CHIEF COMPLAINT: Decreased sensation and weakness in lower extremities, stool
incontinence, and urinary retention for initial admission,
hypoxia for his ICU transfer

PRESENT ILLNESS: Mr [**Known lastname 24347**] is a 61 y/o male with prior history of multiple
myeloma s/p chemo and XRT to pelvis, who presented to ED on [**7-4**]
with decreased sensation and weakness in his lower extremities,
stool incontinence, and urinary retention. MRI showed
compressive metastatic lesions at the T3/T5 levels. He underwent
T2/T4 hemilaminectomies and T3/T5 laminectomies on [**7-5**]. His
post-operative course has been complicated by upper extremity
DVT, for which he was started on heparin gtt.  He was also found
to have lung nodules on chest imaging, for which he underwent
CT-guided biopsy on [**7-11**], pathology pending.
.
Today, the patient was initially normoxic on the floor, but had
progressively worsening hypoxia throughout the day. O2 sats were
95% on room air at 0800, and on evening vital sign checks, he
was found to be satting in the 80s on room air. He was initially
placed on high flow nasal cannula without significant response,
and subsequently required 100% non-rebreather mask to maintain
sats in the low 90s. He was written for fluconazole, acyclovir,
SS bactrim, and 40 mg IV lasix. Prior to transfer to the ICU, he
was satting 93% on the NRB.  He reported worsening shortness of
breath, and frustration at the prospect of transfer to the ICU.
He felt that he had not been eating and receiving pain
medications on time, and that is why his oxygen level was low.
.
On arrival to the ICU, he reports stable labored breathing, and
is requesting to remove his non-rebreather mask. He denies chest
pain, palpitations, nausea, vomiting, or abdominal pain. He does
state that his abdomen is more distended than usual but he is
not constipated. He has no strength or sensation in his legs,
and cannot move them.
.
Review of systems:  As per HPI. Also endorses chronic back pain
that is at its baseline. Otherwise denies fever, chills, night
sweats, cough, chest pressure, dysuria, urinary frequency or
urgency.
.
Oncologic history (per BMT notes):  Patient reports being
diagnosed with multiple myeloma after he presented to an outside
hospital [**2109-3-11**] with bilateral lower extremity pain,
weakness and fatigue, renal
dysfunction and confusion.  Intial bone marrow biopsy
demonstrated MM with 100% invovlement, and IgA 2,655.  The
patient was started on XRT to bonysites of disease in the pelvis
and chemotherapy(velcade/revlimid/dex per outside notes).  Since
that time patient has tolerated therapy well and reports a
significant improvement in symptoms.  Patient has had a
significant decrease in paraprotein, normalization of plasma
cells in marrow and improvement in disease on imaging. During
this hospitalization, in addition to the above spinal imaging,
he also received a CT of his chest, which revealed multiple
pulmonary nodules, concerning for metastatic disease

MEDICAL HISTORY: - Multiple hospitalizations in Spring [**2110**]
 -hospitalized from [**Date range (1) 88502**] at [**Last Name (un) 1724**] with shingles requiring
high dose acyclovir and analgesia, as well as PNA with resultant
bandemia and hypotension requiring ICU admission, treated with 5
days vanco and azithromycin, and seven days pip/tazo
 -hospitalized at [**Last Name (un) 1724**] [**Date range (1) 88503**], with E coli, PCP and [**Date range (1) 1074**]
pneumonia; was initially treated with Bactrim, but experienced
thrombocytopenia and was switched to atovaquone
- DVTs status post IVC filter placement
- HTN
- HL
- Disc herniation with sciatica
- CAD, s/p stent x2
- Hypothyroidism
- Prior R rotator cuff repair
- R knee arthroscopic surgery
- Appendectomy age 17

MEDICATION ON ADMISSION: Medications (home):
ALLOPURINOL 300 mg PO daily
AMLODIPINE 5 mg PO daily
DEXAMETHASONE Dosage uncertain
FENTANYL - 100 mcg/hour Patch/72 hr
FUROSEMIDE 40 mg PO daily
LENALIDOMIDE [REVLIMID] last dose was [**2110-3-13**]
LEVOTHYROXINE 200 mcg PO daily
LORAZEPAM 1 mg PO Q8 hrs PRN
OMEPRAZOLE 40 mg Capsule, Delayed Release(E.C.) PO daily
OXYCODONE 5-10 mg PO Q4-6H PRN PAIN
PROCHLORPERAZINE MALEATE 10 mg PO Q6-8Hrs PRN nausea
SIMVASTATIN 20 mg PO QHS
ASPIRIN 81 mg PO daily
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - Dosage uncertain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Mother died of lung cancer. No other malignancies

SOCIAL HISTORY: +1-1.5 PPD since age 15. No current ETOH, no
illicits. Previosuly worked in automotive parts.
Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Pressure ulcer, stage III,Myelopathy in other diseases classified elsewhere,Acute kidney failure, unspecified,Blood in stool,Cauda equina syndrome without mention of neurogenic bladder,Acute venous embolism and thrombosis of deep veins of upper extremity,Acute posthemorrhagic anemia,Hypogammaglobulinemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Hypoglycemia, unspecified,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Neoplasm related pain (acute) (chronic),Abdominal aneurysm without mention of rupture,Abdominal or pelvic swelling, mass, or lump, other specified site,Tobacco use disorder,Hypoxemia,Dysphagia, unspecified
Mult mye w/o achv rmson,Acute respiratry failure,Food/vomit pneumonitis,Pneumonia, organism NOS,Pressure ulcer,stage III,Myelopathy in oth dis,Acute kidney failure NOS,Blood in stool,Cauda equina synd NOS,Ac DVT/embl up ext,Ac posthemorrhag anemia,Hypogammaglobulinem NOS,Hypothyroidism NOS,Hypertension NOS,Hypoglycemia NOS,Crnry athrscl natve vssl,Backache NOS,Neoplasm related pain,Abdom aortic aneurysm,Abdmnal mass oth spcf st,Tobacco use disorder,Hypoxemia,Dysphagia NOS
Admission Date:  [**2110-7-5**]              Discharge Date:   [**2110-8-9**]

Date of Birth:  [**2049-6-26**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Decreased sensation and weakness in lower extremities, stool
incontinence, and urinary retention for initial admission,
hypoxia for his ICU transfer

Major Surgical or Invasive Procedure:
Elective intubation for CT and MRI scans
Elective intubation for push enteroscopy
S/p laminectomy x2 and hemilaminectomy x2
push enteroscopy
EGD
Capsule endoscopy
TLC placement in RIJ

History of Present Illness:
Mr [**Known lastname 24347**] is a 61 y/o male with prior history of multiple
myeloma s/p chemo and XRT to pelvis, who presented to ED on [**7-4**]
with decreased sensation and weakness in his lower extremities,
stool incontinence, and urinary retention. MRI showed
compressive metastatic lesions at the T3/T5 levels. He underwent
T2/T4 hemilaminectomies and T3/T5 laminectomies on [**7-5**]. His
post-operative course has been complicated by upper extremity
DVT, for which he was started on heparin gtt.  He was also found
to have lung nodules on chest imaging, for which he underwent
CT-guided biopsy on [**7-11**], pathology pending.
.
Today, the patient was initially normoxic on the floor, but had
progressively worsening hypoxia throughout the day. O2 sats were
95% on room air at 0800, and on evening vital sign checks, he
was found to be satting in the 80s on room air. He was initially
placed on high flow nasal cannula without significant response,
and subsequently required 100% non-rebreather mask to maintain
sats in the low 90s. He was written for fluconazole, acyclovir,
SS bactrim, and 40 mg IV lasix. Prior to transfer to the ICU, he
was satting 93% on the NRB.  He reported worsening shortness of
breath, and frustration at the prospect of transfer to the ICU.
He felt that he had not been eating and receiving pain
medications on time, and that is why his oxygen level was low.
.
On arrival to the ICU, he reports stable labored breathing, and
is requesting to remove his non-rebreather mask. He denies chest
pain, palpitations, nausea, vomiting, or abdominal pain. He does
state that his abdomen is more distended than usual but he is
not constipated. He has no strength or sensation in his legs,
and cannot move them.
.
Review of systems:  As per HPI. Also endorses chronic back pain
that is at its baseline. Otherwise denies fever, chills, night
sweats, cough, chest pressure, dysuria, urinary frequency or
urgency.
.
Oncologic history (per BMT notes):  Patient reports being
diagnosed with multiple myeloma after he presented to an outside
hospital [**2109-3-11**] with bilateral lower extremity pain,
weakness and fatigue, renal
dysfunction and confusion.  Intial bone marrow biopsy
demonstrated MM with 100% invovlement, and IgA 2,655.  The
patient was started on XRT to bonysites of disease in the pelvis
and chemotherapy(velcade/revlimid/dex per outside notes).  Since
that time patient has tolerated therapy well and reports a
significant improvement in symptoms.  Patient has had a
significant decrease in paraprotein, normalization of plasma
cells in marrow and improvement in disease on imaging. During
this hospitalization, in addition to the above spinal imaging,
he also received a CT of his chest, which revealed multiple
pulmonary nodules, concerning for metastatic disease


Past Medical History:
- Multiple hospitalizations in Spring [**2110**]
 -hospitalized from [**Date range (1) 88502**] at [**Last Name (un) 1724**] with shingles requiring
high dose acyclovir and analgesia, as well as PNA with resultant
bandemia and hypotension requiring ICU admission, treated with 5
days vanco and azithromycin, and seven days pip/tazo
 -hospitalized at [**Last Name (un) 1724**] [**Date range (1) 88503**], with E coli, PCP and [**Date range (1) 1074**]
pneumonia; was initially treated with Bactrim, but experienced
thrombocytopenia and was switched to atovaquone
- DVTs status post IVC filter placement
- HTN
- HL
- Disc herniation with sciatica
- CAD, s/p stent x2
- Hypothyroidism
- Prior R rotator cuff repair
- R knee arthroscopic surgery
- Appendectomy age 17


Social History:
+1-1.5 PPD since age 15. No current ETOH, no
illicits. Previosuly worked in automotive parts.


Family History:
Mother died of lung cancer. No other malignancies


Physical Exam:
Admission Exam:

7/  ICU-->BMT Transfer Exam:
Vitals T 97.5 HR 73 BP 108/64 RR 20 O2 96 % RA
General: Alert, oriented, no acute distress, sitting upright
working on computer
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi, R>L, no wheeze
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: thin lower extremities with muscle atrophy. 2+ pulses, no
edema
Neuro: AAOx3, Speech fluent, thought process clear. Moving upper
extremities freely, but with limited grip strength in left hand.
Sensation intact throughout upper extremities. Lower extremities
with flaccid paralysis. +sensation intact over distal legs.
.
[**8-2**] ICU Admission Exam:
General: sedated, falling asleep during interview but arousable

HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Upper extremities markedly edematous and firm, LUE with
gauze dressing on, wasting of lower extremities
.
[**8-7**] Updated ICU Exam:
General: Intubated (not sedated), ill-appearing and grossly
edematous, lying in bed in no acute distress, eyes partially
open, does not more fully open eyes or track to voice or sternal
rub.
HEENT: ETT and NGT in place.
Neck: Single left-sided supraclavicular node, firm and mobile
CV: Tachycardic, regular rhythm.  Nl S1/S2.  No murmurs
appreciated.
Lungs: Coarse bilaterally, anteriorly.
Abd: BS+. Soft. NT/ND. Red blood oozing from urethra around
foley.
Ext: 2+ LE pitting edema b/l. Weeping & ecchymoses of the UE
bilaterally, extensively bandaged.
Neuro: Does not follow commands nor respond to voice or touch.
.
DISCHARGE EXAM:
Expired

Pertinent Results:
[**2110-7-14**] 01:06AM BLOOD WBC-19.7* RBC-2.65* Hgb-8.1* Hct-25.0*
MCV-94 MCH-30.6 MCHC-32.4 RDW-19.8* Plt Ct-299
[**2110-7-14**] 01:06AM BLOOD PT-14.2* PTT-91.1* INR(PT)-1.2*
[**2110-7-14**] 01:06AM BLOOD Plt Ct-299
[**2110-7-14**] 07:48AM BLOOD PTT-98.4*
[**2110-7-15**] 03:06AM BLOOD PT-14.3* PTT-113.6* INR(PT)-1.2*
[**2110-7-15**] 03:06AM BLOOD Plt Ct-286
[**2110-7-15**] 11:24AM BLOOD PTT-114.9*
[**2110-7-14**] 01:06AM BLOOD Glucose-146* UreaN-28* Creat-0.5 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-17
[**2110-7-15**] 03:06AM BLOOD Glucose-157* UreaN-31* Creat-0.6 Na-138
K-4.3 Cl-99 HCO3-24 AnGap-19
[**2110-7-15**] 04:36PM BLOOD Glucose-118* UreaN-34* Creat-0.6 Na-138
K-4.4 Cl-100 HCO3-29 AnGap-13
[**2110-7-14**] 01:06AM BLOOD ALT-39 AST-31 LD(LDH)-563* AlkPhos-130
TotBili-0.3
[**2110-7-14**] 06:53PM BLOOD Type-ART Temp-35.7 pO2-56* pCO2-28*
pH-7.52* calTCO2-24 Base XS-0 Intubat-NOT INTUBA

___
MICROBIOLOGY:

[**2110-8-6**] 7:43 am SPUTUM      Source: Endotracheal.
   GRAM STAIN (Final [**2110-8-6**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   BUDDING YEAST.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND SINGLY.
   RESPIRATORY CULTURE (Preliminary):
      MODERATE GROWTH Commensal Respiratory Flora.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
   FUNGAL CULTURE (Preliminary):
   ACID FAST SMEAR (Final [**2110-8-7**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

[**2110-8-1**] 11:48 am BLOOD CULTURE      Source: Line-Picc.
   Blood Culture, Routine (Final [**2110-8-7**]):    NO GROWTH.

[**2110-7-31**] 9:08 am SPUTUM      Source: Induced.
   GRAM STAIN (Final [**2110-7-31**]):
      [**11-4**] PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST.
   RESPIRATORY CULTURE (Final [**2110-8-2**]):
      MODERATE GROWTH Commensal Respiratory Flora.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2110-8-1**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

[**2110-7-18**] 5:44 pm Rapid Respiratory Viral Screen & Culture
      BRONCHIAL LAVAGE.
   Respiratory Viral Culture (Final [**2110-7-23**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
   Respiratory Viral Antigen Screen (Final [**2110-7-21**]):
      Less than 60 columnar epithelial cells;.
      Specimen inadequate for detecting respiratory viral
infection by DFA
      testing.
      Interpret all negative results from this specimen with
caution.
     VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
      No Cytomegalovirus ([**Month/Day/Year 1074**]) isolated.

[**2110-7-18**] 5:44 pm BRONCHOALVEOLAR LAVAGE      BRONCHIAL LAVAGE.
   GRAM STAIN (Final [**2110-7-18**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2110-7-21**]):
      10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2110-7-19**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..
   FUNGAL CULTURE (Final [**2110-8-1**]):
      YEAST.
   NOCARDIA CULTURE (Preliminary):    NO NOCARDIA ISOLATED.
   ACID FAST SMEAR (Final [**2110-7-21**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):
      Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8402**] AND
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16137**] @
      1440, [**2110-8-1**].
      AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
         SENT TO STATE LAB FOR FURTHER IDENTIFICATION [**2110-8-3**].

[**2110-7-15**] 3:06 am Blood (EBV)      Source: Line-PICC.
                            **FINAL REPORT [**2110-7-17**]**
   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2110-7-17**]):    POSITIVE
BY EIA.
   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2110-7-17**]):    POSITIVE
BY EIA.
   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2110-7-17**]):
      NEGATIVE <1:10 BY IFA.
      INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.

[**2110-7-15**] 3:06 am Immunology ([**Month/Day/Year 1074**])      Source: Line-PICC.
                            **FINAL REPORT [**2110-7-17**]**
   [**Month/Day/Year 1074**] Viral Load (Final [**2110-7-17**]):
      [**Month/Day/Year 1074**] DNA not detected.
      Performed by PCR.
      Detection Range: 600 - 100,000 copies/ml.

------
------
IMAGING:

[**8-7**] Renal Doppler
FINDINGS: The exam is somewhat limited due to patient's
intubated status and inability to breath-hold.
The right main renal vein is patent. The right main renal artery
shows a
normal arterial waveform with a peak velocity of 35 cm/sec. The
right upper, mid, and lower pole arterial waveforms are normal
appearing with brisk upstrokes; although resistive index could
not definitely detected with the upper pole, resistive indices
for the mid and lower poles were 0.78 and 0.80 respectively.
The left main renal vein is patent. The left main renal artery
shows a
normal-appearing waveform with a peak velocity of 63 cm/sec.
Resistive
indices for the upper, mid, and lower poles were 0.75, 0.79, and
0.78
respectively.
IMPRESSION: Patent renal arterial and venous vasculature as
described above with normal resistive indices.

RIB UNILAT, W/ AP CHEST LEFT [**8-4**]
There are patchy opacities throughout both lungs. Please see
report of
[**2110-8-3**] chest x-ray for a more complete discussion of this
abnormality. The cardiomediastinal silhouette is widened and a
right-sided PICC line tip appears to overlie the SVC/RA
junction.
No left-sided rib fracture is detected. No focal lytic or
sclerotic rib
lesion is identified.

ECHO [**8-1**]
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>65%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be quanitfied.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. No definite valvular dysfunction identified.
Compared with the prior study (images reviewed) of [**2110-3-14**],
biventricular cavity sizes are somewhat smaller and left
ventricular systolic function is more dynamic. The heart rate is
also much higher and image quality is suboptimal on the current
study.

LENI [**7-10**]:
CONCLUSION: Intraluminal thrombus is noted in one of the
brachial veins, the one lying more anteriorly. PICC line present
in the basilic vein.

LENI [**7-24**]
1. No flow within the distal left subclavian vein with presence
of thrombus. Proximal subclavian vein shows minimal flow.
2. Left internal jugular, axillary, brachial, basilic, and
cephalic veins
appear patent.

LENI [**7-25**]
IMPRESSION: No evidence of DVT within the right upper extremity
veins.
Redemonstration of previously seen thrombus in the left
subclavian vein.

CT Torso [**7-7**]
IMPRESSION:
1. Multiple lung nodules. Differential diagnosis is broad and
includes
infection, vasculitis, and lung involvement of myeloma.
2. Extensive lymphadenopathy .
3. Epidural mass better seen in prior MR [**First Name8 (NamePattern2) 767**] [**7-5**].
4. Right adrenal lesion, not characterized as adenoma.

CT Torso [**7-17**]
IMPRESSION:
1. Multiple bilateral pulmonary lesions are slightly decreased
in size but
show new evidence of cavitation, concerning for septic emboli or
infection
with an organism such as Nocardia or pseudomonas. Additional new
ground-glass opacities predominantly in the upper lobes, right
greater than left, are also concerning for infection, although
asymmetric pulmonary edema could also have this appearance.
2. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe are
concerning for
aspiration pneumonitis/pneumonia.
3. Diffuse lymphadenopathy and soft tissue nodules within the
mediastinum,
parasternal region, posterior cervical region, retroperitoneum,
pelvis, and gluteal region, as described above. These lesions
are consistent with
extraosseous involvement of multiple myeloma, an uncommon
manifestation of the disease described in an article from AJR
dated from [**2103**] (183:929-932).
4. Diffuse metastatic disease involving the axial skeleton, as
described on MR [**First Name8 (NamePattern2) 767**] [**2110-7-5**]. A mid thoracic
paraspinal/epidural mass causes
compression of the spinal cord, most significant at T5, not
appreciably
changed compared to the prior study.
5. Infrarenal abdominal aortic aneurysm measuring up to 5.9 cm.

CT Torso [**7-27**]
IMPRESSION:
1. Progression of right basilar tree-in-[**Male First Name (un) 239**] opacities with new
areas of
consolidation at both bases. Progression of ground-glass
opacities in the
left and right upper lobes. These findings are concerning for
progressive
infectious process. Several pulmonary lesions again seen with
evidence of
cavitation concerning for septic emboli or infection with
Nocardia or
Pseudomonas.
2. Diffuse lymphadenopathy and soft tissue nodules within the
mediastinum,
parasternal region, posterior cervical soft tissue nodules.
These lesions are consistent with extraosseous involvement of
multiple myeloma.
3. Mid thoracic paraspinal mass again seen, better evaluated on
MRI.

Spine MRI - multiple studies, see OMR

Brief Hospital Course:
Prior to patient's ICU courses, the patient underwent
laminectomy x2 and hemilaminectomy x2 and he was subsequently
transferred to the BMT unit for further management of his
multiple myeloma.
.
61 y/o M with past multiple myeloma treated with chemo and XRT,
multiple hospital admissions for pneumonia in recent months, now
admitted on [**7-5**] for lower extremity paralysis related to spinal
cord involvement, c/b upper extremity DVT, and newly found lung
nodules concerning for malignancy, now s/p biopsy. Initially on
Ortho Spine [**Hospital 81944**] transferred to BMT floor following
post-operative stabilization, then transferred to the ICU for
hypoxia and bloody stools.
.
First ICU Course:
Hypoxia improved within hours, with the patient weaning from a
non-rebreather to room air in less than 12 hours. He had an
acute drop in his hematocrit with dysphagia and guaiac positive
stool. He received RBC transfusions and his heparin was stopped,
with subsequent improvement in his hct. GI was consulted and
performed upper endoscopy and capsule endoscopy, neither of
which revealed active bleed. He was scheduled to start radiation
therapy but was unable to lie flat due to back pain. He was
electively intubated, to be able to tolerate imaging studies and
bronchoscopy/BAL. He developed asymmetric left hand weakness,
was seen by neurology, and underwent MRI of brachial plexus and
cervical spine, showing posterior fluid collection between
C5-T2. He had a CT chest on [**7-17**], which showed diffuse
peribronchovacular GGO's, signs of aspiration, and increased
bilateral lymphadenopathy. Concurrent abdominal imaging also
revealed a 5.8cm infrarenal AAA. He was followed by the pain
service for his significant LBP, and he was started on
bortezomib chemotherapy. Transferred back to the BMT service for
management.
.
.
Second ICU Course
.
Readmitted to ICU on [**7-24**] for persistent hypoxia and ongoing GI
bleed.
.
# Hypoxemia: Pt has had multiple recent admissions with various
pulmonary infections, but on admission was not demonstrating
septic physiology or signs of severe systemic infection. He
triggered on the floor for hypoxia, was diuresed and transferred
to the ICU. Diuresis improved his Sp02 to 94% on RA, resolved
respiratory distress, & produced good UOP. Multiple chest
imaging studies were obtained, as follows: CXR showed new lower
lobe opacity with concern for new bacterial lobar pneumonia vs
aspiration pneumonia/pneumonitis. CT chest showed nodules
concerning for malignancy, but this likely an indolent process
which would not account for abrupt worsening of oxygenation over
12 hour course. He underwent a lung nodule biopsy which showed
focal organizing pneumonitis, chronic inflammation, and
non-necrotizing granulomas. Additional CT finding of
ground-glass opacities c/f PNA improved on more recent CT. Pt is
at risk for PE with known DVTs, hematologic malignancy, & recent
interruption in systemic anticoagulation for lung biopsy;
heparin was started but stopped when the pt developed dropping
Hct with guaiac positive stools suspicious for GI bleed (see
below). Pt remained hemodynamically stable throughout his ICU
course. Bronchioalveolar lavage and sputum cultures were
negative including AFB, [**Month/Year (2) 1074**], and PCP, [**Name10 (NameIs) 151**] the exception of one
BAL culture which grew yeast after 5 days. Beta-glucan,
galactomannan and PCP PCR labs were pending at time of transfer.
He was treated empirically with an 8 day course of vancomycin
and zosyn, 5 days azithromycin, 6 days fluconazole (ongoing), 6
days acyclovir (ongoing), and bactrim prophylaxis was started.
.
#GI bleed
Pt suffered a 6-point Hct drop during first ICU admission --
suspected source was upper GI bleed given coincident melanotic
stools. Other possibilities considered and ruled out included:
retroperitoneal bleed (negative CT Abdomen), bleeding into or
rupture of pre-existing 5.8cm AAA (asymptomatic, vital signs
stable), or bleed into recent spinal surgical site (surgical
site appeared non-concerning). Pt underwent capsule endoscopy,
which showed multiple non-bleeding angioectasias throughout the
small bowel but no evidence of active bleeding. Plan from GI was
to prep patient for a colonoscopy in the near future if the
capsule study is negative, but this did not happen as patient's
Hct stabilized at baseline 27 and melanotic stools resolved.
Vital signs remained stable.
.
# Spinal cord compression/paralysis: S/p laminectomy x2 and
hemilaminectomy x2, without subsequent improvement in extremity
strength/sensation.  We continued him on his corticosteroids and
frequently repositioned to avoid skin breakdown. Orthospine
service monitored the patient in the ICU; staples were removed
and post-surgical site appeared clean. Pain service was involved
in pain management; initially controlled on IV methadone, pt was
transitioned to tylenol, lidocaine patch, and dilaudid PCA.
Radiation oncology evaulated the patient for XRT to palliate
pain and  prevent loss of or even improve some neurological
function of the LUE. Patient underwent mapping and completed a
course of XRT. At time of transfer he was on a dexamethaxone
taper with dilaudid PCA for pain management.
.
# DVTs: Pt has lower extremity DVTs diagnosed at [**Last Name (un) 1724**] last month
plus upper extremity DVT in the LUE involving the subclavian,
earlier on this admission. After his lung biopsy on [**7-11**], heparin
gtt was restarted. Anticoagulation was stopped in the context of
Hct drop/suspected GI bleed. Patient refused pneumoboots.
Deferred decision on chronic anticoagulation until GI w/u
complete, including possible evaluation for intracranial
metastases.
.
# Multiple myeloma:
Per onc notes, pt had excellent response to prior treaments, as
of [**2110-3-11**]. No close oncology follow up between that time and
this presentation. CBC/diff not concerning for acute myeloma,
and SPEP showing hypogammaglobulinemia except normal IgA level.
Has elevated free kappa light chains in serum, consistent with
prior IgA kappa MM. He received velkade per hematology consult.
Given concern for metastases to spinal cord and pulmonary
nodules, pt was prepped twice for radiation therapy; the first
time he was unable to tolerate lying flat due to respiratory
distress. He was ultimately able to receive the full course of 5
radiation treatments to C5-C7, last dose received [**2110-7-31**].
Patient was actively followed by BMT through his course in the
[**Hospital Unit Name 153**].
.
# Leukocytosis:
Patient developed elevated WBC to 33.8 in the ICU. Considered
infectious process vs post-operative vs leukemoid reaction from
glucocorticoids. WBC trending down, 23.3 at time of transfer,
s/p several days of broad-spectrum antibiotics including
antivirals and antifungals. Pt afebrile but pt on standing
tylenol. Steroid reponse most likely but persistent bands on
diff (3% today) suggests possible ongoing infectious process.
.
# CAD: Developed CP in the [**Hospital Unit Name 153**]. ECG without ischemic changes.
He was previously ruled out by biomarkers earlier in admission.
On telemetry, no events.
.
# Hypertension: Stable BP in ICU, mildly hypotensive while
sleeping on floor, but improves when awakened. Not listed as
taking beta blocker as outpatient despite CAD. Continued
amlodipine and furosemide in ICU.
.
# Hyperlipidemia: Continued home statin.
.
# Hypothyroidism: Continued home synthroid.
_____

Third ICU Course ([**8-2**] - [**8-9**]):
.
61 y/o M with PMH as above, transferred back to [**Hospital Unit Name 153**] from BMT
service for recurrent GI bleed.
.
# Goals of care: At a meeting between the patient's primary
oncologist and the patient's HCP, the oncologist informed the
HCP that there were no other treatment options available for the
patient's underlying multiple myeloma. At this discussion, the
decision was made to transition the patient to DNR/DNI status
with no further escalation in care. The patient expired on
[**2110-8-9**].
.
# GI bleed: Transferred from BMT unit for melanotic stool and
tachycardia with a Hct 21, requiring 3U PRBC on the day of
transfer to maintain Hct >25. was held. Previous capsule study
did show non-bleeding AVMs in small bowel. Pt required
intubation for push enteroscopy which did not identify any
bleeding source. Plan was for follow-up balloon enteroscopy to
evaluate the small bowel, but no further GI procedures were
performed because patient was persistently ventilator-dependent
post-procedure with mental status changes (see below). Through
the ICU course, melena continued & hematocrits were checked
every 8 hours. The patient was transfused as necessary to meet
transfusion goals: Hct >25 and platelets > 50. In the ICU (as of
[**2110-8-7**]) he had received a total of 10 U PRBCs, 6 platelet
transfusions, and 2 cryoprecipitate transfusions.
.
# Hypoxemia: After transfer back to the ICU he was found to have
a significant A-a gradient on ABG. No evidence of right heart
strain on EKG. At high risk for PE given immobility, known DVTs
in multiple extremities, and active malignancy. Acute onset of
hypoxia was suggestive of vascular event. Unfortunately, ability
to treat suspected PE by anticoagulation was limited by ongoing
GI bleed.
.
Other possible explanations for initial hypoxemia included
infectious process, pulmonary edema, or transfusion-related
pulmonary process given the numerous blood product transfusions
he required for his ongoing GI bleed. Initial CXR showed no
infiltrate and pt was afebrile. No improvement with diuresis.
However, CT chest showed progression of right basilar
tree-in-[**Male First Name (un) 239**] opacities with new areas of consolidation at both
bases, progression of ground-glass opacities in the left and
right upper lobes, and several progressively cavitating
parenchymal lesions concerning for septic emboli, Nocardia,
Pseudomonas or Tuberculosis.
.
Extensive infectious workup was performed in consultation with
Infectious Disease consult service. Empiric antibiotic therapy
with Vancomycin /Zosyn /Acyclovir was continued. Vanc/Zosyn were
stopped given serial negative sputum and blood cultures were
negative but restarted when pt spiked fevers to 102-103; sputum
cultures sent at that time grew GPC and GNR. He was also
continued on Voriconazole for yeast+ sputum cultures; this was
transiently changed to micofungin but changed back to
voriconazole when patient's respiratory status further
deteriorated after the GI procedure. In addition, a BAL culture
sent on [**2110-7-18**] eventually grew AFB positive; cultures were sent
to the state lab for speciation. Pt was placed on TB precautions
and started on empiric therapy for TB/[**Doctor First Name **] (isoniazid, rifampin,
ethanbutol, moxifloxacin, azithromycin). These were all stopped
when serial sputum smears were AFB-negative. Studies were also
negative for the PCP, [**Name Initial (NameIs) 1074**] (and other viral studies); given
acyclovir-induced crystal nephropathy was within the
differential when the patient became anuric (see below),
acyclovir was also stopped when tests returned negative. He
received supplemental oxygen and nebulizers with O2 saturation
>90% until elective intubation for a GI procedure (see below).
.
#Elective intubation: Patient underwent elective intubation for
GI push enteroscopy. Following the procedure he had persistent
respiratory acidosis and was not able to be extubated.
Maintained primarily on pressure support ventilation; took in
large tidal volumes with some improvement in his acidosis. He
had recurrent fever to 102-103, non-responsive to tylenol.
Vancomycin/Zosyn/Voriconazole was continued as above. The
patient did not require sedation on the ventilator. He expired
on the ventilator.
.
#Acure Renal Failure: Patient became acutely anuric with an
elevated serum creatinine. Urine lytes suggested a pre-renal
state. Renal was consulted. Sediment showed muddy-brown casts
c/w ATN. Other possible diagnoses, per Renal, are various types
of "obstructive uropathy" including myeloma cast nephropathy and
acute acyclovir crystallopathy. Renal U/S showed no
hydronephrosis. Per renal recs, repleted the patient
intravascularly with 25% albumin solution and monitored the
patient's CVP. He also received significant albumin load via
multiple blood product transfusions during this time. Serial
ABGs while ventilated showed mixed respiratory/metabolic
acidosis. Her remained anuric.
.
#Mental Status Changes.
Following elective intubation, patient initially required a
fentanyl drip for sedation. However, his mental status gradually
declined such that he did not require sedation on the vent, and
on examination was unresponsive and unable to follow commands.
At the time he remained intubated on mechanical ventilation,
continued to be anuric and anasarcic, and continued to spike
tylenol-nonresponsive fevers to 102 on vancomycin/ zosyn/
micofungin and empiric antibiotics for AFB. Melanotic stools and
dropping Hct continued to require blood and platelet
transfusion. All pain and sedating medications were held. All
meds were checked for renal dosing and non-essential medications
were stopped, including empiric TB antibiotics (AFB negative
smears x3). No improvement in mental, respiratory, or renal
status. [**Name (NI) 1094**] HCP changed his code status from Full to DNR/DNI
with instructions not to escalate care.
.
# Multiple myeloma: Previously started bortezomib therapy and
had completed XRT. BMT actively followed the patient while in
the [**Hospital Unit Name 153**]. Follow-up IgA was elevated, suggesting relapse of MM.
UPEP was sent, showed trace monoclonal free Bence-[**Doctor Last Name **] Kappa
detected and additional monoclonal IgA Kappa Bence-[**Doctor Last Name **] now
representing 4% of urinary protein. In addition, a firm, mobile,
palpable left supraclavicular nodule was identified on exam,
concerning for plasmacytoma. Underwent U/S guided excisional
biopsy. Lymph node microbiology was gram stain-negative,
AFB-negative. Hematopathology examination showed a mass of
plasma cells with necrosis..
.
# DVT: Unable to treat multiple known thromboses given active GI
bleed requiring RBC transfusions. Of note, the patient does have
an IVC filter in place.
.
# Spinal cord mets s/p decompressive laminectomies: Path
consistent with plasma cell metastases. Left with flaccid
paralysis on bilateral lower extremities, although has some
residual sensation. Continued management with pain control and
dexamthasone; all pain medications were stopped when patient's
mental status changed as above.
.
# Chronic back pain: Patient's prior pain regimen of
acetaminophen, gabapentin, dilaudid PCA, tizanidine, and
lidoderm were continued upon transfer to the ICU. When the
patient was intubated, his oral pain regimen and PCA were held,
and pain control was continued with Fentanyl PCA. All pain meds
including gabapentin and fentanyl were stopped when his mental
status changed (as above).
.
# CAD: Patient c/o left-sided CP not associated with SOB and
without radiation. No ischemic changes were seen on ECG. Patient
was monitored on tele with no events noted. Patient underwent
left-sided rib films as patient's pain was reproducible with
palpation. Rib series showed no fractures, focal or sclerotic
lesions.
.
# Nutrition/Hypoglycemia. Pt developed hypoglycemia to 40s,
which started while NPO prior to GI procedure. Unclear etiology,
asymptomatic. Received D50 as needed for hypoglycemia. Tubefeeds
were started after patient was intubated on mechanical
ventilation.

# Hypertension: Home amlodipine was discontinued in the setting
of GI bleed. Patient's BPs were stable with systolic pressures
in the 110s-120s.
.
# Hypothyroidism: Continued home levothyroxine.


Medications on Admission:
Medications (home):
ALLOPURINOL 300 mg PO daily
AMLODIPINE 5 mg PO daily
DEXAMETHASONE Dosage uncertain
FENTANYL - 100 mcg/hour Patch/72 hr
FUROSEMIDE 40 mg PO daily
LENALIDOMIDE [REVLIMID] last dose was [**2110-3-13**]
LEVOTHYROXINE 200 mcg PO daily
LORAZEPAM 1 mg PO Q8 hrs PRN
OMEPRAZOLE 40 mg Capsule, Delayed Release(E.C.) PO daily
OXYCODONE 5-10 mg PO Q4-6H PRN PAIN
PROCHLORPERAZINE MALEATE 10 mg PO Q6-8Hrs PRN nausea
SIMVASTATIN 20 mg PO QHS
ASPIRIN 81 mg PO daily
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - Dosage uncertain

MULTIVITAMIN

Discharge Medications:
Expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Expired

Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired
{'Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Pressure ulcer, stage III,Myelopathy in other diseases classified elsewhere,Acute kidney failure, unspecified,Blood in stool,Cauda equina syndrome without mention of neurogenic bladder,Acute venous embolism and thrombosis of deep veins of upper extremity,Acute posthemorrhagic anemia,Hypogammaglobulinemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Hypoglycemia, unspecified,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Neoplasm related pain (acute) (chronic),Abdominal aneurysm without mention of rupture,Abdominal or pelvic swelling, mass, or lump, other specified site,Tobacco use disorder,Hypoxemia,Dysphagia, unspecified'}


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: Decreased sensation and weakness in lower extremities, stool
incontinence, and urinary retention for initial admission,
hypoxia for his ICU transfer

PRESENT ILLNESS: Mr [**Known lastname 24347**] is a 61 y/o male with prior history of multiple
myeloma s/p chemo and XRT to pelvis, who presented to ED on [**7-4**]
with decreased sensation and weakness in his lower extremities,
stool incontinence, and urinary retention. MRI showed
compressive metastatic lesions at the T3/T5 levels. He underwent
T2/T4 hemilaminectomies and T3/T5 laminectomies on [**7-5**]. His
post-operative course has been complicated by upper extremity
DVT, for which he was started on heparin gtt.  He was also found
to have lung nodules on chest imaging, for which he underwent
CT-guided biopsy on [**7-11**], pathology pending.
.
Today, the patient was initially normoxic on the floor, but had
progressively worsening hypoxia throughout the day. O2 sats were
95% on room air at 0800, and on evening vital sign checks, he
was found to be satting in the 80s on room air. He was initially
placed on high flow nasal cannula without significant response,
and subsequently required 100% non-rebreather mask to maintain
sats in the low 90s. He was written for fluconazole, acyclovir,
SS bactrim, and 40 mg IV lasix. Prior to transfer to the ICU, he
was satting 93% on the NRB.  He reported worsening shortness of
breath, and frustration at the prospect of transfer to the ICU.
He felt that he had not been eating and receiving pain
medications on time, and that is why his oxygen level was low.
.
On arrival to the ICU, he reports stable labored breathing, and
is requesting to remove his non-rebreather mask. He denies chest
pain, palpitations, nausea, vomiting, or abdominal pain. He does
state that his abdomen is more distended than usual but he is
not constipated. He has no strength or sensation in his legs,
and cannot move them.
.
Review of systems:  As per HPI. Also endorses chronic back pain
that is at its baseline. Otherwise denies fever, chills, night
sweats, cough, chest pressure, dysuria, urinary frequency or
urgency.
.
Oncologic history (per BMT notes):  Patient reports being
diagnosed with multiple myeloma after he presented to an outside
hospital [**2109-3-11**] with bilateral lower extremity pain,
weakness and fatigue, renal
dysfunction and confusion.  Intial bone marrow biopsy
demonstrated MM with 100% invovlement, and IgA 2,655.  The
patient was started on XRT to bonysites of disease in the pelvis
and chemotherapy(velcade/revlimid/dex per outside notes).  Since
that time patient has tolerated therapy well and reports a
significant improvement in symptoms.  Patient has had a
significant decrease in paraprotein, normalization of plasma
cells in marrow and improvement in disease on imaging. During
this hospitalization, in addition to the above spinal imaging,
he also received a CT of his chest, which revealed multiple
pulmonary nodules, concerning for metastatic disease

MEDICAL HISTORY: - Multiple hospitalizations in Spring [**2110**]
 -hospitalized from [**Date range (1) 88502**] at [**Last Name (un) 1724**] with shingles requiring
high dose acyclovir and analgesia, as well as PNA with resultant
bandemia and hypotension requiring ICU admission, treated with 5
days vanco and azithromycin, and seven days pip/tazo
 -hospitalized at [**Last Name (un) 1724**] [**Date range (1) 88503**], with E coli, PCP and [**Date range (1) 1074**]
pneumonia; was initially treated with Bactrim, but experienced
thrombocytopenia and was switched to atovaquone
- DVTs status post IVC filter placement
- HTN
- HL
- Disc herniation with sciatica
- CAD, s/p stent x2
- Hypothyroidism
- Prior R rotator cuff repair
- R knee arthroscopic surgery
- Appendectomy age 17

MEDICATION ON ADMISSION: Medications (home):
ALLOPURINOL 300 mg PO daily
AMLODIPINE 5 mg PO daily
DEXAMETHASONE Dosage uncertain
FENTANYL - 100 mcg/hour Patch/72 hr
FUROSEMIDE 40 mg PO daily
LENALIDOMIDE [REVLIMID] last dose was [**2110-3-13**]
LEVOTHYROXINE 200 mcg PO daily
LORAZEPAM 1 mg PO Q8 hrs PRN
OMEPRAZOLE 40 mg Capsule, Delayed Release(E.C.) PO daily
OXYCODONE 5-10 mg PO Q4-6H PRN PAIN
PROCHLORPERAZINE MALEATE 10 mg PO Q6-8Hrs PRN nausea
SIMVASTATIN 20 mg PO QHS
ASPIRIN 81 mg PO daily
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D] - Dosage uncertain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Mother died of lung cancer. No other malignancies

SOCIAL HISTORY: +1-1.5 PPD since age 15. No current ETOH, no
illicits. Previosuly worked in automotive parts. 

### Response:
{'Multiple myeloma, without mention of having achieved remission,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Pneumonia, organism unspecified,Pressure ulcer, stage III,Myelopathy in other diseases classified elsewhere,Acute kidney failure, unspecified,Blood in stool,Cauda equina syndrome without mention of neurogenic bladder,Acute venous embolism and thrombosis of deep veins of upper extremity,Acute posthemorrhagic anemia,Hypogammaglobulinemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Hypoglycemia, unspecified,Coronary atherosclerosis of native coronary artery,Backache, unspecified,Neoplasm related pain (acute) (chronic),Abdominal aneurysm without mention of rupture,Abdominal or pelvic swelling, mass, or lump, other specified site,Tobacco use disorder,Hypoxemia,Dysphagia, unspecified'}
