history of present illness: the patient is a is 39-year-old gentleman with a history of human immunodeficiency virus (with a cd4 count of 244 and a viral load of 16,200 on ), hodgkin's disease (stage ivb), status post adriamycin, bleomycin, vinblastine, dacarbazine; status post one cycle of british mopp; and status post one cycle of adriamycin, bleomycin, vinblastine, dacarbazine who completed his second dose of the first cycle of his adriamycin, bleomycin, vinblastine, dacarbazine on . history is complicated now by neutropenia, and the patient was given g-csf on . one to two days after receiving g-csf the patient experienced increasing nausea and vomiting with fevers. the patient's temperature was 101 degrees fahrenheit orally. in addition, the patient has been having loose watery stools; however, this is baseline for him. he denies any headache, cough, sinus pain, ear pain, sore throat, shortness of breath, abdominal pain, neck pain, dysuria, or back pain. he has no history of trauma. the patient came to the emergency department after several days of the above-mentioned symptoms with a temperature of 104.8 degrees fahrenheit and an absolute neutrophil count of 0. in the emergency department the patient was started on cefepime. however, the patient's blood pressure began to drop, and the patient was started on dopamine and vasopressin. he was subsequently transferred to the intensive care unit requiring intravenous fluids and norepinephrine and vasopressin. after the patient's blood pressure increased, he was weaned off of pressors in the intensive care unit; however, his fevers continued. the patient was found to be clostridium difficile positive. at that point, the patient was transferred to the floor to the o-med service. physical examination on presentation: physical examination revealed the patient's temperature was 102.4 degrees fahrenheit, his heart rate was 108, his blood pressure was 113/62, his respiratory rate was 20, and his oxygen saturation was 97% on room air. on general examination, the patient was a young-appearing male who was mildly diaphoretic. he was lying in bed comfortably. head, eyes, ears, nose, and throat examination revealed the mucous membranes were moist. the oropharynx was clear. pupils were equal, round, and reactive to light and accommodation. the neck was supple. there was no evidence of lymphadenopathy. the lungs were clear to auscultation bilaterally. cardiovascular examination revealed the patient was tachycardic but otherwise a regular rate and rhythm. no murmurs, rubs, or gallops were appreciated. abdominal examination revealed a left-sided scar. the abdomen was nontender and nondistended. bowel sounds were audible. the patient had no evidence of guarding. back examination revealed no midline tenderness. genitourinary examination revealed no evidence of lesions. the patient had a foley catheter without any evidence of erythema, or exudate, or pain. on external rectal examination, there was no evidence of lesions or exudate. on neurologic examination, the patient was alert and oriented times three. there were no focal deficits. the patient had a left subclavian line which was clean, dry, and intact with no evidence of exudate. there was mild pedal edema. past medical history: 1. human immunodeficiency virus diagnosed in . 2. history of mycobacterium avium-intracellulare in . 3. recurrent herpes simplex virus. 4. microsporidiosis in . 5. stage 4 hodgkin's lymphoma diagnosed in . 6. history of idiopathic thrombocytopenic purpura; status post a splenectomy in . 7. severe depression complicated by suicidal ideation and electroconvulsive therapy. 8. history of molluscum contagiosum. 9. chemotherapy-induced pancytopenia. 10. coronary artery disease. (a) status post myocardial infarction in complicated by ventricular tachycardia arrest. (b) status post left anterior descending artery stent with in-stent restenosis and restenting in . 11. dyslipidemia. 12. chronic diarrhea. 13. history of giardia. 14. history of varicella-zoster virus. 16. history of genital warts. 17. hyperhomocystinemia. 18. history of helicobacter pylori. 19. history of h influenza pneumonia in . allergies: 1. compazine. 2. sulfa (causes a rash). medications on admission: (outpatient medications included) 1. acetaminophen. 2. pantoprazole 40 mg once per day. 3. atorvastatin 10 mg once per day. 4. clopidogrel 75 mg once per day. 5. aspirin 325 mg once per day. 6. dapsone 100 mg once per day. 7. risperidone 1 mg twice per day. 8. lithium 300 mg three times per day. 9. folate 1 mg once per day. 10. lorazepam 0.5 mg q. 4-6h. as needed. 11. colace 100 mg twice per day. 12. nystatin swish-and-swallow as needed. 13. dapsone 150 mg once in the morning. 14. oxycodone as needed. 15. lopinavir 600 mg twice per day. 16. didanosine 400 mg every day. 17. tenovir 300 mg once per day. 18. kaletra 13.3/133.3-mg tablets four tablets twice per day. 19. citalopram 10 mg once per day. social history: the patient quit smoking tobacco in . occasional alcohol use. no illicit drugs. he lives with his family in , . pertinent laboratory values on presentation: laboratories on admission revealed the patient's white blood cell count was 1.5, his granulocyte count was 260, and his hematocrit was 25.9. his bicarbonate was 18. his partial thromboplastin time was 30.6. his inr was 2.5. the clostridium difficile toxin was positive. pertinent radiology/imaging: a chest x-ray showed recurrence of nodular opacities, questionable atypical pneumonia. concise summary of hospital course by issue/system: 1. infectious disease issues: on admission to the o-med service, the patient was given neupogen injections subcutaneously. this therapy was continued until his absolute neutrophil count was greater than 1000 for two days. cultures were drawn on the patient including stool and blood cultures on days to , and urine cultures from days to . all of these cultures were negative with the exception of clostridium difficile. on , the patient underwent a computed tomography with contrast of the abdomen which showed no evidence of intra-abdominal abscess or bowel wall thickening. however, there was some evidence of bilateral pleural effusions. a possible pneumonia was considered as a source of fevers; however, it was thought that the abnormalities seen on a recent computerized axial tomography were secondary to fluid overload during aggressive resuscitation in the intensive care unit and nodular opacities from his malignancy. the patient was diagnosed with clostridium difficile on and was subsequently placed on intravenous flagyl. the patient was continued on this regimen secondary to emesis until when he was able to tolerate medications. at that time, he was changed to flagyl. the patient continued to have diarrhea throughout the hospital course. on , the patient developed a warm erythematous region; roughly one foot in diameter about the umbilicus. this was thought to be a cellulitis, and the patient was started on vancomycin on . on , the patient developed a superficial abscess left of the umbilicus. at this time, the infectious disease service was consulted. on , the abscess self-perforated. swabs were performed of the exudate which grew staphylococcus aureus sensitive to oxacillin. on , the vancomycin was discontinued and the patient was changed to dicloxacillin. at this time, the cellulitis had resolved. cefepime was discontinued on ; as per the infectious disease request, as it was thought that this was contributing to the clostridium difficile colitis and diarrhea. the patient continued to have fevers daily during his hospital course until . at that time, the patient defervesced and was afebrile for 48 hours prior to his discharge. on , the patient was restarted on his highly active antiretroviral therapy. at this time, the patient was also noted to have thrush, and he was started on nystatin. 2. hematologic issues: the patient presented with a hematocrit of 22. while in the intensive care unit the patient received 2 units of packed red blood cells. this transfusion was complicated by fevers and rigors. the transfusion was stopped midway through the second infusion. the patient was found to be coombs negative. the patient also received two additional units during his hospital course without complications. at the time of his discharge, his hematocrit was 34.1. on admission, the patient's inr level was 2.5. the etiology of this was unclear, but it was postulated it was secondary to malnutrition. the patient was given vitamin k for two days. at that time, his inr corrected to 1.1, and his partial thromboplastin time was 30.1. the hospital course was complicated by recurrent episodes of nausea and emesis. his emesis was controlled with zofran and ativan. the patient was gradually started on a diet and was advanced gradually to a brat diet and then a regular house diet. condition at discharge: condition on discharge was good; afebrile. discharge status: discharge status was to home with services. discharge diagnoses: 1. clostridium difficile colitis. 2. cellulitis. 3. abscess. 4. human immunodeficiency virus. 5. hodgkin's disease. 6. coronary artery disease. 7. idiopathic thrombocytopenic purpura. medications on discharge: 1. atorvastatin 10 mg once per day. 2. clopidogrel 75 mg once per day. 3. aspirin 325 mg once per day. 4. dapsone 100 mg once per day. 5. risperidone 1 mg twice per day. 6. folic acid 1 mg once per day. 7. bupropion 150 mg once per day. 8. citalopram 10 mg once per day. 9. pantoprazole 40 mg. 10. lithium 300 mg twice per day. 11. flagyl 500 mg three times per day (for 30 days). 12. calcium carbonate 500 mg three times per day (with meals). 13. tenofovir 300 mg once per day. 14. lamivudine 150 mg twice per day. 15. kaletra 33.3/133.3-mg tablets four tablets twice per day. 16. nystatin swish-and-swallow. 17. amprenavir 600 mg twice per day. 18. acyclovir 100 mg twice per day (to be taken during chemotherapy to prevent herpes simplex virus). 19. dicloxacillin 500 mg four times per day (for two weeks). 20. ativan 1 mg q.6h. as needed (for nausea). discharge instructions/followup: 1. the patient was advised to continue taking the dicloxacillin for two weeks after his discharge. 2. in addition, the patient was advised to pack the perforated abdominal abscess with gauze twice per day until it healed. 3. the patient was also advised to take the flagyl continuously two weeks after his dicloxacillin course was completed. 4. the patient was advised not to imodium during this time. 5. the patient was instructed to follow up with dr. in two weeks. 6. the patient was instructed to follow up with dr. in two weeks. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnoses: Cellulitis and abscess of trunk Congestive heart failure, unspecified Unspecified protein-calorie malnutrition Hyposmolality and/or hyponatremia Candidiasis of mouth Human immunodeficiency virus [HIV] disease Intestinal infection due to Clostridium difficile Hodgkin's disease, unspecified type, lymph nodes of multiple sites