CHIEF COMPLAINT: transferred for evaluation of fevers, chills, and
lymphadenopathy, and hepatosplenomegaly

PRESENT ILLNESS: 33 year old man with 3-4 months of chills, fevers, and drenching
night sweats. His symptoms started shortly after he quit
drinking and abusing narcotics, about 3 months ago, and he
initially attributed the chills and fevers to withdrawal.
However, the nightsweats have continued. He has also noticed an
abdominal mass, more prominent on the left side, which is
diffusely painful and which prevents him from taking a deep
breath if he lies down.
.
On arrival to [**Hospital **] Hosp ([**2130-3-6**]), he was febrile to 102.3,
pancytopenic with WBC 3.2, 17 bands, Hgb 7.7, as well as an LDH
of 700. He was transfused and a thoracentesis was performed for
pleural effusion (500 cc drained) and then spleen biopsy was
performed to evaluate his pancytopenia and lymphadenopathy. He
was then transferred to [**Hospital1 18**] for further evaluation and
management of suspected lymphoproliferative disorder.
.
In our ED, vital signs were T103 P103 BP114/71 R20 Sat95% ra.
.
REVIEW OF SYSTEMS:
(+) 13 lb weight gain in the last 2 months.
(-) Denied headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied recent change in bowel or
bladder habits. Denied dysuria. Denied arthralgias or myalgias.
Denied pruritus.

MEDICAL HISTORY: - h/o MRSA cellulitis of the right lower extremity
- eczema
- h/o depression
- pyloric sphincterotomy as an infant

MEDICATION ON ADMISSION: Klonipin 1mg TID.

ALLERGIES: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Bee Pollen / Gadolinium-Containing Agents

PHYSICAL EXAM: T 99.3 BP140/80 HR99 RR22 96% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM, oropharynx clear
Neck - Supple, JVP not elevated, no LAD
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - tachy, normal S1/S2; no murmurs, rubs, or gallops
Abdomen - Well-healed midline epigastric surgical scar.
Normoactive bowel sounds; firm, mildly tender mass in the LUQ
extending along the left flank and to the pelvis, non-distended.
Ext - Small, appropriately tender incision in the right axilla.
Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
Neuro - CN II-XII intact in detail, full strength throughout.

FAMILY HISTORY: Mother with diabetes. No family history of cancer in first
degree relatives.

SOCIAL HISTORY: Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously
worked in construction, smoked one pack of cigarettes daily
prior to going into prison, endorses h/o marijuana use and also
reports that he has had problems with opioid addiction, using
over 80mg of oxycontin several times a day, ending 2 years ago.
He was treated with suboxone for several months, but prior to
this hospitalization, he had not taken any narcotics in the last
2.5 months. Denies IV drug use.
Neutropenia, unspecified,Pneumonia, organism unspecified,Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of multiple sites,Paralytic ileus,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Fever presenting with conditions classified elsewhere,Abdominal pain, unspecified site,Other acute pain,Thrombocytopenia, unspecified,Other nonspecific abnormal serum enzyme levels,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Combinations of opioid type drug with any other drug dependence, unspecified,Other specified cardiac dysrhythmias,Other drugs and medicinal substances causing adverse effects in therapeutic use,Edema,Other chronic nonalcoholic liver disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Dysthymic disorder,Contact dermatitis and other eczema, unspecified cause
Neutropenia NOS,Pneumonia, organism NOS,Hodg lymph-histio mult,Paralytic ileus,Hyposmolality,Ac kidny fail, tubr necr,Pleural effusion NOS,Fever in other diseases,Abdmnal pain unspcf site,Acute pain NEC,Thrombocytopenia NOS,Abn serum enzy level NEC,Drug dermatitis NOS,Adv eff cephalosporin,Opioid/other dep-unspec,Cardiac dysrhythmias NEC,Adv eff medicinal NEC,Edema,Chronic liver dis NEC,Migrne unsp wo ntrc mgrn,Dysthymic disorder,Dermatitis NOS
Admission Date:  [**2130-3-16**]              Discharge Date:   [**2130-3-28**]

Date of Birth:  [**2096-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Bee Pollen / Gadolinium-Containing Agents

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
transferred for evaluation of fevers, chills, and
lymphadenopathy, and hepatosplenomegaly

Major Surgical or Invasive Procedure:
Cycle 1 [**Doctor Last Name **]-dexamethasone


History of Present Illness:
33 year old man with 3-4 months of chills, fevers, and drenching
night sweats. His symptoms started shortly after he quit
drinking and abusing narcotics, about 3 months ago, and he
initially attributed the chills and fevers to withdrawal.
However, the nightsweats have continued. He has also noticed an
abdominal mass, more prominent on the left side, which is
diffusely painful and which prevents him from taking a deep
breath if he lies down.
.
On arrival to [**Hospital **] Hosp ([**2130-3-6**]), he was febrile to 102.3,
pancytopenic with WBC 3.2, 17 bands, Hgb 7.7, as well as an LDH
of 700. He was transfused and a thoracentesis was performed for
pleural effusion (500 cc drained) and then spleen biopsy was
performed to evaluate his pancytopenia and lymphadenopathy. He
was then transferred to [**Hospital1 18**] for further evaluation and
management of suspected lymphoproliferative disorder.
.
In our ED, vital signs were T103 P103 BP114/71 R20 Sat95% ra.
.
REVIEW OF SYSTEMS:
(+) 13 lb weight gain in the last 2 months.
(-) Denied headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied recent change in bowel or
bladder habits. Denied dysuria. Denied arthralgias or myalgias.
Denied pruritus.

Past Medical History:
- h/o MRSA cellulitis of the right lower extremity
- eczema
- h/o depression
- pyloric sphincterotomy as an infant

Social History:
Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously
worked in construction, smoked one pack of cigarettes daily
prior to going into prison, endorses h/o marijuana use and also
reports that he has had problems with opioid addiction, using
over 80mg of oxycontin several times a day, ending 2 years ago.
He was treated with suboxone for several months, but prior to
this hospitalization, he had not taken any narcotics in the last
2.5 months. Denies IV drug use.

Family History:
Mother with diabetes. No family history of cancer in first
degree relatives.

Physical Exam:
T 99.3 BP140/80 HR99 RR22 96% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM, oropharynx clear
Neck - Supple, JVP not elevated, no LAD
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - tachy, normal S1/S2; no murmurs, rubs, or gallops
Abdomen - Well-healed midline epigastric surgical scar.
Normoactive bowel sounds; firm, mildly tender mass in the LUQ
extending along the left flank and to the pelvis, non-distended.
Ext - Small, appropriately tender incision in the right axilla.
Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
Neuro - CN II-XII intact in detail, full strength throughout.

Pertinent Results:
[**2130-3-16**] 12:10PM   PT-15.1* PTT-30.6 INR(PT)-1.3* PLT SMR-LOW
PLT COUNT-118* HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-2+ MACROCYT-1+
MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-1+
BURR-1+ STIPPLED-OCCASIONAL TEARDROP-2+ BITE-OCCASIONAL
NEUTS-40* BANDS-9* LYMPHS-42 MONOS-2 EOS-0 BASOS-1 ATYPS-0
METAS-1* MYELOS-4* PLASMA-1* WBC-3.7* RBC-3.66* HGB-9.3*
HCT-29.0* MCV-79* MCH-25.5* MCHC-32.2 RDW-19.8*

[**2130-3-16**] 12:10PM   LIPASE-30 ALT(SGPT)-118* AST(SGOT)-103*
LD(LDH)-702* TOT BILI-0.7

[**2130-3-16**] 12:10PM   GLUCOSE-109* UREA N-18 CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15

[**2130-3-16**] 12:36PM   LACTATE-1.3

[**2130-3-16**] 02:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029

[**2130-3-16**] 03:01PM BONE MARROW  IPT-D CD23-D CD45-D HLA-DR[**Last Name (STitle) **]
[**Name (STitle) 7736**]7-D KAPPA-D CD2-D CD7-D CD10-D CD19-D CD20-D LAMBDA-D CD5-D

[**2130-3-16**] 09:00PM   CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-2.0 URIC
ACID-5.1
LD(LDH)-580* GLUCOSE-89 UREA N-16 CREAT-0.7 SODIUM-136
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-26 ANION GAP-13

Diagnostics and Imaging:

Bone Marrow Cytogenetics [**3-17**]:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a non-Hodgkin
lymphoma are not seen in specimen. Correlation with clinical
findings and morphology (S09-[**Numeric Identifier 12953**]) is recommended. Flow
cytometry immunophenotyping may not detect all lymphomas as due
to topography, sampling or artifacts of sample preparation.

TTE [**3-17**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal. Quantitative (3D) LVEF = 63%. Transmitral and tissue
Doppler imaging suggests normal diastolic function, and a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. 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 regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion.

IMPRESSION: Normal global and regional biventricular systolic
function.

CT TORSO [**3-17**]:
Several enlarged lymph nodes within the axilla, mediastinum, and
abdomen. The largest of these are located within the axilla.
There is
massive splenomegaly. Additionally, there are numerous small
liver
lesions as described above. Overall, these findings are
consistent with
lymphoma.

BM IMMUNOPHENOTYPING [**3-18**]:
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells comprise 9% of lymphoid-gated events, are polyclonal,
and do not express aberrant antigens.
T cells comprise 68% of lymphoid gated events, express mature
lineage antigens.

INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by a Non-Hodgkin
lymphoma are not seen in specimen. Correlation with clinical
findings and morphology (see S09-[**Numeric Identifier 12953**]; ) is recommended.  Flow
cytometry immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.

PATHOLOGY:
SPECIMEN #1: RIGHT AXILLARY LYMPH NODE, EXCISIONAL BIOPSY
(SLIDES LABELED S09-1787 FROM [**Hospital3 **], [**Location (un) **], MA; FROM
PROCEDURE DATE [**2130-3-8**])
DIAGNOSIS:
HODGKIN LYMPHOMA, NODULAR LYMPHOCYTE PREDOMINANT TYPE, SEE NOTE.
Note: H&E sections show nodal tissue with a vaguely nodular
infiltrate and abundant sclerosis.  The infiltrate consists of a
background of small lymphocytes, plasma cells, and histiocytes
harboring many large atypical cells with abundant vesicular
chromatin, multiple nuclear lobulations, multiple nucleoli, and
scant pale cytoplasm (L&H or popcorn cells).  By
immunohistochemistry performed at [**Hospital1 18**], CD45 is panreactive.
CD20 stains the expanded follicles and highlights L&H cells, as
well as remaining germinal center and interfollicular B cells.
CD15 and CD30 are largely negative within the infiltrate, with
positive internal controls.  Both [**9-8**] and Bob1 are expressed by
the L&H cells.  CD21 highlights few expanded follicular
dendritic cell meshworks.  CD3, CD4, CD5, and CD8 all highlight
background expanded T lymphocytes.  LMP-1 stain highlights rare
positive cell. MIB-1 highlights germinal centers - where the
proliferation fraction is high - as well as scattered large
cells within the expanded B cell nodules.
SPECIMEN #2:  SPLEEN, NEEDLE BIOPSY (SLIDES LABELED S09-1874
FROM [**Hospital3 **], [**Location (un) **], MA)
DIAGNOSIS:
SPLENIC PARENCHYMA WITH MULTIPLE GRANULOMAS. DEFINITIVE
MORPHOLOGIC OR IMMUNOPHENOTYPIC EVIDENCE OF LYMPHOCYTE
PREDOMINANT HODGKIN LYMPHOMA IS NOT SEEN.
Note: H&E sections show several small cores of splenic tissue
with multiple lymphohistiocytic aggregates, which in some areas
coalesce into well-formed granulomas with occasional giant
cells. There are scattered large atypical cells in a background
of lymphocytes, plasma cells, and histiocytes.  However, L&H
cells are not identified. Special stains for acid fast bacteria
and fungus (AFB, PAS, GMS, Giemsa) are all negative for
microorganisms with adequate controls.

Of note, splenic involvement by lymphocyte predominant Hodgkin
lymphoma is infrequent and when present it is usually not a
cause of splenomegaly, let alone massive splenomegaly. Rarely,
however, LP HL can behave clinically in a more aggressive manner
with widespread dissemination to bone marrow and other sites.
Please correlate with other clinical, laboratory and imaging
findings.

MICRO:
   CRYPTOCOCCAL ANTIGEN (Final [**2130-3-24**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.

   HIV-1 Viral Load/Ultrasensitive (Final [**2130-3-21**]):
      HIV-1 RNA is not detected.

   HCV VIRAL LOAD (Final [**2130-3-20**]):
      HCV-RNA NOT DETECTED.

   CMV Viral Load (Final [**2130-3-19**]):
      CMV DNA not detected.

   HBV Viral Load (Final [**2130-3-27**]):
      HBV DNA not detected.

BRUCELLA IGG                  0.03
BRUCELLA IGM                  0.06
REFERENCE RANGE: <0.80

COCCIDIOIDES ANTIBODY, ID     NEGATIVE

EBV PCR:
NA         EBV genomes/10(5) lymphocytes
Remarks:
Expected Results:
-----------------
  Using a modified protocol, the copy number of EBV genomes in
latently
infected adults has been estimated to be 0.1 copies/10(5)
lymphocytes.
Therefore, latency falls below the sensitivity of this assay.
The expected
result for a normal healthy adult with latent EBV infection is
"not detected"
(nd).
  Note: Failure to amplify is reported as "Not Amplifiable" (NA)
and differs
from "not detected".

Histoplasma Quantitative Antigen EIA
Result:  None Detected ng/ml(-)


Brief Hospital Course:
33M with a history of narcotic abuse who presented w 3 months of
fevers, nightsweats, LAD and splenomegaly found to be
pancytopenic upon presentation and subsequently diagnosed with
Hodgkins Lymphoma.
.
# Nodular Lymphocyte Predominant Hodgkins Lymphoma. Review of
path from OSH axillary LN biopsy was consisitent with nodular LP
HL. Bone marrow biospy was not consistent with bone marrow
involvement. The patient was placed on steroids and then
received one cycle of [**Doctor Last Name **]-dexa. He tolerated this regimen
without significant complication although he became quite
uncomfortable once steroids were stopped. As a result, he was
placed on a steroid taper which he was instructed to continue to
taper at his time of discharge. His nightsweats had largely
resolved and he was afebrile for >48 hours at the time of
discharge.
.
# Hepatosplenomegaly. Patient had a splenic biospy at the OSH
which was reviewed by [**Hospital1 18**] pathology and found to contain
granulomas which were concerning for infectious vs
lymphoma-related process. Infectious Disease was consulted and
recommended several viral PCRs as well as serologies be sent.
These results were all negative for a particular etiology and
are contained in the results section of this document. Given
concern for non-specific infectious process status-post
chemotherapy, the patient was started empirically on fluconazole
and levofloxacin. He developed worsening LFT abnormalities as
well as hyperbilirubinemia which improved when fluconazole was
stopped. He was discharged on levofloxacin and asked to continue
taking it until further discussion with his outpatient
oncologist. The patient's LFTs remained elevated throughout his
hospitalization but were trending toward normal at his time of
discharge. This was also thought to be related to infectious vs
lymphoma-related process but was not entirely clear at his time
of discharge and was to be closely followed up on as an
outpatient.
.
# Fevers. The patient had daily fevers until after completion of
chemotherapy during which time he defervesced until his time of
discharge. He was asked to return should he become febrile again
at home. Given his defervescence after chemotherapy in the
setting of multiple negative cultures, it was felt that his
initialy fevers were related to his lymphoma.
.
# Pain. Given patient's history of narcotic abuse, care was
taken to limit narcotic medications. The patient clearly had
significant pain related to his abdominal distention from his
spleen which required low dose morphine SR with IR for
breakthrough pain. He was discharged with a limited script for
these medications with a plan for down-titration with resolution
of his HSM in the setting of lymphoma treatment.
.
On [**3-28**], the patient was afebrile and otherwise hemodynamically
stable with a plan for close follow up in place. He was
therefore discharged to home.


Medications on Admission:
Klonipin 1mg TID.

Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
5. Prednisone 5 mg Tablet Sig: ASDIR Tablet PO once a day for 5
days: Take 4 pills (20mg) on [**3-29**]. Take 2 pills (10mg) on [**3-30**]
and [**3-31**]. Take 1 pill (5mg) on [**4-1**] and [**4-2**]. .
Disp:*10 Tablet(s)* Refills:*0*
6. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours) for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
8. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for 3 weeks.
Disp:*25 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Lymphocyte Predominant Hodgkin Lymphoma with massive
hepatosplenomegaly

Secondary:
History of Narcotic Abuse


Discharge Condition:
Hemodynamically stable with normal vitals and plan for follow up
in place.


Discharge Instructions:
You were admitted to the hospital for diagnosis and further
management of your fever, nightsweats, and abdominal swelling.
You were found to have lymphocyte-predominant Hodgkin lymphoma
causing expansion of your liver and spleen. A bone marrow biopsy
showed that your bone marrow was not involved.

You had 1 cycle of chemotherapy targeted toward your type of
lymphoma. You will need to have 5 more cycles of treatment.
These treatments last a couple of hours and can be done as an
outpatient. Each treatment is 3 weeks from the prior. You will
however need more frequent monitoring of your blood counts and
liver function.

Medication changes:
You should take levofloxacin (an antibiotic) daily to prophylax
against infection.
You should take morphine sustained release twice per day to
prevent pain. You may take morphine immediate release for
breakthrough pain not adequately controlled by the sustained
release medication.
You should complete a steroid taper as outlined in the
prescription provided for you.
You should take protonix while on steroids to protect your
stomach.
You should take a stool softener while taking narcotic
medications to prevent constipation.

Please call your primary doctor or Dr. [**First Name (STitle) **] or go to the ED
should you experience fevers >100.4, cough, nightsweats, chest
pain, shortness of breath, worsening abdominal pain, pain with
urination, changes to your bowels, or any other concerning
symptoms.

Because your spleen is so enlarged, you are at increased risk
for splenic rupture. You should not engage in any heavy labor or
sports.

Followup Instructions:
Please follow up at the following appointments:

[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Location (un) 436**] [**Hospital Ward Name 1826**] Building [**2130-3-30**] 11:30

[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Location (un) 436**] [**Hospital Ward Name 23**] Building
([**Telephone/Fax (1) 3241**]) [**2130-4-3**] 1:00pm (this appointment is for blood
work)

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Location (un) 436**] [**Hospital Ward Name 23**] Building ([**Telephone/Fax (1) 3237**])
[**2130-4-3**] 1:00





Admission Date:  [**2130-3-31**]              Discharge Date:   [**2130-4-30**]

Date of Birth:  [**2096-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Bee Pollen / Gadolinium-Containing Agents

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

Major Surgical or Invasive Procedure:
Splenectomy


History of Present Illness:
This 33 yo male with new diagnosis of lymphocyte predominant
Hodgkin's Lymphoma who presented on day 11 status post CHOP with
one day of fever to 101.4 F and chills.  The patient reported
worsening of his chronic abdominal pain from [**2131-5-14**] to [**9-16**]
over the preceding days but denied any other localizing symptoms
particularly denying shortness of breath, cough, nausea,
vomiting, dysuria, hematuria, or skin changes.  He continued to
have normal bowel movements including one on the morning of
admission. Generally, he reported feeling anxious and agitated
on being back in the hospital.

In the ED, initial vitals were Tmax 102.2, BP: 153/103, HR: 120,
O2sat: 98%RA . Labs were notable for ANC of 36 and elevated
liver enzymes with ALT 243, AST 78, AP 260, and a normal T Bili
of 1.1 (stable from daily outpatient labs). Hct was 24.9 and
platelets 35K which are also stable from his recent discharge.
In the ED blood cultures were drawn and he was given 2 gm IV
cefepime as well as 3 L of IVF . He underwent CXR which showed
atelectasis and question of pneumonia per ED read. CT
abdomen/pelvis was performed given his chronic abdominal pain
and demonstrated stable splenomegaly and LAD. It also showed
mildly dilated loops of small bowel which contained oral
contrast, which could possibly represent early partial SBO vs
early ileus.  He received acetaminophen, ondansetron, and
hydromorphone as well and was admitted for further management.

REVIEW OF SYSTEMS: As per HPI he reported agitation, chills, and
fever.  He denied cough, dyspnea, chest pain, palpitations,
change in bowel or bladder habits, melena, hematochezia,
dysuria, hematuria, or rashes.


Past Medical History:
ONCOLOGIC HISTORY
==================
Lymphocyte Predominant Hodgkin's Lymphoma
-[**2129-12-8**]: Developed B symptoms (chills, fevers, and night
sweats) and left sided abdominal mass while incarcerated
-[**2130-2-5**]: presented to [**Hospital **] Hosp with fever, pancytopenia,
and elevated LDH, He had a thoracentesis for effusion and a
spleen biopsy prior to being transferred to [**Hospital1 18**] for further
management
-[**2130-3-16**]: Arrived at [**Hospital1 18**], pathology found to be consistent with
lymphocyte predominant Hodgkin's Lymphoma, He received his first
cycle of CHOP starting on [**2130-3-20**] and discharged on [**2130-3-26**]

PAST MEDICAL HISTORY:
====================
- History of MRSA cellulitis of the right lower extremity
- Eczema
- Depression
- Pyloric sphincterotomy as an infant

Social History:
Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously
worked in construction, smoked one pack of cigarettes daily
prior to going into prison, endorses h/o marijuana use and also
reports that he has had problems with opioid addiction, using
over 80mg of oxycontin several times a day, ending 2 years ago.
He was treated with suboxone for several months, but prior to
this hospitalization, he had not taken any narcotics in the last
2.5 months. Denies IV drug use.


Family History:
Mother with diabetes. No family history of cancer in first
degree relatives.

Physical Exam:
On Admission:
Vitals - T: 98.4 BP: 122/79 HR: 114 RR: 16 02 sat: 98% on RA
GENERAL: NAD, mildly anxious but easily consoled
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: increased rate, regular rhythm, normal S1/S2, no mrg
LUNG: CTAB
ABDOMEN: distended, hyperactive BS, mildly tender in all
quadrants, no rebound/guarding, massive splenomegaly
M/S: moving all extremities well, no cyanosis, clubbing, +1
non-pitting edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact

Pertinent Results:
LABORATORY RESULTS
==================
Admission labs:
WBC-0.5* RBC-3.20* HGB-8.8* HCT-26.3* MCV-82 RDW-20.3*
--N 12*, LYMPHS-80* MONOS-6 BASOS-2 NUC RBCS-8*
Na 136, K 4.4, Cl 100, HCO3 25, BUN 24*, Cr 0.7
ALT-301* AST-105* LD(LDH)-392* AlkPhos-262* TotBili-1.1

On Discharge:
WBC-5.8 RBC-3.09* Hgb-8.8* Hct-27.3* MCV-89 RDW-19.8* Plt
Ct-470*
---Neuts-94* Lymphs-1* Monos-4 Promyel-1*
Na 139, K 4.5, Cl 103, HCO3 24, BUN 48*, Cr 1.8*, Glu 108*
-Calcium-8.8 Phos-4.8* Mg-2
ALT-125* AST-55* LD(LDH)-444* AlkPhos-391* TotBili-0.3

MICROBIOLOGY
============
-Numerous blood and urine cultures negative.
-CMV Viral Load [**2130-4-5**], [**2130-4-18**], [**2130-4-27**]: Not detected
-Blood cryptococcal antigen [**2130-4-7**]: Not accepted
-EBV PCR [**2130-4-5**]: Not detected
-B Glucan [**4-3**], [**4-7**], [**4-18**]: Negative
-Galactomannan [**4-3**], [**4-7**], [**4-18**]: Negative
-Bartonella Antibody Panel [**2130-4-4**]: Negative
-Human Herpes Virus 6 PCR [**2130-4-27**]: Not detected
-HSV 1 and 2 IgG and IgM Ab test [**2130-4-21**]: Negative
-Coxiella Antibody Screen [**2130-4-5**]: Negative

PATHOLOGY
==========
Shave Biopsy of Left Ring Finger [**2130-4-7**]:
DIAGNOSIS:
Skin, left ring finger:
- Verruca vulgaris, see note.
Note: There is superimposed bacterial infection.

Spleen, Omentum, and Liver [**2130-4-11**]:
DIAGNOSIS:
I.  Splenule (A):
Nodule of splenic tissue with extramedullary hematopoiesis and
prominent interstitial histiocytes.
II.  Omentum (B-C):
Unremarkable fibroadipose tissue.
III.  Spleen, total splenectomy ([**2105**] grams) (D-I, M-U) and  VI.
Splenic tissue, biopsy (L):
Massive splenomegaly with extensive red pulp congestion,
fibrosis and extramedullary hematopoiesis (see note 1).
Multiple vascular thrombi.
Focal splenic infarction and geographic necrosis.
Lymphohistiocytic aggregates and necrotizing granulomas.
Hilar lymph node with atypical lymphoid infiltrate (see note 2).
-Note 1: H&E sections of splenic tissue demonstrate marked red
pulp congestion with extensive interstitial fibrosis. There is
extensive extramedullary hematopoiesis throughout with
megakaryocytes as well as erythroid islands; erythroid
precursors are markedly dyspoietic with asymmetric nuclear
budding noted. Additionally, sections from the grossly visible
necrotic area shows a large area of geographic necrosis. In many
areas, blood vessels with thrombi, including organizing thrombi
are noted; some are recanalized. The white pulp is attenuated
with occasional scattered larger lymphoid cells noted in a
background of smaller lymphocytes and histiocytes. Scattered
histiocytes with ingested hematopoietic precursors
(hemophagocytic histiocytes) are seen. Several scattered
ill-defined lymphohistiocytic aggregates are seen with prominent
central karyorrhectic debris (also noted in perihilar connective
tissue). Some form focal granulomas, including an occasional
large necrotizing one with palisading histiocytes (slide M).
Gamna-Gandy bodies are also noted.
Special stains for microorganisms (acid fast bacilli, fungal and
parasite: AFB, GMS, and Giemsa) are negative with adequate
controls.
By immunohistochemistry performed on block from splenic section
H, LCA (CD45) highlights scattered lymphoid cells. B-cell
markers CD20, PAX-5, and CD79a highlight few scattered, and
occasional loosely clustered B-cells, including a few larger
forms. A subset express bcl-6.  The cells do not express CD30 or
CD15.  CD3 highlights numerous reactive small T lymphocytes,
which are a mixed population of CD4 and CD8 positive cells
(ratio of [**1-10**]:1).  CD57 highlights few scattered germinal center
T cells.  CD21 (DRC) is negative.
CD31 and Factor 8 highlight vascular endothelia. CD8 highlights
dilated sinusoids, which are focally widely separated with
extensive fibrosis in the intervening areas. MPO highlights
numerous granulocytes, while CD68 stains histiocytes.  The
proliferation fraction, measured by Ki-67 (MIB-1) ranges from 10
to 50%, overall 30%.
Overall, the findings are of congestive splenomegaly with
extensive extramedullary hematopoiesis. Several thrombosed
vessels are also noted, and concurrent radiology reports show
nodal masses encompassing portal venous system. The exact
etiology of the splenomegaly and vascular thromboses is
uncertain but possibilities include chronic portal venous
congestion either due to external compression from nodal masses,
or alternatively the possibility of an underlying thrombophilic
condition leading to vascular thromboemboli needs to be
evaluated. The finding of extensive extramedullary
hematopoiesis, which along with fibrosis appears to be the
dominant cause of splenomegaly, is unusual, and correlation with
clinical, cytogenetic, and bone marrow findings to exclude a
possible underlying myeloproliferative disorder is needed.
-Note 2: Sections of hilar lymph nodes show extensive sclerosis
with only scattered lymphoid nodules remaining. By
immunohistochemical staining performed on lymph node block S, a
focal are of large atypical cells with markedly convoluted
nuclei and prominent nucleoli are noted on CD20 immunostaining.
These are CD30 negative (occasional immunoblasts staining). CD15
highlights neutrophils with no aberrant staining seen. Given the
patient's known history of recently diagnoses, partially
treated,  nodular lymphocyte predominant Hodgkin lymphoma, the
findings are suspicious for residual involvement by the same.
IV.     Liver, left lobe, needle core biopsy (J) (reviewed by
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 10165**]):
1.  Moderate portal and lobular lymphoid infiltrate with
prominent sinusoidal pattern with cells consistent with
extramedullary hematopoiesis.
2.  Lobular regeneration with microscopic foci of necrosis with
hemorrhage.
3.  Minimal steatosis.
4.  Trichrome stain shows mild portal fibrosis.
5.  Iron stains shows moderate iron deposition in hepatocytes
and Kupffer cells.
6.  No micro organisms seen on special stains (AFB, GMS, PAS-D).
V.     Liver, right lobe, needle core biopsy (K) (reviewed by
Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10165**]):
1.  Moderate portal and lobular lymphoid infiltrate with
prominent sinusoidal pattern with cells consistent with
extramedullary hematopoiesis.
2.  Lobular regeneration with microscopic foci of necrosis with
hemorrhage.
3.  Minimal steatosis.
Note:  The findings in both biopsies are similar.  There are
some atypical lymphoid cells which have been evaluated by (see
hematopathology note).  The main finding in these biopsies is
the finding of extra-medullary hematopoiesis.  However, there
are microscopic foci of necrosis, the etiology of which cannot
be determined.  Clinical correlation is suggested.  Dr. [**Last Name (STitle) **].
[**Doctor Last Name 10165**] reviewed Parts IV and V.
Hempath note (for liver biopsy):  Diagnostic features of
lymphoma are not seen.  See note.
Note:  Although several periportal and lobular lymphoid
infiltrates are seen, no large cells or L&H variants are noted.
By immunohistochemistry CD20 and PAX5 highlight few scattered,
predominantly small B lymphocytes.  A majority of the
lymphocytes are CD3 positive T cells.  No CD57 positive germinal
center T cells are present.  CD30 is not aberrantly expressed.
CD45 is diffusely immunoreactive in lymphoid cells.

Spleen Immunophenotyping [**2130-4-11**]:
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
B cells are scant in number.
T cells comprise 97% of lymphoid gated events and express mature
lineage antigens.
-INTERPRETATION
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by B-cell non-Hodgkin
lymphoma are not seen in specimen. Correlation with clinical
findings and morphology (see S09-[**Numeric Identifier 82514**]) is recommended. Flow
cytometry immunophenotyping may not detect all lymphomas as due
to topography, sampling or artifacts of sample preparation

Bone Marrow Biospy [**2130-4-21**]:
==============    DIAGNOSIS     ============

SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS: HYPERCELLULAR BONE MARROW WITH MYELOID AND
MEGAKARYOCYTIC HYPERPLASIA AND FREQUENT HEMOPHAGOCYTIC
HISTIOCYTES HIGHLY SUGGESTIVE OF HEMOPHAGOCYTIC
LYMPHOHISTIOCYTOSIS (HEMOPHAGOCYTIC SYNDROME).  THERE IS NO
MORPHOLOGIC EVIDENCE OF LYMPHOCYTE PREDOMINANT HODGKIN LYMPHOMA.
SEE NOTE

Native Renal Biopsy [**2130-4-27**]:
DIAGNOSIS:
Renal biopsy, needle: Consistent with acute tubular injury
("ATN"), see note.
Note:
Light Microscopy: The specimen consists of renal cortex and
medulla, containing approximately 22 glomeruli, of which 0 are
globally sclerotic.  Some [**Hospital1 **] show ischemic type changes, the
remainder are within normal limits.
Patchy widespread interstitial edema is present.  There is
minimal interstitial fibrosis and tubular atrophy.  Minimal
chronic inflammation accompanies the scarring.  Tubules show
vacuolar change, as well as intralumenal necrotic debris and red
blood cells; other signs of acute injury, including occasional
single-cell necrosis are also seen.
Arteries show minimal-mild intimal fibroplasia.
Arterioles show mild mural thickening, with prominent hyaline
change.
-Immunofluorescence:  The specimen consists of renal cortex,
containing approximately 4 glomeruli, of which 0 are globally
sclerotic.  There is 0-trace mesangial staining for IgA, IgM,
C3, fibrin, Kappa, and Lambda.  IgG and C1q are negative.
2+C3 is seen along tubular basement membranes and in vessels.
Albumin is non-contributory.
-Comment:
1.  The amount of deposition is too limited for a diagnosis of
IgA nephropathy.
2.  The degree of arteriolar hyalinosis is noteworthy.
3.  Clinical correlation is necessary to determine the cause(s)
of this process.

OTHER STUDIES
==============
Chest Radiograph [**2130-3-31**]:
IMPRESSION:
Linear area of increased opacity at the left lung base. By
morphology this
is likely atelectasis though an early infectious process is not
excluded and should be correlated to the clinical presentation

CT Abdomen and Pelvis W/Contrast [**2130-3-31**]:
IMPRESSION:
1. Overall, minimal change since [**2130-3-17**] with massive
splenomegaly and lymphadenopathy, which was better demonstrated
on the previous study,
compatible with lymphoma. Previously noted hypodensities within
the liver are not as well imaged on the current study due to
different phase of imaging.
2. Mildly dilated loops of small bowel which contain oral
contrast. This
finding may represent a pseudo- obstruction, but early or
partial
small bowel obstruction is not completely excluded. Repeat
imaging can be
performed to assess for passage of oral contrast into the colon.


CT Chest W/O Contrast [**2130-4-3**]:
IMPRESSION:
1. Bibasilar atelectasis and interval development of new
ground-glass nodular opacities in the right upper lobe which are
worrisome for infection. Viral or atypical bacterial pneumonia
is favored.
2. Stable mediastinal lymphadenopathy and slightly improved
right axillary
lymphadenopathy.
3. Interval enlargement of 3-cm well-circumscribed fluid
collection in the
right axilla which may represent a necrotic lymph node versus a
post-biopsy seroma. Clinical correlation is recommended.
4. Hepatosplenomegaly and a small amount of perisplenic fluid,
unchanged

MRI Abomen W and W/O Contrast [**2130-4-5**]:
IMPRESSION:
1. Hepatosplenomegaly with heterogeneous signal and enhancement
of both liver and spleen probably due to lymphoma. No focal
liver or splenic mass or evidence of abscess is seen.
2. Dropout of signal in both liver and spleen on longer echo
gradient echo
imaging, likely due to iron overload from blood transfusions.
3. Nodal mass surrounding portal vein and celiac access is as
previously
seen.
4. Left lower lobe consolidation/atelectasis persist.
5. Given the patient's multiple other medication allergies as
well as
development of rash immediately after administration of
gadolinium,
premedication for allergic reaction would be recommended should
the patient again receive IV gadolinium. This was discussed with
Dr. [**Last Name (STitle) 4369**].

Ankle Radiograph [**2130-4-9**]:
IMPRESSION:
1. Diffuse soft tissue swelling about ankle.
2. Extreme posterior calcaneus is excluded from the film.
Allowing for this, no fracture or suspicious bone lesion
detected involving the left ankle.
3. Minimal spurring of the distal tibia without other evidence
of
degenerative change.

Chest Radiograph [**2130-4-10**]:
FINDINGS: In comparison with the study of [**4-2**], there is some
progressive
decrease in opacification at the left base. Blunting of both
costophrenic
angles and bibasilar atelectasis persists in this patient with
low lung
volumes.

Bilateral Lower Extremity Ultrasounds [**2130-4-10**]:
IMPRESSION: No lower extremity DVT.

Chest Radiograph [**2130-4-17**]:
FINDINGS: In comparison with the study of [**4-10**], there is now
increasing
opacification at the left base. This appears to be consistent
with pleural
effusion and some underlying atelectasis. The possibility of
superimposed
pneumonia can certainly not be excluded. Streak of atelectasis
overlying the cardiac border on the lateral view is unchanged.

Transthoracic Echocardiogram [**2130-4-18**]:
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.

Chest Radiograph [**2130-4-18**]:
IMPRESSION: AP chest compared to [**4-17**]:
Left lower lobe is still consolidated but volume loss is not as
severe. Mild pulmonary edema, progressive moderate cardiomegaly
and small-to-moderate bilateral pleural effusions are new
indicating cardiac decompensation.

CTA of Chest W and W/O Contrast [**2130-4-18**]:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate-sized bilateral pleural effusions and compressive
atelectasis,
new since the prior study.
3. Stable enlarged mediastinal, internal mammary, and right
axillary lymph
nodes consistent with the patient's history of Hodgkin's
lymphoma.
4. 3.3-cm fluid-filled structure in the right axilla, slightly
enlarged
compared to the prior study and may represent a necrotic lymph
node versus a post-biopsy seroma.
5. Interval increase in abdominal ascites status post
splenectomy.

CT Abdomen and Pelvis W/Contrast [**2130-4-19**]:
IMPRESSION:
1. New right pleural effusion and increased left pleural
effusion with
associated relaxation atelectasis; pneumonia cannot be excluded.

2. Interval splenectomy with splenic vein clot. Fluid
collectionin splenic
bed.
3. Focal hypodense hepatic lesions likely secondary to lymphoma
although
another process such as disseminated fungal infection cannot be
excluded. See the MR of [**2130-4-5**] for further details.
4. Mildly dilated loops of contrast-filled small bowel likely
due to pseudo- obstruction. If clinically indicated could
consider reimaging later to assure expected progression of
contrast.

Liver/GB Ultrasound [**2130-4-20**]:
IMPRESSION:
1. Slight prominence of the common duct, measuring 8 mm.
However, the
extrahepatic common bile duct remains normal in caliber,
measuring 6 mm, and there is no intrahepatic biliary ductal
dilatation seen. The gallbladder is unremarkable, without
evidence of stones.
2. Trace perihepatic ascites.
3. Innumerable hypodense liver lesions not visualized
son[**Name (NI) 5326**].

Chest Radiograph [**2130-4-22**]:
FINDINGS: Cardiomediastinal contours are unchanged. Slight
improved aeration at the right lung base but no significant
change in patchy and linear opacities at the left base. These
findings favor atelectasis as reported on recent chest CT.
Persistent small bilateral pleural effusions.


Brief Hospital Course:
33 year male with new diagnosis of lymphocyte predominant
Hodgkin's Lymphoma now status post one cycle of CHOP presenting
with fever and persistent abdominal pain now dramatically
improved status post splenectomy.

1) Fevers of Unknown Origin: The patient presented with
neutropenic fevers and worsening abdominal apin.  Given he was
neutropenic at the time he was admitted to the oncology service
and treated with multiple broad spectrum antimicrobials
including cefepime, aztreonam ([**Date range (1) 27094**]), vancomycin([**Date range (1) 22023**]),
metronidazole ([**Date range (1) 82515**]), azithromycin ([**Date range (1) 82516**]), and
voriconazole ([**Date range (1) 82517**]) and never had abatement of his fevers.
His neutropenia resolved on [**2130-4-7**].  All blood cultures were
benign and there was no clear urinary or pulmonary source of
infection.  Work up did reveal multiple liver hypodensities but
work up for granulomatous diseases was similarly negative.
Eventually, given the largely negative work-up primary suspicion
was for non-infectious sources of fever.  Therefore, the patient
was started on a steroid taper and had a splenectomy as his
splenomegaly was thought to be contributing to his persistent
abdominal pain and intraoperative biopsies would help with
diagnostic evaluation.  Therefore, he had a splenectomy on
[**2130-4-11**].  Following splenectomy and while on steroid taper the
patient did well and from [**Date range (1) 82518**] he was afebrile
(antibiotics had been stopped on [**2130-4-14**]).  Unfortunately, on
[**2130-4-17**] he once again had fevers and was restarted on broad
spectrum antibiotics (aztreonam/vancomycin then levofloxacin).
From [**2130-4-17**] to [**2130-4-21**] the patient once again was persistently
febrile with no localizing signs of acute infection  and
persistently negative cultures (though pneumonia was suspected
due to his respiratory issues).  On [**2130-4-21**], however, the
patient had an abrupt increase in his LFT's as well as acute
kidney injury.  When he developed yet another episode of acute
respiratory distress later in the day he was transferred to the
intensive care unit where he had a repeat bone marrow biopsy,
which along with the returning path from his splenectomy, and
the results of his labs (including a greater than assay ferritin
level) led to a diagnosis of hemophagocytic lymphohistiocytosis.


2) Hemophagocytic lymphohistiocytosis:  A presumptive diagnosis
of hemophagocytic lymphohistiocytosis was made on [**2130-4-21**] from
bone marrow biopsies showing hemophagocytosis and splenectomy
results as well as fulminant hepatic injury and the elevated
ferritin.  The patient was started on high dose steroids and
etoposide per protocol and after first doses, which were
adjusted for hepatic and renal dysfunction, was put on twice
weekly etoposide and a steroid taper.  With initiation of
therapy liver enzymes rapidly declined and fevers resolved. With
the initiation of transplant lab results dramatically improved
with liver enzymes and LDH trending downward. He tolerated the
steroid therapy and etoposide well. Work up for causes of HLH
included assays for HHV5, HSV1, HSV2, EBV, and CMV and all were
negative. Ultimately, most likely cause of HLH was considered to
be due to a paraneoplastic process from his underlying Hodgkin's
lymphoma. Given his improvement he was discharged to continue
twice a week etoposide and steroid taper as an outpatient. Plan
is to start cyclosporin per protocol as renal function improves.


3) Acute Kidney Injury: On the evening of [**2130-4-25**] the patient
reported dark colored urine*1. Subsequent urinalysis revealed
large heme but no RBC's. Initial concern was for rhabdomyolysis
but CK was normal. The following day as the patient was
diagnosed with HLH and his hemoglobinuria was presumed to be due
to the massive hemolysis precipitated by that syndrome.  From
[**Date range (1) 82519**] Cr also increased from 0.7 to 2. Presumed etiology
was thought likely to be contrast induced nephropathy and/or
pigment nephropathy from hemoglobinuria leading to acute tubular
necrosis. This was confirmed by urine sediment analysis, which
showed muddy brown casts. Cr improved improved to 1.8 at the
time of discharge with conservative management (primarily
avoidance of nephrotoxins). The patient did have some issues
with hyperkalemia after developing renal failure but never any
ECG changes and this resolved as renal function trended back
toward normal and the patient was put on a low K diet. Of note,
the patient's initial urine studies did show an increased
protein/Cr ratio suggesting significant proteinuria, which would
be atypical for acute tubular necrosis. Therefore, he had a
renal biopsy but the results of this were pending as of
discharge.  Repeat urine protein/Cr measurement was improved.

4)Respiratory Distress: The patient had two episodes of acute
respiratory distress on the floor on [**4-17**] and [**2130-4-21**].  These
were each in the context of rigoring from fever and reported
anxiety.  During the first work up showed hypoxia and chest
radiograph showed volume loss perhaps suggesting a collapsed
lobe.  The patient improved from both these incidents with
minimal direct management and his oxygen requirements simply
decreased to baseline each time. The ultimate etiology of his
hypoxia remained unclear.

5) Lymphocyte Predominant Hodgkin's Lymphoma: The patient
received one cycle of CHOP prior to presentation.  Initially,
given that this is generally a rather indolent disease it was
thought likely the cause of his splenomegaly but thought
unlikely to be the cause of his fevers and hemophagocytic
lymphohistiocytosis.  As his hospitalization progressed and
other etiologies of HLH were ruled out this was considered a
possible precipitant of the HLH.  Ultimately, etoposide does
have activity against Hodgkin's Lymphoma as well.  Further
specific treatment for his Hodgkin's lymphoma will be pending
treatment of his HLH.

6) Pain: The patient has a history of opioid abuse and chronic
abdominal pain thus complicating his pain management.  In
consultation with the pain management service in the context of
his splenectomy he was on PCA, which was then transitioned to
extended release morphine and hydromorphone PRN.  With these
interventions his pain steadily improved after his splenectomy
and he was discharged just on scheduled morphine SR for his
chronic abdominal pain.

7) Anxiety: The patient did complain of anxiety particularly
with uncertainty about his plan of care or medical situation but
also just in general from being hospitalized.  This responded
well to standing and PRN clonazepam with minimal sedation or
other side effects.

He received SC heparin for DVT prophylaxis and PPI for GI
prophylaxis.  He was full code.  He was tolerating a full diet
as of the time of discharge.


Medications on Admission:
1. Clonazepam 1 mg PO TID
2. Pantoprazole 40 mg daily
3. Docusate Sodium 100 mg [**Hospital1 **]
4. Levofloxacin 500 mg daily
5. Prednisone 10 mg [**3-31**] (steroid taper), due for 5mg [**Date range (1) 82520**]
6. Morphine 30 mg SR q12h
7. Simethicone 80 mg qid prn
8. Morphine 15 mg PO Q8H prn


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ML PO DAILY
(Daily).
Disp:*300 ML* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Dexamethasone 4 mg Tablet Sig: Five (5) Tablet PO once a day:
For the first 2 weeks the dose is 20 mg/day so you have one more
week on this dose. The dose will be adjusted per protocol by Dr.
[**First Name (STitle) **] and [**Doctor First Name **].
Disp:*150 Tablet(s)* Refills:*2*
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
-Hemophagocytic Lymphohistiocytosis
-Lymphocyte Predominant Hodgkin's Lymphoma
-Non-oliguric acute kidney injury (due to contrast nephropathy
and/or hemoglobinuria)
-Status post splenectomy
-Acute on Chronic abdominal pain


Discharge Condition:
Stable, not hypoxic on room air, with decreased abdominal pain,
without fevers.


Discharge Instructions:
You were admitted to the hospital because your spleen was
enlarged and you had fevers while your counts were low.  You
went on to have a splenectomy and briefly improved before having
fevers again and worsening liver enzymes.  This was caused by
your hemophagocytic syndrome.  We treated this with chemotherapy
and steroids.  You will need continued treatment as an
outpatient.  This is a rare syndrome and we are not entirely
sure what caused it, though we suspect it may be related to your
Hodgkin's Disease.

Your kidneys were also damaged while you were in the hospital
probably by a combination of the IV contrast dye you were given
and the pigment hemoglobin, which was released in large amounts
when your hemophagocytic syndrome was accelerating.  These have
begun to improve on their own and we expect them to make a full
recovery.  The nephrologists did a kidney biopsy to make sure
there was not another process going on in your kidneys.  The
results of this biopsy were still pending at the time of
discharge but can be managed as an outpatient.

Your medications have been changed.  Please take your
medications exactly as prescribed.  Please call your doctors and [**Name5 (PTitle) **] be seen in either the office or the ED if you have fevers,
chills, night sweats, progressive abdominal pain, decreased
urine output, shortness of breath, or any other concerning
changes in your health.

Followup Instructions:
Please follow up on 7 [**Hospital Ward Name **] outpatient on Tuesday at 3:30 pm
for Etoposide. Dr. [**First Name (STitle) **] will be the doctor on service at that
time. Follow up on Friday for Etoposide will also need to be
scheduled at that time.
{"Neutropenia, unspecified,Pneumonia, organism unspecified,Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of multiple sites,Paralytic ileus,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Fever presenting with conditions classified elsewhere,Abdominal pain, unspecified site,Other acute pain,Thrombocytopenia, unspecified,Other nonspecific abnormal serum enzyme levels,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Combinations of opioid type drug with any other drug dependence, unspecified,Other specified cardiac dysrhythmias,Other drugs and medicinal substances causing adverse effects in therapeutic use,Edema,Other chronic nonalcoholic liver disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Dysthymic disorder,Contact dermatitis and other eczema, unspecified cause"}


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: transferred for evaluation of fevers, chills, and
lymphadenopathy, and hepatosplenomegaly

PRESENT ILLNESS: 33 year old man with 3-4 months of chills, fevers, and drenching
night sweats. His symptoms started shortly after he quit
drinking and abusing narcotics, about 3 months ago, and he
initially attributed the chills and fevers to withdrawal.
However, the nightsweats have continued. He has also noticed an
abdominal mass, more prominent on the left side, which is
diffusely painful and which prevents him from taking a deep
breath if he lies down.
.
On arrival to [**Hospital **] Hosp ([**2130-3-6**]), he was febrile to 102.3,
pancytopenic with WBC 3.2, 17 bands, Hgb 7.7, as well as an LDH
of 700. He was transfused and a thoracentesis was performed for
pleural effusion (500 cc drained) and then spleen biopsy was
performed to evaluate his pancytopenia and lymphadenopathy. He
was then transferred to [**Hospital1 18**] for further evaluation and
management of suspected lymphoproliferative disorder.
.
In our ED, vital signs were T103 P103 BP114/71 R20 Sat95% ra.
.
REVIEW OF SYSTEMS:
(+) 13 lb weight gain in the last 2 months.
(-) Denied headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Denied recent change in bowel or
bladder habits. Denied dysuria. Denied arthralgias or myalgias.
Denied pruritus.

MEDICAL HISTORY: - h/o MRSA cellulitis of the right lower extremity
- eczema
- h/o depression
- pyloric sphincterotomy as an infant

MEDICATION ON ADMISSION: Klonipin 1mg TID.

ALLERGIES: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) /
Bee Pollen / Gadolinium-Containing Agents

PHYSICAL EXAM: T 99.3 BP140/80 HR99 RR22 96% RA
General - Resting comfortably in bed, no acute distress
HEENT - Sclera anicteric, MMM, oropharynx clear
Neck - Supple, JVP not elevated, no LAD
Pulm - CTA bilaterally; no wheezes, rales, or rhonchi
CV - tachy, normal S1/S2; no murmurs, rubs, or gallops
Abdomen - Well-healed midline epigastric surgical scar.
Normoactive bowel sounds; firm, mildly tender mass in the LUQ
extending along the left flank and to the pelvis, non-distended.
Ext - Small, appropriately tender incision in the right axilla.
Warm, well perfused, radial and DP pulses 2+; no clubbing,
cyanosis or edema
Neuro - CN II-XII intact in detail, full strength throughout.

FAMILY HISTORY: Mother with diabetes. No family history of cancer in first
degree relatives.

SOCIAL HISTORY: Incarcerated from [**Month (only) 404**] to [**Month (only) 958**] of this year, previously
worked in construction, smoked one pack of cigarettes daily
prior to going into prison, endorses h/o marijuana use and also
reports that he has had problems with opioid addiction, using
over 80mg of oxycontin several times a day, ending 2 years ago.
He was treated with suboxone for several months, but prior to
this hospitalization, he had not taken any narcotics in the last
2.5 months. Denies IV drug use. 

### Response:
{"Neutropenia, unspecified,Pneumonia, organism unspecified,Hodgkin's disease, lymphocytic-histiocytic predominance, lymph nodes of multiple sites,Paralytic ileus,Hyposmolality and/or hyponatremia,Acute kidney failure with lesion of tubular necrosis,Unspecified pleural effusion,Fever presenting with conditions classified elsewhere,Abdominal pain, unspecified site,Other acute pain,Thrombocytopenia, unspecified,Other nonspecific abnormal serum enzyme levels,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Combinations of opioid type drug with any other drug dependence, unspecified,Other specified cardiac dysrhythmias,Other drugs and medicinal substances causing adverse effects in therapeutic use,Edema,Other chronic nonalcoholic liver disease,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Dysthymic disorder,Contact dermatitis and other eczema, unspecified cause"}
