CHIEF COMPLAINT: Neutropenic fever
Confusion

PRESENT ILLNESS: 66-year-old male with MDS, normal pressure hydrocephalus, CAD,
HTN who presented to the [**Hospital1 18**] with neutropenic fever and
respiratory symptoms. He was admitted on [**2164-10-21**] with URI sx
with 2 days of sore throat and this progressed to a dry cough
and was fatigued. He was noted by his wife to be tired and
llethargic and mildly confused at 7am was found by his wife in
the bedroom after having knocked some things over after having
taken some cough syrup and complained off "dizziness" and was
put back into bed. His wife put him to bed and by 9am he was not
appropriately responsive and had the urge to urinate but was
unable to get off the bed and was mildly confused (does not
recall any of these events now and this history was from his
wife). Prior to the ambulance arriving his wife took his temp in
addition to the night before with no pyrexial epispiked noted.
on arrival to the [**Location (un) 620**] ED where initial VS were T 98.8, HR
90, BP 156/61, RR 20, O2 sat 90% on RA and he spiked a fever to
103 and was markedly confused and disoriented and was unable to
recognize his wife and daughter. CXR revealed no pneumonia
although a pulmonary vs line source was suspected (has a
Portacath) and therefore was commenced on IV vanc and cefepime
for febrile neutropenia.He received tylenol 650 mg PR, cefepime
2g IV and vancomycin infusion was started but not completed.
On arrival to the [**Hospital1 18**] ED vital signs were T 102, HR 91, BP
151/68, RR 16, O2 sat 94% 3L NC. On exam patient was A&O x 3,
but very slow and lethargic, taking 1.5 minutes to answer
orientation questions. His port-a-cath site was warm but not
erythematous. He was wheezing. Per report there was difficulty
accessing it. Lactate here was 1.7. Neurosurgery was consulted
and reviewed the CT head images from the OSH and felt that there
was no interval progression of the NPH. He received 1L NS,
vancomycin 1g IV, and nebs.
He was transferred to the ICU for close observation and CT was
unchanged from prior. His Portacath was warm but not
erythematous and did not appear cellulitic. There was however
some difficulty in accessing it. Head CT was reviewed by
neurosurgery
In ICU he was continued on broad spectrum antibiotics adding
azithromycin and he was investigated for possible causes with
rapid respiratory viral screen and a legionella urinary antigen
which were all negative. His confusion improved and he did not
have an LP. Azithromycin was stopped and he was continued on
vancomycin and cefepime with ciprofloxacin started for
additional Gram -ve coverage. His O/P neurologist was contact[**Name (NI) **]
regarding his admission in light of his NPH. repeat CXR on read
felt to be deem at the right base which were postulated to be
due to recent transfusion or drug reaction. Given a possibly new
murmur, he went. On to have a TTE which showed a mildly dilated
LA and EF 65-70% and was otherwise normal. There was no growth
to date on [**Hospital1 **] [**Location (un) 620**] cultures and a CMV VL is pending. On
[**10-22**], he developed [**1-8**] CP and had some T wave inversion on
telemetry in the setting of coming off O2 and arising to urinate
and this resolved with O2. His home anti-hypertensives we ere
restarted and cardiac enzymes were negative x2. He had further
chest pain at 03:26 on [**10-23**] and there was evidence at this time
of ST depressions and flipped T waves however ECG was unchanged.
This resolved with S/L nitroglycerine. Repeat CXR on [**10-23**] still
showed continued pulmonary congestive changes. The chest pain
was felt likely to be demand ischemia in the context of
infection and anemia - he has angina managed witty isosorbide
mononitrate at baseline. his lisinopril was gradually restarted.
By [**10-22**] his confusion had improved 85% and by [**10-23**] he was
pretty much back to his baseline. In addition he was found to be
diabetic on the ICU with high fingerstick blood sugars and an
HbA1c of 8.3%.
He had a profound thrombocytopenia and s last transfused on
[**10-21**] and was transfused 2 units of RCC on [**10-23**] due to a HCt of
19 in the setting of demand ischemia. On discussion with Dr [**Last Name (STitle) 724**]
(neurology) and Dr [**Last Name (STitle) 30635**] (neurosurgery) the plans for VP shunt
placement for his NPH have been deferred to [**Month (only) **] due to his
current infection.
On arrival to the BMT unit, his vitals were T 97.1 BP 142/72 HR
68 RR 16 sO2 100% RA. he currently feels well with no further
chest pain (states when he "over stresses" and when anaemic).
Still has a mild cough which has been unproductive. He has had
no deferasirox since being in hospital.
.
Review of systems:
(+) Per HPI, + nasal congestion + chronic diarrhea related to
deferasirox. He has had no bowel movements since [**10-21**].
(-) Denies headache, sinus tenderness. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure, or
palpitations. Denies nausea, vomiting, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes. No sweats or tremors.

MEDICAL HISTORY: CAD, s/p ant MI [**2139**], with hx LAD and RCA blockages. No stents
or angioplasties.
Angina - once weekly depending on anemia and stress levels
normally lasting 10-15 mins and resolves with nitro. Describes
as a squeezing central/left chest pain with no radiation usually
but can rarely will rarely feel in these locations. No
nausea/vomiting or sweating.
PVD
OSA on CPAP with morbid obesity
History of possible TIA [**2162**] ? CVA - had resolution of eye
position abnormalities over a few days
MDS with thrombocytopenia and anemia dx [**2159**]
Hypertension
Hypercholesterolemia
Asthma, cold-induced
s/p ruptured appendix
s/p right carotid endarterectomy several years ago
.
Hematologic Hx
longstanding history of myelodysplastic disorder
associated with severe pancytopenia, now red cell and platelet
transfusion requiring. Initially diagnosed [**2160-1-30**] when
his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], obtained a
complete blood countas a part of routine maintenance physical
examination. At that
time, he anemia, a low platelet count, and a borderline low
white
blood count. He was treated briefly with azacitidine (Vidaza)
with 4 cycles in [**State 108**] but his disease did not stabilize. He
has been getting PRBC's and platelet tranfusions, as well as
iron chelation with deferasirox (Exjade). There is current
discussion regarding his candidacy for BMT and it seems that the
general feeling is that a patient with his cardiac status would
be at too higher risk to go ahead with an allogeneic transplant
but there is currrent discussion with his cardiologist Dr
[**Last Name (STitle) **]. In the past it has been felt that he was not a candidate
for any kind of stenting procedure because of his significant
thrombocytopenia

MEDICATION ON ADMISSION: Medication upon Admission to ICU:
Bisoprolol fumarate [Zebeta] 15 mg [**Hospital1 **] (am/pm)
Deferasirox [Exjade] [**2153**] mg daily (pm)
Esomeprazole magnesium [Nexium] 40 mg daily (pm)
Ranitidine 150 mg daily (HS)
Folic acid 1 mg daily (am)
Isosorbide dinitrate 40 mg TID (am, noon, pm)
Lisinopril 20 mg daily
Pravastatin 40 mg daily (pm)
Tamsulosin [Flomax] 0.4 mg daily (pm)
Oxybutynin [**Last Name (un) **] 5 mg daily (HS)
Vitamin B6
Cyanocobalamin (vitamin B-12) 1,000 mcg daily
Multivitamin daily
Vitamin D
Potassium gluconate dose unknown

ALLERGIES: Ampicillin

PHYSICAL EXAM: Physical Exam on ICU Admission:
Vitals: T: 103.2 BP: 135/60 P: 102 R: 20 O2: 98% 2L NC
General: Older, obese Caucasian male in NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles L>R. No wheezes.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Father died of non-smoking related lung cancer
Mother died of coronary artery disease, CCF and
hypercholesterolemia also had a AAA repair
Sister who had coronary artery disease and underwent a 4-vessel
CABG.
Daughter is healthy.

SOCIAL HISTORY: Lives with wife in house with stairs
No walking aids but holds onto walls and door-knobs but can walk
to the car and can walk 20-50 yards limited by claudication and
back pain
He previously worked as a computer programmer and retired.
Ex-smoker quit 20 years ago previously 3 packs per day for 25
years.
Alcohol - He has 1 to 2 Scotches per week but can go weeks
without drinking.
He does not use illicit drugs
No recent foreign travel
Pets - 1 dog and 2 cats
Neutropenia, unspecified,Viral pneumonia, unspecified,Idiopathic normal pressure hydrocephalus (INPH),Fever presenting with conditions classified elsewhere,Herpes simplex without mention of complication,Myelodysplastic syndrome, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anemia of other chronic disease,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Other and unspecified angina pectoris,Asthma, unspecified type, unspecified,Morbid obesity,Body Mass Index 33.0-33.9, adult,Unspecified disorder of adrenal glands,Thrombocytopenia, unspecified
Neutropenia NOS,Viral pneumonia NOS,Norml pressure hydroceph,Fever in other diseases,Herpes simplex NOS,Myelodysplastic synd NOS,DMII wo cmp nt st uncntr,Esophageal reflux,BPH w/o urinary obs/LUTS,Crnry athrscl natve vssl,Hypertension NOS,Anemia-other chronic dis,Tobacco use disorder,Obstructive sleep apnea,Angina pectoris NEC/NOS,Asthma NOS,Morbid obesity,BMI 33.0-33.9,adult,Adrenal disorder NOS,Thrombocytopenia NOS
Admission Date:  [**2164-10-21**]              Discharge Date:   [**2164-11-2**]

Date of Birth:  [**2098-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Ampicillin

Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Neutropenic fever
Confusion

Major Surgical or Invasive Procedure:
none


History of Present Illness:
66-year-old male with MDS, normal pressure hydrocephalus, CAD,
HTN who presented to the [**Hospital1 18**] with neutropenic fever and
respiratory symptoms. He was admitted on [**2164-10-21**] with URI sx
with 2 days of sore throat and this progressed to a dry cough
and was fatigued. He was noted by his wife to be tired and
llethargic and mildly confused at 7am was found by his wife in
the bedroom after having knocked some things over after having
taken some cough syrup and complained off "dizziness" and was
put back into bed. His wife put him to bed and by 9am he was not
appropriately responsive and had the urge to urinate but was
unable to get off the bed and was mildly confused (does not
recall any of these events now and this history was from his
wife). Prior to the ambulance arriving his wife took his temp in
addition to the night before with no pyrexial epispiked noted.
on arrival to the [**Location (un) 620**] ED where initial VS were T 98.8, HR
90, BP 156/61, RR 20, O2 sat 90% on RA and he spiked a fever to
103 and was markedly confused and disoriented and was unable to
recognize his wife and daughter. CXR revealed no pneumonia
although a pulmonary vs line source was suspected (has a
Portacath) and therefore was commenced on IV vanc and cefepime
for febrile neutropenia.He received tylenol 650 mg PR, cefepime
2g IV and vancomycin infusion was started but not completed.
On arrival to the [**Hospital1 18**] ED vital signs were T 102, HR 91, BP
151/68, RR 16, O2 sat 94% 3L NC. On exam patient was A&O x 3,
but very slow and lethargic, taking 1.5 minutes to answer
orientation questions. His port-a-cath site was warm but not
erythematous. He was wheezing. Per report there was difficulty
accessing it. Lactate here was 1.7. Neurosurgery was consulted
and reviewed the CT head images from the OSH and felt that there
was no interval progression of the NPH. He received 1L NS,
vancomycin 1g IV, and nebs.
He was transferred to the ICU for close observation and CT was
unchanged from prior. His Portacath was warm but not
erythematous and did not appear cellulitic. There was however
some difficulty in accessing it. Head CT was reviewed by
neurosurgery
In ICU he was continued on broad spectrum antibiotics adding
azithromycin and he was investigated for possible causes with
rapid respiratory viral screen and a legionella urinary antigen
which were all negative. His confusion improved and he did not
have an LP. Azithromycin was stopped and he was continued on
vancomycin and cefepime with ciprofloxacin started for
additional Gram -ve coverage. His O/P neurologist was contact[**Name (NI) **]
regarding his admission in light of his NPH. repeat CXR on read
felt to be deem at the right base which were postulated to be
due to recent transfusion or drug reaction. Given a possibly new
murmur, he went. On to have a TTE which showed a mildly dilated
LA and EF 65-70% and was otherwise normal. There was no growth
to date on [**Hospital1 **] [**Location (un) 620**] cultures and a CMV VL is pending. On
[**10-22**], he developed [**1-8**] CP and had some T wave inversion on
telemetry in the setting of coming off O2 and arising to urinate
and this resolved with O2. His home anti-hypertensives we ere
restarted and cardiac enzymes were negative x2. He had further
chest pain at 03:26 on [**10-23**] and there was evidence at this time
of ST depressions and flipped T waves however ECG was unchanged.
This resolved with S/L nitroglycerine. Repeat CXR on [**10-23**] still
showed continued pulmonary congestive changes. The chest pain
was felt likely to be demand ischemia in the context of
infection and anemia - he has angina managed witty isosorbide
mononitrate at baseline. his lisinopril was gradually restarted.
By [**10-22**] his confusion had improved 85% and by [**10-23**] he was
pretty much back to his baseline. In addition he was found to be
diabetic on the ICU with high fingerstick blood sugars and an
HbA1c of 8.3%.
He had a profound thrombocytopenia and s last transfused on
[**10-21**] and was transfused 2 units of RCC on [**10-23**] due to a HCt of
19 in the setting of demand ischemia. On discussion with Dr [**Last Name (STitle) 724**]
(neurology) and Dr [**Last Name (STitle) 30635**] (neurosurgery) the plans for VP shunt
placement for his NPH have been deferred to [**Month (only) **] due to his
current infection.
On arrival to the BMT unit, his vitals were T 97.1 BP 142/72 HR
68 RR 16 sO2 100% RA. he currently feels well with no further
chest pain (states when he "over stresses" and when anaemic).
Still has a mild cough which has been unproductive. He has had
no deferasirox since being in hospital.
.
Review of systems:
(+) Per HPI, + nasal congestion + chronic diarrhea related to
deferasirox. He has had no bowel movements since [**10-21**].
(-) Denies headache, sinus tenderness. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure, or
palpitations. Denies nausea, vomiting, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes. No sweats or tremors.

Past Medical History:
CAD, s/p ant MI [**2139**], with hx LAD and RCA blockages. No stents
or angioplasties.
Angina - once weekly depending on anemia and stress levels
normally lasting 10-15 mins and resolves with nitro. Describes
as a squeezing central/left chest pain with no radiation usually
but can rarely will rarely feel in these locations. No
nausea/vomiting or sweating.
PVD
OSA on CPAP with morbid obesity
History of possible TIA [**2162**] ? CVA - had resolution of eye
position abnormalities over a few days
MDS with thrombocytopenia and anemia dx [**2159**]
Hypertension
Hypercholesterolemia
Asthma, cold-induced
s/p ruptured appendix
s/p right carotid endarterectomy several years ago
.
Hematologic Hx
longstanding history of myelodysplastic disorder
associated with severe pancytopenia, now red cell and platelet
transfusion requiring. Initially diagnosed [**2160-1-30**] when
his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], obtained a
complete blood countas a part of routine maintenance physical
examination. At that
time, he anemia, a low platelet count, and a borderline low
white
blood count. He was treated briefly with azacitidine (Vidaza)
with 4 cycles in [**State 108**] but his disease did not stabilize. He
has been getting PRBC's and platelet tranfusions, as well as
iron chelation with deferasirox (Exjade). There is current
discussion regarding his candidacy for BMT and it seems that the
general feeling is that a patient with his cardiac status would
be at too higher risk to go ahead with an allogeneic transplant
but there is currrent discussion with his cardiologist Dr
[**Last Name (STitle) **]. In the past it has been felt that he was not a candidate
for any kind of stenting procedure because of his significant
thrombocytopenia

Social History:
Lives with wife in house with stairs
No walking aids but holds onto walls and door-knobs but can walk
to the car and can walk 20-50 yards limited by claudication and
back pain
He previously worked as a computer programmer and retired.
Ex-smoker quit 20 years ago previously 3 packs per day for 25
years.
Alcohol - He has 1 to 2 Scotches per week but can go weeks
without drinking.
He does not use illicit drugs
No recent foreign travel
Pets - 1 dog and 2 cats

Family History:
Father died of non-smoking related lung cancer
Mother died of coronary artery disease, CCF and
hypercholesterolemia also had a AAA repair
Sister who had coronary artery disease and underwent a 4-vessel
CABG.
Daughter is healthy.

Physical Exam:
Physical Exam on ICU Admission:
Vitals: T: 103.2 BP: 135/60 P: 102 R: 20 O2: 98% 2L NC
General: Older, obese Caucasian male in NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles L>R. No wheezes.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Physical exam on BMT unit:
Vitals: T: 98.2 132/74 69 18 97% RA
General: Older, obese Caucasian male in NAD. Large neck.
HEENT: Sclera anicteric, MM dry, oropharynx clear. No purport or
petechiae.L neck scar from CEA.
Neck: supple, no LAD no thyroid enlargement
Lungs: L base crackles.mild intermittent wheeze
CV: Regular rhythm, normal S1 + S2 with very soft ESM at aortic
area no rubs, gallops. No carotid bruits. JVP c4 cm above
sternal angle
Abdomen: RLQ scar. soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. Very
dry skin generally. Pitting deem to mid-shins bilaterally
CNS: GCS 15/15
UL exam normal - normal tone, power, coordination, reflexes and
sensation.
LL exam normal tone, power, coordination, reflexes and
sensation. Plantars flexor bilaterally.
CN exam - II-XII normal witty normal eye movements and visual
fields. PERRL 3+/3+
No fundoscopy performed

2 days after admission, he developed a vesicular rash initially
on his posterior neck at around C6/7 and this then spread to
involve his nares, right cheek, lateral side of left eye and
left ear lobe. The rash was not itchy but developed confluent
erythema which settled with treatment.

Pertinent Results:
[**2164-11-2**] 12:00AM BLOOD WBC-1.4* RBC-3.06* Hgb-9.1* Hct-25.4*
MCV-83 MCH-29.9 MCHC-35.9* RDW-15.2 Plt Ct-17*
[**2164-11-1**] 06:20AM BLOOD WBC-1.3* RBC-2.92* Hgb-8.9* Hct-24.1*
MCV-83 MCH-30.6 MCHC-37.1* RDW-14.9 Plt Ct-21*
[**2164-10-31**] 12:10AM BLOOD WBC-1.7* RBC-3.06* Hgb-9.3* Hct-24.8*
MCV-81* MCH-30.4 MCHC-37.5* RDW-15.4 Plt Ct-37*
[**2164-10-30**] 12:35AM BLOOD WBC-1.6* RBC-3.17* Hgb-9.6* Hct-25.8*
MCV-81* MCH-30.2 MCHC-37.2* RDW-15.3 Plt Ct-10*
[**2164-10-29**] 12:00AM BLOOD WBC-1.5* RBC-2.84* Hgb-8.7* Hct-23.6*
MCV-83 MCH-30.7 MCHC-36.9* RDW-15.6* Plt Ct-15*
[**2164-10-28**] 12:00AM BLOOD WBC-1.6* RBC-2.80* Hgb-8.6* Hct-23.0*
MCV-82 MCH-30.6 MCHC-37.4* RDW-15.5 Plt Ct-20*
[**2164-10-27**] 08:19AM BLOOD Hct-23.7* Plt Ct-25*
[**2164-10-27**] 12:00AM BLOOD WBC-1.4* RBC-2.58* Hgb-7.7* Hct-20.8*
MCV-81* MCH-29.8 MCHC-37.0* RDW-16.5* Plt Ct-9*
[**2164-10-26**] 12:01AM BLOOD WBC-1.3* RBC-2.72* Hgb-8.1* Hct-21.9*
MCV-81* MCH-29.7 MCHC-36.8* RDW-16.2* Plt Ct-14*
[**2164-10-25**] 12:00AM BLOOD WBC-1.0* RBC-2.74* Hgb-8.1* Hct-22.6*
MCV-82 MCH-29.6 MCHC-36.0* RDW-16.4* Plt Ct-16*
[**2164-10-24**] 12:00AM BLOOD WBC-1.2* RBC-2.79* Hgb-8.4* Hct-23.3*
MCV-83 MCH-30.2 MCHC-36.2* RDW-16.3* Plt Ct-18*
[**2164-10-23**] 07:31AM BLOOD WBC-1.1* RBC-2.29* Hgb-7.1* Hct-19.0*
MCV-83 MCH-30.9 MCHC-37.3* RDW-17.6* Plt Ct-31*
[**2164-10-23**] 03:58AM BLOOD WBC-1.2* RBC-2.33* Hgb-7.1* Hct-19.2*
MCV-83 MCH-30.3 MCHC-36.6* RDW-17.6* Plt Ct-30*
[**2164-10-22**] 04:08AM BLOOD WBC-1.3* RBC-2.77* Hgb-8.5* Hct-23.3*
MCV-84 MCH-30.7 MCHC-36.4* RDW-17.3* Plt Ct-36*
[**2164-11-2**] 12:00AM BLOOD Neuts-16* Bands-1 Lymphs-75* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2164-11-1**] 06:20AM BLOOD Neuts-34* Bands-0 Lymphs-60* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2164-10-31**] 12:10AM BLOOD Neuts-44* Bands-0 Lymphs-47* Monos-8
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2164-10-30**] 12:35AM BLOOD Neuts-43* Bands-0 Lymphs-54* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2164-10-29**] 12:00AM BLOOD Neuts-35* Bands-0 Lymphs-62* Monos-2
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2164-10-28**] 12:00AM BLOOD Neuts-36* Bands-0 Lymphs-48* Monos-11
Eos-3 Baso-1 Atyps-1* Metas-0 Myelos-0 NRBC-1*
[**2164-10-27**] 12:00AM BLOOD Neuts-38* Bands-0 Lymphs-47* Monos-14*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2164-10-26**] 12:01AM BLOOD Neuts-36* Bands-0 Lymphs-52* Monos-11
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2164-10-25**] 12:00AM BLOOD Neuts-27* Bands-1 Lymphs-67* Monos-4
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2164-10-24**] 12:00AM BLOOD Neuts-28* Bands-5 Lymphs-61* Monos-5
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2164-10-23**] 03:58AM BLOOD Neuts-22* Bands-0 Lymphs-67* Monos-8
Eos-2 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2164-10-22**] 04:08AM BLOOD Neuts-43* Bands-6* Lymphs-44* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2164-11-2**] 12:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2164-11-1**] 06:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
[**2164-10-31**] 12:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2164-10-30**] 12:35AM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-OCCASIONAL Polychr-NORMAL
[**2164-10-29**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-2+ Ovalocy-1+
[**2164-10-28**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Spheroc-2+ Ovalocy-1+
[**2164-10-27**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-2+
Ovalocy-1+ Schisto-OCCASIONAL
[**2164-10-26**] 12:01AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2164-10-25**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL
[**2164-10-24**] 12:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2164-10-23**] 03:58AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Spheroc-2+
Ovalocy-1+
[**2164-10-22**] 04:08AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
[**2164-11-2**] 12:00AM BLOOD Plt Smr-RARE Plt Ct-17*
[**2164-11-2**] 12:00AM BLOOD PT-15.0* PTT-26.8 INR(PT)-1.3*
[**2164-11-1**] 06:20AM BLOOD Plt Smr-VERY LOW Plt Ct-21*
[**2164-11-1**] 06:20AM BLOOD PT-14.1* PTT-24.3 INR(PT)-1.2*
[**2164-10-31**] 12:10AM BLOOD Plt Smr-VERY LOW Plt Ct-37*
[**2164-10-31**] 12:10AM BLOOD PT-15.1* PTT-33.2 INR(PT)-1.3*
[**2164-10-30**] 05:25AM BLOOD Plt Ct-46*#
[**2164-10-30**] 12:35AM BLOOD Plt Ct-10*
[**2164-10-30**] 12:35AM BLOOD PT-13.6* PTT-24.0 INR(PT)-1.2*
[**2164-10-29**] 12:00AM BLOOD Plt Smr-RARE Plt Ct-15*
[**2164-10-29**] 12:00AM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.3*
[**2164-10-28**] 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-20*
[**2164-10-28**] 12:00AM BLOOD PT-13.6* PTT-24.1 INR(PT)-1.2*
[**2164-10-27**] 08:19AM BLOOD Plt Ct-25*
[**2164-10-27**] 04:18AM BLOOD Plt Ct-28*#
[**2164-10-27**] 12:00AM BLOOD Plt Smr-RARE Plt Ct-9*
[**2164-10-27**] 12:00AM BLOOD PT-13.3 PTT-23.9 INR(PT)-1.1
[**2164-10-26**] 12:01AM BLOOD Plt Smr-RARE Plt Ct-14*
[**2164-10-26**] 12:01AM BLOOD PT-13.1 PTT-23.3 INR(PT)-1.1
[**2164-10-25**] 12:00AM BLOOD Plt Smr-RARE Plt Ct-16*
[**2164-10-25**] 12:00AM BLOOD PT-13.2 PTT-25.3 INR(PT)-1.1
[**2164-10-24**] 12:00AM BLOOD Plt Smr-RARE Plt Ct-18*
[**2164-10-24**] 12:00AM BLOOD PT-13.0 PTT-21.9* INR(PT)-1.1
[**2164-10-23**] 07:31AM BLOOD Plt Ct-31*
[**2164-10-23**] 03:58AM BLOOD Plt Smr-VERY LOW Plt Ct-30*
[**2164-10-22**] 04:08AM BLOOD Plt Smr-VERY LOW Plt Ct-36*
[**2164-10-22**] 04:08AM BLOOD PT-13.5* PTT-21.5* INR(PT)-1.2*
[**2164-10-22**] 12:32AM BLOOD Plt Ct-41*
[**2164-11-2**] 12:00AM BLOOD Gran Ct-245*
[**2164-11-1**] 06:20AM BLOOD Gran Ct-442*
[**2164-10-31**] 12:10AM BLOOD Gran Ct-726*
[**2164-10-30**] 12:35AM BLOOD Gran Ct-671*
[**2164-10-29**] 12:00AM BLOOD Gran Ct-518*
[**2164-10-28**] 12:00AM BLOOD Gran Ct-583*
[**2164-10-27**] 12:00AM BLOOD Gran Ct-532*
[**2164-10-26**] 12:01AM BLOOD Gran Ct-440*
[**2164-10-25**] 12:00AM BLOOD Gran Ct-288*
[**2164-10-24**] 12:00AM BLOOD Gran Ct-409*
[**2164-10-23**] 03:58AM BLOOD Gran Ct-257*
[**2164-10-22**] 04:08AM BLOOD Gran Ct-583*
[**2164-11-2**] 12:00AM BLOOD Glucose-159* UreaN-21* Creat-1.2 Na-132*
K-3.9 Cl-100 HCO3-26 AnGap-10
[**2164-11-1**] 06:20AM BLOOD Glucose-139* UreaN-17 Creat-1.2 Na-136
K-3.7 Cl-103 HCO3-27 AnGap-10
[**2164-10-31**] 12:10AM BLOOD Glucose-146* UreaN-19 Creat-1.1 Na-138
K-3.9 Cl-101 HCO3-28 AnGap-13
[**2164-10-30**] 12:35AM BLOOD Glucose-155* UreaN-15 Creat-1.1 Na-135
K-3.9 Cl-99 HCO3-28 AnGap-12
[**2164-10-29**] 12:00AM BLOOD Glucose-131* UreaN-16 Creat-1.0 Na-139
K-3.6 Cl-100 HCO3-29 AnGap-14
[**2164-10-28**] 12:00AM BLOOD Glucose-133* UreaN-19 Creat-1.0 Na-136
K-3.6 Cl-100 HCO3-30 AnGap-10
[**2164-10-27**] 12:00AM BLOOD Glucose-169* UreaN-17 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-30 AnGap-9
[**2164-10-26**] 12:01AM BLOOD Glucose-173* UreaN-16 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-28 AnGap-11
[**2164-10-25**] 12:00AM BLOOD Glucose-180* UreaN-15 Creat-1.0 Na-135
K-3.6 Cl-102 HCO3-26 AnGap-11
[**2164-10-24**] 12:00AM BLOOD Glucose-199* UreaN-16 Creat-1.0 Na-136
K-3.6 Cl-102 HCO3-25 AnGap-13
[**2164-10-23**] 03:58AM BLOOD Glucose-221* UreaN-15 Creat-1.0 Na-135
K-3.7 Cl-101 HCO3-26 AnGap-12
[**2164-10-22**] 04:08AM BLOOD Glucose-290* UreaN-19 Creat-1.1 Na-136
K-4.1 Cl-100 HCO3-26 AnGap-14
[**2164-11-2**] 12:00AM BLOOD ALT-31 AST-22 LD(LDH)-161 AlkPhos-82
TotBili-1.0
[**2164-11-2**] 12:00AM BLOOD ALT-31 AST-22 LD(LDH)-161 AlkPhos-82
TotBili-1.0
[**2164-11-1**] 06:20AM BLOOD ALT-29 AST-24 LD(LDH)-154 AlkPhos-74
TotBili-1.1
[**2164-10-31**] 12:10AM BLOOD ALT-34 AST-24 LD(LDH)-184 AlkPhos-78
TotBili-1.2
[**2164-10-30**] 12:35AM BLOOD ALT-39 AST-29 LD(LDH)-198 AlkPhos-75
TotBili-1.8* DirBili-0.4* IndBili-1.4
[**2164-10-29**] 12:00AM BLOOD ALT-37 AST-25 LD(LDH)-174 AlkPhos-82
TotBili-1.1
[**2164-10-28**] 12:00AM BLOOD ALT-36 AST-27 LD(LDH)-169 AlkPhos-82
TotBili-1.0
[**2164-10-27**] 12:00AM BLOOD ALT-37 AST-29 LD(LDH)-149 AlkPhos-78
TotBili-0.9
[**2164-10-26**] 12:01AM BLOOD ALT-37 AST-31 LD(LDH)-152 AlkPhos-75
TotBili-1.1
[**2164-10-25**] 12:00AM BLOOD ALT-34 AST-33 LD(LDH)-171 AlkPhos-81
TotBili-1.0
[**2164-10-24**] 12:00AM BLOOD ALT-28 AST-25 LD(LDH)-152 AlkPhos-75
TotBili-1.2
[**2164-10-23**] 03:58AM BLOOD ALT-26 AST-19 LD(LDH)-138 CK(CPK)-88
AlkPhos-75 TotBili-1.1
[**2164-10-22**] 04:08AM BLOOD ALT-28 AST-20 LD(LDH)-163 CK(CPK)-74
AlkPhos-91 TotBili-1.7* DirBili-0.4* IndBili-1.3
[**2164-11-2**] 12:00AM BLOOD Albumin-4.2 Calcium-9.5 Phos-1.7* Mg-2.3
[**2164-11-1**] 06:20AM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.4* Mg-2.2
[**2164-10-31**] 12:10AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.4* Mg-2.3
[**2164-10-29**] 12:00AM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.5* Mg-2.2
[**2164-10-28**] 12:00AM BLOOD Albumin-3.8 Calcium-9.3 Phos-2.8 Mg-2.0
[**2164-10-27**] 12:00AM BLOOD Albumin-3.9 Calcium-9.2 Phos-2.9 Mg-2.0
[**2164-10-26**] 12:01AM BLOOD Albumin-3.9 Calcium-9.0 Phos-2.8 Mg-2.0
[**2164-10-25**] 12:00AM BLOOD Albumin-3.8 Calcium-8.7 Phos-2.7 Mg-1.9
[**2164-10-24**] 12:00AM BLOOD Albumin-4.0 Calcium-9.2 Phos-2.4* Mg-2.0
[**2164-10-23**] 03:58AM BLOOD Phos-1.8* Mg-2.0
[**2164-10-22**] 04:08AM BLOOD Calcium-9.2 Phos-3.1 Mg-2.6
.
Other labs
.
[**2164-10-23**] 03:58AM BLOOD CK-MB-2 cTropnT-<0.01
[**2164-10-22**] 04:08AM BLOOD CK-MB-2 cTropnT-<0.01
[**2164-10-22**] 04:08AM BLOOD %HbA1c-8.3* eAG-192*
[**2164-10-29**] 09:56AM BLOOD IgG-856
[**2164-10-29**] 09:55AM BLOOD Vanco-24.1*
[**2164-10-23**] 07:28AM BLOOD Vanco-9.1*
[**2164-10-23**] 07:59AM BLOOD Type-[**Last Name (un) **] pH-7.36
[**2164-10-23**] 04:24AM BLOOD Lactate-1.2
[**2164-10-22**] 04:34AM BLOOD Lactate-2.6*
[**2164-10-21**] 03:09PM BLOOD Lactate-1.7
[**2164-10-23**] 07:59AM BLOOD freeCa-1.21
.
.
Urine
.
[**2164-10-21**] 10:12PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2164-10-21**] 10:12PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose->1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-NEG
[**2164-10-21**] 10:12PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
[**2164-10-21**] 10:12PM URINE Mucous-RARE
.
.
Microbiology:
.
Urine culture [**10-21**] -ve
.
0/24/10 10:12 pm URINE      Source: CVS.

                            **FINAL REPORT [**2164-10-22**]**

   Legionella Urinary Antigen  (Final [**2164-10-22**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
.
[**2164-10-21**] 9:51 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2164-10-24**]**

   MRSA SCREEN (Final [**2164-10-24**]):    No MRSA isolated.
.

[**2164-10-21**] 7:41 pm Rapid Respiratory Viral Screen & Culture
      Source: Nasopharyngeal swab.

                            **FINAL REPORT [**2164-10-24**]**

   Respiratory Viral Culture (Final [**2164-10-24**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
      Detection of viruses other than those listed above will
only be
      performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
      within 1 week if additional testing is needed.

   Respiratory Viral Antigen Screen (Final [**2164-10-22**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.
.
[**2164-10-22**] 12:45 am Immunology (CMV)

                            **FINAL REPORT [**2164-10-23**]**

   CMV Viral Load (Final [**2164-10-23**]):
      CMV DNA not detected.
      Performed by PCR.
      Detection Range: 600 - 100,000 copies/ml.
.
BCx2 [**10-22**] -ve
.
[**2164-10-25**] 3:05 pm
      Direct Antigen Test for Herpes Simplex Virus Types 1 & 2

                            **FINAL REPORT [**2164-10-26**]**

   Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
      [**2164-10-26**]):
      POSITIVE FOR HERPES SIMPLEX TYPE 1 (HSV1).
         Viral antigen identified by immunofluorescence.
.
[**2164-10-25**] 3:05 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS

                            **FINAL REPORT [**2164-10-26**]**

   DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
[**2164-10-26**]):
      Negative for Varicella zoster by immunofluorescence.
.
[**2164-10-26**] 7:15 pm ASPIRATE      Source: Nasal swab  LEFT NARES.

   VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
      No Virus isolated so far.
.
.
Cardiology
.
TE (Complete) Done [**2164-10-22**] at 3:27:21 PM
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. 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
diameters of aorta at the sinus, ascending and arch levels are
normal. 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. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
.
Cardiology Report	ECG	Study Date of [**2164-10-22**]  4:26:14 AM

Normal sinus rhythm. Left axis deviation. Right bundle-branch
block. Compared
to the previous tracing of [**2164-9-7**] no diagnostic change.
.
Cardiology Report	ECG	Study Date of [**2164-10-23**]  4:51:38 AM

Sinus rhythm. Left axis deviation. Left anterior fascicular
block. Right
bundle-branch block. T wave abnormalities. Since the previous
tracing
of [**2164-10-22**] there is no significant change.
.
.
Radiology
.
XR CHEST (PORTABLE AP)	Study Date of [**2164-10-22**] 12:23 AM
IMPRESSION: Interstitial pulmonary edema has improved since
[**10-21**],
suggesting that the residual interstitial abnormality at the
base of the right
lung is edema rather than pneumonia. Findings could have been
due to recent
transfusion or drug reaction. Heart size is normal. There is no
pleural
effusion or evidence of central adenopathy.
.
XR CHEST (PORTABLE AP)	Study Date of [**2164-10-23**] 5:33 AM
FINDINGS: In comparison with study of [**10-22**], the outer lower
portion of the
left hemithorax has been excluded from the image. There is still
some
engorgement of pulmonary vessels consistent with increased
pulmonary venous
pressure. The possibility of supervening pneumonia at the right
base can
certainly not be excluded in the appropriate clinical setting. A
lateral view
would be helpful if the condition of the patient permits.
Central catheter
remains in place.
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT	Study Date of
[**2164-10-23**] 8:15 AM
Examination is limited due to portable technique. Hepatic
echogenicity is
diffusely increased. No focal liver lesion is identified. The
main portal
vein is patent with hepatopetal flow. There is no intra- or
extra-hepatic
biliary duct dilation. The common bile duct measures 4 mm. The
gallbladder
is unremarkable, without gallstones, wall edema, or visualized
pericholecystic
fluid. There is no ascites.

Left kidney measures 13.1 cm and the right kidney measures 11.2
cm. There is
no hydronephrosis or renal mass identified. The spleen is normal
in size,
measuring up to 11.4 cm. Evaluation of the IVC and abdominal
aorta is
limited, but the included portions are unremarkable. The
pancreas is not well
visualized on this exam.

IMPRESSION:

1. No evidence of gallbladder pathology or biliary obstruction.

2. Diffusely increased hepatic echotexture without focal lesion.
Findings
are likely related to fatty infiltration, but additional liver
processes such
as cirrhosis and fibrosis cannot be excluded.
.
CT CHEST W/O CONTRAST	Study Date of [**2164-10-25**] 10:10 AM
FINDINGS: A tunneled central venous catheter device in the right
anterior
chest wall ends in the mid superior vena cava. There is no
pathologic
enlargement of the supraclavicular, mediastinal or axillary
lymph nodes. Nodes
in the aortopulmonary and subcarinal stations measure 9 mm and 8
mm
respectively.

The cardiac size is normal without pericardial effusion.
Coronary artery
calcifications are minor. There is no pleural effusion. The
central airways
are patent.

Multifocal bronchocentric ground-glass opacity and more
confluent left lower
lobe consolidation are suggestive of an acute viral pneumonia. A
granuloma in
the left posterior basal segment of the left lower lobe is
calcified.

This study is not tailored for subdiaphragmatic evaluation only
to confirm
severe hepatic steatosis, an 18 x 16-mm left adrenal lesion of
28 Hounsfield
units in density and a normal-appearing right adrenal gland.
Lower thoracic
spine osteophytosis is mild.

IMPRESSION:
1. Multifocal ground-glass opacities in a bronchocentric
distribution is most
likely a viral infection. If bronchoalveolar lavage is
considered, the
superior segment of the left lower lobe is the site likely to
give the highest
yield.

2. Incidental finding of left adrenal lesion; MRI suggested if
not previously
evaluated.
.
XR CHEST (PORTABLE AP)	Study Date of [**2164-11-1**] 12:28 PM
Port-A-Cath is seen approaching from the right subclavian artery
into the lower SVC, unchanged in position from prior study
without evidence of
fracture or kinking of the catheter. The remainder of the lungs
are clear
without focal opacity. There is no pleural effusion or
pneumothorax. The
heart size is normal with normal cardiomediastinal silhouette.

IMPRESSION: Normal appearance of right Port-A-Cath without
evidence of
obstruction or damage.

Brief Hospital Course:
66 year old male with MDS transfusion dependent.dx [**1-/2160**] with
pancytopenia - brief rx azacitidine x4 cycles with no effect
having iron chelation with deferasirox, felt at too high risk
for cath or transplant currently. Other PMH significant for
normal pressure hydrocephalus, CAD, HTN and newly diagnosed
T2DM. He presented with neutropenic fever and confusion on
[**10-21**]. He was treated with broad spectrum antibiotics and his
confusion rapidly resolved although his cough persisted. Patient
required transfusions of platelets and RCC to support his
cytopenias. He had a CT-head which was unchanged and a CT-Chest
in keeping with  viral pneumonia. He developed a rash on back
was found to have diseminated HSV-1 for which he was treated
initially with IV acyclopvir and then after his rash had
crusted, with oral valacyclovir. His rash greatly improved as
dis his cough and was discharged on [**2164-11-2**] with hematology
follow-up. An incidental left adrenal lesion was found on CT and
 this should be further evaluated as appropriate in the
community.

# Neutropenic fever: Mr [**Known lastname **] presented with a 2-day history of
cough and latterly confusion and fever to 103F. He was evaluated
in the [**Hospital1 **] ED with a CT-head which showed no change other than
stable features in keeping with NPH and a CXR showed infiltrated
? edema.  He was initially treated with  IV vancomycin, cefepime
and ciprofloxacin (for double pseudomonal coverage) for his
febrile neutropenia and ciprofloxcin was discontinued on
transfer to the BT unit. He was transferred to the ICU on
presentation and stayed there for 2 days before transfer to the
BMT service. His confusion quickly resolved and was at his
baseline on review at the BMT unit. Due to persistent cough, he
had a CT chest on [**10-25**] which showed multifocal bronchocentric
ground-glass opacities and more confluent left lower lobe
consolidation suggestive of an acute viral pneumonia.
Additionally, on [**10-25**], he developed a vesicular rash on his
posterior neck and this was evaluated by dermatology who were
concerned for possible VZV/HSV. A direct antigen test was
performed on scrapings and this was found to be positive for
HSV-1. He had been pre-emptively commenced on IV acyclovir. He
was reviewed by infectious diseases on [**10-26**] at which point
there was evidence of dissemination with the rash appearing on
his right cheek, left nostril and left ear lobe and they
recommended 21 days of antiviral therapy with IV therapy until
his rash was entirely crusted over. He had no further fevers
during his stay and he had no further confusion. Vancomycin was
stopped on [**10-29**] and cefepime on [**10-31**] at which point he was
changed  to oral levofloxacin to complete an antibiotic course
on [**11-5**] for persistent cough. Lesions had completely crusted by
[**11-1**] at which point he was changed from IV acyclovir to oral
valacyclovir 1g tid to finish  on [**11-15**].
.
# MDS - Mr [**Known lastname **] has severe MDS requiring frequent out-patient
transfusions. During his hsopital stay, he required 4 platelet
transfusions and 4 units of RCC. His transfusion goal as an
in-patinet was for a HCt >25 and Pllt >10. He remained
significantly neutropenic during his inpatient stay.
.
# Incidental finding of left adrenal lesion: Mr [**Known lastname **] had a
CT-Chets to evaluate for his persistent cough this showed an 18
x 16-mm left adrenal lesion of 28 Hounsfield units in density
and a normal-appearing right adrenal gland and radiology advised
further imaging with MRI if this has not already been done. This
should be followed up as appropriate by his PCP.
.
# CAD - normally weekly angina on exertion. He had 2 episodes of
chest pain in the ICU which were felt to be demand ischemia with
associated T-wave inversion and ST depression transiently on
telemetry which improved with oxygen and nitro. He was ruled out
for an MI with 2x negative troponins and an echo showed normal
LV function (EF>55%) and was otherwise normal save thickened
aortic valve leaflets with no AS. Due to initial concerns of
neutropenic sepsis in the ICU, he was started on reduced doses
of his home anti-hyprtensives/anti-anginals and these were
slowly titrated up to his home levels during his stay. He was
transfused to a HCt goal of >25. He had no further chest pain
during his admission.
.
# New dx DMT2: Mr [**Known lastname **] was found to have high blood glucose
readings on fingersticks while in the ICU and was found to have
an HbA1c of 8.3% and was started on an insulin sliding scale.
The [**Hospital **] Clinic was consulted and they reviewed his diabetes
daily and titrated up his sliding scale insulin in addition to
regular nightly glargine. He was discharged on an insulin
sliding scale and regular glargine 28 units at night. It was
felt that for the first instance that h should be treated with
insulin and for this to be possibly converted in due course to
oral agents. He received a neutropenic/diabetic diet while
in-house. . Insulin continued  - [**Last Name (un) **] are following. He will
be followed up by [**Last Name (un) **] at [**Location (un) 620**] who he will call for an
appointment.
.
# Rash - Disseminated HSV: On [**10-25**], he developed a vesicular
rash on his posterior neck and this was evaluated by dermatology
who were concerned for possible VZV/HSV. A direct antigen test
was performed on scrapings and this was found to be positive for
HSV-1. He had been pre-emptively commenced on IV acyclovir. He
was reviewed by infectious diseases on [**10-26**] at which point
there was evidence of dissemination with the rash appearing on
his right cheek, left nostril and left ear lobe and they
recommended 21 days of antiviral therapy with IV therapy until
his rash was entirely crusted over.  He received Benadryl for
itch. Much improved and crusted over. Lesions had completely
crusted by [**11-1**] at which point he was changed from IV acyclovir
to oral valacyclovir 1g tid to finish  on [**11-15**].
.
# Normal pressure hydrocephalus - He is awaiting shunt insertion
but this has been delayed due to his disseminated HSV and
episode of febrile neutropenia.
.
# OSA: He continued using his home CPAP machine and other than
being at times slow to rouse in the mornings, there were no
undue sequelae.
.
# Hypertension - Due to initial presentation with febrile
neutropenia and confusion and concerns for decompensation, he
was commenced on reduced doses of his anti-hypertensives and his
BP was not overly high with this. These were slowly titrated up
during his admission and on discharge his BP was well controlled
on his home regime.
.
# Hyperlipidemia: We continued pravastatin
.
# GERD: He was treated with pantoprazole/rantidine while in
house and changed to his home esomeprazole on discharge.
.
# BPH/urinary problems ([**Name2 (NI) 30636**] given NPH): We continued
tamsulosin and oxybutynin.

Medications on Admission:
Medication upon Admission to ICU:
Bisoprolol fumarate [Zebeta] 15 mg [**Hospital1 **] (am/pm)
Deferasirox [Exjade] [**2153**] mg daily (pm)
Esomeprazole magnesium [Nexium] 40 mg daily (pm)
Ranitidine 150 mg daily (HS)
Folic acid 1 mg daily (am)
Isosorbide dinitrate 40 mg TID (am, noon, pm)
Lisinopril 20 mg daily
Pravastatin 40 mg daily (pm)
Tamsulosin [Flomax] 0.4 mg daily (pm)
Oxybutynin [**Last Name (un) **] 5 mg daily (HS)
Vitamin B6
Cyanocobalamin (vitamin B-12) 1,000 mcg daily
Multivitamin daily
Vitamin D
Potassium gluconate dose unknown

Discharge Medications:
1. lancets     Misc Sig: One (1)  Miscellaneous four times a
day.
Disp:*120 lancets* Refills:*2*
2. One Touch Ultra Test     Strip Sig: One (1)  Miscellaneous
four times a day.
Disp:*120 strips* Refills:*2*
3. deferasirox 500 mg Tablet, Dispersible Sig: Four (4) Tablet,
Dispersible PO DAILY (Daily).
Disp:*120 Tablet, Dispersible(s)* Refills:*2*
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
6. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. isosorbide dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

12. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. bisoprolol fumarate 5 mg Tablet Sig: Three (3) Tablet PO bid
().
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
15. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 14 days.
Disp:*80 Tablet(s)* Refills:*0*
17. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
19. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
20. Lantus 100 unit/mL Solution Sig: 28 units  Subcutaneous at
bedtime.
Disp:*qs 1 month supply* Refills:*2*
21. Humalog 100 unit/mL Solution Sig: 1 month supply
Subcutaneous four times a day as needed for as per blood glucose
measurement: See sliding scale.
Disp:*10 ml* Refills:*2*
22. Insulin Syringe [**12-31**] mL 28 x [**12-31**]   Syringe Sig: One (1)
Miscellaneous four times a day: For insulin injection.
Disp:*120 syringes* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 932**] Area VNA

Discharge Diagnosis:
Primary Diagnoses:
Febrile neutropenia
Disseminated HSV-1 infection
New diagnosis of Type 2 Diabetes Mellitus
Incidental left adrenal lesion to be evaluated in the community
Myelodysplastic syndrome requiring transfusion support
.
Secondary diagnoses:
Ischemic heart disease
Peripheral vascular disease
Normal-pressure hydrocephalus
s/p possible TIA
Hypertension
Hypercholesterolemia
Asthma, cold-induced
s/p right carotid endarterectomy


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


Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. It presented with cough
and confusion and had a high fever. You were treated with
broad-spectrum antibiotics in the ED and transferred to the ICU
for closer monitoring. You had a normal Chest X-ray initially
and your confusion completely resolved with the antibiotic
treatment. You had a very low white blood cell count with
neutropenia and antibiotic treatment was continued. You required
transfusions for your myeodysplastc syndroem and had 2 episodes
of chest pain which resolved on their own with oxygen and
nitroglycerine. You had no further episodes of chest pain. Your
blood pressure medications were started at a reduced dose and
slowly increased during your stay to your regular home doses.
You were found to have Type 2 Diabetes while on the ICU with
high blood sugars noted and for this you were started on insulin
and followed by [**Hospital 4171**] [**Hospital **] clinic throughout your stay. You were
felt to be stable and transferred to the BMT unit. Soon after
transfer to the BMT unit, you developed a new rash on your neck
and further rash areas appeared on your nose, cheek and left
ear. You were seen by dermatology who took a smear from the skin
lesiosn and found taht these were positve for Herpes Simplex
Virus 1 (HSV-1) which was widespread (disseminated). You were
then seen by the infetious diseases team who recommended
treatment with an intravenous anti-viral [**Doctor Last Name 360**]. Your rash
improved and you were transitioned to an oral anti-viral tablet.
You will continue anti-viral treatment until [**2164-11-15**]. You
should make an appointment for diabetes follow-up with [**Last Name (un) **] at
[**Location (un) 620**]. You have follow-up with Dr [**Last Name (STitle) 410**] for your
myelodysplastic syndrome on [**11-5**]. You were well and your
symptoms had much immproved on discharge home and we have
organised for you to have some nursing help regarding your
diabetes and for some out-patient physical therapy.
.
Medication changes:
We started you on two types of insulin - Lantus [once daily] and
Humalog [as needed] and you should refer to your sliding scale
sheet for appropriate doses to give yourself.
We gave you prescriptions for insulin syringes and test strips.
We started oral valacyclovir which is an oral anti-viral
medication and should be continued until [**11-15**].
We started levofloxacin which you should take for a further 3
days and then stop.
You should continue your home medications.
.
Patient instructions:
If you have a fever you should seek urgent medical attention due
to your neutropenia.

Followup Instructions:
For labs etc. to be drawn [**2164-11-5**] - appointment has been made.
Appointment later in the week with Dr [**Last Name (STitle) 410**].
.
Provider: [**First Name8 (NamePattern2) 8081**] [**Last Name (NamePattern1) 396**], [**Name12 (NameIs) 30637**] Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2164-11-8**]
10:00
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2164-11-5**] 10:00
.
Please call [**Last Name (un) **] [**Location (un) 620**] on [**Telephone/Fax (1) 19946**] to make diabetes
follow-up appointment
{'Neutropenia, unspecified,Viral pneumonia, unspecified,Idiopathic normal pressure hydrocephalus (INPH),Fever presenting with conditions classified elsewhere,Herpes simplex without mention of complication,Myelodysplastic syndrome, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anemia of other chronic disease,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Other and unspecified angina pectoris,Asthma, unspecified type, unspecified,Morbid obesity,Body Mass Index 33.0-33.9, adult,Unspecified disorder of adrenal glands,Thrombocytopenia, unspecified'}


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: Neutropenic fever
Confusion

PRESENT ILLNESS: 66-year-old male with MDS, normal pressure hydrocephalus, CAD,
HTN who presented to the [**Hospital1 18**] with neutropenic fever and
respiratory symptoms. He was admitted on [**2164-10-21**] with URI sx
with 2 days of sore throat and this progressed to a dry cough
and was fatigued. He was noted by his wife to be tired and
llethargic and mildly confused at 7am was found by his wife in
the bedroom after having knocked some things over after having
taken some cough syrup and complained off "dizziness" and was
put back into bed. His wife put him to bed and by 9am he was not
appropriately responsive and had the urge to urinate but was
unable to get off the bed and was mildly confused (does not
recall any of these events now and this history was from his
wife). Prior to the ambulance arriving his wife took his temp in
addition to the night before with no pyrexial epispiked noted.
on arrival to the [**Location (un) 620**] ED where initial VS were T 98.8, HR
90, BP 156/61, RR 20, O2 sat 90% on RA and he spiked a fever to
103 and was markedly confused and disoriented and was unable to
recognize his wife and daughter. CXR revealed no pneumonia
although a pulmonary vs line source was suspected (has a
Portacath) and therefore was commenced on IV vanc and cefepime
for febrile neutropenia.He received tylenol 650 mg PR, cefepime
2g IV and vancomycin infusion was started but not completed.
On arrival to the [**Hospital1 18**] ED vital signs were T 102, HR 91, BP
151/68, RR 16, O2 sat 94% 3L NC. On exam patient was A&O x 3,
but very slow and lethargic, taking 1.5 minutes to answer
orientation questions. His port-a-cath site was warm but not
erythematous. He was wheezing. Per report there was difficulty
accessing it. Lactate here was 1.7. Neurosurgery was consulted
and reviewed the CT head images from the OSH and felt that there
was no interval progression of the NPH. He received 1L NS,
vancomycin 1g IV, and nebs.
He was transferred to the ICU for close observation and CT was
unchanged from prior. His Portacath was warm but not
erythematous and did not appear cellulitic. There was however
some difficulty in accessing it. Head CT was reviewed by
neurosurgery
In ICU he was continued on broad spectrum antibiotics adding
azithromycin and he was investigated for possible causes with
rapid respiratory viral screen and a legionella urinary antigen
which were all negative. His confusion improved and he did not
have an LP. Azithromycin was stopped and he was continued on
vancomycin and cefepime with ciprofloxacin started for
additional Gram -ve coverage. His O/P neurologist was contact[**Name (NI) **]
regarding his admission in light of his NPH. repeat CXR on read
felt to be deem at the right base which were postulated to be
due to recent transfusion or drug reaction. Given a possibly new
murmur, he went. On to have a TTE which showed a mildly dilated
LA and EF 65-70% and was otherwise normal. There was no growth
to date on [**Hospital1 **] [**Location (un) 620**] cultures and a CMV VL is pending. On
[**10-22**], he developed [**1-8**] CP and had some T wave inversion on
telemetry in the setting of coming off O2 and arising to urinate
and this resolved with O2. His home anti-hypertensives we ere
restarted and cardiac enzymes were negative x2. He had further
chest pain at 03:26 on [**10-23**] and there was evidence at this time
of ST depressions and flipped T waves however ECG was unchanged.
This resolved with S/L nitroglycerine. Repeat CXR on [**10-23**] still
showed continued pulmonary congestive changes. The chest pain
was felt likely to be demand ischemia in the context of
infection and anemia - he has angina managed witty isosorbide
mononitrate at baseline. his lisinopril was gradually restarted.
By [**10-22**] his confusion had improved 85% and by [**10-23**] he was
pretty much back to his baseline. In addition he was found to be
diabetic on the ICU with high fingerstick blood sugars and an
HbA1c of 8.3%.
He had a profound thrombocytopenia and s last transfused on
[**10-21**] and was transfused 2 units of RCC on [**10-23**] due to a HCt of
19 in the setting of demand ischemia. On discussion with Dr [**Last Name (STitle) 724**]
(neurology) and Dr [**Last Name (STitle) 30635**] (neurosurgery) the plans for VP shunt
placement for his NPH have been deferred to [**Month (only) **] due to his
current infection.
On arrival to the BMT unit, his vitals were T 97.1 BP 142/72 HR
68 RR 16 sO2 100% RA. he currently feels well with no further
chest pain (states when he "over stresses" and when anaemic).
Still has a mild cough which has been unproductive. He has had
no deferasirox since being in hospital.
.
Review of systems:
(+) Per HPI, + nasal congestion + chronic diarrhea related to
deferasirox. He has had no bowel movements since [**10-21**].
(-) Denies headache, sinus tenderness. Denies shortness of
breath or wheezing. Denies chest pain, chest pressure, or
palpitations. Denies nausea, vomiting, abdominal pain. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes. No sweats or tremors.

MEDICAL HISTORY: CAD, s/p ant MI [**2139**], with hx LAD and RCA blockages. No stents
or angioplasties.
Angina - once weekly depending on anemia and stress levels
normally lasting 10-15 mins and resolves with nitro. Describes
as a squeezing central/left chest pain with no radiation usually
but can rarely will rarely feel in these locations. No
nausea/vomiting or sweating.
PVD
OSA on CPAP with morbid obesity
History of possible TIA [**2162**] ? CVA - had resolution of eye
position abnormalities over a few days
MDS with thrombocytopenia and anemia dx [**2159**]
Hypertension
Hypercholesterolemia
Asthma, cold-induced
s/p ruptured appendix
s/p right carotid endarterectomy several years ago
.
Hematologic Hx
longstanding history of myelodysplastic disorder
associated with severe pancytopenia, now red cell and platelet
transfusion requiring. Initially diagnosed [**2160-1-30**] when
his primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], obtained a
complete blood countas a part of routine maintenance physical
examination. At that
time, he anemia, a low platelet count, and a borderline low
white
blood count. He was treated briefly with azacitidine (Vidaza)
with 4 cycles in [**State 108**] but his disease did not stabilize. He
has been getting PRBC's and platelet tranfusions, as well as
iron chelation with deferasirox (Exjade). There is current
discussion regarding his candidacy for BMT and it seems that the
general feeling is that a patient with his cardiac status would
be at too higher risk to go ahead with an allogeneic transplant
but there is currrent discussion with his cardiologist Dr
[**Last Name (STitle) **]. In the past it has been felt that he was not a candidate
for any kind of stenting procedure because of his significant
thrombocytopenia

MEDICATION ON ADMISSION: Medication upon Admission to ICU:
Bisoprolol fumarate [Zebeta] 15 mg [**Hospital1 **] (am/pm)
Deferasirox [Exjade] [**2153**] mg daily (pm)
Esomeprazole magnesium [Nexium] 40 mg daily (pm)
Ranitidine 150 mg daily (HS)
Folic acid 1 mg daily (am)
Isosorbide dinitrate 40 mg TID (am, noon, pm)
Lisinopril 20 mg daily
Pravastatin 40 mg daily (pm)
Tamsulosin [Flomax] 0.4 mg daily (pm)
Oxybutynin [**Last Name (un) **] 5 mg daily (HS)
Vitamin B6
Cyanocobalamin (vitamin B-12) 1,000 mcg daily
Multivitamin daily
Vitamin D
Potassium gluconate dose unknown

ALLERGIES: Ampicillin

PHYSICAL EXAM: Physical Exam on ICU Admission:
Vitals: T: 103.2 BP: 135/60 P: 102 R: 20 O2: 98% 2L NC
General: Older, obese Caucasian male in NAD
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Bibasilar crackles L>R. No wheezes.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Father died of non-smoking related lung cancer
Mother died of coronary artery disease, CCF and
hypercholesterolemia also had a AAA repair
Sister who had coronary artery disease and underwent a 4-vessel
CABG.
Daughter is healthy.

SOCIAL HISTORY: Lives with wife in house with stairs
No walking aids but holds onto walls and door-knobs but can walk
to the car and can walk 20-50 yards limited by claudication and
back pain
He previously worked as a computer programmer and retired.
Ex-smoker quit 20 years ago previously 3 packs per day for 25
years.
Alcohol - He has 1 to 2 Scotches per week but can go weeks
without drinking.
He does not use illicit drugs
No recent foreign travel
Pets - 1 dog and 2 cats 

### Response:
{'Neutropenia, unspecified,Viral pneumonia, unspecified,Idiopathic normal pressure hydrocephalus (INPH),Fever presenting with conditions classified elsewhere,Herpes simplex without mention of complication,Myelodysplastic syndrome, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Esophageal reflux,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Anemia of other chronic disease,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Other and unspecified angina pectoris,Asthma, unspecified type, unspecified,Morbid obesity,Body Mass Index 33.0-33.9, adult,Unspecified disorder of adrenal glands,Thrombocytopenia, unspecified'}
