CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: The patient is a 66 year old male with PMHx HTN and recently
diagnosed follicular lymphoma who presents with dyspnea.

MEDICAL HISTORY: 1. Hypertension.
2. Depression.
3. Migraine.
4. Bladder dysfunction.
5. Laminectomy
6. Arthroscopy
7. Sinus reconstruction
8. Varicocele

MEDICATION ON ADMISSION: Allopurinol 300 mg daily
Diovan daily
Lipitor 20 mg daily
Lasix 20mg daily
ProAir as needed
multivitamin
magnesium
B12
fish oil

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: NC
- Father: Bladder cancer
- Sister: Breast cancer
- No history of lymphoma or immune disorders

SOCIAL HISTORY: He is married.  He has 2 grown children.  1 of his sons is
getting married in [**Name (NI) **].  He was a non cigarette smoker but he
was a regular marijuana user particularly over the last 3 to 4
years, often daily, although he quit in [**Month (only) 958**].  No significant
alcohol.  He is a retired electrical engineer, retiring about a
year and a half ago.  He lives in [**Location 620**] with his wife.  [**Name (NI) **] had
been quite active going to a gym and doing some water aerobics
until the last 3 to 4 weeks.
Nodular lymphoma, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Malignant pleural effusion,Malignant ascites,Paroxysmal supraventricular tachycardia,Unspecified essential hypertension,Edema,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Prickly heat
Ndlr lym unsp xtrndl org,Acute respiratry failure,Malignant pleural effusn,Malignant ascites,Parox atrial tachycardia,Hypertension NOS,Edema,Depressive disorder NEC,Anxiety state NOS,Prickly heat
Admission Date:  [**2163-4-24**]              Discharge Date:   [**2163-5-4**]

Date of Birth:  [**2097-1-13**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 38616**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
-Thoracentesis
-Paracentesis
-Pleurex Catheter Placement.


History of Present Illness:
The patient is a 66 year old male with PMHx HTN and recently
diagnosed follicular lymphoma who presents with dyspnea.

The patient has been undergoing workup of lymphoma since [**Month (only) 404**]
when he developed night sweats and weight loss.  He started
noting increase in abdominal girth in [**Month (only) 958**], which progressed to
include DOE as well.  Imaging showed ascites, pleural effusion,
and diffuse LAD.  On [**4-15**], he had a paracentesis with 3L
removed.  He was admitted to BIDN on [**2163-4-18**] for expedited
workup given his symptoms.  During that admission, he underwent
a lymph node biopsy w/ Dr. [**First Name (STitle) 2819**] on [**4-19**], and on [**4-20**] had
ultrasound-guided paracentesis done of 2300 mL and a
thoracentesis was done of 1200 mL.  He was seen by Dr. [**Last Name (STitle) 3274**]
of Oncology with plans for follow up visit next week to discuss
the results of the biopsies.  He was sent home on lasix 20mg
daily which he has been taking.  Since his discharge though, he
has felt increasingly unwell, with fatigue, worsening shortness
of breath, and increased abdominal girth since then as well.  He
has had persistent leg edema as well, left greater than right -
an ultrasound during his last admission was negative for DVT.
He initially presented to [**Location (un) 620**] where CXR showed large pleural
effusion.  He was initially hypotensive which improved after
1LNS, then he was transferred to [**Hospital1 18**] for further workup.

In the ED, initial VS were: 97.3 100 117/67 24 99%.  Labs showed
leukocytosis to 13, Cr of 1.3, lactate of 2.6. ABG showed
7.41/40/343/26.  He was given 1 additional liter NS,
ceftriaxone/azithromycin as pneuomnia could not be excluded,
nebs, and was placed on CPAP which gave him marked improvement
in his respiratory status.  On transfer, vitals were systolic
105, RR 24, O2 100% on NIVVP, 86.

On arrival to the MICU, patient's VS.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies  shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies  constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
1. Hypertension.
2. Depression.
3. Migraine.
4. Bladder dysfunction.
5. Laminectomy
6. Arthroscopy
7. Sinus reconstruction
8. Varicocele

Social History:
He is married.  He has 2 grown children.  1 of his sons is
getting married in [**Name (NI) **].  He was a non cigarette smoker but he
was a regular marijuana user particularly over the last 3 to 4
years, often daily, although he quit in [**Month (only) 958**].  No significant
alcohol.  He is a retired electrical engineer, retiring about a
year and a half ago.  He lives in [**Location 620**] with his wife.  [**Name (NI) **] had
been quite active going to a gym and doing some water aerobics
until the last 3 to 4 weeks.


Family History:
NC
- Father: Bladder cancer
- Sister: Breast cancer
- No history of lymphoma or immune disorders


Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

Discharge Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Left lung reduced air entry to mid-chest. Left pleurex
catheter in place.  right lung clear to air entry with reduced
air entry at the lung base.
Abdomen: distended, no leakage at paracentesis sites, bowel
sounds present, no organomegaly, no tenderness to palpation, no
rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Mild edema bilaterally, left worse than right.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

Pertinent Results:
Admission Labs:
[**2163-4-24**] 02:40AM BLOOD WBC-13.4* RBC-4.70 Hgb-13.3* Hct-42.6
MCV-91 MCH-28.3 MCHC-31.2 RDW-16.2* Plt Ct-225
[**2163-4-24**] 02:40AM BLOOD Neuts-72.8* Lymphs-18.8 Monos-6.7 Eos-1.0
Baso-0.7
[**2163-4-24**] 02:40AM BLOOD PT-11.2 PTT-26.9 INR(PT)-1.0
[**2163-4-24**] 02:40AM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-136
K-4.3 Cl-100 HCO3-22 AnGap-18
[**2163-4-24**] 02:40AM BLOOD ALT-12 AST-31 LD(LDH)-244 AlkPhos-73
TotBili-0.5
[**2163-4-24**] 02:40AM BLOOD Lipase-35
[**2163-4-24**] 02:40AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.1
UricAcd-6.3
[**2163-4-24**] 03:01AM BLOOD Lactate-2.6*
[**2163-4-24**] 05:18AM BLOOD Type-ART Temp-36.7 PEEP-5 FiO2-100
pO2-343* pCO2-40 pH-7.41 calTCO2-26 Base XS-1 AADO2-336 REQ
O2-61 Intubat-NOT INTUBA

[**Hospital3 **]:
[**2163-4-24**] 02:40AM BLOOD Triglyc-274*
[**2163-4-24**] 02:40AM BLOOD HBsAb-PND
[**2163-4-24**] 02:40AM BLOOD b2micro-PND

Ascites:
[**2163-4-24**] 01:59PM ASCITES WBC-[**Numeric Identifier 38617**]* RBC-4000* Polys-3*
Lymphs-95* Monos-2*
[**2163-4-24**] 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1
LD(LDH)-108 Albumin-2.2 Triglyc-379
[**2163-4-24**] 01:59PM OTHER BODY FLUID IPT-PND
[**2163-4-24**] 04:48PM BONE MARROW [**Doctor Last Name 4427**]-PND

Discharge Labs:
[**2163-5-4**] 06:10AM BLOOD WBC-8.0 RBC-4.22* Hgb-12.0* Hct-37.6*
MCV-89 MCH-28.5 MCHC-32.0 RDW-16.8* Plt Ct-365
[**2163-5-3**] 06:06AM BLOOD Neuts-74.6* Lymphs-14.7* Monos-6.4
Eos-3.4 Baso-0.9
[**2163-5-4**] 06:10AM BLOOD Plt Ct-365
[**2163-5-4**] 06:10AM BLOOD PT-10.9 PTT-30.0 INR(PT)-1.0
[**2163-5-4**] 06:10AM BLOOD Fibrino-414*
[**2163-5-4**] 06:10AM BLOOD
[**2163-5-4**] 06:10AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-138
K-4.4 Cl-104 HCO3-27 AnGap-11
[**2163-5-4**] 06:10AM BLOOD ALT-11 AST-18 LD(LDH)-137 AlkPhos-49
TotBili-0.2
[**2163-5-4**] 06:10AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1 UricAcd-5.5

[**2163-4-28**] 03:00PM PLEURAL WBC-5040* RBC-9900* Polys-7* Lymphs-81*
Monos-4* Meso-5* Macro-3*
[**2163-4-25**] 04:45PM PLEURAL WBC-4075* RBC-[**Numeric Identifier 34864**]* Polys-4*
Lymphs-84* Monos-0 Macro-12*
[**2163-4-28**] 03:00PM PLEURAL Glucose-126 Creat-1.1 LD(LDH)-122
Triglyc-75
[**2163-4-25**] 04:45PM PLEURAL TotProt-2.9 Glucose-144 LD(LDH)-93
Albumin-2.3 Cholest-53 Triglyc-62
[**2163-5-3**] 03:44PM ASCITES WBC-8389* RBC-3167* Polys-6* Lymphs-85*
Monos-2* Mesothe-1* Macroph-3* Other-3*
[**2163-4-28**] 09:06AM ASCITES WBC-6125* RBC-[**Numeric Identifier 30005**]* Polys-4* Lymphs-4*
Monos-0 Mesothe-1* Macroph-1* Other-90*
[**2163-4-24**] 01:59PM ASCITES WBC-[**Numeric Identifier 38617**]* RBC-4000* Polys-3*
Lymphs-95* Monos-2*
[**2163-5-3**] 03:44PM ASCITES TotPro-2.4 Glucose-107 LD(LDH)-99
Albumin-1.9
[**2163-4-28**] 09:06AM ASCITES TotPro-2.5 Glucose-163 Creat-1.1
LD(LDH)-84 Amylase-29 TotBili-0.2 Albumin-2.1
[**2163-4-24**] 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1
LD(LDH)-108 Albumin-2.2 Triglyc-379
[**2163-4-24**] 01:59PM OTHER BODY FLUID CD23-DONE CD45-DONE
HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 38618**] CD10-DONE CD19-DONE CD20-DONE Lamba-DONE
CD5-DONE
[**2163-4-24**] 01:59PM OTHER BODY FLUID CD3-DONE
[**2163-4-24**] 01:59PM OTHER BODY FLUID IPT-DONE
[**2163-4-24**] 04:48PM BONE MARROW [**Doctor Last Name 4427**]-DONE

Microbiology:
[**2163-4-24**] 1:59 pm PERITONEAL FLUID
   GRAM STAIN (Final [**2163-4-24**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..
   FLUID CULTURE (Preliminary):
   ANAEROBIC CULTURE (Preliminary):

HBV Viral Load (Final [**2163-4-27**]):
      HBV DNA not detected.
Blood and urine cultures pending
.
[**2163-5-3**] 3:44 pm PERITONEAL FLUID      PERITONEAL FLUID.

   GRAM STAIN (Final [**2163-5-3**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2163-5-6**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

Imaging:
[**4-26**] TTE:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is high (>4.0L/min/m2). Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.

IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild
pulmonary artery hypertension. Dilated ascending aorta. No
pericardial effusion. Bilateral pleural effusions.

[**4-26**] LENIs:
IMPRESSION: No evidence of DVT in the right or left leg.
Enlarged lymph
nodes in the inguinal regions bilaterally.

[**4-27**] CXR:
IMPRESSION:
1. Stable large left pleural effusion and small right pleural
effusion.
2. Atelectasis at the left base

[**4-24**] Bone Marrow Biopsy
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
     Hypercellular bone marrow with extensive involvement by
follicular lymphoma
MICROSCOPIC DESCRIPTION

Peripheral Blood Smear:

The smear is adequate for evaluation.   Red blood cells are
normochromic and normocytic with anisopoikilocytosis including
frequent burr cells, occasional elliptocytes, and macrocytes are
seen.  Rare nuclear RBC's are seen.  The white blood cell count
appears normal.  A subset of lymphocytes are atypical and
display a cleaved nuclear morphology.    Platelet count appears
normal and giant forms are not seen.   Differential shows   74%
neutrophils,  8% monocytes,   17% lymphocytes,  1% eosinophils.


Aspirate Smear:

The aspirate material is suboptimal for evaluation due to
paucity of spicules.   M:E ratio is 2:1.  Erythroid precursors
are  normal in number and exhibit dyspoietic forms with
irregular nuclear contours, asymmetric nuclear budding.  Myeloid
precursors appear normal in number and show normal maturation.
Occasional abnormal nuclear lobation and pseudo Pelger [**Doctor Last Name **]??????t
forms are seen.  Megakaryocytes are present in normal; abnormal
forms are seen including several hypolobated forms,
micromegakaryocytes, forms with disjointed nuclei.  Small
cleaved lymphocytes are seen; no large lymphoid cells are seen.


A  500 cell differential shows:  1% Blasts,  2% Promyelocytes,
6% Myelocytes, 5% Metamyelocytes, 30% Bands/Neutrophils, 1%
Plasma cells,  35% Lymphocytes, 20% Erythroid.

Clot Section and Biopsy Slides:

The core biopsy material is adequate for evaluation.   It
consists of a 0.9 cm core biopsy, trabecular marrow with a
cellularity of over 90%.   Approximately 70% of marrow
cellularity is comprised of atypical lymphocytes with scant
cytoplasm and irregularly shaped nuclei; focal areas (<10%) of
larger cells (centroblasts) with more open chromatin and
nucleoli are seen.  In the remaining cellularity, M:E ratio
estimate is normal.   Erythroid precursors exhibit overall
normoblastic maturation.   Myeloid precursors have complete
maturation to neutrophilic stage.   Megakaryocytes are present
and are loosely clustered focally.

ADDITIONAL STUDIES:

Flow cytometry:  See separate report - shows involvement by
Follicular lymphoma.

[**4-24**] Peritoneal fluid cytology
Peritoneal fluid:

  ATYPICAL.

  Numerous monomorphic small atypical lymphocytes.

[**4-24**] Peritoneal Fluid flow Cytometry
FLOW CYTOMETRY IMMUNOPHENOTYPING

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

RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield.
Lymphoid cells comprise 83% of total analyzed events.
B cells comprise 66% of lymphoid gated events and have a slight
Kappa predominance (Kappa gain).  They co-express pan B-cell
markers CD19, 20, along with CD10, FMC-7.  They do not express
any other characteristic antigens including CD5, CD23.
T cells comprise 28% of lymphoid gated events and express mature
lineage antigens (CD3, CD5).
INTERPRETATION
Immunophenotypic findings consistent with involvement by
follicular lymphoma.  Correlation with clinical findings and
morphology (see S12-20136K) is recommended.

[**4-25**] Pleural fluid cytology
Pleural fluid:

  Numerous lymphoid cells. Please also see corresponding
  flow cytometry report (S12-[**Numeric Identifier **]).

  Mesothelial cells and macrophages are also present.

[**2163-4-25**] Cytogenetics
KARYOTYPE:
nuc ish(MYCx2)[100],(IGH@,BCL2)x4(IGH@ con BCL2x3)[78/100]

Culture of this peritoneal fluid did not yield metaphase
cells for analysis, therefore the chromosome analysis could
not be performed.

FISH analyses of interphase nuclei with the IGH@/BCL2 and
MYC probes were interpreted as ABNORMAL for the IGH@/BLC2
probes, consistent with rearrangement of these loci with an
additional fusion signal seen. The MYC probe hybridization
was interpreted as normal. Please see below for details of
the FISH analyses.


FISH DETAILS:
FISH evaluation for an IGH@-BCL2 rearrangement was
performed on nuclei with the LSI IGH@/BCL2 Dual Color,
Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for
IGH@ at 14q32 and BCL2 at 18q21 and is interpreted as
ABNORMAL. Rearrangement was observed in 78/100 nuclei,
which exceeds the normal range (up to 1%) established for
these probes in the Cytogenetics Laboratory at [**Hospital1 18**]. An
additional fusion signal was seen in all abormal cells.
IGH@-BCL-2 rearrangement is a typical cytogenetic
aberration in a subset B-cell lineage non-Hodgkin's
lymphoma of follicular center cell origin.

FISH evaluation for a MYC rearrangement was performed on
nuclei with the LSI MYC Dual Color Break Apart
Rearrangement Probe ([**Doctor Last Name 7594**] Molecular) at 8q24 and is
interpreted as NORMAL. No rearrangement was observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 4% of cells in normal samples can show
apparent MYC rearrangement using this probe set. A normal
MYC FISH finding can result from absence of a MYC
rearrangement, from an atypical MYC rearrangement, or from
an insufficient number of neoplastic cells in the
specimen.

These FISH tests were developed and their performance
determined by the [**Hospital1 18**] Cytogenetics Laboratory as
required by the CLIA '[**38**] regulations. They have not been
cleared or approved by the U.S. Food and Drug
Administration. The FDA has determined that such clearance
or approval is not necessary. These tests are used for
clinical purposes.


This study was necessary for the analysis
of this specimen.


This study was necessary for the analysis
of this specimen.


This study was necessary for the analysis
of this specimen.


This study was necessary for the analysis
of this specimen.

[**2163-4-29**] Immunophenotyping
FLOW CYTOMETRY REPORT

FLOW CYTOMETRY IMMUNOPHENOTYPING

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

RESULTS

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

Lymphoid cells comprise 1% of total analyzed events.

B cells are scant in number precluding evaluation of clonality.


Within the monocytoid cell / large cell gate, there is a small
population of CD10 positive events, which shows dim CD20 gain
(an artifact cannot be excluded).  These events do not express
CD19. In addition, they do not have light chain (bright)
expression.

T cells comprise 80% of lymphoid gated events,and express mature
lineage antigens CD3,CD5).

INTERPRETATION:

Diagnostic immunophenotypic features of involvement by 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 of sample preparation.

[**2163-5-3**] Paracentesis
Uneventful diagnostic and therapeutic paracentesis with removal
of 4 liters of milky ascitic fluid.

[**2163-5-4**] CXR
In comparison with study of [**5-1**], there has been placement of a
left Pleurx catheter with removal of substantial amount of
pleural fluid.  No definite pneumothorax.  Atelectatic changes
persist at the bases and there is mild blunting of the right
costophrenic angle.


Brief Hospital Course:
66 y/o male with new diagnosis of follicular lymphoma who p/w
dyspnea, found to have recurrent large pleural effusion.
.
ACTIVE ISSUES:
.
# Respiratory distress - The likely cause of his respiratory
distress is the large left pleural effusion, which is likely due
to lymphoma.  He also had significant ascites causing increased
diaphragmatic pressure.  Paracentesis successfully removed 2L of
fluid and relieved his breathing, although he remained on oxygen
support.  Thoracentesis was performed on [**4-25**] with about 1.2L of
fluid removal; no antibiotics were initiated.  One Light's
criteria was met but was borderline (Pleural fluid protein /
Serum protein >0.5), likely c/w exudate [**1-20**] lymphoma. Given the
rapid reaccumulation of fluid from malignant etiology (confirmed
by flow cytometry of pleural fluid), the patient needed more
definitive therapy either via initiation of treatment for
lymphoma or eradication of pleural space. He subsequently
received treatment with bendamustine and rituximab as below, but
continued to reaccumulate pleural effusions requiring recurrent
thoracentesis.  We eventually decided to place a left-sided
pleurx catheter to allow frequent drainage of his malignant
pleural effusions.
.
# Lymphoma - Paracentesis from [**Location (un) 620**] showed cells c/w
follicular lymphoma, his lymph node biopsy was also c/w
follicular lymphoma.  CT torso from [**Location (un) 620**] showed substantial
lymphadenopathy throughout the abdomen.  He was initiated on
dexamethasone [**4-24**] for a planned 4 day course.  Tumor lysis labs
were followed and the patient was provided aggressive hydration.
 Allopurinol was also provided to avoid hyperuricemia.  Provided
acyclovir to prevent HSV reactivation, particularly given
history of post-herpetic neuralgia in legs.  Bone marrow biopsy
performed [**4-24**] was consistent with follicular lymhpoma.  The
patient was transferred to the Oncology service with the
intention of initiating chemotherapy, and started on
bendamustine as well as rituximab.  On first receiving
rituximab, he developed a bas reaction, with tachycardia,
hypertension and rigors.  Infusion was stopped.  The patient was
temporarily transferred to the intensive care unit to receive
rituximab via a 24 hour desensitization protocol.  During the
desensitization, he had a mild episode of tightness in his chest
with no decrease on O2 saturation.  He improved with nebilizers
and was able to be transferred back to floor immediately after
the infusion.  He did however, continue to rapidly reaccumulate
both pleural effusions and ascites, with multiple thoracenteses
and paracenteses, and eventual placement of a pleurx catheter as
above.  He will followup with Dr. [**Last Name (STitle) 3759**] and Dr. [**Last Name (STitle) 3274**] for
further care as an outpatient.

# Ascites: Malignant ascites consistent with follicular
lymphoma.  He underwent three diagnostic and therapeutic
paracenteses during his hospital stay, the first two on the
floor and the third with IR-guidance and removal of 4L ascitic
fluid.  He will need to followup for furtehr therapeutic
paracenteses.

# Lower extremity edema (L>R) - ultrasound of the LLE ([**Hospital1 **]
[**Location (un) 620**]) showed no DVT.  On exam he has L>R lymphadenopathy.  CT
showed massive abdominal and pelvic lymphadenopathy that likely
caused venous compression leading to asymmetric edema.  Repeat
RLE USS also showed no evidence of DVT.  His inguinal
lymphadenopathy and lower extremity edema had improved somewhat
following chemotherapy.
.
#Paroxysmal AVT - Patient had multiple episodes of SVT to the
170s during his time in the [**Hospital Unit Name 153**].  He complained only of
palpitations and remained hemodynamically stable.  He broke
spontaneously and did not require vagal maneuvers or
pharmacologic agents.  The patient had experienced these
episodes at home as well, however they had become more frequent
since his admission to [**Hospital1 18**] and initiation of chemo.  He was
started on a low dose of metoprolol 12.5mg [**Hospital1 **] in an attempt to
suppress these episodes.
.
# Hypertension - Patient was hypotensive on initial presentation
to [**Location (un) 620**] which improved with fluids.  He was normotensive on
transfer to [**Hospital1 18**].
.
Transitional Issues:
- He weill require close outpatient followup with Drs [**Last Name (STitle) 3759**]
and [**Name5 (PTitle) 3274**] for ongoing management of his follicular lymphoma.
He will also need to followup with interventional pulmonology
for management of his pleurx catheter and recurrent pleural
effusions.  Dr. [**Last Name (STitle) 3274**] will also arrange for recurrent
therapeutic paracenteses as needed.

Medications on Admission:
Allopurinol 300 mg daily
Diovan daily
Lipitor 20 mg daily
Lasix 20mg daily
ProAir as needed
multivitamin
magnesium
B12
fish oil


Discharge Medications:
1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*90 Tablet(s)* Refills:*0*
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs * Refills:*0*
5. multivitamin     Capsule Sig: One (1) Capsule PO once a day.

6. Fish Oil 300 mg Capsule Oral
7. cyanocobalamin (vitamin B-12)  Oral
8. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 30 days.
Disp:*qs Tablet(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
14. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
15. oxycodone 5 mg Capsule Sig: [**12-20**] Capsules PO every 4-6 hours
as needed for pain: do not take if drowsy.  Do not drive or
operate heavy machinery while taking this medication.
Disp:*10 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Follicular Lymphoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


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

It was a pleasure taking care of you at the [**Hospital1 771**].  You were admitted with shortness of
breath and abdominal distension from fluid accumulating in your
abdomen and lungs due to follicular lymphoma.  We performed
multiple taps to drain the fluid from your lungs and abdomen,
and placed a catheter in your left chest to allow frequent
drainage of the pleural effusions.  Analysis of the fluid was
consistent with follicular lymphoma, and no other malignant or
infectious process was identified.

While you were here, we also treated you with bendamustine and
rituximab.  You initially developed a reaction to rituximab, but
subsequently underwent uneventful desensitization in the ICU.
Please followup with Drs. [**Last Name (STitle) 3759**] and [**Name5 (PTitle) 3274**] following
discharge, for ongoing management of your follicular lymphoma.

During your hospitalization, you had a number of episodes of a
fast heart rate.  We started you on medication (metoprolol) to
slow down your heart.  Please continue taking this medication
following discharge.

We made the following changes to your medications:

STOPPED
-Valsartan

STARTED
-Escitalopram for anxiety
-Acyclovir and Bactrim to prevent infections
-Metoprolol for blood pressure and heart rate
-Senna and Sodium Docusate to help move your bowels
-Ondansetron for nausea

Please continue taking your other medications as usual.

Followup Instructions:
Department: HEMATOLOGY/BMT
When: FRIDAY [**2163-5-6**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2163-5-6**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], 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 [**2163-5-9**] at 2:00 PM [**Telephone/Fax (1) 38619**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: Thoracic
Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
  MULTI-SPECIALTY THORACIC UNIT-CC9
When: [**2163-5-19**] at 11:00a
With: Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 3373**]


                             [**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**]

Completed by:[**2163-5-7**]
{'Nodular lymphoma, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Malignant pleural effusion,Malignant ascites,Paroxysmal supraventricular tachycardia,Unspecified essential hypertension,Edema,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Prickly heat'}


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: dyspnea

PRESENT ILLNESS: The patient is a 66 year old male with PMHx HTN and recently
diagnosed follicular lymphoma who presents with dyspnea.

MEDICAL HISTORY: 1. Hypertension.
2. Depression.
3. Migraine.
4. Bladder dysfunction.
5. Laminectomy
6. Arthroscopy
7. Sinus reconstruction
8. Varicocele

MEDICATION ON ADMISSION: Allopurinol 300 mg daily
Diovan daily
Lipitor 20 mg daily
Lasix 20mg daily
ProAir as needed
multivitamin
magnesium
B12
fish oil

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: NC
- Father: Bladder cancer
- Sister: Breast cancer
- No history of lymphoma or immune disorders

SOCIAL HISTORY: He is married.  He has 2 grown children.  1 of his sons is
getting married in [**Name (NI) **].  He was a non cigarette smoker but he
was a regular marijuana user particularly over the last 3 to 4
years, often daily, although he quit in [**Month (only) 958**].  No significant
alcohol.  He is a retired electrical engineer, retiring about a
year and a half ago.  He lives in [**Location 620**] with his wife.  [**Name (NI) **] had
been quite active going to a gym and doing some water aerobics
until the last 3 to 4 weeks. 

### Response:
{'Nodular lymphoma, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Malignant pleural effusion,Malignant ascites,Paroxysmal supraventricular tachycardia,Unspecified essential hypertension,Edema,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Prickly heat'}
