CHIEF COMPLAINT: Shortness of breath, headache

PRESENT ILLNESS: 25 male with AML s/p BMT in [**2187**], GVHD, recent PTX medically
managed, presented to [**Hospital 8**] Hosp from [**Hospital1 **] [**2189-6-30**] with
SOB, N/V, and an enlarged hydropneumothorax. He was seen at [**Hospital1 112**]
and discharged about one week ago for a left hydropneumothorax
that was medically managed. He noted the onset of shortness of
breath yesterday at rest, was hypoxic, and found to have a
larger pneumothorax. He was taken to [**Hospital1 **] hosptial where he
was given pain control and had a chest tube placed in his left
5th intercostal space. He was symptomatically improved, and was
transferred here for further care. He has not had recent f/c,
though has been vomiting daily. He has not had diarrhea.
.
He also has had shingles on his left leg, and has been on
valtrex for this. His immunosuppression was recently decreased
due to voriconazole.
.
ED course: He was given IV dilaudid in the ED, seen by thoracic
surgery, and admitted to medicine for workup.
.
On the floor, he was noted to have a serum bicarb of 45 and was
somnolent. An ABG was done which was 7.23/112/144. CXR from 1 am
showed increased left pneumothorax. He was brought to the CCU
for further management of his chest tube.
.
Review of Systems: Nausea and vomiting, rash on left leg, poor
appetite, decreased energy.

MEDICAL HISTORY: AML s/p transplant [**2187**]
? GVHD
Gtube
Depression

MEDICATION ON ADMISSION: Atovaquone, calcium, cipro eye gtt, citalopram, colace, fentanyl
patch, folate, lasix, neurontin, levoflox, ativan, reglan,
lopressor, mirtazapine, mvi, MMF, prednisone, senna, Tacro,
Zosyn, Urodiol, Valtrex, Vori, Albuterol/Ipratrop, lactulose,
dilaudid

ALLERGIES: Compazine / Bactrim / Pentamidine Isethionate / Vancomycin Hcl

PHYSICAL EXAM: Gen- Cachectic, pale, ill appearing male, uncomfortable
Heent- MMdry, blood in mouth and nares, anicteric
Neck- supple, no LAD
Cor- tachy, regular, s1,s2
Chest- breath sounds bilateral, rhonchorous anteriorly; chest
tube draining serosanguinous fluid, no bleeding at site
Abd- soft, tender at g tube site, no g/r. Pos BS.
Ext- no c/c/e
Neuro- AAO 3, drowsy
Skin- Open excoriated lesion on left thigh

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital **] Rehab, no tobacco or EtOH. Single.
Chronic respiratory failure,Acute myeloid leukemia, in remission,Bone marrow replaced by transplant,Other specified alveolar and parietoalveolar pneumonopathies,Gastrostomy status,Depressive disorder, not elsewhere classified
Chronic respiratory fail,Act myl leuk w rmsion,Trnspl status-bne marrow,Alveol pneumonopathy NEC,Gastrostomy status,Depressive disorder NEC
Admission Date:  [**2189-6-30**]              Discharge Date:   [**2189-7-4**]

Date of Birth:  [**2163-7-25**]             Sex:   M

Service: MEDICINE

Allergies:
Compazine / Bactrim / Pentamidine Isethionate / Vancomycin Hcl

Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Shortness of breath, headache

Major Surgical or Invasive Procedure:
none (chest tube placed at OSH)
Intubation,  A line placement


History of Present Illness:
25 male with AML s/p BMT in [**2187**], GVHD, recent PTX medically
managed, presented to [**Hospital 8**] Hosp from [**Hospital1 **] [**2189-6-30**] with
SOB, N/V, and an enlarged hydropneumothorax. He was seen at [**Hospital1 112**]
and discharged about one week ago for a left hydropneumothorax
that was medically managed. He noted the onset of shortness of
breath yesterday at rest, was hypoxic, and found to have a
larger pneumothorax. He was taken to [**Hospital1 **] hosptial where he
was given pain control and had a chest tube placed in his left
5th intercostal space. He was symptomatically improved, and was
transferred here for further care. He has not had recent f/c,
though has been vomiting daily. He has not had diarrhea.
.
He also has had shingles on his left leg, and has been on
valtrex for this. His immunosuppression was recently decreased
due to voriconazole.
.
ED course: He was given IV dilaudid in the ED, seen by thoracic
surgery, and admitted to medicine for workup.
.
On the floor, he was noted to have a serum bicarb of 45 and was
somnolent. An ABG was done which was 7.23/112/144. CXR from 1 am
showed increased left pneumothorax. He was brought to the CCU
for further management of his chest tube.
.
Review of Systems: Nausea and vomiting, rash on left leg, poor
appetite, decreased energy.


Past Medical History:
AML s/p transplant [**2187**]
? GVHD
Gtube
Depression

Social History:
Lives at [**Hospital **] Rehab, no tobacco or EtOH. Single.


Family History:
NC

Physical Exam:
Gen- Cachectic, pale, ill appearing male, uncomfortable
Heent- MMdry, blood in mouth and nares, anicteric
Neck- supple, no LAD
Cor- tachy, regular, s1,s2
Chest- breath sounds bilateral, rhonchorous anteriorly; chest
tube draining serosanguinous fluid, no bleeding at site
Abd- soft, tender at g tube site, no g/r. Pos BS.
Ext- no c/c/e
Neuro- AAO 3, drowsy
Skin- Open excoriated lesion on left thigh


Pertinent Results:
Admission labs:
[**2189-6-30**] 05:53PM   GLUCOSE-99 UREA N-19 CREAT-0.6 SODIUM-134
POTASSIUM-4.7 CHLORIDE-88* TOTAL CO2-42* ANION GAP-9
[**2189-6-30**] 05:53PM   WBC-15.4* RBC-2.89* HGB-9.9* HCT-31.0*
MCV-108* MCH-34.2* MCHC-31.8 RDW-16.9*
[**2189-6-30**] 05:53PM   NEUTS-83.2* LYMPHS-9.7* MONOS-6.6 EOS-0.3
BASOS-0.2
[**2189-6-30**] 05:53PM   PLT COUNT-289
.

Imaging
CT Head [**2188-6-30**] - FINDINGS: No hemorrhage, mass lesion, shift of
normally midline structures or evidence of major territorial
infarction is apparent. There is no hydrocephalus. The orbits
are grossly normal in appearance. There is opacification of
multiple ethmoid air cells and mild mucosal thickening in
bilateral maxillary sinuses consistent with inflammatory
changes. No abnormalities are noted within the bony structures.
IMPRESSION:
1. No acute intracranial abnormality detected.
2. Opacification of multiple ethmoid air cells and mild mucosal
thickening in bilateral maxillary sinuses consistent with
inflammatory changes.

[**2189-6-30**] - UPRIGHT PORTABLE CHEST RADIOGRAPH.
FINDINGS:
There is a mild-to-moderate left hydropneumothorax with a
left-sided chest tube running along the lateral chest wall in an
apical direction. The sideport was unable to be visualized due
to overlying ribs. Obscuration of the left hemidiaphragm is
noted likely reflective of atelectasis from overlying fluid.
Mild right basilar atelectasis is present. There is no evidence
of focal parenchymal infiltrate or pulmonary edema.
Cardiomediastinal silhouette and hilar contours are within
normal limits.
IMPRESSION: Mild-to-moderate left hydropneumothorax with lateral
apical chest tube in place. Sideport unable to be visualized.

CHEST CT WITHOUT IV CONTRAST [**2189-7-2**]:
TECHNIQUE: MDCT was used to obtain contiguous axial images
through the chest without administration of IV contrast.
Standard and lung algorithm images as well as coronal reformats
were obtained. This study was compared with chest radiograph of
[**7-2**], [**7-1**], and [**2189-6-30**].

The image quality of this study is compromised by respiratory
motion. A moderate left hydropneumothorax is similar in size to
the [**2189-7-2**] chest radiograph. Associated atelectasis is
most pronounced at the left lower lobe; coronal reformats show a
3.7 cm ovoid extrapulmonary fluid collection contiguous with
loculated pleural fluid laterally, probably a fibrin clot.

Vague ground-glass and centrilobular opacities, most pronounced
in the right middle lobe, medial left upper lobe, and in
dependent portions of both lower lobes, along with bronchial
wall thickening, most pronounced in the right upper lobe and
left lower lobe, all reflect endobronchial infection. A small
volume of consolidation in the left lower lobe adjacent to the
extraparenchymal loculated fluid is the only candidate for
active pneumonia, and that could be atelectasis.

The left chest tube enters between the sixth and seventh ribs
anterolaterally, courses to the lung apex; it is not contiguous
with the loculated fluid at the left lung base.

A small, layering, nonhemorrhagic, right pleural effusion is
also present. There is no pericardial effusion.
Right PICC terminates in the cavoatrial junction. No mediastinal
lymph nodes are larger than an 8 mm precarinal node (4:90).
This study was not designed to examine the abdomen, however, no
mass lesions are seen in the imaged portion of the liver,
spleen, adrenals, kidneys, or pancreas. A gastrostomy tube is
only partially imaged.
There are no bone findings suspicious for malignancy or
infection
IMPRESSION:
1. Moderate left hydropneumothorax, including basal fluid
loculations not traversed by pleural drain.
2. Minimal left lower lobe consolidation. Mild, multifocal
bronchitis and bronchiolitis.
3. Small right pleural effusion.
Pleural fluid cytology: neg for malignant cells

EMG [**2189-7-3**]:
FINDINGS: Motor nerve conduction study (NCSs) of the left median
nerve were normal, including F waves.
Motor NCSs of the left ulnar nerve showed normal distal latency,
moderate
reduction of response amplitudes, and normal conduction
velocity; F response minimum latency was normal.
Motor responses of the left peroneal nerve, recording extensor
digitorum
brevis and tibialis anterior, were absent.
Motor NCSs of the left tibial nerve showed normal distal
latency, moderate
reduction of response amplitude, and mild slowing of conduction
velocity.
Slow (3-Hz) repetitive nerve stimulation of the left ulnar
nerve, recording abductor digiti minimi, showed no decremental
response at baseline, immediately after 1 minute of maximal
voluntary contraction, or at 1-minute intervals following
maximal voluntary effort out to 5 minutes.

Slow (3-Hz) repetitive nerve stimulation of the left spinal
accessory nerve, recording trapzeius, showed no decremental
response at baseline, immediately after 1 minute of maximal
voluntary contraction, or at 1-minute intervals following
maximal voluntary out to 4 minutes, though the study was
technically limited by movement.

Concentric needle electromyography (EMG) of the left vastus
lateralis showed motor unit potentials (MUPs) of mildly short
duration, small amplitude and increased polyphasia with early
recruitment. EMG examination of the tibialis anterior and medial
gastrocnemius was normal.

EMG of right vastus lateralis showed MUPs of mildly short
duration, small
amplitude and increased polyphasia with early recruitment.

EMG examination of the left deltoid, biceps, and first dorsal
interosseous was normal.

EMG examination of the right deltoid showed a mixed population
of normal MUPs and MUPs of mildly short duration, small
amplitude and increased polyphasia with early recruitment.

The study was prematurely terminated due to the patient's
increasing
respiratory distress. Further needle EMG of proximal muscles and
single-fiber EMG was not performed.

IMPRESSION:
Abnormal, limited study. There is electrophysiologic evidence
for a mild,
generalized myopathic process without denervating features, as
can be seen in critical illness myopathy. The findings also
suggest the possibility of a mild sensorimotor polyneuropathy
with predominantly axonal features. There is no definite
electrophysiologic evidence for a disorder of neuromuscular
transmission, but the limited nature of the study precludes
exclusion of this diagnostic possibility.

**Microbiology:
AEROBIC BOTTLE (Preliminary): [**2189-6-30**].

      ENTEROCOCCUS SP..    PRELIMINARY SENSITIVITY.
         FURTHER IDENTIFICATION TO FOLLOW.

   SENSITIVITIES: MIC expressed in MCG/ML
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------       R
LEVOFLOXACIN----------       R
VANCOMYCIN------------       S

   ANAEROBIC BOTTLE (Preliminary):
      ENTEROCOCCUS SP..
         IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.

PLEURAL FLUID [**2189-7-1**] 10:26 am

   GRAM STAIN (Final [**2189-7-2**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2189-7-4**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

Transfer labs:

[**2189-7-4**] 02:45AM BLOOD WBC-12.6* RBC-3.00* Hgb-10.0* Hct-30.7*
MCV-102* MCH-33.3* MCHC-32.6 RDW-17.4* Plt Ct-250
[**2189-7-4**] 02:45AM BLOOD Neuts-70 Bands-0 Lymphs-10* Monos-17*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-2* NRBC-1*
[**2189-7-4**] 02:45AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Stipple-1+
[**2189-7-4**] 02:45AM BLOOD Plt Smr-NORMAL Plt Ct-250
[**2189-7-4**] 02:45AM BLOOD Glucose-126* UreaN-26* Creat-0.8 Na-135
K-4.5 Cl-88* HCO3-43* AnGap-9
[**2189-7-4**] 02:45AM BLOOD ALT-14 AST-36 LD(LDH)-176 AlkPhos-223*
Amylase-28 TotBili-0.4
[**2189-7-4**] 02:45AM BLOOD Albumin-3.1* Calcium-10.4* Phos-4.2
Mg-2.3
[**2189-7-4**] 05:28PM BLOOD Type-ART Temp-36.3 Rates-30/ Tidal V-300
PEEP-5 FiO2-40 pO2-83* pCO2-79* pH-7.33* calTCO2-44* Base XS-11
-ASSIST/CON Intubat-INTUBATED
[**2189-7-4**] 09:12AM BLOOD Type-ART Temp-35.2 Rates-30/ Tidal V-300
PEEP-5 FiO2-40 pO2-88 pCO2-84* pH-7.27* calTCO2-40* Base XS-8
-ASSIST/CON Intubat-INTUBATED
[**2189-7-4**] 06:41AM BLOOD Type-ART Temp-35.7 PEEP-5 pO2-137*
pCO2-110* pH-7.25* calTCO2-51* Base XS-15 Intubat-INTUBATED
[**2189-7-4**] 05:30AM BLOOD Type-ART Temp-35.7 Tidal V-300 PEEP-5
pO2-71* pCO2-122* pH-7.17* calTCO2-47* Base XS-10
Intubat-INTUBATED

Albumin 3.1
TSH 0.48

Brief Hospital Course:
Impression/Plan: 25 male with h/o AML s/p BMT in [**2187**], GVHD, now
with new pneumothorax and hypercarbic respiratory failure.

# Hypercarbic respiratory failure:  Though pt has no established
history of lung disease, suspect that his hypercarbia has been a
chronic issue.  His pco2 of 112 caused pH of only 7.29, and
serum bicarb of 45, suggesting chronic process.  Possible causes
of hypercarbia considered include sedation from meds--pt had
been getting fentanyl, dilaudid and ativan; question of
myopathy/neuromuscular disease (? steroid myopathy or
chemo-induced myopathy); and/or obstructive lung disease.  His
pain meds were decreased without much effect on his respiratory
status.  He was evaluated by neurology regarding question of
neuro-muscular disease.  An EMG was performed which which showed
mild, generalized myopathic process without denervating
features; however, the study was limited.  [**Name (NI) 1094**] PTX was treated
w/ chest tube
On [**2189-7-3**], pt noted to be increasingly tachypnic and fatigued.
Gas showed worsening hypercarbia (see results section).  CT
chest was performed, which showed persistent hydro-pneumothorax
as well as non-specific ground-glass opacities & tree & [**Male First Name (un) 239**]
structures.
He was tried on bipap w/o improvement in respiratory status.
Thus, in early AM of [**2189-7-4**], he was intubated.  [Of note, pt
consented to intubation prior to procedure.]  He was started on
AC 300 x 26, with some improvement in his CO2@ to the 80's.  He
was maintained on light sedation.  An A-line was placed. His
pulonary physiology was consistent with severe obstructive
process (high peak pressures, low plateaus, and auto-PEEP of
~13).  Pt does not have h/o reactive airway disease or COPD.
Question of GVHD related lung disease raised.  Infectious
process also possible cause (? PCP/viral (partic adeno,
CMV)/fungal).
Pt was started on linezolid and zosyn for coverage of possible
PNA, though no clear infiltrate on CT.

# Pneumothorax:  No history of this before.  Pt had chest tube
placed at [**Hospital 8**] Hospital and transferred to [**Hospital1 18**] (as [**Hospital1 112**] on
divert).  He was admitted to the MICU team.  CT surgery
consulted.  They adjusted chest tube with initial improvement in
respiratory status & improvement of CXR.   Chest Tube placed to
suction.  Small air leak noted.  Pleural fluid studies sent.
Gram stain negative as were cultures.  Fluid bloody.  Tube
draining >150cc daily until [**2189-7-4**], day of transfer, when it was
putting out more ~20 cc of bloody fluid.  He needs to have chest
tube evaluated by thoracics to see if it needs to be readjusted
or pulled.
.
# AML: He is s/p BMT, apparently in remission. Spoke to his
oncologist, Dr [**Last Name (STitle) 11907**] at [**Company 2860**].  Immunosuppresive medications
were continued as were his prophylactive anti-biotics,
atovaquone & voriconazole.  Question of GVHD.  LFTs were checked
for ? of GVHD as well (see results).  Hematology consulted for
question of GVHD in lung.  They felt like this was certainly
possible and recommended Bronchoscopy/VATS to get tissue
diagnosis.

# Pain: Low dose dilaudid and fentanyl patch.

# Leukocytosis: Appears be a chronic issue per [**Hospital **] rehab
notes. He just finished a course of levo/flagyl for unclear
reasons, and no cultures were positive there.  Here his bld cx
was positive for enterococcus, sensitive to vancomycin. However,
since he was allergic to this he was started on linezolid. While
on this medication, his counts will need to be monitored. Zosyn
was also started for concern of PNA as an infectious source.

# R. corneal tear: diagnosed prior to admission.  Pt continued
on cipro eye gtt.

# Depression: continue celexa and remeron

# Nausea: His tube feed have recently been on hold due to high
residuals. These were slowly restarted day prior to transfer and
he is still below goal. Cont to increase TF's and check
residuals; can use reglan as needed to help w/ motility.
.
# Tachycardia: Has been on metoprolol. Unclear if related to
PTX, pain, hypoxia or a combination.

# FEN: Tube feeds as tolerated; regular diet, reglan

# PPx: SC heparin, tums

# Code: full

# Communication: father


Medications on Admission:
Atovaquone, calcium, cipro eye gtt, citalopram, colace, fentanyl
patch, folate, lasix, neurontin, levoflox, ativan, reglan,
lopressor, mirtazapine, mvi, MMF, prednisone, senna, Tacro,
Zosyn, Urodiol, Valtrex, Vori, Albuterol/Ipratrop, lactulose,
dilaudid

Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2
times a day).
2. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
6. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

8. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: 25-100 mcg/hr
Injection INFUSION (continuous infusion).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
13. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q6H:PRN
hold for RR<12, sedation
14. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
17. Linezolid 600 mg IV Q12H
18. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
19. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
20. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
21. Midazolam 5 mg/mL Solution Sig: 0.5-2mg  Injection TITRATE
TO (titrate to desired clinical effect (please specify)).
22. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
23. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO
DAILY (Daily).
24. Mycophenolate Mofetil 200 mg/mL Suspension for
Reconstitution Sig: 500mg  PO BID (2 times a day).
25. Ondansetron 4 mg IV Q8H:PRN
26. Piperacillin-Tazobactam Na 4.5 gm IV Q8H
27. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
28. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
29. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
30. Valacyclovir 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
31. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
1. hydropneumothorax
2. hypercarbic respiratory failure
Secondary:
1. AML s/p BMT


Discharge Condition:
critical


Discharge Instructions:
Transfer to [**Hospital1 112**] MICU for respiratory failure and care under his
primary hematologist, Dr. [**Last Name (STitle) 11907**].

Followup Instructions:
Please f/u with Dr. [**Last Name (STitle) 11907**] of [**Company 2860**]
{'Chronic respiratory failure,Acute myeloid leukemia, in remission,Bone marrow replaced by transplant,Other specified alveolar and parietoalveolar pneumonopathies,Gastrostomy status,Depressive disorder, not elsewhere classified'}


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, headache

PRESENT ILLNESS: 25 male with AML s/p BMT in [**2187**], GVHD, recent PTX medically
managed, presented to [**Hospital 8**] Hosp from [**Hospital1 **] [**2189-6-30**] with
SOB, N/V, and an enlarged hydropneumothorax. He was seen at [**Hospital1 112**]
and discharged about one week ago for a left hydropneumothorax
that was medically managed. He noted the onset of shortness of
breath yesterday at rest, was hypoxic, and found to have a
larger pneumothorax. He was taken to [**Hospital1 **] hosptial where he
was given pain control and had a chest tube placed in his left
5th intercostal space. He was symptomatically improved, and was
transferred here for further care. He has not had recent f/c,
though has been vomiting daily. He has not had diarrhea.
.
He also has had shingles on his left leg, and has been on
valtrex for this. His immunosuppression was recently decreased
due to voriconazole.
.
ED course: He was given IV dilaudid in the ED, seen by thoracic
surgery, and admitted to medicine for workup.
.
On the floor, he was noted to have a serum bicarb of 45 and was
somnolent. An ABG was done which was 7.23/112/144. CXR from 1 am
showed increased left pneumothorax. He was brought to the CCU
for further management of his chest tube.
.
Review of Systems: Nausea and vomiting, rash on left leg, poor
appetite, decreased energy.

MEDICAL HISTORY: AML s/p transplant [**2187**]
? GVHD
Gtube
Depression

MEDICATION ON ADMISSION: Atovaquone, calcium, cipro eye gtt, citalopram, colace, fentanyl
patch, folate, lasix, neurontin, levoflox, ativan, reglan,
lopressor, mirtazapine, mvi, MMF, prednisone, senna, Tacro,
Zosyn, Urodiol, Valtrex, Vori, Albuterol/Ipratrop, lactulose,
dilaudid

ALLERGIES: Compazine / Bactrim / Pentamidine Isethionate / Vancomycin Hcl

PHYSICAL EXAM: Gen- Cachectic, pale, ill appearing male, uncomfortable
Heent- MMdry, blood in mouth and nares, anicteric
Neck- supple, no LAD
Cor- tachy, regular, s1,s2
Chest- breath sounds bilateral, rhonchorous anteriorly; chest
tube draining serosanguinous fluid, no bleeding at site
Abd- soft, tender at g tube site, no g/r. Pos BS.
Ext- no c/c/e
Neuro- AAO 3, drowsy
Skin- Open excoriated lesion on left thigh

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives at [**Hospital **] Rehab, no tobacco or EtOH. Single. 

### Response:
{'Chronic respiratory failure,Acute myeloid leukemia, in remission,Bone marrow replaced by transplant,Other specified alveolar and parietoalveolar pneumonopathies,Gastrostomy status,Depressive disorder, not elsewhere classified'}
