CHIEF COMPLAINT: respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 58-year-old man with a history of AML s/p
allogeneic transplant [**2142**] complicated by graft-versus-host
disease, multiple vertebral fractures and ultimately development
of paraplegia in the setting of a vertebral fracture during a
code situation. Admitted multiple times, most recently [**8-/2148**]
for bacteremia and upper resp infection (cx: staph epi) and
completed a course of vancomcyin, aztreonam. Discharged from
rehab and home (wheelchair bound) with recent clinic followup
[**9-26**] noting baseline health.

MEDICAL HISTORY: Past Medical History:
- CKD (baseline Cr 0.6-0.7)
- Hyperlipidemia
- HTN
- Type 2 DM (last A1c 6.8 [**2144**])
- Depression
- Chronic pain
- Pericardial effusion s/p [**3-23**] drainage.
- Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
- Left interpolar renal lesion, followed with MRs
- Basal cell carcinoma, resected.
- Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
- Multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware).
- Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
- Chronic numbness, neuropathic pain in left upper extremity.
- Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
- Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Atorvastatin 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 10 mg PO DAILY constipation
6. Bisacodyl 10 mg PR HS
7. Duloxetine 30 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
9. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
14. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. MethylPHENIDATE (Ritalin) 5 mg PO NOON
17. Metoprolol Tartrate 12.5 mg PO BID
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. MethylPHENIDATE (Ritalin) 5 mg PO QAM
21. Oxycodone SR (OxyconTIN) 40 mg PO BID
22. Pantoprazole 40 mg PO Q24H
23. PredniSONE 10 mg PO DAILY
24. Senna 2 TAB PO HS
25. Sodium Chloride Nasal [**12-18**] SPRY NU QID:PRN nasal congestion
26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
28. Docusate Sodium 100 mg PO BID
29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm

ALLERGIES: Cefepime / ciprofloxacin / Levofloxacin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Vitals:  T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB
General: Somnolent, but arousable, oriented x 3, no acute
distress, answers one question before falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
copious secretions
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Transmitted upper airway sounds bilaterally, good air
movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Skin laceration on dorsum of left wrist
Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the
waist down.

FAMILY HISTORY: Mother died suddenly in 70s. Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One sister
has [**Name (NI) 5895**].

SOCIAL HISTORY: Discharged from rehab in [**2148-6-16**] and has now been living at
home wiht VNA services and aid from his wife.  [**Name (NI) **] is retired,
worked as a [**Company 22957**] technician. He smoked for 40 pack years, now
quit. He denies EtOH or drugs.
Unspecified septicemia,Pneumonia in other systemic mycoses,Septic shock,Acute respiratory failure,Other pulmonary embolism and infarction,Encephalopathy, unspecified,Other and unspecified mycoses,Complications of transplanted organ, stem cell,Chronic graft-versus-host disease,Acute kidney failure, unspecified,Paraplegia,Severe sepsis,Other specified disorders of skin,Other specified disorders of liver,Other specified cardiac dysrhythmias,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tear film insufficiency, unspecified,Unspecified essential hypertension,Conductive hearing loss, unspecified,Swelling, mass, or lump in chest,Long-term (current) use of steroids,Personal history of myeloid leukemia,Personal history of other malignant neoplasm of skin,Encounter for palliative care,Do not resuscitate status,Personal history of sudden cardiac arrest,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Septicemia NOS,Pneum in oth sys mycoses,Septic shock,Acute respiratry failure,Pulm embol/infarct NEC,Encephalopathy NOS,Mycoses NEC & NOS,Comp tp organ-stem cell,Chronc graft-vs-host dis,Acute kidney failure NOS,Paraplegia NOS,Severe sepsis,Skin disorders NEC,Liver disorders NEC,Cardiac dysrhythmias NEC,DMII wo cmp nt st uncntr,Tear film insuffic NOS,Hypertension NOS,Conduct hearing loss NOS,Chest swelling/mass/lump,Long-term use steroids,Hx of myeloid leukemia,Hx-skin malignancy NEC,Encountr palliative care,Do not resusctate status,Hx sudden cardiac arrest,Abn react-procedure NEC
Admission Date:  [**2148-9-30**]              [**Month/Day/Year **] Date:   [**2148-10-13**]

Date of Birth:  [**2090-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime / ciprofloxacin / Levofloxacin

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress


Major Surgical or Invasive Procedure:
- removal of tunneled line

History of Present Illness:
Mr. [**Known lastname 47367**] is a 58-year-old man with a history of AML s/p
allogeneic transplant [**2142**] complicated by graft-versus-host
disease, multiple vertebral fractures and ultimately development
of paraplegia in the setting of a vertebral fracture during a
code situation. Admitted multiple times, most recently [**8-/2148**]
for bacteremia and upper resp infection (cx: staph epi) and
completed a course of vancomcyin, aztreonam. Discharged from
rehab and home (wheelchair bound) with recent clinic followup
[**9-26**] noting baseline health.

Wife also states he was in his usual state of health until the
morning of admission when she went to wake him he was more
somnolent than usual and seemed to be having difficulty
breathing taking rapid shallow breaths.  His wife attributed his
somnolence to recently starting Ambion and Valium 3 days prior
to admission in addition to his home narcotic regimen of
oxycontin and dilaudid. She also noted that he looked more pale
than usual. She reports that he had a cough starting over the
weekend productive of yellow sputum. No history of fevers, and
outside of baseline pain, he had no complaints. Given his
somnolence, EMS was called and administereed narcan in the field
without improvement so he was admitted to Study hospital on
[**9-30**] for acute respiratory failure. On arrival he was afebrile,
tachycardic to 160s (sinus), hypotensive to 91/58 (though fell
to 60s-70s per wife), RR of 8, and was satting 94% on BIPAP.  He
was bolused 500cc with improvement of HR to 130s. He was bolused
more NS (unclear how much) and remained hypotensive so was
started on norepinephrine 2mcg/min and given stress dose
hydrocortisone. He does have a triple lumen port, but given poor
peripheral access, an intraosseous was placed.  He was given an
additional dose of narcan given continued somnolence and
transferred to the [**Hospital1 18**] at the family's request given that all
of his care has been here.

In the ED, initial VS were T 98.6 HR 128 BP 89/69 RR 17 99% on
BIPAP and initial ABG was 7.27/61/83. Labs were notable for
leukocytosis to 14.2, Trop-T: 0.18, Lactate:3.4, creatinine of
1.1 (baseline 0.6-0.8), and a grossly positive urinalysis with >
182 whites and moderate bacteria. He has an indwelling foley
catheter that was changed this past Thursday. A chest x-ray was
notable for LLL consolidation. He had received emperic
vancomycin at the OSH and received a dose of Zosyn in the ED
here.

On arrival to the MICU, patient's VS were T: 99.5 HR: 115 BP
121/69 RR 20, O2 sat 93% 100% NRB and was receiving levo at
1mcg/min on arrival. He was somnolent but arousable and oriented
x 3, but slow to answer questions. Complained of pain from the
chest up, but otherwise no complaints.

Review of systems:
(+) Per HPI. His wife notes that he did a few episodes of loose
stools. Morning headaches recently.
(-) Denies fever, chills, chest pain, chest pressure,
palpitations. Denies dark or bloody stools.


Past Medical History:
Past Medical History:
- CKD (baseline Cr 0.6-0.7)
- Hyperlipidemia
- HTN
- Type 2 DM (last A1c 6.8 [**2144**])
- Depression
- Chronic pain
- Pericardial effusion s/p [**3-23**] drainage.
- Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
- Left interpolar renal lesion, followed with MRs
- Basal cell carcinoma, resected.
- Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
- Multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware).
- Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
- Chronic numbness, neuropathic pain in left upper extremity.
- Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
- Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]

ONCOLOGIC HISTORY:
- diagnosed with AML in 04/[**2142**].
- [**2143-6-24**] underwent unrelated allogeneic stem cell transplant
with busulfan and cyclophosphamide as his conditioning regimen.
- continues bactrim, voriconazole, acyclovir ppx

POST TRANSPLANT COMPLICATIONS:
- GVHD of the liver and skin. Question of pulmonary cGVHD as
often requires oxygen and steroids in the setting of respiratory
infections (h/o RSV, parainfluenza)
- paraplegia [**1-18**] vertebral fractures during code [**2147**]
- Chronic lower extremity and abdominal edema, refractory to
lasix, suspected to be GVHD
- abdominal spasm - on valium (?etiology paraplegia)
- COP/BOOP: home O2 1-2liters
- Avascular necrosis (bilateral hips and left shoulder)
- Multiple compression fractures of the spine with chronic pain
- Pulmonary embolus in [**11/2144**] and [**5-/2146**], no with IVC [**Year (4 digits) 7448**]
not on anticoagulation
- s/p L5 vertebroplasty [**3-/2145**]
- Ruptured left calf hematoma ([**9-/2146**]) complicated by MRSA
wound infection
- Influenza A [**1-/2147**]
- bilateral Achilles tendon rupture [**2147-5-23**] ( attributed to
levoflox).


Social History:
Discharged from rehab in [**2148-6-16**] and has now been living at
home wiht VNA services and aid from his wife.  [**Name (NI) **] is retired,
worked as a [**Company 22957**] technician. He smoked for 40 pack years, now
quit. He denies EtOH or drugs.


Family History:
Mother died suddenly in 70s. Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One sister
has [**Name (NI) 5895**].


Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:  T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB
General: Somnolent, but arousable, oriented x 3, no acute
distress, answers one question before falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
copious secretions
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Transmitted upper airway sounds bilaterally, good air
movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Skin laceration on dorsum of left wrist
Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the
waist down.

[**Name (NI) 894**] PHYSICAL EXAM

Pertinent Results:
Admission labs:
[**2148-9-30**] 11:00AM BLOOD WBC-14.2* RBC-3.56* Hgb-12.5* Hct-39.2*
MCV-110* MCH-35.1* MCHC-31.9 RDW-17.7* Plt Ct-334
[**2148-9-30**] 11:00AM BLOOD Neuts-78* Bands-7* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2148-9-30**] 11:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-1+

[**2148-9-30**] 11:00AM BLOOD PT-9.1* PTT-28.5 INR(PT)-0.8*
[**2148-9-30**] 11:00AM BLOOD Glucose-174* UreaN-17 Creat-1.1 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-14
[**2148-9-30**] 05:51PM BLOOD CK(CPK)-111
[**2148-10-1**] 02:30AM BLOOD ALT-46* AST-56* AlkPhos-106 TotBili-0.3
[**2148-9-30**] 11:00AM BLOOD cTropnT-0.18*
[**2148-9-30**] 05:51PM BLOOD CK-MB-7 cTropnT-0.16*
[**2148-10-1**] 02:30AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5*
[**2148-9-30**] 06:29PM BLOOD Type-ART O2 Flow-15 pO2-91 pCO2-70*
pH-7.23* calTCO2-31* Base XS-0 Intubat-NOT INTUBA
[**2148-9-30**] 11:31AM BLOOD Glucose-167* Lactate-3.4* K-4.0

[**Month/Day/Year **] labs:


Micro:
[**2148-10-6**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE:
PENDING

[**2148-10-5**] CATHETER TIP-IV WOUND CULTURE- NO
SIGNIFICANT GROWTH (PRELIMINARY)

[**2148-10-5**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING

[**2148-10-4**] URINE URINE CULTURE- NO GROWTH

[**2148-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING

[**2148-10-4**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING

[**2148-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING

[**2148-10-3**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-NO GROWTH; BLOOD/AFB CULTURE-NO GROWTH

[**2148-10-2**] BLOOD CULTURE Blood Culture, Routine-PENDING

[**2148-10-1**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **] (TORULOPSIS)
GLABRATA}; BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram
Stain-FINAL
   BLOOD/FUNGAL CULTURE (Preliminary):
      [**Female First Name (un) **] (TORULOPSIS) GLABRATA.

   BLOOD/AFB CULTURE (Final [**2148-10-3**]):
      DUE TO OVERGROWTH OF YEAST, UNABLE TO CONTINUE MONITORING
FOR AFB.

   Myco-F Bottle Gram Stain (Final [**2148-10-3**]):
      BUDDING YEAST.

[**2148-10-1**] URINE URINE CULTURE-FINAL {YEAST}
   URINE CULTURE (Final [**2148-10-2**]):
      YEAST.    10,000-100,000 ORGANISMS/ML..

[**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING

[**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING


[**2148-9-30**] URINE Legionella Urinary Antigen -FINAL -
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

[**2148-9-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {YEAST}
Source: Expectorated.
   GRAM STAIN (Final [**2148-9-30**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   BUDDING YEAST.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CHAINS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
   RESPIRATORY CULTURE (Preliminary):
      MODERATE GROWTH Commensal Respiratory Flora.
      YEAST.    MODERATE GROWTH.

[**2148-9-30**] BLOOD CULTURE Blood Culture, Routine-PENDING


Studies:
[**2148-10-6**] CT CHEST W/O CONTRAST:

[**2148-10-6**] CHEST (PORTABLE): Right pleural effusion has decreased
in size with associated improvement in adjacent right basilar
atelectasis.  Multifocal areas of heterogeneous consolidation
involving the left lung to a greater degree than the right, have
slightly improved.  A small hyperlucency is present in the
periphery of the left upper lobe at the level of the second and
third anterior ribs, but no discrete visceral pleural line is
identified.  This may represent an area of spared lung
parenchyma from the presumed multifocal pneumonia, but attention
to this area on short-term followup radiograph may be helpful to
exclude an atypical presentation of pneumothorax, given clinical
suspicion for
this entity.

[**2148-10-6**] CHEST (PORTABLE AP): Widespread combined alveolar and
interstitial opacities affecting the left lung to a greater
degree than the right have progressed in the interval,
particularly in the right lower lung where there is also an
increasing pleural effusion with adjacent consolidation and/or
atelectasis. Small left pleural effusion also appears increased
from prior radiograph.

[**2148-10-5**] CHEST (PORTABLE AP): Status post removal of right
subclavian vascular catheter. Widespread heterogeneous combined
alveolar and interstitial opacities affecting the left lung to a
greater degree than the right, have progressed in the interval,
and may represent a multifocal pneumonia with or without
coexisting pulmonary edema.  Pulmonary hemorrhage is also
possible in the appropriate clinical setting.

[**2148-10-4**] CT ABD & PELVIS W & W/O
1.  No evidence of IVC or iliac vein thrombosis.  IVC [**Month/Day/Year 7448**] in
place.
2.  Stable lung base findings include, lingular pneumonia and
bibasal peribronchovascular nodular opacities suggestive of
aspiration. Bilateral small effusions and right lower lobe
pulmonary emboli.
3.  Hepatic steatosis.

[**2148-10-2**] CTA CHEST W&W/O C&RECON
1.  Right lower lobe lobar to subsegmental pulmonary acute
embolism. The most proximal portion of the filling defect is
peripheral in the artery raising the question if this could be
chronic but new since [**2148-6-16**].  There is no dilatation of main
pulmonary artery or right heart [**Doctor Last Name 1754**].
2.  Worsening of bilateral multifocal pneumonia.

[**2148-10-2**] CT HEAD W/O CONTRAST
1.  Limited study due to motion artifact, within this
limitation, no acute intracranial pathology.
2.  Multifocal paranasal sinus and bilateral mastoid air cell
opacification.

[**2148-10-2**] BILAT LOWER EXT VEINS
No deep venous thrombosis in right or left lower extremity.
Bilateral calf edema.

[**2148-10-2**] ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(?#) appear structurally normal with good leaflet excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.

IMPRESSION: Suboptimal image quality. Right ventricular cavity
dilation with free wall hypokinesis. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.

Compared with the prior study (images reviewed) of [**2147-5-24**], the
right ventricular cavity is now dilated with free wall
hypokinesis c/w an acute pulmonary process (e.g., pulmonary
embolism, bronchospasm, etc.).

[**2148-10-2**] ECG
Sinus tachycardia with increase in rate as compared to the
previous tracing of [**2148-6-27**]. Diffuse non-specific ST-T wave
changes are more prominent in the context of wandering baseline
and much baseline artifact. There appears to be more ST segment
depression in leads V3-V6 without diagnostic interim change.

[**2148-10-2**] EEG
This is an abnormal EEG due to disorganized and slow background
mostly consisting of mixed delta and theta suggestive of
moderate encephalopathy but non-specific etiologically. There
was no focal slowing or epileptiform discharges seen. Study
limited by electrode artifact. Recommend repeat study if
clinical concern for seizures persists.

[**2148-10-1**] CHEST (PORTABLE AP)
Previous pulmonary vascular congestion has improved, but there
is still very extensive consolidation in the left lung due to
pneumonia, without improvement, possibly worsened.  Smaller
region of consolidation in the right lower lung medially is
either a second focus of pneumonia or atelectasis. Mild
cardiomegaly is stable.  Dual-channel right supraclavicular
central venous set ends in the region of the superior cavoatrial
junction.  No pneumothorax.

[**2148-10-1**] CHEST (PORTABLE AP)
Progressive heterogeneous opacification in the left mid and
lower lung zone is most likely pneumonia worsening since [**9-30**].  There could be a second focus of right infrahilar
pneumonia, also advancing.  Cardiomediastinal silhouette is
essentially unchanged over several years.  Dual-channel right
supraclavicular central venous set ends close to the superior
cavoatrial junction.  No pneumothorax.

[**2148-9-30**] CHEST (PORTABLE AP)
1. Worsening opacification in the left lung base with associated
bronchial wall thickening concerning for infection.
2. Slight interval improvement in previously noted airspace
disease within the right upper lobe.
3. No definite pulmonary edema.


Brief Hospital Course:
57-year-old man with AML s/p matched unrelated allogeneic stem
cell transplant in [**2142**], complicated by GVHD on chronic
prednisone with multiple admission for infections now presents
with somnolence in the setting if increased sedative medication
use, hypercarbic respiratory distress, cough and CXR with LLL
consolidation found to have segmental PE.

# Goals of care: After frequent discussions with family and
physicians involved in the pt's case and gradual reduction in
number of interventions performed, it was decided to transition
to comfort measures only on [**10-12**]. The below medical treaments,
lab draws, and imaging procedures were held. The pt was kept in
IV morphine, tylenol, and ativan to keep comfortable. He died
peacefully on the morning of [**2148-10-13**].

# PE: Patient with tachycardia, hypoxemia, hypotensive on
admission and history of PE not anticoaguated, with IVC [**Date Range 7448**]
in place. TTE on [**10-2**] revealed large and hypokinetic RV and CTA
showed segmental PE. Unclear if acute vs. subacute given
appearance of clot on CTA. This was not present in [**Month (only) **],
however.  [**Month (only) **] is a potential source of clot as LENIs were
negative. CTV showed no evidence of clot in IVC [**Month (only) 7448**]. Non
contrast head CT was without hemorrhage, so started on heparin
drip with intention to bridge to lovenox. Per discussion with
inpatient heme attending and outpatient hematologist, it was
decided that the pt's risk of hemorrhage was greater than his
risk of clot given the negative LENIs and clean IVC [**Last Name (LF) 7448**], [**First Name3 (LF) **]
heparin gtt was held. He was continued on prophylactic heparin
subc.

# Pneumonia: Productive cough followed by somnolence in the
setting of starting Ambien and Valium in addition to his home
oxycontin. CXR with LLL consolidation. Sputum gram stain with
GPCs in clusters, GPCs in pairs and chains and GNRs and yeast.
Started on vanco, [**Last Name (un) 2830**] (day 1: [**9-30**]), mica (day 1: [**10-3**]) in
consultation with ID. Due to worsening CXR, vanco was changed to
linezolid (day 1: [**10-6**]) per ID recs. Also question of possible
pulmonary congestion, so pt was started on IV lasix. On [**10-8**],
the pt appeared to have worsening WBC and respiratory distress.
He was started on ambisome and given a dose of tobramycin. The
tobramycin was thereafter uptitrated with little effect.
Antibiotics were continued despite little improvement.

# Fungemia: Yeast in urine, sputum and mycolytic blood cultures
positive. Ophtho consulted and did not see evidence of fungal
retinitis.  Patient does have GVHD of conjunctiva, however. He
was continued on micafungin (day 1 = [**10-3**]) and will need two
week course following clearance of fungus. Mycolitic blood
cultures were sent daily. CXR showed nodular areas, which was
conserning for a mold pneumonia. Pt was started on ambisone for
presumed fungal pneumonia. An MR head was performed which ruled
out fungal brain extension. ENT was consulted for possible
involvement of nasal sinuses, who recommended nasal irrigation
as tolerated given sedation.

# Hypotension: He was hypotensive to 60s-70s at OSH and required
pressor support prior to transfer to the [**Hospital Unit Name 153**]. Possible sepsis
as patient met SIRS criteria with tachycardia and leukocytosis
with possible sources of infection including pulmonary given LLL
opacity on CXR and productive cough. Urine source also possible
given dirty urinalysis in the setting of indwelling catheter.
Cardiogenic shock was considered given rising troponins, but
they trended down and were likely elevated in the setting of
tachycardia. ECG was without evidence of ischemia. Hypovolemic
shock also possible given that his PO intake had been down prior
to admission and his BP was fluid responsive on admission. He
was started emperically on vancomycin and meropenem (day 1 =
[**9-30**]) for pneumonia to complete an 8 day total course (through
[**10-7**]).  His urine, blood, and sputum cultures all returned
positive for budding yeast (ID is [**Female First Name (un) **] (TORULOPSIS)
GLABRATA), so he was initially started on IV fluconazole and was
later transitioned to micafungin (day 1 = [**10-3**]). Ambisome was
started and uptitrated as above.

# Hypercarbic respiratory failure/somnolence: Patient difficult
to arouse at home on AM of admission, and may have worsened
since arriving to ICU. Likely multifactorial with hypercarbia
from hypoventilation in the context of new sedating medications
(ambien and valium, in addition to home narcotics), untreated
OSA with likely CO2 retention at baseline, pneumonia, underlying
GVHD of lung and PE. Pt has expressed wishes not to be
intubated. His pneumonia and PE were treated as per above. His
dyspnea was treated with either non-rebreather, venti mask, or
bipap as tolerated in order to achieve sat > 90%. Ambien and
valium were held. However, pt continued to complain of chest
wall pain thought to be secondary to PNA and was continuously
requesting more pain medication. After a goals of care
discussion was held with pt, family, and specialists, it was
decided to make the pt comfortable and give ativant and morphine
despite hypercarbia.

# Tachycardia: Continues to be in sinus tachycardia in the 130s.
Initially in the 160s, but has improved with fluids. Likely
multifactorial with PE, pain, hypovolemia, and withdrawal from
opioids all contributing. He was given several doses of narcan
at OSH and his home narcotics were initially held in the setting
of hypotension. Morphine drip was started to relieve any pain
without any improvement in tachycardia.

# [**Last Name (un) **]: Cr 1.1 from baseline of 0.6-0.7. Unclear etiology, but
likely prerenal in the setting of septic shock (above) with
hypotension and tachycardia. Creatinine improved back to
baseline with treatment of septic shock.

# UTI: Patient has indwelling foley catheter, so would be
considered complicated infection. Has grown E. coli most
recently, though did have a negative urine culture on [**9-26**].
Continue with vancomycin and meropenem as per above.

# Troponinemia: Patient with elevated troponin at OSH, which has
risen on arrival to the [**Hospital1 18**] ED. He denies chest pain and ECG
with sinus tachycardia without ischemic changes.  Likely
troponin leak in the setting of tachycardia to the 160s.

# AML s/p MUD SCT in [**2142**]: Daily CBCs were checked and there was
no evidence of reoccurance. He was continued on bactrim,
acyclovir, and azithromycin. Dr. [**Last Name (STitle) **], outpatient oncologist
following.

# Chronic GVHD : In the past his chronic GVHC has primarily
involved liver and lungs.  His LFT's were mildly elevated at
OSH, but has trended down while at [**Hospital1 18**]. He was continued on
prednisone 10 mg PO daily, and ppx with with acyclovir, bactrim,
and azithromycin.
- IVIG monthly (last dose Thursday)

# Type 2 DM on insulin: Most recent A1c is 6.8 from [**2144**]. His
NPh was decreased to 10 units (from 15) due to low sugars. He
was also placed on a sliding scale.

# Hypertension: metoprolol was held given hypotension

# Clot history: Prior PEs for which he was previously
anticoagulated. Anticoagulation was discontinued in the setting
of back surgery and an IVC [**Year (4 digits) 7448**] was placed. Now with segmental
PE treated with heparin as per above.

# Right axillary mass: Noticed by oncologist Dr. [**Last Name (STitle) **] and was
planning on working up as outpatient with CT scan.

# Paraplegia: Stable during this admission.  A spine consult was
called regarding further management.  Per Spine, lumbar and
thoracic spine x-rays were ordered -- these showed no
significant interval change.

# Transitional issues:
deceased

Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Atorvastatin 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 10 mg PO DAILY constipation
6. Bisacodyl 10 mg PR HS
7. Duloxetine 30 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
9. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
14. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. MethylPHENIDATE (Ritalin) 5 mg PO NOON
17. Metoprolol Tartrate 12.5 mg PO BID
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. MethylPHENIDATE (Ritalin) 5 mg PO QAM
21. Oxycodone SR (OxyconTIN) 40 mg PO BID
22. Pantoprazole 40 mg PO Q24H
23. PredniSONE 10 mg PO DAILY
24. Senna 2 TAB PO HS
25. Sodium Chloride Nasal [**12-18**] SPRY NU QID:PRN nasal congestion
26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
28. Docusate Sodium 100 mg PO BID
29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm


[**Month/Day (2) **] Medications:
deceased

[**Month/Day (2) **] Disposition:
Expired

[**Month/Day (2) **] Diagnosis:
pneumonia, fungemia

[**Month/Day (2) **] Condition:
deceased

[**Month/Day (2) **] Instructions:
deceased

Followup Instructions:
deceased

                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Unspecified septicemia,Pneumonia in other systemic mycoses,Septic shock,Acute respiratory failure,Other pulmonary embolism and infarction,Encephalopathy, unspecified,Other and unspecified mycoses,Complications of transplanted organ, stem cell,Chronic graft-versus-host disease,Acute kidney failure, unspecified,Paraplegia,Severe sepsis,Other specified disorders of skin,Other specified disorders of liver,Other specified cardiac dysrhythmias,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tear film insufficiency, unspecified,Unspecified essential hypertension,Conductive hearing loss, unspecified,Swelling, mass, or lump in chest,Long-term (current) use of steroids,Personal history of myeloid leukemia,Personal history of other malignant neoplasm of skin,Encounter for palliative care,Do not resuscitate status,Personal history of sudden cardiac arrest,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 58-year-old man with a history of AML s/p
allogeneic transplant [**2142**] complicated by graft-versus-host
disease, multiple vertebral fractures and ultimately development
of paraplegia in the setting of a vertebral fracture during a
code situation. Admitted multiple times, most recently [**8-/2148**]
for bacteremia and upper resp infection (cx: staph epi) and
completed a course of vancomcyin, aztreonam. Discharged from
rehab and home (wheelchair bound) with recent clinic followup
[**9-26**] noting baseline health.

MEDICAL HISTORY: Past Medical History:
- CKD (baseline Cr 0.6-0.7)
- Hyperlipidemia
- HTN
- Type 2 DM (last A1c 6.8 [**2144**])
- Depression
- Chronic pain
- Pericardial effusion s/p [**3-23**] drainage.
- Nephrolithiasis, lithotripsy and previous nephrostomy tube and
emergent surgery to repair ureteral damage.
- Left interpolar renal lesion, followed with MRs
- Basal cell carcinoma, resected.
- Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**].
- Multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware).
- Anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**].
- Chronic numbness, neuropathic pain in left upper extremity.
- Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**].
- Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**]
resistent pseudomonas [**7-/2147**]

MEDICATION ON ADMISSION: The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Atorvastatin 10 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 10 mg PO DAILY constipation
6. Bisacodyl 10 mg PR HS
7. Duloxetine 30 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
9. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Hydrocortisone Cream 1% 1 Appl TP QID
apply to affected areas
13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
14. NPH 15 Units Breakfast
NPH 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
15. Ipratropium Bromide Neb 1 NEB IH Q6H
16. MethylPHENIDATE (Ritalin) 5 mg PO NOON
17. Metoprolol Tartrate 12.5 mg PO BID
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. MethylPHENIDATE (Ritalin) 5 mg PO QAM
21. Oxycodone SR (OxyconTIN) 40 mg PO BID
22. Pantoprazole 40 mg PO Q24H
23. PredniSONE 10 mg PO DAILY
24. Senna 2 TAB PO HS
25. Sodium Chloride Nasal [**12-18**] SPRY NU QID:PRN nasal congestion
26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
28. Docusate Sodium 100 mg PO BID
29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm

ALLERGIES: Cefepime / ciprofloxacin / Levofloxacin

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Vitals:  T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB
General: Somnolent, but arousable, oriented x 3, no acute
distress, answers one question before falling asleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
copious secretions
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Transmitted upper airway sounds bilaterally, good air
movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Skin laceration on dorsum of left wrist
Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the
waist down.

FAMILY HISTORY: Mother died suddenly in 70s. Father died of unknown cancer. One
sister with thyroid cancer. One brother has diabetes. One sister
has [**Name (NI) 5895**].

SOCIAL HISTORY: Discharged from rehab in [**2148-6-16**] and has now been living at
home wiht VNA services and aid from his wife.  [**Name (NI) **] is retired,
worked as a [**Company 22957**] technician. He smoked for 40 pack years, now
quit. He denies EtOH or drugs. 

### Response:
{'Unspecified septicemia,Pneumonia in other systemic mycoses,Septic shock,Acute respiratory failure,Other pulmonary embolism and infarction,Encephalopathy, unspecified,Other and unspecified mycoses,Complications of transplanted organ, stem cell,Chronic graft-versus-host disease,Acute kidney failure, unspecified,Paraplegia,Severe sepsis,Other specified disorders of skin,Other specified disorders of liver,Other specified cardiac dysrhythmias,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tear film insufficiency, unspecified,Unspecified essential hypertension,Conductive hearing loss, unspecified,Swelling, mass, or lump in chest,Long-term (current) use of steroids,Personal history of myeloid leukemia,Personal history of other malignant neoplasm of skin,Encounter for palliative care,Do not resuscitate status,Personal history of sudden cardiac arrest,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
