Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: no known allergies / adverse drug reactions attending: chief complaint: seizures major surgical or invasive procedure: picc line placement ngt placement x2 g-tube placement history of present illness: the pt is a 34 y/o woman with cp, spastic quadriparesis, developmental delay (non-verbal) with a history of epilepsy who comes in to the ed after a prolonged atypical seizure for 45 min at day care. the history was gathered from an employee at her group home but was not an eye witness to the event. he states that she typically has about seizure clusters per month. the seizures are characterized by extension of her limbs lasting seconds but clustering within a 10 min period. on the morning of presentation, it was noted that she was having rhythmic arm movements for 45 min. oral ativan was given. she was brought to the ed for further evaluation and treatment. no abnomal movemenst noted by ed staff. at bedside is one of the staff members from the group home who noted a couple of times that she has forced left lateral gave a few times in the span of an hour. otehrwise thinks she is at her baseline. her baseline she is non-verbal, she will eat if fed (crushed meds/ blended diet). she will grab your hand and rub it. wont track. noted to be in status epilepticus on pm and transferred to the tsicu for phenobarbital load and close monitoring. pt had received a total of 5 mg of iv ativan, 1000 of iv keppra and 200 iv phenobarbital prior to transfer. . internal medicine transfer hpi: in brief, ms. is a 34f with cerebral palsy/global developmental delay (nonverbal), spastic quadriparesis, epilepsy, history prolonged atypical seizure, originally admitted to on , who was recently admitted to tsicu for recurrent grunting and deep respirations concerning for seizure activity, transferred to sicu for new fever, sinus tachycardia, and hypophosphatemia. . she re-presented to the ed after a prolonged atypical seizure for 45 minutes at daycare. the history was gathered from an employee at her group home but was not an eye witness to the event. he states that she typically has about seizure clusters per month. the seizures are characterized by extension of her limbs lasting seconds but clustering within a 10 min period. on the morning of it was noted that she was having rythmic arm movements for 45 min. oral ativan was given. she was brought to the ed for further evaluation and treatment. she will grab your hand and rub it, but will not track. noted to be in status epilepticus on and transferred to the tsicu for phenobarbital load and close monitoring. patient had received a total of 5 mg of iv ativan, 1000 of iv keppra and 200 iv phenobarbital prior to transfer. per neurology, etiology of her seizures is unclear, but in patient with significant seizure disorder. resolved without major intervention. they increased dose of phenobarbital to 120mg qd. no obvious seizure activity currently, with huge amount of artifact from bruxism. in addition, patient was noted to have significant anion gap metabolic acidosis on , thought to be due to starvation ketoacidosis, which resolved with initiation of tube feeding. . in the sicu, her phosphate was noted to be 0.5 at 8pm on and tubefeeds were started at slow rate (fibersource, starting at 15ml/hr), unclear if advanced too quickly. there is some concern for poor nutrition at the daycare, with bun of 1 and extremely low phosphate and ? refeeding syndrome. electrolytes are now within normal limits. patient is a terrible stick, picc line placement was attempted today in the right arm, and is currently malpositioned in the left brachiocephalic. iv team is currently pulling back to midline position overnight, with plan to go to ir tomorrow for proper picc positioning. in the meantime, patient has one peripheral iv in right hand. patient was noted to be in sinus tachycardia, and was febrile to 100.5 yesterday, at this time cause unclear, but thought to be due to seizure activity. urine culture, with ua unremarkable, has been sent, and one set of blood culture sent. cxr for picc placement shows no evidence of infiltrate on my read, however patient has had productive cough over last 24 hours. no antibiotics have been started. patient currently has a malpositioned picc (in mid-line position) and a 22 gauge peripheral. iv nursing will likely need to do all lab draws overnight, as patient has poor access. seizure activity has abated, 24 hour eeg still being performed. of note, lenis were also performed on and were negative for clot. . on the floor, vs: 96.3 121/80 108 18 93(ra). patient appeared comfortable, is nonverbal, and does not track or respond to commands, but does respond to hand grip (may be reflex). past medical history: cerebarl palsy with global developmental delay (non-verbal/ non-communicative) spastic quadriparesis scoliosis epilepsy with several electrolyte abnormalities noted after seizures s/p g-tube placement social history: lives at a group home: , which is part of community care. # . director: . guardian is family history: unknown, not in contact with family physical exam: physical exam on admission: vitals: t:97.5 p:82 r: 16 bp: 120/84 sao2:98% general: awake, nad. heent: dry mm neck: supple pulmonary: lungs cta bilaterally cardiac: rrr abdomen: soft. skin: no rashes or lesions noted. neurologic: alert. eye open, not tracking. will look away from the light, perrl. does not reach for me or at objects. she will grasp my hand if placed in her hand and rub it (b/l). moving all four extremities. increased tone throughout with contractures. the legs are able to fullly extend. brisk reflexes throughout. toes are upgoing. ----- discharge examination: general: awake, nad. neck: supple pulmonary: lungs cta bilaterally cardiac: rrr abdomen: soft, nontender skin: no rashes or lesions noted neurologic: alert, eyes open, not tracking, but will look laterally intermittently. perrl. lifts both arms spontaneously against gravity at the shoulders and elbows, extends knees and flexes ankles against gravity spontaneously. increased tone with spasticity in all four limbs. pertinent results: labs on presentation: 12:15pm blood wbc-6.1 rbc-4.06* hgb-13.2 hct-40.5 mcv-100* mch-32.6* mchc-32.6 rdw-12.6 plt ct-368 12:15pm blood neuts-42.1* bands-0 lymphs-46.5* monos-5.7 eos-4.6* baso-1.0 12:15pm blood glucose-88 urean-15 creat-0.6 na-146* k-4.3 cl-109* hco3-26 angap-15 12:15pm blood alt-16 ast-20 alkphos-86 totbili-0.2 12:15pm blood albumin-4.0 calcium-9.1 phos-3.2 mg-2.1 09:00am blood caltibc-174* hapto-286* ferritn-65 trf-134* 07:56pm blood d-dimer-1070* 12:45pm blood tsh-0.53 12:45pm blood 25vitd-17* micro: 9:12 am urine source: catheter. **final report ** urine culture (final ): beta streptococcus. ~7000/ml. 11:55 am urine site: catheter source: catheter. **final report ** urine culture (final ): streptococcus species. ~4000/ml. 1:11 pm blood culture source: line-right midline md. **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. anaerobic bottle gram stain (final ): reported to and read back by brush @ 2107 on - . gram positive cocci. in clusters. cdiff and negative imaging: eeg : impression: this is an abnormal video eeg which captured prolonged runs of rhythmic 1.5 hz low amplitude spike and wave discharges in the right frontal temporal region which did not have any clear clinical correlate. at other times, persistent delta frequency slowing was seen in the same region. these findings suggest a fixed structural defect causing both cortical and subcortical dysfunction. the background was otherwise slow and disorganized consistent with a moderate to severe encephalopathy. eeg : impression: this is an abnormal video eeg which captured 41 pushbutton activations, for 12 tonic seizures characterized by right frontal temporal 2 hz delta frequency spike and wave activity evolving into generalized electrodecrement and superimposed fast activity. on video, the patient most often appears to have neck extension truncal extension and bilateral limb clonic jerking movements. the last seizure occurred at 18:16 after which no further seizure activity was seen. interictal epileptiform discharges are seen frequently in the left frontal and frontal temporal region. the pushbutton activations during the second half of the recording and particularly towards the morning of for labored breathing did not clearly show evolution of activity on eeg to suggest ongoing seizure activity. however, during this time, a significant tachycardia of up to 136 bpm were seen. additionally, rhythmic 2 hz spike and wave discharges were seen in the right frontal temporal region occurring in bursts without any clear clinical correlate. the background initially in the first half of the recording showed a 4 hz activity which became more attenuated and slower with more diffuse generalized beta frequency activity during the second half of the recording is likely due to medication effect from benzodiazepines and barbiturates. eeg : impression: this eeg did not capture any electrographic seizures nor did it capture any clear interictal discharges. the record does give evidence for a diffuse disturbance of the background rhythm with no normal alpha frequency and periods of diffuse delta. there was no clear laterality to this. pelvic us : impression: 1. no acute process including no evidence of free fluid. 2. incidental note is made of a horseshoe kidney. ct head : conclusion: technically limited examination. no gross intracranial hemorrhage. other findings noted above. leni : impression: no signs of dvt in the lower extremities. tte : the left atrium and right atrium are normal in cavity size. the estimated right atrial pressure is 0-5 mmhg. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: suboptimal image quality. normal study. no valvular pathology or pathologic flow identified. ct abdomen without contrast impression: 1. multiple 2-mm renal stones in the right kidney without hydronephrosis. 2. severe dextroscoliosis. 3. given the patient's severe scoliosis, bowel loops and liver are interposed between the stomach and the skin. . impression: uncomplicated placement of a 12 french wills- gastrostomy catheter via a left upper quadrant approach under general anesthesia. the catheter may be used in 24 hours. . eeg impression: this is an abnormal continuous icu monitoring study because of 17 electrographic seizures. during these seizures, the eeg shows fast beta activity at onset, followed by a brief period of electrode decrement, evolving into sharply contoured rhythmic sharp waves that are quickly obscured by myogenic artifact. on video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. these findings are consistent with tonic seizures. in addition, there are multifocal epileptiform discharges more prominently in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. otherwise, background is slow consistent with a moderate diffuse encephalopathy. . eeg impression: this is an abnormal continuous icu video eeg because of 42 electrographic seizures occurring in multiple clusters throughout the recording, lasting 5-10 seconds each in duration. during most of these seizures, the eeg shows a generalized discharge, brief semi-rhythmic delta, fast beta activity, followed by a brief period of electrodecrement, evolving into sharply contoured rhythmic sharp waves that are quickly obscured by myogenic artifact. some seizures have a more subtle pattern characterized by fast activity at onset followed by electrodecrement. on video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. these findings are consistent with tonic seizures. in addition, there are focal epileptiform discharges in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. otherwise, background is slow, consistent with a moderate diffuse encephalopathy. . eeg impression: this is an abnormal continuous icu monitoring study because of 100 electrographic seizures occurring in several clusters throughout the recording. the seizure frequency and duration decrease significantly after 18:04 with only 21 seizures occurring after this time. during most of these seizures, eeg shows a generalized sharp discharge, brief semirhythmic delta, fast beta activity, followed by a brief period of electrodecrement, evolving into sharply contoured rhythmic sharp waves that are abruptly obscured by myogenic artifact. some seizures have a more subtle pattern that is fast activity at onset followed by electrodecrement. on video, most electrographic seizures correlate clinically with brief tonic flexion of the left arm, extension of the right arm, and neck hyperextension. occasionally, there may be a few clonic jerks of the limbs toward the end of the seizures. these findings are consistent with tonic seizures which are occasionally followed by clonic activity. in addition, there are epileptiform discharges more prominently in the left frontal and right temporal regions indicative of highly epileptogenic foci in these areas. otherwise, background is significantly slow consistent with a moderate diffuse encephalopathy. compared to previous day's recording, the overall number of electrographic seizures is increased. however, after 18:04, the frequency and duration of seizures are decreased indicative of a better seizure control. . eeg impression: this is an abnormal video eeg monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. the seizures are clinically characterized by head and eye deviation to the left, bilateral tonic posturing followed by flexion of the left arm and extension of the right arm with superimposed myoclonic twitching. the eeg shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional emg artifact from clonic jerking at the end of the episode. the tonic seizures last between 10 and 40 seconds. there is a total of 55 tonic seizures of this type. in addition, there are frequent electrographic tonic seizures showing an electrodecrement with superimposed low voltage fast activity lasting 4-10 seconds, but no clinical change associated on video. these occur approximately two to five times per hour. background activity is slow and low voltage, with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. there is prominent bruxism artifact throughout the recording. compared to the prior day's recording, the tonic seizures have decreased in frequency and duration. . eeg impression: this is an abnormal video eeg monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. the seizures are clinically characterized by head and eye deviation to the left, left arm extension, then bilateral tonic posturing with occasional superimposed clonic jerking. the eeg shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional emg artifact from clonic jerking at the end of the episode. the tonic seizures last between 10 and 40 seconds. there is a total of 74 tonic seizures of this type. in addition, there are frequent electrographic tonic seizures showing an electrodecrement with superimposed low voltage fast activity lasting 4-10 seconds, but no clinical change associated on video. these occur approximately two to five times per hour. background activity is slow and low voltage with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction, which is etiologically non-specific. there is prominent bruxism artifact throughout the recording. compared to the prior day's recording, the tonic seizures have again increased in frequency and duration. . eeg impression: this is an abnormal video eeg monitoring session because of abundant clinical and electrographic generalized tonic seizures as described above. the seizures are clinically characterized by head and eye deviation to the left, left arm extension, then bilateral tonic posturing with occasional superimposed clonic jerking. the eeg shows an abrupt generalized electrodecrement with superimposed low voltage fast activity and occasional emg artifact from clonic jerking at the end of the episode. the tonic seizures last between 10 and 40 seconds. there is a total of 125 tonic seizures of this type. background activity is slow and low voltage, with abundant superimposed beta activity, indicative of moderate diffuse cerebral dysfunction which is etiologically non-specific. there is prominent bruxism artifact throughout the recording. compared to the prior day's recording, the tonic seizures continue at high frequency. . eeg impression: this is an abnormal video eeg monitoring study mainly due to numerous electrographic generalized tonic seizures the clinical manifestation. several of these seizures are described above as examples. based on the clinical and electrographic manifestations, the seizures can be categorized into three main groups. the first group is the longest, (14-28 seconds). eeg generally shows a diffuse epileptic discharge, then a brief period of rhythmic slowing, followed by electrodecrement, leading to fast activity with crescendo amplitude and terminates in diffuse myogenic artifact. an example of these is found at 05:03:30. on video, she is prone and appears in a sleep state, has a sudden arousal with tonic posturing of all limbs, followed by waxing and flexion of the right arm, flexion of the left arm, and myoclonic jerking of the leftsided limbs. the second group has a similar yet shorter electrographic pattern (6-10 seconds) and less prominent myogenic artifact. an example of these is at 7:21:43 (10 seconds) . on video, she has waxing and flexion of the right arm followed by extension of the left arm. the third group includes very brief electrographic seizures (three to four seconds) 8:50:07. on video, she has brief tonic flexion of the right arm and extension of the left arm. the third category includes very brief electrographic seizures (three to four seconds) with minimal to no clinical correlation. an example of these can be found at 11:14:56 (four seconds). eeg shows electrodecrement with superimposed low voltage beta activity and nearly no myogenic artifact. background rhythm is generally slow and low voltage consistent with a moderate diffuse encephalopathy of non- specific etiology. there is intermittent bruxism related myogenic artifact throughout the recording which obscures part of the background and, therefore, limits interpretation. compared to the prior day's recording, this study has not changed. . eeg impression: this is an abnormal video eeg monitoring study mainly due to 46 generalized tonic electrographic seizures, mostly with clinical manifestations, and 13 right temporal electrographic seizures with no clinical manifestation. examples of these seizures are mentioned above. in the electrographic tonic seizure group, eeg consecutively shows a generalized epileptic discharge, brief rhythmic slowing, electrodecrement, fast activity with crescendo amplitude and termination in myogenic artifact. the longer seizures in this group have more prominent clinical manifestations. an example of the longer seizures is at 10:56:16 (30 seconds). on video, she is supine, appears asleep, arouses with left head and gaze deviation, tonic posturing of four limbs, limbs flexion on the left and extension on the right that waxes and wanes combined with some myoclonic jerks, ending with flaccid limbs and right gaze preference. an example of shorter seizures in this group is at 15:52:41 (five seconds). eeg shows the same pattern seen in longer seizures. on video, there is minimal flexion of the left arm and extension of the right arm. for the second group, the example is found at 20:24:11 (33 seconds). eeg shows rhythmic medium amplitude sharp theta in the right temporal region with no clinical correlation. background rhythm is diffusely slow and attenuated indicative of moderate diffuse encephalopathy of non-specific etiology. throughout the recording, there are periods of prominent myogenic artifact related to bruxism limiting interpretation of the study. compared to the prior day's recording, the tonic electrographic seizures are less frequent; however, there are new focal right temporal seizures that were not seen previously. ferritin 8.3, haptoglobin 8.3, iron 33, tibc 329, trf 253, b12 1153, folate 12.8, reticulocyte count 2.5 hgb 12.3/hct 36.7 (after transfusion of two units prbcs) brief hospital course: 34f with global developmental delay/ spastic quadriparesis / epilepsy who comes in for prolonged atypical seizure. transferred to the icu after recurrent grunting and deep respirations in the setting of tachycardia with concern for status epilepticus, and found to have several electrolyte abnormalities initially concerning for refeeding syndrome. course complicated by ? episodes of aspiration, suspicion for cdiff, and inability to take po's sufficient to meet her nturitional needs, therefore g-tube was placed. thereafter had difficult nutritional course with diarrhea and unclear absorption of aeds with increase in seizure frequency requiring transfer back to neurology service. patient was stabilized on aed regimen as well as bolus feeds and transfered back to group home. 1. seizures: patient was admited with prolonged atypical seizures and intially managed on the neurology service. patient was subsequently transfered to the icu after developing concern for status epilepticus. in the icu, she was uptitrated on aeds with boluses of iv phenobarbital resulting in sedation. these atypical episodes and grunting were later found not to correlate with seizures on eeg and there was no significant epileptiform discharges. her aed regimen was adjusted several times through her >1 mo admission, and ultimately seizures were controlled on an iv regimen until a gtube was placed, at which point gtube was used for aed's. on the medical floor patient was noted to be persistantly tachycardic to the 140s in a sinus rhythm without alternative medical explanation. on patient underwent 24 hour eeg monitoring and found to have signficant seizure activity and found to have status eplilepticus. she was loaded with phenytoin, then with depakote and transfered to the neurology service. her aed regimen at that point consisted of phenytoin, vpa, phenobarb, keppra. over the course of several days, her aeds were switched to vpa, phenobarb, keppra and rufinamide. although she continued to have a multiple of brief seizures with and without clinical correlates, the frequency of these events decreased remarkably. however excessive drowsiness led to the discontinuation of keppra. she was maintained on vpa, phenobarbital, and banzel/rufinamide with adequate seizure control (with continued events but overall return to baseline mental status). seizures consisted mainly of leftward eye deviation, grunting, tonic arm stiffening and sometimes hip flexion (lifting right leg above her head), and other rhythmic facial movements. . 2. electrolyte abnormalities: after initial stabilization of status epilepticus, several lyte abnmls were noted, including low hco3, hypok, hypomg, and hypophos; renal was consulted and thought starvation ketoacidosis was etiology of the ag acidosis. initially concerning for refeeding syndrome given pt's poor ability take po's; lytes were managed with repletion and normalized. however, on the floor, her lytes were noted to have the same pattern after seizures, and therefore it was realized that refeeding syndrome was not likely, but more so electrolyte shifts during seizures. patient had g-tube placed for improved long term nutrtion management. . the group home nurse provided an instruction sheet that she requested md sign off on which include free water boluses which were not provided during our hospitalization. instead, free water was used with medication flushes and for medication delivery as she has a long medication list. this was explicitly documented on the instructions. this may need to be readdressed by her primary physician with possible need to follow her electrolytes. . 3. sinus tachycardia: during seizures she becomes tachycardic to 140-150 that comes down after seizures (also transienty hypoxic); however her baseline also noted to be 90-120 bpm even when not seizing or resting, occasionally but not necessarily responsive to fluids, and during times when not felt to be acutely infected. therefore, possibly her baseline given her habitus. she was started on metoprolol 25 mg for prevention of tachymyopathy. her sinus tachycardia continued with hr in the low 100s for most of the week prior to discharge with further normalization at the time of discharge. . 4. nutrition: initially ngt was placed and pt was receiving tube feeds. however in discussion with her group home, who had successfully been feeding her orally for quite a long time, she was given a chance to eat (i.e. an oral feeding challenge) but was not seen to take in enough nutrition to sustain herself. she was also noted to have ? aspiration episodes while on the floor; while cxr's did not demonstrate this, her lungs were frequently rhonchorous. pt again made npo and ngt placed for tube feeds, until the decision was then made to place a g-tube for long term feedings, which was done on . she was provided multivitamin, thiamine, folate throughout entire hospitalization. ng tube feeds were decreased as residuals were high but increased back to twocal hn bolus feeds to meet caloric demands. she was discharged on a bolus tube feeding regimen. . at discharge, our team was informed that her pharmacy might not cover the tube feeds. she was provided with a three day supply. our case manager contact the primary care physician's office to help coordinate obtaining the supply from a medical equipment company. . 5. fevers, leukocytosis: while on the medicine floor, noted to have brief episode of fever, leukocytosis. cultures were all negative except one blood culture with coag negative staph that quickly cleared and was more likely contaminant. tte showed no endocarditis. she was given 8d of vancomycin/zosyn. given increased diarrhea episode, treatment was started with po vanco for cdiff, despite two negative cdiff tests. alternatively, could have been due to aspiration given rhonchorous lungs, however cxr consistently showed no pneumonitis nor pneumonia. she was treated with a 14 day course of po vancomycin while in house. her diarrhea resolved. 6. anemia: on arrival, hgb was 13.2 and had gradually decreased to 8.0 by discharge. there was no evidence of blood loss, and the rbcs were normocytic with normal rdw. iron studies initially indicated mild anemia of chronic disease, no iron deficiency and no evidence of hemolysis. retic index is inappropriately low at 0.92. most likely etiology of anemia was recurrent phlebotomy in the setting of menses and poor nutritional status. thought unlikely to have marrow suppression with only one cell line down and no peripheral eosinophilia. however, repeat studies indicated severe iron deficiency anemia. her guaiac was negative, although one guaiac was positive in the setting of menses. 7. diarrhea: she had multiple loose stools which were negative for c-diff. this fact led to suspicion of poor aed absorption and increased seizure frequency so aeds were temporarily switched to iv form. nutrition was consulted and recommended adding banana flakes to feeds and standing colace was stopped. her stools decreased in frequency thereafter and were thought normal prior to discharge. transitional issues: patient was listed as a full code during this admission, code status should continue to be reassessed given her co-morbidites and as she is unlikely to tolerate cardiopulmonary resusitation. please observe ms. behavior and record her seizures. please report this information to dr. so that dr. can assess her seizure frequency and decide whether or not to change the dosing of her medications. dr. or her primary care physician can schedule ms. to have lab checks for a complete blood count (cbc) as often as every two weeks to monitor her blood counts. she received a blood transfusion during this hospitalization to replenish her blood cell counts which had been low due to iron deficiency anemia, likely from phlebotomy/frequent lab draws during her long hospitalization. her discharge hgb was 12.3 and hct 36.7. pcp she was being discharged, we were contact by the patient's pharmacy who indicated that they might not be able to provide the tube feeds. we sent her back to the group home with a three day supply. please make arrangements for getting her the tube feeds. pcp review and revise the tube feeding and free water bolus schedule as indicated. consider following her serum electrolytes and discussing with a nutritionist if issues arise. pending studies: eeg reports from medications on admission: phenobarbital 105mg qpm tegretol 400mg tid ativan 1mg prn ca/vit d zantac 150mg milk of magnesia discharge medications: 1. folic acid 1 mg tablet sig: one (1) tablet po daily (daily): crushed, mix 8am meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*30 tablet(s)* refills:*2* 2. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily): crushed, mix 8am meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*30 tablet(s)* refills:*2* 3. calcium 500 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po once a day: crushed, mix 8am meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*30 tablet(s)* refills:*2* 4. ranitidine hcl 150 mg tablet sig: one (1) tablet po bid (2 times a day): crushed, mix with 8am and 8pm meds in total 100 cc warm water at each time and administer via peg, then flush 30 cc water after. disp:*60 tablet(s)* refills:*2* 5. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily): crushed, mix 8am meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*30 tablet(s)* refills:*2* 6. phenobarbital 30 mg tablet sig: four (4) tablet po hs (at bedtime): crushed, mix 8pm meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*120 tablet(s)* refills:*2* 7. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid sig: one (1) teaspoon po tid (3 times a day): flush peg with 30 cc water before and 30 cc water after. disp:*90 teaspoon* refills:*2* 8. rufinamide 400 mg tablet sig: three (3) tablet po twice a day: seizure maintenance, crushed, mix with 8am and 8pm meds in total 100 cc warm water at each time and administer via peg, then flush 30 cc water after. disp:*180 tablet(s)* refills:*2* 9. valproic acid (as sodium salt) 250 mg/5 ml solution sig: one (1) see instructions po q8h (every 8 hours): 500mg at 8am and 12 midnight, 375mg at 4pm, seizure maintenance, flush peg with 30 cc water before and 30 cc water after. disp:*135 teaspoons* refills:*2* 10. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): crushed, mix with 8am and 8pm meds in total 100 cc warm water at each time and administer via peg, then flush 30 cc water after. disp:*60 tablet(s)* refills:*2* 11. twocal hn 0.08-2 gram-kcal/ml liquid sig: one (1) can (see schedule) po three times a day: bolus tube feeding: two cal hn full strength; additives: banana flakes, 3 packets per day; # of cc per feeding: as directed below; # of feedings/day: 3; advancement: start at goal; residual check: before each feeding; hold feeding for residual >= 200 ml; flush w/30 ml water before & after each feeding; other instructions: 1 can at breakfast, can at lunch and 1 can at dinner. disp:*90 cans* refills:*2* 12. banana flakes packet sig: one (1) packet po three times a day: with twocal tube feed boluses. disp:*90 packets* refills:*2* 13. syringe (reusable) 30 ml syringe, reusable sig: one (1) syringe miscellaneous three times a day: for use with water flushes. disp:*90 syringes* refills:*2* 14. syringe (reusable) 5 ml syringe, reusable sig: one (1) syringe miscellaneous three times a day: for use with administering valproic acid, ferrous sulfate, or other liquid medications. disp:*90 syringes* refills:*2* 15. acetaminophen 650 mg suppository sig: one (1) suppository rectal every six (6) hours as needed for pain: as needed for pain. disp:*120 suppositories* refills:*2* 16. multivitamin tablet sig: one (1) tablet po once a day: crushed, mix 8am meds in total 100 cc warm water and administer via peg, then flush 30 cc water after. disp:*30 tablet(s)* refills:*2* 17. lorazepam 4 mg/ml solution sig: one (1) mg injection every 4-6 hours as needed for seizure lasting more than 3 minutes or more than 3 seizures in one hour. disp:*20 ml* refills:*2* 18. lorazepam 2 mg/ml syringe sig: 0.5 ml injection every hours as needed for seizure lasting more than 3 minutes: may administer 1 mg as intramuscular injection for prolonged seizure. disp:*10 syringes* refills:*3* discharge disposition: home discharge diagnosis: primary diagnosis: seizures/status epilepticus secondary diagnosis: electrolyte abnormalities due to seizures, diarrhea, possible clostridium difficile infection discharge condition: mental status: confused - always. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. neurologic: awake, alert, no vocalization, does not follow commands, spasticity in all four limbs with some antigravity spontaneous movement discharge instructions: mrs. was admitted to with prolonged seizures. after these were controlled, it was noted that she had electrolyte problems with her potassium, magnesium, and phosphorous. this was likely due to the seizures themselves and not from "refeeding syndrome" as originally thought. she had some episodes of fevers and diarrhea for which she was started on oral vancomycin for possible colitis. she received a g-tube for enteral nutrition because she was not able to take in enough nutrition on her own. her anti-epileptic medications were converted to g-tube administration, and her seizures were controlled (although she continues to have seizures intermittently). she is likely at her baseline now which includes several subclinical seizures (without outward symptoms or actions) daily. she is being discharged back to her group home and with her outpatient dr. (partners/ hospital) continuing her care. the following changes were made to her medication regimen. - once daily medications can be given at 8am. twice daily medications can be given at 8am and 8pm. three times a day medications can be given at 8am, 4pm, and midnight. 8am medications can be crushed in 100 ml of warm water, administered via the peg, and then flushed with 30 ml of clear water. the same can be repeated at 8pm. for liquid formulation medications at other times, the peg can be flushed with 30 ml of clear water before and after administration of the liquid medication. - start banzel/rufinamide 1200 mg twice daily - start valproic acid 500 mg at 8am and 12 midnight and 375 mg solution at 4pm - change phenobarbital 105 mg qpm to 120 mg at bedtime - stop tegretol 400 mg - start thiamine - start multivitamin - start folate - start metoprolol 25 mg twice daily - start cholecalciferol - start calcium - start ranitidine 150 mg twice daily - start ferrous sulfate solution three times daily - start twocal tube feeds three times daily (1 can in am, 0.5 cans at noon, 1 can in pm) the patient will followup with dr. , her neurologist/epileptologist, as listed below. important: please observe ms. behavior and record her seizures. please report this information to dr. so that dr. can assess her seizure frequency and decide whether or not to change the dosing of her medications. dr. or her primary care physician can schedule ms. to have lab checks for a complete blood count (cbc) as often as every two weeks to monitor her blood counts. she received a blood transfusion during this hospitalization to replenish her blood cell counts which had been low due to iron deficiency anemia, likely from phlebotomy/frequent lab draws during her long hospitalization. followup instructions: neurology followup - dr. , partners/ hospital/, , appointment: at 12 noon please have your group home schedule a follow up appointment with your primary care doctor in the next couple weeks. procedure: enteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances other gastrostomy video and radio-telemetered electroencephalographic monitoring central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: acidosis anemia of other chronic disease other specified cardiac dysrhythmias disorders of phosphorus metabolism intestinal infection due to clostridium difficile grand mal status fever, unspecified urinary incontinence, unspecified leukocytosis, unspecified mechanical complication of other vascular device, implant, and graft adult failure to thrive unspecified congenital anomaly of brain, spinal cord, and nervous system other specified iron deficiency anemias congenital quadriplegia congenital musculoskeletal deformities of spine other specified psychophysiological malfunction other forms of epilepsy and recurrent seizures, with intractable epilepsy other specified delays in development 

Answer: The patient is high likely exposed to