CHIEF COMPLAINT: Confusion

PRESENT ILLNESS: Mr [**Name13 (STitle) 4027**] is a 58 y/o right handed man with history of DM2
and CAD who presented from OSH with increasing confusion,
forgetfulness, peripheral vision loss and agraphia. The patient
was in his usual state of health until [**2175-12-28**] when he was in a
minor car accident after making a wrong turn on a familiar
street, hitting a post from the R side. He was not injured in
the
fender-bender. The next day, he was forgetful and left his car
door open when at work. On Saturday [**12-30**], he stated to his wife
that he felt "muttled", but did not complain of any specific
deficits nor did his wife note any. However, the next day his
daughter reported that he mixed up words when speaking with her.
On Monday ([**1-1**]), he could not remember his address when asked
by
the auto-mechanic. He was able to go to work at court, but was
worried when he could not figure out how to sign his name.
Specifically, he had difficulty writing letters and was
perseverative. Though he knew what he wanted to write, he was
not
able to do so correctly. This event prompted him to consult his
PCP who discovered [**Name Initial (PRE) **] small right peripheral visual field deficit
which Mr. [**Name (NI) 21862**] wife states was "about 10% of his vision".
He
had never had this before. He had no headache. His doctor
requested a head CT which he had on [**1-3**]. The CT scan revealed a
left parietal/occipital mass. The next day, his symptoms
persisted and he was admitted to this hospital.

MEDICAL HISTORY: 1. DM2 with poor control and peripheral neuropathy
2. Coronary artery disease s/p CABGx4 and stent deployment circa
[**2164**]
3. Obstructive sleep apnea (uses CPAP at night)
4. Obesity
5. Dyslipidemia
6. Seasonal Allergies

MEDICATION ON ADMISSION: 1. Plavix
2. Humalog 160 Units Qam and Qpm
3. Humulin 20 Units Qam and Qpm
4. Metformin 300 mg Qam and 200mg Qpm
5. Lyrica 200 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-97.5 BP-131/64 (126-154/57-65) HR-93(74-91)SR RR-20 O2Sat-95%
on Fi40% ventimask
Gen: Lying in bed restrained, NAD
HEENT: Has neurosurgical wound on posterior left aspect of head,
dry oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: Unable to assess
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: no edema
Skin: No rashes
Neurologic examination:
MS:
General:  Awake but drowsy, normal affect, very perseverative
Orientation:  Not oriented to person, place, time, or situation.
Attention: Very inattentive, but temporarily redirectable.
Speech/[**Doctor Last Name **]: He is able to express basic thoughts and give basic
yes/no replies; comprehension intact to simple commands,
repetition intact to "today is a sunny day" but impaired to more
abstarct sentence, could not name or read but claimed to not be
able to see what was being shown and was inattentive
Memory: N/A due to inattention
Calculations: N/A due to inattention
L/R confusion: Appears confused, but difficult to assess given
inattentiveness
Praxis: N/A due to inattention

FAMILY HISTORY: No family history of demyelinating disease such as MS, no
history of neurologic conditions or autoimmune disorders.

SOCIAL HISTORY: The patient is an atorney in [**State 1727**]. He is a college graduate
and received the highest possible score on his LSAT examination.
He is married for 29 years and lives with his wife. [**Name (NI) **] does not
use drugs. He has never had a blood transfusion.
Wife [**Name (NI) **] may be reached at [**Telephone/Fax (1) 81578**], Daughter [**Name (NI) **] may
be reached at [**Telephone/Fax (1) 81579**].
Demyelinating disease of central nervous system, unspecified,Encephalopathy, unspecified,Malignant neoplasm of specified parts of peritoneum,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Aortocoronary bypass status,Obstructive sleep apnea (adult)(pediatric),Other symbolic dysfunction,Morbid obesity,Homonymous bilateral field defects,Long-term (current) use of steroids
Cns demyelination NOS,Encephalopathy NOS,Mal neo peritoneum NEC,DMII neuro nt st uncntrl,Neuropathy in diabetes,Aortocoronary bypass,Obstructive sleep apnea,Symbolic dysfunction NEC,Morbid obesity,Homonymous hemianopsia,Long-term use steroids
Name:  [**Known lastname **],[**Known firstname 441**] F                 Unit No:   [**Numeric Identifier 13068**]

Admission Date:  [**2176-1-4**]              Discharge Date:   [**2176-1-26**]

Date of Birth:  [**2117-6-30**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 542**]
Addendum:
Final pathology of the retroperitoneal mass returned as seminoma
(see path reports below). There are sparse cases of single
demyelinating lesions occurring in pt's with seminomas, thought
to be a paraneoplastic process. See:

Facial numbness in a man with inguinal and retroperitoneal
masses.
[**Last Name (un) 13069**] SR, [**Doctor Last Name 13070**] MV, [**Last Name (un) 13071**] JS.
Nat Clin Pract Oncol. [**2171**] [**Month (only) **];2(1):54-8

and

Solitary focal demyelination in the brain as a paraneoplastic
disorder.
[**Last Name (un) 13072**] JH, Bertorini TE, [**Last Name (un) 13073**] FC Jr, [**Name2 (NI) **] TF, [**Doctor Last Name **] H, Becske
T, [**Last Name (un) 13074**] PG, Handorf CR, Horner LH, M??????nkem??????ller KE.
Med Pediatr Oncol. [**2162**] [**Month (only) **];26(2):111-5.

and

Paraneoplastic demyelinating disorder in the brain of a patient
with seminoma.
[**Doctor Last Name 25**] K, [**Last Name (un) 13075**] P, [**Doctor Last Name **] K, [**Doctor Last Name 13076**] C, Kostashuk E.
J Comput Assist Tomogr. [**2164**] [**Month (only) **]-[**Month (only) **];22(1):136-8.

Retroperitoneal Mass Biopsy [**2176-1-23**]:

DIAGNOSIS:

Retroperitoneal mass (parts 1 - 6)

Metastatic malignant neoplasm (see note).


Immunostains and morphology favor a germ cell tumor, Seminoma.



Note:  The tumor is composed of large cells with abundant clear
cytoplasm, round nuclei with prominent central nucleoli in
sheets with a background of lymphoid hyperplasia and necrotizing
granulomas.  Tumor cells are

          Positive for:  c-Kit

          Negative for: Cytokeratin cocktail, CD30 (immunoblasts
only), S100 (macrophages only), AFP, and PLAP (however, no
internal control).

          An LCA will be reported in an addendum.

ADDENDUM: A stain for LCA is negative (small lymphocytes only).

Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 13077**]/jlh
Date: [**2176-1-29**]

Clinical:   Retroperitoneal mass.
Gross: The specimen is received in six parts, all labeled with
the patient's name, "[**Known lastname 8270**], [**Known firstname **]" and the medical record
number.



Part 1 is additionally labeled "left peritoneal mass biopsy
frozen section." It consists of a fragment of soft tissue
measuring 1 x 0.5 x 0.6 cm.  The peripheral smear was done on
the specimen.  Peripheral smear diagnosis by Dr. [**Last Name (STitle) **] is
"sclerotic tissue with small lymphocytes, likely reactive."  The
specimen was entirely submitted in A.



Part 2 is additionally labeled "retroperitoneal mass, left
frozen section #2." It consists of red tan multiple soft tissue
fragments measuring 1 x 1 x 0.4 cm in aggregate.  The surface of
one of the fragments is smooth and probably has peritoneum.
Frozen section diagnosis by Dr. [**Last Name (STitle) **] is "poorly differentiated
epithelioid neoplasm plus adjacent reactive/fibrotic tissue.
Insufficient for diagnosis."  Frozen section remnant is
submitted in B, the remainder is submitted in C.



Part 3 is additionally labeled "retroperitoneal mass biopsy #3."
It consists of red tan soft tissue fragments measuring 0.9 x 0.4
x 0.2 cm.  The specimen is entirely frozen.  Frozen section
diagnosis by Dr. [**Last Name (STitle) **] is "sclerotic tissue with chronic
inflammation, no malignancy identified."  The specimen is
entirely submitted in D.



Part 4 is additionally labeled "retroperitoneal mass biopsy #4."
It consists of multiple red tan soft tissue fragments measuring
1 x 1 x 1 cm in aggregate. No frozen section was performed on
that specimen. The specimen is entirely submitted in E.



Part 5 is additionally labeled "retroperitoneal mass biopsy #5."
It consists of multiple soft tissue fragments measuring 1 x 1 x
0.5 cm in aggregate. A portion of specimen was frozen.  Frozen
section diagnosis by Dr. [**Last Name (STitle) **] is "positive for poorly
differentiated epithelioid neoplasm."  The specimen was
submitted as follows: Frozen section remnant in F, the remainder
of the specimen is in G.



Part 6 is additionally labeled "retroperitoneal mass biopsy #6."
It was received fresh from the Operating Room.  It consists of
fleshy and hemorrhagic soft tissue fragment measuring 2 x 1.5 x
1 cm in aggregate.  The specimen is partially frozen. Frozen
section diagnosis by Dr. [**Last Name (STitle) **] is "lesional tissue present."
The specimen is entirely submitted as follows: H = frozen
section, I-L = remainder of the specimen.

Lypmh Node Flow Cytometric Immunophenotyping [**2176-1-24**]:

SPECIMEN SUBMITTED: Immunophenotyping, Lymph Node

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2176-1-24**] [**2176-1-24**] [**2176-1-26**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 13078**]/mrr??????
Previous biopsies:    [**Numeric Identifier 13079**]  Retroperitoneal Mass BX,
Retroperitoneal Mass Bx,
  [**Numeric Identifier 13080**]  RETROPERITONEAL MASS. (1 JAR)
  [**Numeric Identifier 13081**]  left occipital lobe tumor, #2 left occipital lobe
tumor,

DIAGNOSIS:

FLOW CYTOMETRY REPORT

FLOW CYTOMETRY IMMUNOPHENOTYPING

The following tests (antibodies) were performed: HLA-DR, FMC-7,
kappa, lambda, and CD antigens 2, 3, 5, 7, 10, 19, 19, 20, 23,
45.



RESULTS:

Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.

B cells comprise 34% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.

T cells comprise 59% of lymphoid gated events, express mature
lineage antigens.



INTERPRETATION

Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings and
morphology (see S09-4354) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.




Discharge Disposition:
Home With Service

Facility:
Community Health and Nursing Services

Discharge Diagnosis:
Retroperitoneal mass: final pathology Seminoma
Left posterior parietal lesion: Final pathology Demyelination

Followup Instructions:
He will follow with his oncologist in [**State 4488**] for treatment of the
seminoma.

                             [**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]

Completed by:[**2176-1-30**]

Admission Date:  [**2176-1-4**]              Discharge Date:   [**2176-1-26**]

Date of Birth:  [**2117-6-30**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Confusion

Major Surgical or Invasive Procedure:
MRI under anesthesia
[**1-8**]: Open left parietal craniotomy for biopsy


History of Present Illness:
Mr [**Name13 (STitle) 4027**] is a 58 y/o right handed man with history of DM2
and CAD who presented from OSH with increasing confusion,
forgetfulness, peripheral vision loss and agraphia. The patient
was in his usual state of health until [**2175-12-28**] when he was in a
minor car accident after making a wrong turn on a familiar
street, hitting a post from the R side. He was not injured in
the
fender-bender. The next day, he was forgetful and left his car
door open when at work. On Saturday [**12-30**], he stated to his wife
that he felt "muttled", but did not complain of any specific
deficits nor did his wife note any. However, the next day his
daughter reported that he mixed up words when speaking with her.
On Monday ([**1-1**]), he could not remember his address when asked
by
the auto-mechanic. He was able to go to work at court, but was
worried when he could not figure out how to sign his name.
Specifically, he had difficulty writing letters and was
perseverative. Though he knew what he wanted to write, he was
not
able to do so correctly. This event prompted him to consult his
PCP who discovered [**Name Initial (PRE) **] small right peripheral visual field deficit
which Mr. [**Name (NI) 21862**] wife states was "about 10% of his vision".
He
had never had this before. He had no headache. His doctor
requested a head CT which he had on [**1-3**]. The CT scan revealed a
left parietal/occipital mass. The next day, his symptoms
persisted and he was admitted to this hospital.

Per his wife, in the days leading up to admission, Mr. [**Name13 (STitle) 4027**]
did not have any fever, cough, weight changes, nausea, vomiting,
or diarrhea, or other signs of infection. He did not complain of
numbness, weakness, tingling, or hearing changes. No recent
travel or tick exposure. Most recent immunization was Influenza
vaccine in [**2175-9-20**], which he had received in prior years
without problems. [**Name (NI) **] prior such episodes.

On admission, his R visual field cut was noted to be more
pronounced. Over the next couple of days([**Date range (1) 61317**])), he had
decreased speech production, decreased attention, and decreased
orientation to his surroundings. He could not remember how to
use
the phone. Because of his clinical deterioration and concern for
high-grade glioma, on [**1-8**], he had a stereotactic brain biopsy
of
the left occipital/parietal mass. He was intubated and sedated
until the morning of [**1-9**]. During the night he was noted to not
be moving his RUE as much as the left, stat head CT was
unchanged. He was extubated and given Haldol 2.5mg for
aggitation
at 9:30am (1.5 hours before exam). He has been on broad-spectrum
empiric Abx (Vanc/gent/Levoflox) given concern for abscess
though
prelim path gram stain was sterile. He has also been placed on
empiric Keppra prophylaxis though no clinical episodes
concerning
for seizure.


Past Medical History:
1. DM2 with poor control and peripheral neuropathy
2. Coronary artery disease s/p CABGx4 and stent deployment circa
[**2164**]
3. Obstructive sleep apnea (uses CPAP at night)
4. Obesity
5. Dyslipidemia
6. Seasonal Allergies


Social History:
The patient is an atorney in [**State 1727**]. He is a college graduate
and received the highest possible score on his LSAT examination.
He is married for 29 years and lives with his wife. [**Name (NI) **] does not
use drugs. He has never had a blood transfusion.
Wife [**Name (NI) **] may be reached at [**Telephone/Fax (1) 81578**], Daughter [**Name (NI) **] may
be reached at [**Telephone/Fax (1) 81579**].


Family History:
No family history of demyelinating disease such as MS, no
history of neurologic conditions or autoimmune disorders.


Physical Exam:
T-97.5 BP-131/64 (126-154/57-65) HR-93(74-91)SR RR-20 O2Sat-95%
on Fi40% ventimask
Gen: Lying in bed restrained, NAD
HEENT: Has neurosurgical wound on posterior left aspect of head,
dry oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: Unable to assess
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: no edema
Skin: No rashes
Neurologic examination:
MS:
General:  Awake but drowsy, normal affect, very perseverative
Orientation:  Not oriented to person, place, time, or situation.
Attention: Very inattentive, but temporarily redirectable.
Speech/[**Doctor Last Name **]: He is able to express basic thoughts and give basic
yes/no replies; comprehension intact to simple commands,
repetition intact to "today is a sunny day" but impaired to more
abstarct sentence, could not name or read but claimed to not be
able to see what was being shown and was inattentive
Memory: N/A due to inattention
Calculations: N/A due to inattention
L/R confusion: Appears confused, but difficult to assess given
inattentiveness
Praxis: N/A due to inattention

CN:
I: not tested
II,III:  Patient inattentive but appears to have a right
homonomous hemianopsia, PERRL 2mm to 1.5mm,
III,IV,V: EOMI, no ptosis. No nystagmus
V:  sensation intact V1-V3 to LT
VII:  Facial strength intact/symmetrical
VIII:  hears finger rub bilaterally
IX,X:  palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]:  SCM/trapezeii [**4-23**] on Left, [**2-22**] on right.
XII:  tongue protrudes midline, no dysarthria

Motor: Normal bulk and ?mild increased tone RLE; no tremor,
asterixis or myoclonus.
Pronator drift N/A due to inattention.
   Delt [**Hospital1 **] Tri WE     FE     Grip  IO
   C5   C6 C7  C6     C7     C8/T1 T1
L  5    5  5   5      5      5     5
R  3    3  3   3      3      3     3
   IP  Quad Hamst DF  [**Last Name (un) 938**]    PF
   L2  L3   L4-S1 L4  L5     S1/S2
L  5   5    5     5   5      5
R  4-  4-   4-    4-  4-     4-
Reflex: No clonus
   [**Hospital1 **] Tri Bra Pat An Plantar
   C5 C7  C6  L4  S1 CST
L  0  0   0   2   0  Extensor
R  0  0   0   2   0  Extensor

Sensation: grimaces and attempts withdrawal from noxious in all
extremities purposefully
Coordination: finger-nose-finger normal on left but R not assess
given hemiparesis.

Gait: N/A
Romberg: N/A


Pertinent Results:
[**2176-1-26**] 06:08AM BLOOD WBC-9.1 RBC-3.72* Hgb-10.7* Hct-32.6*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.4 Plt Ct-121*
[**2176-1-24**] 05:40AM BLOOD WBC-12.9* RBC-3.98* Hgb-11.9* Hct-35.0*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.7* Plt Ct-186
[**2176-1-23**] 08:40AM BLOOD WBC-9.4 RBC-4.03* Hgb-11.8* Hct-34.9*
MCV-87 MCH-29.3 MCHC-33.9 RDW-15.7* Plt Ct-152
[**2176-1-22**] 09:40PM BLOOD WBC-11.1* RBC-4.03* Hgb-12.0* Hct-35.3*
MCV-88 MCH-29.8 MCHC-34.1 RDW-15.5 Plt Ct-156
[**2176-1-19**] 06:09AM BLOOD WBC-11.9* RBC-4.14* Hgb-12.1* Hct-35.1*
MCV-85 MCH-29.2 MCHC-34.4 RDW-15.3 Plt Ct-185
[**2176-1-18**] 06:15AM BLOOD WBC-11.4* RBC-4.12* Hgb-12.4* Hct-35.5*
MCV-86 MCH-30.0 MCHC-34.8 RDW-15.4 Plt Ct-180
[**2176-1-16**] 05:25AM BLOOD WBC-10.7 RBC-4.40* Hgb-13.1* Hct-38.0*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.4 Plt Ct-209
[**2176-1-14**] 07:20AM BLOOD WBC-7.7 RBC-4.35* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.2 MCHC-33.8 RDW-15.2 Plt Ct-221
[**2176-1-13**] 07:45AM BLOOD WBC-6.1 RBC-4.08* Hgb-12.0* Hct-35.5*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-205
[**2176-1-12**] 04:13AM BLOOD WBC-7.4 RBC-3.70* Hgb-11.1* Hct-31.3*
MCV-85 MCH-30.1 MCHC-35.6* RDW-15.3 Plt Ct-181
[**2176-1-11**] 03:05AM BLOOD WBC-11.0 RBC-3.98* Hgb-11.6* Hct-33.5*
MCV-84 MCH-29.1 MCHC-34.6 RDW-15.2 Plt Ct-207
[**2176-1-10**] 02:44AM BLOOD WBC-9.3 RBC-4.16* Hgb-12.1* Hct-35.2*
MCV-85 MCH-29.1 MCHC-34.4 RDW-15.4 Plt Ct-187
[**2176-1-9**] 07:26PM BLOOD WBC-13.9* RBC-4.06* Hgb-11.9* Hct-34.3*
MCV-85 MCH-29.4 MCHC-34.8 RDW-15.5 Plt Ct-184
[**2176-1-9**] 03:26AM BLOOD WBC-13.2* RBC-4.02* Hgb-11.8* Hct-33.7*
MCV-84 MCH-29.4 MCHC-35.1* RDW-15.6* Plt Ct-205
[**2176-1-8**] 04:14PM BLOOD WBC-11.6* RBC-4.31* Hgb-12.7* Hct-36.7*
MCV-85 MCH-29.4 MCHC-34.5 RDW-15.3 Plt Ct-220
[**2176-1-7**] 07:50AM BLOOD WBC-8.2 RBC-4.61 Hgb-13.5* Hct-40.0
MCV-87 MCH-29.3 MCHC-33.7 RDW-15.2 Plt Ct-188
[**2176-1-6**] 07:25AM BLOOD WBC-8.5 RBC-4.39* Hgb-12.7* Hct-37.5*
MCV-86 MCH-29.1 MCHC-33.9 RDW-15.3 Plt Ct-200
[**2176-1-5**] 05:48AM BLOOD WBC-11.6* RBC-4.19* Hgb-12.6* Hct-36.2*
MCV-87 MCH-30.1 MCHC-34.8 RDW-15.3 Plt Ct-194
[**2176-1-4**] 01:45AM BLOOD WBC-10.0 RBC-4.35* Hgb-12.8* Hct-37.1*
MCV-85 MCH-29.5 MCHC-34.6 RDW-15.5 Plt Ct-235
[**2176-1-3**] 11:00PM BLOOD WBC-10.9 RBC-4.58* Hgb-13.4* Hct-38.8*
MCV-85 MCH-29.2 MCHC-34.4 RDW-15.4 Plt Ct-230
[**2176-1-18**] 06:15AM BLOOD Neuts-75.4* Lymphs-17.5* Monos-6.0
Eos-0.7 Baso-0.4
[**2176-1-3**] 11:00PM BLOOD Neuts-68.2 Lymphs-20.7 Monos-5.6 Eos-4.5*
Baso-1.0
[**2176-1-23**] 08:40AM BLOOD PT-14.0* PTT-23.0 INR(PT)-1.2*
[**2176-1-22**] 10:30AM BLOOD PT-13.7* PTT-22.7 INR(PT)-1.2*
[**2176-1-12**] 04:13AM BLOOD PT-15.2* PTT-20.7* INR(PT)-1.3*
[**2176-1-11**] 03:05AM BLOOD PT-14.5* PTT-20.9* INR(PT)-1.3*
[**2176-1-10**] 02:44AM BLOOD PT-14.9* PTT-23.3 INR(PT)-1.3*
[**2176-1-9**] 03:26AM BLOOD PT-14.4* PTT-21.9* INR(PT)-1.3*
[**2176-1-8**] 04:14PM BLOOD PT-14.3* PTT-24.4 INR(PT)-1.2*
[**2176-1-7**] 07:50AM BLOOD PT-15.0* PTT-26.1 INR(PT)-1.3*
[**2176-1-6**] 07:25AM BLOOD PT-14.2* PTT-25.1 INR(PT)-1.2*
[**2176-1-5**] 05:48AM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD PT-15.1* PTT-24.4 INR(PT)-1.3*
[**2176-1-3**] 11:00PM BLOOD PT-14.7* PTT-24.5 INR(PT)-1.3*
[**2176-1-4**] 01:45AM BLOOD ESR-28*
[**2176-1-26**] 06:08AM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-138
K-3.3 Cl-101 HCO3-27 AnGap-13
[**2176-1-24**] 05:40AM BLOOD Glucose-80 UreaN-12 Creat-0.9 Na-140
K-4.2 Cl-105 HCO3-26 AnGap-13
[**2176-1-23**] 08:40AM BLOOD Glucose-164* UreaN-15 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2176-1-22**] 09:40PM BLOOD Glucose-259* UreaN-17 Creat-0.9 Na-140
K-4.3 Cl-103 HCO3-26 AnGap-15
[**2176-1-19**] 06:09AM BLOOD Glucose-54* UreaN-19 Creat-0.8 Na-141
K-3.5 Cl-106 HCO3-26 AnGap-13
[**2176-1-18**] 06:15AM BLOOD Glucose-112* UreaN-18 Creat-0.8 Na-140
K-3.9 Cl-107 HCO3-26 AnGap-11
[**2176-1-17**] 06:15AM BLOOD Glucose-155* UreaN-18 Creat-0.8 Na-137
K-4.4 Cl-101 HCO3-27 AnGap-13
[**2176-1-16**] 05:25AM BLOOD Glucose-216* UreaN-18 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-28 AnGap-11
[**2176-1-14**] 07:20AM BLOOD Glucose-235* UreaN-22* Creat-0.8 Na-137
K-4.2 Cl-102 HCO3-27 AnGap-12
[**2176-1-13**] 07:45AM BLOOD Glucose-262* UreaN-22* Creat-0.8 Na-137
K-4.5 Cl-102 HCO3-24 AnGap-16
[**2176-1-12**] 04:13AM BLOOD Glucose-270* UreaN-22* Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
[**2176-1-11**] 03:05AM BLOOD Glucose-111* UreaN-19 Creat-0.7 Na-138
K-4.3 Cl-103 HCO3-29 AnGap-10
[**2176-1-10**] 02:44AM BLOOD Glucose-172* UreaN-12 Creat-0.8 Na-139
K-4.3 Cl-105 HCO3-26 AnGap-12
[**2176-1-9**] 03:26AM BLOOD Glucose-263* UreaN-15 Creat-0.8 Na-136
K-3.9 Cl-104 HCO3-23 AnGap-13
[**2176-1-8**] 04:14PM BLOOD Glucose-228* UreaN-18 Creat-1.0 Na-135
K-5.4* Cl-102 HCO3-23 AnGap-15
[**2176-1-7**] 07:50AM BLOOD Glucose-275* UreaN-16 Creat-0.8 Na-136
K-4.4 Cl-101 HCO3-23 AnGap-16
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-6**] 07:25AM BLOOD Glucose-192* UreaN-14 Creat-0.8 Na-136
K-4.4 Cl-100 HCO3-26 AnGap-14
[**2176-1-5**] 05:48AM BLOOD Glucose-171* UreaN-16 Creat-0.7 Na-140
K-4.1 Cl-103 HCO3-26 AnGap-15
[**2176-1-4**] 01:45AM BLOOD Glucose-174* UreaN-14 Creat-0.9 Na-138
K-3.9 Cl-102 HCO3-27 AnGap-13
[**2176-1-3**] 11:00PM BLOOD Glucose-105 UreaN-13 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2176-1-24**] 05:40AM BLOOD ALT-72* AST-54* LD(LDH)-277* AlkPhos-84
TotBili-0.5
[**2176-1-17**] 06:15AM BLOOD ALT-91* AST-43* LD(LDH)-271* CK(CPK)-229*
AlkPhos-88 TotBili-0.5
[**2176-1-10**] 02:08PM BLOOD ALT-62* AST-53* LD(LDH)-217 AlkPhos-96
Amylase-14 TotBili-0.3
[**2176-1-9**] 03:26AM BLOOD CK(CPK)-1776*
[**2176-1-8**] 04:14PM BLOOD CK(CPK)-196*
[**2176-1-4**] 01:45AM BLOOD ALT-42* AST-38 AlkPhos-101 TotBili-0.4
[**2176-1-10**] 02:08PM BLOOD Lipase-11
[**2176-1-9**] 03:26AM BLOOD CK-MB-30* MB Indx-1.7 cTropnT-<0.01
[**2176-1-8**] 04:14PM BLOOD CK-MB-5 cTropnT-<0.01
[**2176-1-24**] 05:40AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.1 UricAcd-5.2
[**2176-1-22**] 09:40PM BLOOD Calcium-8.4 Phos-2.4*# Mg-2.0
[**2176-1-18**] 06:15AM BLOOD Calcium-8.3* Phos-4.0 Mg-2.4
[**2176-1-17**] 06:15AM BLOOD TotProt-6.6 Albumin-3.5 Globuln-3.1
Calcium-8.2* Phos-3.5 Mg-2.4
[**2176-1-12**] 04:13AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.3
[**2176-1-11**] 03:05AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.3
[**2176-1-10**] 02:08PM BLOOD Albumin-3.6
[**2176-1-10**] 02:44AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2176-1-9**] 03:26AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.9
[**2176-1-8**] 04:14PM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2176-1-6**] 07:25AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2
[**2176-1-5**] 05:48AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.1
[**2176-1-4**] 01:45AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9
[**2176-1-10**] 02:08PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2176-1-10**] 02:08PM BLOOD HCG-<5
[**2176-1-23**] 06:57PM BLOOD PSA-0.1
[**2176-1-10**] 02:08PM BLOOD AFP-1.9
[**2176-1-4**] 01:45AM BLOOD CRP-8.9*
[**2176-1-17**] 06:15AM BLOOD PEP-NO SPECIFI
[**2176-1-18**] 06:15AM BLOOD HIV Ab-NEGATIVE
[**2176-1-11**] 07:42AM BLOOD Vanco-12.1
[**2176-1-10**] 02:08PM BLOOD HCV Ab-NEGATIVE
[**2176-1-10**] 02:54AM BLOOD Type-ART pO2-96 pCO2-44 pH-7.40
calTCO2-28 Base XS-1
[**2176-1-9**] 12:30PM BLOOD Type-ART pO2-110* pCO2-44 pH-7.37
calTCO2-26 Base XS-0
[**2176-1-9**] 08:45AM BLOOD Type-ART pO2-155* pCO2-36 pH-7.42
calTCO2-24 Base XS-0
[**2176-1-9**] 03:34AM BLOOD Type-ART pO2-102 pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2176-1-8**] 10:09PM BLOOD Type-ART pO2-91 pCO2-33* pH-7.46*
calTCO2-24 Base XS-0
[**2176-1-8**] 06:37PM BLOOD Type-ART pO2-240* pCO2-39 pH-7.41
calTCO2-26 Base XS-0
[**2176-1-8**] 04:30PM BLOOD Type-ART pO2-232* pCO2-47* pH-7.35
calTCO2-27 Base XS-0
[**2176-1-8**] 01:45PM BLOOD Type-ART pO2-204* pCO2-36 pH-7.44
calTCO2-25 Base XS-1 Intubat-INTUBATED
[**2176-1-8**] 11:48AM BLOOD Type-ART pO2-199* pCO2-41 pH-7.41
calTCO2-27 Base XS-1 Intubat-INTUBATED Vent-CONTROLLED
ANGIOTENSIN CONVERTING        10                  [**8-/2134**] U/L
ENZYME

MRI Brain [**2176-1-4**]:
CONCLUSION: Left parietal lesion with inhomogeneous peripheral
enhancement,
surrounding edema, and strikingly slow diffusion in portions of
the periphery.
Although a malignant neoplasm must be considered, the properties
of the
margin, including the diffusion characteristics, raise the
possibility of an
inflammatory or demyelinating process as discussed above.

CT Abd, pelvis [**2176-1-5**]:
IMPRESSION:
1. Large left retroperitoneal soft tissue mass as well as large
retroperitoneal lymphadenopathy. Primary diagnostic
considerations include
paraganglioma, extra-adrenal pheochromocytoma and metastatic
disease.
2: Cholelithiasis.

CT Chest: [**2176-1-5**]:
Airways are patent to the subsegmental levels bilaterally. Lung
volumes are
low bilaterally. Bibasilar dependent atelectasis is visualized.
No focal
pulmonary nodule or mass is visualized. There is no axillary or
mediastinal
lymphadenopathy. Atherosclerotic calcification is visualized of
the coronary
arteries as well as of the aorta. The heart and great vessels
are otherwise
unremarkable. Note is made of a large amount of mediastinal fat.
A large right
pretracheal node measures 13x12 mm (3:14). A large right
epicardiac node
measures 13x9 mm

Brain mass pathology:
1.  "Left occipital lobe tumor #1" (A - B):

Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).



2.  "Left occipital lobe tumor #2" (C - D):

Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).



3.  "Left deep occipital tumor" (E - F):

Demyelinated white matter with extensive macrophage and
perivascular lymphocytic infiltrates (see note).



4.  "Left occipital lobe tumor" (G):

Leptomeninges and gliotic white matter.



Note:  By immunohistochemistry (blocks A-D), the majority of the
lymphocytes are CD-3 and CD-8 positive cytotoxic cells.  A
smaller subset stains positive for CD4.  Only rare scattered
B-lymphocytes are present, marking with CD20.  CD68 highlights
the diffuse infiltrates of macrophages within the white matter.
Polyoma virus ([**Male First Name (un) 2326**] and SV40), EBV latent membrane protein (LMP),
and CMV immunostains are negative. .   Special stains were
performed on blocks A-D. Luxol fast blue (LFB) shows a near
complete loss of myelin staining in the white matter, with
scattered staining present within macrophages.  No hemosiderin
deposition is seen on iron stain arguing against a chronic
vasculitis.   Bodian stain reveals areas within the white matter
showing preserved demyelinated axons. In other white matter
areas there is axon loss.



The findings supportive of an acute and chronic primary
demyelinating disorder (e.g., multiple sclerosis).



Clinical: Specimen submitted: 1. Left occipital lobe tumor #1 2.
Left occipital lobe tumor #2 3. Deep left occipital tumor 4.
Left occipital lobe tumor.

Clinical diagnosis and data:  Tumor left brain.
Gross: The specimen is received fresh in four parts, labeled
with the patient's name, "[**Known lastname **], [**Known firstname **]" and the medical record
number.



Part 1 is additionally labeled "left occipital lobe tumor #1".
It consists of multiple tan-pink soft tissue fragments measuring
0.7 x 0.7 x 0.4 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "Brain with loss of parenchyma, macrophage,
infiltrate, and gliosis and scattered atypical astroglia". The
specimen is entirely submitted as follows: A = frozen section
remnant, B = remaining tissue.



Part 2 is additionally labeled "#2 frozen left occipital tumor".
It consists of multiple tan-pink soft tissue fragments measuring
1.5 x 0.7 x 0.3 cm in aggregate. 50% of the specimen was frozen
and smeared and the intraoperative diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "Destructive white matter process, with gliosis,
macrophages and scattered microglia. Focal neutrophilic
infiltrate". The specimen is entirely submitted as follows: C =
frozen section remnant, D = all remaining tissue.



Part 3 is submitted for intraoperative consultation additionally
labeled "left deep occipital tumor #3". It consists of multiple
tan-pink soft tissue fragments that measure 0.8 x 0.7 x  0.3 cm
in aggregate. 50% of the specimen was used for smear and frozen
section. The frozen section and smear diagnosis by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 4223**] is: "[**Doctor Last Name **] matter and necrotic white matter. Smear
contains some calcified and fibrotic material (? abscess wall)".
The specimen is then entirely submitted as follows: E = frozen
section remnant, F = all remaining tissue.



Part 4 is additionally labeled "left occipital lobe tumor". It
consists of multiple tan-pink fragments that measure 0.5 x 0.2 x
0.1 cm in aggregate. The specimen is entirely submitted in
cassette G.

MRI brain [**2176-1-9**]:
1. Allowing for post-biopsy changes, the left parietal lesion
appears similar
to [**2176-1-4**]. Pathology is pending.

2. No evidence of acute intracranial abnormalities.

3. Normal head MRA.

EEG [**2176-1-10**]:
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized
background, bursts of generalized slowing, and additional focal
delta
slowing in the left posterior quadrant. The first two
abnormalities
signify a widespread encephalopathy. Medications, metabollic
disturbances, and infection are among the most common causes.
The
additional focal slowing indicates subcortical dysfunction in
the left
posterior quadrant, likely related to the reported mass. There
were no
clearly epileptiform features.

retroperitoneal mass needle biopsy:
DIAGNOSIS:
Left retroperitoneal mass, core biopsy:

     1. Fibrous tissue with lymphoplasmacytic inflammation; see
hemepath note.

     2.  Refer to separate cytology report (C09-3221) for
additional information.

Hemepath note (Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]):

     H&E sections show small, tight clusters of CD20-positive
B-cells, with a small population of scattered CD3-positive
T-cells. Although a  reactive process is favored, a low-grade
B-cell lymphoma cannot be ruled out.

Clinical: Rest of retroperitoneal mass. 58 year old male found
to have large left retroperitoneal mass with lymphadenopathy.
Gross:  The specimen is received in a formalin-filled container
labeled with the patient's name "[**Last Name (LF) 4027**], [**Known firstname **] F" and the
medical record number and consists of multiple fragments of core
biopsy and tissue measuring up to 1.0 cm in length. The specimen
is strained through a biopsy bag and submitted entirely in A.

Retroperitoneal mass, needle biopsy touch-prep:
SUSPICIOUS for malignancy.

  A few clusters of highly atypical cells have large nuclei
  and prominent nucleoli. The cytoplasm is stripped and
  further classification is not possible

Scrotal US [**2176-1-23**]
IMPRESSION:
1. No testicular mass. Normal epididymis.
2. Diffusely heterogeneous left testis, without enlargement.
This appearance
likely reflects prior injury such as remote trauma or orchitis


Brief Hospital Course:
This 58 yo man was admitted with confusion and right visual
field loss as outlined in the HPI. His brain MRI showed a large
left posterior lesion, suspicious for tumor. Since this may have
been a met, a CT torso was pursued, which showed a large
retroperitoneal mass with enlarged lymph nodes. He underwent an
open biopsy of his brain lesion, and the intraop pathology
suggested there were no tumor cells and this was a demyelinating
lesion. He was placed on a 5-day course of IV solumedrol
followed by a slow prednisone taper from 60 mg to off over ~ 2
weeks. He has improvement, but not complete resolution of his
visual field loss and confusion. He also sustained some right
weakness, particularly in the delt post brain surgery, however
this improved to nearly full strength over days. He next
received an IR-guided needle bx of his retroperitoneal mass. The
touch-prep of this was suspicious for malignant cells, however
the core histology just showed an inflammatory process. Because
of this disparity, he underwent a laproscopic biopsy of his
retroperitoneal mass. The preliminary results of this suggested
a cancer. The final pathology is still pending, but the
pathologists were able to tell us that it was not a cancer that
required immediate treatment. He received an oncology consult,
and will be followed in the oncology clinic. During the duration
of his admission, he was followed closely by the [**Last Name (un) **] team.
They changed his regimen to Humalog 75/25 90/50/50 TID QAC. His
neurological exam on DC was significant for ongoing deficits in
attention and memory and a right inferior quadrantanopsia.

Medications on Admission:
1. Plavix
2. Humalog 160 Units Qam and Qpm
3. Humulin 20 Units Qam and Qpm
4. Metformin 300 mg Qam and 200mg Qpm
5. Lyrica 200 mg [**Hospital1 **]


Discharge Medications:
1. Pregabalin 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day): Take 750 mg twice daily for 7 days, then 500 mg
twice daily for 7 days, then stop. .
Disp:*70 Tablet(s)* Refills:*0*
3. Bariatric Rolling Walker
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension
Sig: 50-90 units Subcutaneous TID QAC: Take 90 units before
breakfast, 50 units before lunch, and 50 units before dinner.
Disp:*1 month's supply* Refills:*3*
8. your plavix was held at your admission and you should
continue to hold this until final pathology on the
retroperitoneal mass returns and you follow up with oncology


Discharge Disposition:
Home With Service

Facility:
Community Health and Nursing Services

Discharge Diagnosis:
left posterior tumefactive demyelinating lesion

retroperitoneal cancer, final pathology pending


Discharge Condition:
stable. Ongoing trouble with attention and memory.


Discharge Instructions:
You were admitted with a large demyelinating lesion in the
posterior part of your left brain, causing some confusion and
visual loss. You were placed on a course of steroids and have
improved over time. You also had a CT of your abdomen and were
found to have a retroperitoneal mass, which was biopsied. The
final results of this biopsy are pending at the time of
discharge, but preliminary resulys sugges this is a type of
cancer. You can follow up with both oncology and the [**Hospital **] clinic
who can discuss these results with you.

General Instructions
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.


Followup Instructions:
Follow-Up Appointment Instructions
- Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 2 weeks for a wound check.

PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M [**Telephone/Fax (1) 81580**]

Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2176-2-8**] 11:00

Dr.[**Name (NI) **] office from oncology will call you Mon or
Tuesday for an appointment. If you do not hear from them by
[**1-31**], call [**Telephone/Fax (1) 81581**] to schedule.



Completed by:[**2176-1-26**]
{'Demyelinating disease of central nervous system, unspecified,Encephalopathy, unspecified,Malignant neoplasm of specified parts of peritoneum,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Aortocoronary bypass status,Obstructive sleep apnea (adult)(pediatric),Other symbolic dysfunction,Morbid obesity,Homonymous bilateral field defects,Long-term (current) use of steroids'}


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: Confusion

PRESENT ILLNESS: Mr [**Name13 (STitle) 4027**] is a 58 y/o right handed man with history of DM2
and CAD who presented from OSH with increasing confusion,
forgetfulness, peripheral vision loss and agraphia. The patient
was in his usual state of health until [**2175-12-28**] when he was in a
minor car accident after making a wrong turn on a familiar
street, hitting a post from the R side. He was not injured in
the
fender-bender. The next day, he was forgetful and left his car
door open when at work. On Saturday [**12-30**], he stated to his wife
that he felt "muttled", but did not complain of any specific
deficits nor did his wife note any. However, the next day his
daughter reported that he mixed up words when speaking with her.
On Monday ([**1-1**]), he could not remember his address when asked
by
the auto-mechanic. He was able to go to work at court, but was
worried when he could not figure out how to sign his name.
Specifically, he had difficulty writing letters and was
perseverative. Though he knew what he wanted to write, he was
not
able to do so correctly. This event prompted him to consult his
PCP who discovered [**Name Initial (PRE) **] small right peripheral visual field deficit
which Mr. [**Name (NI) 21862**] wife states was "about 10% of his vision".
He
had never had this before. He had no headache. His doctor
requested a head CT which he had on [**1-3**]. The CT scan revealed a
left parietal/occipital mass. The next day, his symptoms
persisted and he was admitted to this hospital.

MEDICAL HISTORY: 1. DM2 with poor control and peripheral neuropathy
2. Coronary artery disease s/p CABGx4 and stent deployment circa
[**2164**]
3. Obstructive sleep apnea (uses CPAP at night)
4. Obesity
5. Dyslipidemia
6. Seasonal Allergies

MEDICATION ON ADMISSION: 1. Plavix
2. Humalog 160 Units Qam and Qpm
3. Humulin 20 Units Qam and Qpm
4. Metformin 300 mg Qam and 200mg Qpm
5. Lyrica 200 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-97.5 BP-131/64 (126-154/57-65) HR-93(74-91)SR RR-20 O2Sat-95%
on Fi40% ventimask
Gen: Lying in bed restrained, NAD
HEENT: Has neurosurgical wound on posterior left aspect of head,
dry oral mucosa.
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: Unable to assess
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Ext: no edema
Skin: No rashes
Neurologic examination:
MS:
General:  Awake but drowsy, normal affect, very perseverative
Orientation:  Not oriented to person, place, time, or situation.
Attention: Very inattentive, but temporarily redirectable.
Speech/[**Doctor Last Name **]: He is able to express basic thoughts and give basic
yes/no replies; comprehension intact to simple commands,
repetition intact to "today is a sunny day" but impaired to more
abstarct sentence, could not name or read but claimed to not be
able to see what was being shown and was inattentive
Memory: N/A due to inattention
Calculations: N/A due to inattention
L/R confusion: Appears confused, but difficult to assess given
inattentiveness
Praxis: N/A due to inattention

FAMILY HISTORY: No family history of demyelinating disease such as MS, no
history of neurologic conditions or autoimmune disorders.

SOCIAL HISTORY: The patient is an atorney in [**State 1727**]. He is a college graduate
and received the highest possible score on his LSAT examination.
He is married for 29 years and lives with his wife. [**Name (NI) **] does not
use drugs. He has never had a blood transfusion.
Wife [**Name (NI) **] may be reached at [**Telephone/Fax (1) 81578**], Daughter [**Name (NI) **] may
be reached at [**Telephone/Fax (1) 81579**]. 

### Response:
{'Demyelinating disease of central nervous system, unspecified,Encephalopathy, unspecified,Malignant neoplasm of specified parts of peritoneum,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Aortocoronary bypass status,Obstructive sleep apnea (adult)(pediatric),Other symbolic dysfunction,Morbid obesity,Homonymous bilateral field defects,Long-term (current) use of steroids'}
