CHIEF COMPLAINT: CLL with [**Doctor Last Name 6261**] Transformation, admitted for Allo SCT

PRESENT ILLNESS: Mr. [**Known lastname **] is a 56-year-old male with history of CLL with P53
mutation, s/p FCR and PCR, and Campath [**2123-7-9**], with recent new
onset ([**2122-12-21**])left cervical lymph node enlargment which upon
biopsy revealed large cell ([**Doctor Last Name 6261**]) transformation, s/p [**Hospital1 **]
([**Date range (1) 60068**]), s/p ESHAP ([**Date range (1) 35870**]/09) ([**Date range (1) 60070**]) admitted now
for an ablative Cytoxan/Busulfan matched ([**7-27**]) unrelated donor
peripheral stem cell transplant.
.
The patient reports fatigue and anorexia since previous
admission with decreased taste sensation.  He is otherwise
feeling well. On review of systems, he denies any fever, chills,
nausea, vomiting, chest pain, SOB, diarrhea, constipation,
dysuria, abdominal pain, weakness, numbness, or tingling.  He
reports anxiety and fear entering transplant, but he has
accepted that it is the next step in his therapy and he is
ready.

MEDICAL HISTORY: Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

MEDICATION ON ADMISSION: Acyclovir 400 mg PO Q8H
Allopurinol 300 mg Tablet PO DAILY
Augmentin 500mg PO TID
Atenolol 100 mg PO Daily
Fluconazole 200 mg PO Q24H
Diltiazem HCl 240 mg PO DAILY
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Pentamidine 300mg inh qm x 6m (last dose [**2124-2-10**])
Compazine 10mg PO q6-8 PRN nausea
Ativan 0.5-1mg PO q4-6 PRN nausea, anxiety, insomnia

ALLERGIES: Bactrim

PHYSICAL EXAM: ON ADMISSION:
VS- 97.1 114/70 80 18 98%@RA
Gen: awake, alert, no acute distress, pleasant
HEENT: mucous membranes moist, always with a different [**Location (un) 86**]
sports hat, today Bruins.
Neck: Non-tender, neck supple, no JVD, no thyromegaly
CV: S1 & S2 regular without murmur
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
Abd: soft, non-tender or distended, no HSM, BS present
Ext: No edema, 2+ DP pulses bilaterally
Neuro: AOx3, CN2-12 intact grossly, strength 5/5 diffusely,
sensation intact diffusely, coordination intact bilaterally.
FTN/HTS intact, negative Romberg's sign.

FAMILY HISTORY: Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.

SOCIAL HISTORY: Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old.
Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Toxic encephalopathy,Other specified septicemias,Sepsis,Hepatic encephalopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute graft-versus-host disease,Bacteremia,Unspecified pleural effusion,Other ascites,Urinary tract infection, site not specified,Alkalosis,Meningitis due to adenovirus,Hemorrhage of gastrointestinal tract, unspecified,Toxic myopathy,Other disorders of neurohypophysis,Candidiasis of mouth,Other specified erythematous conditions,Diarrhea,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hepatitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Human herpesvirus 6 infection,Other specified viral infection,Pure hypercholesterolemia,Unspecified essential hypertension
Oth lymp unsp xtrndl org,Acute kidney failure NOS,Toxic encephalopathy,Septicemia NEC,Sepsis,Hepatic encephalopathy,Ch lym leuk wo achv rmsn,Comp-oth vasc dev/graft,Ac embl suprfcl up ext,Ac graft-versus-host dis,Bacteremia,Pleural effusion NOS,Ascites NEC,Urin tract infection NOS,Alkalosis,Adenoviral meningitis,Gastrointest hemorr NOS,Toxic myopathy,Neurohypophysis dis NEC,Thrush,Erythematous cond NEC,Diarrhea,Neutropenia NOS,Fever in other diseases,Hepatitis NOS,Adv eff antineoplastic,Enterococcus group d,Inf mcr rst ot drg nt ml,Human herpesvirus 6 infc,Oth specf viral infectn,Pure hypercholesterolem,Hypertension NOS
Admission Date:  [**2124-3-1**]              Discharge Date:   [**2124-8-17**]

Date of Birth:  [**2067-4-22**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
CLL with [**Doctor Last Name 6261**] Transformation, admitted for Allo SCT

Major Surgical or Invasive Procedure:
Hickmann Placement & Removal
Central Venous Line Placement and removal x3
PICC Placement and removal x2
Sigmoidoscopy with biopsy
Paracentesis

History of Present Illness:
Mr. [**Known lastname **] is a 56-year-old male with history of CLL with P53
mutation, s/p FCR and PCR, and Campath [**2123-7-9**], with recent new
onset ([**2122-12-21**])left cervical lymph node enlargment which upon
biopsy revealed large cell ([**Doctor Last Name 6261**]) transformation, s/p [**Hospital1 **]
([**Date range (1) 60068**]), s/p ESHAP ([**Date range (1) 35870**]/09) ([**Date range (1) 60070**]) admitted now
for an ablative Cytoxan/Busulfan matched ([**7-27**]) unrelated donor
peripheral stem cell transplant.
.
The patient reports fatigue and anorexia since previous
admission with decreased taste sensation.  He is otherwise
feeling well. On review of systems, he denies any fever, chills,
nausea, vomiting, chest pain, SOB, diarrhea, constipation,
dysuria, abdominal pain, weakness, numbness, or tingling.  He
reports anxiety and fear entering transplant, but he has
accepted that it is the next step in his therapy and he is
ready.

Past Medical History:
Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

Social History:
Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old.


Family History:
Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.


Physical Exam:
ON ADMISSION:
VS- 97.1 114/70 80 18 98%@RA
Gen: awake, alert, no acute distress, pleasant
HEENT: mucous membranes moist, always with a different [**Location (un) 86**]
sports hat, today Bruins.
Neck: Non-tender, neck supple, no JVD, no thyromegaly
CV: S1 & S2 regular without murmur
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
Abd: soft, non-tender or distended, no HSM, BS present
Ext: No edema, 2+ DP pulses bilaterally
Neuro: AOx3, CN2-12 intact grossly, strength 5/5 diffusely,
sensation intact diffusely, coordination intact bilaterally.
FTN/HTS intact, negative Romberg's sign.

ON DISCHARGE:
T: 97.0  BP: 119/92  HR: 86  RR: 18  SP02: 98%RA
General: Quite, slow movements, no acute distress
HEENT: Moist mucous membranes, no palpable LAD, neck is supple
CARDIAC:  Regular rate and rhythm; normal S1 and S2
RESP:  Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
ABDOMEN: +BS, non-tender, non-distended
EXTREMITY: 1+ edema bilaterally; full range of movement
SKIN: Slightly ashen/icteric

Pertinent Results:
Please note, there are 5 months worth of labs in our system.
Please find below the admission labs, and below them, the
discharge labs.
.
ADMISSION LABS:
[**2124-3-1**] 09:25AM BLOOD WBC-14.0* RBC-3.19* Hgb-10.0* Hct-28.0*
MCV-88 MCH-31.2 MCHC-35.5* RDW-19.3* Plt Ct-117*#
[**2124-3-1**] 09:25AM BLOOD Neuts-33* Bands-2 Lymphs-55* Monos-5
Eos-0 Baso-1 Atyps-1* Metas-3* Myelos-0
[**2124-3-1**] 09:25AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-1+
[**2124-3-1**] 09:25AM BLOOD PT-12.0 INR(PT)-1.0
[**2124-3-1**] 09:25AM BLOOD Gran Ct-5320
[**2124-3-1**] 09:25AM BLOOD UreaN-23* Creat-1.1 Na-147* K-4.1 Cl-106
HCO3-28 AnGap-17
[**2124-3-1**] 09:25AM BLOOD ALT-27 AST-33 LD(LDH)-604* AlkPhos-103
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2124-3-1**] 09:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6 UricAcd-4.5
.
DISCHARGE LABS:
Na 131, K 3.7, Cl 101, HC03 18 (stable), BUN 24, Cr. 0.5,
Glucose 172, WBC 6.7, Hgb 9.0, Hct 26.9, Plt 95, Ca 8.2, Mg 1.9,
Phos 2.2.  LFTS (trending down) ALT 214, AST 93, LDH 668, Alk
Phos 421.
Urine culture [**8-14**]: <10,000 organisms.  U/A: Bili small,
bacteria few (most likely contaminated), protein trace, glucose
300, nitrates negative, leukocytes negative.
Other results:
.
Last CMV VL [**2124-8-14**] Negative.
.
ID RESULTS:
-Cdiff negative x4 since [**6-25**]
-[**2124-7-22**] cryptococcal Ag negative
-[**2124-7-20**] Peritoneal fluid negative, Gstain and Cx, Fungal,
anaerobes, AFB all negative
-[**2124-7-14**] CSF negative Gstain, Cx, Crypto, fungal, Ag
-[**2124-7-12**] stool Cx all negative
--VRE bacteremia, s/p linezolid x 2 weeks
- Strep milleri bacteremia, treated, and resolved, TTE [**4-21**] no
vegetation. There is a note that HHV6 was positive at the same
time as patient developed evanescent rash, which was attributed
to HHV6. Repeat serum viral load was negative a week later.
-BK viruria >390 million ([**4-24**]) with bladder spasms, but then
symptoms resolved.
.
Last positive Cx's we have on record are:
Final [**2124-5-17**]: ENTEROCOCCUS FAECIUM.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 60071**]
         [**2124-5-11**].
Anaerobic Bottle Gram Stain (Final [**2124-5-14**]):
      GRAM POSITIVE COCCI IN CHAINS.
.
Aerobic Bottle Gram Stain (Final [**2124-5-15**]):
      GRAM POSITIVE COCCI.
      IN PAIRS AND CHAINS.
.
Culture taken from colon:
Time Taken Not Noted     Log-In Date/Time: [**2124-5-10**] 6:22 pm
      TISSUE COLON.
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   TISSUE (Final [**2124-5-13**]):
      ENTEROCOCCUS SP..    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
PENICILLIN G----------  =>64 R
VANCOMYCIN------------  =>32 R

   ANAEROBIC CULTURE (Final [**2124-5-16**]):
      BACTEROIDES FRAGILIS GROUP.    SPARSE GROWTH.
         BETA LACTAMASE POSITIVE.

   ACID FAST CULTURE (Final [**2124-7-10**]):    NO MYCOBACTERIA
ISOLATED.

   ACID FAST SMEAR (Final [**2124-5-11**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   FUNGAL CULTURE (Final [**2124-5-26**]):    NO FUNGUS ISOLATED.

[**2124-4-15**] 12:05 pm BLOOD CULTURE

                            **FINAL REPORT [**2124-4-18**]**

   Blood Culture, Routine (Final [**2124-4-18**]):
      STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP.    FINAL
SENSITIVITIES.
         CLINDAMYCIN RESISTANT @ > 2MCG/ML.
         ERYTHROMYCIN RESISTANT @>4MCG/ML.
         Sensitivity testing performed by Sensititre.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
PENICILLIN G----------  0.06 S
VANCOMYCIN------------     1 S

   Anaerobic Bottle Gram Stain (Final [**2124-4-16**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1035AM [**2124-4-16**].
      GRAM POSITIVE COCCI IN CHAINS.

The following are significant reports from the last 5 months.
However, due to volume of reports, this list is not inclusive.

[**2124-7-21**] CXR
FINDINGS: In comparison with study of [**7-12**], there is a slightly
better
inspiration with continued enlargement of the cardiac silhouette
and widening of the mediastinum due to extensive mediastinal
lipomatosis. Lungs are clear and there is no vascular
congestion.

CENTRAL CATHETER REMAINS IN PLACE.

[**2124-7-19**] Doppler u/s abdomen
FINDINGS: Transabdominal ultrasound with Doppler demonstrates
patent hepatic veins including the right middle and left hepatic
veins. There is appropriate direction of flow. No thrombus is
seen. Patient evaluation is limited due to patient's inability
to breath-hold. The main portal vein was seen to be patent with
appropriate direction of flow on the earlier study. The hepatic
artery was not visualized. Moderate ascites throughout the
abdomen, unchanged from prior study.

IMPRESSION: Limited evaluation. Hepatic veins are patent with
appropriate
direction of flow with no thrombus seen.

[**2124-7-18**] CT abdomen pelvis


FINDINGS: The lung bases demonstrate increased atelectasis when
compared to prior study of [**2124-5-11**]. In addition, there are
bilateral pleural
effusions, left greater than right, both slightly increased in
size since the prior study. The heart size is normal. The
spleen, gallbladder, pancreas, adrenal glands, stomach are
within normal limits. Both kidneys demonstrate parapelvic cysts
bilaterally. Otherwise, the kidneys both enhance and excrete
contrast symmetrically bilaterally. A small hyperdensity is
noted within the right lobe of the liver (2:22), unchanged in
size and appearance since at least [**2124-3-17**]. Multiple small
retroperitoneal and mesenteric lymph nodes are again noted, none
meeting CT criteria for pathologic enlargement. There is no free
air.

There is a moderate amount of ascites, which has increased in
amount since the CT of [**5-11**]. In addition, there is a
significant amount of soft tissue edema throughout the entire
subcutaneous tissues of the abdomen, which has greatly increased
also since the prior study.

There is persistent mild bowel wall thickening at the ileum that
apperas
moreso in the terminal ileum, not significantly changed. Fatty
change in the wall of the terminal ileum also is stable. In some
of the areas of wall thickening there is striated enhancement,
but the mucosal enhancement is only mildly increased and this is
in collapsed bowel. No distended bowel shows wall thickening
with striated enhancement. There are mildly dilated loops of
jejunum and proximal ileum without a transition pint. Previously
described possible edema of the gastric antrum/pylorus is not
apparent on today's study.

CT OF THE PELVIS WITH IV CONTRAST: The rectum and prostate are
within normal limits. Air within the bladder is likely due to
recent placement of a Foley catheter. A large amount of free
fluid is noted within the pelvis, increased since the prior
study. There is no pelvic or inguinal lymphadenopathy. There is
a small left sided fat containing inguinal hernia.

BONE WINDOWS: No suspicious osseous lesions are seen. Left
eighth rib
deformity consistent with old healed fracture, unchanged.

IMPRESSION:
1. Increased ascites within the abdomen and pelvis. Bilateral
pleural
effusions, left greater than right, also slightly increased
since the prior study. Anasarca.

2. Persistent mild ileal wall thickening and with fatty
deposition in the
terminal ileal wall, unchanged. No convinving active ileitis at
this time
with the findings likely reflecting chronic changes from graft
versus host
disease. No obstruction, but likely mild small bowel ileus.

[**2124-7-15**] MRI head
FINDINGS: The diffusion images, which are adequate for
interpretation,
demonstrate no acute infarct. There is no mass effect or midline
shift. The remaining images are limited by motion demonstrate no
obvious midline shift or hydrocephalus. There are no obvious
areas of enhancement seen on motion limited axial images but
evaluation is limited. Subtle areas of high signal on both basal
ganglia region on post-gadolinium axial images are artifactual
from pulsation artifacts.

IMPRESSION: Limited study due to motion. Diffusion images which
are adequate for interpretation demonstrate no acute infarct.
Other images, which are limited demonstrate no obvious
abnormalities, but for better evaluation if clinically
indicated, a repeat study can be obtained with sedation.

[**2124-7-3**] RUE U/S
FINDINGS:

RIGHT UPPER EXTREMITY VENOUS ULTRASOUND:

The right internal jugular vein is patent. The proximal right
subclavian vein at the level of the internal jugular vein is
patent. Just distal to the internal jugular vein, the subclavian
vein is thrombosed. The vein is
distended with echogenic clot and demonstrates absence of flow
and
compressibility. The axillary vein is now only partially
thrombosed, with
minimal flow seen around the echogenic clot. There is partial
compressibility. The basilic vein is patent.

One of the paired brachial veins remains thrombosed with
echogenic clot
distending the lumen and absence of flow and compressibility.
The other
brachial vein is patent. The cephalic vein remains completely
thrombosed
without compressibility or flow.

The left subclavian vein is patent.

IMPRESSION:

1. Interval improvement in degree of the right upper extremity
thrombosis,
now with only partial clot in the right axillary vein, and flow
in the basilic
vein.

2. Persistent thrombosis of the superficial veins of the right
upper
extremity, with thrombosis of one of the paired brachial veins
and the
axillary vein.

[**2124-6-15**] ECHO
Findings
LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Overall normal LVEF (>55%). No resting LVOT gradient. No VSD.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
masses or vegetations on aortic valve, but cannot be fully
excluded due to suboptimal image quality.

MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
masses or vegetations on mitral valve, but cannot be fully
excluded due to suboptimal image quality. Normal mitral valve
supporting structures. No MS. Mild (1+) MR. LV inflow
uninterpretable due to tachycardia and/or fusion of spectral
Doppler E and A waves

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No masses or vegetations are seen on the tricuspid valve,
but cannot be fully excluded due to suboptimal image quality.
Normal tricuspid valve supporting structures. No TS. Normal PA
systolic pressure.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. No vegetation/mass on pulmonic valve.
Normal main PA. No Doppler evidence for PDA

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Suboptimal image quality - poor echo windows.

Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is small.
Overall left ventricular systolic function is normal (LVEF 70%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. No masses or vegetations are seen on
the aortic valve, but cannot be fully excluded due to suboptimal
image quality. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. Mild (1+) mitral regurgitation is
seen. No masses or vegetations are seen on the tricuspid valve,
but cannot be fully excluded due to suboptimal image quality.
The estimated pulmonary artery systolic pressure is normal. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2124-5-12**], no major change.

IMPRESSION: Suboptimal image quality. No obvious vegetations
seen

If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.

[**2124-7-21**] FLOW CYTOMETRY PERIPHERAL BLOOD

FLOW CYTOMETRY REPORT

FLOW CYTOMETRY IMMUNOPHENOTYPING

The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45.


RESULTS:

 Three color gating (CD45 versus light scatter) is used to
determine population of interest.

 B cells are extremely scant in number, however, appear
polytypic.

 T cells comprise 90% of lymphoid gated events.

 INTERPRETATION

 Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin B-cell
lymphoma are not seen in specimen.  Correlation with clinical
findings is recommended.  Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts or sample preparation.

[**2124-7-20**] FLOW CYTOMETRY ASCITES
FLOW CYTOMETRY REPORT

FLOW CYTOMETRY IMMUNOPHENOTYPING

The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45.

RESULTS:

Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.

B cells are scant in number precluding evaluation of clonality.

T cells comprise 90% of lymphoid gated events.

INTERPRETATION

Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin B-cell
lymphoma are not seen in specimen.  Correlation with clinical
findings is recommended.  Flow cytometry immunophenotyping may
not detect all lymphomas due to topography, sampling or
artifacts or sample preparation.

[**2124-6-26**] FLOW CYTOMETRY OF CSF FLUID
The following tests (antibodies) were performed: Kappa, Lambda,
and CD antigens 19, 45.
RESULTS:

Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.

B cells are scant in number precluding evaluation of clonality.

T cells comprise 99% of lymphoid gated events.

INTERPRETATION

Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by  lymphoma are not
seen in specimen. Correlation with clinical findings is
recommended. Flow cytometry immunophenotyping may not detect all
lymphomas as due to topography, sampling or artifacts of sample
preparation.

[**2124-5-29**] SKIN BX
DIAGNOSIS:
1.  Skin, right forearm, biopsy (A-B):

Interface and superficial perivascular dermatitis with marked
dyskeratosis, dermal melanophages, and extravasated
erythrocytes, see note.

Note: The degree of dyskeratosis (some at basal layer), lack of
eosinophils, and finding of lymphocyte-keratinocyte satellitosis
favor graft versus host disease, if clinically appropriate.  The
histologic differential diagnosis includes a drug eruption..
This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**].
2.  Skin, left upper back, biopsy (C):

Interface and superficial perivascular dermatitis with marked
dyskeratosis, dermal melanophages, and extravasated
erythrocytes, see note.

Note: The degree of dyskeratosis (some at basal layer), lack of
eosinophils, and finding of lymphocyte-keratinocyte satellitosis
favor graft versus host disease, if clinically appropriate.  The
histologic differential diagnosis includes a drug eruption.
This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**].

[**2124-5-18**] GI BX
DIAGNOSIS:

Terminal ileum, biopsy:

Granulation tissue and ulcer bed with crystalline material.  See
note.

Note:  No intact intestinal epithelium is seen.  The crystalline
material is morphologically consistent with sodium polystyrene
sulfonate (Kayexalate), which is reported to be associated with
gastrointestinal tract ulcers.  Reactive atypia is noted within
the granulation tissue, however, no definite viral inclusions
are identified.  An immunohistochemical stain for
cytomegalovirus is in process and results will be reported as an
addendum.  Severe acute graft versus host disease cannot be
excluded based on the morphologic findings.  The case was
reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7108**], who concurs. The findings were
discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2124-5-19**].

ADDENDUM:
Immunohistochemical stain for CMV is negative.

[**2124-3-30**] - SIGMOIDOSCOPY - Impression: Diverticulosis of the
sigmoid colon
Normal mucosa in the sigmoid colon (biopsy)
Otherwise normal sigmoidoscopy to descending colon at 50 cm
.
[**2124-3-30**] - PATHOLOGY - GI BIOPSIES (2 JARS)
DIAGNOSIS:
Colonic mucosa biopsies, two:
A.  Sigmoid: Colonic mucosa, no diagnostic abnormalities
recognized.
B.  Rectum: Colonic mucosa with rare crypt cell apoptosis, see
note.
Note: These findings are not diagnostic for GVHD. Immunostain
for CMV is negative.
.
[**2124-4-12**] - PATHOLOGY - Skin, abdomen:
- Interface dermatitis with dyskeratotic keratinocytes, and mild
superficial perivascular lymphocytic infiltrate consistent with
graft versus host disease, see note.
Note: The histological differential diagnosis includes a
reaction to drugs. The current specimen shows
lymphocyte-keratinocyte satellitosis and marked apoptic bodies
at the interface level, and no eosinophilia is noted. The
keratinocytic dyskeratosis is predominantly seen at the basal
keratinocytes level, and no dermal edema is seen. Overall, a
diagnosis of graft versus host disease (GVHD) is favored, if
compatible with the clinical presentation.
.
MICROBIOLOGY TESTS:
[**2124-4-15**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP}; Anaerobic Bottle Gram
Stain-FINAL
Anaerobic Bottle Gram Stain-FINAL INPATIENT
FINAL SENSITIVITIES.
         CLINDAMYCIN RESISTANT @ > 2MCG/ML.
         ERYTHROMYCIN RESISTANT @>4MCG/ML.
         Sensitivity testing performed by Sensititre.
                              SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------       R
PENICILLIN G----------  0.06 S
VANCOMYCIN------------     1 S

   Anaerobic Bottle Gram Stain (Final [**2124-4-16**]):

[**2124-4-16**] BLOOD CULTURE -FINAL {STREPTOCOCCUS ANGINOSUS
(MILLERI) GROUP}
[**2124-4-18**] BLOOD CULTURE -FINAL NO GROWTH.

Brief Hospital Course:
Mr. [**Known lastname **] is a 56-year-old male with history of CLL with large
cell transformation who was admitted for a scheduled allogeneic
MUD SCT on [**2124-3-10**]. His course was complicated by febrile
neutropenia and acute GVHD involving the intestinal tract, liver
and skin.  He was discharged to [**Hospital1 **] in stable condition
with symptomatic improvement.
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[**Date range (3) 60072**]
# Allo BMT - Day 0: [**2124-3-10**] from MUD ([**7-27**], mismatch at one
HLA-A allele). The patient underwent a Busulfan/Cytoxan
conditioning regimen which did not cause neutropenia and he
tolerated it with only mild diarrhea.  His initial transplant
proceeded without incident. The patient was started on
Acyclovir, Fluconazole and Ursodiol per protocol on Day -2.
Cyclosporine was started Day -1 and monitored by level.
Methotrexate was given per protocol on Days +1, and then again
on Day +7 (delayed due to concern of transaminitis - see below),
and day +11.  He received inhaled pentamidine on a monthly basis
([**3-29**] and [**4-30**]).  He was started on atovaquone for PCP
prophylaxis on [**4-8**].  Fungal prophylaxis was switched micafungin
while the patient had fever & neutropenia.  The patient was on
voriconazole for a short period of time, but changed back to
micafungin due to concern of exacerbating chemotherapy induced
liver toxicity.
.
# Acute GVHD - The patient course was complicated by acute GVHD
which started as a blanching rash on [**3-20**].  The patient was
treated empirically for GVHD with steroids, which improved his
rash, but when the steroids were tapered the patient developed
severe watery diarrhea, up to 2L a day at times. The
gastroenterology service was consulted and on [**3-30**] the patient
had a flexible sigmoidoscopy. Biopsies of the sigmoid and rectum
were non-diagnostic but consistent with GVHD.  Stool cultures
for bacterial and viral pathogens and for C. diff were negative.
 The steroids were again tapered as the patient's diarrhea
improved, however, the patient developed a morbilliform rash and
his diarrhea worsened.  Dermatology biopsied the rash, and the
pathology was consistent with GVHD.  His skin rash evolved into
desquamation and bullae and his diarrhea symptoms flared when
steroids doses were tapered. The patient was treated with
high-dose (2mg/kg) methylprednisone, cellcept, cyclosporine and
Remicade x 2 ([**4-14**] and [**4-22**]).  He also developed liver
involvement with GVHD.  His TBili was elevated to max of 2.7 on
[**4-24**].  After his second dose of remicade, his symptoms improved
and a very slow steroid taper was reattempted.  Steroid taper
was ultimately unsuccessful with patient requiring
methylprednisolone 25 mg in am and 20 mg in pm.

It was thought that the skin rash may have been worsened by
cefepime. The cefepime was switched to meropenem and derm was
once again consulted on [**5-31**]. Derm took a biopsy which showed
results consistent with GVHD and unlikely for drug reaction.
.
# Fevers and neutropenia - The patient developed fevers in the
setting of neutropenia post transplant on [**3-13**] and was treated
with broad spectrum antibiotics and antifungal coverage.
Cultures remained negative and no source was identified. C diff
was negative on multiple occasions throughout this
hospitalization. His counts recovered ([**3-22**]) and antibiotics were
discontinued.
.
# VRE bacteremia - The patient developed bloody diarrhea and
underwent colonoscopy for evaluation ([**5-18**]). He was
hemodynamically stable at this time. The colonscopy was negative
as was an EGD. The following evening the patient developed a
fever to 102 and blood cultures grew VRE bacteremia. He was
started on linezolid and cefepime. His IJ was removed as was his
PICC line for access. The fevers resolved as did the bacteremia.
.
# Fevers - The patient again became febrile on [**5-31**]. He had no
symptoms and his vital signs remained stable. The patient was
continued on meropenem, linezolid and flagyl was added to cover
potential c. diff. He consistently cultured negative. His PICC
was removed with no resolution of the fevers. His IJ was removed
on [**6-9**]. Following this his fevers resolved.
.
# HHV6 infection:  The patient spiked a fever [**3-27**] when he was
no longer neutropenic and he developed a splotchy and evanescent
rash, which disappeared within 24 hours.  A serum HHV6 viral
load was eventually positive, and HHV6 was felt to be the likely
cause of the patient??????s rash.  Repeat testing a week later for
HHV6 was negative.
.
# Strept Milleri Bacteremia: On [**4-15**] blood cultures were drawn
as the patient appeared unwell and had borderline low blood
pressures. The patient was not neutropenic at this time.  Blood
cultures eventually grew Strep milleri.  The patient was treated
with vancomycin initially and then switched to ceftazadime and
flagyl and then to cefepime per ID recommendations.  TTE was
negative for endocarditis.  The patient was deemed to high risk
to undergo TEE so it was determined that he would complete a 4
week course from the first negative blood culture on [**4-18**] (D/C ON
[**5-15**]).
.
# BK virus: In early [**Month (only) **], while the patient was on multiple
immunosuppressant medications for GVHD, he developed dysuria,
difficulty voiding and hematuria.  There was initially concern
about urinary retention; however, once the foley was placed the
patient only had a small amount drained from the bladder.  Urine
bacterial cultures were negative, but urine studies were
positive for BK virus.  He eventually developed BK viremia.  The
patient suffered from painful bladder spasms as a result of his
BK virus.  Urology service was consulted to assist with bladder
spasm control.  His bladder spasms were symptomatically managed
with flomax, detrol, pyridium and a morphine PCA.  ID was
consulted and they recommended treatment with intravesicular
cedofivir. In addition, the patient was given IVIG on [**5-6**] to
help boost his Ig levels in the setting of such high levels of
immunosuppression.  Urology recommended an outpatient cystoscopy
after discharge for further evaluation of microscopic hematuria.
.
# Decreased Mental Status - In Mid [**2124-5-17**], patient had
waxing/[**Doctor Last Name 688**] mental status: AOx2, missing date, with a mild
decrease in his mental status. On [**6-13**] the patient's mental
status worsened. He was able to follow simple commands but not
complex commands. He was also complaining of some visual
halluciantions and made some coherent but nonsensical
statements. An MRI was conducted which showed no pathology that
would account for the mental status change. Neurology was
consulted. It was thought that the most likely cause was
metabolic encephalopathy secondary to one of his medications. In
the past he has had similar symptoms in response to cyclosporin.
At that time he was given a cyclosporin holiday and changed to
tacrolimus with a recovery of his mental status to baseline.  He
is also on steroids and mycophenolate and received etanercept.

#) Hypertension: The patient has a history hypertension that is
generally exacerbated by steroids. His anti-hypertensive
medications required frequent adjustment during this
hospitalization. His Diltiazem was changed to Nifedipine due to
concern regarding hepatotoxicity. His metoprolol dose was
increased. On [**6-11**] nifedipine was stopped due to low blood
pressures.
.
#) Anascarca: The patient's severe GVHD caused an inflammatory
state with required aggressive fluid replacement.  The patient
developed severe anascarca and ascites and had an approximately
40lb weight gain secondary to GVHD.  Once his GVHD stabilized,
he was diuresed with lasix which at one point caused prerenal
acute renal failure with a creatinine peak of 1.7.  However,
this resolved with fluids.  Patient currently has 1+ edema
bilaterally in both legs, but no other symptoms of fluid
overlaod.
.
#) Superficial venous clots: On [**4-14**], the patient developed
superficial venous clots in his left cephalic and basilic veins
near a PICC line site.  He did not have any DVT.
.
#) GERD: The patient was started on a PPI on [**3-28**] due to
increased symptoms of "heartburn" in the setting of high dose
steroids.  He was discharged with omeprazole 20mg.
.
#) Access: The patient had multiple central lines at various
times during this hospitalization, which were required as the
patient was unable to take POs.  He had a Hickmann tunnelled
catheter which was removed because it was non-functional. He
also had right PICC x2 (the first of which was removed due to a
superficial phlebitis), a left IJ, a right subclavian (removed
when the patient was bacteremic) and a right IJ.  He currently
has no central access.

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[**Hospital Unit Name 153**] (Intensive Care Unit) course ([**Date range (2) 60073**])
.
# Hypothermia / MS changes: Multiple possible etiologies in the
immunocompromised pt s/p BMT,  concern for sepsis given elevated
lactate (although unclear as to what pt's baseline lactate level
is given malignancy and adenopathy, was stable at 3.0 on
transfer) and resp alkalosis.  Pt had recent VRE bacteremia,
after central line placement, the midline was removed and sent
for culture. MRI shows possible embolic infarcts which raises
concern for endocarditis as another possible source of sepsis.
TSH was low normal ruling out hypothyroid myxedema. Concern for
meningitis or other central process given persistent resp
alkalosis. Additional concern for med toxicity given hx of MS
changes with cyclosporine. LP was performed and suggestive of
possible aseptic meningitis, etiologies include HSV and other
viruses (CMV, HHV, number of others sent out) vs malignancy
related as 99% lymphs on tap vs drug (chemo/immunosup) toxicity.
Ammonia level normal. BMT/heme thought that the CSF lymphs were
not likely malignant. ID recommended coverage for empiric HSV
with foscarnet (due to better coverage of HSV 6). ID also
recommended, f/u galactomannan, B-D-glucan as another survey for
invasive fungal infection without need for broader fungal
coverage now. We initially placed the patient on Linezolid,
cipro, Meropenem, flagyl, Micafungin, foscarnet and Atovaquone
(pt not taking since NPO), but then d/c'd cipro once it was felt
that pseudomonas was unlikely. The pt reported having some loose
stools but C. diff was negative and empiric flagyl treatment was
d/c'd. Atovaquone was restarted when pt able to PO clear liquid
diet. Otherwise, with this treatment the patient became
normothermic with temps >96, with improved mental status, and
hemodynamically stable (never with need for
intubation/pressors).
.
# Anemia: HCT 22 from 26, now stable 23. Not likely dilutional
(Plts, WBC increased). [**Month (only) 116**] be related to blood draws vs
bleeding. 2U pRBC given.  Hemolysis/DIC labs negative. Continue
to monitor daily labs.
.
Upon discharge from [**Hospital Unit Name 153**]: [**2124-6-20**]:
#GVHD - The patient continued to have copious diarrhea since his
discharge from the [**Hospital Unit Name 153**].  The patient was restarted on
etanercept on [**6-28**].  This was held for several days when the
patient appeared septic on [**7-12**], however, was restarted on
[**2124-7-15**] after the patient's condition improved, and then finally
d/c'd again the week after. The diarrhea improved significantly
on tincture of opium, however this caused the patient to become
confused.  He was switched to lomotil which has alleviated the
diarrhea somewhat.  He continues to be on cellcept 1500mg [**Hospital1 **],
budesonide 3mg tid, and methylprednisolone.
.
#MS changes - The patient had multiple episodes of hypothermia
to as low as [**Age over 90 **]F, with associated mental status changes.  During
his most recent episode on [**2124-7-12**], his blood pressure also
dropped to 90/60, and he was started on meropenem and daptomycin
because of the possibility of sepsis.  The patient's blood
pressure improved with boluses and antibiotics.  MRI head was
negative, and LP glucose, protein were normal.  However, it was
thought that the daptomycin was potentially causing a further
elevation in his bilirubin, and this was stopped on [**7-15**].
.
#Adenovirus - The patient was found to have >100,000 copies of
adenovrius in his blod on [**6-28**].  CSF was sent from [**6-26**] which
also showed evidence of adenovirus.  However, repeat level on
[**7-6**] showed decreasing adenovirus levels and cidofivir was not
started.  A repeat LP was performed on [**2124-7-14**], HHV-6, CMV,
Enterovirus, viral culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus
pending.  Blood adenovirus level also re-sent.
.
#RUE clot - The patient was found to have a RUE clot [**12-20**] picc
line, however his last U/S showed some resolution.  He was not
on anticoag due to hx of GI bleeds, following clinically.
.
#GI bleed - Since leaving the unit, the patient has had several
GI bleeds, first on [**6-29**] after supratherapeutic PTT, more
recently on [**7-11**].  Both episodes were managed conservatively
with fluids given that the likely etiology was graft vs. host
disease.
.
#Ascites/edema - The patient was placed on lasix 20bid to
improve his overall anasarca and ascites.

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From [**2124-7-17**] to [**2124-8-17**] (Date of Discharge)
1. GVHD: By the beginning of [**Month (only) **], the pt did not have any
GVHD associated rash and he was not having any significant
amount of diarrhea, however he did have increases in his LFT's
and total bilirubin (as below) that were associated with altered
mental status, increased somnolence and decreased responsiveness
(see below, AMS). GVHD was in the differential of this liver
dysfunction.  He continued on immunosuppressive regimen of
cellcept, Budesonide, Methylprednisolone and enterecept.
Enterecept was eventually discontinued and doses of other
immunosuppressive were readjusted in accordance with liver
function.  He was also started on Rituxan once per week and had
received [**1-19**] doses by the time of discharge. By d/c his LFT's
were still increased, with a Tbili holding steady in the 6's.
The amt of diarrhea changed from day to day but was typically
[**12-22**] loose stools per day, occasionally with frank blood, and
occasionally with guiac + but not frankly bloody.  On discharge,
patient was kept on Methylprednisone 25mg AM/20mg PM, Cellcept
750mg every 8 hours and budesonide 3mg TID.  He will receive one
more dose of Rituxan on [**8-19**].
.
2. Increased Tbili: This was thought to be GVHD vs drug effect.
The Tbili steadily increased in late [**Month (only) 216**] until early
[**Month (only) **], when it peaked at 9.6 and this was concurrent with
his altered mental staus (as below). Acyclovir was d/c'd. Pt was
to get an MRI abdomen but was unable to sit still long enough to
get it, therefore was sent for CT abdomen with and without
contrast [**2124-7-18**], which showed an interval increase in his
ascites, increase in his pleural effusions L>R, and chronic
ileal wall thickening c/w GVHD.  Hepatology was consulted and a
paracentesis was performed in early [**Month (only) **] that was
essentially non-diagnostic, ascites cultures were negative, and
the picture was essentially consistent with portal hypertension.
Rifaxamin was started. Liver Bx was recommended but was not
performed because by this time the pt was clinically improving,
waking up, and AMS was resolving. However, despite the improved
mental status, his LFT's and Tbili continued to increase and
peaked at 9.6 before they again began to decline again and were
steadily in the 6's on d/c. He began to clinically improve, his
scleral icterus got better and no liver Bx was ever performed.
Rifaxamin was stopped without consequence.  Acyclovir was added
on and continued at discharge.
.
3. Altered Mental Status: The first week of [**Month (only) **], the
patient was noted to be very somnolent, confused and saying
nonsensical things.  Concurrent with this was hypothermia and
hypotension.  This was thought to be mostly due to hepatic
encephalopathy.  An LP performed on [**7-14**] was non diagnostic and
all viral studies from that procedure were negative. MRI head
[**7-14**] was also non diagnostic. Neuro was consulted and
recommended a 24hr bedside EEG to evaluate for subclinical
seizures, however he eventually began to dramatically turn
around though and became more awake, was conversational, able to
express himself, was requesting food, and EEG was not felt to be
necessary. His mental status steadily cleared up although it was
noted that he would have occasional delirium, would be a little
restless at night (he had actually pulled out a central venous
line one night, another was placed, but he then pulled that one
out several days later), saying odd things in the morning before
he fully woke up, and sundowning a little at night. At baseline,
he is lethargic but appropriate early in the morning, will
follow commands, but later in the day after he has fully woken
up he is very appropriate, concerned about his care, his health
and his plan.
.
4. Hypothermia and Hypotension--Seen to be occasionally
hypotensive to the 90's, which responded to fluid boluses, and
hypothermic to a low of 93.8. Was put on a warmer.  The pt's
Metoprolol was d/c'd and his bp's began to improve from high
90's/low 100's to the 110's. Temperature began to improve as
well. By the time the pt's mental status improved, his blood
pressures and hypothermia were no longer an issue. His vital
signs remained stable and hypothermia/hypoTN were not an issue
for several weeks leading up to discharge. In fact, the pt's
blood pressure and heart rate began to increase the week after
Metoprolol was d/c'd and was added back in with a decrease in bp
and pulse seen. He was d/c'd on Metoprolol 12.5 TID with steady
vitals.
.
5. GIB--While he was AMS, pt was not having active GI bleed or
diarrhea issues, but after he woke up he began having loose BM's
with obvious dark red blood. For the next several weeks in
[**Month (only) **], the pt would occasionally have dark red stools, which
required occasional PRBC transfusion, but never compromised him
from a hemodynamic standpoint. He also received occasional
platelets --> During [**Month (only) **], the pt required 6U of PRBC's and
5 of platelets. GI was consulted but felt the pt not stable for
colonoscopy as the large ammount of ascites fluid would lead to
infection.  They also felt that he had been scoped within the
past several months and no change would be seen since his
clinical condition was not much changed. By the time of
discharge the pt's Hct was stable, he was having occasional
guiac + stools but not felt to be compromised by them.
.
6. Adenoviremia: Patient was found to have >100,000 copies of
adenovrius in his blood on [**6-28**], also with adenovirus in CSF
from [**6-26**]. Repeat level on [**7-6**] showed decreasing adenovirus
levels at approx. 3000 and cidofivir was not started.  A repeat
LP was performed on [**2124-7-14**], HHV-6, CMV, Enterovirus, viral
culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus were all negative.
Blood adenovirus level was present and found to be positive at
titer approx. 1900. A repeat measurement later in [**Month (only) **]
showed a titer of 696, and no specific therapy was started.
.
7. RUE clot: Found to have RUE clot of several months duration
but not anti-coagulated due to h/o GIB's.  On [**2124-7-24**] pt's R hand
and forearm seen to be acutely grossly swollen, L hand normal,
however by the afternoon the pt's R arm returned to its normal
size without any interventions. It was questioned whether he was
sleeping on that arm which led to its swelling. In any event,
the patient was unable to be anticoagulated to the GIB's.
.
8. Anasarca: The pt was grossly edematous up to his abdomen.
After Metoprolol was d/c'd and hypotension resolved, Lasix was
increased to 40mg IV bid with appropriate response. He continued
to put out urine and as his anasarca steadily decreased his
Lasix was tapered. By the point of discharge, his legs were
drastically reduced from earlier, with barely any baseline
swelling even being noticeable. His Lasix was stopped.
.
9. Nutrition: The patient was started on TPN while his mental
status was poor and he was not eating, but by the time he began
to wake up he was requesting food.  TPN was continued for
several weeks even after he had woken up, and eventually was
totally stopped, as the pt was increasingly taking good PO
solids and liquids. He had also pulled out two central lines by
this point and did not have access for TPN anyways. So he was
given a trial to take PO on his own, which he has done well with
by the time of discharge.
.
10. BK viruria: The pt was noted to have RBC's in his UA during
[**Month (only) **] and thus a BK virus assay was sent, which came back >5
million copies. No specific therapy was initiated.  Follow up
UA's then showed that the RBC's were zero.  Given recent
complaints of dysuria, another BK virus was sent and results are
pending.
.
11. Mood: The pt had appropriately depressed moods at various
points and was very desolate that he had been in bed 5 mos,
couldn't move his legs, and didn't feel he was making progress.
Remeron was tried for several nights (to increase his sleep at
night and stimulate his appetite) but was thought to increase
restlessness/confusion at night, then was stopped.  He was never
tried on any other stimulant or antidepressant. His mood would
likely get better as his clinical condition, mobility, and
overall status improve, and this was repeatedly explained to
him.
.
12. Disposition: The pt basically needs aggressive
rehabilitation at this point, as he has major proximal LE muscle
wasting and myopathy likely due to long term steroid use. He has
good distal LE strength, but cannot stand or lift his legs very
well. If steroids can be tapered, he may be able to regain his
strength. We were attempting to use Rituxan in an attempt to
wean steroids. He is eating and drinking well and needs to be
encouraged to eat and drink. If food and drink is put in front
of him he will eat it.

Medications on Admission:
Acyclovir 400 mg PO Q8H
Allopurinol 300 mg Tablet PO DAILY
Augmentin 500mg PO TID
Atenolol 100 mg PO Daily
Fluconazole 200 mg PO Q24H
Diltiazem HCl 240 mg PO DAILY
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Pentamidine 300mg inh qm x 6m (last dose [**2124-2-10**])
Compazine 10mg PO q6-8 PRN nausea
Ativan 0.5-1mg PO q4-6 PRN nausea, anxiety, insomnia

Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2     Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products     Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QSUN ([**Doctor First Name **]).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS
DIRECTED).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ASDIR (AS DIRECTED).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
17. Mycophenolate Mofetil 500 mg Tablet Sig: 1.5 Tablets PO Q 8H
(Every 8 Hours).
18. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses.

19. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous DAILY (Daily).
20. Rituximab 10 mg/mL Concentrate Sig: Seven Hundred-Fifteen
(715) MG Intravenous Give dose #4 (last dose) on [**2124-8-19**] for 1
doses: Please give 715mg on [**2124-8-19**].
21. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty Five (25) MG Injection QAM : Please give 25mg of
methylprednisolone sodium succ every morning.
22. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty (20) MG Injection Q PM: Please give 20MG of
methylprednisolone sodium succ every night.

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary/active diagnoses on discharge:
1. CLL s/p [**Doctor Last Name 6261**] Transformation
2. Allogeneic Stem Cell Transplant [**2124-3-10**]
3. Chronic Graft versus Host disease of the liver, GI system,
and skin
4. Chronic GI bleed
5. Chronic Anemia
6. Thrombocytopenia
7. Hypertension
8. BK viruria
9. Adenoviremia
10. Extensive RUE deep venous thromboses

Discharge Condition:
By the time of discharge, the pt's chronic graft versus host
disease was stable, his chronic GI bleed was not hemodynamically
compromising, the pt had been working with PT to increase his
strength and mobility, was taking good PO foods and liquids,
vital signs were stable, and was medically cleared for
discharge.

Discharge Instructions:
You have been admitted to the hospital for an allogeneic stem
cell transplant on [**2124-3-10**].  Please see discharge summary for
COMPLETE SUMMARY of your hospital course since [**2124-3-1**].
.
Please see attached for COMPLETE LIST of your current
medications.  This was RECONCILED with admission list.
.
If you experience fever >100, shortness of breath, chest pain,
abdominal pain, headache, pain with urination, weight loss, or
any other concerning symptom, please call Dr. [**Last Name (STitle) **] or 911
immediately.

Followup Instructions:
Patient will need complete CBC with differential and complete
chemistry (Chem 10) within 24-48 hours of discharge on [**8-18**].
Please fax results to Dr. [**Last Name (STitle) **] at: [**Telephone/Fax (1) 21962**].
.
DR. [**Last Name (STitle) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**2124-8-21**] at 12:30pm. [**Telephone/Fax (1) 3241**] or
[**Telephone/Fax (1) 3237**].
.
Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2124-9-18**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2124-9-18**] 10:30
.
Urology for blood in urine: Wednesday [**9-20**] at 4pm [**Hospital Ward Name 23**] [**Location (un) **].
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Toxic encephalopathy,Other specified septicemias,Sepsis,Hepatic encephalopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute graft-versus-host disease,Bacteremia,Unspecified pleural effusion,Other ascites,Urinary tract infection, site not specified,Alkalosis,Meningitis due to adenovirus,Hemorrhage of gastrointestinal tract, unspecified,Toxic myopathy,Other disorders of neurohypophysis,Candidiasis of mouth,Other specified erythematous conditions,Diarrhea,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hepatitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Human herpesvirus 6 infection,Other specified viral infection,Pure hypercholesterolemia,Unspecified essential hypertension'}


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: CLL with [**Doctor Last Name 6261**] Transformation, admitted for Allo SCT

PRESENT ILLNESS: Mr. [**Known lastname **] is a 56-year-old male with history of CLL with P53
mutation, s/p FCR and PCR, and Campath [**2123-7-9**], with recent new
onset ([**2122-12-21**])left cervical lymph node enlargment which upon
biopsy revealed large cell ([**Doctor Last Name 6261**]) transformation, s/p [**Hospital1 **]
([**Date range (1) 60068**]), s/p ESHAP ([**Date range (1) 35870**]/09) ([**Date range (1) 60070**]) admitted now
for an ablative Cytoxan/Busulfan matched ([**7-27**]) unrelated donor
peripheral stem cell transplant.
.
The patient reports fatigue and anorexia since previous
admission with decreased taste sensation.  He is otherwise
feeling well. On review of systems, he denies any fever, chills,
nausea, vomiting, chest pain, SOB, diarrhea, constipation,
dysuria, abdominal pain, weakness, numbness, or tingling.  He
reports anxiety and fear entering transplant, but he has
accepted that it is the next step in his therapy and he is
ready.

MEDICAL HISTORY: Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

MEDICATION ON ADMISSION: Acyclovir 400 mg PO Q8H
Allopurinol 300 mg Tablet PO DAILY
Augmentin 500mg PO TID
Atenolol 100 mg PO Daily
Fluconazole 200 mg PO Q24H
Diltiazem HCl 240 mg PO DAILY
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Pentamidine 300mg inh qm x 6m (last dose [**2124-2-10**])
Compazine 10mg PO q6-8 PRN nausea
Ativan 0.5-1mg PO q4-6 PRN nausea, anxiety, insomnia

ALLERGIES: Bactrim

PHYSICAL EXAM: ON ADMISSION:
VS- 97.1 114/70 80 18 98%@RA
Gen: awake, alert, no acute distress, pleasant
HEENT: mucous membranes moist, always with a different [**Location (un) 86**]
sports hat, today Bruins.
Neck: Non-tender, neck supple, no JVD, no thyromegaly
CV: S1 & S2 regular without murmur
Lungs: Clear to auscultation bilaterally, no
wheezes/rales/rhonchi
Abd: soft, non-tender or distended, no HSM, BS present
Ext: No edema, 2+ DP pulses bilaterally
Neuro: AOx3, CN2-12 intact grossly, strength 5/5 diffusely,
sensation intact diffusely, coordination intact bilaterally.
FTN/HTS intact, negative Romberg's sign.

FAMILY HISTORY: Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.

SOCIAL HISTORY: Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old. 

### Response:
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Toxic encephalopathy,Other specified septicemias,Sepsis,Hepatic encephalopathy,Chronic lymphoid leukemia, without mention of having achieved remission,Other complications due to other vascular device, implant, and graft,Acute venous embolism and thrombosis of superficial veins of upper extremity,Acute graft-versus-host disease,Bacteremia,Unspecified pleural effusion,Other ascites,Urinary tract infection, site not specified,Alkalosis,Meningitis due to adenovirus,Hemorrhage of gastrointestinal tract, unspecified,Toxic myopathy,Other disorders of neurohypophysis,Candidiasis of mouth,Other specified erythematous conditions,Diarrhea,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hepatitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Infection with microorganisms without mention of resistance to multiple drugs,Human herpesvirus 6 infection,Other specified viral infection,Pure hypercholesterolemia,Unspecified essential hypertension'}
