CHIEF COMPLAINT: Rigors

PRESENT ILLNESS: Mr. [**Known lastname 39623**] is a 53 yo M with AML Day+333 s/p cord SCT who
presented to clinic with fever and back pain. He was discharged
on [**10-13**] with course of cipro, clinda for cellulitis.  This AM he
awoke with fevers and rigors and came to clinic for evaluation.

MEDICAL HISTORY: Past Medical History Per OMR, updated and confirmed with
patient:
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

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg PO bid
ATOVAQUONE - 1500 PO DAILY
CARVEDILOL - 12.5 mg [**Hospital1 **]
COMBIVENT - 2 puffs QID PRN
CYANOCOBALAMIN- 1,000 mcg/mL Solution IM once per month
FUROSEMIDE 40 mg PO qdaily
GABAPENTIN - 100 mg Capsule - 3 3x tid
INSULIN ASPART
INSULIN GLARGINE - 5 u at bedtime
LANSOPRAZOLE - 30 mg Tablet,Rapid Dissolve  PO daily
LISINOPRIL - 5 mg PO daily
MONTELUKAST - 10 mg PO DAILY
MYCOPHENOLATE MOFETIL - 500mg PO bid q 12pm
NITROGLYCERIN - 0.3 mg Tablet sublingually ASDIR PRN
OXYCODONE - 5 mg PO q6hrs PRN pain
PREDNISONE - 20mg PO mouth daily
VORICONAZOLE - 300 mg PO q12
AMINO ACIDS-MAGNESIUM SULFATE [MG-PLUS-PROTEIN] - (OTC) -
Tablet - 1 Tablet(s) by mouth once a day
ASCORBIC ACID [VITAMIN C] - 500 mg Tablet PO q daily
ASPIRIN - 81 mg Tablet PO QOD
CALCIUM CARBONATE - 1000mg PO Q 12H
CHOLECALCIFEROL (VITAMIN D3) - 400 unit PO daily
HEXAVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
LORATADINE - 10 mg PO daily
MICONAZOLE NITRATE - 2 % Powder - apply to affected areas twice
a
day
MICONAZOLE NITRATE [CRITIC-AID CLEAR AF] - 2 % Ointment - apply

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: VS: BP 90/50 HR 108 O2 Sat 100% on Face mask
GEN: Obese male ill-appearing
HEENT: EOMI, PERRL, anicteric
NECK: Supple, no JVD, no meningismus
CHEST: CTABL, no w/r/r
CV: Tachycardic, RR, S1S2, no m/r/g
ABD: Soft/NT/ND, Obese, negative [**Doctor Last Name **] sx, +BS
EXT: Warm, 3+ pitting edema bilaterally, 2+ DPs
SKIN: no rashes, line intact without erythema
Neuro: AAOx3, CN ii-xii intact, strength 4+/5 R HF, 5/5 L HF,
[**5-17**] dorsiflexion bilaterally
Lines: Hickman triple lumen

FAMILY HISTORY: Father- CAD s/p CABG. Type II Diabetes, HTN
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

SOCIAL HISTORY: Patient is married, lives in [**Location 620**] with his wife [**Name (NI) 2048**] and
16 year old son. [**Name (NI) **] 3 other grown children (2 sons and 1
daughter). Has not worked in 2 years due to illness and is on
disability; worked as an auto parts supervisor and mechanic for
many years. Has 2 grandchildren.
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.
Complications of transplanted bone marrow,Other specified septicemias,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aspergillosis,Acute myeloid leukemia, in remission,Systolic heart failure, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Peripheral stem cells replaced by transplant,Other and unspecified infection due to central venous catheter,Graft-versus-host disease, unspecified,Ingrowing nail,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis
Compl marrow transplant,Septicemia NEC,Severe sepsis,Acute respiratry failure,Acute kidney failure NOS,Aspergillosis,Act myl leuk w rmsion,Systolic hrt failure NOS,Alveol pneumonopathy NEC,Trspl sts-perip stm cell,Oth/uns inf-cen ven cath,Graft-versus-host NOS,Ingrowing nail,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Thrombocytopenia NOS,MRSA elsewhere/NOS,Herpes simplex NOS,Hyperpotassemia,DMII wo cmp nt st uncntr,Rheumatoid arthritis
Admission Date:  [**2184-10-18**]              Discharge Date:   [**2184-11-5**]

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

Service: MEDICINE

Allergies:
Benadryl Allergy / Ambisome / Flomax

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

Major Surgical or Invasive Procedure:
[**11-3**] Wedge resection of right halux onchocrytptosis


History of Present Illness:
Mr. [**Known lastname 39623**] is a 53 yo M with AML Day+333 s/p cord SCT who
presented to clinic with fever and back pain. He was discharged
on [**10-13**] with course of cipro, clinda for cellulitis.  This AM he
awoke with fevers and rigors and came to clinic for evaluation.

In clinic, VS: T 99.4 HR 125 BP 158/86 Sat 95%/RA. He then
spiked a temp to 101.1. Two sets of blood cultures were drawn.
He received 1 L NS, 5 mg oxycodone, and Tylenol and was
transferred to BMT service.
On arrival to the floor, systolic BP of 85. He was rigoring and
satting 85% on 2L. He came up to 99% on 5L facemask. He was
given Vancomycin and meropenem and transferred to the [**Hospital Unit Name 153**] for
further management of presumed sepsis.

On ROS, pt reports vomiting x 1 this AM. He denies abdominal
pain, diarrhea, cough, SOB, rash. He reports arthralgias of
several months duration and chronic back pain that seemed worse
this AM.

Past Medical History:
Past Medical History Per OMR, updated and confirmed with
patient:
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. 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 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) Hx of post chemo cardiomyopathy; TTE [**6-19**] with preserved EF.
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**])
14) BOOP requiring extended ICU/hospital course in 3/[**2184**].
15) Peripheral Neuropathy


Social History:
Patient is married, lives in [**Location 620**] with his wife [**Name (NI) 2048**] and
16 year old son. [**Name (NI) **] 3 other grown children (2 sons and 1
daughter). Has not worked in 2 years due to illness and is on
disability; worked as an auto parts supervisor and mechanic for
many years. Has 2 grandchildren.
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:
Father- CAD s/p CABG. Type II Diabetes, HTN
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.


Physical Exam:
VS: BP 90/50 HR 108 O2 Sat 100% on Face mask
GEN: Obese male ill-appearing
HEENT: EOMI, PERRL, anicteric
NECK: Supple, no JVD, no meningismus
CHEST: CTABL, no w/r/r
CV: Tachycardic, RR, S1S2, no m/r/g
ABD: Soft/NT/ND, Obese, negative [**Doctor Last Name **] sx, +BS
EXT: Warm, 3+ pitting edema bilaterally, 2+ DPs
SKIN: no rashes, line intact without erythema
Neuro: AAOx3, CN ii-xii intact, strength 4+/5 R HF, 5/5 L HF,
[**5-17**] dorsiflexion bilaterally
Lines: Hickman triple lumen

Pertinent Results:
pH 7.34 pCO2 41 pO2 79 HCO3 23 Lactate:2.7

140  105  37     AGap=15
--------------< 88
4.3  24  1.6
Ca: 8.4 Mg: 1.4 P: 1.9
.
ALT: 38 AP: 128 Tbili: 0.6 Alb: 3.8
AST: 43 LDH: 290 CK: 15
UricA:8.7 TSH:1.8 Cholesterol:158
T4: 5.7 CRP: 13.9
.
     10.5
5.5 >----<  55
     30.9
N:92 Band:3 L:2 M:0 E:2 Bas:0 Myelos: 1 Nrbc: 1  Neuts: TOXIC
GRANULATION PRESENT Anisocy: OCCASIONAL Macrocy: 2+ Microcy:
OCCASIONAL Polychr: OCCASIONAL Tear-Dr: OCCASIONAL
.
PT: 13.2  PTT: 23.7  INR: 1.1
.
Blood culture ([**10-19**]): STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA

Blood culture ([**10-18**]):
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA
|
CEFTAZIDIME----------- 8 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Studies:
CT L-spine ([**10-19**]): No obvious evidence for
discitis/osteomyelitis or epidural collection, though evaluation
is limited by CT technique. Consider MRI for further evaluation,
if indicated.
.
CT Chest ([**10-19**]):
1. Interval improvement of previously seen ground glass and
peribronchiolar opacities. No focal consolidation. No evidence
of bacterial or fungal pneumonia on the current study.
2. Decreasing small bilateral pleural effusions.
3. Splenomegaly and mediastinal and hilar lymphadenopathy again
identified.
.
CXR ([**10-23**]): Persistent asymmetrical pulmonary opacities, for
which differential diagnosis includes asymmetrical pulmonary
edema, infection such as PCP, [**Name10 (NameIs) **] hemorrhage, and drug
toxicity.
.
CT Chest ([**10-28**]):
1. New clustered peribronchovascular and peribronchiolar nodules
in the right upper lobe and less marked in the left upper lobe,
suggesting endobronchial spread of infection.
2. Diffuse heterogeneous attenuation and widespread air trapping
is more marked than on [**10-19**], probably related to acute
infectious process and small airway disease. Rapid progression
makes bronchiolitis obliterans very less likely.
3. No volume overload. No pleural effusion.
4. Splenomegaly and mediastinal and hilar lymphadenopathy.
.
Cardic Echo:
([**10-20**]) The left atrium is elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). 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
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. There is mild pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. Compared with the findings of
the prior study (images reviewed) of [**2184-10-11**], the left
ventricular ejection fraction is somewhat reduced.
.
([**11-3**])No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers. However,
the study is technically suboptimal. If the clinical suspicion
of intracardiac shunt is high, right heart catheterization is
recommended.


Brief Hospital Course:
53 M d 338 s/p allo SCT presented on [**10-18**] with fever and diffuse
pain, then hypoxic repiratory failure, found to have
stentotrophomonas bacteremia.
.
ICU COURSE - He had two ICU stays on this admission. On [**10-18**], he
was transferred to the [**Hospital Unit Name 153**] for respiratory distress. He is on
2L NC for BOOP at home and he was transferred to [**Hospital Unit Name 153**] with a O2
sat of 85% on 2L NC. He was given Vanc and Meropenem. Overnight
in the [**Hospital Unit Name 153**] he did well and in the a.m. of [**10-19**] he was called
out to the floor as he was sating well on 2L NC which was back
to baseline.
.
The evening of [**10-19**], a code blue was called for acute
respiratory distress 30 minutes after Hickman was flushed. At
the time, he had wheezing, RR > 40, coughing, agitated, he was
hypertensive and tachycardic. His sat had dropped to 69% with a
good pleth on a non-rebreather. He had a depressed mental status
and was not responding commands. A code was called and a plan
was made to intubate- just prior to intubation while being
bag-mask ventilated his O2 sat increased to 100% and then he was
switched to a non rebreather and was feeling well. Patient felt
acutely short of breath- this was preceeded by rigors. He felt
that it was difficult to take a breath of air in, he also began
coughing at that time but had not been coughing previously. He
denied any orthopnea. no chest pain. No hemoptysis. Cough was
minimally non productive. He began to feel better slowly when
the non rebreather was applied. He states that he was beginning
to get tired of breathing but then he started to improve and
since has been steadily improving. + nausea, no vomiting. He did
have chills / rigors that were witnessed during his "code blue."

.
In the ICU, he was found to have GNR bacteremia, likely [**2-14**]
infected hickman. On [**10-20**], his hickman was removed and he was
given a dose of Tobra. Based on the sensitivities of the GNR,
abx were changed to ceftaz. An echo showed no vegitations but
global hypokenesis. On [**10-21**] he was started on bactrim for
possible stenotrophomonas and carvedilol. On [**10-22**] GNR found to
be steno; Ceftaz was discontinued.
.
STENOTROPHOMONAS BACTEREMIA - Following admission to the floor,
he remained afebrile, without leukocytosis, with no indwelling
lines. He was continued on IV bactrim. Surveilence cultures
remained negative. Bactrim was stopped on [**11-1**] for hyperkalemia
with mild T-wave changes, at which point he had completed a 12
day course.
.
HYPOXEMIA- His oxygen requirement improved from 5L NC on
transfer to the floor to his baseline of 1.5L at rest and 3L
with activity. The original elevation was thought to be related
to volume overload vs mild ARDS/[**Doctor Last Name **] from bacteremia. He has
significant underlying lung disease. He was continued on gentle
diuresis home dose lasix, goal 0-1 L per day, but this was
stopped on [**10-28**] given elevated creatinine. A CT with contrast
showed a new cluster of peribronchovascular and peribronchiolar
nodules, concerning for infection. Pulmonary was consulted, who
had seen him as an outpatient, and felt his respiratory issues
to be chronic. Given concern for pulmonary hypertension, a
bubble study was done, showing no evedence of cardiac shunt.
Beta-glucan and galactomanan sent on presentation were negative.
He was continued on prednisone. Outpatient pulmonary follow-up
was scheduled.
** Will likely need outpatient right-heart catheterization
** Follow-up repeat beta-glucan/galactomanan
.
MENTAL STATUS CHANGES - Per nursing and patient, he has had some
mild decine in short-term memory and occasionally will lose
track of what people are saying. Mental status and neurological
exams were normal. An MRI was ordered to assess for change in
mental status. MRI/MRA showed only mild brain atrophy, but no
evidence of infarct or signs of acute or chronic ischemia.
.
ACUTE RENAL FAILURE - Creatinine rose steadily on IV bactrim,
lasix, lisinopril. Renal was consulted and felt that the
creatinine rise was largely dut to the non-toxic effect of
bactrim on creatinine absorbtion. Lasix and acyclovir were held.
Renal consult team felt that the increased creatinine was due to
the benign effect of bactrim on inhibiting tubular secretion of
creatinine that would resolve following discontinuation of
treatment. Urine lytes were unrevealing. Cr remained at 2.0-2.1
for 2 days following discontinuation of bactrim but then
returned to 1.6 on discharge. Renal follow up was scheduled. He
will return to clinic on monday for electrolytes.
** continue to monitor Creatinine.
.
ACUTE MYELOGENOUS LEUKEMIA, history of STEM CELL TRANSPLANT -
Daily CBCs with differential showed his disease to be in
remission. He was transfused to keep Hct > 25 and continued on
immunosuppression with cellcept.
** Atovaquone was stopped, he needs to restart Bactrim at PCP
prophylaxis levels.
.
INGROWN TOENAILS - Patient with chronic ingrown toenails, missed
podietry appointment secondary to hospital stay. On [**11-3**]
developed new toe redness and bloody pirulent discharge.
Vancomycin was started and podietry evaluated. A wedge resection
of right halux onchocrytptosis was done and cultures were sent.
He was given two doses of vancomycin and started on a 5 day
course of augmentin. Podietry follow-up appointment was
scheduled.
** Follow wound culture and adjust abx as needed
.
HEART FAILURE - An echocardiogram in the ICU was notable for an
EF of 40 % which is depressed compared to [**10-11**]. He did not
require lasix to maintain volume status and this was held while
his creatinine was elevated and there were no exam findings of
volume overload. He was discharged on his home dose of lasix
with sheduled follow up in heart failure clinic.
** Consider follow-up echo to look for resolution of depressed
ejection fraction
.
ASPIRGILLOSIS - He was continued on voriconazole 300 po q12h.
.
HYPERTENSION - In the ICU, he was restarted on carvedilol and
recently restarted on his ACE. SBP 117-152 in ICU. His ace was
subsequently held for elevated creatinine
** consider restarting ACE if Cr stable..
.
BLURRY VISION - Patient had blurry vision on this and previous
admission that was associated with early sepsis. These vision
changes resolved quickly both times with resussitation, but he
notes his lens prescription is out of date. He was scheduled for
opthomology follow-up.
.
NEUROPATHY - He was continued on neurontin.
.
FEN/GI - Regular diet
.
Full Code


Medications on Admission:
ACYCLOVIR - 400 mg PO bid
ATOVAQUONE - 1500 PO DAILY
CARVEDILOL - 12.5 mg [**Hospital1 **]
COMBIVENT - 2 puffs QID PRN
CYANOCOBALAMIN- 1,000 mcg/mL Solution IM once per month
FUROSEMIDE 40 mg PO qdaily
GABAPENTIN - 100 mg Capsule - 3 3x tid
INSULIN ASPART
INSULIN GLARGINE - 5 u at bedtime
LANSOPRAZOLE - 30 mg Tablet,Rapid Dissolve  PO daily
LISINOPRIL - 5 mg PO daily
MONTELUKAST - 10 mg PO DAILY
MYCOPHENOLATE MOFETIL - 500mg PO bid q 12pm
NITROGLYCERIN - 0.3 mg Tablet sublingually ASDIR PRN
OXYCODONE - 5 mg PO q6hrs PRN pain
PREDNISONE - 20mg PO mouth daily
VORICONAZOLE - 300 mg PO q12
AMINO ACIDS-MAGNESIUM SULFATE [MG-PLUS-PROTEIN] - (OTC) -
Tablet - 1 Tablet(s) by mouth once a day
ASCORBIC ACID [VITAMIN C] - 500 mg Tablet PO q daily
ASPIRIN - 81 mg Tablet PO QOD
CALCIUM CARBONATE - 1000mg PO Q 12H
CHOLECALCIFEROL (VITAMIN D3) - 400 unit PO daily
HEXAVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
LORATADINE - 10 mg PO daily
MICONAZOLE NITRATE - 2 % Powder - apply to affected areas twice
a
day
MICONAZOLE NITRATE [CRITIC-AID CLEAR AF] - 2 % Ointment - apply

to affected area twice a day as needed for rash
THIAMINE HCL - 50 mg Tablet - 1 Tablet(s) by mouth once a day

Discharge Medications:
1. Oxygen
Supplemental oxygen continuous at 2 liters for portability pulse
dose system
2. Lasix 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day: use as
needed for fluid overload or weight gain.
Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Combivent 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*4 inhailers* Refills:*0*
5. Cyanocobalamin 1,000 mcg/mL Solution [**Hospital1 **]: One (1) injection
Injection once a month.
6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO every
twelve (12) hours.
Disp:*60 Capsule(s)* Refills:*2*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
8. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
10. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
11. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every
12 hours).
Disp:*90 Tablet(s)* Refills:*2*
12. Calcium Carbonate 1,000 mg Tablet, Chewable [**Last Name (STitle) **]: One (1)
Tablet, Chewable PO twice a day.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
13. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Loratadine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
16. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Amoxicillin-Pot Clavulanate 500-125 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO Q8H (every 8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
18. Enteric Aspirin 81 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
19. Hexavitamin     Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Five (5) units
Subcutaneous at bedtime.
Disp:*10 ml* Refills:*2*
21. Insulin Aspart 100 unit/mL Solution [**Last Name (STitle) **]: variable units
Subcutaneous four times a day: as per sliding scale.
Disp:*10 ml* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
STENOTROPHOMONAS BACTEREMIA
HYPOXIC RESPIRATORY FAILURE
MENTAL STATUS CHANGES
ACUTE RENAL FAILURE
ACUTE MYELOGENOUS LEUKEMIA, history of STEM CELL TRANSPLANT
INGROWN TOENAIL
SYSTOLIC HEART FAILURE
ASPIRGILLOSIS
HYPERTENSION
BLURRY VISION
NEUROPATHY


Discharge Condition:
Stable
VS: T 97.9, HR 80, BP 138/78, RR 18, Sat 98%/1.5 L
Cr: 1.6, K 4.9


Discharge Instructions:
You were admitted with fevers and general body ached and found
to have a rare bacteria called Stenotrophomonas.  You were
treated in the ICU and completed a course of IV antibiotics for
this infection.  It is likely that this antibiotic temporarily
reduced your kidney function.  You should follow up in clinic on
Monday to have your kidney function checked.  You should also
follow up with your kidney doctor.
You also had difficulties breathing that have returned to
baseline.  You should follow up in pulmonary clinic to discuss
further studies and treatments.
An ingrown toenail was removed.  You should complete your course
of oral antibiotics for this and follow up in [**Hospital 39629**] clinic.
In the ICU, your heart function was somewhat decreased.  You
should follow up with cardiology to ensure this returns to
normal.

Followup Instructions:
[**2184-12-7**]  10:00a   [**Location (un) **],TCC SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
PULMONARY UNIT-CC7 (SB)
[**2184-12-7**]  09:30a   [**First Name9 (NamePattern2) 1570**] [**Hospital Ward Name **] 7 - RM 2  [**Hospital6 29**], [**Location (un) **] PULMONARY LAB
[**2184-12-1**]  01:00p   [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]  SC [**Hospital Ward Name **] CLINICAL CTR,
[**Location (un) **] HEMATOLOGY/ONCOLOGY-SC
[**2184-11-25**]  09:00a   [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Hospital Ward Name **] CLINICAL
CTR, [**Location (un) **] RENAL DIV-CC7 (SB)
[**2184-11-16**]  03:20p   PODIATRY,[**Doctor Last Name 15351**]  BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC (SB)
[**2184-11-16**]  02:00p   [**Doctor Last Name 22344**] [**Last Name (LF) **],[**First Name3 (LF) **]  SC [**Hospital Ward Name **] CLINICAL
CTR, [**Location (un) **] OPTOMETRY
[**2184-11-11**]  03:50p   PODIATRY,[**Doctor Last Name 15351**]  BA [**Hospital Unit Name **] ([**Hospital Ward Name **]
COMPLEX), [**Location (un) **] [**Hospital 1947**] CLINIC (SB)
[**2184-11-10**]  02:30p   [**Last Name (LF) 3524**],[**First Name3 (LF) 3523**]  SC [**Hospital Ward Name **] CLINICAL
CTR, [**Location (un) **] NEUROLOGY UNIT CC8 (SB)
[**2184-11-10**]  01:00p   EMG,ALL   SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
EMG LAB Phone:[**Telephone/Fax (1) 2846**]
[**2184-11-9**]  03:30p   NP-HF  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
CC7-HEART FAILURE (SB) [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
[**2184-11-8**]  01:00p   BED 1-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F



Completed by:[**2184-11-5**]

Admission Date:  [**2184-11-8**]              Discharge Date:   [**2184-11-12**]

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

Service: MEDICINE

Allergies:
Benadryl Allergy / Ambisome / Flomax

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Joint pain, toe pain

Major Surgical or Invasive Procedure:
- Excisional debridement of left hallux
- PICC line placement


History of Present Illness:
53 year old male with AML day +354 s/p myeloablative sequential
unrelated double cord blood transplant presenting to the
outpatient 7F clinic with generalized body aches and painful
toes. Mr. [**Known lastname 39623**] has had several admissions over the last
several weeks. He was admitted from [**Date range (1) 39630**]/08 with a right
lower extremity rash and was treated for cellulitis. He was
treated with vancomycin and cefepime until [**10-12**] and then
transitioned to clindamycin/ciprofloxacin to complete a course
on [**2184-10-26**]. He was seen by Podiatry on that hospitalization,
who did not feel that his toes were the source of infection.
.
He was hospitalized again from [**Date range (3) 39631**] for fevers and
back pain and had a long/complicated course including,
hypotension/sepsis, fevers, respiratory distress,
Stenotrophomonas bacteremia, acute renal failure, hyperkalemia,
diffuse joint pains, infected ingrown toenail and decreased EF
on echocardiogram. He completed 11 days of a 14 day course of
high dose bactrim, stopped due to renal failure, persistent
hyperkalemia and joint pains. He was feeling well on the day of
discharge without specific complaint. He was discharged to
complete a 7 day course of Augmentin for the infection related
to his ingrown toenail.
.
He presents to the 7F outpatient clinic today complaining of
diffuse joint/generalized body aches and painful toes. Reports
all joints are painful, and particularly shoulders, hips,
elbows, and knees bilaterally. Joint pain is chronic, although
this is worse than he has ever experienced. Improvement with
oxycodone, worsened when climbing stairs. Toe pain present from
last hospital stay. Large toes bilaterally and spreading
laterally with erythema, pain, and bleeding.
.
Of note, his creatinine remains elevated from baseline, but
improved from the last hospitalization. He also has
leukocytosis, elevated potassium, and stable thrombocytopenia.
.
On review of systems, also complains of general fatigue
worsening since discharge. Febrile to 100.3 two days prior to
admission that resolved without intervention. Denies dyspnea.
Home oxygen requirement unchanged - 1.5L NC when sleeping, 3L NC
walking. Slight dysuria, now resolved. Denies chest pain,
abdominal pain. Bowel movements daily.

Past Medical History:
Past Medical History (taken from previous notes)
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+334. Day 100 bone marrow biopsy showed no
siagnostic 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 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) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
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/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy

Social History:
Patient is married, lives in [**Location 620**] with his wife and 16 year
old son. [**Name (NI) **] 3 other grown children (2 sons and 1 daughter). Has
not worked in 2 years due to illness and is on disability;
worked as an auto parts supervisor and mechanic for many years.
Has 2 grandchildren.

Family History:
Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

Physical Exam:
GEN: Well appearing, in NAD
SKIN: Bilateral big toe erythematous, with erythema spreading to

HEENT: NC/AT, Anicteric, conjuntiva non-injected, O/P clear
CV: RRR, normal S1/S2, no murmurs or gallops
PULM: Crackles at left base extending to left middle lung field

ABD: Obese, soft, NT/ND.
EXT: WWP, [**1-14**]+ edema to level of knees
NEURO/PSYCH: A&Ox3. CN2-12 intact. Strength 4+ lower
extremities; upper extremity exam limited by joint pain; grip
strength 5+

Pertinent Results:
[**2184-11-12**] 06:15AM BLOOD WBC-7.2 RBC-2.52* Hgb-8.6* Hct-25.8*
MCV-103* MCH-34.1* MCHC-33.3 RDW-13.6 Plt Ct-71*
[**2184-11-12**] 06:15AM BLOOD Neuts-78.7* Lymphs-11.9* Monos-8.6
Eos-0.5 Baso-0.4
[**2184-11-12**] 06:15AM BLOOD Glucose-123* UreaN-41* Creat-1.5* Na-143
K-4.2 Cl-106 HCO3-28 AnGap-13
[**2184-11-12**] 06:15AM BLOOD ALT-15 AST-9 LD(LDH)-233 AlkPhos-152*
TotBili-0.2

[**2184-11-12**] Radiology PICC LINE PLACMENT SCH     [**Last Name (LF) **],[**First Name3 (LF) **] E.
Unread
[**2184-11-11**]   Radiology TOE(S), 2+ VIEW BILAT P     [**Last Name (LF) **],[**First Name3 (LF) **] E.
Unsigned
[**2184-11-10**]   Cardiology ECHO   [**2184-11-10**] [**Last Name (LF) **],[**First Name3 (LF) **] E.
[**2184-11-9**]   Radiology US EXTREMITY NONVASCULA     [**Last Name (LF) **],[**First Name3 (LF) **] E.
Approved
[**2184-11-9**]   Radiology UNILAT UP EXT VEINS US      [**Last Name (LF) **],[**First Name3 (LF) **] E.
Approved
[**2184-11-8**]   Radiology BILAT HIPS (AP,LAT & AP


Brief Hospital Course:
53 year old male day diffuse joint pain and painful toes;
recently hospitalized with hypoxic repiratory failure and found
to have stentotrophomonas bacteremia.
.
1. Toe pain - Presented with history of chronic in-grown toe
nails. s/p toe nail biopsy at previous hospitalization. Wound
culture with coag positive Staph aureus. At previous
hospitalization, was initially treated with vancomycin (2
doses), then given at discharge 5 day course of Augmentin. On
admission for present hospitalization, vancomycin IV was
started. Podiatry was also consulted; excisional debridement of
left first toe was performed. Pain and erythema improved
considerably on IV antibiotics. On discharge, patient was
provided information to arrange follow-up with podiatry in one
week. A PICC line was also placed to allow the patient to
complete additional 7 day course of vancomycin IV.
.
2. Stenotrophomonas bactermia - Patient did not complete
antibiotic course for Stenotrophomonas bacteremia at last
infection secondary to renal failure and hyperkalemia which was
thought to be due to Bactrim. Received 12 of 14 day course.
Stenotrophomonas sensitivities from previous hospitalization
show sensitivity to Bactrim and ceftazidime. On admission,
patient was restarted on ceftazidime based on the possibility
that his diffuse arthralgias may be due to a systemic infection.
Blood cultures were no growth to date. Ultrasound at former
central line site was ultrasounded to assess for abscess - no
abscess or clot was seen. Given patient's improvement on
steroids (as explained below), ceftazidime was stopped prior to
discharge.
.
3. Diffuse arthralgias/myalgias - Has history of aspergillosis,
which can in itself cause severe muscle aches. Has been on
voriconazole. Differential diagnosis on presentation also
included GVH, avascular necrosis given longterm steroid use,
rhemautoid arthritis, osteoarthritis, gout, Still's, Lyme. No
outdoor exposure. Voriconazole was continued at home regimen of
300mg PO Q12. Hip films were negative for avascular necrosis.
Neurology was consulted given that patient's outpatient workup
for these issues included an EMG - their recommendation was to
hold off on the EMG as would likely not alter management. Two to
three days after presentation, patient was tried on increased
dose of prednisone. Within 12-24 hours, patient's pain
completely resolved. On discharge, patient was on prednisone
20mg PO QAM and 15mg PO QPM. Further dose adjustment/tapering is
to be done on an outpatient basis. Overall, the aches were
thought to be secondary to GVH.
.
4. Renal failure - Creatinine better than at discharge, although
considerably higher [**First Name8 (NamePattern2) **] [**Month (only) **]/[**Month (only) 205**] of this year. Source unclear,
although during previous admission creatinine rose steadily on
IV bactrim, furosemide, lisinopril. Creatinine continued to
improve during this hospitalization with IV fliuds, increased PO
intake.
.
5. Acute myelogyenous leukemia - s/p allo SCT. Continued
Cellcept per home regimen. Monitored daily blood counts.
Transfused for platelets <10. Transfused for hematocrit <25.
.
6. Hyperkalemia - On presentation. Unclear reason. At last
admission was thought to be related to renal failure, which was
thought to be secondary to Bactrim. Hyperkalemia improved on
admission with Kayexelate. Patient was given calcium and
furosemide given EKG changes associated with hyperkalemia.
Resolved without further intervention. Potassium levels were
checked twice daily.
.
7. History of aspergillosis - Continued voriconazole 300 PO Q12H
per home regimen.
.
8. Hypertension - During previous admission was restarted on
carvedilol; ACE inhibitor was held secondary to elevated
creatinine.  Continued to hold ACE inhibitor as creatinine
improved.
.
9. Neuropathy - Continued neurontin per home regimen.
.
10. Diabetes mellitus - Continued glargine 4U at bedtime.
Sliding scale insulin with QID blood glucose checks. Of note,
blood glucose ran high after [**Hospital1 **] steroids were started.

**FULL CODE
**Contact - Wife, ([**Telephone/Fax (1) 39632**] (h) or ([**Telephone/Fax (1) 39633**] (c)

Medications on Admission:
Lasix 40 mg Tablet on tablet daily
Carvedilol 12.5 mg [**Hospital1 **]
Combivent 2 puffs qid prn
B12 1000 mcg/mL once monthly
Gabapentin 300 mg q12 hours
Lansoprazole 30 mg daily
Singulair 10 mg daily
MMF 500 mg [**Hospital1 **]
Oxycodone 5 mg po q4h prn pain
Voriconazole 300 mg po q12 hours
Calcium, Vitamin D
Loratadine 10 mg daily
Prednisone 20 mg daily
Augmnetin q8h
Aspirin 81 mg daily
MVI
Lantus 5u qhs, Aspart prn SSIg

Discharge Medications:
1. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

2. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
3. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for Dyspnea.
4. Gabapentin 300 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO Q12H (every
12 hours).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Montelukast 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
8. Voriconazole 200 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO Q12H (every 12
hours).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
10. Loratadine 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Daily ().
11. Mycophenolate Mofetil 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
12. Insulin Glargine 100 unit/mL Cartridge [**Last Name (STitle) **]: Five (5) U
Subcutaneous at bedtime.
13. Insulin Aspart 100 unit/mL Cartridge [**Last Name (STitle) **]: Per home sliding
scale regimen  Subcutaneous four times a day as needed for based
on sliding scale regimen.
14. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
BID (2 times a day). Tablet(s)
15. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
16. Prednisone 5 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO QPM (once a
day (in the evening)) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 10 days: Last Dose
[**2184-11-22**].
Disp:*20 gram* Refills:*0*
18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
Disp:*14 Tablet(s)* Refills:*2*
19. Saline Flush 0.9 % Syringe [**Month/Day/Year **]: 5-10 cc Injection three
times a day: prn: line care, antibiotics.
Disp:*60 syringes* Refills:*2*
20. Heparin Flush 10 unit/mL Kit [**Month/Day/Year **]: Three (3) cc Intravenous
three times a day: prn: line care, antibiotics.
Disp:*60 flushes* Refills:*2*
21. Oxycodone 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
22. Acyclovir 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary
1. Graft versus host disease
2. MRSA infection of left first digit
3. Herpes infection of oral mucosa
Secondary
1. Acute myelogenous leukemia s/p cord blood transplant


Discharge Condition:
Ambulatory. Hemodynamically stable.


Discharge Instructions:
You were admitted on [**2184-11-8**] with joint pain and pain
in your toes. While in the hospital your prednisone dose was
increased and your joint pain resolved. You were also started on
vancomycin, an antibiotic, and seen by podiatry and your toe
pain improved.

Your medication regimen has changed. Continue taking your home
medications as you were prior to this hospitalization EXCEPT for
the following changes.
- Stop taking Augmentin.
- Take vancomycin through your PICC line for an additional 10
days.
- In addition to the 20mg prednisone which you take in the
morning, take 15mg prednisone in the evenings for the next 3
nights (Friday-Sunday).
- Take acyclovir daily.
- Take Bactrim every Monday, Wednesday, and Friday.

Please follow-up with your provider as below.

Please return to the emergency department or call your provider
for any increase in joint pain, fevers, toe pain or pus, or for
any other concerns.

Followup Instructions:
Outpatient 7F clinic appointment:
- Provider: [**Name10 (NameIs) 3310**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-7F
Date/Time:[**2184-11-15**] 9:30
-Dr. [**First Name (STitle) **], [**2184-12-1**] 1 pm

Optometry follow Up:
- Provider: [**Name10 (NameIs) **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2184-11-16**] 2:00

Podiatry Follow Up:
- Tuesday [**2184-11-16**] 3:20 pm, Dr. [**Last Name (STitle) **], [**Hospital Ward Name **] 3

Renal Follow Up:
- [**2184-11-25**] 9 am. Dr. [**Last Name (STitle) **]. [**Hospital Ward Name 23**] [**Location (un) **]



Completed by:[**2184-11-15**]
{'Complications of transplanted bone marrow,Other specified septicemias,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aspergillosis,Acute myeloid leukemia, in remission,Systolic heart failure, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Peripheral stem cells replaced by transplant,Other and unspecified infection due to central venous catheter,Graft-versus-host disease, unspecified,Ingrowing nail,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis'}


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: Rigors

PRESENT ILLNESS: Mr. [**Known lastname 39623**] is a 53 yo M with AML Day+333 s/p cord SCT who
presented to clinic with fever and back pain. He was discharged
on [**10-13**] with course of cipro, clinda for cellulitis.  This AM he
awoke with fevers and rigors and came to clinic for evaluation.

MEDICAL HISTORY: Past Medical History Per OMR, updated and confirmed with
patient:
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

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg PO bid
ATOVAQUONE - 1500 PO DAILY
CARVEDILOL - 12.5 mg [**Hospital1 **]
COMBIVENT - 2 puffs QID PRN
CYANOCOBALAMIN- 1,000 mcg/mL Solution IM once per month
FUROSEMIDE 40 mg PO qdaily
GABAPENTIN - 100 mg Capsule - 3 3x tid
INSULIN ASPART
INSULIN GLARGINE - 5 u at bedtime
LANSOPRAZOLE - 30 mg Tablet,Rapid Dissolve  PO daily
LISINOPRIL - 5 mg PO daily
MONTELUKAST - 10 mg PO DAILY
MYCOPHENOLATE MOFETIL - 500mg PO bid q 12pm
NITROGLYCERIN - 0.3 mg Tablet sublingually ASDIR PRN
OXYCODONE - 5 mg PO q6hrs PRN pain
PREDNISONE - 20mg PO mouth daily
VORICONAZOLE - 300 mg PO q12
AMINO ACIDS-MAGNESIUM SULFATE [MG-PLUS-PROTEIN] - (OTC) -
Tablet - 1 Tablet(s) by mouth once a day
ASCORBIC ACID [VITAMIN C] - 500 mg Tablet PO q daily
ASPIRIN - 81 mg Tablet PO QOD
CALCIUM CARBONATE - 1000mg PO Q 12H
CHOLECALCIFEROL (VITAMIN D3) - 400 unit PO daily
HEXAVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
LORATADINE - 10 mg PO daily
MICONAZOLE NITRATE - 2 % Powder - apply to affected areas twice
a
day
MICONAZOLE NITRATE [CRITIC-AID CLEAR AF] - 2 % Ointment - apply

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: VS: BP 90/50 HR 108 O2 Sat 100% on Face mask
GEN: Obese male ill-appearing
HEENT: EOMI, PERRL, anicteric
NECK: Supple, no JVD, no meningismus
CHEST: CTABL, no w/r/r
CV: Tachycardic, RR, S1S2, no m/r/g
ABD: Soft/NT/ND, Obese, negative [**Doctor Last Name **] sx, +BS
EXT: Warm, 3+ pitting edema bilaterally, 2+ DPs
SKIN: no rashes, line intact without erythema
Neuro: AAOx3, CN ii-xii intact, strength 4+/5 R HF, 5/5 L HF,
[**5-17**] dorsiflexion bilaterally
Lines: Hickman triple lumen

FAMILY HISTORY: Father- CAD s/p CABG. Type II Diabetes, HTN
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

SOCIAL HISTORY: Patient is married, lives in [**Location 620**] with his wife [**Name (NI) 2048**] and
16 year old son. [**Name (NI) **] 3 other grown children (2 sons and 1
daughter). Has not worked in 2 years due to illness and is on
disability; worked as an auto parts supervisor and mechanic for
many years. Has 2 grandchildren.
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. 

### Response:
{'Complications of transplanted bone marrow,Other specified septicemias,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Aspergillosis,Acute myeloid leukemia, in remission,Systolic heart failure, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Peripheral stem cells replaced by transplant,Other and unspecified infection due to central venous catheter,Graft-versus-host disease, unspecified,Ingrowing nail,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Thrombocytopenia, unspecified,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Herpes simplex without mention of complication,Hyperpotassemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rheumatoid arthritis'}
