38PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
SCHISTOCY-1+ TEARDROP-OCCASIONAL
[**2103-5-22**] 10:38PM   PLT SMR-LOW PLT COUNT-138*
[**2103-5-22**] 10:38PM   PT-11.5 PTT-28.8 INR(PT)-1.0
DISCHARGE LABS

[**2103-6-7**] 05:47AM BLOOD WBC-6.9 RBC-3.45* Hgb-11.3* Hct-34.5*
MCV-100* MCH-32.7* MCHC-32.7 RDW-17.2* Plt Ct-178
[**2103-6-7**] 05:47AM BLOOD Glucose-84 UreaN-12 Creat-0.5 Na-147*
K-3.6 Cl-107 HCO3-30 AnGap-14

MICRO
[**6-3**] C. diff negative
[**5-31**] C. diff negative
[**5-29**] CSF gram stain neg
FLUID CULTURE (Final [**2103-6-1**]):    NO GROWTH.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.
[**5-29**] BCX x2 Negative
[**5-28**] BCX x2 Negative
[**5-28**] UCX negative
[**5-27**] Bcx Negative
[**5-25**] c. diff negative
5/12/2011Sputum: Pneumocystis jirovecii (carinii)-negative
[**2103-5-23**]    Stool
FECAL CULTURE (Final [**2103-5-25**]):    NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2103-5-25**]):    NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2103-5-24**]): Feces
negative for C.difficile toxin A & B by EIA.
FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): NEGATIVE
FECAL CULTURE - R/O VIBRIO (Pending): NEGATIVE
FECAL CULTURE - R/O YERSINIA (Pending): NEGATIVE
[**2103-5-23**] URINE CULTURE-negative
[**2103-5-22**] Blood Culture, Routine-NEGATIVE

CSF: NEGATIVE FOR MALIGNANT CELLS.

MRI Head
IMPRESSION: Status post right pterional craniotomy for
glioblastoma resection. Compared to [**2103-3-26**] MR, there is no
suspicous interval change to suggest recurrence, and no evidence
of acute pathology.

CT HEAD [**2103-5-29**]
IMPRESSION:
1. No acute intracranial hemorrhage.
2. The right temporal tumor site and posttreatment changes are
better
evaluated on the head MRI from [**2103-5-28**].
3. Stable enlargement of the ventricles.
4. Unchanged air-fluid level in the right sphenoid sinus.

EEG [**2103-5-30**]
IMPRESSION:  This is an abnormal extended routine EEG, due to
the
presence of continuous 0.5-1 Hz delta slowing seen over the
right
fronto-temporal region with rare associated sharp discharges
(F4/T4).
This is consistent with a focal underlying structural lesion
with
epileptogenic potential. In addition, the presence of a
disorganized
[**6-19**] Hz theta frequency background is suggestive of a mild
diffuse
encephalopathy, seen with medication effect, metabolic
disturbance, or
infection.

Brief Hospital Course:
[**Known firstname **] [**Known lastname 13013**] is a 56-year-old man with glioblastoma, s/p
resection and chemo-irradiation, and most recently on
bevacizumab and dexamethasone as well as history of PCP PNA and
PE Bilat DVTs admitted to OSH ICU for bilateral PNA.  He
completed an 8 day course of vancomycin/Zosyn for healthcare
assocaited pneumonia.  His hospitalization was complicated by
confusion related to sedating medications.

(1) Pneumonia:  Patient initially hypoxic and was on BIPAP on
presentation to OSH in the ICU, concern for HAP vs aspiration
PNA. OSH imaging suggestive of bibasilar atelectasis and
consolidation.  He was initially treated with imipenem and
tigecycline at OSH.  On arrival to [**Hospital1 18**], he was changed to
vancomycin and Zosyn for HCAP, he completeed an 8 day course
[**2103-5-29**].  Induced sputum was negative for PJP.

(2) Seizure Disorder:  Patient suffered seizure and cardiac
arrest [**11/2102**] and has been on valproic acid since.  VPA level
133 prior to transfer from OSH and VPA dose lowered 1750
Q8H->1250 Q8H. After discussion with primary oncologist, VPA
dose was returned to 1770 Q8H.  Patient developed worsening
confusion [**5-26**] and given recently decreased VPA dose, concern
was raised for non-convulsive seizures, 20 min EEG was obtained
and showed no epileptiform discharges and only diffuse
encephalopathy which had been seen on previous EEGs.  On
[**2103-5-29**], patient had possible convulsive seizure witnessed by
shaking of L>R extremities and patient was given 1mg Ativan
however shaking had resolved prior to medication administration.
 Neurological examination was unchanged.  Head CT was obtained
which was negative for acute hemorrhage.  MRI head obtained 10
hours prior to the event (as part of oncologic work up) showed
stable GBM.  A 24-hour EEG showed epileptiform discharges
however the findings were relatively subtle and unlikely to
cause convulsive seizure activity.  Valproate was lowered to
1250mg Q8H.  No further shaking episodes were observed.

(3) Altered Mental Status:  Patient was noted to be lethargic on
[**2103-5-29**], with noted jerking movements of his upper extremities
bilaterally.  Differential for this included underlying
glioblastoma multiforme, question of seizure activity, infection
and medications with sedative properties.  He underwent lumbar
puncture to rule out meningitis, CSF culture was negative and
cell count was not suggestive of meningitis.  Sedating
medications were held, including lorazepam, gabapentin,
morphine, oxycodone and diphenhydramine and mental status
improved markedly. Methylphenidate was increased.

(4) Sepsis:  On [**2103-5-29**], patient developed hypothermia and
hypotension to SBP 90's.  He was bolused with IVNS and pressures
returned to 110's. A warming blanket was placed, blood cultures
sent and an lumbar puncture was performed as above. Given
clinical deterioration, patient was transferred to the ICU for
closer monitoring.  Infectious workup was negative, pressures
stabalized and he was called out to the medical floor.

(5) Diarrhea:  On admission, patient was having [**1-15**] loose bowel
movements daily, and abdominal pain was attributed to enteritis.
LFTs and lipase were unrevealing. He was C. diff negative.  He
appeared distended on [**2103-5-29**] and a plan film of the abdomen
showed no evidence of obstruciton or megacolon.  Repeat studies
for C. diff were negative.  Diarrhea is attributed to antibiotic
therapy with secondary effect on GI flora.  At the time of
discharge, stool had become soft. Started loperamide for
diarrhea.

(6) Gliobastoma/Seizure Disorder:  Patient s/p resection with
intracranial chemo and s/p VP shunt.  Course complicated by
intracranial hemorrhage x 3.  He is currently on dexamethasone
and bevacizumab.  He completed C4D1 of bevacizumab while in
hospital [**2103-5-31**].  MRI shows stable disease however concern was
raised for progression of glioblastoma that cannot be seen on
MRI.  Dexamethasone tapered to 1mg daily on [**2103-5-26**], and to
0.75mg daily on [**2103-6-5**].  He continued atovaquone and
fluconazole PPx.  Ritalin was increased to 20mg daily.  He
received increased AM gabapentin for headaches.  Valproate was
decreased.  He continued carbidopa/levodopa.  Plan to taper
dexamethasone to 0.5mg daily [**2103-6-12**]. Patient will follow up
with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] for bevacizumab treatments.

(7) Headahce:  Following removal of oxycodone and morphine for
pain control, patient complained of intermittant headaches.  His
neurological examination remained unchanged and there was low
suspicion for acute intracranial process. Headahces responded to
acetaminophen and, to a limited extent, to Fioricet.  After one
day of firocet therapy, he again appeared somnolent and fiorcet
was discontinued. Headaches were believed to have a component of
rebound following withdraw of opiates.  His a.m. gabapentin dose
was increased 300 to 600mg.  Gabapentin 300 Q noon added
[**2103-6-7**], could increase to 600 Q noon if headaches worsen.

(8) Acute Renal Failure:  Patient developed acute renal failure
related to vancomycin.  Vancomycin was discontinued.  Creatinine
peaked at 1.5, and returned to baseline after one day.

(9) Goals of Care:  Given his poor prognosis of glioblastoma,
family meeting was held with the wife and code status was
changed to DNR/DNI.  His wife plans to bring him home after he
completes [**Month/Day/Year **] and is arranging for handicap
accessable home.

(10) History of DVT/PE:  This was diagnosed in [**11/2102**] with
bilateral PE and patient has IVC filter in place, not
systemically anticoagulated due to history of intracranial
bleeding x 3.  He continued Heparin 5000U SC QID per outpatient
oncologists Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] recommendation.  He developed
oozing at heparin sites and heparin was changed to heparin SC
5000 TID.

(11) Macrocytic Anemia:  This is likely related to
chemotherapeutic agents.  B12 and folate were within normal
limits.

(12) Thrombocytopenia:  His platelets trended up form low 100's
at OSH likely medication effect from chemotherapeutic agents.
HIT was considered unlikely. Platelet count had normalized by
the time of discharge.

(13) Osteoporosis:  This is related to chronic dexamethasone
therapy.  He has a history of compression fractures.  He
continued alendronate, vitamin C, calcium and vitamin D.

(14) Precautions for:  VRE, MRSA, and C. diff.

(15) CODE:  DNR/DNI changed on [**2103-5-31**].

(16) Contact:  [**Name (NI) **], wife [**Name (NI) 553**] [**Name (NI) 13013**] [**Telephone/Fax (1) 84006**].

Medications on Admission:
Medication on Transfer
alendronate 70mg q week
ascorbic acid 1000mg TID
Valcium vitamin d 1 tab
Carbidopa/levodopa 1 dab daily
Methylphenidate 5mg daily
Colchicine 0.6mg daily
fluconazole 100mg daily
furosemide 20mg daily
gabapentin 300mg QAM 1200mg QPM
Potassium chloride 20meq daily
Thiamine 100mg
Valproate 1250mg
Heparin sub q 500units TID
fluticasone 2 sprays Q24
nystatin 500,000 units QID
ipratropium 0.5mg UINH Q6H
Levalbuterol 1.25mg Q6H
Dexamethasone 2mg IV Q6H
Pantoprazole 40mg IV daily
Acetaminophen 650 Q4h PRN
[**Doctor Last Name **]/hydrox/mg hydrox/simethicone 30ml Q4H PRN
Guaifenesin 200mg Q6H PRN
Mag hydroxide 10mL QHS PRN
Docusate 100mg [**Hospital1 **] PRN
Ondansetron 4mg Q6H PRN
Ibuprofen 400mg Q8H PRN
Tramadol 50mg Q4H PRN
acetaminophen 650mg PR PRN
albuterol sulgate 2.5 mg INH Q4H PRN
Ipratropium 0.5mg INH Q4H PRN
Pertolatum/zinc oxide 1 appl daily prn
miconazole nitrate 1 appl [**Hospital1 **] PRN
.
Home meds
accutane 20 mg 1 capsule [**Hospital1 **] x 3 weeks ([**2103-1-30**])
accutane 40 mg 2 caps po BID x 3 weeks ([**2103-1-30**])
acetylcysteine 20% (200 mg/mL) solution nebs q2hrs prn
albuterol sulfate 90 mcg HFA inhaler 90 mcg nasal q4h prn
alendronate 70 mg 1 po weekly
atovaquone 750 mg/5 ml suspension 10 ml po daily
carbidopa-levodopa 25 mg-100 mg 1 tab po BID
colchicine 0.6 mg 1 tab po daily
dexamethasone 0.75 mg 1 tab po daily
esomeprazole magnesium (nexium) 40 mg E.C. 1 cap po daily
gabapentin 300 mg 1 cap po qam and 4 qhs
heparin 5,000 units/mL cartridge 500 units sub-Q q6 hours
ibuprofen 600 mg 1 tab po q8h prn
methylphenidate 5 mg 1 tab po qam
nystatin 100,000 unit/mL suspensi9on 10 mL po daily
ondansetron 4 mg tab 1 po q8h prn
potassium chloride 20 mEq ER 1 tab po daily
sodium chloride 2.5 mEq/nL parenteral solution 20 mg daily
valproic acid 250 mg 7 caps po TIC
OTC:
acetaminophen 325 mg 2 tabs po q6h prn
acetaminophen extra strength 500 mg 2 tabs po qhs prn headache
ascorbic acid 500 mg 1 tab po BID
calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400 unit
[**Unit Number **] tab po TID
diphenhydramine HCL 25 mg [**1-14**] caps po QHS prn insomnia
docusate sodium 100 mg 1 cap po BID
multivitamin 1 po daily
thiamine HCL 100 mg 1 po daily

Discharge Medications:
1. acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) neb
Miscellaneous Q2H (every 2 hours) as needed for dyspnea, wheeze.

2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QFRI (every
Friday).
4. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
5. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QAM.
8. gabapentin 400 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection Q6H (every 6 hours): DVT Treatment per primary
oncologist.
10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for fever or pain.
11. methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO once
a day.
13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at
bedtime as needed for headache.
16. calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit
Tablet Sig: One (1) Tablet PO three times a day.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation: Hold for loose stools.
18. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
21. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: 1250
(1250) mg PO Q8H (every 8 hours).
22. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
23. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
24. dexamethasone 1.5 mg Tablet Sig: 0.5 tablets PO DAILY
(Daily).
25. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
26. loperamide 2 mg Tablet Sig: 1-2 Tablets PO four times a day:
Hold for constipation.
27. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 12PM .
28. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).

Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary
Health Care Associated Pneumonia

Toxic metabolic encephalopathy
Glioblastoma Multiforme
Seizure disorder
Acute renal failure

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

Discharge Instructions:
Mr [**Known lastname 13013**],
As you know, you were transferred from [**Hospital3 417**] Hospital
to [**Hospital1 18**] for pneumonia. We treated you with antibiotics and your
symptoms improved.

Your primary oncologist, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] noted that you seemed
confused and was concerned that you were having a seizure, we
performed an EEG which did not show anything to explain the
confusion.  We held sedating medicaitons and your confusion
improved.

You were having diarrhea and we checked you for an infectious
cause and the tests were negative.  We belive that the diarrhea
is related to antibiotics and will resolve with time.  We
recommend that you take

Medication changes
START Loperamide for diarrhea
INCREASE Methylphenidate
INCREASE Gabapentin
STOP Carbidopa/levodopa
STOP sodium chloride
STOP Diphenhydramine

Followup Instructions:
Avastin appointment.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2103-6-14**] 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
{'Pneumonia, organism unspecified,Toxic encephalopathy,Acute kidney failure, unspecified,Toxic myopathy,Pressure ulcer, lower back,Malignant neoplasm of temporal lobe,Other convulsions,Personal history of venous thrombosis and embolism,Anemia, unspecified,Presence of cerebrospinal fluid drainage device,Osteoporosis, unspecified,Diarrhea,Adrenal cortical steroids causing adverse effects in therapeutic use,Do not resuscitate status'}


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: Transfer for management of pneumonia and all oncology care.

PRESENT ILLNESS: The patient is a 56-year-old man with history of right temporal
lobe glioblastoma, s/p resection and XRT, currently on
bevacizumab and dexamethasone followed by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] as
outpatient, who was sent to [**Hospital3 417**] hospital from [**Hospital1 15454**] [**Hospital1 **] in [**Location (un) 701**], MA on [**2103-5-19**] with
SOB and fevers.  CTA revealed posterior consolidations
bilaterally most consistent with pneumonia.  He was started on
imipenem/tigacycline, defervesced, requiring 3-4L of oxygen via
nasal cannula. Per ICU attending there, his imaging/presentation
did not seem consistent with PCP and serum LDH was normal at
230.  He was transfered to [**Hospital1 18**] for further management and
since all of his oncology care has been coordinated by Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**].  Of note, his nasal swabs at [**Hospital3 417**] tested
positive for MRSA and VRE.

MEDICAL 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 intracranial temozolamide chemo-radiation, followed
by adjuvant temozolomide (4 cycles) [**2102-1-23**] to [**2102-3-7**]
- Ventriculoperitoneal shunt placement [**2102-8-1**]
- Procarbazine, CCNU, and Vincristine (PCV) on [**2102-8-23**]
and had 1 cycle so far
- Hospitalization from [**Date range (3) 84005**], during which time he
had:  PCP PNA, [**Name Initial (PRE) **]/p PEA arrest and flail chest from compression,
PE s/p IVC filter, was previously on lovenox
- Discharged to [**Hospital1 **] course c/b C. difficile, ESBL
PNA
- plan was to treated with bevacizumab but this was delayed due
to ICH Per wife has had 3 IC bleeds post craniectomy and as such
has meant that anticoagulation was contraindicated
- start bevacizumab treatment on [**2103-2-28**] and had 1 cycle so
far at 5 mg/kg.
- C. difficile:  First diagnosed during [**11/2102**] hospitalization
with relapse on [**2103-3-26**], for which patient has completed an
extended course of po vancomycin on [**2103-5-3**].
- Previous left knee cartilage operation
- osteoporosis
- epilepsy
- PE/bilateral DVTs (s/p IVC filter placement [**11/2102**])

MEDICATION ON ADMISSION: Medication on Transfer
alendronate 70mg q week
ascorbic acid 1000mg TID
Valcium vitamin d 1 tab
Carbidopa/levodopa 1 dab daily
Methylphenidate 5mg daily
Colchicine 0.6mg daily
fluconazole 100mg daily
furosemide 20mg daily
gabapentin 300mg QAM 1200mg QPM
Potassium chloride 20meq daily
Thiamine 100mg
Valproate 1250mg
Heparin sub q 500units TID
fluticasone 2 sprays Q24
nystatin 500,000 units QID
ipratropium 0.5mg UINH Q6H
Levalbuterol 1.25mg Q6H
Dexamethasone 2mg IV Q6H
Pantoprazole 40mg IV daily
Acetaminophen 650 Q4h PRN
[**Doctor Last Name **]/hydrox/mg hydrox/simethicone 30ml Q4H PRN
Guaifenesin 200mg Q6H PRN
Mag hydroxide 10mL QHS PRN
Docusate 100mg [**Hospital1 **] PRN
Ondansetron 4mg Q6H PRN
Ibuprofen 400mg Q8H PRN
Tramadol 50mg Q4H PRN
acetaminophen 650mg PR PRN
albuterol sulgate 2.5 mg INH Q4H PRN
Ipratropium 0.5mg INH Q4H PRN
Pertolatum/zinc oxide 1 appl daily prn
miconazole nitrate 1 appl [**Hospital1 **] PRN
.
Home meds
accutane 20 mg 1 capsule [**Hospital1 **] x 3 weeks ([**2103-1-30**])
accutane 40 mg 2 caps po BID x 3 weeks ([**2103-1-30**])
acetylcysteine 20% (200 mg/mL) solution nebs q2hrs prn
albuterol sulfate 90 mcg HFA inhaler 90 mcg nasal q4h prn
alendronate 70 mg 1 po weekly
atovaquone 750 mg/5 ml suspension 10 ml po daily
carbidopa-levodopa 25 mg-100 mg 1 tab po BID
colchicine 0.6 mg 1 tab po daily
dexamethasone 0.75 mg 1 tab po daily
esomeprazole magnesium (nexium) 40 mg E.C. 1 cap po daily
gabapentin 300 mg 1 cap po qam and 4 qhs
heparin 5,000 units/mL cartridge 500 units sub-Q q6 hours
ibuprofen 600 mg 1 tab po q8h prn
methylphenidate 5 mg 1 tab po qam
nystatin 100,000 unit/mL suspensi9on 10 mL po daily
ondansetron 4 mg tab 1 po q8h prn
potassium chloride 20 mEq ER 1 tab po daily
sodium chloride 2.5 mEq/nL parenteral solution 20 mg daily
valproic acid 250 mg 7 caps po TIC
OTC:
acetaminophen 325 mg 2 tabs po q6h prn
acetaminophen extra strength 500 mg 2 tabs po qhs prn headache
ascorbic acid 500 mg 1 tab po BID
calcium carbonate-vitamin D3 500 mg calcium (1,250 mg)-400 unit
[**Unit Number **] tab po TID
diphenhydramine HCL 25 mg [**1-14**] caps po QHS prn insomnia
docusate sodium 100 mg 1 cap po BID
multivitamin 1 po daily
thiamine HCL 100 mg 1 po daily

ALLERGIES: hydromorphone

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS:  Temperature 96.6 F, blood pressure 139/101, pulse
94, respiration 16, and oxygen saturation 96% on 3L NC; pain
[**7-22**] in abdomen.
GENERAL:  No apparent distress; slow response time to questions,
but normal verbal fluency
HEENT:  No trauma, pupils round and reactive to light and
accommodation, no LAD, oropharynx clear, no exudates
CARDIOVASCULAR:  Regular rate and rhythm, no
murmurs/gallops/rubs
PULMONARY:  Clear to auscultation bilaterally, but inspirtory
effort is poor.  He has no rales/crackles/rhonchi
ABDOMEN:  Soft, non-tender, non-distended; no guarding/rebound
EXTREMITIES:  No clubbing/cyanosis; 2+ pitting edema L>R, 2+
distal pulses; peripheral IV present

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

SOCIAL HISTORY: Semi-retired accountant.  He was transfered from [**Year (4 digits) **]
but previously at home with wife and children.  Mobility at
[**Year (4 digits) **] was only standing for a few seconds while holding
onto walker.  He has no history of tobacco use.  He previously
drank socially, but without drug use. 

### Response:
{'Pneumonia, organism unspecified,Toxic encephalopathy,Acute kidney failure, unspecified,Toxic myopathy,Pressure ulcer, lower back,Malignant neoplasm of temporal lobe,Other convulsions,Personal history of venous thrombosis and embolism,Anemia, unspecified,Presence of cerebrospinal fluid drainage device,Osteoporosis, unspecified,Diarrhea,Adrenal cortical steroids causing adverse effects in therapeutic use,Do not resuscitate status'}
