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Patient: Ishamma T M, 81F, MR 000384802 (KIMS Health, Trivandrum)
Family: Sameer Badarudeen (son, remote coordinator), Nisha (caretaker, bedside)

Primary Dx: AML with MDS-related gene mutations (RUNX1, ASXL1, BCOR, SRSF2, STAG2, NRAS). Adverse-risk. Karyotype 46,XX (normal). Dx Nov 2025.

Treatment: Azacitidine + Venetoclax. Port placed 2025-12-09. Cycle 1 started 2025-12-09/10. Day 21 BMBx (2025-12-31) showed response — cellularity 60%→25-30%, reticulin Grade 1-2→1.

CRITICAL STATUS (2026-06-01)

[!danger] SEVERE NEUTROPENIA — ANC 990 (Grade 3)
June 1, 2026: ANC dropped to 990 cells/cumm (<1000 = Grade 3 severe neutropenia). Deepest nadir since March 2026 stabilization. CRITICALLY ELEVATED infection risk. Acyclovir + posaconazole prophylaxis ESSENTIAL. Monitor for fever >38°C (urgent evaluation required), mucositis, infections. Avoid crowds/sick contacts/uncooked food. Expected recovery: ANC should rise within 3-7 days (~June 4-8) based on platelet recovery (Plt 252K, fully recovered). Repeat CBC in 2-3 days. No G-CSF available.

Concurrent findings June 1: WBC 2200 (deepest nadir), Hb 11.3 (dropped from 12.0 landmark), Plt 252K (N — fully recovered), MCV 100 fL (highest on record). See Anc, Wbc.

Cycle history:
- Cycle 1: Started 2025-12-09/10 (port placed same day). Day 21 BMBx on 2025-12-31. AZA/VEN durations unknown.
- Cycle 2: Started 2026-01-19. AZA 5 days + VEN 10 days.
- Cycle 3: Started 2026-03-02 (confirmed by patient). Pegfilgrastim given → significant bone pain. AZA/VEN durations unknown.
- Cycle 4+: 2026-04-06 to 2026-04-13. AZA 5 days + VEN 5 days. IV azacitidine. Mar 30 visit: week off, then chemo.
- Schedule trend: AZA 5d since at least Cycle 2. VEN reduced: 10d (C2) → 5d (C4+).

Pegfilgrastim: DISCONTINUED (2026-03-30). Significant bone pain. No G-CSF support going forward.

Aza route: IV (confirmed for most recent cycle, Apr 2026).

Supportive meds (since diagnosis): Acyclovir (antiviral prophylaxis), Posaconazole (antifungal prophylaxis — strong CYP3A4 inhibitor, enables VEN dose reduction to 50–100 mg from 400 mg as cost-reduction strategy), Renerve (methylcobalamin B12 + B6 + alpha lipoic acid + folate, once daily oral — newly documented 2026-04-29, start date unknown, prescriber unknown).

Transfusion reaction: 2025-12-10 — sudden chills and breathing difficulty during transfusion. Reported by Nisha (caretaker). Pre-medicate for future transfusions. Now documented in Allergy List.

Antibiotics: Meropenem used as Zosyn alternative during Cycle 1 (Dec 2025).

Latest labs:
- 2026-06-01 (Bill L041256126 — TODAY): ANC 990 (L — SEVERE NEUTROPENIA, Grade 3 <1000 — DEEPEST NADIR), WBC 2200 (L — deepest leukopenia), Hb 11.3 (L — dropped from 12.0 landmark), Plt 252 (N — FULLY RECOVERED +145K from May 27). Polymorphs 46% (lowest on record), Lymphs 42.8% (relative lymphocytosis), Monos 5.6%, Eos 3.7%, Baso 1.9% (H). ALC 920 (L), AMC 120 (L), AEC 80 (L), ABC 40 (L). RBC 3.53 (L), MCV 100 (H — HIGHEST KIMS MCV ON RECORD), MCH 32 (N), MCHC 32 (N), RDW 18.3 (H). MPV 11.1. Dr. Bijay. Collected 11:11 AM. CRITICAL INFECTION RISK.
- 2026-05-27 (Bill L040020926): Hb 12.0 (N — FIRST NORMAL since AML Dx), WBC 2400 (L — deepening leukopenia), ANC 1460 (L — MODERATE NEUTROPENIA, below 1500 threshold — NADIR), Plt 107 (L, stabilizing), RBC 3.77 (L, recovering), MCV 95 (H), RDW 17.8 (H). Na 137 (N), K 4.4 (N), Cl 98 (N — lower limit), HCO3 28 (N). MPV 11. Dr. Bijay. Collected 10:42 AM.
- 2026-05-23 (Bill L038904126): Hb 11.6 (L), WBC 3500 (L), ANC 2430 (N borderline), Plt 117 (L), RBC 3.76 (L), MCV 94.7 (H), RDW 18.0 (H). Na 141 (N), K 4.6 (N), Cl 99 (N), HCO3 29.5 (H borderline — above upper limit 29). Smear checked. Dr. Bijay.
- 2026-05-17 (Bill L037179526): Hb 9.9 (L — severe nadir, −1.9 from May 11), WBC 4600 (N), ANC 3400 (N), Plt 103 (L), RBC 3.17 (L — severe nadir). Na 140, Cl 103, HCO3 25.7 — all normal.

Lineage cascade May-June 2026 (confirmed and extended): Plt nadir May 11 (103-113K) → Hb/RBC nadir May 17 (9.9/3.17) → WBC/ANC nadir May 27–June 1 (2400/1460 → 2200/990). Classic dissociated lineage kinetics: Plt recovered fully to 252K (N) while ANC at deepest nadir (990). Hb transiently reached first normal 12.0 (May 27), then dropped to 11.3 (June 1).

LANDMARK (2026-05-27, TRANSIENT): Hb 12.0 = first normal hemoglobin since AML diagnosis (Nov 2025). Brief — dropped to 11.3 by June 1.

CRITICAL CONCERN (2026-06-01): ANC 990 = SEVERE neutropenia (Grade 3). CRITICALLY ELEVATED infection risk. Life-threatening bacterial/fungal infection risk. Acyclovir + posaconazole prophylaxis ESSENTIAL. Fever >38°C requires urgent evaluation. Recovery expected ~June 4–8 based on platelet recovery trajectory.

Prior labs (Apr-May 2026): May 11: Hb 11.8, WBC 5700, Plt 113 (L — nadir), ANC 3950, Mg 1.5 (L), Cl 96 (L), HCO3 29.1 (H). May 4: Hb 11.9, WBC 4000 N, ANC 2360 N, Plt 213 N, Na 142 N, Mg 1.6 N.

LFTs (VERIFIED, 3 panels): Jan 19: TBil 0.4, ALT 14, AST 19, ALP 77, TP 7.6, Alb 4.4. Mar 2: TBil 0.3, ALT 11, AST 16, ALP 60. Apr 6: TBil 0.2, ALT 11, AST 15, ALP 63, TP 7.3, Alb 4.4. All normal. No hepatotoxicity after 4+ months. See Lft.

Magnesium trend: 1.4 (Mar 2) → 1.2 (Apr 20, nadir) → 1.4 (Apr 27) → 1.6 (May 4, normalized) → 1.5 (May 11, re-dropped slightly). No Mg on May 23 or May 27 panels. Recheck Mg at next draw. Supplement active at 400 mg TID (1200 mg/day). See Magnesium, Magnesium Oral.

Sodium trend: Normalized. 128 nadir (Apr 20) → 134 (Apr 27) → 142 (May 4, normalized) → 137 (May 11) → 141 (May 23) → 137 (May 27, continued normal). SIADH workup still outstanding. See Sodium, Hyponatremia.

Calcium: Transient hypercalcemia 10.7 (Jan 19, H) → 10.1 (Jan 22, rapid self-resolution) → 9.9 (Mar 2, N). See Calcium.

May 2026 cycle — full lineage cascade now complete:
- Plt nadir May 11: 213K→113K→103K (nadir). Then recovering: 117K (May 23) → 107K (May 27)
- Hb/RBC nadir May 17: 11.9→11.8→9.9 (nadir) / 3.79→3.73→3.17. Rapid recovery: 11.6 (May 23) → 12.0 N (May 27 — first normal)
- WBC/ANC nadir May 27: 5700/3950 (May 11) → 4600/3400 (May 17) → 3500/2430 (May 23) → 2400/1460 (May 27 — NADIR)
- Pattern confirmed across 3 cycles: Platelets always drop first, followed by Hb ~6 days later, followed by WBC/ANC ~10 days after Plt nadir

[!info] May 27 Status: Landmark Hb + Active ANC nadir
LANDMARK: Hb 12.0 (N) — first normal since AML diagnosis.
ACTIVE NADIR: WBC 2400 (L), ANC 1460 (L — moderate neutropenia).
STABLE: Plt 107 (L, stabilizing). Na/K/Cl/HCO3 all normal.

Last Query

  • 2026-05-27: "Based on current is it ok to travel" — NOT travel-suitable. Confirmed May 27 nadir: Hb 12.0 (N — landmark, first normal since AML Dx), WBC 2400 (L), ANC 1460 (L — moderate neutropenia, NADIR), Plt 107K (L). Hb normalization does NOT offset active ANC nadir. No G-CSF rescue available. Active contraindications: neutropenia, thrombocytopenia, DM poor control, medication logistics. Clearance requires: ANC ≥1500–2000 on serial CBC, Dr. Bijay explicit clearance, fresh labs within 48–72h of departure. Earliest plausible window: ~June 4–10, 2026. Synthesis updated → Travel Clearance 2026 05 27.
  • 2026-05-24: "Medication list" — Simple retrieval from Active Medications. 13 active meds (5 AML/supportive, 3 DM, 1 CV, 1 neuropathic pain, 3 supplements); 4 confirmed non-adherent (nifedipine, atorvastatin, insulin glargine, prednisolone). No synthesis filed (straightforward retrieval). No new gaps discovered.
  • 2026-05-17: "Will transfer" — incomplete query. Clarification requested. Possible meanings: care transfer, transfusion, port, venetoclax. Awaiting user response. No synthesis filed.
  • 2026-05-06: "update overview" — Full overview rewrite. Resolved: pancytopenia (May 4), hyponatremia (May 4). May 4 labs: Hb 11.9 (-0.1 from threshold), WBC 4000 N, ANC 2360 N, Plt 213K N, Na 142 N, Mg 1.6 N, Cl 103 N. 13 active meds; 4 confirmed non-adherent. No synthesis filed (update not a query).
  • 2026-05-06: "Cymbalta what time to take" — Morning with food. SNRI noradrenergic activation → avoid evening. Half-life ~12h (once daily). Geriatric start: 30 mg q.d. with breakfast × 2 wk, then 60 mg. Pre-initiation labs still required (GFR, Na, LFTs) — all gaps already documented. No synthesis filed (straightforward PK/tolerability). See Duloxetine Vs Mirtazapine Diabetic Neuropathy.
  • 2026-04-29: "How many days to next chemo" — Cycle 4 Day 1 was Apr 6. Estimated Cycle 5: May 4–17 (5–18 days). ANC 1990 on Apr 27 is the actual gating factor. No appointment record in vault — gap.
  • 2026-04-20: "What are the insights from the latest labs apart from hematology" — Integrated non-hematology analysis of Apr 20 panel. Na 128 new nadir (moderate hyponatremia), Mg 1.2 worsening, Cl 93 persistent, HCO3 22.8 low-normal; K/LFT/Cr/BUN stable. SIADH-type euvolemic pattern confirmed. 6 gaps: no LFT/Cr/urine osm/ECG/Ca/Phos on Apr 20. Hyponatremia condition page updated. Filed → Non Hematology Labs Insights Apr2026.
  • 2026-04-19: "what are the dietary modifications a Keralite can do to increase magnesium" — Kerala-specific dietary Mg augmentation plan. Top 3: ellu (sesame, ~351 mg/100g, add to any thoran), ragi puttu (swap for rice puttu, ~137 mg/100g, lower GI, good for DM), muringa ila thoran (~86–150 mg/100g, typically home-grown). Sample day ~660 mg Mg/day within ~650 mL fluid (SIADH-compatible). All foods cooked (neutropenia safe). Caveats: Mg measured only once (Mar 2), repeat needed; oral Mg supplement (Mg glycinate) recommended. Filed → Magnesium Diet Kerala Context.
  • 2026-04-19: "diet changes in indian context to manage SIADH" — Comprehensive Kerala-adapted dietary guidance for presumed SIADH. Four pillars: fluid restriction (800–1000 mL/day, limit kanji/rasam/moru), salt loading (tablets, pickles, upperi), protein increase (fish/eggs/kadala for solute load, BUN only 13.4), and Mg-rich foods (muringa ila, ragi, ellu). Sample meal plan included. Key gaps: SIADH unconfirmed, BP undocumented, current diet unknown. Filed → Siadh Diet Indian Context.
  • 2026-04-19: "cytogenetics" — Karyotype 46,XX[10] (normal) from 2025-11-29. Despite normal cytogenetics, patient has adverse-risk AML due to molecular profile (RUNX1, ASXL1, SRSF2 mutations override favorable karyotype). No synthesis created (straightforward retrieval from existing Karyotype 2025 11 29 and Aml pages). Writeback completed.
  • 2026-04-19: "medication list" — Simple retrieval from Active Medications. 4 active meds (AZA, VEN, acyclovir, posaconazole), 1 discontinued (pegfilgrastim). No synthesis created (straightforward retrieval). Gap persists: exact doses unknown, non-oncology meds not documented.
  • 2026-04-19: Treatment regimen assessment. Aza-Ven guideline-concordant & responding, but gaps: no drug levels, no MRD, doses unknown, VEN reduction rationale undocumented, electrolytes unworked-up. Filed → Treatment Regimen Assessment.
  • 2026-04-19: Vaptan assessment. Both tolvaptan & conivaptan contraindicated — CYP3A4 substrates, blocked by posaconazole. Fluid restriction + salt + Mg correction preferred for mild hyponatremia. SIADH workup still missing. Filed → Vaptan Assessment.
  • 2026-04-19: CYP3A4 metabolizer status analysis. Hepatic resilience raises possibility of rapid metabolism → venetoclax exposure may be lower than expected under posaconazole boosting strategy. Venetoclax/posaconazole trough levels and pharmacogenomic testing recommended. Filed → Cyp3A4 Metabolizer Venetoclax Implications.
  • 2026-04-19: Medication cessation risk assessment. All 4 meds form interlocking system: Aza-Ven (leukemia control) + posaconazole (antifungal + VEN booster) + acyclovir (VZV prophylaxis). Stopping all → AML relapse (4-8 wks), fungal/viral infection risk (immediate), death (months). Non-oncology meds unknown. Filed → Medication Cessation Risk Assessment.
  • 2026-04-19: Source labs for 2022 inflammatory episode located. Two DDRC SRL reports: Sept 20 (peak: CRP 128, ESR 119, WBC 14,770, IgE 203) and Sept 27 (resolving: Plt 501K, Hb 11.0). Filed synthesis → 2022 Inflammatory Episode Clonal Evolution: hypothesis connecting 2022 proliferative phenotype to 2025 AML failure phenotype via clonal evolution. 3-year data gap (Sep 2022 – Jul 2025) is the critical missing period.

Last Refinement

  • 2026-04-17 (batch 6): /refine pass on 6 source files. KEY: 3rd LFT discovered (Apr 6) — Ishamma T M.pdf was "CBC only" but contains full LFT+Renal+Electrolytes. Also: calcium self-resolution documented (10.7→10.1 in 3 days), creatinine now 5 data points, Oncomine NGS deeply enriched (genomic loci, transcripts, interpretations, QC), Feb 23 DDRC RBC indices added, BMBx #1 authorization dates added. Added 15+ data points across 11 lab pages.
  • 2026-04-17 (batch 5): /refine pass on 8 lab PDFs. KEY DISCOVERY: LFTs EXIST — 2 full LFT panels (Jan 19 and Mar 2, both normal). Resolves critical gap. Also found: Magnesium 1.4 (LOW), transient hypercalcemia Ca 10.7 (Jan 19), Creatinine 0.7-0.8 (stable), Lipid panel #2 (Mar 2, optimal), and Greeshma M Nair as biochemistry authorizer. Added 7 potassium, 5 chloride, 7 bicarbonate, 4 RBC, 5 MCV, 7 RDW data points. Created Lft, Magnesium. Updated calcium (3 pts), creatinine (3 pts), lipid-panel (2 pts). Page count 67→69.

Last Ingest

  • 2026-05-29 (TODAY): 1 PDF from raw/assets/ — DUPLICATE of May 27 lab report:
  • raw/labs/2026-05-29_Ishamma_T_M_1.pdf — Bill L040020926 (May 27 CBC + Electrolytes), same data as previously ingested raw/labs/20260527_Ishamma T M 1 5-27-2.pdf
  • Action: Source reference added to 11 lab marker pages. No data re-extraction. Sources 63→64.
  • 2026-05-27: 3 PDFs from raw/assets/ — 2 unique lab reports:
  • May 27 (Bill L040020926): Hb 12.0 (N — first normal since AML Dx), WBC 2400 (L), ANC 1460 (L — moderate neutropenia — NADIR), Plt 107 (L), RBC 3.77 (L). Na 137, K 4.4, Cl 98, HCO3 28 (all N).
  • May 23 (Bill L038904126): Hb 11.6 (L), WBC 3500 (L), ANC 2430 (N borderline), Plt 117 (L). Na 141, K 4.6, Cl 99, HCO3 29.5 (H borderline). Smear checked.
  • Duplicate (L038904126) — source reference added, not re-ingested.
  • Updated: 11 lab marker pages (Hb, WBC, ANC, Plt, RBC, MCV, RDW, Na, K, Cl, HCO3). _lab-timeline (added missing May 17 entry + May 23 + May 27). _lab-trends. index. overview. hot. Sources 61→63. No new pages.
  • 2026-05-06: raw/clinic-notes/20260506_155027_note.md. Content: "she is taking Magnesium (oral supplement) 400mg tid." Dose documented for first time: 400 mg TID = 1200 mg/day (maximum oral dose). Magnesium-oral status corrected: discontinued → active. Magnesium Oral updated. Active Medications updated: 12 → 13 active meds. Sources 58→59.
  • 2026-05-06: raw/clinic-notes/20260506_154959_note.md. Content: "she is not taking Prednisolone (Predniod)". Patient non-adherence confirmed. Prednisolone status active → discontinued. Steroid risks (hyperglycemia worsening, infection augmentation) now resolved — clinically favorable. 4th medication confirmed not being taken from the 2026-05-04 prescription (nifedipine, atorvastatin, insulin glargine, prednisolone). Active medication count 13 → 12 at time of this note. Sources 57→58.
  • 2026-04-29 (2nd clinic note): raw/clinic-notes/20260429_124418_note.md. Content: "taking renerve once daily." Corroborates first Apr 29 note. Renerve already documented — source reference added. No new clinical information. Sources 49→50.
  • 2026-04-29: Clinic note (raw/clinic-notes/2026-04-29_note.md). Single finding: Renerve once daily (methylcobalamin B12 + B6 + ALA + folate). Previously undocumented medication. Created Renerve. Updated Active Medications, Profile, Index. Pages 80→81, sources 48→49.
  • 2026-04-29: Dr Lal PathLabs fructosamine report (Lab 515013880). Fructosamine 310 µmol/L (HIGH) — reveals HbA1c improvement is spurious. True diabetes likely persists with poor control. HbA1c unreliable in AML. Created Fructosamine. Updated Diabetes Mellitus, Hba1C, Lab Trends, Lab Timeline, Overview. Source: raw/labs/2026-04-29_ISHAMMA.pdf
  • 2026-04-27: KIMS lab report (Bill L031606726). CBC + Electrolytes + Magnesium. KEY FINDINGS: WBC 3000 (L), ANC 1990 (L — mild neutropenia), Plt 196 (N — strong recovery from 99K), Hb 11.4 (stable), Na 134 (improved from 128), Mg 1.4 (improved from 1.2). Lineage-dissociated kinetics: platelets recovering while granulopoiesis suppressed. Updated 12 lab pages + 4 meta pages. Source: raw/labs/20260427_Ishamma T M 1 ok.pdf
  • 2026-04-20: Clinic note (raw/clinic-notes/2026-04-20_note.md). KEY FINDING: Patient was taking oral Mg supplement but ran out ~2 weeks ago (~Apr 6). This explains worsening Mg 1.4 → 1.2 and is a previously undocumented medication. Created Magnesium Oral. Updated Magnesium, Active Medications, Hyponatremia. Pages 78→79, sources 45→46.
  • 2026-04-20: KIMS lab report (Bill L029731026). CBC + Electrolytes + Magnesium. THREE CRITICAL FINDINGS: Na 128 (new nadir, moderate hyponatremia), Plt 99K (below 100K), Mg 1.2 (worsening). Hb 11.4 (↑), WBC 4100 (recovered to normal), ANC 2970 (N). Updated 12 lab pages + 3 meta pages. Source: raw/labs/20260420_Ishamma T M today.pdf

Gaps

From /lint audit 2026-05-06 — items not previously tracked:

  • BP never measured — on losartan monotherapy; HTN diagnosis is presumed. Obtain at next clinic visit.
  • No May 2026 clinic note from Dr. Bijay — Only lab reports exist for May 2026. No clinic note documents current clinical assessment, treatment plan, or travel/activity guidance for this cycle. Drop next clinic note into raw/clinic-notes/ and run /ingest.
  • Falls risk assessment absent — 81F + pregabalin + Hb 11.9 + VPT 29–33V. No TUG documented.
  • jothydev-clinic-note-2022-11-25.md misclassified — type: condition should be type: clinic-note.
  • wiki/_jobs/ undeclared in schema — either document in CLAUDE.md or confirm ephemeral.
  • wiki/summaries/ empty — run /new-provider or /med-rec to populate.
  • ~~wiki/overview.md updated: stale`~~ — RESOLVED 2026-05-06: full overview rewrite with May 4–6 data; frontmatter updated to 2026-05-06.
  • Serratiopeptidase indication/frequency unknown — role in AML context unclear.
  • Insulin glargine → degludec switch undocumented — date and reason unknown.
  • Lint synthesis: Lint Report 2026 05 06

Pending/Gaps

  • GFR/Cr + LFTs required before duloxetine initiation (NEW, May 6) — Query revealed duloxetine is preferred agent for DPN. Contraindicated if GFR < 30; dose-adjust for hepatic impairment. Last Cr Apr 6 (must recheck); LFTs last Apr 6 (normal). Also: Na must be rechecked (prior SIADH — SNRI is a known precipitant); start at 30 mg q.d. (geriatric). See Duloxetine Vs Mirtazapine Diabetic Neuropathy.
  • DPN not formally documented (NEW, May 6) — Pregabalin 75 mg indication is presumed DPN. No formal diagnosis page exists, no pain severity/NRS score. Confirm DPN is the indication before adding duloxetine.
  • Renerve start date and prescriber unknown (NEW, Apr 29) — Documented as active med but when it was started and who prescribed it are unknown. No serum B12 baseline. Confirm variant (standard/Plus/G). Drop Rx or pharmacy label into raw/prescriptions/ and run /ingest.
  • Cycle 5 appointment not documented (Apr 29) — No scheduling confirmation, clinic visit note, or appointment letter for Cycle 5 in vault. Cycle 4 Day 1 was 2026-04-06; ANC 1990 on Apr 27 (mild neutropenia) is the active gating factor. Estimated window: May 4–17. Drop scheduling letter or next clinic note into raw/clinic-notes/ and run /ingest.
  • TRUE DIABETES WITH POOR CONTROL (NEW, Apr 29) — Fructosamine 310 µmol/L (HIGH) reveals HbA1c improvement is spurious. No diabetes-specific medication documented. Consider home glucose monitoring, repeat fructosamine in 4 weeks, and evaluate need for metformin or other DM therapy. See Fructosamine, Diabetes Mellitus.
  • Height/Weight/BMI not documented — Profile lacks anthropometric data. Typically found in clinic visit vitals, hospital H&P, or discharge summaries. No ingested documents contain vitals.
  • ~~LFT results never ingested~~ — RESOLVED (batch 5 refine). 2 LFT panels found in Ishamma T M 1 7.pdf (Jan 19) and Ishamma T M 4.pdf (Mar 2). All normal. See Lft.
  • Hypomagnesemia improving but not normalized — Mg 1.2 (Apr 20) → 1.4 (Apr 27, partial recovery). Still below normal (1.60–2.60). Supplement resumed (inferred). Must continue supplementation. See Magnesium and Magnesium Oral.
  • SIADH workup outstanding — Na improved 128→134 but etiology still unconfirmed. No urine osm, urine Na, serum osm on record. See Hyponatremia.
  • Apr 27 panel gaps — No LFT (last Apr 6, 21 days ago), no Cr (last Apr 6), no Ca, no Phosphorus, no ECG (ANC 1990 + Mg 1.4 in 81yo).
  • ~~Oral Mg dose unknown~~ — PARTIALLY RESOLVED (2026-05-06): Dose now documented as 400 mg TID (1200 mg/day). Formulation (glycinate vs. oxide vs. citrate) and prescriber remain unknown. Drop Rx or pharmacy printout into raw/prescriptions/ to fully resolve.
  • No prescription documents ingested (medication doses unknown)
  • No venetoclax or posaconazole trough levels — critical gap given pharmacokinetic boosting strategy. CYP3A4 pharmacogenomic testing also not done. See Cyp3A4 Metabolizer Venetoclax Implications
  • Allergy list populated with transfusion reaction but no formal allergy testing results
  • ~~Immunization record empty~~ — PARTIALLY RESOLVED: Zostavax (~2016) documented. Still missing: influenza, COVID-19, pneumococcal records. Prior herpes zoster history documented → see Herpes Zoster
  • No molecular MRD testing documented — RUNX1 VAF tracking recommended after 2–3 cycles; discuss with Dr. Bijay. See Mrd Targets Explained
  • IHC (M1) recommended on Day 21 BMBx — result not in raw docs
  • No imaging documents — Vault has zero imaging entries. Most likely existing document: post-port-placement CXR (2025-12-09) for line position verification. Also likely: CT CAP for AML staging, ECHO for cardiac baseline. To populate: drop radiology reports into raw/imaging/ and run /ingest.
  • 2022 inflammatory episode (CRP 128, ESR 119) — etiology undocumented. Source labs located (Sept 20 & 27, DDRC SRL). Clonal evolution hypothesis filed in 2022 Inflammatory Episode Clonal Evolution but no molecular/biopsy data from 2022 to prove or disprove
  • 3-year data gap (Sep 2022 – Jul 2025) — No lab data exists for this period. Any transitional hematologic changes (rising MCV, emerging cytopenias, CHIP detection) are unknown and unrecoverable

Unresolved

  • Hyponatremia etiology (SIADH? Aza-Ven related?)
  • ANC monitoring without G-CSF — will counts hold? (currently 1990, mild neutropenia Apr 27)
  • Long-term treatment plan / response assessment milestones
  • Transfusion reaction type/management — details not in this conversation
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