CHIEF COMPLAINT: cough, dyspnea, O2 requirement, tranaminitis

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 4580**] is a 59 year old male with monoclonal
gammopathy,
severe oral lichen planus, recent GIST tumor s/p surgical
resection
[**2170-12-27**], possible neuromuscular disorder who presents with cough
and fever X 3 days.
.
His symptoms began three days ago beginning with one day of low
grade fever to 100.4, cough, and fatigue. He was noted to have
increased O2 requirement and transaminitis and was referred to
the ED. Patient has had no abdominal or GI symptoms.
.
Of note patient has had a long and complicated medical history
beginning in [**2169-8-20**] when he suddenly lost his sense of
taste after treatement of social anxiety with proproanolol. It
was the start of a progressive course of oral lichen planus. Due
to loss of taste, he last 20 lbs. He developed respiratory
problems including a number of sinus infections in the summer of
[**2170**] requiring treatmetn with antibitotics. Workup by his PCP
[**Name Initial (PRE) 7837**] "abnormal immunoglobulin levles, further evaluated with
bone marrow biopsy revealing MGUS. He began to develop rashes,
and worsening of his oral lichen planus with mouth, pain and
thrush. He had biopsies of his tongue confirming diagnosis
lichen planus. Biopsy of plaques on the dorum of his knuckles
were suggestive of Gottren's papules, making diagnosis
concerning for dermatomyositis. Given patient had not had
weakness consistent with this, it was suggested that he had a
diagnosis of sine dermatomyositis. Later with subsequent biopsy,
this diagnosis was challenged with systemic lichen planus.
Furthermore, as dermatomyositis was raised, patient underwent an
exhausive workup for malignancy including colonsocopy and
endoscopy. A gastric mass was discovered, found to be a benign
GIST tumor. Throughout these hospitalization, patient became
malnourished as workup for his symptoms continued. He developed
several pneumonia . During his most recent hospitalization for
low grade temperature, cough, and hypoxia, he was found to have
a possible aspiration and/or bronchiectasis/bronchiolitis with
resultant transpulmonary
shunt. Sputum cultures grew MSSA and pan-sensitive Pseudomonas.
He was treated with a 10day course of cipro and cefazolin. At
time of discharge he was satting in the low 90s on room air with
ambulatory sats in the mid-90s on room air. A cause of his
weakness has not been discovered. Neurology has recommended a
voltage gated calcium channel antibiody [**Hospital1 **] nicotinic receptor
binding antibody which must be ordered as outpatient. Weakness
was also thought to be the cuase of his aspiration risk and NIF
of -40. It was unclear whether this was a neuromuscular process
or rheumatologic condition. Decision was made to initiate
treatment with steroids. Patient's breathing improved (NIF
improved to -80). He was discharged on a prolonged steroid
course.
.
Of note, skin biopsy recently showed overlap between lichen
planus and connective tissue disorder (lichen planus with immune

MEDICAL HISTORY: Bronchiolitis, Bronchiectasis
Monoclonal gammopathy with balanced 2;21 translocation and 10%
plasma cells in [**2170-4-20**]
Clinical judgement of "amyopathic dermatomyositis"
4.2 cm gastric stromal tumor s/p endo-lap resection [**2170-12-27**]
Biopsy proven Lichen planus with oral and peripheral lesions
Shingles 5 years ago
s/p hernia repair at age 16
?Autoimmune hepatitis ([**1-/2171**])

MEDICATION ON ADMISSION: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic TID (3 times a day).
2. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H
(every 4 hours).
3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Systane Balance 0.6 % Drops Sig: One (1) Ophthalmic prn ()
as needed.
7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane

ALLERGIES: vancomycin / daptomycin

PHYSICAL EXAM: On admission:
Vitals: 95.9 98/64 97 20 90% on 3L
General: Alert, oriented, emaciated gentleman appearing older
than stated age, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with healing mucosal
ulcerations.
Neck: supple, JVP not elevated, no LAD, muscle atrophy noted.
Lungs: Fair airmovement, with audible expiratory wheezes, forced
expiratory wheeze elicits cough.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:CN2/12 intact. Strenth [**4-25**] throguhout, overall weak to my
assessment, lower extremity worse than upper. Gait narrow and
steady, mentally clear and responds to questions appropriately.

FAMILY HISTORY: Mother died of MI in her 70s.  Father had emphysema and angina
and died at 78.  Had one older brother who died of [**Name (NI) 8751**] in
college.

SOCIAL HISTORY: Is a self-employed TV engineering consultant who builds TV
studios.  Remote tobacco - quit [**2144**].  Rare alcohol (a few
glasses of wine per week prior to getting sick, none with his
altered taste sensation).
No illicits.  Married for 20+ years and lives with wife who
travels around the world doing preformance art.  No children.  +
cat (indoor only).  No other pets.  Summers at family home in
[**State 1727**] on the ocean.  No known exposures/bites including ticks.
Myelodysplastic syndrome, unspecified,Acute and subacute necrosis of liver,Acute respiratory failure,Methicillin susceptible Staphylococcus aureus septicemia,Other severe protein-calorie malnutrition,Pneumonia due to Pseudomonas,Hemophagocytic syndromes,Other pancytopenia,Other disorders of neurohypophysis,Bronchiectasis with acute exacerbation,Body Mass Index less than 19, adult,Infection and inflammatory reaction due to other vascular device, implant, and graft,Autoimmune disease, not elsewhere classified,Other emphysema,Autoimmune hepatitis,Lichen planus,Personal history of tobacco use,Nontoxic uninodular goiter,Anxiety state, unspecified,Cephalosporin group causing adverse effects in therapeutic use,Long-term (current) use of steroids,Anemia, unspecified,Blepharitis, unspecified,Do not resuscitate status,Foreign body in respiratory tree, unspecified
Myelodysplastic synd NOS,Acute necrosis of liver,Acute respiratry failure,Meth susc Staph aur sept,Oth severe malnutrition,Pseudomonal pneumonia,Hemophagocytic syndromes,Other pancytopenia,Neurohypophysis dis NEC,Bronchiectasis w ac exac,BMI less than 19,adult,React-oth vasc dev/graft,Autoimmune disease NEC,Emphysema NEC,Autoimmune hepatitis,Lichen planus,History of tobacco use,Nontox uninodular goiter,Anxiety state NOS,Adv eff cephalosporin,Long-term use steroids,Anemia NOS,Blepharitis NOS,Do not resusctate status,FB respiratory tree NOS
Admission Date:  [**2171-2-1**]              Discharge Date:   [**2171-3-18**]

Date of Birth:  [**2111-5-11**]             Sex:   M

Service: MEDICINE

Allergies:
vancomycin / daptomycin

Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
cough, dyspnea, O2 requirement, tranaminitis

Major Surgical or Invasive Procedure:
liver biopsy

History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 4580**] is a 59 year old male with monoclonal
gammopathy,
severe oral lichen planus, recent GIST tumor s/p surgical
resection
[**2170-12-27**], possible neuromuscular disorder who presents with cough
and fever X 3 days.
.
His symptoms began three days ago beginning with one day of low
grade fever to 100.4, cough, and fatigue. He was noted to have
increased O2 requirement and transaminitis and was referred to
the ED. Patient has had no abdominal or GI symptoms.
.
Of note patient has had a long and complicated medical history
beginning in [**2169-8-20**] when he suddenly lost his sense of
taste after treatement of social anxiety with proproanolol. It
was the start of a progressive course of oral lichen planus. Due
to loss of taste, he last 20 lbs. He developed respiratory
problems including a number of sinus infections in the summer of
[**2170**] requiring treatmetn with antibitotics. Workup by his PCP
[**Name Initial (PRE) 7837**] "abnormal immunoglobulin levles, further evaluated with
bone marrow biopsy revealing MGUS. He began to develop rashes,
and worsening of his oral lichen planus with mouth, pain and
thrush. He had biopsies of his tongue confirming diagnosis
lichen planus. Biopsy of plaques on the dorum of his knuckles
were suggestive of Gottren's papules, making diagnosis
concerning for dermatomyositis. Given patient had not had
weakness consistent with this, it was suggested that he had a
diagnosis of sine dermatomyositis. Later with subsequent biopsy,
this diagnosis was challenged with systemic lichen planus.
Furthermore, as dermatomyositis was raised, patient underwent an
exhausive workup for malignancy including colonsocopy and
endoscopy. A gastric mass was discovered, found to be a benign
GIST tumor. Throughout these hospitalization, patient became
malnourished as workup for his symptoms continued. He developed
several pneumonia . During his most recent hospitalization for
low grade temperature, cough, and hypoxia, he was found to have
a possible aspiration and/or bronchiectasis/bronchiolitis with
resultant transpulmonary
shunt. Sputum cultures grew MSSA and pan-sensitive Pseudomonas.
He was treated with a 10day course of cipro and cefazolin. At
time of discharge he was satting in the low 90s on room air with
ambulatory sats in the mid-90s on room air. A cause of his
weakness has not been discovered. Neurology has recommended a
voltage gated calcium channel antibiody [**Hospital1 **] nicotinic receptor
binding antibody which must be ordered as outpatient. Weakness
was also thought to be the cuase of his aspiration risk and NIF
of -40. It was unclear whether this was a neuromuscular process
or rheumatologic condition. Decision was made to initiate
treatment with steroids. Patient's breathing improved (NIF
improved to -80). He was discharged on a prolonged steroid
course.
.
Of note, skin biopsy recently showed overlap between lichen
planus and connective tissue disorder (lichen planus with immune

deposition). Serologic tests include: negative [**Doctor First Name **], ANCA,
anti-synthetase antibodies and normal CK. Inflammatory markers
were markedly elevated. Sine dermatomyositis was suggested, but
seems less likely based on his clinical course.
.
In the ED, initial vital signs were 98.7 102 101/60 22. He
triggered for hypoxia 84% on RA. CXR from earlier in the day was
clear. He was not given antibiotics. He was admitted for
management of hypoxia. He was given 1L NS. Vital sings on
tranfer were: 112/75, 101, 90% 4L nc.
.
On the floor, patient has no new complaints. Looking forward to
returning home.


Past Medical History:
Bronchiolitis, Bronchiectasis
Monoclonal gammopathy with balanced 2;21 translocation and 10%
plasma cells in [**2170-4-20**]
Clinical judgement of "amyopathic dermatomyositis"
4.2 cm gastric stromal tumor s/p endo-lap resection [**2170-12-27**]
Biopsy proven Lichen planus with oral and peripheral lesions
Shingles 5 years ago
s/p hernia repair at age 16
?Autoimmune hepatitis ([**1-/2171**])

Social History:
Is a self-employed TV engineering consultant who builds TV
studios.  Remote tobacco - quit [**2144**].  Rare alcohol (a few
glasses of wine per week prior to getting sick, none with his
altered taste sensation).
No illicits.  Married for 20+ years and lives with wife who
travels around the world doing preformance art.  No children.  +
cat (indoor only).  No other pets.  Summers at family home in
[**State 1727**] on the ocean.  No known exposures/bites including ticks.


Family History:
Mother died of MI in her 70s.  Father had emphysema and angina
and died at 78.  Had one older brother who died of [**Name (NI) 8751**] in
college.

Physical Exam:
On admission:
Vitals: 95.9 98/64 97 20 90% on 3L
General: Alert, oriented, emaciated gentleman appearing older
than stated age, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with healing mucosal
ulcerations.
Neck: supple, JVP not elevated, no LAD, muscle atrophy noted.
Lungs: Fair airmovement, with audible expiratory wheezes, forced
expiratory wheeze elicits cough.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:CN2/12 intact. Strenth [**4-25**] throguhout, overall weak to my
assessment, lower extremity worse than upper. Gait narrow and
steady, mentally clear and responds to questions appropriately.

On dishcarge:
Patient expired.
Temperature 96.2, no heart or breath sounds on ascultation.

Pertinent Results:
[**2171-2-1**] 10:45AM BLOOD WBC-3.4* RBC-4.27* Hgb-12.8* Hct-36.9*
MCV-86 MCH-30.0 MCHC-34.8 RDW-16.2* Plt Ct-204
[**2171-2-1**] 10:45AM BLOOD Neuts-72.4* Lymphs-16.6* Monos-10.3
Eos-0.4 Baso-0.3
[**2171-2-1**] 04:10PM BLOOD PT-11.4 PTT-30.7 INR(PT)-1.1
[**2171-2-1**] 04:10PM BLOOD Glucose-136* UreaN-18 Creat-0.5 Na-132*
K-3.6 Cl-97 HCO3-24 AnGap-15
[**2171-2-1**] 10:45AM BLOOD ALT-602* AST-259* AlkPhos-185*
TotBili-0.6
[**2171-2-1**] 04:10PM BLOOD Calcium-8.6 Phos-3.0 Mg-2.0
[**2171-2-1**] 10:45AM BLOOD calTIBC-216* VitB12-1676* Folate-15.7
Ferritn-2285* TRF-166*
[**2171-2-2**] 06:45AM BLOOD TSH-2.0
[**2171-2-2**] 06:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2171-2-2**] 11:26AM BLOOD AMA-NEGATIVE
[**2171-2-2**] 06:45AM BLOOD Smooth-NEGATIVE
[**2171-2-2**] 06:45AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2171-2-2**] 06:45AM BLOOD IgG-971 IgM-18*
[**2171-2-2**] 06:45AM BLOOD tTG-IgA-3
[**2171-2-1**] 04:37PM BLOOD Lactate-2.5*
[**2171-2-5**] 03:29PM BLOOD CERULOPLASMIN-   34
[**2171-2-5**] 03:29PM BLOOD ALPHA-1-ANTITRYPSIN- 244
[**2171-2-2**] 06:45AM BLOOD VARICELLA ZOSTER ANTIBODY, IGM- neg
[**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX (HSV) 2, IGG- neg
[**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX (HSV) 1, IGG- neg
[**2171-2-2**] 06:45AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM- neg

CXR:
 PA and lateral chest compared to [**1-10**] through [**1-16**],
extent of peribronchial thickening and impaction of extensive
bibasilar
bronchiectasis may have increased slightly since the most recent
prior lateral chest radiograph, [**1-10**]. There is really no
change in the appearance of the frontal views as recently as
[**1-16**]. Generalized hyperinflation is due to emphysema.
Heart size is normal. There is no pulmonary edema,
consolidation. A tiny right pleural effusion may be new, but
probably not clinically significant. Findings would therefore be
attributed to decompensation of emphysema and bronchiectasis.

RUQ U/S:
1. Normal hepatic Doppler examination.
2. Sludge and likely polyps within the gallbladder. No
pericholecystic fluid or wall thickening.

CT Abd: 1. Bibasilar bronchiectasis with mucoid plugging of
several bronchi. 2. Normal morphologic-looking liver with a
single hamartoma in segment III of the liver.
3. Bilateral renal cysts.
4. Replaced right hepatic artery arising from the superior
mesenteric artery.

Liver Bx:
Liver, needle core biopsy:

1.Marked peri-centrivenular, mild portal and periportal
inflammation consisting of lymphocytes, plasma cells,
neutrophils and macrophages with apoptotic hepatocytes and
peri-centrivenular hepatocyte drop out (confirmed by reticulin
stain).
2.Associated foci of central endothelialitis with
peri-centrivenular hemorrhagic necrosis identified.
3.No significant steatosis seen.
4.Trichrome stain highlights central vein damage; no definitive
increase in fibrosis identified.
5.Iron stain shows mild iron within predominantly
peri-centrivenular hepatocytes.
6.[**Country 7018**] red stains are negative for amyloid, with satisfactory
control.
Note:  The features are those of a marked active hepatitis with
a predominantly centrivenular pattern of injury. The
differential includes an immune-mediated drug effect and
autoimmune hepatitis; viral hepatitis is less likely. Further
correlation with clinical and serologic findings is needed.
Given the patient's history of monoclonal gammopathy and the
presence of rare binucleate plasma cells, the case will be
further reviewed by hematopathology and their findings issued
separately in an addendum.
.
Video Swallow:
Penetration, but no gross aspiration, with thin and nectar thick

liquids, similar to prior study.
.
Thyroid US [**2171-2-27**]: 11 mm spongy nodule in the left thyroid
without worrisome features.
,
EKG [**2171-3-4**]: Sinus tachycardia with increase in rate as compared
with previoui tracing of [**2171-2-23**]. Variation in precordial lead
placement. Except for rate, the tracing remains normal without
diagnostic interim change.
.
CTA [**2171-3-4**]: 1. No evidence for PE.
2. Improved nodular opacities in the right lower lobe consistent
with
resolving infection.
3. Unchanged bronchiectasis with bronchial wall thickening and
mucous
plugging in the lower lobes.
.
CXR [**2171-3-6**]: Heart size and mediastinum are unremarkable. Right
lower lobe and left lower lobe bronchiectasis with bronchial
wall thickening and endobronchial impaction overall appear
unchanged since the prior examination with no evidence of
interval progression of the infectious process. Note is made
that the left costophrenic angle was not included in the field
of view. There is no appreciable pleural effusion or
pneumothorax. The Dobbhoff tube tip is in the stomach.
Substantial hyperinflation is redemonstrated.
.
CXR [**2171-3-11**]: IMPRESSION:
1. Dobbhoff feeding tube is seen coursing below the diaphragm
with the tip
not completely identified but positioned within the stomach
proximally. It
does not appear to be significantly changed. Bilateral lower
lobe
bronchiectasis is stable. No focal airspace consolidation is
seen to suggest an acute pneumonia. No pleural effusions or
pneumothoraces. Overall, cardiac and mediastinal contours are
unchanged. Lungs remain hyperinflated.
.
CXR [**2171-3-13**]: Bronchial wall thickening or peribronchial
infiltration in the lower lungs where most pronounced
bronchiectasis is have worsened since [**3-11**] consistent
either with a flare of bronchiectasis or development of
peribronchial pneumonia. Heart size is normal. There is no
pleural effusion, no pneumothorax. Feeding tube ends in the
upper stomach.

CXR [**2171-3-14**]: As compared to the previous radiograph, there is no
relevant change. Moderate-to-severe overinflation with known
areas of bronchiectasis and perifocal parenchymal opacities. The
opacities are unchanged in distribution and severity. Normal
size of the cardiac silhouette. Normal hilar and mediastinal
structures. No newly appeared focal parenchymal changes.
.
CXR [**2171-3-17**]: 1) Small left effusion with underlying collapse
and/or consolidation. In the appropriate clinical setting, the
differential would include a pneumonic infiltrate. Findings
discussed with the covering house officer on the afternoon of
the exam.


Brief Hospital Course:
BRIEF HOSPITAL COURSE
This is a 59 year old gentleman with systemic disease of unclear
etiology now with fever, cough, hypoxia, and transaminitis who
eventually decompensated on [**2171-3-16**] with respiratory failure
(multifactorial, pls see below) and was made CMO on [**2171-3-17**] and
passed away on [**2171-3-18**].
.
.
# Hypoxia: Likely [**2-21**] known bibasilar bronchiectasis, initially.
Sputum with moderate pan-sensitive pseudomonas. Was treated with
suppression ciprofloxacin, aggressive chest PT, mucolytics,
nebulizers (many of which were refused). Transitioned from
albuterol to xopenex nebs b/c the former left the patient
feeling too "jittery". Remained stable on 2L O2 with O2 sat in
low 90s. Had a desaturation episode on [**2-22**] in the setting of a
prolonged attempt at dobhoff placement. Repeat CT at that time
suggested no abscess but RLL nodular densities concerning for
spread of infx (aspergillosis or fungal) vs inflammatory
nodules. His respiratory status remained stable with a 2L O2
requirment. He was started on atovaquone for PCP [**Name Initial (PRE) **] (bactrim
held given possible contribution to LFT elevations and pt did
not tolerate daptomycin --> episode of flushing, tachycardia).
Pulmonary deferred on bronch vs VATS to bx the peripheral nodule
given the patient's strong preference and his aspiration risk.
Pulm also suggested an acapella flutter device, [**Doctor First Name **] nebs 3x/wk
(started [**3-2**]), and blood testing for CF. On the afternoon of
[**3-4**] the patient had a desaturation episode in the setting of a
fever to 102F. A CXR at that time demonstrated a new RLL PNA.
His antibiotics were broadened and he stayed overnight in the
MICU before returning to the floor. He improved gradually and
his O2 requirement remained stable 2-3L. On [**3-13**] a CXR performed
in the setting of persistent tachycardia demonstrated a flare of
his bronchiectasis vs a peri-bronchial PNA. He was broadened to
cefepime and the [**Doctor First Name **] nebs were d/c'd.
.
By [**2171-3-16**], Patient was having trouble clearing secretions, with
known pseduomonas colonization of his sputum. Patient was kept
on cefepime, with daily aggressive chest PT and frequent
reminders to take guaifenisen for mucolytic therapy, as he has
significant difficulty clearing secretions. On [**2171-3-17**],
respiratory status worsened with tachypnea, venous blood gas
showed increased CO2. CXR showed LLL opacification/collapse.
Case discussed with the pulmonary fellow and [**Hospital Unit Name 153**] team. The
pulmonary fellow discussed with the patient and his wife the
code status and recommended against CPAP/intubation as futile
measures. The patient became DNR/DNI. A morphine drip to titrate
to confort was started, as discussed and agreed by the patient,
his wife, the pulmonary fellow, attending Dr [**Last Name (STitle) **] and [**Hospital Unit Name 153**]
resident. Patient's antibiotics and every other med including
IVIG and CSA were continued. Despite increasing doses of
morphine drip, patient continued to exhibit tachypnea and
patient was made CMO that evening. Patient received morphine
bolus doses on top of drip and all other medications were held.
Patient passed away on [**2171-3-18**] at 4:05pm.
.
# Lichen planus: Worst in mouth but also has diffuse skin
lesions. Appreciate dermatology c/s who discussed case w/
multiple colleagues and has been incredibly helpful throughout
his course. His multiple skin  biopsies are consistent with an
exuberant lichen-planus like eruption, which for the moment we
are categorizing as severe generalized lichen planus. Our work
up for  paraneoplastic syndrome, namely the LP varient of PAMS,
has thus far been negative: no Dsg1 or Dsg3 antibodies, and
indirect immunoflouresence has been negative (although
immunoflouresence on rat bladder is still pending - will be run
by [**Hospital1 **]). Meanwhile, the search for an underlying cause (i.e.
malignancy) has been unrevealing. Flow cytometry from [**2-21**]: no
features of leukemia. BM bx suggested possible mastocytosis, but
derm felt that skin biopsies were less consistent with this
possibility, and a tryptase was negative. Paraneoplastic
pemphigus send-out returned negative. Arsenic negative. Based on
a discussion between heme/onc and derm, the pt underwent a 4-day
course of IVIG 0.5 g/kg/day (25g/day) under the premise that
though this is not a treatment for lichen planus per se it might
target the underlying pathology. He was maintained on IV
steroids briefly but then switched back to po prednisone and is
currently on a long taper. After extensive discussion involving
GI and heme/onc (appreciate derm's continued input), commenced
cyclosporine 25 mg [**Hospital1 **] on [**3-7**] and then increased to 50 [**Hospital1 **] on
[**3-10**] and 100 [**Hospital1 **] on [**3-14**]. Has tolerated well so far. The rest of
his skin regimen includes clobetasol + plastic wrapping,
mupirocin for his lower face and neck, and topical tacrolimus
(mixed 1:1 with vaseline) for around his eyes.
.
# Bacteremia: Grew out MSSA from blood cultures 2/03 in the
setting of persistent fevers. Received linezolid [**Date range (1) 19593**] and
also daptomycin but had a rxn during infusion. Started on
cefepime (narrowed to nafcillin on [**2-28**]), and was afebrile until
[**3-4**]. Blood cx grew GPC in clusters until [**2-26**] (last positive cx
[**2-25**]). ID narrowed to nafcillin [**2-28**]. ID followed, but signed off
[**3-1**] (note: pt should f/u with [**Doctor Last Name 13895**] of ID w/in 2 wks of d/c;
need to fax labs qweek to ID dept). Pt had poor quality TTE that
did not reveal vegetations but a TEE was deferred given
aspiration risk and pt preference. Daily surveillence cultures
were obtaiend [**Date range (1) 19594**]. Cultures remained negative and patient
was afebrile. On [**3-13**] an infectious workup for tachycardia
yielded blood cultures that grew MRSA, and on [**3-14**] he was
broadened to cefepime/linezolid.
.
# Nutrition/deconditioning: Pt's weight down to ~115 from
pre-illness weight 170. Poor PO intake [**2-21**] mouth pain a/w eating
(due to oral lichen planus). An oral video swallow previously
showed no change from prior. An EMG was normal. Pt is adamant in
refusal of G-tube and TPN. Dobhoff placed [**2-25**] with help of
surgery. TF to 90/hr x 12 hrs (9PM-9AM) on [**2-27**] (~1620 cals); pt
tolerating well. Nutrition followed the patient while in house.
He required dexamethasone and gelclair along with viscous
lidocaine for oral care. He is unable to tolerate a variety of
foods (dry, salty, spicy, tangy, etc.). His wife provides
high-calorie milkshakes. TF were switched from cycled initially
to continuous and then back to cycled (the last change to
stimulate the patient's appetite).
.
# Transaminitis: Pt had mild transaminitis since [**Month (only) **] of
[**2170**].  From the 30s to 50s. This increased in [**Month (only) 1096**] to 100s
range, thought to be secondary to antibiotic effect. At time of
his most recent discharge he was set up to have LFTs followed up
after discontinuation of antibiotics to ensure resolution of
transaminitis.  In follow up appointment he was noted to have
LFTs with ALT 627, AST 276, Alk Phos 198, TBili 0.5.  He was
admitted to the hospital for workup.  Hepatology was consulted.
Vital hepatitidies, CMV, EBV, VZV, HSV with negative serologies
and/or viral loads.  RUQ ultrasound unremarkable, as was CT
abdomen. He underwent liver biopsy which was suggestive of drug
induced immune reaction vs autoimmune hepatitis.  He was
continued on high dose prednisone throughout.  Despite this,
during his hosptialization, his LFTs continued to rise peaking
in 1400s.  The hepatology team also recommended further workup
with antiLKM ab, serum VEGF levels to r/o POEMS, which were all
unrevealing. He was continued on prednisone (40-60 mg daily) and
started on azathioprine with continued worsening of his
transaminitis. Ultimately azathioprine was discontinued after 10
days ([**Date range (1) **]). Bactrim was also held given its potential
contribution. His LFTs started to improve without clear
precipitant. Interestingly his synthetic function was intact
throughout this period of liver injury. His LFTs continued to
decline, and he was briefly transitioned to IV
methylprednisolone before being switched back to prednisone. By
the first week of [**Month (only) 956**] his LFTs had more or less stabilized
at ALT 200s, AST ~100, AlkPhos ~200. LFTs were followed
periodically after this and they continued to decline toward
normal range.
.
# Hyponatremia - Na was persistently low despite IVF with NS,
withholding free water from tube feeds, etc. Urine lytes [**3-2**]
indicate SIADH (UOsm 799). However, pt was without symptoms per
se and strongly preferred that his IVF be maintained (due to
perceived dryness/cracking in mouth that prevents him from
sleeping). Following a switch in the patient's continuous tube
feeds (namely a different formula with a reduced free water
content), the hyponatremia resolved.
.
# Thyroid nodule: 1.1 cm thyroid nodule discovered incidentally
on chest CT on [**2-22**]. Given a potential connection between the
patient's presumed autoimmune disorder and underlying
malignancy, it was thought that this nodule merited further
workup. T4 and TSH nl. Thyroid U/S performed [**2-27**]; nodule not
concerning; defer further w/u for now.
.
# Leukopenia: Has been present since last admission. WBC
declined < 3K but climbed after conclusion of IVIG tx 5-6K
(~[**2-23**] - [**2-26**]). Has been declining since.
.
# PLASMA CELL DYSCRASIA/MGUS: Patient has 10% plasma cells,
negative skeletal survey, normal calcium and no renal
insufficiency. He refused BMBX on [**1-15**]. Given other hemotologic
abnormalities repeat bone marrow biopsy may be indicated.
.
# Blepharitis/severe dry eyes: Pt c/o dry eyes; must use
artificial tears to keep eyes open. Ophthalmology consulted re
possible ocular involvement of lichen planus and additional
options for eye care. They suggested gel vs frequent artificial
tears. Felt that no ocular involvement per se.
.
# Anxiety: History of severe anxiety/panic attacks at his prior
admission. Social work following ([**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**]); has been a
source of incredible support for pt and wife. On low-dose xanax
for anxiety and clonazepam for sleep.


Medications on Admission:
1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic TID (3 times a day).
2. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H
(every 4 hours).
3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Systane Balance 0.6 % Drops Sig: One (1) Ophthalmic prn ()
as needed.
7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane

QID (4 times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day,
decreased to 30mg on Tuesday, [**2171-1-29**]
11. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)

Tablet PO DAILY (Daily).
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One

(1) Tablet PO DAILY (Daily).
14. lorazepam 0.5 mg Tablet Sig: 0.5-1 Tablet PO every 4-6 hours

as needed for insomnia
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day
17. GELCLAIR Gel in Packet Sig: 15ml Mucous membrane three
times a day.
18. B Complex-Vitamin B12 Tablet Sig: One (1) Tablet PO once
a day.


Discharge Medications:
none. patient expired.

Discharge Disposition:
Expired

Discharge Diagnosis:
patient expired

Discharge Condition:
patient expired
resp failure likely [**2-21**] bronchiectasis, mucous plugging,
deconditioning, muscle weakness, and atelectasis.

Discharge Instructions:
patient expired

Followup Instructions:
patient expired
{'Myelodysplastic syndrome, unspecified,Acute and subacute necrosis of liver,Acute respiratory failure,Methicillin susceptible Staphylococcus aureus septicemia,Other severe protein-calorie malnutrition,Pneumonia due to Pseudomonas,Hemophagocytic syndromes,Other pancytopenia,Other disorders of neurohypophysis,Bronchiectasis with acute exacerbation,Body Mass Index less than 19, adult,Infection and inflammatory reaction due to other vascular device, implant, and graft,Autoimmune disease, not elsewhere classified,Other emphysema,Autoimmune hepatitis,Lichen planus,Personal history of tobacco use,Nontoxic uninodular goiter,Anxiety state, unspecified,Cephalosporin group causing adverse effects in therapeutic use,Long-term (current) use of steroids,Anemia, unspecified,Blepharitis, unspecified,Do not resuscitate status,Foreign body in respiratory tree, 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: cough, dyspnea, O2 requirement, tranaminitis

PRESENT ILLNESS: Mr. [**Known firstname **] [**Known lastname 4580**] is a 59 year old male with monoclonal
gammopathy,
severe oral lichen planus, recent GIST tumor s/p surgical
resection
[**2170-12-27**], possible neuromuscular disorder who presents with cough
and fever X 3 days.
.
His symptoms began three days ago beginning with one day of low
grade fever to 100.4, cough, and fatigue. He was noted to have
increased O2 requirement and transaminitis and was referred to
the ED. Patient has had no abdominal or GI symptoms.
.
Of note patient has had a long and complicated medical history
beginning in [**2169-8-20**] when he suddenly lost his sense of
taste after treatement of social anxiety with proproanolol. It
was the start of a progressive course of oral lichen planus. Due
to loss of taste, he last 20 lbs. He developed respiratory
problems including a number of sinus infections in the summer of
[**2170**] requiring treatmetn with antibitotics. Workup by his PCP
[**Name Initial (PRE) 7837**] "abnormal immunoglobulin levles, further evaluated with
bone marrow biopsy revealing MGUS. He began to develop rashes,
and worsening of his oral lichen planus with mouth, pain and
thrush. He had biopsies of his tongue confirming diagnosis
lichen planus. Biopsy of plaques on the dorum of his knuckles
were suggestive of Gottren's papules, making diagnosis
concerning for dermatomyositis. Given patient had not had
weakness consistent with this, it was suggested that he had a
diagnosis of sine dermatomyositis. Later with subsequent biopsy,
this diagnosis was challenged with systemic lichen planus.
Furthermore, as dermatomyositis was raised, patient underwent an
exhausive workup for malignancy including colonsocopy and
endoscopy. A gastric mass was discovered, found to be a benign
GIST tumor. Throughout these hospitalization, patient became
malnourished as workup for his symptoms continued. He developed
several pneumonia . During his most recent hospitalization for
low grade temperature, cough, and hypoxia, he was found to have
a possible aspiration and/or bronchiectasis/bronchiolitis with
resultant transpulmonary
shunt. Sputum cultures grew MSSA and pan-sensitive Pseudomonas.
He was treated with a 10day course of cipro and cefazolin. At
time of discharge he was satting in the low 90s on room air with
ambulatory sats in the mid-90s on room air. A cause of his
weakness has not been discovered. Neurology has recommended a
voltage gated calcium channel antibiody [**Hospital1 **] nicotinic receptor
binding antibody which must be ordered as outpatient. Weakness
was also thought to be the cuase of his aspiration risk and NIF
of -40. It was unclear whether this was a neuromuscular process
or rheumatologic condition. Decision was made to initiate
treatment with steroids. Patient's breathing improved (NIF
improved to -80). He was discharged on a prolonged steroid
course.
.
Of note, skin biopsy recently showed overlap between lichen
planus and connective tissue disorder (lichen planus with immune

MEDICAL HISTORY: Bronchiolitis, Bronchiectasis
Monoclonal gammopathy with balanced 2;21 translocation and 10%
plasma cells in [**2170-4-20**]
Clinical judgement of "amyopathic dermatomyositis"
4.2 cm gastric stromal tumor s/p endo-lap resection [**2170-12-27**]
Biopsy proven Lichen planus with oral and peripheral lesions
Shingles 5 years ago
s/p hernia repair at age 16
?Autoimmune hepatitis ([**1-/2171**])

MEDICATION ON ADMISSION: 1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic TID (3 times a day).
2. dexamethasone 0.5 mg/5 mL Elixir Sig: Five (5) ML PO Q4H
(every 4 hours).
3. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
4. Systane Balance 0.6 % Drops Sig: One (1) Ophthalmic prn ()
as needed.
7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane

ALLERGIES: vancomycin / daptomycin

PHYSICAL EXAM: On admission:
Vitals: 95.9 98/64 97 20 90% on 3L
General: Alert, oriented, emaciated gentleman appearing older
than stated age, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with healing mucosal
ulcerations.
Neck: supple, JVP not elevated, no LAD, muscle atrophy noted.
Lungs: Fair airmovement, with audible expiratory wheezes, forced
expiratory wheeze elicits cough.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:CN2/12 intact. Strenth [**4-25**] throguhout, overall weak to my
assessment, lower extremity worse than upper. Gait narrow and
steady, mentally clear and responds to questions appropriately.

FAMILY HISTORY: Mother died of MI in her 70s.  Father had emphysema and angina
and died at 78.  Had one older brother who died of [**Name (NI) 8751**] in
college.

SOCIAL HISTORY: Is a self-employed TV engineering consultant who builds TV
studios.  Remote tobacco - quit [**2144**].  Rare alcohol (a few
glasses of wine per week prior to getting sick, none with his
altered taste sensation).
No illicits.  Married for 20+ years and lives with wife who
travels around the world doing preformance art.  No children.  +
cat (indoor only).  No other pets.  Summers at family home in
[**State 1727**] on the ocean.  No known exposures/bites including ticks. 

### Response:
{'Myelodysplastic syndrome, unspecified,Acute and subacute necrosis of liver,Acute respiratory failure,Methicillin susceptible Staphylococcus aureus septicemia,Other severe protein-calorie malnutrition,Pneumonia due to Pseudomonas,Hemophagocytic syndromes,Other pancytopenia,Other disorders of neurohypophysis,Bronchiectasis with acute exacerbation,Body Mass Index less than 19, adult,Infection and inflammatory reaction due to other vascular device, implant, and graft,Autoimmune disease, not elsewhere classified,Other emphysema,Autoimmune hepatitis,Lichen planus,Personal history of tobacco use,Nontoxic uninodular goiter,Anxiety state, unspecified,Cephalosporin group causing adverse effects in therapeutic use,Long-term (current) use of steroids,Anemia, unspecified,Blepharitis, unspecified,Do not resuscitate status,Foreign body in respiratory tree, unspecified'}
