CHIEF COMPLAINT: Cough, malaise, hypotension

PRESENT ILLNESS: 56 year old man with a h/o AML s/p allo SCT in [**2143-6-16**] c/b
chronic skin and pulmonary GVHD treated with prednisone 10mg
daily. He reports 5-6 days of URI symptoms, myalgias, cough
productive of yellow sputum, decreased appetite, and poor PO
intake. No fevers, though he has been taking tylenol. He
presented to heme/onc clinic today and reported headache and
nausea with improved after 1L NS. He was afebrile but hypoxic to
90% on RA, which improved to 94% on 2L. Nasal swab and blood
cultures were sent. CXR was negative. He was given
vancomycin/aztreonam (due to cefepime allergy) and admitted for
further workup.
.
O2 sats were in the mid-80s on RA so he was placed on nasal
cannula and then shovel mask. 6pm ABG was: 7.46/37/69. Lactate
1.1.
.
Overnight pt became more hypoxic and tachypnic. Febrile to
101.8. Azithro was added to his abx. Chest CT [**First Name9 (NamePattern2) 5692**] [**Last Name (un) 22975**] tree
[**Male First Name (un) 239**] opacities and concern for brochiolitis/pneuonitis. BMT
wanted to give IVIG due to low IgG, but pt was too hypoxic.
Eventually 86% on NRB. [**Hospital Unit Name 153**] was called. Pt given albuterol x 1,
and CXR taken. Pt c/o resp fatigue. Transfered to ICU.
.
ROS:
(+) As noted above.
(-) No current chest pain, palpitations, SOB, abdominal pain,
N/V/D.

MEDICAL HISTORY: # Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on
warfarin
# Acute myeloid leukemia:
- [**3-/2143**]: diagnosed
- [**6-/2143**]: underwent a matched unrelated allogeneic stem cell
transplant.
- post-transplant course c/b bx-proven GVHD of the liver and an
intermittent skin rash, s/p management with cyclosporine,
mycophenolate, rituximab, and currently, steroids.
# type 2 DM: steroid-induced
# hyperlipidemia
# bilateral hip AVN
# HTN
# nephrolithiasis: s/p lithotripsy and previous nephrostomy tube

MEDICATION ON ADMISSION: MEDICATIONS:
- Acyclovir 400mg PO TID
- Atorvastatin 20mg daily
- Budesonide 3mg TID
- Folic acid 1mg daily
- Gabapentin 300mg QHS
- Oxycodone ER 40mg Q8h
- Hydromorphone 4mg; 0.5-1 tablet daily prn
- NPH 10units [**Hospital1 **]
- Humalog SS
- Metoprolol tartrate 12.5mg [**Hospital1 **]
- Pantoprazole 40mg [**Hospital1 **]
- Prednisone 10mg daily
- Bactrim 400mg-80mg Tablet daily
- Warfarin 2.5mg alternating with 5mg daily
- Calcium carbonate 648mg TID
- Cholecalciferol 1000unit daily
.
ALLERGIES:
- Cefepime
- Cipro

ALLERGIES: Cefepime / Cipro Cystitis

PHYSICAL EXAM: Admission physical exam
Vitals: 101.8 132/88 109 24 91% NRB FS 127
General: A&Ox3 but appears SOB, speaking full sentences
HEENT: dry MMM, clear OP, no scleral icterus
Neck: Supple, no masses
Lungs: Coarse breath sounds througout, no wheezes.
CV: Regular, nml S1/S2, no murmurs.
Abdomen: Soft, NT, ND, +BS
Extrem: Hands and feet warm and well perfused, no cyanosis, 2+
pedal pulses, no edema.
Neuro: CN grossly intact, strength and sensation grossly intact.

FAMILY HISTORY: Mother died suddenly in her 70s.
Father died of unknown cancer.
One sister has thyroid cancer.
One brother has diabetes.
One sister has [**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and son. [**Name (NI) **] is retired, worked as a [**Company 22957**]
technician
Tobacco - 40 pk year hx, quit 5 yrs ago.
EtOH - denies
Drug use - denies.
Influenza due to identified avian influenza virus with pneumonia,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Rash and other nonspecific skin eruption,Cystitis, unspecified,Backache, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Flu dt iden avian w pneu,Acute respiratry failure,Ac myl leuk wo achv rmsn,Compl marrow transplant,Chronc graft-vs-host dis,Sec DM wo cmp nt st uncn,Adv eff corticosteroids,Hypertension NOS,Hyperlipidemia NEC/NOS,Obstructive sleep apnea,Hx-ven thrombosis/embols,Long-term use anticoagul,Nonspecif skin erupt NEC,Cystitis NOS,Backache NOS,Abn react-procedure NEC
Admission Date:  [**2147-1-27**]              [**Year/Month/Day **] Date:   [**2147-2-12**]

Date of Birth:  [**2090-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime / Cipro Cystitis

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Cough, malaise, hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
56 year old man with a h/o AML s/p allo SCT in [**2143-6-16**] c/b
chronic skin and pulmonary GVHD treated with prednisone 10mg
daily. He reports 5-6 days of URI symptoms, myalgias, cough
productive of yellow sputum, decreased appetite, and poor PO
intake. No fevers, though he has been taking tylenol. He
presented to heme/onc clinic today and reported headache and
nausea with improved after 1L NS. He was afebrile but hypoxic to
90% on RA, which improved to 94% on 2L. Nasal swab and blood
cultures were sent. CXR was negative. He was given
vancomycin/aztreonam (due to cefepime allergy) and admitted for
further workup.
.
O2 sats were in the mid-80s on RA so he was placed on nasal
cannula and then shovel mask. 6pm ABG was: 7.46/37/69. Lactate
1.1.
.
Overnight pt became more hypoxic and tachypnic. Febrile to
101.8. Azithro was added to his abx. Chest CT [**First Name9 (NamePattern2) 5692**] [**Last Name (un) 22975**] tree
[**Male First Name (un) 239**] opacities and concern for brochiolitis/pneuonitis. BMT
wanted to give IVIG due to low IgG, but pt was too hypoxic.
Eventually 86% on NRB. [**Hospital Unit Name 153**] was called. Pt given albuterol x 1,
and CXR taken. Pt c/o resp fatigue. Transfered to ICU.
.
ROS:
(+) As noted above.
(-) No current chest pain, palpitations, SOB, abdominal pain,
N/V/D.


Past Medical History:
# Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on
warfarin
# Acute myeloid leukemia:
- [**3-/2143**]: diagnosed
- [**6-/2143**]: underwent a matched unrelated allogeneic stem cell
transplant.
- post-transplant course c/b bx-proven GVHD of the liver and an
intermittent skin rash, s/p management with cyclosporine,
mycophenolate, rituximab, and currently, steroids.
# type 2 DM: steroid-induced
# hyperlipidemia
# bilateral hip AVN
# HTN
# nephrolithiasis: s/p lithotripsy and previous nephrostomy tube

and emergent surgery to repair ureteral damage
# BCC s/p excision
# SCC left cheek, s/p Mohs' [**5-/2144**]
# multiple back surgeries: L5-S1 surgery x 3, and cervical spine
fusion (bone graft, no hardware)
# anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and

C6-C7 [**2-/2144**]
# chronic numbness, neuropathic pain in left upper extremity
# multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4
# OSA: refused biPAP at home


Social History:
Lives with his wife, and son. [**Name (NI) **] is retired, worked as a [**Company 22957**]
technician
Tobacco - 40 pk year hx, quit 5 yrs ago.
EtOH - denies
Drug use - denies.

Family History:
Mother died suddenly in her 70s.
Father died of unknown cancer.
One sister has thyroid cancer.
One brother has diabetes.
One sister has [**Name (NI) 5895**].

Physical Exam:
Admission physical exam
Vitals: 101.8 132/88 109 24 91% NRB FS 127
General: A&Ox3 but appears SOB, speaking full sentences
HEENT: dry MMM, clear OP, no scleral icterus
Neck: Supple, no masses
Lungs: Coarse breath sounds througout, no wheezes.
CV: Regular, nml S1/S2, no murmurs.
Abdomen: Soft, NT, ND, +BS
Extrem: Hands and feet warm and well perfused, no cyanosis, 2+
pedal pulses, no edema.
Neuro: CN grossly intact, strength and sensation grossly intact.

[**Name (NI) **] physical Exam:
Please refer to daily progress note.

Pertinent Results:
ICU Admission Labs:
pH 7.45, pCO2 38, pO2 50 HCO3 27 from clotted sample
pH 7.42 pCO2 40 pO2 75 HCO3 27, on face mask 100%
Lactate:1.4
Ca: 8.7 Mg: 2.0 P: 2.7
ALT: 22 AP: 94 Tbili: 0.3
AST: 25 LDH: 292
MCV 108
wbc 3.1
plts 158
hct 41.9
N:79 Band:3 L:9 M:8 E:0 Bas:1
MB: 2  Trop-T: <0.01
================================================================
Pertinent Labs:
[**2147-1-27**] 11:15AM BLOOD IgG-61* IgA-19* IgM-15*
[**2147-1-27**] 11:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-27**] 09:57PM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-28**] 06:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2147-1-28**] 11:30AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-223*
[**2147-1-28**] 10:50AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- 0.1

[**2147-1-28**] 10:50AM BLOOD B-GLUCAN- <31 pg/mL
[**2147-1-29**] 04:30AM BLOOD PT-37.8* PTT-40.1* INR(PT)-3.9*
[**2147-1-30**] 04:04AM BLOOD PT-44.7* PTT-39.4* INR(PT)-4.8*
[**2147-2-5**] 02:58AM BLOOD IgG-523*
[**2147-2-9**] 05:54AM BLOOD Gran Ct-5040
[**2147-2-10**] 06:30AM BLOOD LD(LDH)-240
================================================================
Labs on [**Month/Day/Year **]:
[**2147-2-12**] 06:00AM BLOOD WBC-6.0 RBC-2.76* Hgb-10.0* Hct-29.4*
MCV-106* MCH-36.3* MCHC-34.1 RDW-16.5* Plt Ct-215
[**2147-2-12**] 06:00AM BLOOD PT-19.6* PTT-25.7 INR(PT)-1.8*
[**2147-2-12**] 06:00AM BLOOD Glucose-167* UreaN-14 Creat-1.0 Na-140
K-3.8 Cl-99 HCO3-34* AnGap-11
[**2147-2-12**] 06:00AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9
================================================================
Microbiology:
[**2147-1-27**] 12:00 pm Rapid Respiratory Viral Screen & Culture
      Source: Nasopharyngeal swab.
                            **FINAL REPORT [**2147-1-30**]**
   Respiratory Viral Culture (Final [**2147-1-30**]):
      TEST CANCELLED, PATIENT CREDITED.
      Refer to respiratory viral antigen screen and respiratory
virus
      identification test results for further information.
   Respiratory Viral Antigen Screen (Final [**2147-1-30**]):
      THIS IS A CORRECTED REPORT.
      Positive for Respiratory viral antigens.
      PREVIOUSLY REPORTED AS.
      Negative for Respiratory Viral Antigen [**2147-1-28**].
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      REPORTED BY PHONE TO [**Doctor Last Name **] FOREST AT 1135  [**2147-1-30**].
   Respiratory Virus Identification (Final [**2147-1-30**]):
      REPORTED BY PHONE TO S. FOREST 11.35A [**2147-1-30**].
      POSITIVE FOR INFLUENZA A VIRAL ANTIGEN.
         Viral antigen identified by immunofluorescence
[**2147-1-28**] 11:17 am   CMV Viral Load (Final [**2147-1-31**]): CMV DNA not
detected.
[**2147-2-3**] 4:07 am URINE Legionella Urinary Antigen  (Final
[**2147-2-3**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2147-2-5**] 6:10 pm SPUTUM      Source: Induced.
   GRAM STAIN (Final [**2147-2-5**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN CLUSTERS.
   RESPIRATORY CULTURE (Final [**2147-2-7**]):
      HEAVY GROWTH Commensal Respiratory Flora.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2147-2-6**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..
   FUNGAL CULTURE (Preliminary):
      YEAST.
[**2147-2-6**] 8:21 am Influenza A/B by DFA
      Source: Nasopharyngeal swab.
                            **FINAL REPORT [**2147-2-6**]**
   DIRECT INFLUENZA A ANTIGEN TEST (Final [**2147-2-6**]):
      Negative for Influenza A.
   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2147-2-6**]):
      Negative for Influenza B.
================================================================
Imaging
CTA chest [**1-28**] 1. Bibasilar bronchiectasis, unchanged compared
with yesterdays examination with mulktilobar peribronchovascular
ground-glass opacity with a tree-in-[**Male First Name (un) 239**] configuration. This
pattern is nonspecific infectious or inflammatory, and
consistent with small airways infection, atypical infections
including fungal infection such as aspergillosis.  2. There is
no pulmonary embolism.

Echocardiography [**1-30**]: Poor image quality. The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated with normal free
wall contractility. The ascending aorta is mildly dilated. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.


Brief Hospital Course:
56M with h/o AML s/p allo SCT c/b chronic skin/pulmonary GVHD,
who presented to clinic with URI symptoms, myalgias, and
decreased PO intake and was found to be hypoxic, admitted on
[**2147-1-27**] and discharged on [**2147-2-12**].

# Hypoxia: On admission was hypoxic to 90% on RA, febrile and
w/o leukocytosis then rapidly developed more profound hypoxia on
the floor. On transfer to the ICU required 100% non rebreather
mask. Underwent CTA which demonstrated multifocal tree-[**Male First Name (un) 239**]
opacities consistent with bronchiolitis and ruled out PE. Nasal
swab DFA Was positive for influenza. His high oxygen demand was
thought to be multifactorial with viral
bronchiolitis/pneumonitis and possibly exacerbation of
underlying chronic pulmonary GVH. Other contributing mechanisms
were atelectasis, under-recruitment and sleep apnea as evidenced
by his improved oxygenation with non-invasive positive pressure
ventilation. Significant Heart Failure was ruled out per [**Male First Name (un) 72257**] and
normal echocardiography. Patient was treated with Tamiflu 150mg
[**Hospital1 **] and will complete 10 days of treatment on day of ICU
[**Hospital1 **] (this increased dose and prolonged dose is as per
recent guidelines for Flu treatment in BMT patients). D/t to his
high risk of superinfection as well as possible LLL infiltrate
he was also covered with Abx: Vanco+Aztereonem+Azithro were
started on [**1-27**], on [**2-2**] aztreonem was changed to meropenem for
more wide spectrum coverage. Azithromycine was intially given
[**Date range (1) 72263**] and then restarted on [**2-2**] and continued untill
[**2-5**] when urine legionella returned neg. On day of ICU
[**Month/Year (2) **] patient is thus on day 11 of Vanco and day 5 of
Meropenem. Patient's home prednsione dose of 10mg daily was
increased to 40mg daily for suspected Acute on chronic pulmonary
GVHD, this was reduced back to home dose a day prior to ICU
[**Month/Year (2) **]. IVIG was given on [**1-30**] for hypogammaglobulinemia and
influenza infection without complications. Acyclovir and Bactrim
prophylaxis were continued. Patient continued to require 60-80%
of Oxygen throughout most of his ICU stay which we were able to
wean to 50% on non-invasive ventilation, but patient did not
tolerated this due to discomfort from the mask. Over the final
24h of his ICU stay his oxygemnation improved remarkably and on
ICU discharged O2 requirement is down to 4L through nasal canula
with Saturations >92%.  He was then transferred to the floor
with gradual improvement of his oxygenation as he completed the
antiviral ([**2-9**], 10 day course) and antibiotics ([**2-11**], 10 day
course).  He declined CPAP on the floor.  His O2Sat remained
stable and he was discharged with home oxygen.  He was
instructed to have follow up appointment with his doctor to
determine further need for oxygen requirement as his pneumonia
improves.

# AML: s/p SCT ([**6-/2143**]), c/b chronic GVHD of skin/lungs.
Patient was on higher dose of prednisone while in the ICU which
was tapered back to home dose of 10 mg by the time of transfer
from ICU to floor.  He remained on home prednisone and ID
prophylaxis with acyclovir and Bactrim.

# Hypogammaglobulinemia.  He received 0.4g/kg of IVIG on [**1-30**].
IgG on [**2-5**] improved to 523.  No additional IVIG was given.  His
level can be monitored in the outpatient setting.

# H/o PE:  Patient was intially supertheraputic d/t azithromycin
therapy, recieved vitamin K and warfarine was held. He then
became undertheraputic and was bridged with Lovenox. Warfarin
was restarted on [**2-3**] at 5mg daily, INR is 2.1 on day of ICU
[**Month/Year (2) **] and Lovenox was discontinued.  He continued with 5 mg
warfarin with INR beteween 2.0-2.3 until [**2147-2-11**] when INR
level dropped to 1.8 and he received a total of 7 mg warfarin on
the evening of [**2147-2-11**] with INR still at 1.8.  He was
instructed to take 7.5 mg of warfarin on Sunday and 5 mg of
warfarin on [**Year (4 digits) 766**] with lab on Tuesday in the outpatient
setting, so that his INR can be followed up by his doctor.
Adjustment of his warfarin is likely given recent
discontinuation of antibiotics.

# Type 2 DM.  Because of his poor po intake initially, NPH was
held.  As his appetite improved, his insulin was readjusted to
10 unit NPH [**Hospital1 **] and then to 12 unit NPH [**Hospital1 **] with insulin sliding
scale.  Patient reports that his home dose insulin is 12 units
and not 10 units [**Hospital1 **].  He was discharged on home dose NPH.

# Hypertension.  He continued with home metoprolol tartrate 12.5
mg [**Hospital1 **] as at home.

# Hyperlipidemia.  He continued with home atorvastatin 20 mg
daily.

# Previous EKG changes: Early in ICU course patient noted to
have transient lateral/posterior ST depressions in V4-V6, I and
AvL. With CE x 3 neg. and No CP. This was likely demand ischemia
in this patient with multiple coronary risk factors but no known
CAD.  He continued statin and beta blocker.  Consider outpatient
stress test.

# FEN.  Patient refused a diabetic diet and preferred regular
diet while on the floor.

# Access: PICC while in the hospital.

# Code status: Full Code, ICU consent done with wife/HCP [**Name (NI) 4457**], h
[**Telephone/Fax (1) 72264**], c-[**Telephone/Fax (1) 72265**]

Medications on Admission:
MEDICATIONS:
- Acyclovir 400mg PO TID
- Atorvastatin 20mg daily
- Budesonide 3mg TID
- Folic acid 1mg daily
- Gabapentin 300mg QHS
- Oxycodone ER 40mg Q8h
- Hydromorphone 4mg; 0.5-1 tablet daily prn
- NPH 10units [**Hospital1 **]
- Humalog SS
- Metoprolol tartrate 12.5mg [**Hospital1 **]
- Pantoprazole 40mg [**Hospital1 **]
- Prednisone 10mg daily
- Bactrim 400mg-80mg Tablet daily
- Warfarin 2.5mg alternating with 5mg daily
- Calcium carbonate 648mg TID
- Cholecalciferol 1000unit daily
.
ALLERGIES:
- Cefepime
- Cipro


[**Hospital1 **] Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. warfarin 5 mg Tablet Sig: 0.5-1 Tablet PO Once Daily at 4 PM:
Please take 1.5 tablets (7.5 mg) on Sunday and then take 1
tablet (5 mg) daily until your INR is above 2. Further dosage
adjustment per your healthcare provider.
10. calcium carbonate 648 mg Tablet Sig: One (1) Tablet PO three
times a day.
11. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
12. budesonide 3 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO three times a day.
13. Insulin Sliding Scale
Use Humalog insulin sliding scale as you have been at home.
Dosage per your healthcare [**Provider Number 72266**]. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
15. hydromorphone 4 mg Tablet Sig: 0.5-1 Tablet PO once a day as
needed for pain.
16. vitamin B12
Injection per month, dosage per your healthcare [**Provider Number 72267**]. Insulin NPH
10-12 units twice a day.
Dosage adjustment per your healthcare [**Provider Number 72268**]. Home Oxygen
Continuous oxygen 2-3L flow per minute via nasal cannula.
Pulse dose for portability.
For pnuemonia.
19. Outpatient Lab Work
Please have a PT and INR checked on Tuesday, [**2147-2-14**], and have
the results faxed or called in to your PCP's office (Dr. [**Last Name (STitle) 1683**].
Phone [**Telephone/Fax (1) 22609**], Fax [**Telephone/Fax (1) 22611**].


[**Telephone/Fax (1) **] Disposition:
Home With Service

Facility:
[**Location (un) **] oxygen

[**Location (un) **] Diagnosis:
Primary diagnosis:
- Influenza A pneumonia

Secondary diagnoses:
- Chronic graft versus host disease- Lung and Skin
- Type 2 Diabetes
- History of pulmonary embolism


[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


[**Location (un) **] Instructions:
Dear Mr. [**Known lastname 47367**],

It was a pleasure to take care of you at [**Hospital1 827**].

You were admitted to the hospital for cough and increased
trouble with breathing.  In the hospital, it was found that you
have influenza pneumonia.  Because of your increased oxygen use,
you were transferred to the intensive care unit for close
monitoring.  You were treated with an antiviral for the flu as
well as antibiotics for possible bacterial pneumonia as well.
You completed the course of the antiviral and antibiotics while
in the hospital.

Please note the following changes in your medications:
- Please START supplemental oxygen at 2-3L/min, continuously,
until your pneumonia and shortness of breath have resolved. Your
doctors [**Name5 (PTitle) **] [**Name5 (PTitle) **] [**Name5 (PTitle) **] when you can stop using oxygen.

You will need to have your INR level checked on Tuesday, [**2147-2-14**],
and have the results faxed to your PCP who manages your
coumadin.

It will be important for you to follow up with your doctors [**First Name (Titles) 3**] [**Name5 (PTitle) 57228**] below.

Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2147-2-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], 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: HEMATOLOGY/BMT
When: THURSDAY [**2147-2-16**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DERMATOLOGY
When: [**Hospital Ward Name **] [**2147-4-14**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2722**], MD [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2147-2-12**]
{'Influenza due to identified avian influenza virus with pneumonia,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Rash and other nonspecific skin eruption,Cystitis, unspecified,Backache, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Cough, malaise, hypotension

PRESENT ILLNESS: 56 year old man with a h/o AML s/p allo SCT in [**2143-6-16**] c/b
chronic skin and pulmonary GVHD treated with prednisone 10mg
daily. He reports 5-6 days of URI symptoms, myalgias, cough
productive of yellow sputum, decreased appetite, and poor PO
intake. No fevers, though he has been taking tylenol. He
presented to heme/onc clinic today and reported headache and
nausea with improved after 1L NS. He was afebrile but hypoxic to
90% on RA, which improved to 94% on 2L. Nasal swab and blood
cultures were sent. CXR was negative. He was given
vancomycin/aztreonam (due to cefepime allergy) and admitted for
further workup.
.
O2 sats were in the mid-80s on RA so he was placed on nasal
cannula and then shovel mask. 6pm ABG was: 7.46/37/69. Lactate
1.1.
.
Overnight pt became more hypoxic and tachypnic. Febrile to
101.8. Azithro was added to his abx. Chest CT [**First Name9 (NamePattern2) 5692**] [**Last Name (un) 22975**] tree
[**Male First Name (un) 239**] opacities and concern for brochiolitis/pneuonitis. BMT
wanted to give IVIG due to low IgG, but pt was too hypoxic.
Eventually 86% on NRB. [**Hospital Unit Name 153**] was called. Pt given albuterol x 1,
and CXR taken. Pt c/o resp fatigue. Transfered to ICU.
.
ROS:
(+) As noted above.
(-) No current chest pain, palpitations, SOB, abdominal pain,
N/V/D.

MEDICAL HISTORY: # Pulmonary embolism x2 ([**2143**] and dx [**5-/2146**] in RML and RLL): on
warfarin
# Acute myeloid leukemia:
- [**3-/2143**]: diagnosed
- [**6-/2143**]: underwent a matched unrelated allogeneic stem cell
transplant.
- post-transplant course c/b bx-proven GVHD of the liver and an
intermittent skin rash, s/p management with cyclosporine,
mycophenolate, rituximab, and currently, steroids.
# type 2 DM: steroid-induced
# hyperlipidemia
# bilateral hip AVN
# HTN
# nephrolithiasis: s/p lithotripsy and previous nephrostomy tube

MEDICATION ON ADMISSION: MEDICATIONS:
- Acyclovir 400mg PO TID
- Atorvastatin 20mg daily
- Budesonide 3mg TID
- Folic acid 1mg daily
- Gabapentin 300mg QHS
- Oxycodone ER 40mg Q8h
- Hydromorphone 4mg; 0.5-1 tablet daily prn
- NPH 10units [**Hospital1 **]
- Humalog SS
- Metoprolol tartrate 12.5mg [**Hospital1 **]
- Pantoprazole 40mg [**Hospital1 **]
- Prednisone 10mg daily
- Bactrim 400mg-80mg Tablet daily
- Warfarin 2.5mg alternating with 5mg daily
- Calcium carbonate 648mg TID
- Cholecalciferol 1000unit daily
.
ALLERGIES:
- Cefepime
- Cipro

ALLERGIES: Cefepime / Cipro Cystitis

PHYSICAL EXAM: Admission physical exam
Vitals: 101.8 132/88 109 24 91% NRB FS 127
General: A&Ox3 but appears SOB, speaking full sentences
HEENT: dry MMM, clear OP, no scleral icterus
Neck: Supple, no masses
Lungs: Coarse breath sounds througout, no wheezes.
CV: Regular, nml S1/S2, no murmurs.
Abdomen: Soft, NT, ND, +BS
Extrem: Hands and feet warm and well perfused, no cyanosis, 2+
pedal pulses, no edema.
Neuro: CN grossly intact, strength and sensation grossly intact.

FAMILY HISTORY: Mother died suddenly in her 70s.
Father died of unknown cancer.
One sister has thyroid cancer.
One brother has diabetes.
One sister has [**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and son. [**Name (NI) **] is retired, worked as a [**Company 22957**]
technician
Tobacco - 40 pk year hx, quit 5 yrs ago.
EtOH - denies
Drug use - denies. 

### Response:
{'Influenza due to identified avian influenza virus with pneumonia,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Obstructive sleep apnea (adult)(pediatric),Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Rash and other nonspecific skin eruption,Cystitis, unspecified,Backache, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
