CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: This is a 68 yo woman with a history of Large B cell Lymphoma,
s/p SCT [**2158**], complicated by intra-parenchymal and SDH and
subsequent seizures with baseline aphasia who presents with
confusion and worsening gait. Of note she has had multiple
admissions for the same symptoms and recent admission [**Date range (1) 69952**]
for altered mental status (worsening gait, aphasia) of unclear
etiology though seemed to improve with antibiotics (though no
clear infection). Of note her MS waxed and waned during that
admission with no evidence of seizure activity corresponding,
negative LP and MRI. She does have a chronically trapped left
ventricle so neurosurgery was consulted regarding semi-elective
stereotactic drainage of her chronically trapped left ventricle
when all infectious issues resolved. Regarding infection she had
c.diff neg x2, WBC on UA but culture negative (was treated with
ceftazidime transitioned to cefixime for discharge-[**Date range (1) 69953**] for
10 day course). She was also treated briefly with levofloxacin
starting on admit [**2-29**] for cough, but returned + for influenza
B.

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. Seizure disorder- as above
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 [**2-16**] 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
15. Bilateral pulmonary emboli and LLE DVT in [**10-14**]

MEDICATION ON ADMISSION: Atovaquone 750 mg/5 mL PO DAILY
Gabapentin 300 mg PO Q12H
Lamotrigine 275 mg Tablet PO BID ->husband giving her 225 [**Hospital1 **]
due to confusing nature of d/c medications
Leucovorin Calcium 10 mg PO DAILY
Metoprolol Tartrate 25 mg PO BID
Pantoprazole 40 mg PO Q24H
Multivitamin PO DAILY
Thiamine HCl 100 mg PO DAILY
Senna with Docusate Sodium 8.6-50 mg as needed for constipation

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: Gen: Elderly woman in NAD, lying in bed with eyes closed
HEENT: NC/AT, mm slightly dry, sclera anicteric, OP clear
without ulcerations, exudates, or erythema
Neck: supple, no LAD or elevated JVP
CV: RRR, no murmurs, rubs, gallops, nl S1, S2
Resp: scant rales in left base, no wheezes or rhonchi, unlabored
breathing
Abd: soft NT/ND, no HSM, bowel sound present
Back: no CVAT
Extrem: no cyanosis, clubbing, edema, + hammer toes
Skin: large right shoulder/back ecchymosis, abrasions and
ecchymosis over both knees, no other rashes
Neuro: drowsy, mumbling with some coherant words and sentences,
does follow motor commands (but does not open her eyes); CN
II-XII intact, PERRLA, motor: nl bulk and tone, strength 5/5 UE
(shoulder abduction, adduction, elbow felx/ext, wrist ext,
grip), LE (hip flex, knee flex/ext, dorsiplantar flex/ext)
bilaterally, sensation intact to light touch bilaterally, DTR's
2+ biceps, triceps, bracioradialis, 1+ patellar, toes downgoing
bilaterally.  no myoclonus, Gait defered

FAMILY HISTORY: Notable for [**Company 499**] cancer and prostate cancer.

SOCIAL HISTORY: Ms. [**Name13 (STitle) **] worked at [**Company 378**] as a customer support
service.  She is currently disabled.  She has been married for
over 40 years.  She has two children, one son and one daughter
and four grandchildren.  She is a nonsmoker and does not drink
alcohol.
Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Pneumonia, organism unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other complications due to other vascular device, implant, and graft,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Toxic encephalopathy,Surgical or other procedure not carried out because of patient's decision,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Surgical or other procedure not carried out because of contraindication,Unspecified essential hypertension,Hypopotassemia
Epilep NEC w/o intr epil,Pneumonia, organism NOS,Oth lymp unsp xtrndl org,Comp-oth vasc dev/graft,Urin tract infection NOS,Int inf clstrdium dfcile,Toxic encephalopathy,No proc/patient decision,Abn react-procedure NEC,Accid in resident instit,Enterococcus group d,No proc/contraindication,Hypertension NOS,Hypopotassemia
Admission Date:  [**2160-3-22**]              Discharge Date:   [**2160-5-9**]

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

Service: NEUROLOGY

Allergies:
Heparin Agents / Motrin / Phenobarbital / Vancomycin

Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 68 yo woman with a history of Large B cell Lymphoma,
s/p SCT [**2158**], complicated by intra-parenchymal and SDH and
subsequent seizures with baseline aphasia who presents with
confusion and worsening gait. Of note she has had multiple
admissions for the same symptoms and recent admission [**Date range (1) 69952**]
for altered mental status (worsening gait, aphasia) of unclear
etiology though seemed to improve with antibiotics (though no
clear infection). Of note her MS waxed and waned during that
admission with no evidence of seizure activity corresponding,
negative LP and MRI. She does have a chronically trapped left
ventricle so neurosurgery was consulted regarding semi-elective
stereotactic drainage of her chronically trapped left ventricle
when all infectious issues resolved. Regarding infection she had
c.diff neg x2, WBC on UA but culture negative (was treated with
ceftazidime transitioned to cefixime for discharge-[**Date range (1) 69953**] for
10 day course). She was also treated briefly with levofloxacin
starting on admit [**2-29**] for cough, but returned + for influenza
B.

She returned to the ED today with complaint of functional
decline at home, characterized by increased episodes of
agitation and yelling. Per her husband this she was doing better
on discharge [**3-13**] but not back to baseline. In the several days
prior to admission, she had a slowly decline, with episodes of
aggitation (sometimes aggressive), worsening aphasia, and
worsening ambulation (she was unable to get to bathroom,
seemingly unable to move her feet). Of note she had a couple of
falls at home recently. Her husband reports this is very similar
to her presentation in [**Month (only) **] and when she was admitted [**10-15**].
He notes no focal symptoms at home (no cough, HA, sob, nausea,
vomitting, diarrhea, constipation, abdominal pain, dysuria,
rash).

In the ED, initial vs were: T 99.2 rectal P 66 BP 192/66 R 18 O2
100% RA. BP down to 116/59 after ativan. Patient was given
ativan 1mg iv x2 for agitation with good effect, though on
previous admit had paradoxical rxn to ativan and responded well
to haldol. She was seen in the ED by the neurology service and
thought to have no new neurologic symptoms on exam. Head Ct neg.

On arrival to the floor, she was found to less responsive and
difficult to arouse. Neurology consulted and recommended Ativan
with the possibility that she may have been seizing. Over the
course of the subsequent hour, she became arousable and followed
commands but remained somnolent and confused.

ROS: She is unable to provide. Per her husband no fevers,
chills, c/o HA, neck pain, cough, sob, cp, palpitations, nausea,
vomitting, diarrhea, constipation, dysuria, back pain, rash,
joint swelling or pain, abdominal pain. She ate some breakfast
this morning with his assistance and slept poorly last night,
waking frequently. He does note her BP has been elevated to 160
systolic this past week.

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. Seizure disorder- as above
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 [**2-16**] 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
15. Bilateral pulmonary emboli and LLE DVT in [**10-14**]


Social History:
Ms. [**Name13 (STitle) **] worked at [**Company 378**] as a customer support
service.  She is currently disabled.  She has been married for
over 40 years.  She has two children, one son and one daughter
and four grandchildren.  She is a nonsmoker and does not drink
alcohol.


Family History:
Notable for [**Company 499**] cancer and prostate cancer.


Physical Exam:
Gen: Elderly woman in NAD, lying in bed with eyes closed
HEENT: NC/AT, mm slightly dry, sclera anicteric, OP clear
without ulcerations, exudates, or erythema
Neck: supple, no LAD or elevated JVP
CV: RRR, no murmurs, rubs, gallops, nl S1, S2
Resp: scant rales in left base, no wheezes or rhonchi, unlabored
breathing
Abd: soft NT/ND, no HSM, bowel sound present
Back: no CVAT
Extrem: no cyanosis, clubbing, edema, + hammer toes
Skin: large right shoulder/back ecchymosis, abrasions and
ecchymosis over both knees, no other rashes
Neuro: drowsy, mumbling with some coherant words and sentences,
does follow motor commands (but does not open her eyes); CN
II-XII intact, PERRLA, motor: nl bulk and tone, strength 5/5 UE
(shoulder abduction, adduction, elbow felx/ext, wrist ext,
grip), LE (hip flex, knee flex/ext, dorsiplantar flex/ext)
bilaterally, sensation intact to light touch bilaterally, DTR's
2+ biceps, triceps, bracioradialis, 1+ patellar, toes downgoing
bilaterally.  no myoclonus, Gait defered

Pertinent Results:
CT Head: 1. No hemorrhage or evidence of acute edema. 2.
Atrophy, microangiopathic change, and large area of left
temporoparietal
occipital encephalomalacia, unchanged. 3. Interval increase in
right maxillary sinus opacification and air-fluid level.

CXR:
Low lung volumes. No evidence of pneumonia.


Brief Hospital Course:
ICU Course:
1. Altered mental status: admitted to ICU for monitoring after
episode of somnolence which improved with Ativan administration.
Neurology followed closely. Patient had EEG which demonstrated
diffuse slowing without seizure activity.  Keppra continued,
Keppra level pending.  Toxic metabolic work up started.  No
evidence of infection.  Plan for 24 hour EEG, MRI/MRA and LP
under fluoroscopic guidance tomorrow.  During ICU course, had
brief periods of calling out initially, but at transfer, no
further episodes of agitation or somnolence for hours.

2. Hip Pain: X-ray negative for fracture

3. Seizure disorder: EEGs as above. Checking Keppra level.
Continued on keppra, lamotrigine and gabapentin

4. Disposition: transferred to neurology service for further
work up. Seen by BMT team, they will follow.

Floor Hospital Course:
Patient was transferred to neurology service and prolonged video
EEG monitoring was initiated. She had several episodes of
screaming and agitation, no EEG correlation for seizure activity
was noted. patient responded well to low doses of Haldol.

on [**2160-3-25**] patient had a prolonged episode in the morning where
she was unresponsive, EEG showed fast activity but lots
superimposed artifacts were noted. She was in a presumed non
convulsive status, Ativan 2mg + 2mg was given and we noticed EEG
changes and clinically the patient improved and became
responsive.

On [**2160-3-26**] Keppra was decreased and the discontinued on
[**2160-3-27**] due to the possibility of contributing for her
behavioral deterioration. lamotrigine was increased on [**2160-3-27**]
300mg twice a day.

Patient had a schedule ventriculostomy with shunt of the
encephalomalacia cavity per neurosurgery. During this admission
this procedure was cancelled and will be re-addressed after
evaluation of her lymphoma stage status.

On [**2160-3-30**] patient presented episode of unresponsiveness, not
responded to ativan IV, No obvious change in the EEG. ABG
revealed hypoxia. Chest CTA was done concerning for PE which she
had in the past, and showed 1. Limited exam demonstrates no
definite PE. 2. New ground-glass and tree-in-[**Male First Name (un) 239**] opacities
within both lungs concerning for an infectious process. In
addition urine culture was positive for enterococcus. Patient
started on ciprofloxacin, linezolid and piperacillin-Tazobactam.
She was gradually improving her overall condition. The agitation
periods were sparse and less PRN Haldol was required. Her
cognitive function was markedly improved.

The prolonged EEG monitoring showed frequent activity in the
left temporal region. Short runs of fast activity was seen with
no clear clinical correlation. Patient underwent brain PET to
evaluate areas of abnormal metabolism and significant changes
were observed. On [**2160-4-2**] Neurontin was discontinued and Lyrica
was started with the goal of better seizure/epileptiform
activity control.

Patient had an 8 days course of antibiotics. After D/C ATB she
continued to present episodes of agitiation and confusion.
Cultures from urine, blood were negative.
Keppra was discontinued on [**2160-4-8**]. EEG leads were placed on
[**2160-4-9**] and IV Depakote was given. Depakote 500mg standing dose
was initiated on [**2160-4-10**], and lamotrigine was decrease to [**1-11**]
dose 150mg [**Hospital1 **] (from 300mg [**Hospital1 **])

MICU Course:
On [**2160-4-10**] the medical intensive care unit team was called to the
bedside for an episode of unresponsiveness.  Per the neurology
team this episode was acute.  It occurred while she was on
continuous EEG monitoring and there was no seizure activity
present.  There was report per the neurology team that she was
bradycardic at the initiation of this episode but this was
unable to be confirmed.  On arrival she was unresponsive to
sternal rub and hypotensive to the 70s.  Her blood sugar was
normal.  Her ABG was without hypercarbia.  Her electrolytes were
within normal limits with the exception of a midly elevated
serum sodium.  Her EKG was without ischemic changes.  She had
only a PICC line in place so additional peripheral access was
obtained and she received two liters of normal saline boluses.
She transiently required peripheral dopamine while IV access was
being obtained prior to MICU transfer.  While in the medical ICU
no interventions were taken.  She was hemodynamically stable.
Her mental status improved to baseline within approximately 30
minutes of arrival.   It was felt her episode was primarily
neurologic in nature so her care was returned to the neurology
service.

Floor Course:
[**2160-4-11**] Patient was transferred back to the floor and remained
stable. Red blood cell was persistently dropping, patient
received 2 units transfusion on [**2160-4-11**] and hct remained stable
thereafter.

On [**2160-4-13**] metoprolol 25mg [**Hospital1 **] was restarted due to persistent
elevated blood pressure and sustained heart rate of
120beats/min.  This was titrated up to 50mg [**Hospital1 **].

On [**2160-4-17**] she developed fever, somnolence and diarrhea.  [**1-12**]
stools were positive for c. dif.  She also had a positive UA at
that time.  She was covered with IV flagyl, zosyn, and
vancomycin.  Medicine was consulted.  Urine culture only grew
yeast and cleared after foley removal.  She received IV flagyl
for 7 days with improvement in her mental status before
transition to po vancomycin w/ planned 14 day course ([**2079-4-23**]).
She had a relative decrease in her BP and metoprolol was stopped
and during recovery again titrated for elevated SBP.  In the
setting of c. dif she was found to have some subclinical seizure
activity on EEG while off lyrica and lamotrigine due to
inability to take po.  She also has an episode on [**4-26**] of
decreased responsiveness.  Both responded to IV ativan 1mg.

On [**2160-4-10**] she developed a gradually increasing transaminitis
which resolved by [**4-18**].  This recurred on [**4-21**] and peaked on
[**4-26**].  Right upper quadrant u/s and ammonia were normal.  It was
attributed to depakote and seemed to occur and worsen as she
recovered from c. dif and began eating again.  She was put back
on keppra with vitamin B6 to help with any adverse effects on
mood with plan to wean off depakote but she developed severe
agitation and would either scream or cry when staff entered the
room and had some violent behavior.  Keppra and B6 were stopped
and carnitor added on [**4-29**] and by the following morning she was
much less agitated.

Patient refused her PO medications and lab draws occasionally.
She has intermittent screaming when agitated which generally
self resolve.  In the past these have been treated with low dose
haldol if she is truely combative.  This has not been necessary
in over 2 weeks.

On [**4-26**] she developed right arm swelling and was found to have
thrombus around her PICC which was removed.  No anticoagulation
was pursued given her history of intracranial hemorrage.

Calorie count [**Date range (1) 69954**] found that she's only consuming 30% of
the calories she needs.  She is not taking the supplement well
per her husband who is aware of her poor intake.  He expresses
consistent wishes not to have a peg placed.  Recommend
encouraging high calorie foods as possible.

Palliative care consult was obtained to assist in discussing
goals of care.  [**Known firstname 4115**] was taking only 30% of her goal
calories, yet the husband does not want a g-tube, yet he hopes
she'll improve.  Family meeting with her long term and current
care providers was recommended.  Plan of care and long term
goals were discussed at the meeting.  The family was considering
going home with nursing and seeing how she does, home hospice,
or rehab and leaning toward the 1st option.

The following day [**2160-5-6**] pt was more somnolent and developed
tachypnea and hypoxia followed by bilious emesis.  She was
evaluated by medicine and transferred back to the MICU.  She was
presumed to have aspiration.  The family made the decision to
move to comfort care and she was transferred back to the floor.
The following day she was breathing easily and alert appering
comfortable.  The morning of discharge she was flushed but
breathing comfortably.  Home hospice was arranged at home.
Midline catheter remains in place for comfort medications.

Medications on Admission:
Atovaquone 750 mg/5 mL PO DAILY
Gabapentin 300 mg PO Q12H
Lamotrigine 275 mg Tablet PO BID ->husband giving her 225 [**Hospital1 **]
due to confusing nature of d/c medications
Leucovorin Calcium 10 mg PO DAILY
Metoprolol Tartrate 25 mg PO BID
Pantoprazole 40 mg PO Q24H
Multivitamin PO DAILY
Thiamine HCl 100 mg PO DAILY
Senna with Docusate Sodium 8.6-50 mg as needed for constipation

Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Q6H
Ipratropium Bromide 0.02 Q6H
Polyvinyl Alcohol 1.4 % 1-2 Drops Ophthalmic every 4 hours as
needed for eye irritation
Calcium Carbonate 500 mg One PO 3 times a day
Acetaminophen 325 mg 1-2 Tablets PO every 6 hours as needed
Levetiracetam 1000 mg PO 3 times a day
lorazepam 0.5mg prn

Discharge Medications:
1. Acetaminophen 650 mg Suppository [**Hospital1 **]: Two (2) Suppository
Rectal Q4H (every 4 hours) as needed for fever or pain.
Disp:*30 Suppository(s)* Refills:*0*
2. Morphine Concentrate 20 mg/mL Solution [**Hospital1 **]: 1-20 mg PO Q1H
(every hour) as needed for pain, shortness of breath.
Disp:*30 ml* Refills:*0*
3. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup [**Hospital1 **]: Ten
(10) ml PO Q12H (every 12 hours): Concentrated elixer to be
provided for po/pr administration when able, then will be given
IV.
Disp:*200 * Refills:*2*
4. Lorazepam 2 mg/mL Concentrate [**Hospital1 **]: 0.5-2 mg PO every four (4)
hours: to be given sublingual.
Disp:*QS 1 month * Refills:*2*
5. Lorazepam in Normal Saline 100 mg/100 mL (1 mg/mL) Solution
[**Hospital1 **]: One (1) mg Intravenous q1h as needed for status
epilepticus: to be given in midline.
Disp:*30 ml* Refills:*0*
6. haldol  [**Hospital1 **]: 0.5-4  Sublingual every 4-6 hours as needed for
agitation or delerium.


Discharge Disposition:
Home With Service

Facility:
Hospice of the Good [**Doctor Last Name 9995**]

Discharge Diagnosis:
Primary
Seizure disorder
Hospital acquired Pneumonia
Urinary tract infection
Clostridium difficile
Right arm deep venous thrombosis
Aspiration

Secondary:
Large B cell lymphoma
intracranial bleeding/ encephalomalacia/ aphasia


Discharge Condition:
Fair


Discharge Instructions:
You were admitted to this hospital to evaluate episodes of
agitation alternating with unresponsiveness. You underwent
prolonged video EEG monitoring and in one ocasion seizure was
noted. You presented other unresponsiveness events with hypoxia
associated to hospital acquire pneumonia and other suggestive of
vasal vagal reflex.

Your seizure medications were adjusted: Depakote was started
during this admission. Because of drug interaction Lamictal was
decreased in half dose. Lyrica was also initiated and neurontin
discontinued. Because of increases in your liver enzymes while
on depakote, keppra was started in preparation to stop depakote.
 You had increased agitation on keppra so this was stopped.
Vitamin B6 was given to help with the potential side effects of
keppra without success.

No infectious source was identified at the begining, but in your
day 8 of admission you were found to have pneumonia and positive
urine culture. You had 8 days course with antibiotics.  Then you
were found to have a c. dif infection treated with flagyl IV and
then vancomycin by mouth.  A family meeting occured to discuss
goals of care on [**5-5**].  On [**5-6**] you developed respiratory
distress and vomiting.  The decision was made to redirect your
care toward comfort measures and home hospice was arranged.

Followup Instructions:
None
As needed



Completed by:[**2160-5-9**]
{"Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Pneumonia, organism unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other complications due to other vascular device, implant, and graft,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Toxic encephalopathy,Surgical or other procedure not carried out because of patient's decision,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Surgical or other procedure not carried out because of contraindication,Unspecified essential hypertension,Hypopotassemia"}


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: Altered Mental Status

PRESENT ILLNESS: This is a 68 yo woman with a history of Large B cell Lymphoma,
s/p SCT [**2158**], complicated by intra-parenchymal and SDH and
subsequent seizures with baseline aphasia who presents with
confusion and worsening gait. Of note she has had multiple
admissions for the same symptoms and recent admission [**Date range (1) 69952**]
for altered mental status (worsening gait, aphasia) of unclear
etiology though seemed to improve with antibiotics (though no
clear infection). Of note her MS waxed and waned during that
admission with no evidence of seizure activity corresponding,
negative LP and MRI. She does have a chronically trapped left
ventricle so neurosurgery was consulted regarding semi-elective
stereotactic drainage of her chronically trapped left ventricle
when all infectious issues resolved. Regarding infection she had
c.diff neg x2, WBC on UA but culture negative (was treated with
ceftazidime transitioned to cefixime for discharge-[**Date range (1) 69953**] for
10 day course). She was also treated briefly with levofloxacin
starting on admit [**2-29**] for cough, but returned + for influenza
B.

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. Seizure disorder- as above
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 [**2-16**] 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
15. Bilateral pulmonary emboli and LLE DVT in [**10-14**]

MEDICATION ON ADMISSION: Atovaquone 750 mg/5 mL PO DAILY
Gabapentin 300 mg PO Q12H
Lamotrigine 275 mg Tablet PO BID ->husband giving her 225 [**Hospital1 **]
due to confusing nature of d/c medications
Leucovorin Calcium 10 mg PO DAILY
Metoprolol Tartrate 25 mg PO BID
Pantoprazole 40 mg PO Q24H
Multivitamin PO DAILY
Thiamine HCl 100 mg PO DAILY
Senna with Docusate Sodium 8.6-50 mg as needed for constipation

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: Gen: Elderly woman in NAD, lying in bed with eyes closed
HEENT: NC/AT, mm slightly dry, sclera anicteric, OP clear
without ulcerations, exudates, or erythema
Neck: supple, no LAD or elevated JVP
CV: RRR, no murmurs, rubs, gallops, nl S1, S2
Resp: scant rales in left base, no wheezes or rhonchi, unlabored
breathing
Abd: soft NT/ND, no HSM, bowel sound present
Back: no CVAT
Extrem: no cyanosis, clubbing, edema, + hammer toes
Skin: large right shoulder/back ecchymosis, abrasions and
ecchymosis over both knees, no other rashes
Neuro: drowsy, mumbling with some coherant words and sentences,
does follow motor commands (but does not open her eyes); CN
II-XII intact, PERRLA, motor: nl bulk and tone, strength 5/5 UE
(shoulder abduction, adduction, elbow felx/ext, wrist ext,
grip), LE (hip flex, knee flex/ext, dorsiplantar flex/ext)
bilaterally, sensation intact to light touch bilaterally, DTR's
2+ biceps, triceps, bracioradialis, 1+ patellar, toes downgoing
bilaterally.  no myoclonus, Gait defered

FAMILY HISTORY: Notable for [**Company 499**] cancer and prostate cancer.

SOCIAL HISTORY: Ms. [**Name13 (STitle) **] worked at [**Company 378**] as a customer support
service.  She is currently disabled.  She has been married for
over 40 years.  She has two children, one son and one daughter
and four grandchildren.  She is a nonsmoker and does not drink
alcohol. 

### Response:
{"Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Pneumonia, organism unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other complications due to other vascular device, implant, and graft,Urinary tract infection, site not specified,Intestinal infection due to Clostridium difficile,Toxic encephalopathy,Surgical or other procedure not carried out because of patient's decision,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Surgical or other procedure not carried out because of contraindication,Unspecified essential hypertension,Hypopotassemia"}
