CHIEF COMPLAINT: Altered Mental Status.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 38 year old female with ALL s/p double cord
blood SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease who was sent in from onc
floor today for confusion.  Pt arrived for appointment with Dr.
[**Last Name (STitle) **] today; she thought she was to go to 7F to see her MD.
In actuality, she had no appointment today, and her appointment
would have been in [**Hospital Ward Name 23**] had she had one.  Per her father, she
has been confused for 3-4 days with complaints of recurrent and
chronic abdominal pain.  She describes her abdominal pain as
constant and nonradiating, the same as always.
.
In the ED, VS 97.1 77 135/105 16 100% RA.  In ED, AOx2(not date)
with c/o abdominal pain. Labs notable for creatinine 3.6,
Lactate 8, K 6, ALT 210 AP: 173 Tbili: 4.7 AST: 144 LDH: 575
Dbili: 3.7 Lip: 154. AG 24. WB 14.9 plt 131 Hct 31 INR: 16.7.  A
right femoral line was placed.  Head CT was negative.  CXR was
unremarkable.  Given calcium Gluconate 1g/10mL, Sodium
Kayexelate 30mg, Phytonadione 10mg/mL Amp,
Vanc/Piperacillin-Tazob. She was afebrile in ED and prior to
leaving 80 137/95 20 100% on RA. She received 1 amp d50, 10units
of insulin. She received 1L NS.
.
Of note patient had recent admission to [**Hospital Ward Name 3242**] [**Date range (3) 94160**]
where she presented with nausea, vomiting and abdominal pain in
addition to acute on chronic renal failure. She was found to
have peritonitis with lymphocytic predominance with unclear
etiology but Tb vs malignancy was explored. It seems she was
seen by cardiology for CHF (including ICU stay for diuresis with
BP support), renal for ARF, psych for coping, ID for peritonitis
and surgery for peritonitis.  Surgery did not think it wise to
do peritoneal biopsy.  There is no discharge summary, but
following medication changes appear to have occurred: start
acyclovir, stop carvedilol and start Toprol, decrease torsemide
to 40mg daily (from 40mg).
.
She was last seen by Dr. [**Last Name (STitle) **] on [**5-20**] at which point
prednisone was decreased to 50 mg a day.  She was continued on
Cellcept despite a slight transaminitis at that time.  She also
had thrush and was started on fluconazole.  Bactrim was
continued for PCP [**Name Initial (PRE) 1102**].  Her torsemide was increased to
60mg qday due to worse lower extremity edema.
.
Upon arrival to the ICU, pt's father reports improvement in MS
since interventions in ED.

MEDICAL HISTORY: ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

MEDICATION ON ADMISSION: ACYCLOVIR -  (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours
ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 HFA(s) inhaled every four (4) hours as
needed
for sob or wheeze
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM -  (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for nausea
METOPROLOL SUCCINATE -  (Prescribed by Other Provider) - 100 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY
(Daily)
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours as needed for pain
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet
Extended Release - 1 Tablet(s) by mouth every twelve (12) hours
MYCOPHENOLATE MOFETIL -  (Prescribed by Other Provider) - 500 mg
Tablet - 2 Tablet(s) by mouth twice a day
PREDNISONE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 2.5
Tablet(s) by mouth DAILY (Daily)
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
TORSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 3
Tablet(s) by mouth DAILY (Daily)
WARFARIN -  (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day
.
Medications - OTC
DOCUSATE SODIUM -  (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] -  (Prescribed by Other
Provider) - 400 mg/5 mL Suspension - 30 Suspension(s) by mouth
every six (6) hours as needed for constipation
MULTIVITAMIN -  (Prescribed by Other Provider) -   Tablet - 1
Tablet(s) by mouth once a day
OMEPRAZOLE -  (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth daily
SIMETHICONE -  (Prescribed by Other Provider) - 80 mg Tablet,
Chewable - 1 Tablet(s) by mouth four times a day as needed for
abdominal pain or gas

ALLERGIES: Prochlorperazine / Heparin Agents

PHYSICAL EXAM: Upon admission:
Vitals: T: 96.4 BP: 143/113 P: 87 R: 19 O2: 97%(RA)
General: Oriented xself, place, month/year and able to do DoW
task forward (not backwards), but somnolence and need to
re-arouse multiple times during exam.  NAD.
HEENT: Sclera anicteric, Dry MM, oropharynx clear no palatal
findings
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  +BS, voluntary guarding, mild distension with diffuse
TTP but worst in RUQ.  Unable to assess fluid wave.  No rebound
tenderness
GU: foley in place
Ext: all extremities cool (but uncovered), cap refill wnl, 1+
pulses, trace LE edema
Neuro: Non focal

FAMILY HISTORY: Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

SOCIAL HISTORY: She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis.  Lifelong nonsmoker, but not currently. Denies
illicits or EtOH.
Complications of transplanted bone marrow,Acute on chronic systolic heart failure,Pneumonia due to parainfluenza virus,Hepatic encephalopathy,Secondary cardiomyopathy, unspecified,Chronic kidney disease, Stage IV (severe),Acute lymphoid leukemia, in remission,Jaundice, unspecified, not of newborn,Other ascites,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Chronic graft-versus-host disease,Other chronic pulmonary heart diseases,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Chronic passive congestion of liver,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pain in joint, lower leg,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of other medications,Abnormal coagulation profile,Anemia, unspecified,Hypocalcemia,Surgical or other procedure not carried out because of patient's decision,Epistaxis,Abnormality of gait,Tachycardia, unspecified,Other convulsions
Compl marrow transplant,Ac on chr syst hrt fail,Parinfluenza viral pneum,Hepatic encephalopathy,Second cardiomyopath NOS,Chr kidney dis stage IV,Act lym leuk w rmsion,Jaundice NOS,Ascites NEC,Acute kidney failure NOS,Hyposmolality,Chronc graft-vs-host dis,Chr pulmon heart dis NEC,Abn react-procedure NEC,Accident in place NEC,Chr passiv congest liver,Adv eff antineoplastic,Hy kid NOS w cr kid I-IV,Joint pain-l/leg,Sec DM wo cmp nt st uncn,Adv eff corticosteroids,Long-term use meds NEC,Abnrml coagultion prfile,Anemia NOS,Hypocalcemia,No proc/patient decision,Epistaxis,Abnormality of gait,Tachycardia NOS,Convulsions NEC
Admission Date:  [**2174-5-25**]              Discharge Date:   [**2174-8-10**]

Date of Birth:  [**2135-11-15**]             Sex:   F

Service: MEDICINE

Allergies:
Prochlorperazine / Heparin Agents

Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Altered Mental Status.

Major Surgical or Invasive Procedure:
Paracentesis
Cardiac catheterization
Broncheoalveolar lavage


History of Present Illness:
Ms. [**Known lastname **] is a 38 year old female with ALL s/p double cord
blood SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease who was sent in from onc
floor today for confusion.  Pt arrived for appointment with Dr.
[**Last Name (STitle) **] today; she thought she was to go to 7F to see her MD.
In actuality, she had no appointment today, and her appointment
would have been in [**Hospital Ward Name 23**] had she had one.  Per her father, she
has been confused for 3-4 days with complaints of recurrent and
chronic abdominal pain.  She describes her abdominal pain as
constant and nonradiating, the same as always.
.
In the ED, VS 97.1 77 135/105 16 100% RA.  In ED, AOx2(not date)
with c/o abdominal pain. Labs notable for creatinine 3.6,
Lactate 8, K 6, ALT 210 AP: 173 Tbili: 4.7 AST: 144 LDH: 575
Dbili: 3.7 Lip: 154. AG 24. WB 14.9 plt 131 Hct 31 INR: 16.7.  A
right femoral line was placed.  Head CT was negative.  CXR was
unremarkable.  Given calcium Gluconate 1g/10mL, Sodium
Kayexelate 30mg, Phytonadione 10mg/mL Amp,
Vanc/Piperacillin-Tazob. She was afebrile in ED and prior to
leaving 80 137/95 20 100% on RA. She received 1 amp d50, 10units
of insulin. She received 1L NS.
.
Of note patient had recent admission to [**Hospital Ward Name 3242**] [**Date range (3) 94160**]
where she presented with nausea, vomiting and abdominal pain in
addition to acute on chronic renal failure. She was found to
have peritonitis with lymphocytic predominance with unclear
etiology but Tb vs malignancy was explored. It seems she was
seen by cardiology for CHF (including ICU stay for diuresis with
BP support), renal for ARF, psych for coping, ID for peritonitis
and surgery for peritonitis.  Surgery did not think it wise to
do peritoneal biopsy.  There is no discharge summary, but
following medication changes appear to have occurred: start
acyclovir, stop carvedilol and start Toprol, decrease torsemide
to 40mg daily (from 40mg).
.
She was last seen by Dr. [**Last Name (STitle) **] on [**5-20**] at which point
prednisone was decreased to 50 mg a day.  She was continued on
Cellcept despite a slight transaminitis at that time.  She also
had thrush and was started on fluconazole.  Bactrim was
continued for PCP [**Name Initial (PRE) 1102**].  Her torsemide was increased to
60mg qday due to worse lower extremity edema.
.
Upon arrival to the ICU, pt's father reports improvement in MS
since interventions in ED.

Past Medical History:
ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

Social History:
She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis.  Lifelong nonsmoker, but not currently. Denies
illicits or EtOH.

Family History:
Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

Physical Exam:
Upon admission:
Vitals: T: 96.4 BP: 143/113 P: 87 R: 19 O2: 97%(RA)
General: Oriented xself, place, month/year and able to do DoW
task forward (not backwards), but somnolence and need to
re-arouse multiple times during exam.  NAD.
HEENT: Sclera anicteric, Dry MM, oropharynx clear no palatal
findings
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  +BS, voluntary guarding, mild distension with diffuse
TTP but worst in RUQ.  Unable to assess fluid wave.  No rebound
tenderness
GU: foley in place
Ext: all extremities cool (but uncovered), cap refill wnl, 1+
pulses, trace LE edema
Neuro: Non focal

At discharge:
Vitals: T: 99.1 BP 114/68 HR 105  RR 18 O2 Sat 94% RA
General: Patient lying in bed in no acute distress
HEENT: MMM. OP clear without erythema or exudate. Cushingnoid
appearance.
NECK: no LAD
LUNGS: Clear to ascultation bilaterally. No crackles or wheezes.
CV: RRR. No murmurs, rubs, or gallops.
ABDOMEN: Normal active bowel sounds. Soft, non-distended. Liver
tip appreciated. Mild tenderness to palpation over RUQ.
EXT: Trace pitting edema in RLE. 1+ pitting edema in LLE. No
clubbing or cyanosis.
NEURO: CN II-XII intact bilaterally.

Pertinent Results:
ADMISSION LABS
=============

[**2174-5-25**] 06:20PM BLOOD WBC-15.4* RBC-3.50* Hgb-10.8* Hct-34.5*
MCV-99* MCH-30.9 MCHC-31.4 RDW-21.0* Plt Ct-138*#
[**2174-5-25**] 06:20PM BLOOD Neuts-90.7* Lymphs-5.0* Monos-3.8 Eos-0.2
Baso-0.2
[**2174-5-25**] 06:20PM BLOOD PT-124.8* PTT-32.3 INR(PT)-15.5*
[**2174-5-25**] 08:30PM BLOOD Glucose-148* UreaN-102* Creat-3.6*#
Na-138 K-6.2* Cl-94* HCO3-20* AnGap-30*
[**2174-5-25**] 08:30PM BLOOD ALT-210* AST-144* LD(LDH)-575*
AlkPhos-173* TotBili-4.7* DirBili-3.7* IndBili-1.0
[**2174-5-26**] 11:40AM BLOOD CK-MB-8 cTropnT-0.04* proBNP-GREATER TH
[**2174-5-26**] 01:40AM BLOOD Calcium-8.8 Phos-7.7*# Mg-2.8*
UricAcd-11.4*
[**2174-5-25**] 11:46PM BLOOD Lactate-8.7* K-6.0*
.
DISCHARGE LABS
=============
.
CHEMISTRY: 126/4.6 89/24 87/2.6 < 177 7.3/1.9/5.3
CBC: 4.4 > 8.5/23.4 <26
LFTS: ALT 17 AST 62 LDH 993 ALK PHOS 491 TBILI 1.4
INR: 1.1
.

Micro:
[**2174-6-29**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING 	
[**2174-6-29**] 	BLOOD CULTURE 	Blood Culture, Routine-PENDING 	
[**2174-6-28**] 	URINE 	URINE CULTURE-PENDING 	
[**2174-6-24**] 	Immunology  	CMV Viral Load-FINAL 	
[**2174-6-18**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	
[**2174-6-18**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	
[**2174-6-17**] 	STOOL 	CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
	
[**2174-6-15**] 	STOOL 	CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
	
[**2174-6-14**] 	STOOL 	CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
	
[**2174-6-13**] 	Immunology 	CMV Viral Load-FINAL 	
[**2174-6-6**] 	Immunology 	CMV Viral Load-FINAL 	
[**2174-5-28**] 	STOOL 	CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
	
[**2174-5-27**] 	PERITONEAL FLUID 	ACID FAST SMEAR-FINAL; ACID FAST
CULTURE-PRELIMINARY 	
[**2174-5-26**] 	IMMUNOLOGY 	HCV VIRAL LOAD-FINAL 	
[**2174-5-26**] 	IMMUNOLOGY 	HBV Viral Load-FINAL 	
[**2174-5-26**] 	Immunology (CMV) 	CMV Viral Load-FINAL 	
[**2174-5-26**] 	Blood (EBV) 	[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-FINAL 	
[**2174-5-26**] 	URINE 	URINE CULTURE-FINAL 	
[**2174-5-25**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	
[**2174-5-25**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	
.
BAL CULTURE: NGTD
SPUTUM CULTURE: 1 COLONY OF ASPERGILLUS FUMIGATUS
BLOOD CULTLURES: NGTD
MYCOLYTIC AND AFB BLOOD CULTURES: NGTD
.
Imaging:
=======
TTE [**2174-5-26**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is severely depressed (LVEF= 20 %). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. There is abnormal diastolic
septal motion/position consistent with right ventricular volume
overload. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. An eccentric, posteriorly
directed jet of mild (1+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
.
IMPRESSION: Severely depressed left ventricular systolic
function with elevated left ventricular filling pressure. Mild
global free wall hypokinesis in the setting of right ventricular
volume overload. Mild aortic and mitral regurgitation. Moderate
tricuspid regurgitation. Indeterminate pulmonary artery systolic
pressure. Very small pericardial effusion without
echocardiographic evidence of tamponade.

Compared with the prior study (images reviewed) of [**2174-5-16**],
the global left ventricular systolic function is worse. Mild
aortic and mitral regurgitation are new. The severity of
pulmonary artery hypertension was not able to be determined on
the current study, but was previously moderate.
.
TTE ([**2174-7-4**])
Normal left ventricular cavity size with regional and global
systolic dysfunction. Right ventricular free wall hypokinesis.
Pulmonary artery systolic hypertension. Mild mitral
regurgitation. Moderate tricuspid regurgitation. Compared with
the prior study (images reviewed) of [**2174-6-29**], global left
ventricular systolic function is minimally improved (some
regionality was suggested on review of the prior study) and the
severity of tricuspid regurgitation is now reduced. The
estimated pulmonary atery systolic pressure is similar. The
pericardial effusion is minimally larger.
.
TTE [**2174-7-7**]
LVEF: 40% to 45%
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the mid to distal inferior wall, inferior septum and
inferolateral wall. Right ventricular chamber size is normal.
with depressed free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Trivial mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. [In the setting
of at least moderate to severe tricuspid regurgitation, the
estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is a small to moderate sized pericardial effusion without
evidence of tamponade physiology.
.
Compared with the prior study (images reviewed) of [**2174-7-4**],
overall function has increased slightly due to slight
improvement in inferior/inferoseptal/inferolateral segments. The
size and distribution of the pericardial effusion is similar.
.
CARDIAC MRI
.
Impression:
1. Mildly increased left ventricular cavity size with mild
global hypokinesis.
The LVEF was moderately depressed at 30%. The effective forward
LVEF was
severely depressed at 25%. There was a diffuse increase in
signal intensity of
the myocardium on the T2 images which may be consistent with
edema or
inflammation. The increase in signal intensity was relative to
the skeletal
muscle and liver.
2. Normal right ventricular cavity size with mild free wall
hypokinesis. The
RVEF was moderately depressed at 31%.
3. Mild mitral regurgitation. Moderate to severe tricuspid
regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were
normal. The main pulmonary artery diameter index was mildly
increased.
5. Biatrial enlargement.
6. Small pericardial effusion.
.
These findings are most consistent with myocarditis (subacute
versus chronic).
In the future, gadolinium enhanced images may be useful for the
assessment of
myocardial fibrosis (gadolinium was not given on the current
study due to low
eGFR).
.
CT CHEST WITHOUT CONTRAST:
.
There is a small non-hemorrhagic pericardial effusion, slightly
decreased from
[**2174-1-13**], without evidence of tamponade physiology. Heart is
otherwise
unremarkable. There is no significant coronary artery
calcification. There
is a right PICC extending to the low SVC. The esophagus is
normal. The
trachea and central airways are patent to the subsegmental
level. There are
no endobronchial lesions identified.
.
In the lungs, there are diffuse, multifocal ground-glass
opacities, both in a
peribronchovascular and peripheral distribution. These are new
from prior
study. There are no consolidative or cavitary opacities. There
is no pleural
abnormality; previous effusions have resolved.
.
This examination is not tailored to evaluation of
subdiaphragmatic structures,
except to note normal appearance of the included portions of the
liver,
spleen, and adrenal glands. There is no acute process
identified.
.
No lytic or sclerotic osseous lesions identified.
.
IMPRESSION:
.
1. Multifocal ground-glass opacities scattered throughout both
lungs,
compatible with multifocal pneumonia, though hemorrhage could
have a similar
appearance. If this is infectious, viral etiologies are favored,
though
bacterial pneumonia or PCP cannot be excluded.
2. Resolution of prior pleural effusions. Small pericardial
effusion
persists.
.
CHEST CT
.
FINDINGS: The visualized thyroid gland is normal. No axillary,
mediastinal,
or hilar lymphadenopathy meeting CT criteria for pathologic
enlargement is
present. A right-sided PICC follows normal course terminating at
the
cavoatrial junction. The heart size is normal with unchanged
small
pericardial effusion.
.
There is severe progressive peribronchial ground-glass opacity
with septal
thickening consistent with infection, most likely viral. The
rapidly more
widespread distribution--perihilar and lower lobe
predominant--is atypical for
a fungal infection. There is no pleural effusion or
pneumothorax.
.
Visualized portion of the upper abdomen is unremarkable.
.
BONE WINDOWS: No suspicious lytic or sclerotic osseous lesion is
identified.
.
IMPRESSION:
.
1. Marked progression of peribronchovascular ground-glass
opacity consistent
with infection, most likely viral rather than fungal.
.
2. Unchanged small pericardial effusion.
.
SINUS CT
.
The frontal sinuses are normally aerated. There is minimal
mucosal thickening
in the right and left ethmoid air cells. There is an air-fluid
level in the
right sphenoid sinus and minimum mucosal thickening in the left
sphenoid
sinus. There is mild circumferential mucosal thickening in the
bilateral
maxillary sinuses, with an air-fluid level seen on the left.
There is no
adjacent sclerosis to suggest chronicity of inflammation. There
is no
hyperdensity or calcification to suggest fungal colonization.
There is no
osseous erosion or adjacent soft tissue change to suggest
invasive disease.
.
The ostiomeatal units are patent bilaterally, though narrowed by
mucosal
thickening. The nasal septum is midline. The lamina papyracea
and cribriform
plates are intact. The roofs of the ethmoids are symmetric in
height. There
is a single septum identified within the sphenoid sinus,
inserting upon the
left carotid groove.
.
The bony orbits and intraorbital contents are normal. There is
no intraocular
fat stranding or inflammatory change.
.
The visualized intracranial contents are normal. There is no
extra-axial
fluid collection.
.
The mastoid air cells are well aerated and clear, as are the
middle ears.
.
IMPRESSION:
.
Mild pansinus mucosal disease, with air-fluid levels seen in the
left
maxillary and right sphenoid sinuses. Clinical correlation is
recommended to
exclude acute sinusitis. There is no hyperdensity or
calcification to
specifically suggest fungal colonization. There is no bony
sclerosis to
suggest chronicity of inflammation. There is no bony erosion or
adjacent soft
tissue change to suggest invasive disease.
.
ECHO [**2174-8-4**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size is normal. with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is
mild pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
.
IMPRESSION: Mildly symmetric left ventricular hypertrophy with
normal cavity size and borderline-normal global left ventricular
systolic function. Mild pulmonary artery systolic hypertension.
Small pericardial effusion without echocardiographic evidence of
tamponade.
.
Compared with the prior study (images reviewed) of [**2174-7-27**],
the previously mentioned wall motion abnormalities appear to
have improved and the global left ventricular systolic function
is now near-normal.

Brief Hospital Course:
38-year-old female with ALL s/p double cord blood SCT [**1-/2173**]
c/b GVHD, CHF secondary to anthracycline induced cardiomyopathy,
embolic CVA on coumadin presented with altered mental status,
ascites secondary to congestive hepatopathy, and acute on
chronic systolic heart failure exacerbation presumed to be
secondary to cardiac GVHD with initial EF <10%.
.
# AMS: Patient initially admitted to the [**Hospital Unit Name 153**] with altered
mental status likely multifactorial in etiology from factors
such as uremia and hepatic encephalopathy. There was no evidence
of infection or substance abuse. Given INR of ~ 16, a CT head
was performed not indicating an intracranial bleed. Paracentesis
was performed on ascites that was not suggestive of peritonitis.
Her mental status improved without clear change in potential
underlying cause. She was started on broad-spectrum antibiotics
including vancomycin and zosyn. Her outpatient cardiologist was
contact[**Name (NI) **] and felt that the clinical picture could all be
related to cardiac failure. She was subsequently transferred to
the CCU.
.
# Acute on chronic congestive heart failure with systolic
dysfunction:  Patient presented with a depressed EF secondary to
presumed GVHD. Her ECHO on admission was read as 20%, but upon
further review by Dr. [**First Name (STitle) 437**] was <10% consistent with profoundly
low cardiac output. She was volume overloaded on admission.
Given the waxing and [**Doctor Last Name 688**] clinical course, the impression was
that this did not represent anthracycline-based cardiomyopathy
since this would be quite dramatic and irreversible at late
stages. She had myocardial biopsies in the past not showing
T-cell infiltration based on prior pathology records, however,
it was theorized that her presentation was most likely a result
of GVHD affecting the heart. In the CCU, she was diuresed with a
combination of milrinone for inotropic support and furosemide
with adjunctive metalozone.  For presumed GVHD, she was pulsed
with solumedrol 1 g followed by taper from 60 mg IV to 15 mg IV
BID in addition to continuing mycophenolate. On transfer out the
CCU, she was net negative 13.9 L. Repeat TTE showed LVEF 35%.
After transfer out of the CCU, steroids were tapered and she was
given a dose of ritxuan as a steroid sparing [**Doctor Last Name 360**]. Ejection
fraction plummeted from 40 to 20%. She was again admitted to the
CCU where she was diuresed and was taken for right heart cath
which demonstrated pulmonary hypertension responsive to
sildenafil. She was started on Nifedipine and Sildenafil with
improvement in EF to 40%. Torsemide was resumed and titrated to
maintain volume status even.
*** Include discharge weight under CHF section:
Admission: 64.86 kgs.   (142.99 lbs)   [**2174-4-19**]
Discharge: 136.5 on [**2174-8-9**]
.
# Pulmonary HTN: Pulmonary HTN was investigated with RHC on
[**6-30**]. Initial numbers: RA pressure of 20, wedge 12, CI of 1.2,
pulm vasc resistence 560, PCP [**Last Name (NamePattern4) **] 38. With 100% FiO2: no change
in wedge, PVR decreased to 480, wedge increased to 22. With
inhaled NO:  no significant change in PA pressures, wedge
pressures increased to 31, PVR decreased further to 160
indicating significantly improved LV filling. With addition of
milrinone: wedge decreased from 31 to 22, there was no change in
cardiac output and PVR increased from 160 to 400. Sildenafil was
started and was uptitrated to 80 mg TID. Nifedipine was also
started at 30 mg per day and uptitrated to 60mg daily.
.
# Acute on chronic renal failure: Patient baseline creatinine
2.5 - 3.0 with admission Cr 3.8. Urine sediment with many
hyaline casts and few granular casts. FeUrea 38% consistent with
pre-renal state.  Likely multifactorial - may be part of GVHD,
drug side effect tacrolimus, poor output secondary to CHF. Renal
ultrasound was negative for obstruction. Her creatinine trended
down with diuresis. Throughout the remainder of her course,
creatinine fluctuated as her cardiac output changed.
.
# Parainfluenza pneumonia: Patient developed new fever and
pulmonary infiltrates on [**2174-7-7**], she was started IV vancomycin
and cefepime for hospital acquired pneumonia coverage. Nasal
swab returned positive for parainfluenza 3. Antibiotics were
continued for a 14 day course given concern for bacterial
suprainfection. A bronchoscopy with BAL sample collected in
light of fevers. A sputum collection was also collected; 1
colony of aspergillus fumigatus grew out of the patient's
culture. She also developed a nose bleed. There was concern that
she had developed an invasive fungal infection of the sinuses
that was perhaps dripping down through  BAL samples had no
growth to date on the day of discharge.
.
# Transaminitis:  Worsened on admission compared to last set of
outpatient labs on [**5-20**]. Secondary to congestive hepatopathy
given CHF.  Hepatology was consulted and felt that clinical
picture represented cholestatic hepatitis, but may be having
fulminant hepatic failure if INR not due to coumadin effect.
LFTs were trended, multiple hepatic markers were checked and
negative, and diagnostic paracentesis revealed SAAG >1.1. LFTs
trended downward with diuresis. On day of discharge, patient's
LFTs ALT: 17 AP: 491 Tbili: 1.4 AST: 62 LDH: 993.
 .
# Coagulopathy: Supratherapeutic INR to ~16 on admission,
reversed with Vit K and 2U FFP.  Elevated INR is multifactorial
and related to congestive hepatopathy and drug interaction
between fluconazole and warfarin.  Coumadin and Fluconazole were
held, and INR trended down. On day of discharge, the patient's
INR was 1.1.
.
# ALL: s/p double cord blood SCT [**1-/2173**] complicated by GVHD on
immunosuppression with recent decrease in prednisone dose to
50mg prior to admission. She was continued on mycophenolate,
bactrim, and acyclovir. Tacrolimus was discontinued given renal
failure. She was treated with methylprednisolone as above. She
was discharged home on CellCept 1000mg [**Hospital1 **] and
methylprednisolone 60mg IV once daily.
.
#Left knee pain: While in hospital, patient developed acute
onset of atraumatic left knee pain of unclear etiology.
Arthrocentesis ruled out infection and crystalline disease.  The
joint fluid was sterile and contained a large number of
marcrophages and lymphocytes as did the peritoneal fluid sampled
during her last admission.   This may be a sign of broad
serositis secondary to GVHD.  A left knee xray was performed to
rule out AVN, but noted a periosteal reaction with bone mottled,
which was concerning for early AVN.  Rheumatology was consulted
who recommended MRI of the knee. The patient repeatedly refused
the MRI of the knee. Risks and benefits of undiagnosed AVN were
discussed with her and she remained unwilling to undergo MRI.
With time, the pain resolved, etiology remains unclear.
.
# Hyponatremia: Sodium trended down to mid-120s during diuresis
likely from heart failure given decreased effective circulating
volume in addition to usage of thiazide. TSH and cortisol were
normal. Sodium eventually trended to normal after diuresis.
.
# Hypocalcemia:  Likely secondary to bisphosphonate
administration. Patient symptomatic with episodes of lock jaw.
Her calcium was increased and was given IV when symptomatic.
Vitamin D level was extremely low so patient was started on
50,000 units qweek.  Ativan was given for muscle spasms for
symptomatic relief.
.
# Thrombocytopenia: Patient noted to have decrease in platelets
since recent [**5-20**] labs of unclear etiology. Hematology was
following with impression of thrombotic microangiopathy from
HIT, medication side effect, or other etiology based on blood
smear and rising hemolysis markers.  Tacrolimus TMA seemed less
likely as LDH rise preceded tacrolimus initiation. Her HIT PF4
antibody returned weakly positive but a serotonin assay was
negative.
.
# Normocytic anemia: Patient was admitted with Hct 34.5 that
trended down to 22.8 requiring 2 units of pRBC. No signs or
symptoms or acute blood loss. Etiology may be low grade
hemolysis given insidious trend related to aforementioned
thrombotic angiopathy. Coomb's was negative.
.
# Embolic stroke in [**3-/2174**]: Patient was on coumadin as an
outpatient.  Her INR was supratherapeutic at time of admission
and was held. Neurologic exam was monitored and non-focal. In
discussion with her primary oncologist and review of the MRI
findings at the time of diagnosis, it was determined that
embolic stroke was unlikely and Coumadin was discontinued.
.
# Abdominal pain: Extensive work-up in past with no clear
etiology.  Managed with MS contin and Morphine IR.
.
# Hyperglycemia: Secondary to steroid usage and tacrolimus. HISS
was used for coverage.


Medications on Admission:
ACYCLOVIR -  (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours
ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 HFA(s) inhaled every four (4) hours as
needed
for sob or wheeze
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM -  (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for nausea
METOPROLOL SUCCINATE -  (Prescribed by Other Provider) - 100 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY
(Daily)
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours as needed for pain
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet
Extended Release - 1 Tablet(s) by mouth every twelve (12) hours
MYCOPHENOLATE MOFETIL -  (Prescribed by Other Provider) - 500 mg
Tablet - 2 Tablet(s) by mouth twice a day
PREDNISONE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 2.5
Tablet(s) by mouth DAILY (Daily)
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
TORSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 3
Tablet(s) by mouth DAILY (Daily)
WARFARIN -  (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day
.
Medications - OTC
DOCUSATE SODIUM -  (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] -  (Prescribed by Other
Provider) - 400 mg/5 mL Suspension - 30 Suspension(s) by mouth
every six (6) hours as needed for constipation
MULTIVITAMIN -  (Prescribed by Other Provider) -   Tablet - 1
Tablet(s) by mouth once a day
OMEPRAZOLE -  (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth daily
SIMETHICONE -  (Prescribed by Other Provider) - 80 mg Tablet,
Chewable - 1 Tablet(s) by mouth four times a day as needed for
abdominal pain or gas


Discharge Medications:
1. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
2. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
Disp:*12 Capsule(s)* Refills:*2*
4. sildenafil 20 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
6. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO QPM (once a day (in the evening)).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
8. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety/nausea.
Disp:*60 Tablet(s)* Refills:*0*
10. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
12. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice a day.
Disp:*28 Tablet Extended Release(s)* Refills:*0*
13. methylprednisolone sodium succ 500 mg Recon Soln Sig: Sixty
(60) mg Intravenous once a day.
Disp:*1800 mg* Refills:*0*
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-6**] Tablet,
Rapid Dissolves PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
16. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
17. torsemide 20 mg/2 mL (10 mg/mL) Solution Sig: Forty (40) mg
Intravenous once a day.
Disp:*120 mL* Refills:*0*
18. Home O2
Home oxygen @2 LPM continuous via nasal canula, conserving
device for portability.
Dx: CHF, pulmonary hypertension
19. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous twice a day: Please administer 10 units
before breakfast and 10 units before dinner. .
Disp:*600 mL* Refills:*0*
20. Insulin Syringe 1 mL 30 x [**6-20**]  Syringe Sig: One (1)
syringes Miscellaneous twice a day: Use to administer insulin
NPH.
Disp:*60 syringes* Refills:*0*
21. glucometer
Please dispense one glucometer and test strips. Patient should
check her fingersticks before giving herself insulin at
breakfast and dinner.


Discharge Disposition:
Home With Service

Facility:
Care Group

Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Graft vs. Host Disease
Pulmonary arterial hypertension
Parainfluenza pneumonia
Congestive hepatopathy


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
It was a pleasure to care for you in your stay at [**Hospital1 771**].
.
Your were brought to the hospital with confusion and found to be
in heart failure. Your heart failure is very complex and related
to Graft vs. Host Disease and high blood pressure in your lungs
(pulmonary arterial hypertension). You underwent cardiac
catheterization to diagnose pulmonary hypertension and were
started on nifedipine and sildenafil to treat pulmonary
hypertension. We also treated you with diuretics (torsemide) to
remove the extra water that had accumulated in your lungs and
legs as a result of the heart failure. With time, we removed the
fluid and your breathing improved. You will continue the
torsemide at home, receiving it through the PICC.
.
While in the hospital, you developed pneumonia and were found to
have a viral infection called parainfluenza. Patients with this
infeciton commonly have a bacterial infection in the lungs as
well and we treated you with antibiotics. You also underwent
bronchoscopy to collect samples for culture to identify a cause
for your fevers. There have been no organisms that have been
grown from your samples collected from the bronchoscopy. A
sputum culture that was collected grew out a mold called
Aspergillus fumigatus so you were started on Voriconazole for
treatment. As part of the work-up to determine where this mold
may have come from, you had a CT of your sinuses, which did not
show evidence of infection.
.
We made the following changes to your home medication list:
START Nifedipine for pulmonary hypertension
START Sildenafil for pulmonary hypertension
START Voriconazole for treatment of Aspergillus infection
START Solumedrol (methyprednisolone) 60mg IV daily
START digoxin for heart failure
START omeprazole to protect your stomach while on steroids
CHANGE torsemide to 40mg IV daily for heart failure
STOP carvedilol. Instead, take metoprolol succinate (Toprol XL)
50mg once a day.
STOP valsartan
STOP coumadin
STOP pentamidine monthly
STOP fluticasone-salmeterol (Advair) inhaler
STOP morphine. Instead, take MS Contin (long-acting pain
medication) twice a day. Then, if you still have pain, take
oxycodone as needed.
.
You will be seeing Dr. [**Last Name (STitle) **] tomorrow. You also have
appointments [**Last Name (STitle) 1988**] with Dr. [**First Name (STitle) 437**] and Dr. [**Last Name (STitle) 724**] (infectious
disease).
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
Please check your finger sticks before you give yourself insulin
before breakfast and diner. Please keep a journal of your
numbers and bring them to your appointments.

Followup Instructions:
Department: [**Name8 (MD) 3242**]/ONCOLOGY UNIT
When: THURSDAY [**2174-8-11**] at 11:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST     Best Parking: Main GarageDepartment:
[**Location (un) 3242**]/ONCOLOGY UNIT
.
When: FRIDAY [**2174-8-12**] at 12:00 PM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST     Best Parking: Main Garage
.
Department: HEMATOLOGY/[**Location (un) 3242**]
When: THURSDAY [**2174-8-25**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2174-8-29**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: THURSDAY [**2174-9-15**] at 11:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
{"Complications of transplanted bone marrow,Acute on chronic systolic heart failure,Pneumonia due to parainfluenza virus,Hepatic encephalopathy,Secondary cardiomyopathy, unspecified,Chronic kidney disease, Stage IV (severe),Acute lymphoid leukemia, in remission,Jaundice, unspecified, not of newborn,Other ascites,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Chronic graft-versus-host disease,Other chronic pulmonary heart diseases,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Chronic passive congestion of liver,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pain in joint, lower leg,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of other medications,Abnormal coagulation profile,Anemia, unspecified,Hypocalcemia,Surgical or other procedure not carried out because of patient's decision,Epistaxis,Abnormality of gait,Tachycardia, unspecified,Other convulsions"}


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



### Clinical text :
CHIEF COMPLAINT: Altered Mental Status.

PRESENT ILLNESS: Ms. [**Known lastname **] is a 38 year old female with ALL s/p double cord
blood SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease who was sent in from onc
floor today for confusion.  Pt arrived for appointment with Dr.
[**Last Name (STitle) **] today; she thought she was to go to 7F to see her MD.
In actuality, she had no appointment today, and her appointment
would have been in [**Hospital Ward Name 23**] had she had one.  Per her father, she
has been confused for 3-4 days with complaints of recurrent and
chronic abdominal pain.  She describes her abdominal pain as
constant and nonradiating, the same as always.
.
In the ED, VS 97.1 77 135/105 16 100% RA.  In ED, AOx2(not date)
with c/o abdominal pain. Labs notable for creatinine 3.6,
Lactate 8, K 6, ALT 210 AP: 173 Tbili: 4.7 AST: 144 LDH: 575
Dbili: 3.7 Lip: 154. AG 24. WB 14.9 plt 131 Hct 31 INR: 16.7.  A
right femoral line was placed.  Head CT was negative.  CXR was
unremarkable.  Given calcium Gluconate 1g/10mL, Sodium
Kayexelate 30mg, Phytonadione 10mg/mL Amp,
Vanc/Piperacillin-Tazob. She was afebrile in ED and prior to
leaving 80 137/95 20 100% on RA. She received 1 amp d50, 10units
of insulin. She received 1L NS.
.
Of note patient had recent admission to [**Hospital Ward Name 3242**] [**Date range (3) 94160**]
where she presented with nausea, vomiting and abdominal pain in
addition to acute on chronic renal failure. She was found to
have peritonitis with lymphocytic predominance with unclear
etiology but Tb vs malignancy was explored. It seems she was
seen by cardiology for CHF (including ICU stay for diuresis with
BP support), renal for ARF, psych for coping, ID for peritonitis
and surgery for peritonitis.  Surgery did not think it wise to
do peritoneal biopsy.  There is no discharge summary, but
following medication changes appear to have occurred: start
acyclovir, stop carvedilol and start Toprol, decrease torsemide
to 40mg daily (from 40mg).
.
She was last seen by Dr. [**Last Name (STitle) **] on [**5-20**] at which point
prednisone was decreased to 50 mg a day.  She was continued on
Cellcept despite a slight transaminitis at that time.  She also
had thrush and was started on fluconazole.  Bactrim was
continued for PCP [**Name Initial (PRE) 1102**].  Her torsemide was increased to
60mg qday due to worse lower extremity edema.
.
Upon arrival to the ICU, pt's father reports improvement in MS
since interventions in ED.

MEDICAL HISTORY: ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

MEDICATION ON ADMISSION: ACYCLOVIR -  (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours
ALBUTEROL SULFATE -  (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 HFA(s) inhaled every four (4) hours as
needed
for sob or wheeze
FLUCONAZOLE - 200 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM -  (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth every six (6) hours as needed for nausea
METOPROLOL SUCCINATE -  (Prescribed by Other Provider) - 100 mg
Tablet Extended Release 24 hr - 1 Tablet(s) by mouth DAILY
(Daily)
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet - 1
Tablet(s) by mouth every twelve (12) hours as needed for pain
MORPHINE -  (Prescribed by Other Provider) - 15 mg Tablet
Extended Release - 1 Tablet(s) by mouth every twelve (12) hours
MYCOPHENOLATE MOFETIL -  (Prescribed by Other Provider) - 500 mg
Tablet - 2 Tablet(s) by mouth twice a day
PREDNISONE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 2.5
Tablet(s) by mouth DAILY (Daily)
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth DAILY (Daily)
TORSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 3
Tablet(s) by mouth DAILY (Daily)
WARFARIN -  (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day
.
Medications - OTC
DOCUSATE SODIUM -  (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] -  (Prescribed by Other
Provider) - 400 mg/5 mL Suspension - 30 Suspension(s) by mouth
every six (6) hours as needed for constipation
MULTIVITAMIN -  (Prescribed by Other Provider) -   Tablet - 1
Tablet(s) by mouth once a day
OMEPRAZOLE -  (OTC) - 20 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s) by mouth daily
SIMETHICONE -  (Prescribed by Other Provider) - 80 mg Tablet,
Chewable - 1 Tablet(s) by mouth four times a day as needed for
abdominal pain or gas

ALLERGIES: Prochlorperazine / Heparin Agents

PHYSICAL EXAM: Upon admission:
Vitals: T: 96.4 BP: 143/113 P: 87 R: 19 O2: 97%(RA)
General: Oriented xself, place, month/year and able to do DoW
task forward (not backwards), but somnolence and need to
re-arouse multiple times during exam.  NAD.
HEENT: Sclera anicteric, Dry MM, oropharynx clear no palatal
findings
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  +BS, voluntary guarding, mild distension with diffuse
TTP but worst in RUQ.  Unable to assess fluid wave.  No rebound
tenderness
GU: foley in place
Ext: all extremities cool (but uncovered), cap refill wnl, 1+
pulses, trace LE edema
Neuro: Non focal

FAMILY HISTORY: Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

SOCIAL HISTORY: She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis.  Lifelong nonsmoker, but not currently. Denies
illicits or EtOH. 

### Response:
{"Complications of transplanted bone marrow,Acute on chronic systolic heart failure,Pneumonia due to parainfluenza virus,Hepatic encephalopathy,Secondary cardiomyopathy, unspecified,Chronic kidney disease, Stage IV (severe),Acute lymphoid leukemia, in remission,Jaundice, unspecified, not of newborn,Other ascites,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Chronic graft-versus-host disease,Other chronic pulmonary heart diseases,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Chronic passive congestion of liver,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pain in joint, lower leg,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of other medications,Abnormal coagulation profile,Anemia, unspecified,Hypocalcemia,Surgical or other procedure not carried out because of patient's decision,Epistaxis,Abnormality of gait,Tachycardia, unspecified,Other convulsions"}
