CHIEF COMPLAINT: Recurrent HTLV1 associated adult T-cell leukemia/lymphoma

PRESENT ILLNESS: This is a 72 year old female with past medical history of
hypertension, coronary artery disease, and hyperlipidemia who
was newly diagnosed with the lymphomatous form of HTLV
associated T-Cell lymphoma/leukemia in [**2147-5-30**].  She
received fluids and bisphosphonate for hypercalcemia and CHOP*1
before being discharged on Zidovudine and Interferon alpha
therapy.  Interferon had to be discontinued due to cytopenias
and AZT was continued through [**Month (only) 547**] of this year.  She recieved
an additional six cycles of CHOP coupled with Denileukin
diftitox and was in complete remission at the cessation of cycle
five (her fourth as an outpatient).  Next, she received two
additional cycles of CHOP + Denileukin diftitox consolidation
before proceeding to maintenance therapy with Denileukin
diftitox two doses Q14 days.

MEDICAL HISTORY: -Angina w/ history of negative cardiac catheterization
-Hypertension
-Hyperlipidemia
-Right rotator cuff injury
-Hypertension
-History of choelithiasis
-History of presyncope
-Status post right knee arthroscopy

MEDICATION ON ADMISSION: -Trimethoprim/Sulfamethaxosole 1 DS tab PO 3*/wk
-Mirtazapine 7.5 mg PO daily
-Metoprolol 25 mg PO BID
-Docusate and Senna PRN

ALLERGIES: Codeine / Penicillins

PHYSICAL EXAM: VS: T 99.0, BP 104/60, HR 80, RR 16, O2 Sat 98% on 2L
Gen: Well appearing, NAD
HEENT: Normocephalic, anicteric, PERRL, OP benign, MMM
Neck: Supple, no thyroid nodules
Lymphadenopathy: There are numerous 1-2 cm posterior cervical
lymph nodes, one 1-2 cm right pre-auricular node, a one cm left
sided occipital node, multiple supraclavicular nodes
bilaterally, an approximately 2 cm right sided axillary node and
a 1.5 cm left sided node, these are all mobile and rubbery,
inguinal exam was deferred, no antecubital or popliteal
lymphadenopathy appreciated
CV: RRR, [**12-5**] PSM; mild jugular venous distension; no carotid
bruits; DP, PT, Radial, and carotid pulses 2+ bilaterally
Pulm: Expansion equal bilaterally, mild bilateral inspiratory
crackles.
Abd:Soft, NT, ND, BS+, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E, there is some scarring
around her left ankle related to a childhood injury per the
patient
Neuro: A and O*3, CNII-XII grossly intact, strength 5/5 in all
extremities
Psych: Pleasant, cooperative, thought process linear and
goal-directe

FAMILY HISTORY: Her mother died of CHF.  Her great aunt died of an unclear GYN
malignancy.

SOCIAL HISTORY: She was born in [**Doctor Last Name 15076**] and immigrated to the United States in
the early [**2108**]'s.  She worked as a housekeeper until the end of
[**2145**].  She lives with her husband and daughter with several
other adult children in the area.  Never smoker and very rare
alcohol user.
Encounter for antineoplastic chemotherapy,Acute kidney failure, unspecified,Acute lymphoid leukemia, without mention of having achieved remission,Acute systolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Other primary cardiomyopathies,Paralytic ileus,Human T-cell lymphotrophic virus, type I [HTLV-I],Mycosis fungoides, unspecified site, extranodal and solid organ sites,Mixed acid-base balance disorder,Other and unspecified infection due to central venous catheter,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Dermatitis due to drugs and medicines taken internally,Stomatitis and mucositis, unspecified,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia
Antineoplastic chemo enc,Acute kidney failure NOS,Ac lym leuk wo achv rmsn,Ac systolic hrt failure,Other pulmonary insuff,Bacteremia,Prim cardiomyopathy NEC,Paralytic ileus,Htlv-1 infection oth dis,Mycs fng unsp xtrndl org,Mixed acid-base bal dis,Oth/uns inf-cen ven cath,Staphylococcus unspcfied,Adv eff antineoplastic,Drug dermatitis NOS,Stomatitis/mucositis NOS,Anemia NOS,Thrombocytopenia NOS,Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS
Admission Date:  [**2148-4-18**]              Discharge Date:   [**2148-5-24**]

Date of Birth:  [**2075-8-22**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Penicillins

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Recurrent HTLV1 associated adult T-cell leukemia/lymphoma

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 72 year old female with past medical history of
hypertension, coronary artery disease, and hyperlipidemia who
was newly diagnosed with the lymphomatous form of HTLV
associated T-Cell lymphoma/leukemia in [**2147-5-30**].  She
received fluids and bisphosphonate for hypercalcemia and CHOP*1
before being discharged on Zidovudine and Interferon alpha
therapy.  Interferon had to be discontinued due to cytopenias
and AZT was continued through [**Month (only) 547**] of this year.  She recieved
an additional six cycles of CHOP coupled with Denileukin
diftitox and was in complete remission at the cessation of cycle
five (her fourth as an outpatient).  Next, she received two
additional cycles of CHOP + Denileukin diftitox consolidation
before proceeding to maintenance therapy with Denileukin
diftitox two doses Q14 days.

Unfortunately, in [**2147-1-28**] the patient began to experience a
hematologic relapse with a rise in her WBC to 9.4 and atypical
lymphs on a CBC from [**2148-2-9**].  Her LDH had peaked in the
1300-1600 range and then she went on to receive CHOP w/
Denileukin diftitox on [**2148-2-26**].  This led to a response with her
LDH dropping to 199 and cytopenias ensuing.  She was admitted to
NEBH from [**Date range (3) 79098**] with neutropenic fever and phayrngitis
for which she was treated with levofloxacin.  Since that
admission, she reported dealing with recurrent lymphadenopathy
with palpable cervical, preauricular, occipital, and axillary
nodes.  She had also developed fevers and night sweats over the
past four days prior to admission.  The highest fever she has
had was 101.4 after a Denileukin diftitox dose two days prior to
presentation. She had a repeat chest CT on [**2148-4-9**] that showed
increased lymphadenopahthy.

She was admitted again on [**4-18**] for [**Hospital1 **]. She had developed
adriamycin induced cardiomyopathy (EF 25-30%) and had to stop
[**Hospital1 **] 3 days into therapy.  Since then her volume status has
been difficult to manage on the floor, and she was alternatively
being given IVFs and diuresed with Lasix.  She had a brief stay
in the Medical ICU ([**Hospital Ward Name 332**]) from respiratory distress, which was
felt to be pulm edema and was treated with aggressive diuresis.
She was then tried on ARA-G (last course was on [**5-15**]) but was
running into problems with tumor lysis syndrome and the fluids
necessary to treat/prevent this.  She was also started on
vanc/levofloxacin for suspected line infection and pneumonia on
[**5-20**].
.


Past Medical History:
-Angina w/ history of negative cardiac catheterization
-Hypertension
-Hyperlipidemia
-Right rotator cuff injury
-Hypertension
-History of choelithiasis
-History of presyncope
-Status post right knee arthroscopy

Social History:
She was born in [**Doctor Last Name 15076**] and immigrated to the United States in
the early [**2108**]'s.  She worked as a housekeeper until the end of
[**2145**].  She lives with her husband and daughter with several
other adult children in the area.  Never smoker and very rare
alcohol user.

Family History:
Her mother died of CHF.  Her great aunt died of an unclear GYN
malignancy.

Physical Exam:
VS: T 99.0, BP 104/60, HR 80, RR 16, O2 Sat 98% on 2L
Gen: Well appearing, NAD
HEENT: Normocephalic, anicteric, PERRL, OP benign, MMM
Neck: Supple, no thyroid nodules
Lymphadenopathy: There are numerous 1-2 cm posterior cervical
lymph nodes, one 1-2 cm right pre-auricular node, a one cm left
sided occipital node, multiple supraclavicular nodes
bilaterally, an approximately 2 cm right sided axillary node and
a 1.5 cm left sided node, these are all mobile and rubbery,
inguinal exam was deferred, no antecubital or popliteal
lymphadenopathy appreciated
CV: RRR, [**12-5**] PSM; mild jugular venous distension; no carotid
bruits; DP, PT, Radial, and carotid pulses 2+ bilaterally
Pulm: Expansion equal bilaterally, mild bilateral inspiratory
crackles.
Abd:Soft, NT, ND, BS+, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E, there is some scarring
around her left ankle related to a childhood injury per the
patient
Neuro: A and O*3, CNII-XII grossly intact, strength 5/5 in all
extremities
Psych: Pleasant, cooperative, thought process linear and
goal-directe

Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-11.1*# RBC-2.81* Hgb-8.7* Hct-27.2* MCV-97 RDW-19.5* Plt
Ct-150#
-Neuts-44* Bands-0 Lymphs-29 Monos-14* Eos-6* Baso-1 Atyps-4*
Metas-1* Myelos-1*
-RBC Morph:Hypochr-OCCASIONAL Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Tear Dr[**Last Name (STitle) 833**])
PT-12.7 PTT-26.4 INR(PT)-1.1
Glucose-142* UreaN-18 Creat-1.0 Na-142 K-4.1 Cl-106 HCO3-25
AnGap-15
ALT-18 AST-40 LD(LDH)-671* AlkPhos-87 TotBili-0.2
Calcium-9.4 Phos-3.5 Mg-2.0 UricAcd-5.0

On Discharge ([**2148-5-23**]):
WBC 57
RBC 3.82
HGB 11.6
HCT 37.1
PLT 24

Na 139
K 5
Cl 92
HCO3 13
BUN 42
Creat 2.2
Glucose 109

ALT 40
AST 110
LDH 1827
Alk Phos 120
Amylase 19
TBili 0.7
Lipase 10

CK MB 3
Troponin T 0.36

Ca 8.6
Phos 6.9
Mg 2.1

ABG 7.36/110/21

Lactate 13.0
Other Labs:
[**2148-4-21**] 05:42AM BLOOD CK-MB-7 cTropnT-0.37* proBNP-[**Numeric Identifier 79099**]*
[**2148-4-21**] 02:58PM BLOOD CK-MB-7 cTropnT-0.20*
[**2148-4-22**] 05:45AM BLOOD CK-MB-3 cTropnT-0.26*
[**2148-4-23**] 12:30AM BLOOD CK-MB-4 cTropnT-0.10*

MICROBIOLOGY
==============
Blood Culture [**2148-4-22**]:
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL
SENSITIVITIES.
                             SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------     4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE----------     2 S
VANCOMYCIN------------     2 S

Blood Culture [**2148-4-23**]:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL SENSITIVITIES.
 SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------     8 I
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
VANCOMYCIN------------     2 S

All other blood and urine cultures no growth to date
Rapid respiratory viral screen on [**2148-4-25**] with no viral antigens
detected.

OTHER RESULTS
===============
Chest Radiograph [**2148-4-18**]:
IMPRESSION: No acute intrathoracic process. No evidence of
pneumonia.

CT Chest W/Contrast [**2148-4-9**]:
IMPRESSION:
1. Increase in size of the bilateral axillary lymph nodes.
2. Moderate increase in size of the pre-existing mediastinal
lymph nodes.
3. Unremarkable lung parenchyma.
4. No evidence of abdominal lymph nodes.
5. No evidence of osteolytic lesions.

CT Abdomen and Pelvis W/Contrast [**2148-4-18**]:
IMPRESSION:
1. Interval increase left lateral breast lymphadenopathy,
abutting the
pectoralis. Differential includes lymphoma versus breast origin.

2. Interval increase of retroperitoneal lymphadneopathy.
3. Unchanged thickened distal antrum and pylorus. Recommend
correlations in the clinical context of lymphoma.

Transthoracic Echocardiogram [**2148-4-18**]:
IMPRESSION: Mild regional left ventricular systolic dysfunction
(EF 45%), c/w CAD. Mild right ventricular systolic dysfunction.
Mild aortic regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2147-6-3**],
regional left ventricular systolic dysfunction is more evident
because of a technically-better study. The findings are similar.


ECG [**2148-4-21**]:
Baseline artifact. Sinus tachycardia, probably with atrial
premature beats. Right bundle-branch block. ST-T wave
abnormalities. Since the previous tracing of [**2147-11-20**] the rate
is faster. ST-T wave abnormalities are new.  Clinical
correlation is suggested.

ECG [**2148-4-22**]:
Probable sinus tachycardia. Right bundle-branch block. Since the
previous
tracing the rhythm is more regular. QRS width is somewhat less.

Chest Radiograph [**2148-4-22**]:
IMPRESSION: Findings still suggest pulmonary edema, less likely
widespread
hemorrhage.

Transthoracic Echocardiogram [**2148-4-23**]:
IMPRESSION: Moderate regional and global left ventricular
systolic dysfunction (EF 30%). Dilated right ventricle with mild
global systolic dysfunction. Mild to moderate mitral
regurgitation. Moderate to severe tricuspid regurgitation. Mild
pulmonary hypertension. Dilated coronary sinus.  Compared with
the prior study (images reviewed) of [**2148-4-23**], LV systolic
function has deteriorated. There is persistence of
previously-noted regional LV wall motion abnormalities, with
additional global LV hypokinesis. Right ventricular systolic
function has declined. Severity of valvular regurgitation is
greater.

Abdominal Radiograph [**2148-4-23**]:
IMPRESSION: Unremarkable bowel gas pattern

Abdominal Radiograph [**5-23**]
IMPRESSION:
1. Gas distended stomach.
2. No free air. No bowel obstruction.

CXR [**5-23**]
REASON FOR EXAMINATION: Acute tachypnea, recent intubation.

The ET tube tip at the origin of the right main bronchus and
should be pulled back at least 3 cm. By the time of dictation of
this study findings were communicated to Dr. [**Last Name (STitle) **], that informed
me that the ET tube had been already re-positioned. The NG tube
tip is in the stomach. There is no change in the cardiomegaly,
left basal atelectasis and bilateral pleural effusions. The
patient is in mild volume overload that is not significantly
different from the prior study. The right subclavian line is in
unchanged position.


Brief Hospital Course:
72 year old female with coronary artery disease and hypertension
presenting with recurrent HTLV-1 associated Adult T-Cell
Leukemia/Lymphoma (ATLL) after 8 cycles of CHOP w/denileukin
diftitox.
.
1) Adult T-Cell Leukemia/Lymphoma (lymphomatous form): The
patient was admitted for further treatment of her ATLL.  Her
major symptoms from this lymphoma were her significant
lymphadenopathy as well as her fevers and night sweats.  After
obtaining an echocardiogram to assess her baseline cardiac
function and ejection fraction chemotherapy with the [**Hospital1 **]
regimen was started late in the evening of [**2148-4-19**].  Given her
previous exposure to eight cycles of CHOP there was
consideration of the amount of adriamycin she had previously
received as she was calculated to be near her upper limits of
acceptable dose.  Nevertheless, as she was proceeding with
[**Hospital1 **], which has a much lower risk of cardiac toxicity secondary
to the anthracycline being given as a slow infusion, the
possible benefits of [**Hospital1 **] were considered to outweigh the
risks.

[**Hospital1 **] was given per protocol with our standard premedication
regimen of ondansetron and 100 mg of prednisone daily for nausea
and the patient initially tolerated it well with minimal nausea
and no other issues.  Uric acid remained normal on allopurinol.
Unfortunately, [**Hospital1 **] was stopped on [**2148-4-21**] during an episode of
acute respiratory distress and was not restarted given concern
for incremental cardiotoxcity from the anthracycline.  Despite
her limited course of chemotherapy the patient responded well
with significant decrease in her palpable lymphadenopathy and a
drop in her LDH.  She was briefly placed on filgrastim for
concern of preventing her nadir given concern of an active
bacteremia (see below) but this was stopped on [**2148-4-29**] without
significant leukopenia and she was never neutropenic.  She did
develop anemia and thrombocytopenia requring pRBC transfusions,
but never had signs of bleeding.  She also had mild mucositis
treated with local cares with good improvement in her symptoms
and she took good PO throughout her hospitalization.

After the patient was presumed stable with regards to her
systolic CHF decompensation and febrile illness, she was treated
with ARA-G therapy day one [**2148-5-8**].  She was monitored for signs
of neurotoxicity.  On the night of [**2148-5-18**], the patient became
more somnolent, unarousable.  Neurology was consulted regarding
her recent treatment with ARA-G.  She had a non-contrast head CT
which did not show evidence of acute process.  She also had an
LP which did not show evidence of infection or malignant
process.  While the patient was being treated with ARA-G, tumor
lysis labs were checked Q6H and she was treated with allopurinol
and fluids.  Her uric acid peaked at 8.8 and did not require
rasburicase, however it was considered.
.
On the evening of admission to the [**Name (NI) 153**], pt had been complaining
of abdominal pain.  She was also becoming increasingly
tachypneic, breathing at a rate in the 40s but satting 95% on
3L.  An abdominal x-ray prelim read showed no evidence of free
air, no air-fluid levels, only a large air-filled stomach.  It
was felt that she might have been splinting.  A NGT was placed,
and subsequent Xray showed complete decompression of the
stomach.  During this time an ABG was obtained:  7.36/21/110.
Lactate was noted to be 13.0.  Initially, pt was able to answer
questions.  In between breaths, she only complained of
difficulty breathing.  She denied any abdominal pain, even with
palpation.  She denied any chest pain.  Her mental status began
to wane.  She was immediately brought down to the Medical ICU
([**Hospital Ward Name 332**]), where she was intubated on arrival.  The family was
consulted and confirmed her CMO status, and she expired
peacefully prior to decisions pending extubation.  Time of death
4:56PM.  [**Name (NI) 1094**] husband consented to autopsy.  Pt's oncologist was
contact[**Name (NI) **].
.
2) Acute systolic heart failure:  The patient had a previous
history of reported coronary artery disease but a previous clean
catheterization per report.  At admission an echocardiogram was
obtained that showed an EF of 45% and a local wall motion defect
consistent with ischemic cardiomyopathy.  Nevertheless, as her
EF was normal it was considered reasonable to proceed with
chemotherapy.  She had no shortness of breath or chest pain
throughout this course.  On [**2148-4-21**] she received one unit of
pRBC's as well as continuing fluids with her chemotherapy (she
was also on prednisone).  She had received 20 mg of IV
furosemide with this blood given known low-ish ejection
frection.  Later that evening, however she developed acute
shortness of breath.  Chest rardiograph revealed acute pulmonary
edema and so she received 40 mg IV furosemide and had 0.5 inch
nitro paste placed.  ABG revealed 7.22/62/74 so she was
transferred to the ICU for non-invasive ventilation (BiPAP).

She improved dramatically with BiPAP and began to put out brisk
urine and never required intubation.   Her cardiac enzymes
returned with mildly positive troponin (0.37) and negative ck-mb
(tropnonin steadily declined afterward and CK-MB never came out
of normal range.  Cardiology consult thought this was most
likely due to demand ischemia and heart failure (BNP was 18,063)
rather than acute ischemia.  She had some mild feeling of chest
pressure at the worst of her respiratory symptoms but was
otherwise without chest pain and she improved quickly with
diuresis and she was transferred back to the floor on the
evening of [**2148-4-22**].  Repeat echocardiogram showed diffuse
hypokinesis and a decreased EF to 30%.  The diffuse hypokinesis
continued to suggest a general cardiomyopathy overlying ischemic
cardiomyopathy (with adriamycin considered the most likely
cause).  Aspirin was held given concern for recent chemotherapy
and thrombocytopenia, but she was started on a good heart
failure regimen with long acting beta blocker and low dose of
short acting ACEi (as her BP's were relatively low).  She was
eventually transitioned to long acting ACEi in order to address
dosing concerns with her marginal BP's, but was not continued as
the patient's blood pressure was marginal.  The patient remained
mildly hypotensive, thus metoprolol was decreased to 12.5mg [**Hospital1 **].

During the course of ARA-G, the patient required extensive
diuresis given the large amount of fluids to prevent tumor lysis
syndrome.  She ultimately responded well to 80mg IV lasix [**Hospital1 **].
During her course on the oncology med service she episodes of
dyspnea with O2 desats at night and tachypnea with crackles in
her lungs, which responded to lasix at increasing doses up to
300 mg per night. On [**5-23**], despite a negative fluid balance
during the day, she had an acute episode of dyspnea
characterized by labored breathing, clear lungs, and
desaturations that did not improve with nebs/O2 mask. An ABG
revealed a metabolic acidosis (lactate 13) with compensating
respiratory alkalosis(CO2 21). At this point, due to her labored
breathing and deteriorating condition, she was transferred to
the [**Hospital Unit Name 153**] and intubated as an immediate discussion with family
decided that it would be appropriate for the patient to be
intubated.
.
3) Fevers: The patient was febrile during the majority of her
hospitalization.  She defervesced with therapy but spiked a
fever to 102.7 in the ICU and was empirically started on
vancomycin and meropenem.  Cultures grew coagulase negative
staph while she was in the unit.  Meropenem was stopped the
following day but vancomycin was continued given the patient's
blood culture came back positive and she had an indwelling port
for chemotherapy.  In an attempt to preserve the port, the
decision was made to try and treat through the infection so
surveillance cultures were taken for the following days.
Culture from [**2148-4-23**] did also grow coagulase negative staph but
all other cultures returned negative for growth.  As her blood
cleared the decision was made to attempt to salvage the
patient's port so she continued to receive vancomycin with
vancomycin locks of her ports.  She deferversced and ultimately
completed 16 days of therapy.  A CXR was done which showed
evidence of infiltrate, a follow up Chest CT showed ground glass
opacities on the left side.  Pulmonary was consulted for
possible bronchoscopy, however the decision was made to treat
for possible pulmonary infection empirically with levofloxacin
for 7 days.  After her treatment with ARA-G, the patient's fever
curve decreased, then increased at day 12 of the treatment.  She
was mildly hypotensive, tachycardic, decreased urine output, and
had no other localizing symptoms other than generalized
weakness.  Vancomycin and Levofloxacin were restarted on [**2148-5-20**]
to treat the presumed line infection and possible pulmonary
source.
.
4) Abdominal Pain: On [**2148-4-23**] after transfer back to the floor
the patient developed an episode of acute abdominal pain.  This
was diffuse abdominal pain without rebound or guarding and with
active bowel sounds.  Abdominal exam revealed distension and
tenderness but good bowel sounds.  As the patient reported not
having had a bowel movement in two days and feeling constipated
this was most likely thought to be due to ileus probably
secondary to the vincristine she received as well as her diet
change in the hospital and pain medicine she received in the
ICU.  This resolved by the following day after being put on more
aggressive medications for dyspepsia and after having a large
bowel movement on a better stool softening regimen.
.
5) Rash:  The patient developed a rash following using topical
lotion.  Dermatology was consulted and did a skin biopsy which
showed likely hypersensitivity reaction.  Lymphoma involvement
of the skin was considered, but the pathology showed
intraepidermal lymphocytes, mounded parakeratosis, dermal
erythrocyte extravasation, and superficial perivascular
lymphocytic inflammation with scattered interstitial eosinophils
consistent with hypersensitivity reaction.  She was treated with
oral antihistamines and topical steroids.  Sutures were removed
on [**2148-5-20**].
.
Prophylaxis: She was on TMP-Sulfa for PCP prophylaxis at home
and was started on acyclovir for viral prophylaxis when she was
admitted given her presumed T cell dysfunction and vulnerability
to viral infections, these were discontinued prior to discharge
as she was not neutropenic. On recommendation of ID a
strongyloides serological assay was checked and was negative.
No anticoagulation for DVT prophylaxis but the patient ambulated
regularly.

Medications on Admission:
-Trimethoprim/Sulfamethaxosole 1 DS tab PO 3*/wk
-Mirtazapine 7.5 mg PO daily
-Metoprolol 25 mg PO BID
-Docusate and Senna PRN

Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Cardiopulmonary arrest
HTLV1 associated adult t-cell leukemia/lymphoma
Adriamycin related cardiomyopathy
Acute systolic congestive heart failure
Coagulase negative staphylococcus bactermia


Discharge Condition:
deceased

Discharge Instructions:
N/A

Followup Instructions:
N/A

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Encounter for antineoplastic chemotherapy,Acute kidney failure, unspecified,Acute lymphoid leukemia, without mention of having achieved remission,Acute systolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Other primary cardiomyopathies,Paralytic ileus,Human T-cell lymphotrophic virus, type I [HTLV-I],Mycosis fungoides, unspecified site, extranodal and solid organ sites,Mixed acid-base balance disorder,Other and unspecified infection due to central venous catheter,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Dermatitis due to drugs and medicines taken internally,Stomatitis and mucositis, unspecified,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}


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: Recurrent HTLV1 associated adult T-cell leukemia/lymphoma

PRESENT ILLNESS: This is a 72 year old female with past medical history of
hypertension, coronary artery disease, and hyperlipidemia who
was newly diagnosed with the lymphomatous form of HTLV
associated T-Cell lymphoma/leukemia in [**2147-5-30**].  She
received fluids and bisphosphonate for hypercalcemia and CHOP*1
before being discharged on Zidovudine and Interferon alpha
therapy.  Interferon had to be discontinued due to cytopenias
and AZT was continued through [**Month (only) 547**] of this year.  She recieved
an additional six cycles of CHOP coupled with Denileukin
diftitox and was in complete remission at the cessation of cycle
five (her fourth as an outpatient).  Next, she received two
additional cycles of CHOP + Denileukin diftitox consolidation
before proceeding to maintenance therapy with Denileukin
diftitox two doses Q14 days.

MEDICAL HISTORY: -Angina w/ history of negative cardiac catheterization
-Hypertension
-Hyperlipidemia
-Right rotator cuff injury
-Hypertension
-History of choelithiasis
-History of presyncope
-Status post right knee arthroscopy

MEDICATION ON ADMISSION: -Trimethoprim/Sulfamethaxosole 1 DS tab PO 3*/wk
-Mirtazapine 7.5 mg PO daily
-Metoprolol 25 mg PO BID
-Docusate and Senna PRN

ALLERGIES: Codeine / Penicillins

PHYSICAL EXAM: VS: T 99.0, BP 104/60, HR 80, RR 16, O2 Sat 98% on 2L
Gen: Well appearing, NAD
HEENT: Normocephalic, anicteric, PERRL, OP benign, MMM
Neck: Supple, no thyroid nodules
Lymphadenopathy: There are numerous 1-2 cm posterior cervical
lymph nodes, one 1-2 cm right pre-auricular node, a one cm left
sided occipital node, multiple supraclavicular nodes
bilaterally, an approximately 2 cm right sided axillary node and
a 1.5 cm left sided node, these are all mobile and rubbery,
inguinal exam was deferred, no antecubital or popliteal
lymphadenopathy appreciated
CV: RRR, [**12-5**] PSM; mild jugular venous distension; no carotid
bruits; DP, PT, Radial, and carotid pulses 2+ bilaterally
Pulm: Expansion equal bilaterally, mild bilateral inspiratory
crackles.
Abd:Soft, NT, ND, BS+, no organomegaly or masses appreciated
Extrem: Warm and well perfused, no C/C/E, there is some scarring
around her left ankle related to a childhood injury per the
patient
Neuro: A and O*3, CNII-XII grossly intact, strength 5/5 in all
extremities
Psych: Pleasant, cooperative, thought process linear and
goal-directe

FAMILY HISTORY: Her mother died of CHF.  Her great aunt died of an unclear GYN
malignancy.

SOCIAL HISTORY: She was born in [**Doctor Last Name 15076**] and immigrated to the United States in
the early [**2108**]'s.  She worked as a housekeeper until the end of
[**2145**].  She lives with her husband and daughter with several
other adult children in the area.  Never smoker and very rare
alcohol user. 

### Response:
{'Encounter for antineoplastic chemotherapy,Acute kidney failure, unspecified,Acute lymphoid leukemia, without mention of having achieved remission,Acute systolic heart failure,Other pulmonary insufficiency, not elsewhere classified,Bacteremia,Other primary cardiomyopathies,Paralytic ileus,Human T-cell lymphotrophic virus, type I [HTLV-I],Mycosis fungoides, unspecified site, extranodal and solid organ sites,Mixed acid-base balance disorder,Other and unspecified infection due to central venous catheter,Staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Dermatitis due to drugs and medicines taken internally,Stomatitis and mucositis, unspecified,Anemia, unspecified,Thrombocytopenia, unspecified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia'}
