CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 57 y/o M hx AML s/p MUD allo [**6-22**] in remission with multiple
complications including GVH of liver, skin, lung, most recently
on photopheresis since the end of [**Month (only) 1096**]. Also with DM, AVN of
hips/shoulders, chronic compression fx's, PE's on lifelong
anticoagulation, and b/l achilles tendon rupture after
fluoroquinolone course in [**5-27**]. Multiple recent admissions for
shortness of breath, though infectious (GGO on CT) treated with
abx, as well as norovirus. Recently discharged on O2 and azithro
and pred 20 for SOB and at that time if was unclear from imaging
and exam whether it was due to infectious etiology vs. GVHD.
.
The pt's breathing had improved since d/c up until a couple of
days about when he noticed increasing SOB especially with
exertion. He denies associated CP, fevers/ chills or rash. He
does note worsening productive cough. He also claims that his LE
edema has been increasing b/l as well and this has been going on
for several weeks also. He denies hx of chf. He also has noted
that his RLE in particular has not only become more swollen but
also has become more red and painful as well.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
.
POST TRANSPLANT COMPLICATIONS:
*GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Delayed & Ext.Release -
1 (One) Capsule(s) by mouth three times a day PLEASE DISPENSE 3
MONTH SUPPLY
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day please dispense 90 day supply
HYDROMORPHONE - 4 mg Tablet - 0.5 (One half) to 1 Tablet(s) by
mouth once a day as needed for pain
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as per sliding
scale four times a day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
OXYCODONE [OXYCONTIN] - 40 mg Tablet Extended Release 12 hr - 2
Tablet(s) by mouth every eight (8) hours
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day PLEASE DISPENSE 3 MONTH SUPPLY
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
please dispense 3 month supply
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
WARFARIN - 4 mg Tablet - 1 Tablet(s) by mouth once a day or as
directed

ALLERGIES: Cefepime / ciprofloxacin / Levofloxacin

PHYSICAL EXAM: Admission Physical Exam:
Vitals - T:97.7 BP:163/96 HR:77 RR:18 02 sat: 99% 2L
GENERAL: obese male w/ moon facies, prefers to keep his eyes
closed
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, erytematous RLE
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, difficult to assess JVD due to habbitus
CARDIAC: RRR, S1/S2, no mrg
LUNG: crackles present in LL b/l
ABDOMEN: obeses, nondistended, +BS, moderately tender in Lower
quadrants b/l, no rebound/guarding, no hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE medial healed ulcer from prior mrsa infection, LLE
warm, erythematous small puncture wound on posterior distal calf
weeping serous fluid, both LE weeping serous fluid, severe [**1-19**]+
edema present to distal thigh b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact

FAMILY HISTORY: Mother died suddenly in 70s.  Father died of unknown cancer. One
sister with thyroid cancer.  One brother has diabetes.  One
sister has [**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and son.  [**Name (NI) **] is retired, worked as a
[**Company 22957**] technician.  He smoked for 40 pack years, now quit. He
denies EtOH or drugs.
Complications of transplanted organ, stem cell,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Cardiac arrest,Acute and chronic respiratory failure,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission,Chronic graft-versus-host disease,Aseptic necrosis of head and neck of femur,Paraplegia,Other specified alveolar and parietoalveolar pneumonopathies,Secondary hyperparathyroidism (of renal origin),Myelopathy in other diseases classified elsewhere,Mixed acid-base balance disorder,Acute posthemorrhagic anemia,Other disorders of neurohypophysis,Glucocorticoid deficiency,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Edema,Other chronic pain,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of other malignant neoplasm of skin,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of lower limb, unspecified,Exophoria
Comp tp organ-stem cell,Acute necrosis of liver,Food/vomit pneumonitis,Pneumonia, organism NOS,Ac kidny fail, tubr necr,Cardiac arrest,Acute & chronc resp fail,Cellulitis of leg,Act myl leuk w rmsion,Chronc graft-vs-host dis,Aseptic necrosis femur,Paraplegia NOS,Alveol pneumonopathy NEC,Sec hyperparathyrd-renal,Myelopathy in oth dis,Mixed acid-base bal dis,Ac posthemorrhag anemia,Neurohypophysis dis NEC,Glucocorticoid deficient,Long-term use anticoagul,Hx pulmonary embolism,Edema,Chronic pain NEC,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,Hx-skin malignancy NEC,Obstructive sleep apnea,Obesity NOS,Adv eff corticosteroids,Mononeuritis leg NOS,Exophoria
Admission Date:  [**2148-2-13**]              [**Month/Day/Year **] Date:   [**2148-4-9**]

Date of Birth:  [**2090-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime / ciprofloxacin / Levofloxacin

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
T3-T7 laminectomy and fusion


History of Present Illness:
57 y/o M hx AML s/p MUD allo [**6-22**] in remission with multiple
complications including GVH of liver, skin, lung, most recently
on photopheresis since the end of [**Month (only) 1096**]. Also with DM, AVN of
hips/shoulders, chronic compression fx's, PE's on lifelong
anticoagulation, and b/l achilles tendon rupture after
fluoroquinolone course in [**5-27**]. Multiple recent admissions for
shortness of breath, though infectious (GGO on CT) treated with
abx, as well as norovirus. Recently discharged on O2 and azithro
and pred 20 for SOB and at that time if was unclear from imaging
and exam whether it was due to infectious etiology vs. GVHD.
.
The pt's breathing had improved since d/c up until a couple of
days about when he noticed increasing SOB especially with
exertion. He denies associated CP, fevers/ chills or rash. He
does note worsening productive cough. He also claims that his LE
edema has been increasing b/l as well and this has been going on
for several weeks also. He denies hx of chf. He also has noted
that his RLE in particular has not only become more swollen but
also has become more red and painful as well.

.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias.All other systems negative.


Past Medical History:
ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
.
POST TRANSPLANT COMPLICATIONS:
*GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory

infections (h/o RSV, parainfluenza)
*Chronic lower extremitiy edema, refractory to lasix, suspected
to be GVHD
*Avascular necrosis (bilateral hips and left shoulder)
*Multiple compression fractures of the spine with chronic pain
*Type 2 DM
*Pulmonary embolus in [**11/2144**] and [**5-/2146**], on lifelong
anticoagulation
*s/p L5 vertebroplasty [**3-/2145**]
*Ruptured left calf hematoma ([**9-/2146**]) complicated by MRSA wound

infection
*Influenza A [**1-/2147**]
*bilateral Achilles tendon rupture [**2147-5-23**] ( attributed to
levoflox).
.
OTHER PAST MEDICAL HISTORY (From [**Month/Day/Year **]):
*CKD with baseline Cr 1.1
*Pericardial effusion s/p [**3-23**] drainage.
*Hyperlipidemia, no meds.
*HTN, on metoprolol.
*Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
*Left interpolar renal lesion, followed with MRs
*Basal cell carcinoma, resected.
*Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
*Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical

spine fusion (bone graft, no hardware).
*Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
*Chronic numbness, neuropathic pain in left upper extremity.
*Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
*Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]

Social History:
Lives with his wife, and son.  [**Name (NI) **] is retired, worked as a
[**Company 22957**] technician.  He smoked for 40 pack years, now quit. He
denies EtOH or drugs.


Family History:
Mother died suddenly in 70s.  Father died of unknown cancer. One
sister with thyroid cancer.  One brother has diabetes.  One
sister has [**Name (NI) 5895**].


Physical Exam:
Admission Physical Exam:
Vitals - T:97.7 BP:163/96 HR:77 RR:18 02 sat: 99% 2L
GENERAL: obese male w/ moon facies, prefers to keep his eyes
closed
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, erytematous RLE
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, difficult to assess JVD due to habbitus
CARDIAC: RRR, S1/S2, no mrg
LUNG: crackles present in LL b/l
ABDOMEN: obeses, nondistended, +BS, moderately tender in Lower
quadrants b/l, no rebound/guarding, no hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE medial healed ulcer from prior mrsa infection, LLE
warm, erythematous small puncture wound on posterior distal calf
weeping serous fluid, both LE weeping serous fluid, severe [**1-19**]+
edema present to distal thigh b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact

[**Month/Day (3) 894**] EXAM:
afebrile, 122/84, 103, 22, 95% on 0.5L NC
GENERAL: obese male w/ moon facies
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, RLE wrapped in bandages
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, MMM
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: obeses, nondistended, +BS, NT, no rebound/guarding, no
hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE ulcer wrapped in clean, dry, dressings, LLE warm,
both LE edematous 1+
NEURO: paralyzed in LE bilaterally. sensation intact but
reduced. incontinent with foley in place. upper extremity motor
and sensation intact, CN 2-12 intact

Pertinent Results:
Pertinent Lab results:
[**2148-2-12**] 08:15AM BLOOD WBC-5.6 RBC-3.10* Hgb-11.6* Hct-35.7*
MCV-115* MCH-37.3* MCHC-32.4 RDW-16.1* Plt Ct-214
[**2148-2-12**] 08:15AM BLOOD Neuts-85* Bands-1 Lymphs-2* Monos-10
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1* NRBC-3*
[**2148-2-12**] 08:15AM BLOOD PT-14.8* INR(PT)-1.4*
[**2148-2-13**] 03:25PM BLOOD UreaN-16 Creat-0.9 Na-141 K-4.3 Cl-102
HCO3-32 AnGap-11
[**2148-2-13**] 03:25PM BLOOD ALT-120* AST-64* LD(LDH)-386*
AlkPhos-135* TotBili-0.1
[**2148-2-13**] 03:25PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.0
[**2148-3-5**] 05:26AM BLOOD WBC-5.8 RBC-2.86* Hgb-10.1* Hct-33.6*
MCV-118* MCH-35.2* MCHC-30.0* RDW-16.9* Plt Ct-177
[**2148-3-6**] 01:37PM BLOOD WBC-8.8# RBC-2.16* Hgb-7.6* Hct-26.0*
MCV-121* MCH-35.1* MCHC-29.1* RDW-17.0* Plt Ct-178
[**2148-3-6**] 05:00PM BLOOD WBC-8.0 RBC-1.99* Hgb-6.9* Hct-23.4*
MCV-117* MCH-34.8* MCHC-29.7* RDW-17.3* Plt Ct-171
[**2148-3-6**] 07:00PM BLOOD WBC-6.1 RBC-1.99* Hgb-6.2* Hct-20.2*
MCV-102*# MCH-31.4 MCHC-30.8* RDW-25.1* Plt Ct-102*
[**2148-3-6**] 09:53PM BLOOD WBC-5.9 RBC-2.82*# Hgb-8.3*# Hct-26.2*#
MCV-93# MCH-29.5 MCHC-31.6 RDW-23.1* Plt Ct-72*
[**2148-3-7**] 02:02AM BLOOD WBC-5.6 RBC-3.28* Hgb-9.9* Hct-29.7*
MCV-91 MCH-30.2 MCHC-33.3 RDW-22.1* Plt Ct-78*
[**2148-3-7**] 07:20AM BLOOD WBC-7.1 RBC-3.08* Hgb-9.2* Hct-27.9*
MCV-91 MCH-30.0 MCHC-33.2 RDW-22.5* Plt Ct-85*
[**2148-3-7**] 11:52AM BLOOD WBC-8.1 RBC-3.17* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.4 MCHC-31.9 RDW-23.5* Plt Ct-81*
[**2148-3-6**] 01:37PM BLOOD Hapto-213*
[**2148-2-29**] 11:44AM BLOOD PTH-250*
[**2148-3-6**] 06:28AM BLOOD PTH-64
[**2148-2-29**] 11:44AM BLOOD 25VitD-14*
[**2148-2-18**] 04:00PM BLOOD IgG-236* IgA-36* IgM-7*
[**2148-2-29**] 06:00AM BLOOD IgG-643* IgA-40* IgM-12*
[**2148-2-15**] 06:49AM BLOOD Vanco-12.9
[**2148-2-20**] 04:43AM BLOOD Vanco-17.9

MICRO:
Blood Culture, Routine (Final [**2148-2-19**]):    NO GROWTH.
Blood Culture, Routine (Final [**2148-2-20**]):    NO GROWTH
URINE CULTURE (Final [**2148-2-15**]):    NO GROWTH

 **FINAL REPORT [**2148-2-16**]**

   GRAM STAIN (Final [**2148-2-14**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      1+    (<1 per 1000X FIELD):   BUDDING YEAST.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2148-2-16**]):
      SPARSE GROWTH Commensal Respiratory Flora.

[**2148-2-17**] 3:41 pm Rapid Respiratory Viral Screen & Culture
      Site: NASOPHARYNX      Source: Nasopharyngeal swab.

                            **FINAL REPORT [**2148-2-20**]**

   Respiratory Viral Culture (Final [**2148-2-20**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
      Detection of viruses other than those listed above will
only be
      performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
      within 1 week if additional testing is needed.

   Respiratory Viral Antigen Screen (Final [**2148-2-18**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.

Blood Culture, Routine (Final [**2148-3-5**]):    NO GROWTH

IMAGAING:
CT CHEST W/O CONTRAST Study Date of [**2148-2-12**] 1:12 PM
IMPRESSION:
1. Near resolution of right lower and middle lobe ground glass
opacities that were new in [**2147-12-17**], consistent with
resolving infectious process.
2. Other bilateral lung and airway findings (including mild
bronchial
dilation and wall thickening) are similar to baseline CT study
in [**2147-4-16**], and are accompanied by moderate expiratory air
trapping. Although
non-specific, they may be related to history of chronic GVHD.
3. Multiple stable compression fractures and rib fractures.

L-SPINE (AP & LAT) Study Date of [**2148-2-12**] 1:53 PM
FINDINGS: There is a previously known sclerotic focus in the
right iliac
crest. There are also several compression fractures identified
along with
severe degenerative changes of the lumbar spine, all previously
identified. Patient is status post kyphoplasty of the L5
vertebral body. No new fractures are seen.

UNILAT LOWER EXT VEINS RIGHT Study Date of [**2148-2-13**] 6:33 PM
FINDINGS: [**Doctor Last Name **]-scale and color son[**Name (NI) 1417**] were acquired of the
right common femoral, superficial femoral, popliteal, posterior
tibial, and peroneal veins. There is normal compressibility,
flow, and augmentation throughout. There is subcutaneous edema
in the calf
2. Subcutaneous edema in the calf

Pulmonary Report SPIROMETRY, LUNG VOLUMES, DLCO Study Date of
[**2148-2-16**]  1:48 PM
Impression:
Mild to moderate restrictive ventilatory defect with a coexsting

obstructive ventilatory defect and a moderate gas exchange
defect. Compared to the prior study of [**2147-3-30**] the FVC has
decreased by 0.74 L (-21%) and the FEV1 has decreased by 0.58 L
(-25%). Compared to the prior study of [**2145-9-9**] the TLC has
decreased by 1.10 L (-19%) and the DLCO has decreased by 2.82
ml/min/mm Hg (-18%).

CT LOW EXT W/O C RIGHT Study Date of [**2148-2-16**] 2:40 PM
IMPRESSION:
1. No CT evidence for osteomyelitis.
2. Large osteochondral fracture with articular collapse
involving the lateral femoral condyle. Subtle changes were seen
in this area on the prior radiograph from [**2146-12-7**];
however, findings have worsened.
3. Prominent amount of subcutaneous soft tissue swelling and
skin thickening compatible with known diagnosis of cellulitis.
There is no air within the soft tissues.
4. Focal 2-mm nodular area of soft tissue attenuation within the
posterior
medial calf, unable to fully characterize.

MR CALF W/O CONTRAST RIGHT Study Date of [**2148-2-18**] 11:30 AM
IMPRESSION:
1. Extensive subcutaneous soft tissue edema throughout the right
lower
extremity consistent with cellulitis in the appropriate clinical
setting.
Lobulated high T2 focus seen in the posteromedial distal right
lower extremity measuring approximately 4.2 x 0.9 cm. could
represent a small focus of fluid, though the ddx includes dense
edema, in the absence of IV contrast.
2. Incompletely characterized ovoid area measuring 1.0 x 1.5 cm
in the distal right lower extremity posteromedial subcutaneous
soft tissues corresponding to an area of soft tissue density on
recent prior CT examination and calf MRI from [**2147-5-25**] may
represent complex fluid or small area of hemorrhage.
3. Fascial fluid and edema between the medial head gastrocnemius
and soleus musculature, slightly more than seen on the most
recent prior MRI. No associated areas of magnetic susceptibility
artifact to suggest foci of gas, nor are any foci of gas seen on
recent prior CT. No other fascial fluid or edema identified
between muscles. Please correlate clinically to exclude the
possibility of necrotizing fasciitis.
4. Muscle edema involving the soleus musculature and medial
aspect of the
lateral head of the gastrocnemius, which could reflect mild
myositis.
5. Incompletely seen osteochondral fracture involving the
lateral tibial
plateau, better assessed on CT examination from [**2148-2-16**].
6. Bone infarcts in the distal tibia and proximal femur.

CT CHEST W/O CONTRAST Study Date of [**2148-2-24**] 3:40 PM
IMPRESSION:
1. Continued resolution of previously seen bilateral
ground-glass and nodular opacities consistent with infection. No
new consolidation.
2. Stable chronic changes including bibasilar scarring and
bronchiectasis.  Mild centrilobular emphysema.
3. Hepatic steatosis.

CHEST (PORTABLE AP) Study Date of [**2148-2-27**] 9:27 AM
IMPRESSION: Unchanged exam. No rib fractures evident.

MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Study Date of [**2148-2-28**] 9:23 AM
IMPRESSION:
1. New T5 inferior endplate fracture with retropulsion of its
dorsal cortex, narrowing the ventral spinal canal, with no
spinal cord signal abnormality.  This is new compared to CT
chest done only four days ago, and should be correlated directly
with the symptomatic site.
2. Likely endplate fracture of T7; however, a mild wedge
deformity was present on CT chest four days ago making if
difficult to determine whether there is an acute component.
3. Previously-seen sites of spinal canal stenosis at C3/C4 and
C6 with
indentation and remodeling of the spinal cord have progressed
slightly,
compared to [**2144-10-2**]. The associated focal abnormality
of cord
intrinsic signal from C4/5 to C5, is unchanged compared to
[**2144-10-2**], and likely represents established
myelomalacia.
4. T12 kyphosis with retropulsion and cord compression is
unchanged in degree, compared to [**2146-8-24**].
5. Remaining old lumbar vertebral compression fractures and
multilevel
degenerative changes are unchanged.

HAND (AP, LAT & OBLIQUE) RIGHT Study Date of [**2148-2-28**] 5:18 PM
IMPRESSION:
1. Erosive change with sclerotic margin at the base of the ulnar
aspect
distal ring finger phalanx with adjacent small calcifications
suggestive of tophi, which may represent gout in the appropriate
clinical setting.
Alternatively, this could be post-traumatic in nature and less
likely an
enchondroma.
2. Old ununited right ulnar styloid fracture or accessory
ossicle, grossly
stable.

TTE:
The left ventricle is not well seen. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The aortic valve is not well seen. The mitral valve
leaflets are not well seen. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad. There are no echocardiographic signs of
tamponade.
IMPRESSION: Suboptimal image quality. Overall LV function is
probably normal. However, due to technical difficulties, a focal
wall motion abnormality cannot be fully excluded. Anterior space
likely represents a prominent fat pad (patient on high dose
steroids; recent CT of chest/abdomen also confirms significant
visceral fat around heart and organs). Dr. [**Last Name (STitle) **] was notified
of the limited study and results by telephone today at 4:10 p.m.

CHEST (PA & LAT) Study Date of [**2148-2-29**] 11:22 AM
IMPRESSION: 1. Probable right mid lung atelectasis but followup
is
recommended. 2. Low lung volumes and increased bibasilar
atelectasis. 3. Mild pulmonary vascular congestion.

BILAT LOWER EXT VEINS Study Date of [**2148-3-1**] 8:46 AM
IMPRESSION:
Mildly limited examination secondary to habitus/subcutaneous
edema without
left or right lower extremity DVT.

CHEST (PORTABLE AP) Study Date of [**2148-3-2**] 9:52 PM
FINDINGS: As compared to the previous radiograph, the lung
volumes are
unchanged and relatively low. Borderline size of the cardiac
silhouette
without pulmonary edema or pneumonia. No pleural effusions.
Unchanged
appearance of the mediastinum. Cervical fixation devices.
Unchanged
hemodialysis catheter.

CHEST (PORTABLE AP) Study Date of [**2148-3-6**] 1:58 PM
FINDINGS: In comparison with the study of [**3-2**], there is no
interval change.  Low lung volumes may account for the mild
prominence of the cardiac silhouette. No evidence of pulmonary
edema or pleural effusion or acute pneumonia.
Cervical fixation device and hemodialysis catheter are
essentially unchanged.

.
.
[**2148-3-6**] CT ABD & PELVIS W/O CON:
IMPRESSION
1. Left retroperitoneal hematoma in the pararenal spaces, with
extension inferiorly into the pelvis.
2. Multilevel vertebral body compression fractures. Old healing
bilateral rib fractures. Possible bilateral femoral head AVN.
3. Fatty liver. Gallbladder stones or sludge.
4. Bibasilar lung opacities concerning for infection.
.
[**3-7**] MR [**Name13 (STitle) **] W& W/O CONTRAST
IMPRESSION:
Since the previous MRI of [**2148-2-28**] there is slightly increased
compression and signal changes within the T5 vertebra identified
with signal changes in the inferior endplate which could be
related to previous compression and fluid adjacent to the
endplate. The slightly increased retropulsion together with
epidural lipomatosis results in some deformity of the spinal
cord at this level, but the evaluation for increased signal
within the cord is limited secondary to motion but such
possibility cannot be completely excluded.  Postoperative
changes are seen in the cervical region as before. The
appearance of lower thoracic spine has remained unchanged
compared to the previous MRI.
.
[**3-11**] CT chest w/o con:
IMPRESSION:
1. Multifocal widespread ground glass opacities with tree-in-[**Male First Name (un) 239**]
opacities along the periphery, most compatible with multifocal
pneumonia. Atypical infections such as mycobacterial can also be
considered.
2. Increased bilateral pleural effusions with worsening adjacent
compressive atelectasis.
3. Incompletely visualized retroperitoneal hematoma, as seen on
the [**2148-3-6**] CT examination.
4. Hepatic steatosis.
5. Unchanged multiple chronic rib fractures and severe
thoracolumbar
vertebral wedge compression deformities.
.
[**3-18**] Head CT:
IMPRESSION:
Bilateral symmetric exophthalmos, new since [**2142**], increased
since [**2143**], and unchanged since [**2148-1-10**]. No evidence of
post-septal mass.
Normal brain CT.
.
[**3-19**] CTA
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Persistent right and left upper lobe opacities, consistent
with pneumonia.
3. Right central bronchial secretions.
.
[**Month/Day (4) 894**] LABS:
[**2148-4-9**] 12:30AM BLOOD WBC-8.4 RBC-3.12* Hgb-10.4* Hct-33.4*
MCV-107* MCH-33.2* MCHC-31.0 RDW-21.3* Plt Ct-251
[**2148-4-9**] 12:30AM BLOOD PT-9.6 PTT-26.6 INR(PT)-0.9
[**2148-4-9**] 12:30AM BLOOD Glucose-219* UreaN-16 Creat-0.8 Na-141
K-4.2 Cl-99 HCO3-35* AnGap-11
[**2148-4-9**] 12:30AM BLOOD ALT-33 AST-30 AlkPhos-221* TotBili-0.2
[**2148-4-9**] 12:30AM BLOOD Calcium-9.0 Phos-3.8 Mg-1.6

Brief Hospital Course:
Mr. [**Known lastname 47367**] is a 57M h/o GVHD involving liver, skin, lung from
allo transplant for AML, and recent admission for SOB of unclear
etiology initially presenting with worsening SOB and RLE
swelling, pain.  He has a h/o thoracic spine compression
fractures, and during this hospitalization received a T3-T7
laminectomy/spinal fusion in [**2-26**] for acute cord compression in
the setting of a code blue and one chest compression.  He had a
[**Hospital Unit Name 153**] admission for respiratory depression thought [**1-18**] medication
sedation effect, and was called out to BMT on [**3-21**] after his pain
Rx were adjusted and his sedation had improved. On [**3-28**], he had
several episodes of SBP 70's, and later became unresponsive with
ABG's showing hypoxemia and acidemia, and the pt was transferred
to the [**Hospital Unit Name 153**]. His AMS and hypercarbia improved with CPAP, and he
was called out to the BMT floor again on [**3-30**]. His Abx were
progressively stopped, and he remained afebrile. He was
continued on azithromycin for infection prophylaxis, and plan
was made to continue this at the discretion of the outpatient
physician, [**Name10 (NameIs) 1023**] can decided when or whether or not to stop.
.
ACTIVE ISSUES:
.
# Graft vs Host Disease- Involving his lungs, GI tract, eyes and
skin. On admission, the pt was complaining of persistent SOB. He
had been admitted in mid [**2148-1-17**] with a similar presentation.
He was empirically treated with Vanc/Aztreonam during that
admission for a prolonged course, and his cultures were all
unremarkable. Pulmonary felt that his lung symptoms were the
result of GVHD c/w a bronchiolitis obliterans picture. It was
recommended to start Advair and Albuterol-Ipratropium as well as
pulse dose steroids. IgG level was checked and returned below
500. He was given IVIG once which also improved his symptoms.
PFTs were obtained during this admission and showed a mild to
moderate restrictive ventilatory defect with a coexisting
obstructive ventilatory defect and a moderate gas exchange
defect. He had documented PE's in the past and was continued on
anticoagulation. While he was on stress doses of hydrocortisone
during his ICU stays, these were changed back to his prednisone
10mg in AM and 5mg in PM without incident.
.
# HCAP in setting of pulmonary GVHD: In an effort to elucidate
an etiology for his hypoxia, a repeat chest CT was performed.
It was negative for pulmonary embolism, but showed areas of
consolidation concerning for new PNA.  As such, the patient was
restarted on IV vanco & meropenem for planned 8 day course, but
on [**3-27**] pt was found increasingly somnolent with PCO2>100. PT
was transferred back to the [**Hospital Unit Name 153**], was put temporarily on
positive airway pressure with improvement in mental status.
Blood gases showed significant improvement. He was sent to the
floor [**2148-3-30**] on an antimicrobial regimen which included vanc,
[**Last Name (un) 2830**], voriconazole, bactrim, azithromycin. These were
progressively d/c'd, and the pt was weaned down to 0.5L NC and
continued on azithromycin for infection prophylaxis and
discharged to rehab.
.
#Osteopenia, s/p laminectomy - Pt has had multiple fractures in
the past due to chronic steroid use. During this
hospitalization, he fractured his distal ulnar after bumping it
on a table. He fractured his R tibial plateau after bumping into
a door while ambulating to the bathroom. Ortho was consulted and
for each fracture determined that no surgical intervention was
warranted. While bending over to pull up his bed sheets, he
experienced significant pain originating in his thoracic spine
and radiating to his anterior chest. He had no neuro deficits on
exam. An MRI of his spine was obtained which showed new
fractures at T5 and T7. Ortho was again consulted and cleared
him for ambulation they recommended cervicothoracic brace for
comfort. He continued to have significant burning pain
occassionally with movement. Ortho was again consulted and we
were planning on performing a vertebroplasty / kyphoplasty of
both T5 and T7 for pain relief. Pt was then noted to have acute
sensorimotor loss below the level of T5-6 with complete loss of
movement in the lower extremities, loss of rectal tone, fecal
incontinence, and complete loss of sensation to the level of the
T5-T6 dermatome on [**3-7**]. He was sent for STAT MRI which showed a
new epidural compression on T4/T5 with hyperdensity in that
area, and new spinal cord signal change with edema. In the OR a
mass was removed from his cord. It is unclear what caused this
acute cord compression, report from ortho that there may have
been a "fat pad" in the epidural space, or trauma from one chest
compression during his preceding code blue. He was taken
urgently to the OR for urgent T3-T7 laminectomy and fusion by
ortho spine. Endocrine was consulted for assistance with
management of severe osteopenia and recommended that we continue
to give high dose vitamin D and calcium supplementation daily.
He did not have any motor function in his LE, although he did
have some remaining sensation in b/l LE. He was discharged to
rehab.
.
# Retroperitoneal Bleed - In preparation for
vertebroplasty/kyphoplasty, the pt's warfarin was discontinued
and he was started on a Heparin gtt. The morning after
initiation of the drip the pt was noted to be tachycardic on
vitals and pale in appearance. The heparin gtt was turned off
and a stat CBC showed a 7 point Hct drop. He subsequently became
hypotensive to the 70s. He was bolused 2L NS and given a total
of 5 units of blood. He was transfered to the ICU for further
management and hemodynamic stablization. On arrival to the ICU,
patient had an acute episode of LOC with BP drop to 40/doppler.
A code blue was called and abruptly cancelled after patient
awoke following one chest compression. A CT of the Abdomen and
Pelvis was obtained which showed left perinephric
retroperitoneal hematoma. Anticoagulants were discontinued and
patient remined hemodynamically stable.  Given that he was no
longer a candidate for anticoagulation, in conjunction with a
h/o multiple pulmonary embolisms, he was taken to IR for
placement of an IVC filter which was placed on [**3-8**].
.
# Chronic Pain - pt has chronic neuropathic pain in LE and also
back pain from old compression fractures and hip / shoulder pain
from avascular necrosis as complication of chronic steroid use.
We initially continued his home doses of PO Dilaudid, Oxycotin
and Gabapentin, but due to oversedation and respiratory
compromise, his Rx were adjusted. Ultimately, the Pain service
was consulted and recommended celebrex, ritalin [**Hospital1 **] for synergy,
APAP, cymbalta, oxycontin, and small PO doses of dilaudid for
breakthrough pain.
.
# Intermittent binocular diplopia: Pt first noticed this while
in the [**Hospital Unit Name 153**] in early [**3-28**]. The pt had anisocoria observed in
[**Hospital Unit Name 153**] in setting of nebulizers, and had head CT which was
negative. Pt had had cataract surgery in 04 and [**4-26**]. Also has
intermittent blurry vision; has no h/o corrective eyewear.
Ophthalmology felt that the pt had significantly dry eyes and a
decompensating exophoria - they recommended aggressive lub with
artificial tear ointment [**Hospital1 **] and preservative free artificial
tears q1h. His blurry vision and diplopia improved thereafter
.
# RLE cellulitis - On presentation, his RLE was significantly
swollen and erythematous.  LENi's were obtained and negative for
DVT. He had a puncture wound in his RLE and from hitting his leg
while walking at home. It was felt that he had a cellulitis of
the RLE. ID was consulted and he was placed on Vancomycin and
meropenem for his cellulitis. He completed a two week course of
IV antibiotics with significant improvement in erythema and
swelling. His wounds were dressed daily per wound care
recommendations.
.
Chronic Issues:
.
#DM II- We continued twice per day dosing of NPH which required
frequent titration while on pulse dose steroid. He was also
placed on humalog sliding scale for prandial coverage.  On
4/12pm  he triggered for FSG 29 (rpt 40) in the setting of no PO
intake for the entire day; was given 1 amp of D50; was tired but
still responsive during that episode.
.
#[**Name (NI) 10952**] Pt was on chronic warfarin for mult PE in past. Please see
above retroperitoneal bleed for adjustments made to this
regimen.
.
# HTN- continued metoprolol.
.
# GVHD [**Name (NI) 2701**] Pt has been suffering from severe GVHD since his
allo transplant in [**2142**]. He is on chronic prednisone at home. He
was then placed on pulse dose steroids and given IVIG which
resulted in improvement in his respiratory symptoms. We
continued Acyclovir, Bactrim and Voriconazole for
immunosuppression prophylaxis.
.
TRANSITIONS OF CARE:
- cont azithromycin for infection prophylaxis
- goal O2 sat 89-92% due to patient's history of OSA and likely
chronic hypoxia at baseline

Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Delayed & Ext.Release -
1 (One) Capsule(s) by mouth three times a day PLEASE DISPENSE 3
MONTH SUPPLY
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day please dispense 90 day supply
HYDROMORPHONE - 4 mg Tablet - 0.5 (One half) to 1 Tablet(s) by
mouth once a day as needed for pain
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as per sliding
scale four times a day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
OXYCODONE [OXYCONTIN] - 40 mg Tablet Extended Release 12 hr - 2
Tablet(s) by mouth every eight (8) hours
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day PLEASE DISPENSE 3 MONTH SUPPLY
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
please dispense 3 month supply
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
WARFARIN - 4 mg Tablet - 1 Tablet(s) by mouth once a day or as
directed

Medications - OTC
BLOOD SUGAR DIAGNOSTIC, DISC [BREEZE 2 TEST STRIPS] -   Strip -
use as directed 2-4 times a day
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 Capsule(s)
by mouth once a day
INSULIN SYRINGE-NEEDLE U-100 [BD LO-DOSE ULTRA-FINE SHORT] - 31
gauge X [**5-1**]" Syringe - Use as directed for insulin
administration 3  times daily
LANCETS MISC. -   Kit - Lancets for Accu check cartridge twice a
day
NPH INSULIN HUMAN RECOMB [HUMULIN N] -  (Dose adjustment - no
new
Rx) - 100 unit/mL Suspension - 10 units subcutaneously twice a
day
PEG 400-PROPYLENE GLYCOL [SYSTANE GEL] -  (Not Taking as
Prescribed: pt states the eye drops sting his eyes and is no
onger taking them) - 0.3 %-0.4 % Drops, Gel - 1 ribbon in each
eye at bedtime
PEG 400-PROPYLENE GLYCOL [SYSTANE ULTRA] -  (Not Taking as
Prescribed: pt states the eye drops sting his eyes and is no
longer taking them) - 0.3 %-0.4 % Drops - 1 gtt in each eye
every
hour


[**Month/Year (2) **] Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) spray Nasal DAILY (Daily).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily): hold for loose stool.
13. celecoxib 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Please give in morning and at noon.  .
16. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. oxycodone 40 mg Tablet Extended Release 12 hr Sig: Two (2)
Tablet Extended Release 12 hr PO Q12H (every 12 hours): hold for
sedation or RR<10.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
20. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day): hold for loose stool.
21. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: Two
(2) Drop Ophthalmic Q2-3H ().
22. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
23. sodium phosphates 19-7 gram/118 mL Enema Sig: One (1) enema
Rectal DAILY (Daily) as needed for constipation.
24. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours): while awake.
25. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours):
while awake.
26. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
27. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QHS (once a day (at bedtime)).
28. hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4
hours) as needed for pain: hold for oversedation, RR< 10.
29. prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
30. prednisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
31. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.

32. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Six (36) units Subcutaneous qAM.
33. Humalog 100 unit/mL Solution Sig: Five (5) units
Subcutaneous three times a day: at breakfast, lunch, and dinner.

34. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous as directed.
35. azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
36. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every 6-8 hours as needed for nausea.


[**Hospital1 **] Disposition:
Extended Care

Facility:
[**Hospital1 700**]

[**Hospital1 **] Diagnosis:
Graft versus host disease
Bronchiolitis [**Hospital **]
Healthcare-associated pneumonia
Vertebral cord compression
Vertebral Compression fractures
Rib fractures


[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


[**Hospital **] Instructions:
Dear Mr. [**Known lastname 47367**],

It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you had a
skin infection on your leg and shortness of breath. During your
stay, you required a back surgery to fix the compression on your
back, as well as antibiotics and other therapies for pneumonias
and your GVHD. After you left the ICU, your condition continued
to improve, and you can be discharged to your rehab.

Your new medication list is attached. Please take all of these
medications as directed and no additional medications.

Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: [**Hospital1 **] [**2148-4-15**] at 10:30 AM

Department: HEMATOLOGY/ONCOLOGY
When: [**Year (4 digits) **] [**2148-4-15**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/BMT
When: [**Hospital Ward Name **] [**2148-4-15**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Complications of transplanted organ, stem cell,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Cardiac arrest,Acute and chronic respiratory failure,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission,Chronic graft-versus-host disease,Aseptic necrosis of head and neck of femur,Paraplegia,Other specified alveolar and parietoalveolar pneumonopathies,Secondary hyperparathyroidism (of renal origin),Myelopathy in other diseases classified elsewhere,Mixed acid-base balance disorder,Acute posthemorrhagic anemia,Other disorders of neurohypophysis,Glucocorticoid deficiency,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Edema,Other chronic pain,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of other malignant neoplasm of skin,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of lower limb, unspecified,Exophoria'}


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: shortness of breath

PRESENT ILLNESS: 57 y/o M hx AML s/p MUD allo [**6-22**] in remission with multiple
complications including GVH of liver, skin, lung, most recently
on photopheresis since the end of [**Month (only) 1096**]. Also with DM, AVN of
hips/shoulders, chronic compression fx's, PE's on lifelong
anticoagulation, and b/l achilles tendon rupture after
fluoroquinolone course in [**5-27**]. Multiple recent admissions for
shortness of breath, though infectious (GGO on CT) treated with
abx, as well as norovirus. Recently discharged on O2 and azithro
and pred 20 for SOB and at that time if was unclear from imaging
and exam whether it was due to infectious etiology vs. GVHD.
.
The pt's breathing had improved since d/c up until a couple of
days about when he noticed increasing SOB especially with
exertion. He denies associated CP, fevers/ chills or rash. He
does note worsening productive cough. He also claims that his LE
edema has been increasing b/l as well and this has been going on
for several weeks also. He denies hx of chf. He also has noted
that his RLE in particular has not only become more swollen but
also has become more red and painful as well.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
.
POST TRANSPLANT COMPLICATIONS:
*GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth twice a day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Delayed & Ext.Release -
1 (One) Capsule(s) by mouth three times a day PLEASE DISPENSE 3
MONTH SUPPLY
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
a
day please dispense 90 day supply
HYDROMORPHONE - 4 mg Tablet - 0.5 (One half) to 1 Tablet(s) by
mouth once a day as needed for pain
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - as per sliding
scale four times a day
METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by
mouth twice a day
OXYCODONE [OXYCONTIN] - 40 mg Tablet Extended Release 12 hr - 2
Tablet(s) by mouth every eight (8) hours
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth twice a day PLEASE DISPENSE 3 MONTH SUPPLY
PRAVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
please dispense 3 month supply
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
WARFARIN - 4 mg Tablet - 1 Tablet(s) by mouth once a day or as
directed

ALLERGIES: Cefepime / ciprofloxacin / Levofloxacin

PHYSICAL EXAM: Admission Physical Exam:
Vitals - T:97.7 BP:163/96 HR:77 RR:18 02 sat: 99% 2L
GENERAL: obese male w/ moon facies, prefers to keep his eyes
closed
SKIN: warm and well perfused, red rash present over chest and
darker discoloration of lower abdomen per pt from mult lovenox
injections, weeping skin in LE b/l, erytematous RLE
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, difficult to assess JVD due to habbitus
CARDIAC: RRR, S1/S2, no mrg
LUNG: crackles present in LL b/l
ABDOMEN: obeses, nondistended, +BS, moderately tender in Lower
quadrants b/l, no rebound/guarding, no hepatosplenomegaly
Extremities- UE multiple ecchymosis b/l in wrist and dorsum of
hands, RLE medial healed ulcer from prior mrsa infection, LLE
warm, erythematous small puncture wound on posterior distal calf
weeping serous fluid, both LE weeping serous fluid, severe [**1-19**]+
edema present to distal thigh b/l
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact

FAMILY HISTORY: Mother died suddenly in 70s.  Father died of unknown cancer. One
sister with thyroid cancer.  One brother has diabetes.  One
sister has [**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and son.  [**Name (NI) **] is retired, worked as a
[**Company 22957**] technician.  He smoked for 40 pack years, now quit. He
denies EtOH or drugs. 

### Response:
{'Complications of transplanted organ, stem cell,Acute and subacute necrosis of liver,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Acute kidney failure with lesion of tubular necrosis,Cardiac arrest,Acute and chronic respiratory failure,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission,Chronic graft-versus-host disease,Aseptic necrosis of head and neck of femur,Paraplegia,Other specified alveolar and parietoalveolar pneumonopathies,Secondary hyperparathyroidism (of renal origin),Myelopathy in other diseases classified elsewhere,Mixed acid-base balance disorder,Acute posthemorrhagic anemia,Other disorders of neurohypophysis,Glucocorticoid deficiency,Long-term (current) use of anticoagulants,Personal history of pulmonary embolism,Edema,Other chronic pain,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Personal history of other malignant neoplasm of skin,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of lower limb, unspecified,Exophoria'}
