CHIEF COMPLAINT: (1) Planned admission for autologous SCT on BEAM regimen
(2) left intraparenchyma bleed

PRESENT ILLNESS: This is a 65-year-old woman with Stage III high grade B cell
lymphoma admitted for autologous stem cell transplant on the
BEAM regimen.

MEDICAL HISTORY: Past Medical History:
- Non-Hodgkin's lymphoma as outlined above.
- Bilateral pulmonary emboli and left leg DVT.
- Heparin-induced thrombocytopenia
- Hypertension
- Osteoarthritis
- s/p Tonsillectomy
- s/p Cholecystectomy
- s/p Removal of a benign tumor from her right lower abdomen
- s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic)
involving the infrarenal IVC as well as a thrombosis of the left
common iliac vein and left femoral veins.

MEDICATION ON ADMISSION: - B-Complex with Vitamin C 1 tab PO daily
- Atenolol 100 mg PO daily
- Oxycodone 5 mg PO Q6H PRN pain
- Potassium chloride 20mEq PO daily
- Tylenol PRN back pain
- Ativan PRN insomnia

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: Vital Signs: Temperature 97.7 F, blood pressure 134/81, heart
rate 83, respiratory rate 20, O2 sat 100% in room air.
GENERAL: NAD, Alert and oriented x 3
HEENT: PERRLA, Anicteric, MMM, No JVP
CARDIOVASCULAR: RRR, Normal S1 + S2, No murmurs, rubs or gallops

FAMILY HISTORY: - Mother: [**Name (NI) **] cancer.
- Father: Prostate [**Name (NI) 3730**]
- Patient has had two negative colonoscopies

SOCIAL HISTORY: She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability. She is also caring for her grandchild. She has been
married for 41 years. She has two children, one son and one
daughter, and four grandchildren. She is a nonsmoker and does
not drink alcohol.
Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Candidiasis of mouth,Congestive heart failure, unspecified,Varicella without mention of complication,Personal history of venous thrombosis and embolism,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension,Anticoagulants causing adverse effects in therapeutic use,Edema,History of fall,Sprain of unspecified site of back,Fall from other slipping, tripping, or stumbling,Fall resulting in striking against other object,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Delirium due to conditions classified elsewhere,Aphasia
Oth lymp unsp xtrndl org,Int inf clstrdium dfcile,Brain hem NEC w/o coma,Thrush,CHF NOS,Varicella uncomplicated,Hx-ven thrombosis/embols,Idio periph neurpthy NOS,Hypertension NOS,Adv eff anticoagulants,Edema,Personal history of fall,Sprain of back NOS,Fall from slipping NEC,Fall striking object NEC,Elev transaminase/ldh,Delirium d/t other cond,Aphasia
Admission Date:  [**2158-3-21**]              Discharge Date:   [**2158-6-1**]

Date of Birth:  [**2092-3-5**]             Sex:   F

Service: NEUROLOGY

Allergies:
Heparin Agents / Motrin / Phenobarbital / Vancomycin

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
(1) Planned admission for autologous SCT on BEAM regimen
(2) left intraparenchyma bleed

Major Surgical or Invasive Procedure:
Autologous stem cell transplant

Left craniotomy and evacuation of hematoma x 2

History of Present Illness:
This is a 65-year-old woman with Stage III high grade B cell
lymphoma admitted for autologous stem cell transplant on the
BEAM regimen.

Upon admission, the patient reports she is feel well with the
exception of a pulled muscle in her back which occurred this
morning after slipping in the shower. Her pain is a [**2161-4-13**] and
she was able to walk after this occurred. Additionally, she
reports that is having a recurrence of diarrhea. She recently
completed a course of PO Flagyl for C dificile. She was doing
fine without recurrence of diarrhea until approximately 2-3 days
ago when she started having multiple episodes of diarrhea every
day, worse in the morning after eating breakfast and has [**5-14**]
episodes of diarrhea in a short period of time. She reports that
her current diarrhea appears to be the same as when she had C.
difficile.

On review of systems, she complains of a dry cough for over week
but reports this has improved steadily and only has this
intermittently. She denies fevers, chills, night sweats, sore
throat, nausea, vomiting, diarrhea or shortness of breath. The
patient is currently off her anticoagulation (has a history of
HIT) and admits to persistent bilateral lower extremity edema
(L>R) which has improved slightly which has remained. She is off
anticoagulation given her thrombocytopenia and h/o HIT. She
continues to have significant neuropathies in her feet with
numbness, and loss of proprioception of the feet while
ambulating.

Past Medical History:
Past Medical History:
- Non-Hodgkin's lymphoma as outlined above.
- Bilateral pulmonary emboli and left leg DVT.
- Heparin-induced thrombocytopenia
- Hypertension
- Osteoarthritis
- s/p Tonsillectomy
- s/p Cholecystectomy
- s/p Removal of a benign tumor from her right lower abdomen
- s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic)
involving the infrarenal IVC as well as a thrombosis of the left
common iliac vein and left femoral veins.

Past Oncologic History: (Per OMR note, [**2158-3-18**])
Onc history begins in [**10/2157**] when patient began to experience
two week history of diarrhea, abdominal distention and
discomfort. She was seen by her primary care provider and
started on ciprofloxacin. Then on [**2157-10-18**], the patient
presented to the [**Hospital3 **] emergency room with acute episode
of shortness of breath. She was found to have bilateral
pulmonary emboli on CTA and was started on heparin. Additional
symptoms at that time included night sweats and fever but no
weight loss.

Evaluation during Mrs.[**Known lastname 69951**] initial admission with CTA showed
bilateral proximal large PE's. CT of the chest, abdomen, and
pelvis revealed a moderate-size right pleural effusion with
enlarged axillary lymph nodes measuring 2.5 cm on the left and
1.5 cm on the right. There was noted a pericardial mass
measuring 2.2 cm x 2.5 cm. There was also abnormal enhancement
and thickening of the omentum of the lower abdomen and pelvis as
well as large right inguinal lymph nodes measuring 2.6 cm. Note
was also made of filling defect within the left common femoral
artery consistent with DVT of the left lower extremity. Mrs.
[**Known lastname **] was initiated on heparin therapy and underwent a left
inguinal lymph node biopsy on [**2157-10-25**], which revealed
high-grade large B-cell lymphoma with immunohistochemistry study
strongly positive for BCL-2 and CD20. Cells were also positive
for CD19, CD10, and lambda light chain. The C-MYC analysis was
found to be 57%. Bone marrow aspirate and biopsy on [**2157-10-25**]
revealed no evidence for lymphoma. Her LDH at diagnosis was 586.
Mrs. [**Known lastname **] was then discharged on Lovenox and Coumadin. She
underwent a PET scan on [**2157-10-28**], which revealed intense
uptake within bilateral axillary node, presternal node,
pericardial node, bulky mesenteric mass consistent with matted
lymphadenopathy along with some right iliac and bilateral
inguinal nodes and some uptake within the subcutaneous region
around the umbilicus. She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7117**] at
[**Hospital6 2561**] on [**2157-11-1**] for initiation of treatment.


Mrs. [**Known lastname **] was started on R-CHOP chemotherapy which was planned
on a dose-dense schedule with her first cycle on [**2157-11-2**]. She
was able to keep on schedule despite admissions for fever and
neutropenia. Her sixth cycle was delayed by one week due to an
admission for fever and neutropenia with completion of
chemotherapy on [**2158-1-17**]. Her treatment was otherwise
supported with Neulasta along with Aranesp. In [**11-14**],
patient was found to have worsening swelling in her left lower
extremity and was found to have heparin induced
thrombocytopenia. She was started initially on lepirudin and
then transitioned to Coumadin. Additionally, she also was found
to have staph infection of her finger requiring surgical
drainage and antibiotics and a subsequent staph infection of her
right toe. These have both resolved. She had a POC placed for
venous access but this became clotted and did not function. She
then had a double lumen PICC line placed for the remainder of
her treatment. This has since been removed.

Mrs. [**Known lastname **] underwent a PET scan after four cycles of her
chemotherapy on [**2158-12-9**]. This showed significant improvement
within the chest with essentially complete resolution of FDG
avid lymphadenopathy within the axilla and pericardial region.
There was also significant improvement noted in the size of
mesenteric mass with marked decrease degree of FDG uptake,
although still with mild-to-moderate uptake noted. A PET scan at
the completion of treatment showed no FDG-avid disease. Because
Mrs. [**Known lastname **] presented with stage III high-grade lymphoma with
significant adenopathy and aggressive disease, it was felt that
autologous stem cell transplant offered the best potential for
cure. This, however, presented with some difficulties due to her
history of HIT and the fact that there would be periods of
thrombocytopenia during her treatment course. The stem cells
could be collected without the use of heparin and her [**Known lastname **]
catheter could be maintained using sodium citrate instead of
heparin flushes. Mrs. [**Known lastname **] also had a Port-A-Cath in place which
was not functioning. In preparation for her chemotherapy for
mobilization and stem cell collections and subsequent autologous
transplant, Mrs. [**Known lastname **] was seen in interventional radiology on
[**2158-2-10**] for Port-A-Cath removal and IVC filter placement. At
the time of the IVC filter placement, there was demonstration of
a large thrombus which was chronic in nature involving the
infrarenal IVC as well as a thrombosis of the left common iliac
vein and left femoral veins. Therefore, the IVC filter was
placed in the suprarenal area. Her Port-A-Cath was also removed
due to its nonfunctioning nature. The decision was made to
proceed with a temporary [**Year (4 digits) **] catheter placement at the time
of her stem cell collection as well as a temporary central line
at the time of her autologous transplant. Because she would
require periods of being off her Coumadin, Mrs. [**Known lastname **] would
continue anticoagulation with fondaparinux 7.5 mg subcutaneous
daily.

Mrs. [**Known lastname **] was admitted for high dose Cytoxan for stem cell
mobilization on [**2158-2-16**]. She tolerated this relatively well
with some diarrhea, but developed profound pancytopenia as is
expected requiring platelet and red cell transfusions. Her
fondaparinux has been on hold since [**2158-2-24**] due to low
platelets. She also required an admission on [**2158-3-1**] due to
fever and chills. No infection source was found and the fevers
were felt related to her Neupogen and recovering counts. Her
stem cell collections were completed in eight days with over 5
million CD34 cells/kg collected.

Social History:
She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability. She is also caring for her grandchild. She has been
married for 41 years. She has two children, one son and one
daughter, and four grandchildren. She is a nonsmoker and does
not drink alcohol.

Family History:
- Mother: [**Name (NI) **] cancer.
- Father: Prostate [**Name (NI) 3730**]
- Patient has had two negative colonoscopies

Physical Exam:
Vital Signs: Temperature 97.7 F, blood pressure 134/81, heart
rate 83, respiratory rate 20, O2 sat 100% in room air.
GENERAL: NAD, Alert and oriented x 3
HEENT: PERRLA, Anicteric, MMM, No JVP
CARDIOVASCULAR: RRR, Normal S1 + S2, No murmurs, rubs or gallops

RESPIRATORY: Clear to auscultation bilaterally, No wheezes or
crackles
ABDOMEN: Soft, Nontender, NABS, No hepatosplenomegaly. Large
scar in the RLQ from prior surgery.
BACK: Tender upon active range of motion, but no pain upon
palpation
EXTREMITIES: No cyanosis, clubbing or edema; Lower extremities
with 1+ edema in RLE and 2+ in LLE (which appears chronic)
skin/nails: no rashes/no jaundice

NEUROLOGICAL EXAMINATION: She was awake, alert, and oriented x
3. She was able to moves all 4 extremities spontaneously.

Pertinent Results:
[**2158-4-12**] 12:00AM BLOOD WBC-9.7 RBC-3.31* Hgb-10.2* Hct-28.9*
MCV-88 MCH-30.8 MCHC-35.2* RDW-17.8* Plt Ct-20*
[**2158-4-8**] 12:00AM BLOOD WBC-0.2* RBC-2.78* Hgb-8.7* Hct-23.5*
MCV-85# MCH-31.2 MCHC-36.8* RDW-17.8* Plt Ct-10*#
[**2158-3-30**] 12:00AM BLOOD WBC-4.0 RBC-2.84* Hgb-9.0* Hct-25.9*
MCV-91 MCH-31.6 MCHC-34.7 RDW-20.9* Plt Ct-37*
[**2158-3-21**] 12:28PM BLOOD WBC-6.4 RBC-3.04* Hgb-9.8* Hct-28.2*
MCV-93 MCH-32.3* MCHC-34.9 RDW-22.0* Plt Ct-86*
[**2158-3-28**] 12:00AM BLOOD Neuts-98.8* Bands-0 Lymphs-0.3*
Monos-0.6* Eos-0.1 Baso-0.1
[**2158-3-26**] 12:01AM BLOOD Neuts-94.9* Bands-0 Lymphs-3.3*
Monos-1.4* Eos-0.2 Baso-0.2
[**2158-3-21**] 12:28PM BLOOD Neuts-81.7* Lymphs-13.8* Monos-3.6
Eos-0.7 Baso-0.2
[**2158-3-28**] 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Stipple-OCCASIONAL
[**2158-4-12**] 12:00AM BLOOD Plt Ct-20*
[**2158-4-7**] 12:00AM BLOOD Plt Ct-36*
[**2158-3-27**] 01:30AM BLOOD Plt Ct-62*
[**2158-3-21**] 12:28PM BLOOD Plt Ct-86*
[**2158-3-21**] 12:28PM BLOOD PT-14.0* PTT-25.4 INR(PT)-1.2*
[**2158-3-22**] 12:00AM BLOOD Fibrino-430*
[**2158-4-12**] 12:00AM BLOOD Gran Ct-7310
[**2158-4-11**] 12:00AM BLOOD Gran Ct-5350
[**2158-4-10**] 12:10AM BLOOD Gran Ct-940*
[**2158-4-9**] 12:00AM BLOOD Gran Ct-110*
[**2158-4-8**] 12:00AM BLOOD Gran Ct-0*
[**2158-4-7**] 12:00AM BLOOD Gran Ct-10*
[**2158-4-6**] 12:00AM BLOOD Gran Ct-20*
[**2158-4-5**] 12:00AM BLOOD Gran Ct-10*
[**2158-4-4**] 12:00AM BLOOD Gran Ct-0*
[**2158-4-3**] 12:00AM BLOOD Gran Ct-10*
[**2158-4-1**] 12:00AM BLOOD Gran Ct-80*
[**2158-3-31**] 12:00AM BLOOD Gran Ct-1440*
[**2158-3-30**] 12:00AM BLOOD Gran Ct-3910
[**2158-3-29**] 12:00AM BLOOD Gran Ct-4490
[**2158-4-12**] 12:00AM BLOOD Glucose-97 UreaN-14 Creat-0.6 Na-135
K-3.7 Cl-100 HCO3-25 AnGap-14
[**2158-4-8**] 12:00AM BLOOD Glucose-141* UreaN-24* Creat-0.6 Na-135
K-3.6 Cl-105 HCO3-24 AnGap-10
[**2158-3-29**] 12:00AM BLOOD Glucose-171* UreaN-20 Creat-0.6 Na-140
K-3.8 Cl-107 HCO3-23 AnGap-14
[**2158-3-21**] 12:28PM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-144
K-3.8 Cl-109* HCO3-27 AnGap-12
[**2158-4-12**] 12:00AM BLOOD ALT-16 AST-25 LD(LDH)-373* AlkPhos-90
TotBili-0.5
[**2158-4-5**] 12:00AM BLOOD ALT-16 AST-12 LD(LDH)-240 AlkPhos-47
TotBili-0.5
[**2158-3-29**] 12:00AM BLOOD ALT-41* AST-26 LD(LDH)-184 AlkPhos-45
TotBili-0.5
[**2158-3-21**] 12:28PM BLOOD ALT-25 AST-21 LD(LDH)-195 AlkPhos-63
Amylase-30 TotBili-0.3
[**2158-3-22**] 12:00AM BLOOD Lipase-34
[**2158-3-21**] 12:28PM BLOOD Lipase-40
[**2158-4-12**] 12:00AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9 UricAcd-2.0*
[**2158-4-9**] 12:00AM BLOOD Albumin-3.1* Calcium-8.0* Phos-3.3 Mg-2.1
UricAcd-1.6*
[**2158-4-4**] 12:00AM BLOOD Albumin-3.2* Calcium-8.1* Phos-2.7 Mg-1.7
UricAcd-2.8
[**2158-3-29**] 12:00AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7 UricAcd-4.3
[**2158-3-24**] 12:00AM BLOOD Albumin-3.6 Calcium-8.2* Phos-2.7 Mg-1.8
UricAcd-5.2
[**2158-3-21**] 12:28PM BLOOD Albumin-3.6 Calcium-8.9 Phos-3.3 Mg-2.0
UricAcd-5.9*
[**2158-3-27**] 01:30AM BLOOD Hapto-168
[**2158-4-5**] 12:00AM BLOOD Triglyc-94
[**2158-3-27**] 08:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2158-3-21**] 11:28PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2158-3-27**] 08:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2158-3-21**] 11:28PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

   CMV Viral Load (Final [**2158-3-29**]):
      CMV DNA not detected.
      Performed by PCR.
      Detection Range: 600 - 100,000 copies/ml.
      FOR RESEARCH USE ONLY..
      NOT FOR USE IN DIAGNOSTIC PROCEDURES.
      This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].

All other culture data (-), CDiff [**3-22**] +, CDiff [**4-5**] (-), CDiff
[**4-6**] (-)

CXR [**3-21**] - FINDINGS: AP single view of the chest obtained with
patient in sitting upright position is analyzed in direct
comparison with a similar chest examination of [**2158-3-1**]. Heart size is unchanged and within normal limits. Mildly
elongated thoracic aorta with some calcium deposits in the wall
at the level of the arch, also unchanged. No pulmonary vascular
congestion and no evidence of acute infiltrates.
IMPRESSION: Stable chest findings. No evidence of acute
cardiovascular pulmonary processes.

LSpine xray - The vertebral bodies are intact and normally
aligned with no evidence of compression fracture. Pedicles and
posterior elements appear normal. There is no paravertebral soft
tissue swelling. Slight scoliosis, convex right is visualized.
There are some surgical clips in the right upper quadrant and an
IVC filter noted.
IMPRESSION:
L-spine shows only subtle degenerative changes and slight
scoliosis but no evidence for metastasis, compression fracture
or definite explanation for back pain.

[**3-26**] - MRI spine - FINDINGS: No vertebral or paraspinal
pathology is seen. There is no spinal stenosis or
spondylolisthesis. The visualized distal spinal cord, conus
medullaris, and cauda equina are unremarkable.
There are moderate-sized anterior osteophytes extending off of
the T12 and L1 vertebral bodies.
At L2/3, there is a minimal disc bulge with no neural
compression.
At L3/4, there is a mild disc bulge indenting the thecal sac
with no neural compression.
IMPRESSION:
1. L2/3 and L3/4 disc bulges with no neural compression.

KUB [**3-31**] - No evidence of free intraabdominal air is noted. No
evidence of small bowel dilatation is noted. Air is noted within
the ascending [**Month/Year (2) 499**] and sigmoid [**Month/Year (2) 499**] excluding a small bowel
obstruction. Small-sized air-fluid levels are noted within the
small bowel. Incidental note is made of IVC filter. The
visualized portions of lung bases are unremarkable.
IMPRESSION: No evidence of bowel obstruction or free
intraabdominal air is noted.

[**4-8**] - CXR portable - FINDINGS: There is no significant change
in the right subclavian line with tip in the SVC/RA junction.
There is some patchy increased opacity at the left base similar
to the film from two weeks ago. There is no new infiltrate.
There is no pneumothorax. The cardiac and mediastinal
silhouettes are unchanged.

Brief Hospital Course:
Mrs. [**Known lastname **] is a 65-year-old woman with Stage III high grade B
cell lymphoma admitted for autologous stem cell transplant on
the BEAM regimen.

(1) Stage III High-Grade Non-Hodgkin's Lymphoma: The patient was
admitted for autologous stem cell transplant with BEAM therapy.
She tolerated her chemotherapy well.  She was continued on
Ciprofloxacin for prophylaxis.  Her counts were supported with
PRBCs and platelets as needed.  Her course was complicated by
recurrent diarrhea for which she was found to be positive C
dificle.  She has a history of C. difficile and recently
finished a 2 week course of PO Flagyl.  In this setting, she was
started on PO Vancomycin for possible treatment failure C
dificile.  The patient received 9 total bags of stem cells and
was found to be approximately 15 pounds up from her admission
weight after getting IVFs during chemotherapy and her stem
cells.  She was gently diuresed on a daily basis back to near
her admission weight.  Additionally, while he patient was
neutropenic, she began to experience increased abdominal pain
described as crampy in nature and worse in the RLQ for which
Cefepime/Flagyl were added for possible infectious process.  Her
abdominal pain seemed to improve after starting antibiotics, and
days prior to her discharge, was significantly improved.  She
was started on Neupogen on Day +4 and continued for a total of 9
days.

(2) Abdominal Pain: As the patient's counts trended down, she
complained of right sided abdominal pain and was started on
Cefepime/Flagyl for concern of an infectious process in the
setting of treatment failure C dif.  An xray was performed which
showed no obstruction or free air, only occasional air fluid
levels.  The patients abdominal pain improved significantly
after having bowel movements.  The abdominal pain recurred after
her fourth evacuation of her SDH. The etiology was unclear.
Abd/pelvic CT was negative for a concerning abdominal process.
The patient was given suppositories with some relief.

(3) C. Difficile Diarrhea: The patient has a history of C.
difficile diarrhea for which she completed a two week course of
PO Flagyl about 10 days prior to admission.  She had a
recurrence of loose stools and was found to be positive again
for C. difficile during this hospitalization.  She was started
initially on PO Vancomycin for possible Flagyl treatment
failure.  During her autologous transplant, she experienced
worsening of her diarrhea for which IV Flagyl was added, in
addition to PO vancomycin - with which she was not fully
compliant as she did not like the taste.  The patient's flagyl
course was completed.  The diarrhea resolved over a 5 day period
with antibiotics and assistance of loperamide.

(4) h/o Pulmonary Embolus and HIT: The patient was diagnosed
with heparin induced thrombocytopenia during her inital workup
and presentation at [**Hospital6 2561**].  A filter was placed
and she was put on Fondoparinux for a period of time.  On
admission, her fondaparinox had been stopped because of low
platelets.  All heparin products were avoided given history of
HIT.  Patient was not treated with any anticoagulation
throughout her stay.  Her platelets had a small drop after the
initiation of famotidine treatment and this medication was
discontinued the day prior to her discharge.

(5) Lower Extremity Edema, L>R: The patient has a history of
chronic lower extremity edema thought to be secondary to the
lower extremity DVTs found when she was initially diagnosed with
lymphoma.  She has a left common femoral DVT which explains her
left > right lower extremity edema.  The patient's lower
extremity edema was stable.

(6) Back Pain: History and physical exam were most consistent
with a muscle strain.  A xray of the lumbar spine was negative
for compression fractures or other obvious etiology to explain
her disease.  An MRI did show slight disc protrusions at L2/3
and L3/4 but no evidence of neural impingement.  The patient was
treated with warm compresses and PRN Oxycodone.

(7) Neuropathy: Per patient, this is chemotherapy related
peripheral neuropathy.  Patient reports difficulty with
proprioception and occasional falls at home when ambulating.
She takes a Vitamin B complex as per outpatient regimen which
was discontinued temporarily during her autologous transplant.
She was seen by physical therapy upon admission and used a
walker to ambulate for most of her stay.  She was put on fall
precautions. She did have one fall (see SDH/IPH).

(8) Left ICH/SDH: Patient fell and hit her head just prior to
d/c home (with plt count of 18), suffered left parieto-occipital
IPH and SDH.  Patient was confused and mildly disoriented
post-fall (on [**4-12**]), but on [**4-13**] on way to CT scanner pt acutely
decompensated and became non-responsive/only withdrawing to
pain, and her CT showed increased size of bleed.  Patient was
taken emergently to Or for L craniotomy and evacuation of
hematoma; her post-op CT was not significantly changed, so she
returned to the OR later that same day ([**4-13**]) for repeat
evacuation.  The follow-up CT at this time showed decreased mass
effect and midline shift.

On the morning of [**2158-4-18**], patient developed acute change in
mental status, with progression from disorientation to
unresponsiveness in the setting of hypertension fever, and
hypoxia;   Repeat head CT x 2 was done on [**2158-4-18**], and showed
no acute changes post her neurosurgery.  She was started on
Ceftaz, vancomycin, and Acyclovir. She was put on a nitro drip
for her HTN. An LP was done which showed [**5-17**] WBC w/ lymphocyte
predominance.  We checked her daily dilantin level corrected for
albumin for goal 15-20. She had an EEG done on [**2158-4-18**] which
showed spike waves in left frontal and temporal region c/w her
prior bleeding. MRI on [**2158-4-19**] showed left hemisphere swelling,
but no acute ischemic changes.  Her mental status gradually
improved from brainstem reflex only on the early morning of
[**2158-4-18**] to withdraw to pain stimulus on mid morning of
[**2158-4-18**], to opening eyes spontaenously, following commands,
moving all extremities, said "hi" on morning of [**2158-4-19**], to
able to speak a couple words, but continued expressive,
Wernicke's type, aphasia on morning of [**2158-4-20**]. She was weaned
of her nitro drip and started on metoprolol 25 mg PO TID to keep
SBP<160.  Her respitory status improved as her mental status
improved back to her baseline prior to [**Hospital Unit Name 153**] transfer. Neurology
and neurosurgery continued to followed the patient during her
course.  She was called out on to the BMT service on [**2158-4-21**].

While on the BMT service the patient's neurological status
improved. PT was working with her and her Wernicke's aphasia was
also improving. On [**2158-4-26**], the patient's neuro exam changed.
She had worsening RLE and RUE hemiparesis and was much less
verbally interactive. A repeat heat CT and MRI showed increasing
size of the SDH compared to her scan on [**2158-4-18**]. She
was given platelets to increase her platelet count from 70 to >
100. Neurosurgery was notified and took the patient to the OR
for evacuation of the blood. She was transferred back to BMT
service on [**4-29**] but a repeat CT scan on [**2158-5-1**] showed
increasing size of the SDH and shift. Her clinical exam was
slightly improved to stable. Her SBP was kept below 160 and her
platelets were kept >80 at all times. She was again transferred
to the NS service and underwent surgical evacuation of her SDH
(fourth time).

She was transferred back to the BMT service on [**2158-5-3**]. Her
exam was improved. She was able to lift her RUE against gravity
and had 5/5 strength in her LUE. She would wiggle both toes to
command and would move both legs intermittantly, but not to
command. She was kept on dilantin for seizure prophylaxis.

Her course was further complicated by ongoing agitation and
fever of unkown origin. She have fever spikes daily to 101-103,
with no source of infection identified. She was broadly covered
with Vanc/Cefepime/Voriconazole/Flagyl. Thought to be possible
aspiration event, but her respiratory status was not compromised
and she continued to spike fevers despite treatment. As of
[**2158-5-20**] - she continued to have fevers.

Agitation: she would have parocysms of extreme dysphoria, with
loud moaning and crying. Due to her aphasia, she was unable to
communicate any specific discomfort. Initially this was
attempted to be controlled with Dilaudid and Ativan. We obtained
both neurology and psychiatry input. With there help, we changed
the aggitation managment to Haldol.  She was uptitrated on
Keppra and downtitrated on Dilantin for seizure prophylaxys.
However, her WBC began to drop and keppra was supected as a
possible [**Doctor Last Name 360**]. [**5-20**] neurology was asked about an alterantive
seizure medicine. this also would help ally psychiatry's fears
of keppra causing some of her aggitation.
Agitations finally improved on standing low dose haldol (1mg
every 8 hours) and keppra. All narcotics were held to prevent
further mental status depression.

(9) Transaminitis: The patient developed transaminitis in the
setting of abdominal pain, delirium, and expressive aphasia. It
was difficult to ascertain the cause of this transaminitis and
if it was related to her abdominal pain. Both an abdominal USN
and abd/pelvic CT were done which did not reveal any pathology.
Her fluconazole and acyclovir were held as these were possible
sources of her transaminitis.

(10) Thrush: The patient developed thrush and was started on
fluconazole. The fluc was discontinued once her LFTs became
elevated. .

(11) Yeast UTI: urine cultures positive for 10K-100K yeast.
Treated with 5 days of fluconazole.

(12) Nutrition: Status post J-tube placement and tubefeeds
(concentrated TFs to keep rate less than 40ml/hour; higher rates
caused emesis.). TF changed to nutren 2.0 + beneprotein, which
caused some diarrhea.

(13) Respiratory Distress: Desatted to mid-80s on room air and
became tachypneic to 40/min. Chest Xray was consistent with
volume overload and basilar atelectasis vs aspiration. Repeat
CXR with new infiltrate. Improved with antibiotics and diuresis.


(14) Zoster: Rash on back that was confirmed by DFA to be VZV.
It was treated with 7 days of Acyclovir.

(15) Cytopenia: This is from unclear etiology, was thought to be
related to drugs. All antibiotics were held and GCSF restarted.
WBC finally recovered, and GCSF could be held again. Of note,
during the course of cytopenia antibiotics had to be restarted
again without negative effect on cell counts.

Medications on Admission:
- B-Complex with Vitamin C 1 tab PO daily
- Atenolol 100 mg PO daily
- Oxycodone 5 mg PO Q6H PRN pain
- Potassium chloride 20mEq PO daily
- Tylenol PRN back pain
- Ativan PRN insomnia

Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Blistex Lip Ointment     Ointment Sig: One (1)  Topical QID
(4 times a day).
3. Acetaminophen 160 mg/5 mL Solution Sig: One (1)  PO Q8H
(every 8 hours) as needed for fever.
4. Therapeutic Multivitamin     Liquid Sig: Five (5) ML PO DAILY
(Daily).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheezing.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Sodium Chloride 0.9%  Flush 10 ml IV EVERY SHIFT & PRN CVL
with HX HIT
10 ml NS to each lumen every shift and PRN. Inspect site every
shift.
11. MethylPREDNISolone Sodium Succ 10 mg IV Q24H
12. Levetiracetam 500 mg IV Q 8H
13. FoLIC Acid 1 mg IV DAILY
[**Month (only) **] PUT THRU PEG TUBE!
14. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO every Mo
We Fr.
15. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.

16. Acyclovir Sodium 500 mg Recon Soln Sig: Eight Hundred (800)
mg Intravenous three times a day for 4 days: Last dose Sunday,
[**2158-6-4**] in PM.
17. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day: start on Monday, [**2158-6-5**].

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
1. Non-Hodgkin's lymphoma

Secondary:
1. Bilateral pulmonary emboli and left leg DVT.
2. Heparin-induced thrombocytopenia
3. Hypertension
4. Osteoarthritis
5. s/p Tonsillectomy
6. s/p Cholecystectomy
7. s/p Removal of a benign tumor from her right lower abdomen
8. s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic)
involving the infrarenal IVC as well as a thrombosis of the left
common iliac vein and left femoral veins.

Discharge Condition:
Patient discharged to home in stable condition, afebrile,
ambulating on her own, tolerating PO feeds and fluids.

Discharge Instructions:
Patient was admitted for chemotherapy and stem cell transplant.
Patient is advised to do the following:
1.  Keep all follow-up appointments.
2.  Take all medications as prescribed.
3.  To seek medical attention if she acquires chest pain,
shortness of breath, nausea, vomiting, or any other concern that
is out of the ordinary for her.

Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**7-18**] days



Completed by:[**2158-6-1**]
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Candidiasis of mouth,Congestive heart failure, unspecified,Varicella without mention of complication,Personal history of venous thrombosis and embolism,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension,Anticoagulants causing adverse effects in therapeutic use,Edema,History of fall,Sprain of unspecified site of back,Fall from other slipping, tripping, or stumbling,Fall resulting in striking against other object,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Delirium due to conditions classified elsewhere,Aphasia'}


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: (1) Planned admission for autologous SCT on BEAM regimen
(2) left intraparenchyma bleed

PRESENT ILLNESS: This is a 65-year-old woman with Stage III high grade B cell
lymphoma admitted for autologous stem cell transplant on the
BEAM regimen.

MEDICAL HISTORY: Past Medical History:
- Non-Hodgkin's lymphoma as outlined above.
- Bilateral pulmonary emboli and left leg DVT.
- Heparin-induced thrombocytopenia
- Hypertension
- Osteoarthritis
- s/p Tonsillectomy
- s/p Cholecystectomy
- s/p Removal of a benign tumor from her right lower abdomen
- s/p suprarenal IVC filter [**2158-2-10**]: Large thrombus (chronic)
involving the infrarenal IVC as well as a thrombosis of the left
common iliac vein and left femoral veins.

MEDICATION ON ADMISSION: - B-Complex with Vitamin C 1 tab PO daily
- Atenolol 100 mg PO daily
- Oxycodone 5 mg PO Q6H PRN pain
- Potassium chloride 20mEq PO daily
- Tylenol PRN back pain
- Ativan PRN insomnia

ALLERGIES: Heparin Agents / Motrin / Phenobarbital / Vancomycin

PHYSICAL EXAM: Vital Signs: Temperature 97.7 F, blood pressure 134/81, heart
rate 83, respiratory rate 20, O2 sat 100% in room air.
GENERAL: NAD, Alert and oriented x 3
HEENT: PERRLA, Anicteric, MMM, No JVP
CARDIOVASCULAR: RRR, Normal S1 + S2, No murmurs, rubs or gallops

FAMILY HISTORY: - Mother: [**Name (NI) **] cancer.
- Father: Prostate [**Name (NI) 3730**]
- Patient has had two negative colonoscopies

SOCIAL HISTORY: She was working fulltime at [**Company 378**] in customer support services
prior to her diagnosis and treatment; she is currently on
disability. She is also caring for her grandchild. She has been
married for 41 years. She has two children, one son and one
daughter, and four grandchildren. She is a nonsmoker and does
not drink alcohol. 

### Response:
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Other and unspecified intracranial hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Candidiasis of mouth,Congestive heart failure, unspecified,Varicella without mention of complication,Personal history of venous thrombosis and embolism,Unspecified hereditary and idiopathic peripheral neuropathy,Unspecified essential hypertension,Anticoagulants causing adverse effects in therapeutic use,Edema,History of fall,Sprain of unspecified site of back,Fall from other slipping, tripping, or stumbling,Fall resulting in striking against other object,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Delirium due to conditions classified elsewhere,Aphasia'}
