CHIEF COMPLAINT: Altered mental status and diarrhea

PRESENT ILLNESS: This is a 57-year-old gentleman with CLL and large cell
transformation, s/p antigen mismatched URD SCT on [**2124-3-10**] (now
day +164), recently discharged from [**Hospital1 18**] to [**Hospital **] Rehab on
[**8-17**] and now re-admitted to 7 [**Hospital Ward Name 1826**] from clinic for diarrhea,
waxing/[**Doctor Last Name 688**] mental status, and electrolyte abnormalities.  As
per physician at [**Name9 (PRE) **], patient had been having voluminous
diarrhea, and was overall "not doing well."
.
Mr. [**Known lastname **] was last admitted on [**2124-3-1**] (Tax Day, as he likes
to remind everyone) and went for antigen mismatched URD SCT
after Busulfan/ Cytoxan conditioning regimen.  Although he
tolerated the transplant well, Mr. [**Known lastname 60074**] subsequent 5[**Hospital **]
hospital course was complicated by GVHD of liver and GI tract,
continous slow GIB, hematuria with BK viruria, adenoviremia,
altered mental status, and extreme deconditioning.  All of his
acute issues had resolved by the time of discharge, and Mr.
[**Known lastname **] was transferred to [**Hospital1 **] for continued
rehabilitation.
.
In clinic pt appeared comfortable although depressed. His vitals
were stable. labs are at baseline except for lytes which will be
repleted. On arrival to the floor pt appears tired but otherwise
has no distress.

MEDICAL HISTORY: Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

MEDICATION ON ADMISSION: 1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2     Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products     Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)

ALLERGIES: Bactrim

PHYSICAL EXAM: PHYSICAL EXAM:
98.4, 138/90, 92/min, 20/min,
General:  appears comfortable at rest, no apparent distress
Neck:  supple, no jvd
Cardiac:  RRR, frequent pvc, no murmurs, rubs, or gallops
reduced air entry bilaterally
Abdomen: distended, but soft, no rebound/guarding/regidity
Extremities:  1+ edema bilaterally

FAMILY HISTORY: Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.

SOCIAL HISTORY: Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old.
Other specified non-arthropod-borne viral diseases of central nervous system,Unspecified septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Acute respiratory failure,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Unspecified pleural effusion,Acidosis,Other ascites,Paroxysmal ventricular tachycardia,Toxoplasmosis, unspecified,Chronic lymphoid leukemia, in remission,Chronic graft-versus-host disease,Diarrhea,Viremia, unspecified,Thrombocytopenia, unspecified,Unspecified accident,Hypothermia not associated with low environmental temperature,Anemia of other chronic disease,Neutropenia, unspecified,Foreign body in respiratory tree, unspecified,Gross hematuria,Hypoglycemia, unspecified,Cardiogenic shock,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Viral encephalitis NEC,Septicemia NOS,Severe sepsis,Food/vomit pneumonitis,Encephalopathy NEC,Acute respiratry failure,Oth lymp unsp xtrndl org,Gastrointest hemorr NOS,Pleural effusion NOS,Acidosis,Ascites NEC,Parox ventric tachycard,Toxoplasmosis NOS,Chr lym leuk w rmsion,Chronc graft-vs-host dis,Diarrhea,Viremia NOS,Thrombocytopenia NOS,Accident NOS,Hypothrm-wo low env tmp,Anemia-other chronic dis,Neutropenia NOS,FB respiratory tree NOS,Gross hematuria,Hypoglycemia NOS,Cardiogenic shock,Abn react-org transplant
Admission Date:  [**2124-8-21**]              Discharge Date:   [**2124-9-26**]

Date of Birth:  [**2067-4-22**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Altered mental status and diarrhea

Major Surgical or Invasive Procedure:
Central line placement
Lumbar puncture

History of Present Illness:
This is a 57-year-old gentleman with CLL and large cell
transformation, s/p antigen mismatched URD SCT on [**2124-3-10**] (now
day +164), recently discharged from [**Hospital1 18**] to [**Hospital **] Rehab on
[**8-17**] and now re-admitted to 7 [**Hospital Ward Name 1826**] from clinic for diarrhea,
waxing/[**Doctor Last Name 688**] mental status, and electrolyte abnormalities.  As
per physician at [**Name9 (PRE) **], patient had been having voluminous
diarrhea, and was overall "not doing well."
.
Mr. [**Known lastname **] was last admitted on [**2124-3-1**] (Tax Day, as he likes
to remind everyone) and went for antigen mismatched URD SCT
after Busulfan/ Cytoxan conditioning regimen.  Although he
tolerated the transplant well, Mr. [**Known lastname 60074**] subsequent 5[**Hospital **]
hospital course was complicated by GVHD of liver and GI tract,
continous slow GIB, hematuria with BK viruria, adenoviremia,
altered mental status, and extreme deconditioning.  All of his
acute issues had resolved by the time of discharge, and Mr.
[**Known lastname **] was transferred to [**Hospital1 **] for continued
rehabilitation.
.
In clinic pt appeared comfortable although depressed. His vitals
were stable. labs are at baseline except for lytes which will be
repleted. On arrival to the floor pt appears tired but otherwise
has no distress.

Past Medical History:
Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

Patient underwent allo SCT on [**2124-3-10**] from MUD ([**7-27**], mismatch
at one HLA-A allele). The patient underwent a Busulfan/Cytoxan
conditioning regimen which did not cause neutropenia and he
tolerated it with only mild diarrhea.  His initial transplant
proceeded without incident.  His post-transplant course was
complicated by severe GVHD, febrile neutropenia, and viremia.

Social History:
Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old.

Family History:
Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.

Physical Exam:
PHYSICAL EXAM:
98.4, 138/90, 92/min, 20/min,
General:  appears comfortable at rest, no apparent distress
Neck:  supple, no jvd
Cardiac:  RRR, frequent pvc, no murmurs, rubs, or gallops
reduced air entry bilaterally
Abdomen: distended, but soft, no rebound/guarding/regidity
Extremities:  1+ edema bilaterally

[**Hospital Unit Name 60075**] EXAM:

GEN: intubated, sedated ill-appearing edematous gentleman, not
responsive to voice commands or painful stimuli.
HEENT: marked chemiosis bilaterall and extensive bilateral
scleral icterus, pupils equal and reactive to light
CV: regular rate, no murmurs appreciated
Lungs: coarse, ventilated breath sounds B/L, poor air mvmnt in
bases
Abd: markedly distended, hypoactive bowel sounds, soft
Ext: 4+ pitting edema B/L UE and LE up to sacrum, c/w anasarca
GU: extensive scrotal edema, foley in place w/ hematuria
draining
Skin: multiple areas of skin breakdown, skin oozing clear serous
fluid in upper extremities, multiple scattered ulcerations


Pertinent Results:
[**2124-8-21**] 03:15PM   GLUCOSE-206* UREA N-19 CREAT-0.5 SODIUM-134
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-20* ANION GAP-14
[**2124-8-21**] 03:15PM   ALT(SGPT)-139* AST(SGOT)-62* LD(LDH)-487* ALK
PHOS-511* TOT BILI-6.6* DIR BILI-4.9* INDIR BIL-1.7
[**2124-8-21**] 03:15PM   ALBUMIN-2.5* CALCIUM-8.7 PHOSPHATE-1.8*
MAGNESIUM-1.9
[**2124-8-21**] 03:15PM   TSH-0.15*
[**2124-8-21**] 03:15PM   T4-4.2* T3-35* FREE T4-1.2
[**2124-8-21**] 03:15PM   WBC-6.3 RBC-2.56* HGB-8.8* HCT-25.4* MCV-99*
MCH-34.2* MCHC-34.6 RDW-26.1*
[**2124-8-21**] 03:15PM   NEUTS-87* BANDS-5 LYMPHS-1* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*

MRI [**9-20**]: Unchanged mildly compressive bilateral subdural
collections which appears simple based on signal
characteristics.
No acute infarct or abnormal intracranial enhancement


Brief Hospital Course:
Mr. [**Known lastname **] is a 57-year-old gentleman with CLL and large cell
transformation ([**Doctor Last Name 6261**]) s/p MURD SCT on [**3-10**], recently
discharged from [**Hospital1 18**] to rehab, now readmitted for increased
diarrhea, abdominal pain, and waxing/[**Doctor Last Name 688**] mental status.
He was admitted to the Intensive Care Unit following PEA arrest.


ALTERED MENTAL STATUS:  Altered mental status was thought to be
of infectious etiology, though the CSF was negative for BK
virus, [**Male First Name (un) 2326**] virus, CMV, HSV, Herpes 6, and Toxoplasma.  Adenovirus
was detected in the blood, less than 50,000 copies, and BK virus
was highly positive in the blood.  Due to deterioration in
mental status and persistent altered state, the patient was
started on empiric cidofovir therapy at 5mg/kg IV weekly with
oral probenecid for renal protection, per ID recommendations,
for possible BK encephalitis pending the CSF results.  An NG
tube was placed in the ICU for probenecid administration.  His
acyclovir was discontinued since cidofovir was reinstituted.
Patient was also started on thiamine and folate. He received 2
doses of cidofovir on the [**8-25**] and [**9-1**].
Neurology was consulted for altered mental status and once
patient was released from ICU he underwent 24-hour video
monitored EEG.  EEG was negative for seizure activity.

Despite treatment with cidofovir, mental status continued to wax
and wane. After which Infectious Disease recommended not to
continue therapy for BK viremia.  Patient had periods of extreme
agitation during which time he would thrash around in bed and
strike his head against the side-rails.  He would moan and cry
out--however when asked if he was in pain, Mr. [**Known lastname **] would
always shake his head "no."  During this time, patient required
extensive sedation with anti-psychotics, benzodiazepines, and
pain medication.  He was also restrained in bed.  By the time of
transfer to the ICU on [**9-8**], Mr. [**Known lastname **] had become almost
unresponsive. On [**9-10**], He sustained PEA arrest and was
intubated, then sent to the [**Hospital Unit Name 153**] (see [**Hospital Unit Name 153**] course below).

BILATERAL SUBDURAL HEMATOMAS:  A CT head from [**9-7**] showed small
bilateral hematomas.  Most likely from trauma due to thrashing
around in bed with low platelets.  A repeat head CT on [**9-9**]
showed no interval change in the hematomas.  Neurosurgery
recommended no intervention at this time.
.
BK VIREMIA:  Mr. [**Known lastname **] continued to have persistent BK
viremia.  Despite two treatments with cidofovir, BK viral load
increased to 200,000.  We began lowering immunosuppression, in
hopes that Mr. [**Known lastname **] could fight off the virus.  Another BK
viral load is pending.
.
#HYPOTHERMIA-thought to be secondary to infection.  Patient has
displayed this physiology with prior viral infectious.  Possibly
secondary to an endocrine source, but patient is on steroids and
a cortisol stimulation test would be inaccurate. Thyroid studies
were consistent with a sick euthyroid picture. He was treated on
broad spectrum antibiotics in case this was a bacterial sepsis
picture. He was given warming blankets to maintain appropriate
temperatures.

The patient was readmitted to the ICU from [**Date range (1) 16255**] for
hypothermia, confirmed to 92.8 degrees Farenheit by rectal
temperature.  He was warmed with a bair-hugger.

CLL S/P RICTHER'S TRANSFORMATION WITH ALLO SCT IN [**2-24**]:  Disease
in remission. Immunosuppression continued, BMT team closely
following.

GI BLEEDING:  Patient with long-standing heme positive stool,
however, GI bleeding increased in early [**Month (only) 359**].  His hematocrit
remained stable during these bleeding episodes.  He underwent
flex sigmoidoscopy, which indicated bleeding from above the
level of the transverse colon.  No other pathology was found at
the time.  GI bleeding abated on its own.
.
#ELEVATED LFTS/TBILI: Related to GVHD, medications, and chronic
viral infection.
.
#ANEMIA/THROMBOCYTOPENIA:  Secondary to
immunosuppresion/infection/GVHD.  Patient's hematocrit remained
in the low 20s throughout admission, and he was transfused on a
"as needed" basis.  We tried to keep his platelets above 30-40
in light of GI bleeding and subdural hematomas.
.
#DECREASED URINE OUTPUT:  During first ICU course, patient had
mild decrease in urine output.  He appeared intravascularly
depleted and was give fluid boluses throughout the day and
night. His urine output increased appropriately.

#HTN:  Metoprolol was continued throughout admission.
.
[**Hospital Unit Name 153**] Course ([**2036-9-4**]): patient transferred to the ICU for
hypothermia, with an axillary temperature approx. 89oF on the
floor, he had previously been hypothermic with prior infections.
 He was transferred to the ICU for rectal temperature monitoring
and rewarming.  Overnight he was placed on a bair hugger and his
temperature increased to the 96 range rectally.  The rectal
temperature probe was discontinued when he was found to be newly
neutropenic.  After his initial warming his temperature remained
around 96 on the bair hugger and he was deemed medically stable
for transfer back to the floor. During his ICU stay he continued
to have worsening mental status, he was oriented to place, but
extremely agitated.

[**Hospital Unit Name 153**] Course ([**Date range (1) 60076**] ):

Early morning [**9-10**], the patient was found to have Cheynne
[**Doctor Last Name **] respirations and quickly lost a pulse.  Epinephrine was
given once per ACLS protocol, and compressions were initiated on
the floor.  Once the patient was identified as DNR, but
intubation and pressors okay, the compressions were stopped. The
patient returned to afib in the 150s with pulse. He was
intubated and transfered to the [**Hospital Unit Name 153**]. Finger BS was in the 130s.
He was briefly started on norepinephrine for blood pressure
support.

In the ICU, the patient was started on phenylephrine and
vasopressin and titrated off the norepinephrine due to atrial
fibrillation.  He was started on an amiodarone drip, and he
quickly converted back to sinus rhythm.

Pan-CT showed new consolidation seen at the right and left upper
lobes near the apices, consistent with pneumonia, bilateral
small pleural effusions, left greater
than right, with right being new, small-to-moderate amount of
free fluid within the abdomen and diffuse anasarca. He was
intubated for inability to protect his airway and started on
broad spectrum antibiotics for coverage of pneumonia.

Throughout the remainder of his [**Hospital Unit Name 153**] course, his waxing and
[**Doctor Last Name 688**] mental status became a significant barrier to extubation.
The underlying etiology of his altered mental status was
unknown, as multiple blood and urine cultures exihibited no
microbial growth. Head CTs repeated on [**10-27**] and [**9-19**]
showed no interval change in his subdural hematomas and no new
intracranial hemorrhage. His mental status was inconsistent and
extubation was considered given his good FiO2 but concerns were
his inability to protect his airway. He was able to be extubated
since he seemed to have some improvement in mental status, with
some alertness and responsiveness to voice commands. His wife
had noted that over a period of a few hours he was able to say
"yes" and "no."

Unforunately, on [**9-15**] he developed progressive bradycardia,
followed by PEA arrest and was re-intubated by anesthesia, who
suctioned a mucus plus. After the 1st mg of epinephrine, he
regained his pulse. The arrest was thought to be due to mucous
plugging, although he had normal O2 sat prior to arrest. He had
a few episodes of bradycardia throughout the night and received
atropine. His neurologic function continued to deteriorate
without an obvious cause during his course. He suffered from
hematuria and melena and was seen by urology and
gastroenterology respectively.
A full infectious work-up for mental status change revealed no
acute pathology so MRI was performed.

MRI done on [**9-20**] did not reveal any additional abnormalities.
Neurology was consulted, repeat EEG was done on [**9-20**] but this
showed low voltage background consisting of diffuse slow
polymorphic delta activity. There were no focal lateralizing
lesions or epileptiform features noted that would be consistent
with seizure like activity. Neurosurgery was consulted regarding
subdural hematomas and whether there was utility in draining
them by Burr Hole; however, the risks of the procedure given Mr.
[**Known lastname 60074**] underlying comorbidities were far too great.

Due to his deteriorating clinical course and grim prognosis,
several family meetings were held and he was made comfort
measures only on [**9-25**]. A morphine drip was started and patient
was maintained on propofol for sedation and comfort. He was
extubated and passed in the presence of his family members,
including devoted wife and daughter on [**2124-9-26**] at 14:33.


Medications on Admission:
1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2     Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products     Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)

Capsule PO QSUN ([**Doctor First Name **]).
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS

DIRECTED).
12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
ASDIR (AS DIRECTED).
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
17. Mycophenolate Mofetil 500 mg Tablet Sig: 1.5 Tablets PO Q 8H

(Every 8 Hours).
18. Potassium & Sodium Phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses.

19. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous DAILY (Daily).
20. Rituximab 10 mg/mL Concentrate Sig: Seven Hundred-Fifteen
(715) MG Intravenous Give dose #4 (last dose) on [**2124-8-19**] for 1
doses: Please give 715mg on [**2124-8-19**].
21. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty Five (25) MG Injection QAM : Please give 25mg of
methylprednisolone sodium succ every morning.
22. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig:
Twenty (20) MG Injection Q PM: Please give 20MG of
methylprednisolone sodium succ every night.

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

Completed by:[**2124-9-28**]
{'Other specified non-arthropod-borne viral diseases of central nervous system,Unspecified septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Acute respiratory failure,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Unspecified pleural effusion,Acidosis,Other ascites,Paroxysmal ventricular tachycardia,Toxoplasmosis, unspecified,Chronic lymphoid leukemia, in remission,Chronic graft-versus-host disease,Diarrhea,Viremia, unspecified,Thrombocytopenia, unspecified,Unspecified accident,Hypothermia not associated with low environmental temperature,Anemia of other chronic disease,Neutropenia, unspecified,Foreign body in respiratory tree, unspecified,Gross hematuria,Hypoglycemia, unspecified,Cardiogenic shock,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Altered mental status and diarrhea

PRESENT ILLNESS: This is a 57-year-old gentleman with CLL and large cell
transformation, s/p antigen mismatched URD SCT on [**2124-3-10**] (now
day +164), recently discharged from [**Hospital1 18**] to [**Hospital **] Rehab on
[**8-17**] and now re-admitted to 7 [**Hospital Ward Name 1826**] from clinic for diarrhea,
waxing/[**Doctor Last Name 688**] mental status, and electrolyte abnormalities.  As
per physician at [**Name9 (PRE) **], patient had been having voluminous
diarrhea, and was overall "not doing well."
.
Mr. [**Known lastname **] was last admitted on [**2124-3-1**] (Tax Day, as he likes
to remind everyone) and went for antigen mismatched URD SCT
after Busulfan/ Cytoxan conditioning regimen.  Although he
tolerated the transplant well, Mr. [**Known lastname 60074**] subsequent 5[**Hospital **]
hospital course was complicated by GVHD of liver and GI tract,
continous slow GIB, hematuria with BK viruria, adenoviremia,
altered mental status, and extreme deconditioning.  All of his
acute issues had resolved by the time of discharge, and Mr.
[**Known lastname **] was transferred to [**Hospital1 **] for continued
rehabilitation.
.
In clinic pt appeared comfortable although depressed. His vitals
were stable. labs are at baseline except for lytes which will be
repleted. On arrival to the floor pt appears tired but otherwise
has no distress.

MEDICAL HISTORY: Past Medical History:
Hypertension
Hypercholesterolemia (diet controlled)
S/p tonsillectomy
CLL (see below)
.
Past Oncologic History (Per [**Hospital **] Clinic Note):
Pt presented with his disease back in [**10/2119**] with an elevated
white count and LDH. He was without any splenomegaly or any
cytopenias at that time. He did have some bulky lymphadenopathy.
Over the course of six months, his white count began to rise and
essentially doubled to approximately 130,000 with a rising in
his LDH of up to 1400, and he also was noted to have worsening
palpable lymphadenopathy. He then completed four cycles of FCR
therapy, which he completed back in 09/[**2119**]. He had an excellent
response to therapy and was monitored off treatment for
approximately two years. He then presented in [**7-/2122**] with a
rising white count, approximately 50% lymphocytes,
and a mildly elevated LDH. He also had some mild worsening
palpable lymphadenopathy. He then received four cycles of PCR,
but did not have much in the way of response and his treatment
regimen was switched to R-CVP of which he received two cycles.
He did again not have a significant response, though continued
to have an excellent performance status, and he was ultimately
switched to Campath therapy. He did have resolution of his
lymphocytosis, and his white count has come down nicely, but did
not have much in the way of response in terms of reducing his
bulky lymphadenopathy. He had received chemotherapy initially
through 06/[**2122**]. We had decided to observe him off treatment,
and ultimately, we had decided to move forward with an
allogeneic stem cell transplant; however, back at the end of the
summer, his donor had backed out. He also had return of his
disease, and we reinitiated Campath regimen. This, however,
ultimately was cut short on [**2123-7-7**] due to question of an
infection versus PE for which he was ruled out. He has been
followed closely by ID and has been treated on Augmentin since
that time through therapy. He then was restarted back on Campath
and completed six weeks of treatment dose as previously his
cycles have been interrupted. He again had normalization of his
white count and also no longer had any lymphocytosis. However,
he again did not have much in the way of significant response to
his lymphadenopathy. He then eventually had developed an
enlarging left cervical node which was biopsied and was found to
have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for
[**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his
first course of ESHAP on [**2124-2-2**], and tolerated this well.
.
Four cycles of FCR (Fludarabine, Cytoxan,
Rituxan) completed on [**2120-8-15**], four cycles of PCR
(Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two
cycles of R-CVP completed on [**2123-3-11**], Campath treatment
subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**],
reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted
on [**2123-10-11**] and completed approximately six weeks of therapy
which he completed on [**2123-12-3**]. Reinitiated therapy due to
[**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous
infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**],
Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**].
D/t inadequate disease response from [**Hospital1 **] regimen was switched
to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous
infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**],
Cytarabine 2g/m2 IV over 2 hours on day 5 only).

MEDICATION ON ADMISSION: 1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day).
2. Saliva Substitution Combo No.2     Solution Sig: One (1) ML
Mucous membrane QID (4 times a day).
3. Oral Wound Care Products     Gel in Packet Sig: One (1) ML
Mucous membrane QID (4 times a day) as needed for mouth pain.
4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
5. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical QID (4 times a day) as needed for GVHD.
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Please see attached sliding
scale.
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze.
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)

ALLERGIES: Bactrim

PHYSICAL EXAM: PHYSICAL EXAM:
98.4, 138/90, 92/min, 20/min,
General:  appears comfortable at rest, no apparent distress
Neck:  supple, no jvd
Cardiac:  RRR, frequent pvc, no murmurs, rubs, or gallops
reduced air entry bilaterally
Abdomen: distended, but soft, no rebound/guarding/regidity
Extremities:  1+ edema bilaterally

FAMILY HISTORY: Notable for father who died of prostate cancer, with question of
lung involvement at the end.  His mother had a history of MS and
one of his brothers is obese.  An uncle with pancreatic cancer
and an aunt with breast cancer.

SOCIAL HISTORY: Has been married for 30 years. He works as a software engineer.
He does not smoke and drinks occasional alcohol  He has one
daughter who is 20-years-old. 

### Response:
{'Other specified non-arthropod-borne viral diseases of central nervous system,Unspecified septicemia,Severe sepsis,Pneumonitis due to inhalation of food or vomitus,Other encephalopathy,Acute respiratory failure,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Unspecified pleural effusion,Acidosis,Other ascites,Paroxysmal ventricular tachycardia,Toxoplasmosis, unspecified,Chronic lymphoid leukemia, in remission,Chronic graft-versus-host disease,Diarrhea,Viremia, unspecified,Thrombocytopenia, unspecified,Unspecified accident,Hypothermia not associated with low environmental temperature,Anemia of other chronic disease,Neutropenia, unspecified,Foreign body in respiratory tree, unspecified,Gross hematuria,Hypoglycemia, unspecified,Cardiogenic shock,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
