CHIEF COMPLAINT: Dysarthria and abdominal pain

PRESENT ILLNESS: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date:[**2137-11-15**]
PCP:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 10066**] [**Name (STitle) 87750**] 2202 65th Street [**Location (un) **]
Bay Parkway and West 6th Street [**Telephone/Fax (1) 87751**]
GI: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87752**] [**Telephone/Fax (1) 87753**]
_
________________________________________________________________
HPI:
74M s/p recent L hernia repair on [**2137-10-6**] with chest pain,
+pleuritic x 4 weeks, +n/v x 4 weeks, +intermittent abdominal
pain, question recent aphasic episode [**1-22**] pain per family.  He
is currently being evaluated by GI for appetite and minimal
weight loss x 3 weeks.  + Early satiety. Immediately after
eating he regurgitates solid food. No dysphagia for solids or
liquids or signs of aspiration with eating. Slurred speech x 2
days. No facial asymmetry or focal weakness. Increased weakness
and sweats.
He received ASA and SLNG with some improvement in his pain from
[**9-24**].  R>L asymmetric swelling of the lower extremities

MEDICAL HISTORY: Enlarged prostate
Shingles - 18 months ago and he is on  lyrica
H/o PNA one year ago during which opacities were found, s/p
bronchoscopy.  His PNA was diagnosed as part of an evaluation
for weight loss. He did not have fevers, chills or cough
S/p hernia repair in [**9-/2137**]

MEDICATION ON ADMISSION: avodart 0.5 mg
uroxatral/alfuzosin alpha 1 blocker 10 mg
Lidoderm patch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T = 97 P = 86 BP = 108/62 RR 18 O2Sat = 98% on 2L Wt, ht,
BMI
GENERAL: Elderly male laying in bed
Nourishment: At risk, + temporal wasting
Grooming: good
Mentation: Alert, speaks in full sentences. He feels tired
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP, poor
dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at R base
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: distended, slightly firm. Tender to palpation
in RUQ and LUQ
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: 2+ edema b/l, 2+ radial, DP pulses b/l.  R>L edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Normal gait
Psychiatric:  appropriate

FAMILY HISTORY: Sister died of breast cancer
Brother died of lung cancer
Another sibling died of stomach cancer

SOCIAL HISTORY: SOCIAL HISTORY/ FUNCTIONAL STATUS:
Son: HCP [**Name (NI) 2491**] [**Name (NI) 87754**]: [**Telephone/Fax (1) 87755**]
Office: [**Telephone/Fax (1) 87756**]
Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Tumor lysis syndrome,Pneumonia, organism unspecified,Defibrination syndrome,Other specified aplastic anemias,Compression of vein,Acidosis,Herpes zoster with other nervous system complications,Acute kidney failure, unspecified,Candidiasis of mouth,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dermatitis due to drugs and medicines taken internally,Contact dermatitis and other eczema, unspecified cause,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
Oth lymp unsp xtrndl org,Tumor lysis syndrome,Pneumonia, organism NOS,Defibrination syndrome,Aplastic anemias NEC,Compression of vein,Acidosis,H zoster nerv syst NEC,Acute kidney failure NOS,Thrush,BPH w/o urinary obs/LUTS,Drug dermatitis NOS,Dermatitis NOS,Adv eff antineoplastic
Admission Date:  [**2137-11-15**]              Discharge Date:   [**2137-12-11**]

Date of Birth:  [**2062-12-24**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Dysarthria and abdominal pain

Major Surgical or Invasive Procedure:
Central line placement


History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date:[**2137-11-15**]
PCP:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 10066**] [**Name (STitle) 87750**] 2202 65th Street [**Location (un) **]
Bay Parkway and West 6th Street [**Telephone/Fax (1) 87751**]
GI: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87752**] [**Telephone/Fax (1) 87753**]
_
________________________________________________________________
HPI:
74M s/p recent L hernia repair on [**2137-10-6**] with chest pain,
+pleuritic x 4 weeks, +n/v x 4 weeks, +intermittent abdominal
pain, question recent aphasic episode [**1-22**] pain per family.  He
is currently being evaluated by GI for appetite and minimal
weight loss x 3 weeks.  + Early satiety. Immediately after
eating he regurgitates solid food. No dysphagia for solids or
liquids or signs of aspiration with eating. Slurred speech x 2
days. No facial asymmetry or focal weakness. Increased weakness
and sweats.
He received ASA and SLNG with some improvement in his pain from
[**9-24**].  R>L asymmetric swelling of the lower extremities

In ER:
Triage Vitals: 8 99 108 108/62 14 99% 4L NC
Meds Given: levoquin 750 mg IV x T
Fluids given: 2L NS
Radiology Studies:
consults called.
VS on transfer HR = 90, BP = 102/58, RR = 16, 98% on 2L
.

PAIN SCALE: 0/10
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL:        [] All Normal
[ ] Subjective fever   [ ] Chills   [ ] Sweats  [ ] Fatigue   [
] Malaise   [ ]Anorexia  [ ]Night sweats
[ +] __5___ lbs.    weight  loss/ over _1____ months

HEENT:          [] All Normal
[ ] Blurred vision   [ ] Blindness  [ ] Photophobia
[ ] Decreased acuity [ +] Dry mouth  [ ] Bleeding gums
[ ] Oral ulcers  [ ] Sore throat    [ ] Epistaxis  [ ] Tinnitus
[ ] Decreased hearing    [ ]Tinnitus [ ] Other: [+]occasional
dbl vision when laying down.

RESPIRATORY:    [] All Normal
[ -] SOB     [ ] DOE    [ ] Can't walk 2 flights     [+ ] Cough-
occasional yellow phlegm/
[ ] Wheeze  [ ] Purulent sputum    [ ] Hemoptysis   [++
]Pleuritic pain
[ ] Other:

CARDIAC:        []  All Normal
[ ] Angina    [ ] Palpitations   [+ ] Edema   [ ] PND
[ ] Orthopnea    [+ ] Chest Pain [ ] Other:

GI:             [] All Normal
[ ] Blood in stool     [ ] Hematemesis     [ ] Odynophagia
[ ] Dysphagia:   [ ] Solids    [ ] Liquids
[ ] Anorexia    [+] Nausea  [] Vomiting   [ ] Reflux
[ -] Diarrhea    [ -] Constipation  [+]  Abd pain  [ ] Other:

GU:             [X] All Normal
[] Dysuria      [ ] Frequency    [ ] Hematuria  []Discharge
[]Menorrhagia

SKIN:           [] All Normal
[ +]Scaling rash of R knee        [ ] Pruritus

MS:             [X] All Normal
[ ] Joint pain    [ ] Jt swelling   [ ] Back pain  [ ] Bony pain

NEURO:          [X] All Normal
[ ] Headache    [ ] Visual changes   [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures   [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache

ENDOCRINE:     [X] All Normal
[ ] Skin changes  [ ] Hair changes   [ ] Temp subjectivity

HEME/LYMPH:    [X] All Normal
[ ] Easy bruising   [ ] Easy bleeding    [ ] Adenopathy

PSYCH:         [x] All Normal
[ ] Mood change        []Suicidal Ideation  [ ] Other:

[X]all other systems negative except as noted above


Past Medical History:
Enlarged prostate
Shingles - 18 months ago and he is on  lyrica
H/o PNA one year ago during which opacities were found, s/p
bronchoscopy.  His PNA was diagnosed as part of an evaluation
for weight loss. He did not have fevers, chills or cough
S/p hernia repair in [**9-/2137**]

Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS:
Son: HCP [**Name (NI) 2491**] [**Name (NI) 87754**]: [**Telephone/Fax (1) 87755**]
Office: [**Telephone/Fax (1) 87756**]

< 65
Cigarettes: [ X] never  [ ] ex-smoker   [x] current Pack-yrs: 10
                       quit: ______
ETOH:       [x] No   [ ] Yes     drinks/day: _____
Drugs: none
Occupation: retired engineer
Migrated from [**Country 532**] in [**2115**]
Marital Status: [X ] Married  [] Single
Lives:          [ ] Alone    [X] w/ family  [ ] Other:
Received influenza vaccination in the past 12 months [ ]Y [X ]N
Received pneumococcal vaccinationin the past 12 months [ +]Y [
]N





>65

ADLS:

Independent of ALL ADLS:

Independent of  ALL IADLS:
At baseline walks: [+]independently [ ] with a cane [ ]wutwalker
[ ]wheelchair at baseliine
H/o fall within past year: [+]Y- walking   []N


Family History:
Sister died of breast cancer
Brother died of lung cancer
Another sibling died of stomach cancer

Physical Exam:
VS: T = 97 P = 86 BP = 108/62 RR 18 O2Sat = 98% on 2L Wt, ht,
BMI
GENERAL: Elderly male laying in bed
Nourishment: At risk, + temporal wasting
Grooming: good
Mentation: Alert, speaks in full sentences. He feels tired
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP, poor
dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at R base
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: distended, slightly firm. Tender to palpation
in RUQ and LUQ
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: 2+ edema b/l, 2+ radial, DP pulses b/l.  R>L edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Normal gait
Psychiatric:  appropriate

On Discharge:
VS: T98.3 BP 138/74 HR 84 RR 18 O2 sat 95%
Gen: pleasant gentleman sitting in chair in NAD
Skin: resolving erythematous rash on back
HEENT: anicteric sclerae, MMM, slight ulceration under tongue,
no exudates
CV: RRR, no murmurs, rubs, gallops
Pulm: slightly decreased breaths sounds in the right base,
otherwise CTAB
Abd: soft, non tender, non distended; pos BS
Extr: 3+ LE edema b/l
Neuro: A&Ox3, CNII-XII intact, motor and sensation grossly
intact

Pertinent Results:
ADMISSION LABS:
[**2137-11-15**] 06:35PM   WBC-8.0 RBC-4.15* HGB-11.9* HCT-33.8* MCV-81*
MCH-28.6 MCHC-35.2* RDW-16.8*
[**2137-11-15**] 06:35PM   NEUTS-60 BANDS-5 LYMPHS-12* MONOS-16* EOS-0
BASOS-0 ATYPS-4* METAS-3* MYELOS-0 NUC RBCS-1*
[**2137-11-15**] 06:35PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2137-11-15**] 06:35PM   PLT SMR-VERY LOW PLT COUNT-77*
[**2137-11-15**] 06:35PM   PT-13.8* PTT-33.0 INR(PT)-1.2*
[**2137-11-15**] 06:35PM   proBNP-909*
[**2137-11-15**] 06:35PM   cTropnT-<0.01
[**2137-11-15**] 06:35PM   GLUCOSE-94 UREA N-27* CREAT-1.1 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-15* ANION GAP-25*
[**2137-11-15**] 07:23PM   D-DIMER-1103*
[**2137-11-15**] 08:45PM   LACTATE-7.9*
[**2137-11-15**] 11:35PM URINE  COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005
[**2137-11-15**] 11:35PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2137-11-15**] 11:35PM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2

MICRO:
[**11-15**] Blood cultures- no growth
[**11-15**] Urine cx- no growth
[**2137-11-18**] 9:29 am SPUTUM      Source: Expectorated.

                            **FINAL REPORT [**2137-11-20**]**

   GRAM STAIN (Final [**2137-11-18**]):
      <10 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2137-11-20**]):
      RARE GROWTH Commensal Respiratory Flora.

[**2137-11-23**] 9:05 am SPUTUM     Site: EXPECTORATED
      ACID FAST CULTURE X 3 TIMES.

   GRAM STAIN (Final [**2137-11-23**]):
      <10 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    SINGLY AND IN PAIRS.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2137-11-25**]):
      MODERATE GROWTH Commensal Respiratory Flora.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


   ACID FAST SMEAR (Final [**2137-11-24**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**12-7**] B glucan- negative
[**12-7**] galactomannan- negative

[**11-19**] IgG 473* IgA 52* IgM 302

STUDIES:
[**11-15**] CTA Chest/Abd/Pelvis:
1. Right upper lobe ground-glass parenchymal opacity, suggestive
of
pneumonia. Multifocal coalescent ground-glass nodules,
predominating upper
lobes but also present in left lower lobe, raise question of
metastatic
involvement. Moderate right pleural effusion.

2. Massive conglomerate aortocaval mass with central areas of
necrosis, which compresses the IVC, right common and external
iliac veins, and likely also right proximal ureter. Extensive
mediastinal, hilar, mesenteric, retroperitoneal, and iliac
lymphadenopathy and massive splenomegaly. Overall picture
suggestive of lymphoma/lymphoproliferative disease.

3. Mildly prominent common bile duct. Please correlate with
liver function
test.

4. Diffuse gallbladder mural edema, likely related to systemic
disease,
unlikely due to cholecystitis.

5. Multiple left renal lesions are incompletely evaluated,
including a 12-mm interpolar left renal lesion (3, 301), which
could be further characterized by ultrasound.

[**11-15**] CT Head- 1. No acute intracranial hemorrhage or mass
effect. 2. Although there is no CT evidence of large
intracranial mass, MRI with gadolinium is superior in evaluation
of such lesions and can be considered if not contraindicated.

[**11-15**] LENI- No evidence of right lower extremity deep venous
thrombosis.

[**11-15**] EKG: ST at 108 bpm, no other acute changes

[**11-18**] Trans thoracic Echo- The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.

[**11-25**] Renal U/S: 1. No evidence of hydronephrosis, with
resolution of the mild hydronephrosis seen on CT [**2137-11-15**]. 2.
Nonvisualization of left renal interpolar region indeterminate
lesion seen on CT scan [**2137-11-15**], due to limited visualization.
For further evaluation,if clinically relevant, an MR could be
performed.

[**12-3**] CXR: The heart size remains normal and no typical
configurational abnormalities is seen. Thoracic aorta, stable
and within normal limits. Position of previously described left
subclavian approach advanced central venous catheter remains
unchanged terminating overlying the SVC at the level of the
carina.  No pneumothorax is seen. In comparison with the next
preceding portable examination, the findings have cleared up
markedly. In particular the basal bilateral densities strongly
suggestive of bilateral pleural effusions as seen on [**2137-11-21**], have now practically cleared completely, as both lateral
and posterior pleural sinuses are free with the patient in
upright position. Also, the parenchymal densities have
regressed; however, significant residuals remain on both sides.
These consist of lateral located hazy parenchymal densities
close to the pleural space at the level of the third and fourth
rib. On the left side these parenchymal densities are also in
peripheral location but somewhat higher up and overlying the
second and third ribs including the corresponding interspace. In
comparison with the preceding single view examination, it is
possible that these parenchymal densities have progressed
slightly and thus, further followup chest examinations in this
patient with history of lymphoma is recommended.

[**12-4**] CT Chest: 1. Widespread peripheral consolidations which
are new or increasing. These are not entirely specific, but the
striking peripheral character of consolidations is very
suggestive of an inflammator etiology such as eosinophilic
pneumonia or organizing pneumonia, either of which could be
associated with a drug reaction. The appearance would be much
less typical for an infectious etiology or progression of
lymphoma, which has apparently responded overall very well to
treatment.

2. New mild extrahepatic biliary ductal dilatation of uncertain
significance. Correlation with liver function tests is
recommended. If the apppearance may be clinically significant
based on laboratory data or clinical presentation, then MRCP
could be considered or follow-up CT or ultrasound. Extrinsic
compression by lymphadenopathy that is not imaged on this study
is a possible, though somewhat unusual, possibility.

[**12-4**] CT Head: 1. No evidence of intracranial metastatic
disease. MR (if feasible) would be more sensitive than CT for
detection of metastatic lesions. 2. No acute intracranial
process.

[**12-9**] CXR: Heart size is normal. Mediastinal position, contour,
and width are unremarkable and stable. The abnormalities
demonstrated on prior chest
radiograph and chest CT appears to be grossly unchanged except
for may be
minimal progression at the level of the left lower lobe and
right upper
superficial area as well as interval development of minimal
amount of pleural effusion on the right. The finding continues
to be nonspecific with the differential diagnosis being broad
including eosinophilic pneumonia, cryptogenic organizing
pneumonia, drug reaction, and less likely infection.

PATHOLOGY:
[**11-17**] Bone marrow biopsy- MARKEDLY HYPERCELLULAR MARROW WITH
EXTENSIVE INVOLVEMENT BY A LYMPHOPROLIFERATIVE DISORDER, MOST
CONSISTENT WITH DIFFUSE LARGE B-CELL LYMPHOMA.

[**11-17**] R axillary lymph node biopsy- DIFFUSE LARGE B CELL
LYMPHOMA, HIGH GRADE.

[**11-17**] Immunophenotyping Flow Cytometry: Immunophenotypic finding
consistent with involvement by a kappa-restricted B-cell
lymphoproliferative disorder.  Correlation with concurrent bone
marrow biopsy (S10-48307G) is recommended.

DISCHARGE LABS:
142  107  15  85   AGap=12
-------------
3.4  26  0.8
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes

Ca: 9.3 Mg: 2.0 P: 2.4
ALT: 35 AP: 226 Tbili: 0.7 Alb: 3.0
AST: 27 LDH: 249 Dbili:  TProt:
[**Doctor First Name **]:  Lip:
UricA:3.2

20.5 > 8.8 < 186
       24.7
N:98.0 L:0.9 M:0.9 E:0.1 Bas:0.1
Other Hematology
Gran-Ct: [**Numeric Identifier 87757**]

PT: 12.9  PTT: 28.1  INR: 1.1

Brief Hospital Course:
ASSESSMENT:
74 year old male with BPH, s/p R inguinal hernia repair present
with pleuritic abdominal/chest pain found to have a extensive
lymphadenopathy throughout torso and aotocaval large
conglomerate mass with compression of IVC and R common iliac
vein.
.
# Lymphoma- Patient was initially admitted to the medical floor
for expedited evaluation of presumed lymhoproliferative disorder
in the setting of CTA which showed bulky lymphadenopathy and
aortocaval large conglomerate mass with
compression of IVC and right common iliac vein. Initial labs in
the ED were remarkable for lactic acidosis with HCO3 of 15 and a
lactate of 7.9. On the medical floor, he was found to have a
uric acid of 13.5 and an LDH of 604 in the setting of normal
calcium/ phosphate/ potassium. He was started on allopurinol and
IVF due to concern for TLS. A heme-onc consult was called and an
axillary LN biopsy showed prelimary path c/w aggressive
lymphoma. Bone marrow biopsy eventually showed diffuse large B
cell lymphoma. Patient was noted to have increased work of
breathing with ABG showing worsening acidosis 7.32/19/111 and
lactate of 11.4. A bicarb drip was initiated and due to concern
for worsening lactic acidosis, patient was transferred to the
ICU. Lactic acidosis was attributed to tumor mass necrosis vs.
infection and patient was started on vanc/zosyn/azithro for
pneumonia visualized on CT chest (see below). He received [**Hospital1 **]
for treatment of his lymphoma and tumor lysis labs were
monitored q6 given his spontaneous tumor lysis syndrome on
admission. He received rasburicase for persistently elevated
uric acid and new renal failure (creatinine 1.3 from 1.0) with
improvement of his symptoms. He became fluid overloaded and was
diuresed with lasix. He was called out to the floor where he
received a round of RCHOP with good effect and no subsequent
tumor lysis. He had some mucositis which was managed with pain
medications and mouth care. He was discharged home on D5 RCHOP
with follow up scheduled in the 7 [**Hospital Ward Name 1826**] outpatient clinic and
a plan to establish care in NY with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**]
(appointment tentatively scheduled for [**12-24**]).

# Pneumonia- Patient had chest CT with ground-glass parenchymal
opacity, suggestive of pneumonia. He was started on
vanco/zosyn/azithro and was continued on these antibiotics for 7
days after he was no longer neutropenic per pulmonary
recommendations. Repeat imaging with CT scan showed widespread
peripheral consolidations concerning for an inflammatory
etiology such as eosinophilic pneumonia or organizing pneumonia,
but ultimately attributed to resolving pneumonia in the setting
of a reconstituted immune system as the patient was asymptomatic
and appeared well. Patient will need repeat imaging in [**12-22**] weeks
after discharge to assess progression.
.
# Rash- Patient developed an erythematous papular eruption on
his back as well as a well demarcated erythematous plaque on his
lower L back. Dermatology was consult and attributed the former
to a resolving drug reaction and that latter to a contact
dermatitis. Triamcinolone was applied topically to the plaque
with gradual improvement.
.
#. Fluid retention: Patient received fluids as part of his
chemotherapy regimen. His weight increased 10 lbs over several
days secondary to fluid retention. He was diuresed with good
effect and subsequently reaccumulated fluid in his legs with the
second round of chemo. He was restarted on lasix and sent home
to continue diuresis with f/u in the outpatient clinic.
.
#. Headache: Patient complained of mild intermittent R
retro-orbital pain without associated visual changes, diploplia,
or floaters. Was seen by opthalmology who attributed his eye
symptoms to dry eyes. CT head w/ and w/o contrast was negative
for bleeds and metastatic disease.
.
# Shingles- Patient complained of continued post herpetic
neuralgia related to his shingles episode six months earlier.
His pain was managed with lidocaine patches and
oxycodone/oxycontin.
.
#. BPH: No active issues. Patient was continued on finasteride
and tamsulosin as his home BPH medications were not on
formulary.

Medications on Admission:
avodart 0.5 mg
uroxatral/alfuzosin alpha 1 blocker 10 mg
Lidoderm patch

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take while you are taking oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours) for 10 days.
Disp:*10 injections* Refills:*0*
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
8. oral wound care products     Gel in Packet Sig: One (1)
Packet Mucous membrane TID (3 times a day) as needed for
Mucositis.
Disp:*20 Packet* Refills:*0*
9. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): Do not
drink or drive while taking this medication.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day:
Please take while taking lasix.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
13. alfuzosin 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Diffuse Large B Cell Lymphoma
Pneumonia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 87754**],

You were admitted to the hospital with chest and abdominal pain.
You had a CT scan of your chest, lymph node and bone marrow
biopsies which showed that you have diffuse large B cell
lymphoma. You received two rounds of chemotherapy while you were
in the hospital. You were also diagnosed with a pneumonia for
which you were treated with antibiotics. You will need to have a
repeat CT of your chest in [**12-22**] weeks to assess the improvement
of this infection. Your body was retaining fluid so you were
started on a water pill to help remove some of this fluid.
Please continue to take this at home as directed until you
follow up on Friday. Please also weigh yourself daily and call
Dr.[**Name (NI) 14047**] office if your weight increases.

We have made the following changes to your medications:
- START taking filgrastim (injections) as directed for your
blood counts
- START taking fluconazole for prevention of infection
- START taking acyclovir for prevention of infection
- START taking ranitidine for your stomach
- START taking oxycontin for your pain; please take colace and
senna as needed while taking this medication to prevent
constipation; do not drive while taking oxycontin as it is
sedating
- START taking lasix for the fluid in your legs
- START taking potassium as directed while taking lasix
- you may use gelclair as needed for mucositis pain in your
mouth

You make continue taking your other medications as you were
previously.

It was a pleasure taking care of you. We wish you a speedy
recovery.

Followup Instructions:
Please come to the 7 [**Hospital Ward Name 1826**] Outpatient Clinic at 10:00AM on
Friday [**12-13**] for tests to check your blood counts and
your chemistries.

Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2137-12-13**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST     Best Parking: Main Garage

You will be contact[**Name (NI) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**] at [**Hospital1 107**] [**Doctor Last Name **]
[**Hospital 87758**] Cancer Center in NY about an appointment on [**12-24**]. If you do not hear from his office regarding the timing of
this appointment please contact him at [**Telephone/Fax (1) 87759**]. In the
meantime, if any issues arise, you have an appointment with Dr.
[**First Name (STitle) **] as below (you can cancel this appointment once your
appointment in NY is finalized):

Department: HEMATOLOGY/BMT
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2137-12-11**]
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Tumor lysis syndrome,Pneumonia, organism unspecified,Defibrination syndrome,Other specified aplastic anemias,Compression of vein,Acidosis,Herpes zoster with other nervous system complications,Acute kidney failure, unspecified,Candidiasis of mouth,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dermatitis due to drugs and medicines taken internally,Contact dermatitis and other eczema, unspecified cause,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}


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: Dysarthria and abdominal pain

PRESENT ILLNESS: EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date:[**2137-11-15**]
PCP:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 10066**] [**Name (STitle) 87750**] 2202 65th Street [**Location (un) **]
Bay Parkway and West 6th Street [**Telephone/Fax (1) 87751**]
GI: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87752**] [**Telephone/Fax (1) 87753**]
_
________________________________________________________________
HPI:
74M s/p recent L hernia repair on [**2137-10-6**] with chest pain,
+pleuritic x 4 weeks, +n/v x 4 weeks, +intermittent abdominal
pain, question recent aphasic episode [**1-22**] pain per family.  He
is currently being evaluated by GI for appetite and minimal
weight loss x 3 weeks.  + Early satiety. Immediately after
eating he regurgitates solid food. No dysphagia for solids or
liquids or signs of aspiration with eating. Slurred speech x 2
days. No facial asymmetry or focal weakness. Increased weakness
and sweats.
He received ASA and SLNG with some improvement in his pain from
[**9-24**].  R>L asymmetric swelling of the lower extremities

MEDICAL HISTORY: Enlarged prostate
Shingles - 18 months ago and he is on  lyrica
H/o PNA one year ago during which opacities were found, s/p
bronchoscopy.  His PNA was diagnosed as part of an evaluation
for weight loss. He did not have fevers, chills or cough
S/p hernia repair in [**9-/2137**]

MEDICATION ON ADMISSION: avodart 0.5 mg
uroxatral/alfuzosin alpha 1 blocker 10 mg
Lidoderm patch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T = 97 P = 86 BP = 108/62 RR 18 O2Sat = 98% on 2L Wt, ht,
BMI
GENERAL: Elderly male laying in bed
Nourishment: At risk, + temporal wasting
Grooming: good
Mentation: Alert, speaks in full sentences. He feels tired
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP, poor
dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at R base
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: distended, slightly firm. Tender to palpation
in RUQ and LUQ
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: 2+ edema b/l, 2+ radial, DP pulses b/l.  R>L edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Normal gait
Psychiatric:  appropriate

FAMILY HISTORY: Sister died of breast cancer
Brother died of lung cancer
Another sibling died of stomach cancer

SOCIAL HISTORY: SOCIAL HISTORY/ FUNCTIONAL STATUS:
Son: HCP [**Name (NI) 2491**] [**Name (NI) 87754**]: [**Telephone/Fax (1) 87755**]
Office: [**Telephone/Fax (1) 87756**] 

### Response:
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Tumor lysis syndrome,Pneumonia, organism unspecified,Defibrination syndrome,Other specified aplastic anemias,Compression of vein,Acidosis,Herpes zoster with other nervous system complications,Acute kidney failure, unspecified,Candidiasis of mouth,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Dermatitis due to drugs and medicines taken internally,Contact dermatitis and other eczema, unspecified cause,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}
