CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: Mr. [**Known lastname 39623**] is a 52-year-old male with a history of AML who
is now day +120 status post a myeloablative sequential unrelated
double cord blood transplant.  He developed shortness of breath
at 5 a.m. with paroxysmal coughing spasms.  His wife states that
he was awake for most of the night with unrelenting dry,
non-productive cough that had been worsening over the past 3
days.  He suddenly became unresponsive and per his wife fell
forward and turned blue.  His wife immediately called EMS and
gave rescue breaths in the few minutes before their arrival.
Per her report, he had not had any fevers, chills, diarrhea, or
productive cough.  She had noted some shakes in the middle of
the night but states that he did not feel cool or warm to the
touch.  Patient had reported increased lower extremity edema the
prior day.  His recent abdominal pain and nausea had improved
over the previous days since he had been switched from
Tacrolimus to Cyclosporine.
.
In the ambulance, he received nitroglycerin x 2 and Lasix 40 mg.
 On arrival BP 200/90, RR 30, SpO2 78% on RA.  ABG 7.4/39/49.
He denied chest pain.  SpO2 improved to 80% on 15L NRB.  He was
intubated and was treated with ASA 325 mg, levofloxacin 750 mg,
rocephin 1 gram.   It was felt that he went flashed with fluid
resuscitation, and he was started on a nitroglycerin drip.  He
was sedated and paralyzed with succinyl choline and propofol.
BP's 132-179/76-100 with HR 118-124.   He was transfered to the
[**Hospital1 18**] ED.
.
On arrival to our ED, Tm 102.2, BP 104/55, HR 96, SpO2 100% on
ACC with TV 550 x 22, FiO2 100%, PEEP 5.  ABG 7.27/50/87.
Nitroglycerine gtt was discontinued.  He received Tylenol 1000
mg PR, 2 mg IV dexamethasone, Vanc 1 gram, and Zosyn 2.25 gram.
Repeat ABG was 7.23/53/127. Blood culture x 1 was drawn.

MEDICAL HISTORY: 1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+120.  Day 100 bone marrow biopsy showed no
diagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares initially maintained on
anidulafungin after being on posaconazole for several months in
an effort to "rest" his liver.  This was switched to
voriconazole
when he developed epistaxis and sinus tenderness in the side of
prior disease.  He has remained on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Cardiomyopathy of unclear etiology. The patient underwent a
cardiac MRI in [**7-/2182**] prior to chemotherapy and was noted to
have an ejection fraction of 45%-50%.  Most recent TTE [**6-19**]
with preserved systolic function EF>55%.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses ([**8-/2182**])

MEDICATION ON ADMISSION: Ursodiol 300 mg [**Hospital1 **]
Acyclovir 400 mg TID
Atovaquone 1500 mg daily
Sulcralfate 1 g QID
Protonix 40 mg [**Hospital1 **]
Labetolol 100 mg [**Hospital1 **]
Doxazosin 4 mg qHS
Cyclosporine 100 mg [**Hospital1 **]
Lorazapam 0.5-1 mg PRN nausea
Zyprexa 5 mg daily PRN nausea

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: Vital Signs
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F)
HR: 89 (88 - 91) bpm
BP: 120/64(82) {120/64(82) - 125/68(353)} mmHg
RR: 24 (22 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: The patient's parents are alive. His father has hypertension, a
h/o CAD status post three-vessel CABG, and sarcoidosis. He notes
that his mother is in good health. He has one brother and two
sisters who are all alive and well. He notes that his
grandmother was diagnosed with a type of cancer. He denies any
family history of bleeding disorders.

SOCIAL HISTORY: The patient is married and lives with his wife [**Name (NI) 2048**] in
[**Location (un) 620**], [**State 350**]. He has 4 children. He previously worked
as a mechanic until [**2173**], and then he worked at a car
dealership. The patient has a history of tobacco use and notes
that he smoked one-half pack per day x30 years.  He uses alcohol
Other pulmonary insufficiency, not elsewhere classified,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Bacterial pneumonia, unspecified,Paralytic ileus,Critical illness myopathy,Pressure ulcer, buttock,Thrombocytopenia, unspecified,Hyperpotassemia,Intermediate coronary syndrome,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Acute sphenoidal sinusitis,Coronary atherosclerosis of native coronary artery,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of unspecified site
Other pulmonary insuff,Alveol pneumonopathy NEC,Acute kidney failure NOS,Ac myl leuk wo achv rmsn,Trspl sts-perip stm cell,Bacterial pneumonia NOS,Paralytic ileus,Critical illness myopthy,Pressure ulcer, buttock,Thrombocytopenia NOS,Hyperpotassemia,Intermed coronary synd,Hypertension NOS,Chr airway obstruct NEC,Adv eff antineoplastic,Ac sphenoidal sinusitis,Crnry athrscl natve vssl,Pancreatic disorder NEC,Adv eff corticosteroids,Mononeuritis NOS
Admission Date:  [**2184-3-18**]              Discharge Date:   [**2184-5-13**]

Date of Birth:  [**2131-3-30**]             Sex:   M

Service: MEDICINE

Allergies:
Benadryl Allergy / Ambisome / Flomax

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy x 2

History of Present Illness:
Mr. [**Known lastname 39623**] is a 52-year-old male with a history of AML who
is now day +120 status post a myeloablative sequential unrelated
double cord blood transplant.  He developed shortness of breath
at 5 a.m. with paroxysmal coughing spasms.  His wife states that
he was awake for most of the night with unrelenting dry,
non-productive cough that had been worsening over the past 3
days.  He suddenly became unresponsive and per his wife fell
forward and turned blue.  His wife immediately called EMS and
gave rescue breaths in the few minutes before their arrival.
Per her report, he had not had any fevers, chills, diarrhea, or
productive cough.  She had noted some shakes in the middle of
the night but states that he did not feel cool or warm to the
touch.  Patient had reported increased lower extremity edema the
prior day.  His recent abdominal pain and nausea had improved
over the previous days since he had been switched from
Tacrolimus to Cyclosporine.
.
In the ambulance, he received nitroglycerin x 2 and Lasix 40 mg.
 On arrival BP 200/90, RR 30, SpO2 78% on RA.  ABG 7.4/39/49.
He denied chest pain.  SpO2 improved to 80% on 15L NRB.  He was
intubated and was treated with ASA 325 mg, levofloxacin 750 mg,
rocephin 1 gram.   It was felt that he went flashed with fluid
resuscitation, and he was started on a nitroglycerin drip.  He
was sedated and paralyzed with succinyl choline and propofol.
BP's 132-179/76-100 with HR 118-124.   He was transfered to the
[**Hospital1 18**] ED.
.
On arrival to our ED, Tm 102.2, BP 104/55, HR 96, SpO2 100% on
ACC with TV 550 x 22, FiO2 100%, PEEP 5.  ABG 7.27/50/87.
Nitroglycerine gtt was discontinued.  He received Tylenol 1000
mg PR, 2 mg IV dexamethasone, Vanc 1 gram, and Zosyn 2.25 gram.
Repeat ABG was 7.23/53/127. Blood culture x 1 was drawn.

Past Medical History:
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+120.  Day 100 bone marrow biopsy showed no
diagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares initially maintained on
anidulafungin after being on posaconazole for several months in
an effort to "rest" his liver.  This was switched to
voriconazole
when he developed epistaxis and sinus tenderness in the side of
prior disease.  He has remained on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Cardiomyopathy of unclear etiology. The patient underwent a
cardiac MRI in [**7-/2182**] prior to chemotherapy and was noted to
have an ejection fraction of 45%-50%.  Most recent TTE [**6-19**]
with preserved systolic function EF>55%.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses ([**8-/2182**])

Social History:
The patient is married and lives with his wife [**Name (NI) 2048**] in
[**Location (un) 620**], [**State 350**]. He has 4 children. He previously worked
as a mechanic until [**2173**], and then he worked at a car
dealership. The patient has a history of tobacco use and notes
that he smoked one-half pack per day x30 years.  He uses alcohol

occasionally; however, is not drinking at this time. He denies
use of illicit drugs.

Family History:
The patient's parents are alive. His father has hypertension, a
h/o CAD status post three-vessel CABG, and sarcoidosis. He notes
that his mother is in good health. He has one brother and two
sisters who are all alive and well. He notes that his
grandmother was diagnosed with a type of cancer. He denies any
family history of bleeding disorders.

Physical Exam:
Vital Signs
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F)
HR: 89 (88 - 91) bpm
BP: 120/64(82) {120/64(82) - 125/68(353)} mmHg
RR: 24 (22 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)



Ventilator mode: CMV/ASSIST
Vt (Set): 550 (550 - 550) mL
RR (Set): 22
PEEP: 15 cmH2O
FiO2: 100%

Physical Examination
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, NG
tube
Lymphatic: Cervical WNL, Supraclavicular WNL, thick neck
Cardiovascular: (S1: Normal), (S2: Normal), unable to assess JVP
due to thickness of neck
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : at bases bilaterally, Rhonchorous: scattered, in all
fields)
Abdominal: Soft, Non-tender, quiet bowel sounds
Extremities: Right: 1+, Left: 1+ edema
Skin:  Warm, well-perfused
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed



Pertinent Results:
ADMISSION LABS
[**2184-3-18**] 09:45AM BLOOD WBC-6.0 RBC-3.03* Hgb-10.1* Hct-31.2*
MCV-103* MCH-33.3* MCHC-32.4 RDW-14.7 Plt Ct-52*
[**2184-3-18**] 09:45AM BLOOD Neuts-78.6* Lymphs-12.8* Monos-7.2
Eos-1.1 Baso-0.3
[**2184-3-18**] 04:32PM BLOOD PT-15.6* PTT-34.8 INR(PT)-1.4*
[**2184-3-18**] 09:45AM BLOOD Glucose-164* UreaN-32* Creat-1.8* Na-133
K-5.0 Cl-104 HCO3-21* AnGap-13
[**2184-3-22**] 04:48AM BLOOD Glucose-140* UreaN-75* Creat-3.0* Na-142
K-5.3* Cl-107 HCO3-21* AnGap-19
[**2184-3-18**] 09:45AM BLOOD ALT-11 AST-22 LD(LDH)-244 CK(CPK)-32*
AlkPhos-127* TotBili-0.8
[**2184-3-18**] 09:45AM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-6884*
[**2184-3-22**] 07:12AM BLOOD VitB12-311 Folate-2.6
[**2184-3-29**] 04:40AM BLOOD Hapto-161
[**2184-3-18**] 08:31PM BLOOD Cortsol-8.0

DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2184-5-13**] 12:10AM    5.2 3.05* 10.5* 33.6* 110* 34.2* 31.1
18.7* 52*1
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso
[**2184-5-13**] 12:10AM    72.4*   19.6 5.7 2.0 0.3
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2184-5-13**] 12:10AM    289* 32* 0.9 137 4.6 103 25 14
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos  TotBili
[**2184-5-12**] 12:00AM    32 15 232   115   0.3

PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
[**2184-4-25**] 12:00AM    HYPOGAMMAG1 376* 59* 124 NO MONOCLO2

MICROBIOLOGY
galactomannan and B-glucan were negative on 4 separate dates

[**2184-5-11**] Immunology (CMV) CMV Viral Load-NEG
[**2184-5-7**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-5-3**] Immunology (CMV) CMV Viral Load-FINAL NEG
[**2184-4-28**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-4-28**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-4-26**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-20**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-19**] URINE URINE CULTURE-NEG
[**2184-4-18**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] STOOL OVA + PARASITES-NEG
[**2184-4-17**] URINE URINE CULTURE-NEG
[**2184-4-16**] STOOL OVA + PARASITES-NEG
[**2184-4-14**] 8:55 pm URINE
                           **FINAL REPORT [**2184-4-17**]**
   URINE CULTURE (Final [**2184-4-17**]):
      ENTEROCOCCUS SP..    10,000-100,000 ORGANISMS/ML..
                              SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------  =>32 R
LINEZOLID-------------     2 S
NITROFURANTOIN--------   256 R
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------  =>32 R

[**2184-4-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL; Immunoflourescent test for
Pneumocystis jirovecii (carinii)-FINAL; FUNGAL CULTURE-FINAL
INPATIENT -NEG
[**2184-4-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-NEG
[**2184-4-10**] Immunology (CMV) CMV Viral Load-NEG
[**2184-4-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL INPATIENT NEG
[**2184-4-9**] URINE Legionella Urinary Antigen -NEG
[**2184-4-8**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-4-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-4-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-30**] URINE URINE CULTURE-NEG
[**2184-3-30**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-30**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-29**] ASPIRATE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-FINAL INPATIENT   NEG
[**2184-3-29**] 1:59 pm ASPIRATE      Source: Sinus.
                            **FINAL REPORT [**2184-4-12**]**
   GRAM STAIN (Final [**2184-3-29**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
   RESPIRATORY CULTURE (Final [**2184-3-31**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON REQUEST..
   FUNGAL CULTURE (Final [**2184-4-12**]):    NO FUNGUS ISOLATED.
[**2184-3-29**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] Rapid Respiratory Viral Screen & Culture Rapid
Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-FINAL
INPATIENT NEG
[**2184-3-27**] Influenza A/B by DFA - Bronch Lavage DIRECT INFLUENZA
A ANTIGEN TEST-NEG; DIRECT INFLUENZA B ANTIGEN TEST-NEG
[**2184-3-27**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; Immunoflourescent test
for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-FINAL INPATIENT    NEG
[**2184-3-27**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-FINAL INPATIENT   NEG
[**2184-3-27**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-FINAL; BLOOD/AFB CULTURE-PENDING INPATIENT
[**2184-3-27**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-27**] URINE URINE CULTURE-NEG
[**2184-3-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE NEG;
FUNGAL CULTURE-NEG
[**2184-3-26**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEG
[**2184-3-26**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-26**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-26**] URINE URINE CULTURE-FINAL INEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-25**] URINE URINE CULTURE-FINAL NEG
[**2184-3-25**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB NEG;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-NEG; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-NEG
[**2184-3-25**] Immunology (CMV) CMV Viral Load-NEG
[**2184-3-25**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-24**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-NEG
[**2184-3-24**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-24**] URINE URINE CULTURE-NEG
[**2184-3-24**] STOOL OVA + PARASITES-NEG
[**2184-3-22**] STOOL OVA + PARASITES-NEG
[**2184-3-22**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL INPATIENT  NEG
[**2184-3-22**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; MICROSPORIDIA STAIN-FINAL;
CYCLOSPORA STAIN-FINAL; Cryptosporidium/Giardia (DFA)-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL; VIRAL CULTURE-FINAL
INPATIENT  NEG
[**2184-3-21**] ASPIRATE Immunoflourescent test for Pneumocystis
jirovecii (carinii)-NEG
[**2184-3-21**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-21**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-21**] Influenza A/B by DFA DIRECT INFLUENZA A ANTIGEN
TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL; VIRAL
CULTURE-FINAL INPATIENT
[**2184-3-19**] Rapid Respiratory Viral Screen & Culture Rapid
Respiratory Viral Antigen Test-FINAL; VIRAL CULTURE-FINAL
INPATIENT  NEG
[**2184-3-19**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; Immunoflourescent test
for Pneumocystis jirovecii (carinii)-FINAL; FUNGAL
CULTURE-FINAL; ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY; VIRAL CULTURE-FINAL; VIRAL CULTURE: R/O
CYTOMEGALOVIRUS-FINAL INPATIENT  NEG
[**2184-3-19**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-19**] SEROLOGY/BLOOD CRYPTOCOCCAL ANTIGEN-NEG
[**2184-3-19**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-18**] 1:11 pm SPUTUM      Source: Endotracheal.
                            **FINAL REPORT [**2184-4-1**]**
   GRAM STAIN (Final [**2184-3-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.
   RESPIRATORY CULTURE (Final [**2184-3-22**]):
      RARE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    RARE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
[**2184-3-18**] BLOOD CULTURE BARTONELLA BLOOD CULTURE-NEG
[**2184-3-18**] URINE URINE CULTURE-NEG
[**2184-3-18**] URINE Legionella Urinary Antigen -NEG
[**2184-3-18**] BLOOD CULTURE Blood Culture, Routine-NEG
[**2184-3-18**] Influenza A/B by DFA Rapid Respiratory Viral Antigen
Test-FINAL; VIRAL CULTURE-FINAL INPATIENT NEG
[**2184-3-18**] Immunology (CMV) CMV Viral Load-NEG
[**2184-3-18**] BLOOD CULTURE Blood Culture, Routine-NEG
.
HERPES 6 DNA PCR, QUANTITATIVE
  Test Name                     In Range       Out of Range
 Reference Range
---------                     --------       ------------
---------------
Herpes Virus 6 DNA, Quantitative Real-Time PCR
  Herpes Virus 6 DNA, QN PCR   <500
<500 copies/mL

This test was developed and its performance characteristics have
been
determined by Focus Diagnostics. Performance characteristics
refer to
the analytical performance of the test. This test is performed
pursuant
to a license agreement with [**Doctor Last Name **] Molecular Systems, Inc. The
quantitative
range of this assay is 500 - 2,000,000 HHV-6 DNA copies/mL
.
HERPESVIRUS 6 IGG & IGM ANTIBODY PANEL
  Test                          Result              Reference
Range/Units
HERPESVIRUS 6 IGM             <1:20               <1:20

HERPESVIRUS 6 IGG             1:40  H             <1:10

INTERPRETATION: PAST INFECTION

STRONGYLOIDES ANTIBODY,IGG
  Test Name                   In Range      Out of Range
Reference Range
---------                   --------      ------------
---------------
Strongyloides Antibody, IgG ([**Doctor First Name **])
  Strongyloides IgG           <1.00
<1.00

Interpretive Criteria
  <1.00 Antibody Not Detected
  > or = 1.00 Antibody Detected






IMAGING STUDIES

[**2184-3-18**] LENI:  IMPRESSION: No evidence of DVT.

[**2184-3-18**] TTE:
The left atrium is elongated. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic arch is mildly dilated. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is a small to moderate sized pericardial effusion. There
are no echocardiographic signs of tamponade. No right atrial or
right ventricular diastolic collapse is seen.

Compared with the findings of the prior study (images reviewed)
of [**2183-10-22**], a small-to-moderate pericardial effusion is
now present.

EKG:  Sinus rhythm. Normal tracing. Compared to the previous
tracing of [**2183-12-12**] the rate is slightly slower and limb lead
voltage is lower. Clinical
correlation is suggested.

[**3-19**] CXR portable-IMPRESSION: Improving pulmonary opacifications,
most likely representing decreasing pulmonary edema.

CT CHEST [**2184-3-26**] : Within limits of the study without contrast,
the heart and great vessels are within normal limits.
Mediastinal and hilar lymph nodes have decreased in size
compared to prior examination. There are moderate bilateral
pleural effusions and associated lower lobe atelectasis.
Separate from this, there are patchy areas of opacities in the
lower lobes as well as the left upper lobe, lingula, and right
upper lobe. No pulmonary edema is identified. Endotracheal,
central venous catheter, and nasogastric tube are in unchanged
position. Visualized portions of the upper abdomen are
unremarkable.
IMPRESSION:
1. Patchy multifocal opacities consistent with pneumonia.
2. Moderate bilateral pleural effusions and bilateral lower lobe
atelectasis.
3. No evidence of pulmonary edema. Small amount of pericardial
fluid and ascites.

CT CHEST W/O CONTRAST  [**2184-4-16**] 11:11 AM
FINDINGS: Diffuse lung parenchymal abnormalities have
progressed, including areas of consolidation, ground-glass
attenuation, and poorly defined nodules. The areas of
consolidation have a striking subpleural distribution except for
at the lung bases where they are combined bronchovascular and
subpleural in distribution. Areas of ground-glass attenuation
are more variable in distribution, and poorly defined nodules
are predominantly peribronchovascular. Within the lower lungs,
there is also smoothly marginated septal thickening present. A
small amount of retained secretions are present within the
central airways, but there are no suspicious lesions.

Numerous mediastinal lymph nodes are again demonstrated with
slight increase in size. For example, a right paratracheal lymph
node at the level of the aortic arch is now 13 mm compared to 10
mm, and a lower right paratracheal lymph node at the level of
the carina now measures 16 mm in short axis and previously
measured 15 mm. Bilateral hilar nodes appear similar allowing
for difficulty in measurement due to absence of intravenous
contrast. Heart is normal in size. Moderate-sized dependent
posterior pericardial effusion has slightly increased, and small
dependent pleural effusions have minimally decreased on the
right and minimally increased on the left.

Examination is not specifically tailored to evaluate the
subdiaphragmatic region, but a small incompletely imaged cyst in
the right lobe of the liver is incidentally noted as well as
diffuse increased attenuation of the liver. Adrenal glands are
normal. Please note that absence of intravenous and oral
contrast reduced sensitivity of CT for detecting abdominal
abnormalities.

Subcutaneous 17-mm diameter round lesion in the upper right
posterior chest wall appears unchanged. There are no acute
skeletal abnormalities. Incidental note is made of an apparent
hemangioma in the lower thoracic spine as well as an area of
disc calcification.

IMPRESSION:
1. Worsening of widespread lung parenchymal abnormalities, with
combined subpleural and peribronchovascular distributions. The
differential diagnosis is broad, but cryptogenic organizing
pneumonia is a likely contributing diagnosis. However, the
severity of abnormalities in the lower lungs and the presence of
associated septal thickening raise the concern for a secondary,
coexisting process such as atypical infection or edema.

2. No change in subcutaneous soft tissue nodule in upper right
chest wall. This could potentially represent a sebaceous cyst,
but correlation with physical exam findings is suggested for
initial further assessment if the diagnosis is not already known
clinically.

CT CHEST W/O CONTRAST  [**2184-4-26**] 10:14 AM
IMPRESSION:
1. Improvement of the widespread lung parenchymal abnormalities
including ground-glass opacities, peribronchovascular
infiltrates, and subpleural consolidation. The improvement is
more pronounced in the ventral segments of the lung. The left
pleural effusion has completely resolved while the right pleural
effusion has persisted.

CT HEAD W/O CONTRAST  [**2184-5-4**] 10:39 PM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or acute vascular territorial infarction. Ventricles and
sulci are normal in size and configuration. There is no
fracture. There is mild mucosal thickening in the bilateral
maxillary sinuses.
IMPRESSION: No acute intracranial process. Please note that MRI
with diffusion-weighted imaging is more sensitive for the
detection of acute brain ischemia.

MR/A HEAD W & W/O CONTRAST  [**2184-5-5**] 4:17 PM
FINDINGS: There is no hemorrhage, infarct, or edema. No abnormal
signal intensity within the brain parenchyma. There is no
abnormal enhancement.
Increased signal on the post-contrast images (series16, im 14)in
the internal auditory canals can be real or due to 3T scanner
effect as this is not identifiable on post contrast MRA neck
images.

MRA OF THE BRAIN: The intracranial vertebral and internal
carotid arteries and their major branches are normal with no
evidence of stenosis, occlusion, or aneurysm.

MRA OF THE CAROTIDS AND VERTEBRAL ARTERIES: Carotid and
vertebral arteries are visualized from the origins to the
intracranial courses. No stenosis or occlusion identified. The
distal ICA measures 5 mm on the right and 4 mm on the left.

Soft tissues demonstrate a T1 hypointense, T2 hyperintense ovoid
well-defined structure within the soft tissues at the right
cranial vertex measuring approximately 1.7 x 0.9 cm.

IMPRESSION:
1. No acute infarction.
2. Increased signal on post contrast images of brain in the
internal auditory canals can be real or artifactual related to
3T scanner effect amd is not associated with increased FLAIR
signal or seen on postcontrast MRA neck images. Clinical
correlation and if necessary LP can be useful.
3. No focal flow limiting stenosis, occlusion or aneurysm more
than 3mm within the resolution of MRA.
4. Well-defined nodule in the subcutaneous tissues of the
parietal vertex, which may represent a sebaceous cyst, lymph
node, or nodule of uncertain etiology.

PERSANTINE MIBI  [**2184-5-7**]
INTERPRETATION:
Left ventricular cavity size is mildly dilated.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 49%.
IMPRESSION: Normal myocardial perfusion on scintigraphy. Mildly
dilated left
ventricular cavity size. LVEF 49%.

STRESS Study Date of [**2184-5-7**]
 EXERCISE RESULTS

RESTING DATA
EKG:  SINUS, PROM. VOLT.
HEART RATE:  80 BLOOD PRESSURE:  118/64

PROTOCOL  /
STAGE TIME SPEED ELEVATION [**Doctor Last Name 10502**] HEART BLOOD RPP
  (MIN) (MPH) (%)   RATE PRESSURE
1 0-4 0.142MG/ KG/MIN   90 98/60 8820

TOTAL EXERCISE TIME:  4 % MAX HRT RATE ACHIEVED:  54

SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This 53 year old man was referred to the lab for

evaluation of chest pain. The patient was infused with 0.142
mg/kg/min
of dipyridamole over 4 minutes. No arm, neck, back or chest
discomfort
was reported by the patient throughout the study. There were no
ST
segment changes during the infusion or in recovery. The rhythm
was
sinus with no ectopy. Appropriate hemodynamic response to the
infusion.
The dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ischemic EKG changes.
Nuclear
report sent separately.



Brief Hospital Course:
53 yo male with history of AML, s/p cord blood transplant who
presented in early [**Month (only) 958**] with ARDS of unclear etiology requiring
intubation. He was called out to the floor after stablilization.
Floor course was complicated by increasing hypoxia so he was
readmitted to the ICU for increasing respiratory distress/ARDS,
found to have BOOP, treated with high dose steroids after which
he made steady improvements and continued to make progress on
the floor. Hospital course by problem:

# ACUTE RESPIRATORY DISTRESS SYNDROME: Upon admission, the
patient was started on broad spectrum antibiotic treatment in
order to treat an infectious process responsible for a clinical
picture consistent with ARDS.  Antibiotics included vancomycin,
cefepime, levofloxacin, as well as bactrim and voriconozole.
The patient was followed by infectious disease during this
course, with coverage of antibiotics eventually being changed to
vanc/meropenem/levofloxacin/flagyl as well as prophylactic doses
of voriconozole and atovaquone.  The patient underwent a
bronchoscopy, and BAL was sent.  All work up for infectious
etiology was unrevealing.  There was some concern that the ARDS
was secondary to rare cyclosporine toxicity, which had been
intiated 3 days prior to presentation, however this was later
felt not to be the case.  This medication was weaned, and
ultimatly discontinued.  The patient was noted to have pleural
effusions and gross body volume overload in the setting of ARF
with an elevated BNP upon admission, but was an unlikely primary
source of patients respiratory decompenstation.  Patient
remained intubated from [**2184-3-18**] to [**2184-3-30**].  Patient was
difficult to wean from the vent, possibly due to a VAP, but
process was facilitated through continued diuresis and
adjustments in antibiotics.  Since extubation patient breathed
comfortably on NC. Prior to transfer to the medical floor
vancomycin and cefepime had been discontinued. He completed an
empiric course of levaquin on [**4-8**]. He was volume overloaded on
transfer and diuresis was continued with 100mg IV lasix daily.
On [**4-3**] the patient briefly desated to 88% on 6L NC and required
NRB, occurred in the setting of [**10-22**] chest pain. The patient
was given additional diuresis, morphine and sl ntg and recovered
to previous O2 requirement of 6L. CEs were negative. No ECG
changes during event. Over the course of the next few days, he
remained stable from a pulmonary standpoint with a requirement
of 6L NC. On [**4-9**], the patient transiently desaturated to 90% on
6L with mild shortness of breath. He was afebrile and
hemodynamically stable. CT chest revealed increased diffuse
bilateral peribronchovascular infiltrates as compared to
previous. Cefepime (d/c'd on [**4-10**]) and azithromycin (d/c'd on
[**4-12**]) were added for empiric coverage of hospital-acquired
pneumonia. He was switched to levofloxacin on [**4-11**]. Pulmonary
and ID were consulted. His oxygenation status continued to
deteriorate and he desatted frequently to the 70-80s on 6L with
only minimal exertion. He had some transient improvement with
lasix. TTE on [**4-12**] revealed a normal EF with mild hypokinesis of
the basal to mid inferior segments of the LV, which had been
seen on a prior TTE on [**4-2**]. On the morning of [**4-13**], the patient
became hypoxic to 86% and required NRB to maintain sats in the
low-mid 90s. EKG was unchanged. CXR appeared more volume
overloaded. He received lasix 80mg IV, atrovent neb, SLN and was
transferred to the unit. The etiology of his respiratory
distress was unclear with the differential including BOOP, ILD,
and CHF. Infection was felt to be less likely.
.
Pt was transferred back to the ICU for repeated desaturations on
RA to the low 80s, with the concern for either a cardiogenic or
pulmonary process.  Cardiology was consulted and recommended
maximizing medical management given the context of pt's AML. LAD
calcifications were noted on Chest CT, suggesting coronary
artery disease. Pt was therefore placed on metoprolol titrated
to maintain HR in the 70s, as well as ASA 81mg QOD.  Pt also
responded well to furosemide IV diuresis.
.
CT chest revealed likely BOOP, and pt was started on
methylprednisolone IV with planned slow taper. He tolerated the
taper well, and was weaned eventually to 1-2L O2. He was
transitioned to prednisone and discharged on 20mg prednisone po
BID, which he should continue for 2 weeks until he follows up
with his pulmonologist Dr. [**Last Name (STitle) 4507**]. At that point he will have a
follow up Chest CT and PFTs and Dr. [**Last Name (STitle) 4507**] will advise on plan
for further taper. He should continue the atrovent/spiriva and
prn albuterol nebs. He is being discharged to a pulmonary rehab
facility.
.
# Coronary artery disease: The patient had an episode of
nausea/diaphoresis in ICU and was evaluated with EKG that showed
non-specific changes. CE's negative. CT chest showed
calcifications of the LAD. Cardiology felt impression most
consistent with angina and recommended continuation of aspirin
and beta-blocker. Had been poorly tolerant of beta-blockade
thought secondary to sleep disordered breathing, dose was
decreased to 100mg TID. Further decreased in setting of
transient facial numbness/weakness on [**5-4**] and improved since
then. P-MIBI on [**5-7**] showed no ECG changes, and normal
myocardial perfusion on scintigraphy, mildly dilated left
ventricular cavity size with mild depression of systolic
function (LVEF 49%). He was continued on ASA qod given
thrombocytopenia and Metoprolol 75mg TID (adjust as needed)
given episode of facial weakness/numbness thought to be [**2-14**] to
relative hypotension.  Goal SBP of 120's. Addition of
statin/acei can be discussed as an outpatient.
.
#Facial Weakness/numbness and Altered Mental Status: Patient had
a transient episode of facial weakness and numbness with AMS on
[**5-4**]. VSS, finger stick normal. Neuro evaluated and felt it was
unlikely to be TIA/Stroke. MRI/MRA negative. Most likely was due
to poor perfusion in setting of relative hypotension (SBP upper
90's). He had no further episodes.
.
# ID: An extensive infectious workup for the etiology of the
patient's ARDS was unrevlealing.  While intubated, the patient
developed persistent fevers.  His Hickman line site showed no
evidence of infection.  Lower extremity ultra-sound showed no
evidence of DVT, and CT of chest showed a question of a
multifocal pneumonia.  Additionally, patient had CT of the
sinuses, which had a question of sinusitis.  ENT was not
markedly empressed by CT, and an aspirate was sent and has been
negative to date.  He was followed by ID during the
hospitalization.  Given concern that the fevers may be
medication related, antibiotics have been systemacilly
discontinued.  The meropenem was d/c'd on [**3-30**], and the vanc and
flagyl were stopped on [**3-31**]. His levaquin was discontinued on
[**4-4**]. He defervesced and his respiratory status improved with
treatment BOOP as above.
.
# H/O LEUKEMIA, ACUTE s/p cord blood transplantation for AML.
Concern that ARDS was secondary to GVH prophylactic medation
cyclosporine.  Patient was admitted with supertherapeutic
levels.  The dose was tapered, and ultimatly discontinued.  The
patient was started on tacrolimus on [**3-31**] and then was held in
the ICU. He was continued on cellcept which is being slowly
tapered. He is currently on a daily regimen of 500mg qam, 250mg
qnoon, 500mg qpm. This should be decreased to 500mg [**Hospital1 **] on
[**2184-5-15**]. His oncologist Dr. [**First Name (STitle) **] will adjust as necessary at his
follow up appointment. He was continued on prophylactic regimen
of voriconozole, atovaquone, and acylovir.
.
# RENAL FAILURE, ACUTE: The patient presented with ARF, and over
intial days had a rising Cr to a peak of 3.0 with oliguric renal
production.  Renal was consulted, who felt that ARF was seondary
to cyclosporine toxicity, as patient was admitted with
supratherapeutic levels of near 400.  Patients renal function
improved as dose was lowered.  He was grossly fluid overloaded
due to aggressive fluid hydration with oliguria, and has
required diuresis to help mobilize fluid. After aggressive
diuresis on the regular medical floor, his creatinine again
increased to a peak of 1.7. Urine electrolytes were consistent
with a pre-renal etiology and creatinine improved after diuresis
was held.
.
# h/o ASPERGILLUS INFECTION: The patient has a history of sinus
aspergillosis, on Voriconazole home regimen. Glucan &
galactomannin neg. Pt developed new fevers & Head CT on [**3-26**]
reported L sphenoid sinusitis, d/w ENT, very subtle & nothing to
drain, performed nasal washing & sent aspirate for fungal
culture to r/o fungal infections.  Continued home voriconozole
regimen.
.
# Thrombocytopenia: Patient remained at baseline levels of
around 50 throughout hospitalziation.
.
#. PROPHYLAXIS pneumoboots/ambulation for DVT prophylaxis, PPI
given high dose steroids, Atovaquone, acyclovir, voriconazole
.
# Ulcer: Site: Mid inner aspect right and left buttock. Pt has
acquired healing stage II pressure ulcers while inpatient
secondary to friction and sheer. There are small and circular in
size, pink wound bed with surrounding skin intact. There is no
drainage or odor to these wounds. Upon d/c they are scabbed over
and healing.
Care: Daily and prn cleansing. Barrier cream applied daily and
prn.
.
#. CODE - full
.
Dispo- pulm rehab, outpatient pulm f/u with CT chest/PFTs and
outpatient oncology follow up


Medications on Admission:
Ursodiol 300 mg [**Hospital1 **]
Acyclovir 400 mg TID
Atovaquone 1500 mg daily
Sulcralfate 1 g QID
Protonix 40 mg [**Hospital1 **]
Labetolol 100 mg [**Hospital1 **]
Doxazosin 4 mg qHS
Cyclosporine 100 mg [**Hospital1 **]
Lorazapam 0.5-1 mg PRN nausea
Zyprexa 5 mg daily PRN nausea

Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Atovaquone 750 mg/5 mL Suspension [**Last Name (STitle) **]: 1500 (1500) mg PO
DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: Four (4) Tablet PO DAILY (Daily).

7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day) as needed.
8. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day) as needed.
9. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO QID
(4 times a day).
11. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every
12 hours).
12. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Guaifenesin 100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H (every 6
hours) as needed.
14. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1)  Inhalation
Q6H (every 6 hours).
15. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO EVERY OTHER DAY (Every Other Day).
16. Sucralfate 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
17. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day:
adjust per pulmonologist recs.
18. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO Q 12H (Every 12 Hours).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
20. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q4H (every 4 hours) as needed.
21. Acyclovir 200 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q8H (every
8 hours).
22. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for flatulence.
23. Nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) Tablet,
Sublingual Sublingual ASDIR (AS DIRECTED) as needed for chest
pain.
24. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO TID (3
times a day).
25. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
26. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily) for 2 days: at noon.
27. Ursodiol 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
28. Ondansetron 4 mg IV Q8H:PRN
29. Heparin Flush (10 units/ml) 2 mL IV PRN
10 ml NS followed by 2 ml of 10 units/ml heparin (20 units
heparin) to each lumen daily and PRN. Inspect site every shift.
30. Heparin Flush Hickman (100 units/ml) 2 mL IV DAILY:PRN
10 mL NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
31. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifty Two (52)
units Subcutaneous at bedtime: adjust [**Name8 (MD) **] MD recs.
32. Insulin Aspart 100 unit/mL Cartridge [**Name8 (MD) **]: per sliding scale
Subcutaneous breakfast, lunch, dinner: FS 0-70 mg/dL, give [**1-14**]
amp D50; 71-120 , 0 u; 121-160, 2u; 161-200, 4u; 201-240, 6u;
241-280, 8u; 281-320, 10u; 321-360, 12u; 361-400, 14u; >400 [**Name8 (MD) 138**]
MD .
33. Insulin Aspart 100 unit/mL Cartridge [**Name8 (MD) **]: as instructed
Subcutaneous at bedtime: FS 0-70 mg/dL, give [**1-14**] amp D50; 71-120
, 0 u; 121-160, 1u; 161-200, 1u; 201-240, 3u; 241-280, 4u;
281-320, 6u; 321-360, 8u; 361-400, 10u; >400 [**Name8 (MD) 138**] MD .


Discharge Disposition:
Extended Care

Facility:
[**Hospital 8629**]

Discharge Diagnosis:
1. Acute myelogenous leukemia
2. Hypoxic respiratory failure due to ARDS and bronchiolitis
obliterans organizing pneumonia
3. Diabetes secondary to steroids
4. Atypical chest pain
5. Mild chronic systolic heart dysfunction
6. ICU neuropathy and myopathy
7. transient facial weakness of unknown etiology
8. coronary artery disease


Discharge Condition:
VSS, on 1LO2, breathing comfortably, lungs clear, ambulates with
assistance


Discharge Instructions:
You were admitted to the hospital with respiratory failure
thought due to ARDS/BOOP. You were treated with broad spectrum
antibiotics (vancomycin, cefepime, levoflox, bactrim,
voriconazole, then vanc, meropenem, levoflox, flagyl) and you
were started on high dose steroids with good response, and are
now being tapered slowly. Please continue to take prednisone
20mg po BID until your appointment with Dr. [**Last Name (STitle) 4507**] in 2 weeks.
He will discuss decreasing the dose further at that time. You
will need to have a repeat Chest CT without contrast before the
appointment as scheduled. Please continue to take PCP and fungal
prophylaxis (atovaquone and fluconazole) as prescribed. Please
continue to take montelukast 10mg daily and nebulizers as
prescribed. Please continue to take pantoprazole as prescribed
as this will protect your stomach in the setting of high dose
steroids.
.
You were also noted to have chest pain with deep breaths. You
had a stress test which was negative for ischemic changes or
perfusion defects. You had an echocardiogram which showed mildly
depressed ejection fraction (50%) which indicates you have mild
chronic systolic heart dysfunction. Please continue to take
aspirin as precribed, every other day, as well as the metoprolol
as prescribed. Monitor your weight daily and report weight gain
of >3lbs to the doctor.
.
While you were in the ICU you developed lower extremity weakness
and tingling. Neurology evaluated you and felt you had ICU
neuropathy and myopathy. You should continue to work with
physical therapy to regain your strength.
.
While in the hospital it was also noted that your blood sugars
were high. This likely was exacerbated by steroids, but could
suggest underlying insulin resistance. Please continue to take
the lantus and insulin sliding scale as ordered. Your doctor
will adjust the doses as needed based on your insulin
requirements. You should have your fasting blood sugars checked
as an outpatient once you have finished your steroid course.
.
Continue to take cellcept (mycophenolate) 500mg qam, 250mg qnoon
and 500mg qpm on [**5-13**] and [**5-14**]. Beginning [**2184-5-15**] reduce this to
500mg [**Hospital1 **] (500mg twice a day).
.
Please take all medications as prescribed. Please go to all
follow up appointments.
.
If you develop fever, shortness of breath, chest pain, cough,
bleeding, light headedness, mental status changes, or any other
concerning symptoms, please call your doctor or come to the
hospital.

Followup Instructions:
Please go to [**Hospital Ward Name 23**] [**Location (un) **] for a chest CAT SCAN
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-5-26**] 10:30. Please arrive at
10:15. Do not eat or drink anything for 3 hours prior to the
study.
.
Pulmonary follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4507**], ([**Telephone/Fax (1) 3554**], on Wed
[**5-26**], at 2pm. Please show up at 1:30 pm as you will go to the
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2184-5-26**]
1:40, before the appointment.
.
Please go to your scheduled appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2184-5-21**] 10:30; Provider: [**Name10 (NameIs) 674**] [**Name8 (MD) 39626**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2184-5-21**] 10:30.
.
Please come to the oncology clinic again the following week
(week of [**5-24**]) as instructed by Dr. [**First Name (STitle) **].



Completed by:[**2184-5-13**]
{'Other pulmonary insufficiency, not elsewhere classified,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Bacterial pneumonia, unspecified,Paralytic ileus,Critical illness myopathy,Pressure ulcer, buttock,Thrombocytopenia, unspecified,Hyperpotassemia,Intermediate coronary syndrome,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Acute sphenoidal sinusitis,Coronary atherosclerosis of native coronary artery,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of unspecified site'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: Mr. [**Known lastname 39623**] is a 52-year-old male with a history of AML who
is now day +120 status post a myeloablative sequential unrelated
double cord blood transplant.  He developed shortness of breath
at 5 a.m. with paroxysmal coughing spasms.  His wife states that
he was awake for most of the night with unrelenting dry,
non-productive cough that had been worsening over the past 3
days.  He suddenly became unresponsive and per his wife fell
forward and turned blue.  His wife immediately called EMS and
gave rescue breaths in the few minutes before their arrival.
Per her report, he had not had any fevers, chills, diarrhea, or
productive cough.  She had noted some shakes in the middle of
the night but states that he did not feel cool or warm to the
touch.  Patient had reported increased lower extremity edema the
prior day.  His recent abdominal pain and nausea had improved
over the previous days since he had been switched from
Tacrolimus to Cyclosporine.
.
In the ambulance, he received nitroglycerin x 2 and Lasix 40 mg.
 On arrival BP 200/90, RR 30, SpO2 78% on RA.  ABG 7.4/39/49.
He denied chest pain.  SpO2 improved to 80% on 15L NRB.  He was
intubated and was treated with ASA 325 mg, levofloxacin 750 mg,
rocephin 1 gram.   It was felt that he went flashed with fluid
resuscitation, and he was started on a nitroglycerin drip.  He
was sedated and paralyzed with succinyl choline and propofol.
BP's 132-179/76-100 with HR 118-124.   He was transfered to the
[**Hospital1 18**] ED.
.
On arrival to our ED, Tm 102.2, BP 104/55, HR 96, SpO2 100% on
ACC with TV 550 x 22, FiO2 100%, PEEP 5.  ABG 7.27/50/87.
Nitroglycerine gtt was discontinued.  He received Tylenol 1000
mg PR, 2 mg IV dexamethasone, Vanc 1 gram, and Zosyn 2.25 gram.
Repeat ABG was 7.23/53/127. Blood culture x 1 was drawn.

MEDICAL HISTORY: 1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+120.  Day 100 bone marrow biopsy showed no
diagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares initially maintained on
anidulafungin after being on posaconazole for several months in
an effort to "rest" his liver.  This was switched to
voriconazole
when he developed epistaxis and sinus tenderness in the side of
prior disease.  He has remained on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Cardiomyopathy of unclear etiology. The patient underwent a
cardiac MRI in [**7-/2182**] prior to chemotherapy and was noted to
have an ejection fraction of 45%-50%.  Most recent TTE [**6-19**]
with preserved systolic function EF>55%.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses ([**8-/2182**])

MEDICATION ON ADMISSION: Ursodiol 300 mg [**Hospital1 **]
Acyclovir 400 mg TID
Atovaquone 1500 mg daily
Sulcralfate 1 g QID
Protonix 40 mg [**Hospital1 **]
Labetolol 100 mg [**Hospital1 **]
Doxazosin 4 mg qHS
Cyclosporine 100 mg [**Hospital1 **]
Lorazapam 0.5-1 mg PRN nausea
Zyprexa 5 mg daily PRN nausea

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: Vital Signs
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 37.1 ??????C (98.8 ??????F)
HR: 89 (88 - 91) bpm
BP: 120/64(82) {120/64(82) - 125/68(353)} mmHg
RR: 24 (22 - 25) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: The patient's parents are alive. His father has hypertension, a
h/o CAD status post three-vessel CABG, and sarcoidosis. He notes
that his mother is in good health. He has one brother and two
sisters who are all alive and well. He notes that his
grandmother was diagnosed with a type of cancer. He denies any
family history of bleeding disorders.

SOCIAL HISTORY: The patient is married and lives with his wife [**Name (NI) 2048**] in
[**Location (un) 620**], [**State 350**]. He has 4 children. He previously worked
as a mechanic until [**2173**], and then he worked at a car
dealership. The patient has a history of tobacco use and notes
that he smoked one-half pack per day x30 years.  He uses alcohol 

### Response:
{'Other pulmonary insufficiency, not elsewhere classified,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Peripheral stem cells replaced by transplant,Bacterial pneumonia, unspecified,Paralytic ileus,Critical illness myopathy,Pressure ulcer, buttock,Thrombocytopenia, unspecified,Hyperpotassemia,Intermediate coronary syndrome,Unspecified essential hypertension,Chronic airway obstruction, not elsewhere classified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Acute sphenoidal sinusitis,Coronary atherosclerosis of native coronary artery,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Mononeuritis of unspecified site'}
