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: amoxicillin / clarithromycin / penicillins / macrolide antibiotics / dilantin attending: chief complaint: lower extremity weakness major surgical or invasive procedure: : cervical spine traction / tongs : c5/6/7 corpectomies and c4-t1 anterior fusion : c3-t3 posterior fusion : tracheostomy peg history of present illness: 56 yo f with cervical myelopathy s/p extensive posterior decompressive laminectomy c3-c7, foraminotomy 3 years prior with progressive leg weakness and increased falls over several months. she had recent admission for similar complaints in and underwent cervical mri but left ama for financial reasons. since that time, her condition has worsened. at home, she has minimal ability to ambulate and has been using wheelchair at home intermittently since of last year. she continues to have moderate-severe neck pain as well requiring opioids. she was readmitted to on at which time her neurodiagnostics were reevaluated. on further review, there was question of a fibrous scarring band at c5-c6 that might be acting as a compression anchor on the cord. nsurg also felt that she had pathologically brisk reflexes and upgoing toes b/l and recommended repeat mri cervical spine w/ contrast (report not available). neurology and nsurg noted edema around cord at c6-c7. recommended iv steroids and continued neck brace as well as transfer to . pt wears soft c-collar at all times and requires significant pain medication (percocet, flexeril, vistaril). she is noted to be a 1-assist to commode with unsteady gait. past medical history: hl arthritis, + , treated with hydroxychloroquine asthma ibs endometriosis chronic hip/back pain, treated with oxycodone social history: she lives at home with her husband on ; smokes pk daily, minimal alcohol family history: nc physical exam: admission physical exam: vitals: t: 98.3 hr 64 rr: 16 bp: 125/65 sao2: 99%ra general: awake, cooperative, nad. heent: no scleral icterus noted, , no lesions noted in oropharynx, soft collar in place with some neck tenderness on palpation neck: in soft collar, no carotid bruits appreciated. nuchal rigidity not assessed pulmonary: lungs cta bilaterally without r/r/w cardiac: rrr, nl. s1s2, no m/r/g noted abdomen: soft, nt/nd, normoactive bowel sounds, no masses or organomegaly noted. extremities: no c/c/e bilaterally, 2+ radial, dp pulses bilaterally. skin: no rashes or lesions noted. neurologic: -mental status: alert, oriented x 3. able to relate history without difficulty. attentive, able to name backward without difficulty. language is fluent with intact repetition and comprehension. normal prosody. there were no paraphasic errors. pt. was able to name both high and low frequency objects. able to read without difficulty. speech was low volume and slightly horse but not dysarthric. able to follow both midline and appendicular commands. pt. was able to register 3 objects and recall at 5 minutes. the pt. had good knowledge of current events. there was no evidence of apraxia or neglect. -cranial nerves: i: olfaction not tested. ii: perrl 4 to 2mm and brisk. vff to confrontation. funduscopic exam defered. iii, iv, vi: eomi without nystagmus. normal saccades. v: facial sensation intact to light touch. vii: no facial droop, facial musculature symmetric. viii: hearing intact to finger-rub bilaterally. ix, x: palate elevates symmetrically. : 5/5 strength in trapezii and scm bilaterally. xii: tongue protrudes in midline. -motor: decreased bulk in upper extremity, increased tone in lower extremity. pseudoathetosis in upper extremity bilaterally. no adventitious movements, such as tremor, noted. no asterixis noted. delt bic tri wre ffl fe io ip quad ham ta edb l 5 5 4- 5 5 4 4- 5 5 4 4+ 5 5 5 r 5 5 4- 5 5 4 3 4+ 5 4 4 5 4 5 -sensory: decreased light touch, pinprick, cold sensation, vibratory sense, proprioception in hands bilaterally. no extinction to dss. significant lower extremity sensory loss to light touch, pinprick, vibration, cold, -dtrs: tri pat ach l 3 3 3 3 3 (with clonus) r 3 3 3 3 3 (with clonus) plantar response was ext bilaterally. -coordination: no intention tremor, no dysdiadochokinesia noted. no dysmetria on fnf b/l, hks could not be performed weakness. -gait: defered physical exam upon discharge: 98 tc, 114/70 (110-121/69-73), 78, 20, 100% on ra, fsg 123 (fsg on : 139, 156, 103, 123) i/o: 1.5/inc 620+ general: alert, interactive, appropriate, no acute distress. heent: , , intact eom, conversing neck: brace in place, posterior incision well healed cv: rrr, normal s1/s2, no m/g/r. pulm: scat rhonchi anteriorly, able to clear with cough, otherwise cta, no wheezes/rales. abd: +bs, soft, non-distended, very mild left quadrant tenderness over peg tube site, site looks c/d/i, + bs. small ecchymotic area on llq r/t heparin injection. skin: small healing ulcer on her submadibular area, and small scab on occipital area above the brace neuro: conversing this am, a+ox 3, eomi, face symmetric, tongue midline. able to wiggle all finges and toes, lift legs from bed. she oob to chair with min assist pertinent results: c-spine xray: history: spondylolisthesis in traction. 7 ap and lateral radiographs of the cervical spine show little change in the appearances including the grade 3 anterolisthesis with deformed c6 body on c7 since exam . c-spine xray: this is the second of four similar radiographs of the cervical spine obtained over 14-hour interval. the grade 2 anterolisthesis of c6 on c7 and grade anterolisthesis of c4 on c5 are little changed allowing for differences in rotation. c-spine xray: the patient is status post posterior fusion spanning c3-c6. there is again seen grade ii anterolisthesis of c4 over c5 which measures 9 mm and is stable. there is also anterolisthesis of c6 over c7, which measures 11 mm and is also relatively stable. degenerative changes with loss of intervertebral disc height at multiple levels is seen. there is sclerosis of the c7 vertebral body. overall, there has been no appreciable change. c-spine xray: single side lateral film of the cervical spine shows posterior fusion hardware extending from c3 through c6. there is osseous anterior fusion of c2 and c3 as well as c5 and c6. there is a grade 2 anterolisthesis of c4 on c5 and c6 on c7 with appearance unchanged from similar bedside exam 23 minutes earlier. portable chest xray: no significant changes since prior study. lungs are well expanded and clear bilaterally. there is no pleural effusion, masses or lesions. there is no pneumothorax. the cardiomediatinal silhouette is within normal limits and stable. pleural surfaces and osseous structures are unremarkable. ct cervical spine: impression: limited study due to streak artifact from hardware demonstrates new anterior cervical discectomy and fusion from c4 to t1. expected postoperative changes. chest xray: as compared to the previous radiograph, there has been a cervical fusion. there is no evidence of pneumonia or other pathologic changes in the lungs. unchanged mild symetrical apical thickening. normal size of the cardiac silhouette. no pleural effusions, no pneumothorax. lower extremity doppler us: no evidence of dvt ct c-spine- 1. c4-t1 anterior and c3-t3 posterior fusion. increasing fluid/air collections throughout the prevertebral, intraspinal, and perivertebral spaces and superior mediastinum could represent post-surgical changes, but it is difficult to exclude superimposed infection. if clinically indicated, contrast-enhanced study of the neck and chest could be ordered to assess for possible abscess, fistula, and/or mediastinitis. this was paged to nurse on at 12:50 a.m. 2. moderate retropharyngeal edema. limited evaluation of supraglottic structures due to retained secretions cxr- : as compared to the previous radiograph, the patient has received a left-sided picc line. the course of the line is unremarkable, the tip of the line projects over the mid svc. there is no evidence of complications, notably no pneumothorax. cxr findings: compared to the previous radiograph, there is no relevant change. the tip of the endotracheal tube projects 2.7 cm above the carina. the course of the left-sided picc line is constant. no acute lung changes. normal size of the cardiac silhouette. vertebral stabilization devices in unchanged position. cxr: findings: in comparison with study of , the tip of the endotracheal tube measures about 5 cm above the carina. nasogastric tube extends well into the stomach. no acute cardiopulmonary disease. eeg: impression: this is an abnormal continuous icu monitoring study because of a slow and disorganized background. there is diffuse slowing of background for a few hours which could be indicative of medication effect. however, the background activity appears again after that portion of the recording. these findings are indicative of a mild diffuse encephalopathy which is etiologically non-specific. there were no focal asymmetries or epileptiform features. compared to the prior day's recording, there is slight improvement and more organization of the background activity. cxr a tracheostomy is in place. at the periphery of these films, cervical fixation hardware is noted. the apices are obscured by overlying mask. allowing for this, the lungs appear hyperinflated. heart size is at the upper limits of normal. there is upper zone redistribution, without overt chf. there is minimal hazy density in the left lung, which most likely represents mild atelectasis. no frank consolidation or gross effusion. left subclavian picc line tip overlies mid/lower svc. allowing for artifact due to the oxygen mask, no pneumothorax is detected. lenies findings: grayscale and color doppler son with spectral analysis of the bilateral common femoral veins, superficial femoral and popliteal veins was performed. there is normal compressibility, flow and augmentation. there is normal flow and compressibility in the left peroneal and posterior tibial veins. the right calf veins were not visualized. impression: no bilateral lower extremity dvt. right calf veins not visualized. : ct c-spine/neck impression: preliminary report1. 2.5 x 2.1 x 6.2 cm fluid collection at the surgical access site at the posterior cervical spine extending from c2 to t1 might be postsurgical, however, superimposed infection cannot be excluded. 2. interval decrease of the previously seen prevertebral and superior mediastinal fluid collections. 3. 2.4-cm supraglottic/pre-epiglottic soft tissue mass. ddx includes ectopic thyroid, atypical thyroglossal duct cyst or supraglottic carcinoma. : findings: the liver shows no focal or textual abnormalities. the portal vein is patent showing hepatopetal flow. multiple small gallbladder stones are seen. no thickening or edema is seen in the gallbladder wall. there is no intra- or extra-hepatic biliary duct dilatation. the cbd measures 0.3 cm. the right kidney measures 10.2 cm and is normal without hydronephrosis or stones. the left kidney measures 8.8 cm and is normal without hydronephrosis or stones. atherosclerotic disease of the aorta. impression: cholelithiasis without signs of cholecystitis. : mri of head- impression: 1. hyperintense signal on diffusion weighted and flair images in right medial frontal and parietal lobe without corresponding low signal on adc images. this likely represents seizure related change. 2.flair hyperintensity in left posterior temporal lobe sulci, which is unchanged since the prior study. this likely represents a cortical vein 3. focal and confluent t2/flair hyperintensities in bilateral periventricular and subcortical white matter of bilateral cerebral hemispheres and pons. the differential for this finding includes demyelination, changes of chronic small vessel ischemic disease or changes of vasculitis. 4. no abnormal leptomeningeal or parenchymal enhancement. mri of c-spine: 1. post-operative changes in the form of anterior fusion from c4 to t1 vertebrae and posterior fusion at t2-t3 level. although it is difficult to compare across imaging modalities, and the mr images are obscured by artifact from the fusion hardware, anterolisthesis of c3 over the fused vertebrae appears more severe than the prior ct. repeat ct is advised if clinically indicated. 2. peripherally enhancing collection in posterior paraspinal soft tissues from c2 to c5 level which likely represents post-operative fluid collection. this has decreased in size since the prior study. 3. hyperintense signal in the spinal cord at c6-c7 level, which likely represents edema from prior compression. 4. no abnormal leptomeningeal or intramedullary enhancement. 5. supraglottic mass which is better evaluated on the prior ct images. eeg: findings: continuous eeg recording: began at 7:01 on the morning of and continued through 19:53 that evening. it showed normal posterior hz alpha frequency activity posteriorly wakefulness, as well as some drowsiness and sleep. spike detection programs: showed no clearly epileptiform features. seizure detection programs: captured no electrographic seizures. pushbutton activations: there were none. sleep: the patient progress from wakefulness to sleep at different times with no additional findings. cardiac monitor: showed a generally regular rhythm. impression: this telemetry captured no pushbutton activations. the background appeared remain normal, in wakefulness and sleep. there were no electrographic seizures ekg: normal sinus rhythm. small inferior q waves consistent with possible inferior myocardial infarction. no significant change from tracing of . tracing #1 intervals axes rate pr qrs qt/qtc p qrs t 101 132 76 346/417 68 51 75 findings: bilateral intracranial internal carotid arteries, vertebral arteries, basilar artery and their major branches are patent with no evidence of stenosis, occlusion or vascular malformation. there are tiny outpouchings arising from the medial aspect of the right cavernous ica, which are less than 2 mm in size. these may represent infundibula of tiny branch vessels or small aneurysms. evaluation of the brain parenchyma was limited on these angiographic images. impression: tiny outpouchings from the medial aspect of right cavernous ica may represent small aneurysms or infundibula of branch vessels. otherwise, unremarkable mra of the brain. echo: conclusions regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is no aortic valve stenosis. mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. impression: based on limited apical views only (no parasternal imaging available), left ventricular regional and global systolic function are normal. mild aortic regurgitation. ekg: sinus rhythm. there are q waves in the inferior leads consistent with possible myocardial infarction. there are q waves in the anterolateral leads consistent with possible myocardial infarction. compared to the previous tracing of there is no significant change. intervals axes rate pr qrs qt/qtc p qrs t 76 150 68 86 video swallow: findings: barium passes freely through the oropharynx and esophagus without evidence of obstruction. there is profound gross aspiration with ice, nectar-thick and pudding consistencies. the patient is status post anterior and posterior cervical spinal fusion with pre-epiglottic and prevertebral fluid collections seen on ct of . there is apparent holdup of barium at the upper esophageal sphincter, which may be related in part to narrowing of the esophagus due to swelling and fluid collections in the neck. impression: profound gross aspiration with ice, nectar thick and pudding consistencies. holdup of barium at the ues may be related to prevertebral fluid collections seen on ct of . ekg: normal sinus rhythm. possible prior inferior myocardial infarction. compared to the previous tracing of no diagnostic interval change. intervals axes rate pr qrs qt/qtc p qrs t 84 140 78 390/432 65 29 85 admission labs: ================ 05:45am blood wbc-11.4* rbc-3.80* hgb-10.4* hct-31.6* mcv-83 mch-27.4 mchc-32.9 rdw-15.0 plt ct-330 04:45am blood neuts-89.3* lymphs-6.5* monos-2.7 eos-1.3 baso-0.2 05:45am blood pt-10.1 ptt-26.5 inr(pt)-0.9 05:45am blood glucose-82 urean-18 creat-0.6 na-142 k-3.5 cl-105 hco3-30 angap-11 04:58am blood alt-44* ast-46* ld(ldh)-231 alkphos-289* totbili-0.9 05:45am blood calcium-8.8 phos-3.0 mg-1.8 06:27am blood hapto-371* 05:30am blood triglyc-114 hdl-48 chol/hd-4.5 ldlcalc-146* rheum labs: ============= 11:25am blood anca-negative b 08:03pm blood -negative dsdna-negative 08:03pm blood c3-172 c4-30 08:03pm blood aca igg-1.2 aca igm-16.2* sm antibody test result reference range/units sm antibody <1.0 neg <1.0 neg ai ro & result reference range/units sjogren's antibody (ss-a) <1.0 neg <1.0 neg ai sjogren's antibody (ss-b) <1.0 neg <1.0 neg ai methylmalonic acid test result reference range/units methylmalonic acid 66 l 87-318 nmol/l cardiac labs: ============== 05:30am blood %hba1c-4.9 eag-94 05:30am blood triglyc-114 hdl-48 chol/hd-4.5 ldlcalc-146* 09:53am blood ck-mb-12* mb indx-18.8* ctropnt-<0.01 02:46am blood ck-mb-12* mb indx-20.3* ctropnt-<0.01 11:00am blood ck-mb-13* mb indx-19.7* 05:30am blood ck-mb-13* ctropnt-0.01 04:55am blood ck-mb-11* mb indx-20.0* ctropnt-<0.01 heme labs: =========== 06:27am blood ret aut-2.4 12:10pm blood ret aut-4.2* 07:05pm blood fibrino-779* 08:30pm blood fibrino-752* 09:30am blood fibrino-470*# 06:27am blood hapto-371* 04:59am blood vitb12-749 04:55am blood caltibc-264 ferritn-236* trf-203 05:54am blood hapto-353* discharge labs: ================ lytes from this pm still pnd 07:05am blood calcium-9.3 phos-4.7*# mg-1.7 04:55am blood alt-54* ast-37 ck(cpk)-55 alkphos-275* totbili-0.2 05:15am blood glucose-102* urean-17 creat-0.4 na-141 k-3.2* cl-102 hco3-29 angap-13 05:15am blood wbc-10.1 rbc-3.11* hgb-9.1* hct-29.5* mcv-95 mch-29.3 mchc-30.8* rdw-15.3 plt ct-563* urine: 10:55am urine color-straw appear-clear sp -1.013 10:55am urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-sm 10:55am urine rbc-1 wbc-18* bacteri-few yeast-none epi-1 cerebral fluid: 02:31pm cerebrospinal fluid (csf) wbc-0 rbc-0 polys-0 lymphs-40 monos-60 02:31pm cerebrospinal fluid (csf) totprot-15 glucose-86 02:31pm cerebrospinal fluid (csf) herpes simplex virus pcr-test name microbiology: 12:06 pm stool consistency: not applicable source: stool. **final report ** fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 9:44 am stool consistency: soft source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). 3:02 am urine source: catheter. **final report ** urine culture (final ): no growth. 12:42 am blood culture source: venipuncture. **final report ** blood culture, routine (final ): no growth. 11:34 pm blood culture source: line-r picc. **final report ** blood culture, routine (final ): no growth. 3:28 pm sputum source: endotracheal. **final report ** gram stain (final ): >25 pmns and >10 epithelial cells/100x field. gram stain indicates extensive contamination with upper respiratory secretions. bacterial culture results are invalid. please submit another specimen. 2:31 pm csf;spinal fluid source: lp #3. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. fungal culture (final ): no fungus isolated. acid fast culture (preliminary): the sensitivity of an afb smear on csf is very low.. if present, afb may take 3-8 weeks to grow.. no mycobacteria isolated. viral culture (preliminary): no virus isolated. 9:02 am sputum source: endotracheal. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). 1+ (<1 per 1000x field): budding yeast with pseudohyphae. respiratory culture (final ): commensal respiratory flora absent. pseudomonas aeruginosa. moderate growth. piperacillin/tazobactam sensitivity testing performed by . yeast. rare growth. of two colonial morphologies. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- <=1 s ceftazidime----------- 2 s ciprofloxacin---------<=0.25 s gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- s tobramycin------------ <=1 s brief hospital course: on ms was transferred from osh to for neurosurgical management. her imaging studies were uploads and revealled c7 to t1 listhesis. patient was admitted to the intensive care unit and placed in cervical traction. after reducing adequately, she was taken to the operating room on and underwent a c5/6/7 corpectomies and c4-t1 fusion. this was without complication. she was extubated, removed from traction and transferred back to the icu. post operative ct revealed good fusion. a somi brace was ordered and she was liberalized to hob at 45 degrees. the patient was febrile to 102.6 on with a leukocytosis of 17.7. blood and urine cultures were sent. cxr did not show a definite infiltrate however the patient did have a productive cough. in the setting of elevated wbc, fever and cough she was started on levofloxacin for pna. sputum culture was requested. lower extremity dopplers were negative for dvt. a speech and swallow eval was ordered given patient's swallowing difficulties and was performed on . unfortunately the patient failed the study and so she was placed on strict npo diet. on she was taken back to the or and underwent a c3-t3 fusion. during positioning she was noted to have a sacral decubitis so a wound care consult was called. inr was 1.5 and hct was 22 so she was transfused with prbc's and ffp. post operatively she was not extubated due to laryngeal edema (difficult intubation) therefore ent was consulted for evaluation. they recommended steroids, ppi and to keep her intubated. she was continued on vanc/gent for prophylaxsis. on her exam was grossly stable but difficult to examine due to being intubated. ct c-spine revealed moderate retropharyngeal edema but no hardware malfunction or misalignment. on she remained stable, extubation was discussed but she was not doing well on cpap trial and also did not have a cuff leak. on , patient self extubated. she was breathing well on face mask. strength was full post operatively and her pain was being treated with morphine. on , the decadron was being weaned due to delirium and she required the addition of olanzapine. she was febrile to 101 on and she was pancultured. on this day she was reintubated for hypoxia. she required high sedation to prevent self extubation. on the patient was being prepped for the or with ent but was noticed in the afternoon to be unresponsive with eyes deviated laterally and out, with flickering of the eye lids. she was given dilantin and ativan and a stat head ct was performed which was questionable for a right temporal hypodensity. per neurorad recommendation an mri was performed. this was negative for stroke or lesion therefore an eeg was ordered to rule out seizure activity. eeg was negative therefore it was discontinued along with the dilatin. on the patient was very lethargic so her sedation was held (> 1 hr) for examination. during this time she self-extubated. o2 sats were stable but she was noted to be aspirating therefore she was reintubated and subsequently trached. on she was neurologically stable and vent was weaned to a trach collar. her staples were d/c'd. on patient was transferred to the floor. however, she spiked another low grade temp of 100.8 and was recultured and had an additional chest x-ray. fever work-up was negative, except for positive pan-sensitive pseudomonas on sputum culture. on infectious disease consult was called due to patient's leukocytosis and continued fevers. they recommended switching her antibiotics to cefepime, obtaining a mini-bal, a clostridium difficile culture, and possible ir guided lp. these studies were found to be negative. on her inr was found to be trending upwards. hematology was consulted for their input and recommended vit. k+. her peg was delayed because on her fever and wbc. nutrition recommendations for tpn was initiated. ent was also re-contact for possibility of scoping this pt for eval of possible para-vocal mass that was initially seen on intubation for acdf. due to concern surrounding her waxing/wanning mental status on her inr returned to , her tpn was initiated as per nutrition. ent did a fiberoptic evaluation and they found poor management of secretions, but no mass and they signed off. she had her lp in inr on this day. neuromedicine saw her and fel;t that she was in a oculogyrate crisis. benadryl was given without good effect. she was transfered to medicine due to the complexity of her problems. her medical floor course can be summarized as follows: ====================================================== inactive tissues: ================= #. fevers/leukocytosis: she was inherited on vanco/cefepime broad spectrum antibiotics without clear source of infection- a pan sensitive psuedomonas was found in the sputum but no radiographic evidence of pneumonia was ever apparent. on , her antibiotics were discontinued due to the lack of fevers and a downtrending wbc. a small fluid collection seen on ct along the posterior cervical surgical incision site was sampled via ir/ultrasonography, with a bland fluid not suggestive of infection. urine, blood cultures were negative, as were c dif. on , she spiked to 102, she was then restarted on vanco and cefepime. she had pan culture which at the time was all negative. her only + culture was from sputum the day before with pan-sensitive pseudomonas, although there was no radiologic evidence of infection (pneumonia) this was thought to be causing elevation in wbc- so she was treated with cefepime for a total of 10 days last day was on and she has been afebrile since then. #. delirium/encephalopathy: she showed a waxing and level of responsiveness. eeg had previously shown only diffuse slowing of encephalopathy, which could have been from her surgical interventions, steroids, zyprexa, infection. there was concern for seizure activity due to contraction of the arms and eye deviation, so an extended eeg was conducted without definite evidence of seizures. deliriogenic meds avoided. she was then treated for seizures with keppra and then dilantin was added since she continue to have seizure activity. within hours of her dilantin infusion, she developed a severe rash. so this was stopped and she was continued on keppra and started on lacosamide. she was doing well and then had her last episode of confusion last week in the setting of receiving trazadone for sleep and pain meds. her sedating meds were held and pt has been doing much better. now a+o x 3. she was restarted on oxycodone for pain and i would consider restarting ambien once pt is stable on her new location. there were multiple head images which did not show anatomical cause of her confusion or seizures #. oculogyric crisis: she had a dystonic reaction from zyprexa with an unclosable mouth and eye deviation. this lysed with iv benadryl on . she had similar symptoms on which again responded to iv benadryl. anti-psychotics were avoided. active issues: =============== # seizures: has been having unusual eeg activity and three confirmed seizures since , most recently on . she was loaded on keppra on . loaded with dilantin on but experienced a drug rash. she then had recurrence of witnessed sz over the weekend on 03/25th that lasted 3 min with lip smacking, arm movement and blinking. no other event since then. spoke to neurology who recommended increasing dose of lacosamide from 200-> 300 mg on . we still uncertain what is causing the sz activity, multiple head images did not show anatomical causes. possible encephalalitis r/t medications. however, pt has remained stable. neuro is okay with us restarting pt on neurontin for neuropathic pain, so this was done on and dose was increased to . - continue po keppra 1500mg and lacosamide 300mg - started on neurontin 300mg on for neuropathic pain which can increase to today if tolerating well and may increase to tid - neurology will be calling your facility to schedule a follow-up appointment within 2 weeks. # s/p tracheostomy: patient was complaining of sore throat and discomfort. no change in oxygen saturations. dr. , general surgeon, did not feel she was amenable to a trach revision to a smaller trach. recommended ent evaluation for increased secretions, failed speech and swallow, apparent difficulty with the trach. ent saw pt on and scoped pt at bedside and findings are consistent with weakened muscles and aspiration, so no intervention at this time, except for cont with trach care, humidified oxygen and speech therapy. she also had video swallow on that showed aspiration. so for now pt should cont to be npo. - continue supplemental oxygen via trach mask - trach care - cont to work with speech therapy - pt able to clear secreations and to use passmier valve . # s/p cervical fusion/anterolisthesis: she was taken to the operating room on and underwent a c5/6/7 corpectomies and c4-t1 fusion. this was without complication, but as noted above she had multiple complications. anterolisthesis (anterior dislocation of her spinous process) was found to have worsened on the most recent mri c-spine. somi cervical brace was placed per neurosurgery and should be on at all times. the brace was just adjusted yesterday and is fitting more comfortable by patient. she has small pressure ulcer on her chin that is healing and on the back of her head that is also healing. neurosurgery will be following the patient and she has appointment on . she will have a repeat ct scan at that time. - per neurosurgery: patient must be lying flat if she is in an aspen collar, otherwise she must be put in a full neck brace at all times (would prefer not changing from somi brace to collar since concern for dislocation). # pain: pt with pain at her surgical site and due to position related to brace. she has also chronic neuropathic pain and has been on neurontin and multiple meds prior to her admission. she asked to have neurotin restarted. neuro was okay in adding this medication. - cont on tylenol 650mg q 6 hours as needed - restarted on oxycodone 5mg q 6 hours as needed - restarted on neurotin 300mg once daily, will increase to tomorrow if tolerates and to tid on the following day . # cp/sob: patient had previously reported having new, sudden onset chest pain that was sharp and substernal . normal ekg, cxr and trop. ckmb was initially 18.8 and has been trended down to 11. given downward trend and current clinical status there is no concern for acs. demand ischemia was considered but cardiac echo performed on showed that the left ventricular regional and global systolic functions are normal w/ only mild aortic regurgitation. ckmb may be originating from brain tissue. -continue lipitor, low dose aspirin, and metoprolol . # brain imaging findings: there were initial concerns about vasculitis since mri of brain on that showed focal and confluent t2/flair hyperintensities in bilateral periventricular and subcortical white matter of bilateral cerebral hemispheres and pons. the differential for this finding includes demyelination, changes of chronic small vessel ischemic disease or changes of vasculitis. so, rheumatology was consulted for evaluation of vasculitis, especially given her hx of + . she also had a mra brain on was not c/w vasculitis. rheum panel was sent w/ only abnormality being anticardiolipin antibody igm elevated to 16.2, which may occur with vasculitis, sle or aca syndrome. however rheumo does not think that pt's findings are consistent with vasculitis. . # drug rash: due to dilantin given timing of rash with dilantin administration. allergy list updated - hold dilantin . # blurry vision: pt c/o "foggy vision at times" which has been happening since surgery. she with normal visual acuity. she was also evaluted by neuro and had multiple head images which did not show an anatomical abnormality. this does not appear to be an acute issue. the other potentially cause could be optic neuritis due to ms. ms has not been r/o yet as the mri findings are some what suggestive. - she will be followed by neuro . # skin: pt with a small healing ulcer on submandibular are and scab on posterior occipital area. she also had a very small sacral decubitus ulcer that has healed. no signs of infection. cont with positioning and skin care. . . # fen: replete electrolytes, npo on tpn, q4h oral care # prophylaxis: subcutaneous heparin ( be d/c with increase mobility), ppi, bowel regimen # access: peripherals # code: full code (from chart) # communication: patient and her husband # disposition: at transition of care: =================== # she will need to follow-up with neurology who will be calling to schedule appointment with 2 weeks. if you do not hear from then by , please call the neurology office to schedule f/u appointment at # continue to monitor for seizures, pt may continue to have occ seizures (usually associated with blank starring with blinking of the eyes, and arm movement. this has only lasted a few minutes at the time. during her last episode on she had an episode of hypoxia and had to have supplement 02 via ambu bag for a short period of time and this quickly improved with supportive care. if continues to have episodes of seizures please call the neurologist on call and may ask for advice (). # she will be following up with neurosurgery on with repeat ct-cervical spine. if there is any concern with her brace please call neops (company that made the brace). if any other concerns may also call and ask to speak to neurosurgeon on call. please feel free to contact us with any additional questions in regards her care: - pgy 3 or dr. at medications on admission: ambien 10mg at night percocet q6h prn zetia 10mg daily alprazolam 1mg tid prn anxiety vistaril 50mg q6h prn gabapentin 300mg tid paxil 40mg daily estrogen 1.25mg daily hydroxychloroquine 40mg daily amitryptyline 100mg at night albuterol prn advair prn discharge medications: 1. paroxetine hcl 10 mg/5 ml suspension : forty (40) mg po daily (daily). 2. senna 8.8 mg/5 ml syrup : one (1) tablet po daily (daily). 3. glucagon (human recombinant) 1 mg recon soln : one (1) recon soln injection q15min () as needed for hypoglycemia protocol. 4. docusate sodium 50 mg/5 ml liquid : one (1) po bid (2 times a day). 5. bisacodyl 5 mg tablet, delayed release (e.c.) : one (1) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 6. ipratropium bromide 0.02 % solution : one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 7. insulin regular human 100 unit/ml solution : one (1) injection injection asdir (as directed). 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) neb inhalation q6h (every 6 hours) as needed for wheezing. 9. chlorhexidine gluconate 0.12 % mouthwash : one (1) ml mucous membrane (2 times a day). 10. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical qid (4 times a day) as needed for itching. 11. atorvastatin 20 mg tablet : one (1) tablet po daily (daily). 12. metoprolol tartrate 25 mg tablet : 0.5 tablet po bid (2 times a day): please hold for sbp<100 and hr<60. 13. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 14. oxycodone 5 mg/5 ml solution : five (5) mg po q6h (every 6 hours) as needed for pain : please hold for sedation and rr<12. 15. levetiracetam 100 mg/ml solution : 1500 (1500) mg po bid (2 times a day). 16. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 17. lacosamide 10 mg/ml solution : three hundred (300) mg po bid (2 times a day). 18. oxycodone 5 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain: please hold for sedation and rr<12. 19. acetaminophen 325 mg tablet : two (2) tablet po q6h (every 6 hours) as needed for pain. 20. gabapentin 300 mg capsule : one (1) capsule po twice a day: just started on as , increase dose today to . increse dose to tid as tolerated . 21. ondansetron hcl (pf) 4 mg/2 ml solution : four (4) injection q6h (every 6 hours) as needed for nausea. 22. diphenhydramine hcl 50 mg/ml solution : twenty five (25) ml injection q6h (every 6 hours) as needed for itching: please hold for sedation . 23. heparin (porcine) 5,000 unit/ml solution : one (1) injection injection tid (3 times a day): ***okay to d/c if patient has increse mobility. discharge disposition: extended care facility: cape & islands discharge diagnosis: cervical myelopathy dysphagia failure to thrive fever of unknonw origin leukocytosis vap pna supraglottic edema c6-c7 listhesis hypomobile right vocal cord delirium hypoxia to 60's coagulopathy malnutrition cachexia vitamin k deficiency oculogyrate crisis discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mrs. , it was a pleasure taking care of you. you were admitted to for cervical fusion on . unfortunately, you had a very complicated post-operative course which included infection, respiratory failure requiring a tracheostomy. you also had seizures of uncertain etiology that have now been treated with anti-seizure medication. you also had a peg-tube placed for you have been afebrile for at least 2 weeks now, you are also tolerating the tracheal tube well and your sezures have become less frequent. you have shown great improvement and you will need to follow-up with the neurosurgeon and with the neurologist as noted below. once you leave the rehab facility you will also need to have follow-up with your primary care doctor. this are the instructions given by neurosurgery: ?????? do not smoke. ?????? no tub baths or pool swimming for two weeks from your date of surgery. ?????? no pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? you are required to wear the somi cervical brace at all times ?????? take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. this medication is as needed for pain, you do not need to take it if you have no pain. ?????? do not take any anti-inflammatory medications such as motrin, advil, aspirin, and ibuprofen etc until cleared by dr. ?????? clearance to drive and return to work will be addressed at your post-operative office visit. you had one episode of chest pain and your cardiac enzymes where mildly elevated, so you were started on medications for your heart which include metoprolol, atorvastatin and on aspirin. you were just restarted on medication for your neuropathic pain: neurotin 300mg once daily on , this will be able to be increased to twice daily today and to three times daily as you tolerate. you were given medication for your seizures. you had a very bad allergic reaction to dilantin and you should not received this medication again. you are currently on levetiracetam oral solution 1500 mg twice daily and on lacosamide 300 mg twice daily. we have not been giving you sleeping aid (trazadone) since you had episodes of delerium (confusion) while taking this medication. once you are stable in your new location, you should discuss when would be okay to start on ambien. followup instructions: follow up instructions/appointments you will have an appointment with dr. , neurosurgeon, in 4 weeks, on please call ( you will need cat scan of c-spine prior to your appointment. so you should arrive at the neurologist will call your facility with a follow-up appointment at procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung spinal tap incision of lung fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances percutaneous [endoscopic] gastrostomy [peg] laryngoscopy and other tracheoscopy temporary tracheostomy other cervical fusion of the anterior column, anterior technique excision of intervertebral disc excision of bone for graft, other bones excision of bone for graft, other bones repair of vertebral fracture insertion or replacement of skull tongs or halo traction device plastic operation on pharynx insertion or replacement of skull tongs or halo traction device plastic operation on pharynx spinal traction using skull device insertion of interbody spinal fusion device fusion or refusion of 4-8 vertebrae fusion or refusion of 4-8 vertebrae insertion of recombinant bone morphogenetic protein insertion of recombinant bone morphogenetic protein refusion of other cervical spine, posterior column, posterior technique diagnoses: esophageal reflux tobacco use disorder acquired coagulation factor deficiency asthma, unspecified type, unspecified other and unspecified hyperlipidemia other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure pneumonitis due to inhalation of food or vomitus pressure ulcer, other site pressure ulcer, lower back dermatitis due to drugs and medicines taken internally epilepsy, unspecified, without mention of intractable epilepsy encephalopathy, unspecified ventilator associated pneumonia unspecified hereditary and idiopathic peripheral neuropathy irritable bowel syndrome pressure ulcer, stage ii cervical spondylosis with myelopathy pathologic fracture of vertebrae edema of larynx hydantoin derivatives causing adverse effects in therapeutic use acquired spondylolisthesis malnutrition of moderate degree physical restraints status other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use body mass index between 19-24, adult other and unspecified nonspecific immunological findings kyphosis, postlaminectomy other dissociated deviation of eye movements 

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