CHIEF COMPLAINT: Hypoxia, hypotension

PRESENT ILLNESS: 65 year old male with Non hodgkins lymphoma on HCD122 chemo
protocol, prior mycobacterium xenopi and MRSA PNA, emphysema,
HTN, s/p PEG placement, who was admitted to ED from oncology
clinic appt with right shoulder/chest pain, mild hypoxia,
hypotension, and tachycardia.
.
The patient had gone to oncology clinic for scheduled chemo
(CD40 inhibitor study drug), when found to have new right-sided
chest/shoulder pain, hypoxia to high 80s/low 90s on RA,
tachycardia to 120s, and hypotension to 83/58. Patient describes
1 week h/o right sided pleuritic pain, fatigue, malaise, and
decreased PO intake. Some increase in chronic cough Notes this
pain is similar to symptoms of prior PNA. Also has slightly
increased right arm swelling and reported G-tube with malodorous
drainage. Denies fever, chills, diarrhea, wheezing, chest pain,
palpitations. Has some increased urinary frequency without
hematuria. He has had multiple hospitalizations in last year,
the most recent being [**Date range (1) 55849**] for RSV infection - discharged
on 10 days of levaquin for bacterial superinfection ppx. Since
then he has been getting his chemo infusions, and had recently
left rehab to live at sister's house, doing well until one week.

MEDICAL HISTORY: - Follicular lymphoma with evidence of documented large cell
transformation from lymph node bx done in [**1-3**]. Has been
refractory to multiple chemotherapeutic regimens, currently
enrolled on protocol DF#08-019 which is a Phase I/A/II
multicenter open label study of HCD122 which is administered
intravenously once weekly for 4 weeks
-s/p 4 cycles of R-CVP
-s/p 4 cycles of R-CHOP
-s/p Zevalin in [**7-/2130**]
-s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**]
-s/p 6 cycles bendamustine in [**2-/2132**]
-s/p radiation therapy mesenteric mass in [**9-/2133**]
-s/p radiation therapy to left pelvic lymphadenopathy causing
ureteral obstruction) in [**1-/2134**]
-s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**]
.
Other Medical History:
1) Mycobacterium xenopi infection since [**2132-12-26**]: Had
received one year of Levofloxacin/Azithromycin therapy until
[**3-/2134**] with good effect. Both were discontinued at that time but

MEDICATION ON ADMISSION: Acyclovir 400mg [**Hospital1 **]
Azithromycin 1,200mg Qweek
Diltiazem 30mg QID
Fluconazole 200mg daily
Flagyl 500mg [**Hospital1 **]
Fluticasone 110mcg, 2 puffs [**Hospital1 **]
Hydrocodone acetaminophen 5/500, 1-2tabs Q6hr prn
Combivent 18/103, 1-2 puffs Q6hr prn
Lansoprazole 30mg daily
Loperaminde 2mg QID prn
Megestrol 400mg [**Hospital1 **] prn
Mirtazapine 30mg QHS prn
Compazine 10mg Q6hr prn
Trazodone 50mg QHS prn
Pentamadine Qmonth
Tylenol prn
Colace prn
Senna prn
Simethicone prn
Multivitamins

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission
GENERAL: Elderly male with nasal cannula in place, not using
accessory muscles, in NAD
HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous
membranes. No thrush or oropharyngeal lesions.
NECK: Supple.
LYMPH NODES: Possible small right anterior cervical at
base/supraclavicular node. Otherwise, no other
cervical, supraclavicular, infraclavicular or inguinal
lymphadenopathy noted.
CHEST: Decreased at bases. Trace crackles at bases
CARDIAC: RR, no MRG
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. G-tube with some crusting along side, but without
redness or erythema or drainage. No
suprapubic tenderness.
BACK: Without CVA tenderness.
EXTREMITIES: 1+ edema in his right hand, otherwise, no LE edema

FAMILY HISTORY: Notable for heart problems in a sister. [**Name (NI) **] has two brothers who
are older than him who are healthy. His father died young due to
an old war injury. His mother died in her 90's.

SOCIAL HISTORY: The patient has been living at sister's house, prior to this had
been at Colony house for rehabilitation following multiple
extended hospitalizations over the past several months. He is a
retired mechanic. He was a heavy drinker for many years but quit
about 20 years ago. Has extensive smoking history up to 2ppd x
50 years, just quit 12/[**2134**]. He has never been married. He has a
daughter in [**Name (NI) 55851**].
Methicillin resistant pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Severe sepsis,Hypogammaglobulinemia, unspecified,Unspecified protein-calorie malnutrition,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage I,Adult failure to thrive,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Gastrostomy status,Mitral valve disorders,Other chronic pulmonary heart diseases,Pulmonary diseases due to other mycobacteria
Meth res pneu d/t Staph,Acute kidney failure NOS,Oth lymp unsp xtrndl org,Int inf clstrdium dfcile,Severe sepsis,Hypogammaglobulinem NOS,Protein-cal malnutr NOS,Meth resis Staph carrier,Thrombocytopenia NOS,Food/vomit pneumonitis,Hy kid NOS w cr kid I-IV,Chro kidney dis stage I,Failure to thrive-adult,Chr airway obstruct NEC,Hypoxemia,Gastrostomy status,Mitral valve disorder,Chr pulmon heart dis NEC,Pulmonary mycobacteria
Admission Date:  [**2135-5-2**]              Discharge Date:   [**2135-5-30**]

Date of Birth:  [**2070-1-31**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Hypoxia, hypotension

Major Surgical or Invasive Procedure:
None

History of Present Illness:
65 year old male with Non hodgkins lymphoma on HCD122 chemo
protocol, prior mycobacterium xenopi and MRSA PNA, emphysema,
HTN, s/p PEG placement, who was admitted to ED from oncology
clinic appt with right shoulder/chest pain, mild hypoxia,
hypotension, and tachycardia.
.
The patient had gone to oncology clinic for scheduled chemo
(CD40 inhibitor study drug), when found to have new right-sided
chest/shoulder pain, hypoxia to high 80s/low 90s on RA,
tachycardia to 120s, and hypotension to 83/58. Patient describes
1 week h/o right sided pleuritic pain, fatigue, malaise, and
decreased PO intake. Some increase in chronic cough Notes this
pain is similar to symptoms of prior PNA. Also has slightly
increased right arm swelling and reported G-tube with malodorous
drainage. Denies fever, chills, diarrhea, wheezing, chest pain,
palpitations. Has some increased urinary frequency without
hematuria. He has had multiple hospitalizations in last year,
the most recent being [**Date range (1) 55849**] for RSV infection - discharged
on 10 days of levaquin for bacterial superinfection ppx. Since
then he has been getting his chemo infusions, and had recently
left rehab to live at sister's house, doing well until one week.

.
In the clinic, he was given heparin bolus 5000 units for concern
of PE given increased lymphedema on right side and risk factors,
and sent to ED.
.
In the ED, the patient's initial vitals were afebrile, tachy to
120s, BP 89/60, HR 24, 96% on 4L. CXR showed persistent right
mid lung patchy opacity likely representing resolving pneumonia,
with slightly enlarged right- sided pleural effusion. CTA showed
no PE but showed increased R effusion and ground glass opacity
likely persistent resolving infection, LLL opacity increased
from prior. RUL US negative for DVT. CT abd/pelvis without
contrast showed no acute process. Given IV vanc/cefepime,
mucomyst prior to procedure, 2L NS. Labs significant for lactate
3.1, WBC 16.3 with 12 bands and 64N, Cr 2.4, LDH 262, uric acid
8.2. Patient's outpatient oncologist was made aware, pt was
transferred to [**Hospital Unit Name 153**] for further care of her sepsis, hypoxia. On
transfer, vitals were T98.9, HR120-150, 103/74, 24-28, 98% on
3L.
.
On arrival to the ICU, the patient's BP was 100-120s systolic.
Patient still complaining of right sided pleuritic pain,
otherwise with no other complaints.
.
Review of systems was otherwise negative.

Past Medical History:
- Follicular lymphoma with evidence of documented large cell
transformation from lymph node bx done in [**1-3**]. Has been
refractory to multiple chemotherapeutic regimens, currently
enrolled on protocol DF#08-019 which is a Phase I/A/II
multicenter open label study of HCD122 which is administered
intravenously once weekly for 4 weeks
-s/p 4 cycles of R-CVP
-s/p 4 cycles of R-CHOP
-s/p Zevalin in [**7-/2130**]
-s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**]
-s/p 6 cycles bendamustine in [**2-/2132**]
-s/p radiation therapy mesenteric mass in [**9-/2133**]
-s/p radiation therapy to left pelvic lymphadenopathy causing
ureteral obstruction) in [**1-/2134**]
-s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**]
.
Other Medical History:
1) Mycobacterium xenopi infection since [**2132-12-26**]: Had
received one year of Levofloxacin/Azithromycin therapy until
[**3-/2134**] with good effect. Both were discontinued at that time but

restarted in [**7-/2134**] as patient was having increased respiratory

symptoms. Per ID, will need to continue for a total 6 month
course (finish [**2135-2-16**]), after which he will be switched to
azithromycin alone.
s/p left VATS w wedge resections in [**2133**] for pulmonary nodules
2) C difficile colitis diagnosed during hospitalization in [**9-3**].

He was initially treated on PO metronidazole then converted to
PO vancomycin on [**2134-9-22**].
3) During last [**Hospital1 **] admission ([**Date range (1) 32408**]), he had a MRSA UTI,
treated with a total of 2 weeks of Vancomycin and then Bactrim.
4) Admitted [**Date range (1) 55850**] for neutropenic fever and acute renal
failure. ARF thought to be prerenal. No source identified for
fever, treated empirically with cefepime.
5) Repeat admission for failure to thrive resulted in PEG tube
placement on [**2135-1-5**].
6) Emphysema with smoking history

Social History:
The patient has been living at sister's house, prior to this had
been at Colony house for rehabilitation following multiple
extended hospitalizations over the past several months. He is a
retired mechanic. He was a heavy drinker for many years but quit
about 20 years ago. Has extensive smoking history up to 2ppd x
50 years, just quit 12/[**2134**]. He has never been married. He has a
daughter in [**Name (NI) 55851**].


Family History:
Notable for heart problems in a sister. [**Name (NI) **] has two brothers who
are older than him who are healthy. His father died young due to
an old war injury. His mother died in her 90's.

Physical Exam:
On admission
GENERAL: Elderly male with nasal cannula in place, not using
accessory muscles, in NAD
HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous
membranes. No thrush or oropharyngeal lesions.
NECK: Supple.
LYMPH NODES: Possible small right anterior cervical at
base/supraclavicular node. Otherwise, no other
cervical, supraclavicular, infraclavicular or inguinal
lymphadenopathy noted.
CHEST: Decreased at bases. Trace crackles at bases
CARDIAC: RR, no MRG
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. G-tube with some crusting along side, but without
redness or erythema or drainage. No
suprapubic tenderness.
BACK: Without CVA tenderness.
EXTREMITIES: 1+ edema in his right hand, otherwise, no LE edema

NEUROLOGIC: grossly nonfocal

On discharge:
GENERAL: Elderly male, NAD
HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous
membranes. No thrush or oropharyngeal lesions.
NECK: Supple.
LYMPH NODES: Righa anterior cervical node, no other LAD.
CHEST: Crackles and decreased breath sounds on left, clear on
right
CARDIAC: RR, no MRG
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. G-tube with some crusting along side, but without
redness or erythema or drainage. No suprapubic tenderness.
BACK: Without CVA tenderness.
EXTREMITIES: 1+ edema in his right hand, wrapped in ace bandage.
No LE edema
NEUROLOGIC: grossly nonfocal


Pertinent Results:
[**2135-5-2**] 09:00AM   GRAN CT-[**Numeric Identifier 55506**]*
[**2135-5-2**] 09:00AM   PLT SMR-NORMAL PLT COUNT-245
[**2135-5-2**] 09:00AM   HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2135-5-2**] 09:00AM   NEUTS-64 BANDS-12* LYMPHS-7* MONOS-9 EOS-0
BASOS-0 ATYPS-0 METAS-4* MYELOS-3* PROMYELO-1*
[**2135-5-2**] 09:00AM   WBC-16.3* RBC-2.85* HGB-10.2* HCT-30.2*
MCV-106* MCH-35.9* MCHC-33.9 RDW-18.4*
[**2135-5-2**] 09:00AM   TOT PROT-5.2* ALBUMIN-3.3* GLOBULIN-1.9*
CALCIUM-9.1 PHOSPHATE-5.1* MAGNESIUM-1.7 URIC ACID-8.2*
[**2135-5-2**] 09:00AM   LIPASE-11
[**2135-5-2**] 09:00AM   ALT(SGPT)-18 AST(SGOT)-22 LD(LDH)-262* ALK
PHOS-95 AMYLASE-30 TOT BILI-0.3 DIR BILI-0.2 INDIR BIL-0.1
[**2135-5-2**] 09:00AM   UREA N-57* CREAT-2.4* SODIUM-142
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-19* ANION GAP-24*
[**2135-5-2**] 09:20AM   PT-14.9* INR(PT)-1.3*
[**2135-5-2**] 09:20AM   D-DIMER-767*
[**2135-5-2**] 10:25AM   LACTATE-3.1*
[**2135-5-2**] 03:22PM   LACTATE-2.6*
[**2135-5-2**] 03:22PM   TYPE-ART PO2-86 PCO2-29* PH-7.42 TOTAL
CO2-19* BASE XS--3
[**2135-5-2**] 03:50PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2135-5-2**] 03:50PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2135-5-2**] 03:50PM URINE  OSMOLAL-345
[**2135-5-2**] 03:50PM URINE  HOURS-RANDOM CREAT-43 SODIUM-25
[**2135-5-2**] 11:41PM   CALCIUM-7.9* PHOSPHATE-5.8* MAGNESIUM-2.3
[**2135-5-2**] 11:41PM   GLUCOSE-93 UREA N-49* CREAT-2.0* SODIUM-140
POTASSIUM-4.3 CHLORIDE-112* TOTAL CO2-18* ANION GAP-14

MICRO:
RESPIRATORY CULTURE (Final [**2135-5-6**]):
      MODERATE GROWTH OROPHARYNGEAL FLORA.
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------  =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

LEGIONELLA CULTURE (Final [**2135-5-10**]):    NO LEGIONELLA ISOLATED.

FUNGAL CULTURE (Final [**2135-5-17**]): YEAST.

STOOL CULTURE
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2135-5-22**]):
CLOSTRIDIUM DIFFICILE: FECES POSITIVE FOR C. DIFFICILE TOXIN BY
EIA.
(Reference Range-Negative).

-------
IMAGING:
CTA [**5-2**]:
1. No pulmonary embolus or acute aortic pathology.
2. Slightly increased right pleural effusion with associated
atelectasis.
3. Persistent ground-glass airspace opacity in the right lower
lobe likely
represents resolving infectious process.
4. Increased nodular density adjacent to the left lower lobe
suture line,
which is a nonspecific finding and may represent inflammatory
changes,
although an infectious etiology cannot be excluded.
5. Resolution of left lower lobe mucoid impaction seen on prior
study.
6. No change in axillary adenopathy. Mediastinal nodes are also
stable, not
pathologically enlarged

CT Chest and Neck [**5-17**]:
IMPRESSION: No relevant change as compared to the previous
examination.
Unchanged pre- existing right basal parenchymal opacities, with
small ventral opacities that have newly occurred and most likely
correspond to healing infection or atelectasis. No evidence of
mediastinal or hilar lymphadenopathy. No pleural effusions. No
recent pneumonia. No evidence of lymphoma in the abdomen.

TTE [**5-19**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild global left ventricular
hypokinesis (LVEF = 50%). The right ventricular cavity is mildly
dilated with depressed systolic function (more precise
assessment is limited by poor acoustic windows). 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 leaflets are mildly thickened. Mild to moderate
([**1-28**]+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.

IMPRESSION: Mildly dilated right ventricle with mild global
biventricular systolic dysfunction. Mild to moderate mitral and
tricuspid regurgitation. Mild pulmonary hypertension.

Compared with the prior study (images reviewed) of [**2135-4-29**],
right ventricle is larger and biventricular systolic function is
lower. Severity of mitral and tricuspid regurgitation.

CT abdomen and pelvis [**5-21**]:
1. Loculated pleural effusion anteriorly is decreased in size
although
demonstrates enhancement and empyema can therefore not be
excluded.
2. Unchanged appearance of infiltrative soft tissue mass
involving the root of mesentery and retroperitoneum. Left pelvic
side wall and right peri-psoas lymphadenopathy is also
unchanged.
3. Stable mild intrahepatic ductal dilatation with no evidence
for acute
cholecystitis.
4. Unchanged bilateral renal cysts.

CT Chest [**2135-5-27**]:
IMPRESSION: Mild interval decrease in right pleural fluid.
Otherwise, no
relevant change in the appearance of the chest. Specifically, no
evidence of new parenchymal infectious process

DISCHARGE LABS:
WBC: 13.4/9.2/28.1/347
CHEM 7: 136/4/96/25/29/1.3/97

Brief Hospital Course:
65 year old male with refractory Non hodgkins lymphoma on trial
anti CD40 chemo protocol with a complicated medical history
including COPD and M. xenopi infection as well as multiple
recent pneumonias who presented with sepsis requiring brief ICU
stay in the setting of a MRSA pneumonia. Treated with vancomycin
and completed course.  Developed C. diff and was treated with
oral vancomycin starting [**2135-5-21**], total duration of treatment
should be 2 weeks every 6 hours.  Patient should then continue
on prophylaxis of vancomycin 125mg po bid indefinitely. Patient
was discharged in stable condition to rehab with oncology follow
up.

#. MRSA Pneumonia, sepsis:  Given the patient's hypoxia and
right-sided pleuritic chest pain upon presentation, a CTA was
done which failed to find a PE. The patient completed a 14 day
course of vancomycin during which his clinical status as well as
his pleuritic chest pain improved dramatically. By the end of
his treatment course he was able to ambulate on room air without
desaturation. On [**5-21**], a CT abdomen was done to investigate
diarrhea but ended up noting a loculated effusion at the lung
base. Pulmonary was consulted and given than effusion was
deceasing in size, no acute intervention was necessary as he was
clinically improving. Recommend repeat chest CT in 2 weeks to
trend size.

# C.Diff: On [**5-20**] the patient began to complain of multiple
loose stools with associated abdominal pain. Given his
persistent bandemia and recent antibiotics, a C. diff culture
was sent and returned positive. He was started on PO vanco for a
total of 2 weeks, last dose should be the evening on [**2135-6-4**] and
then should be continued [**Hospital1 **] indefinitely as above.
Additionally, he was treated with IvIg on [**2135-5-29**] given
persisently low IgG levels.

#. Hypotension: The patient's home diltiazem was held given his
initial hypotension. Once his clinical status improved however,
he was persistently tachycardic and orthostatic. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim
test was within normal limits as was TSH. Every attempt was made
to maintain euvolemia without third spacing in the setting of
hypoalbuminemia. He was started on [**Last Name (NamePattern4) 55852**] with slight
improvement. A TTE was repeated and showed decreased LV and RV
function. A cardiology consult was called and recommended
uptitrating beta-blockage in the setting of a multi-factorial
atrial and multi-focal atrial tachycardia from deconditioning,
COPD, and progressive failure to thrive.

#. Acute on chronic renal failure: Improved to stage 1 CKD with
attainment of euvolemia.

#. Non Hodgkins Lymphoma:  Continued on prophylactic acyclovir
and fluconazole as well as monthly pentamidine. He was also
given a dose of IVIG. Per his primary oncologist, the CD40 study
drug could not be obtained for the patient until 2 weeks after
his completion of antibiotics (to end [**2135-6-4**]). While in the
hospital, the patient noted a new, right-sided supraclavicular
lymph node. This node was monitored and remained approximately
1.5 by 0.5 cm in size. CT head and neck were done without
contrast to evaluate for progression of disease and did not show
any obvious progression. Patient to have repeat echocardiogram
and will follow up with his primary oncologist further
treatment.

# COPD: With long smoking history, currently without cigarettes
for last 4 months. He was continued on home fluticasone and
combivent and nebs prn.

# Mycobacterium Xenopi: The patient was continued on
Azithromycin q tuesday.

# FTT, aspiration:  Has been on going since [**11/2134**], head
imaging and LP at that time were unrevealing.  Unclear cause of
aspiration, likely secondary to overall poor conditioning. The
patient was maintained on tube feeds via his G-tube. He was
evaluated by speech and swallow by bedside and video swallow at
which time he was noted to be aspirating all types of foods and
liquids. The patient was adament that he continue to be allowed
occasional drinks PO. He was given swallowing exercises and
continued to work with the speech therapy team on techniques to
improve his swallowing and allow for eventual advancement of PO
intake.  His repeat video swallow on [**2135-5-26**] showed slight
improvement but continued aspiration.  He was kept NPO except
for sips of tea as patient was insistent on drinking tea and
unwilling to be entirely NPO.  Has repeat out patient video
swallow in several weeks.

# Code: FULL


Medications on Admission:
Acyclovir 400mg [**Hospital1 **]
Azithromycin 1,200mg Qweek
Diltiazem 30mg QID
Fluconazole 200mg daily
Flagyl 500mg [**Hospital1 **]
Fluticasone 110mcg, 2 puffs [**Hospital1 **]
Hydrocodone acetaminophen 5/500, 1-2tabs Q6hr prn
Combivent 18/103, 1-2 puffs Q6hr prn
Lansoprazole 30mg daily
Loperaminde 2mg QID prn
Megestrol 400mg [**Hospital1 **] prn
Mirtazapine 30mg QHS prn
Compazine 10mg Q6hr prn
Trazodone 50mg QHS prn
Pentamadine Qmonth
Tylenol prn
Colace prn
Senna prn
Simethicone prn
Multivitamins


Discharge Medications:
1. Fluconazole 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.

2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): per G-tube.
3. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
5. Acyclovir 200 mg/5 mL Suspension [**Last Name (STitle) **]: Four Hundred (400) mg
PO every eight (8) hours.
6. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime): per g-tube.
7. Trazodone 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia: per g-tube.
8. Azithromycin 600 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO 1X/WEEK
(TU) as needed for mycobacterium: Total is 1200mg
per g-tube.
9. Fludrocortisone 0.1 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): per g-tube.
11. Allopurinol 300 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily):
per g-tube.
12. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Indwelling Port (e.g. Portacath), non-heparin dependent: Flush
with 10 mL Normal Saline daily, PRN, and when de-accessing, per
lumen.
13. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
14. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
15. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours): Last dose evening of [**2135-6-4**].
16. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension [**Date Range **]:
15-30 MLs PO QID (4 times a day) as needed for gas.
17. Fluticasone 110 mcg/Actuation Aerosol [**Date Range **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
20. Erythromycin 5 mg/g Ointment [**Hospital1 **]: One (1) application
Ophthalmic QID (4 times a day) for 6 days: apply to both eyes.
Can decrease to [**Hospital1 **] if sx improve in 2 days.
21. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain, fever.
22. Ipratropium Bromide 0.02 % Solution [**Age over 90 **]: One (1) neb
Inhalation Q8H (every 8 hours).
23. Saliva Substitution Combo No.2     Solution [**Age over 90 **]: Thirty (30)
ML Mucous membrane TID (3 times a day).


Discharge Disposition:
Extended Care

Facility:
Colony House Nursing & Rehabilitation Center - [**Location (un) 32775**]

Discharge Diagnosis:
Primary:
Methicillin Resisitant Staph Aureus Pneumonia
Clostridium Difficile Diarrhea
Failure To Thrive

Secondary:
Follicular lymphoma with evidence of documented large cell
transformation from lymph node bx done in [**1-3**]. Has been
refractory to multiple chemotherapeutic regimens, currently
enrolled on protocol DF#08-019 which is a Phase I/A/II
multicenter open label study of HCD122 which is administered
intravenously once weekly for 4 weeks
-s/p 4 cycles of R-CVP
-s/p 4 cycles of R-CHOP
-s/p Zevalin in [**7-/2130**]
-s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**]
-s/p 6 cycles bendamustine in [**2-/2132**]
-s/p radiation therapy mesenteric mass in [**9-/2133**]
-s/p radiation therapy to left pelvic lymphadenopathy causing
ureteral obstruction) in [**1-/2134**]
-s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**]
.
Other Medical History:
1) Mycobacterium xenopi infection since [**2132-12-26**]: Had
received one year of Levofloxacin/Azithromycin therapy until
[**3-/2134**] with good effect. Both were discontinued at that time but

restarted in [**7-/2134**] as patient was having increased respiratory

symptoms. Per ID, will need to continue for a total 6 month
course (finish [**2135-2-16**]), after which he will be switched to
azithromycin alone.
s/p left VATS w wedge resections in [**2133**] for pulmonary nodules
2) C difficile colitis diagnosed during hospitalization in [**9-3**].

He was initially treated on PO metronidazole then converted to
PO vancomycin on [**2134-9-22**].
3) During last [**Hospital1 **] admission ([**Date range (1) 32408**]), he had a MRSA UTI,
treated with a total of 2 weeks of Vancomycin and then Bactrim.
4) Admitted [**Date range (1) 55850**] for neutropenic fever and acute renal
failure. ARF thought to be prerenal. No source identified for
fever, treated empirically with cefepime.
5) Repeat admission for failure to thrive resulted in PEG tube
placement on [**2135-1-5**].
6) Emphysema with smoking history
7) [**2135-3-13**] RSV infection - 10 day course of levofloxacin to
prevent regrowth


Discharge Condition:
Hemodynamically stable.


Discharge Instructions:
You were admitted to the hospital due to your difficult
breathing and low blood pressure. You were found to have a MRSA
pneumonia for which you were treated with 14 days of an IV
antibiotic named vancomycin. [**Name2 (NI) **] completed that course with
improvement in your breathing status but then developed
worsening diarrhea and were found to have an infectious diarrhea
called C.diff. You had treatment for this with the oral form of
the same antibiotic (vancomycin).  After you finish this
treatment (which is vancomycin 4 times a day), you will need to
continue this medication twice a day to ensure that the
infection does not recur.  You will need to be on it
indefinitely.

You blood pressure was also quite low and your heart rate was
often fast for unclear reasons. You were started on a medication
named [**Name (NI) 55852**] with improvement in your blood pressure.

Additionally, you developed conjunctivitis (and eye infection)
and were started on an anti-bacterial ointment four times a day.
 You should continue this until [**2135-6-2**].

Please be sure to keep all of your appointments as listed below.


If you have any shortness of breath, fever, abdominal pain,
chest pain, arm swelling, severe pain, headache, blurry vision
or any other concerning symptom, please seek medical care
immediately.

It was a pleasure meeting you and participating in your care.

Followup Instructions:
ECHOCARDIOGRAM: Monday [**6-6**] 3pm, [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 5074**] [**Hospital1 18**]. [**Location (un) 436**] in Cardiology department. [**Telephone/Fax (1) 62**].

ONCOLOGY:
[**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-6-15**]
12:30
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2135-6-15**] 12:30

VIDEO SWALLOW: Thursday [**6-9**] at 1pm.  [**Hospital1 18**]. Clinical
Center, [**Hospital Ward Name 517**], [**Location (un) 10043**] in Radiology Deparment.
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Severe sepsis,Hypogammaglobulinemia, unspecified,Unspecified protein-calorie malnutrition,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage I,Adult failure to thrive,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Gastrostomy status,Mitral valve disorders,Other chronic pulmonary heart diseases,Pulmonary diseases due to other mycobacteria'}


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: Hypoxia, hypotension

PRESENT ILLNESS: 65 year old male with Non hodgkins lymphoma on HCD122 chemo
protocol, prior mycobacterium xenopi and MRSA PNA, emphysema,
HTN, s/p PEG placement, who was admitted to ED from oncology
clinic appt with right shoulder/chest pain, mild hypoxia,
hypotension, and tachycardia.
.
The patient had gone to oncology clinic for scheduled chemo
(CD40 inhibitor study drug), when found to have new right-sided
chest/shoulder pain, hypoxia to high 80s/low 90s on RA,
tachycardia to 120s, and hypotension to 83/58. Patient describes
1 week h/o right sided pleuritic pain, fatigue, malaise, and
decreased PO intake. Some increase in chronic cough Notes this
pain is similar to symptoms of prior PNA. Also has slightly
increased right arm swelling and reported G-tube with malodorous
drainage. Denies fever, chills, diarrhea, wheezing, chest pain,
palpitations. Has some increased urinary frequency without
hematuria. He has had multiple hospitalizations in last year,
the most recent being [**Date range (1) 55849**] for RSV infection - discharged
on 10 days of levaquin for bacterial superinfection ppx. Since
then he has been getting his chemo infusions, and had recently
left rehab to live at sister's house, doing well until one week.

MEDICAL HISTORY: - Follicular lymphoma with evidence of documented large cell
transformation from lymph node bx done in [**1-3**]. Has been
refractory to multiple chemotherapeutic regimens, currently
enrolled on protocol DF#08-019 which is a Phase I/A/II
multicenter open label study of HCD122 which is administered
intravenously once weekly for 4 weeks
-s/p 4 cycles of R-CVP
-s/p 4 cycles of R-CHOP
-s/p Zevalin in [**7-/2130**]
-s/p Rituximab, fludarabine, and mitoxantrone in [**4-/2131**]
-s/p 6 cycles bendamustine in [**2-/2132**]
-s/p radiation therapy mesenteric mass in [**9-/2133**]
-s/p radiation therapy to left pelvic lymphadenopathy causing
ureteral obstruction) in [**1-/2134**]
-s/p 1 course [**Hospital1 **] [**Date range (1) **]/[**2134**]
.
Other Medical History:
1) Mycobacterium xenopi infection since [**2132-12-26**]: Had
received one year of Levofloxacin/Azithromycin therapy until
[**3-/2134**] with good effect. Both were discontinued at that time but

MEDICATION ON ADMISSION: Acyclovir 400mg [**Hospital1 **]
Azithromycin 1,200mg Qweek
Diltiazem 30mg QID
Fluconazole 200mg daily
Flagyl 500mg [**Hospital1 **]
Fluticasone 110mcg, 2 puffs [**Hospital1 **]
Hydrocodone acetaminophen 5/500, 1-2tabs Q6hr prn
Combivent 18/103, 1-2 puffs Q6hr prn
Lansoprazole 30mg daily
Loperaminde 2mg QID prn
Megestrol 400mg [**Hospital1 **] prn
Mirtazapine 30mg QHS prn
Compazine 10mg Q6hr prn
Trazodone 50mg QHS prn
Pentamadine Qmonth
Tylenol prn
Colace prn
Senna prn
Simethicone prn
Multivitamins

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission
GENERAL: Elderly male with nasal cannula in place, not using
accessory muscles, in NAD
HEENT: Sclerae anicteric. Conjunctivae not pale. Moist mucous
membranes. No thrush or oropharyngeal lesions.
NECK: Supple.
LYMPH NODES: Possible small right anterior cervical at
base/supraclavicular node. Otherwise, no other
cervical, supraclavicular, infraclavicular or inguinal
lymphadenopathy noted.
CHEST: Decreased at bases. Trace crackles at bases
CARDIAC: RR, no MRG
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds. G-tube with some crusting along side, but without
redness or erythema or drainage. No
suprapubic tenderness.
BACK: Without CVA tenderness.
EXTREMITIES: 1+ edema in his right hand, otherwise, no LE edema

FAMILY HISTORY: Notable for heart problems in a sister. [**Name (NI) **] has two brothers who
are older than him who are healthy. His father died young due to
an old war injury. His mother died in her 90's.

SOCIAL HISTORY: The patient has been living at sister's house, prior to this had
been at Colony house for rehabilitation following multiple
extended hospitalizations over the past several months. He is a
retired mechanic. He was a heavy drinker for many years but quit
about 20 years ago. Has extensive smoking history up to 2ppd x
50 years, just quit 12/[**2134**]. He has never been married. He has a
daughter in [**Name (NI) 55851**]. 

### Response:
{'Methicillin resistant pneumonia due to Staphylococcus aureus,Acute kidney failure, unspecified,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Severe sepsis,Hypogammaglobulinemia, unspecified,Unspecified protein-calorie malnutrition,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Thrombocytopenia, unspecified,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage I,Adult failure to thrive,Chronic airway obstruction, not elsewhere classified,Hypoxemia,Gastrostomy status,Mitral valve disorders,Other chronic pulmonary heart diseases,Pulmonary diseases due to other mycobacteria'}
