Chief Complaint    Altered mentation  History of Present Illness      Patient is a 60-year-old female with a past medical history of hypertension, type 2 diabetes, metastatic breast cancer, paroxysmal A. fib, osteomyelitis s/p right BKA, essential tremor presented to Hospital transfer from another facility for further management of altered mental status.   On my interaction patient is awake, moves extremities voluntarily but unable to provide medical history secondary to altered mental status.  History obtained from chart review and from outside hospitals documentation.  Patient was admitted to initial facility on 11/11 for declining mental status from her nursing home.  Patient son was concerned that patient might have been overmedicated and she was started recently on you medication for essential tremors.  Also patient has not been eating/drinking for 4 to 5 days prior to presentation.  Patient was diagnosed with urinary tract infection and acute renal failure and was treated with ciprofloxacin, ertapenem.  Urine culture ultimately grew Citrobacter brachii, VRE.  Patient's mentation continued to decline and she was evaluated by telemetry neurology and underwent extensive work-up with CT head, MRI brain, EEG x2 and all of which were unrevealing.  LP was done and culture data pending.  Patient was briefly on acyclovir but it was discontinued on 11/12 as concern for meningitis was low on the differential diagnosis.  As patient's mentation continued to be progressively worsen patient was ultimately transferred to Hospital for further care.  Review of Systems     Unable to obtain 2/2 AMS  Physical Exam  Vitals & Measurements  T: 36.5 °C  HR: 59  RR: 16  BP: 162/76  SpO2: 96%      Gen: Awake, does not follow commands, semi purposeful movements noted  HEENT: MMM, EMOI, PERRLA  Neck: Supple, No LAD  CVS: S1,S2 positive, No MRG  Lungs: CTAB, no added sounds  Abd: Soft, NT, ND, no organomegaly, bowel sounds positive  Neuro: Awake, does not follow commands, semi purposeful movements noted, rigidity noted, diminished reflexes Extremities: Rt BKA noted  Assessment/Plan      Encephalopathy     Problem list:  Rapidly progressive acute encephalopathy: Unclear etiology at this point  CT head, CTA on 11/8: No acute pathology noted  EEG x 2 -- > moderate encephalopathy  LP 11/11: CSF -- > oligoclonal bands, AFB culture and stain, Arbovirus IgM, Cryptococcus Ag, EBV, Enterovirus, JC, HSV PCR, Lyme panel, VDRL, Fungal pending  MRI on 11/11: No acute pathology noted  CBC, CMP, ANA, B12, FA, TSH, UA, Blood cultures pending  Will obtain neurology evaluation  Consider repeat LP/MRI and paraneoplastic work up    UTI:  Citrobacter Braakii positive 11/10  VRE positive on 11/12 BC 1/2 -- > Staph hominis on 11/10  Cipro: 11/12 to present  Vancomycin: 11/10-11/12  Ertapenem: 11/10-present  Acyclovir: 11/11-11/12   Rigidity and UE tremors: ?PD  Pt was started on Sinemet 50/200mg tid and amantadine 100 mg bid  Hold above meds per neurology recs  Pt was diagnosed with acute generalized dystonia on 10/28/21 and was started on tetrabenazine   DM2: Insulin sliding scale  Hypoglycemic precautions   Afib: Telemetry monitoring  Eliquis was on hold  Will give Lovenox 100 mg bid   HLD: Lipitor 40 mg daily   H/o breast cancer: On letrozole+Kisqali (3 weeks on , 1 week off). Will need to check with pharmacy and restart