CHIEF COMPLAINT: Fever

PRESENT ILLNESS: Mr. [**Known lastname 86903**] is a 66 yo man with AML M1-2 s/p induction currently
C1D16 on HIDAC consolidation who presents with R shoulder pain
and fatigue. Seen at 7Feldberg outpatient clinic for count check
yesterday; he complained of feeling very poorly and requested to
come in early, gait was unstable & he used a wheelchair. He
states that since sleeping on his R shoulder on Sunday night, he
has had [**8-4**] pain in the shoulder and difficulty moving it
secondary to pain. States that he was unable to sleep at all the
past two nights secondary to the pain. His vital signs at clinic
the day prior to admission were BP 129/86, HR 116 T 98.2 RR 18
O2 Sat%: 98%. His labs were wbc 0.1 hgb.7.8/hct.21.8 and
platelets 5; he was transfused with 2u prbc and 1 bag of
platelets.
.
Today the patient reports that he was feeling extremely fatigued
and so called an ambulance. He was taken to an outside hospital
where he received vancomycin and zosyn. He was then transferred
to [**Hospital1 18**] for further management and found to have T 103.3,
tachycardia to 120s, and SBP 94. Blood cultures were sent and he
was started on vanc/cefepime.

MEDICAL HISTORY: Oncologic History:
His induction chemotherapy was complicated by acute kidney
injury and neutropenic fever.  Induction with 3+7 was
unsuccessful, so he was re-induced with MEC, which resulted in
prolonged cytopenias and a brief ICU stay for respiratory
difficulty.  His only sibling is not a match and a search for a
matched unrelated donor has not been fruitful. He has therefore
enrolled in a dendritic fusion vaccine trial (protocol 09-014)
with PT1 and is now starting consolidation.
.
ROS: He reports extreme fatigue, R shoulder pain, blood tinged
mucus from right nostril. Denies wght loss, headache, dizziness,
visual changes, chest pain, dyspnea, cough, abd pain, back pain,
constipation, diarrhea, hematochezia, hematuria, other urinary
symptoms, or rash.
.
Past Medical History:
- AML M1-2, normal cytogenetics, NPM-1 negative, FLT3 negative,
s/p 3+7 induction, MEC re-induction, complicated by acute kidney

MEDICATION ON ADMISSION: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 100.8 105 102/65 76 96%3L nc.
Gen: NAD
HEENT: MM dry, OP clear without lesions, exudate, or erythema.
CV: Tachy S1+S2.
Pulm: Bibasilar crackles (R>L)
Abd: S/NT/ND _bs
Ext: Trace edema bilaterally.
MSK: Right shoulder pain to active and passive motion.
Neuro: AOx3, CN II-XII intact.

FAMILY HISTORY: Thinks he had an uncle w/ liver cancer.  Father died of AAA,
mother of ?CHF.  Multiple family members w/ CVA as cause of
death.  No known h/o hematologic malignancies.

SOCIAL HISTORY: Never married, no children.  Lives alone.  Retired fireman.
U.S.M.C. veteran during [**Country 3992**], stationed in Okinawa.  He is a
never smoker, denies alcohol and illicit drug use.  He
frequently travels to the southwest (e.g. [**State 15946**]).
Methicillin susceptible Staphylococcus aureus septicemia,Septic pulmonary embolism,Septic shock,Other specified aplastic anemias,Pyogenic arthritis, shoulder region,Acute myeloid leukemia, without mention of having achieved remission,Jaundice, unspecified, not of newborn,Disorders of bursae and tendons in shoulder region, unspecified,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Effusion of joint, shoulder region,Other atopic dermatitis and related conditions,Severe sepsis,Other fluid overload
Meth susc Staph aur sept,Septic pulmonary embolsm,Septic shock,Aplastic anemias NEC,Pyogen arthritis-shlder,Ac myl leuk wo achv rmsn,Jaundice NOS,Rotator cuff synd NOS,Drug induced neutropenia,Adv eff antineoplastic,Hypertension NOS,Cardiac dysrhythmias NEC,Joint effusion-shlder,Other atopic dermatitis,Severe sepsis,Fluid overload NEC
Admission Date:  [**2158-10-24**]              Discharge Date:   [**2158-11-10**]

Date of Birth:  [**2092-6-29**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
Placement of PICC
Aspiration of fluid from right Shoulder


History of Present Illness:
Mr. [**Known lastname 86903**] is a 66 yo man with AML M1-2 s/p induction currently
C1D16 on HIDAC consolidation who presents with R shoulder pain
and fatigue. Seen at 7Feldberg outpatient clinic for count check
yesterday; he complained of feeling very poorly and requested to
come in early, gait was unstable & he used a wheelchair. He
states that since sleeping on his R shoulder on Sunday night, he
has had [**8-4**] pain in the shoulder and difficulty moving it
secondary to pain. States that he was unable to sleep at all the
past two nights secondary to the pain. His vital signs at clinic
the day prior to admission were BP 129/86, HR 116 T 98.2 RR 18
O2 Sat%: 98%. His labs were wbc 0.1 hgb.7.8/hct.21.8 and
platelets 5; he was transfused with 2u prbc and 1 bag of
platelets.
.
Today the patient reports that he was feeling extremely fatigued
and so called an ambulance. He was taken to an outside hospital
where he received vancomycin and zosyn. He was then transferred
to [**Hospital1 18**] for further management and found to have T 103.3,
tachycardia to 120s, and SBP 94. Blood cultures were sent and he
was started on vanc/cefepime.

Past Medical History:
Oncologic History:
His induction chemotherapy was complicated by acute kidney
injury and neutropenic fever.  Induction with 3+7 was
unsuccessful, so he was re-induced with MEC, which resulted in
prolonged cytopenias and a brief ICU stay for respiratory
difficulty.  His only sibling is not a match and a search for a
matched unrelated donor has not been fruitful. He has therefore
enrolled in a dendritic fusion vaccine trial (protocol 09-014)
with PT1 and is now starting consolidation.
.
ROS: He reports extreme fatigue, R shoulder pain, blood tinged
mucus from right nostril. Denies wght loss, headache, dizziness,
visual changes, chest pain, dyspnea, cough, abd pain, back pain,
constipation, diarrhea, hematochezia, hematuria, other urinary
symptoms, or rash.
.
Past Medical History:
- AML M1-2, normal cytogenetics, NPM-1 negative, FLT3 negative,
s/p 3+7 induction, MEC re-induction, complicated by acute kidney

injury and neutropenic fever.
- Osteoarthritis, s/p L TKA, R THA.
- h/o negative colonoscopy-last [**2154**].
- Hypertension.
- Seasonal Allergies.
- GERD.

Social History:
Never married, no children.  Lives alone.  Retired fireman.
U.S.M.C. veteran during [**Country 3992**], stationed in Okinawa.  He is a
never smoker, denies alcohol and illicit drug use.  He
frequently travels to the southwest (e.g. [**State 15946**]).


Family History:
Thinks he had an uncle w/ liver cancer.  Father died of AAA,
mother of ?CHF.  Multiple family members w/ CVA as cause of
death.  No known h/o hematologic malignancies.

Physical Exam:
VS: 100.8 105 102/65 76 96%3L nc.
Gen: NAD
HEENT: MM dry, OP clear without lesions, exudate, or erythema.
CV: Tachy S1+S2.
Pulm: Bibasilar crackles (R>L)
Abd: S/NT/ND _bs
Ext: Trace edema bilaterally.
MSK: Right shoulder pain to active and passive motion.
Neuro: AOx3, CN II-XII intact.


Pertinent Results:
Admission Labs:
[**2158-10-23**] 11:10AM BLOOD WBC-0.1*# RBC-2.45* Hgb-7.8* Hct-21.8*
MCV-89 MCH-31.8 MCHC-35.6* RDW-15.7* Plt Ct-5*#
[**2158-10-24**] 12:45PM BLOOD Neuts-0* Bands-0 Lymphs-87* Monos-13*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2158-10-23**] 11:10AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2158-10-23**] 11:10AM BLOOD Plt Smr-RARE Plt Ct-5*#
[**2158-10-24**] 12:45PM BLOOD PT-13.4 PTT-25.3 INR(PT)-1.1
[**2158-10-24**] 12:45PM BLOOD Fibrino-787*#
[**2158-10-24**] 05:55PM BLOOD Gran Ct-0*
[**2158-10-23**] 11:10AM BLOOD UreaN-24* Creat-1.1 Na-137 K-4.0 Cl-102
HCO3-26 AnGap-13
[**2158-10-23**] 11:10AM BLOOD ALT-65* AST-31 LD(LDH)-157 AlkPhos-186*
TotBili-1.1
[**2158-10-25**] 12:00AM BLOOD proBNP-4078*
[**2158-10-24**] 12:45PM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.9 Mg-1.6

Micro:
Blood cultures- [**10-24**], [**Date range (1) 86904**], [**10-30**], [**10-31**]- No growth.
C. diff- [**10-27**], [**10-28**]- Negative
.
[**2158-10-26**] 10:00 am JOINT FLUID      Source: Right Shoulder.
   GRAM STAIN (Final [**2158-10-26**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2158-10-29**]):    NO GROWTH.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
   ACID FAST SMEAR (Final [**2158-10-27**]): NO ACID FAST BACILLI SEEN
ON DIRECT SMEAR.
   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.
Jt fluid- 2500 WBC; 0% polys
.
[**2158-10-31**] 1:25 pm JOINT FLUID      Source: R shoulder.
GRAM STAIN (Final [**2158-10-31**]): 2+   (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2158-11-3**]):    NO GROWTH.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2158-11-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.
Jt Fluid- 4500 WBC; 83% polys
.
[**2158-11-3**] 4:00 pm FLUID,OTHER      RIGHT SHOULDER.
                            **FINAL REPORT [**2158-11-9**]**
   GRAM STAIN (Final [**2158-11-3**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2158-11-6**]):    NO GROWTH.
   ANAEROBIC CULTURE (Final [**2158-11-9**]):    NO GROWTH.

Studies:
[**10-25**] TTEcho: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The ascending aorta and aortic
arch are mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No masses or vegetations are seen on the mitral
valve, but cannot be fully excluded due to suboptimal image
quality. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2158-8-1**], the
left ventricular systolc function is now less vigorous (low
normal) but without regional dysfunction. Valvular morphology is
similar.

[**10-25**] EKG: Sinus tachycardia. Otherwise, normal tracing. Compared
to
the previous tracing ST-T wave changes are less prominent and
the Q-T interval is shorter.

[**10-26**] RUQ U/S: The liver demonstrates no definite focal or
textural abnormality. There is no biliary dilatation. The CBD is
normal in caliber, measuring 4 mm. The portal vein demonstrates
normal hepatopetal flow. The gallbladder appears mildly
distended without evidence of internal stone or sludge.
Previously seen tiny anterior wall gallbladder polyp is not
demonstrated on current exam. There is no gallbladder wall
thickening or pericholecystic fluid. A 3.6 cm simple upper pole
right renal cyst is unchanged. There is no perihepatic fluid.
Partially visualized pancreas appears within normal limits. No
elicited [**Doctor Last Name **] sign.

IMPRESSION:
1. No focal liver abnormality.
2. Mildly distended gallbladder without wall thickening or
pericholecystic
fluid.
3. Stable simple right renal cyst.

[**10-27**] CT Chest/Abdomen/Pelvis-
1. Multifocal bilateral ground-glass opacities represent either
infectious or inflammatory foci.
2. Small amount of new, intermediate density peritoneal and
pelvic fluid, but no evidence of organized chest, abdominal or
pelvic fluid collections to suggest abscess.
3. Unchanged, enlarged pulmonary artery measuring 4 cm
consistent with
pulmonary hypertension.

[**10-27**] CT Head- There is no evidence for acute intracranial
hemorrhage, large mass, mass effect, edema, or hydrocephalus.
There is bifrontal cortical atrophy. Sinus mucosal disease is
again seen with increased opacification of the anterior ethmoid
air cells, increased mucosal thickening and a mucus retention
cyst in the left sphenoid sinus, and mild mucosal thickening in
the maxillary sinuses. Visualized bony structures are grossly
unremarkable.

[**10-30**] MRI R Shoulder- 1. Small glenohumeral joint effusion.
Extensive subacromial/subdeltoid bursitis. In the setting of
neutropenia and fever, infection is a primary consideration. In
presence of full-thickness rotator cuff tear, bursal fluid is in
direct communication with joint space. The bursal fluid is
amenable to ultrasound guided aspiration.
2. Extensive myositis; the differential diagnosis is broad and
includes
infection among other causes for myositis.
3. Full-thickness tear of supraspinatus tendon with retraction.
4. Tendinopathy of the infraspinatus tendon.
5. Long head of the biceps tendon tear.
6. Abnormal signal in superior and inferior labrum.
7. Moderate AC joint arthropathy.
8. Abnormal signal in the posterior right lung, suboptimally
evaluated on
this nondedicated study. Should further investigation be
required, this would be better evaluated with CT.

[**10-30**] R Shoulder U/S: Two focal fluid collections about the right
shoulder, the larger measuring 3.0 x 1.9 x 0.5 cm and located
along the anterolateral aspect of the joint.

[**11-4**]: RUE Venous U/S: No evidence of right upper extremity DVT.

[**11-8**] Chest CT:  Many new predominantly peripheral nodules, a
couple with
cavitation, as well as increasing mixed consolidative and
ground-glass opacity in the lingula. Although differential
considerations include the possibility of septic emboli, the
appearance is not entirely typical, and atypical etiologies of
infection including the possibility of aspergillosis should be
considered in the appropriate clinical setting.

[**11-10**] TTEcho:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
No mass or vegetation is seen on the mitral valve. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Preserved regional and global biventricular ventricular systolic
function.
Compared with the prior study (images reviewed) of [**2158-10-25**],
heart rate is slower. Estimated pulmonary artery pressures are
lower. Left ventricular function is slightly more vigorous.
.
Discharge Labs:
Na 139 Cl 103  BUN 14  gluc 87   AGap=14
K 3.9 HCO3 26 Cr 0.9
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 9.3 Mg: 2.0 P: 5.0
ALT: 17 AP: 257 Tbili: 0.8 Alb: 3.3
AST: 16 LDH: 178 Dbili:  TProt:
[**Doctor First Name **]:  Lip:
Source: Line-PICC
WBC 2.6 HGB 8.9 24.8 plts 76
 N:52 Band:0 L:20 M:26 E:0 Bas:0 Atyps: 1 Myelos: 1
Hypochr: NORMAL Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Microcy: 1+
Polychr: 1+ Spheroc: 1+ Ovalocy: 1+ Schisto: OCCASIONAL
Comments: MANUALLY COUNTED
Plt-Est: Very Low
Other Hematology
Gran-Ct: 1378
Source: [**Name (NI) 71017**]
PT: 13.7  PTT: 26.9  INR: 1.2

Brief Hospital Course:
66 year old male with history of AML s/p 7+3 therapy and D17 s/p
cycle 1 HIDAC on presentation, admitted with right shoulder pain
and fatigue.

# MSSA sepsis: Patient was initially admitted to BMT floor
service and treated with vanco and cefepime with intermittent
hypotensive which improved after 4L IVF and 1 unit PRBC. Morning
after admission, patient developed a new O2 requirement and was
felt to be volume overloaded, and so received 30 mg IV lasix.
OSH blood cultures were then found to be positive for S.aureus
(within 12 hours) ([**2-26**]) and he received a dose of linezolid in
addition to vancomycin. He then was febrile to 102 and was found
to be hypotensive to SBP 70s that was unresponsive to 1L IVF. He
was started on peripheral levophed and transferred to the [**Hospital Unit Name 153**]
for further management.

He was started on Vancomycin, cefepime, and linezolid for
empiric therapy for febirle neutropenia. He required a brief
period of pressor support with norepinepherine as his MAP was
<60 on ICU admission.  During this time, he was also
experiencing right shoulder pain.  Joint space aspiration
revealed 2500 leukocytes concerning for a septic joint.  His
blood cultures from OSH grew out [**2-26**] MSSA.  TTE was negative for
valvular vegetations.  His abx therapy was down graded to
nafcillin and ciprofloxacin by ICU day #3.  However, due to
recurrent low grade fevers, he was placed on fluconazole.  A
thoracic CT scan as well as head CT were performed to look for
an indolent infection/abscess/phlegmon.  CT's failed to reveal a
distinct collection, though did show multifocal bilateral
ground-glass opacities. He continued to have low grade fevers
which were attributed to a possibly septic joint/shoulder
infection.

He was transferred back to the floor after a 4 day ICU stay and
his antibiotics were reduced to primarily nafcillin, with
fluconazole and acyclovir for PPX. He remained febrile until
after undergoing two further drainages of the fluid from his
shoulder (see below). After the second drainage, patient was
afebrile for the rest of his hospitalization and continued on
nafcillin without event.

He underwent repeat chest CT when an CXR showed possible
progression of the earlier opacities/nodules and this showed new
predominantly peripheral nodules, a couple with cavitation, as
well as increasing mixed consolidative and ground-glass opacity
in the lingula concerning for septic emboli. Pulmonology was
consulted and recommended TTE (Please see note for further
details). Patient underwent a repeat TTE to assess for valvular
disease which was negative. TEE was deferred secondary to the
patient's low platelets.

To Follow Up-
- Patient will need repeat chest CT in [**12-28**] months to assess
progression of nodules and ground glass opacities
- urine histoplasma and galactomannan pending on discharge
.
# Febrile neutropenia: Presented s/p 7+3 therapy and C1D17 from
HIDAC.  Fevers were thought to be due to MSSA septicemia in
conjunction with septic joint.  Neutropenic [**12-27**] chemotherapy.
Started on filgastrim and continued until counts recovered.
.
# R septic shoulder:  On presentation patient had extreme right
shoulder pain. Orthopedics was consulted and felt that his
symptoms were secondary to a rotator cuff tear though septic
joint was in the differential. They tapped the shoulder- joint
fluid showed 2500 leukocytes- elevated in the setting of
leucopenia concerning for septic arthritis. As the patient's
neutropenia resolved his shoulder swelled up signficantly and
pain worsened. He underwent MRI of the shoulder which showed
joint effusion, extensive subacromial/subdeltoid bursitis,
extensive myositis of the shoulder girdle and a full thickness
rotator cuff tear. The patient underwent two subsequent taps,
one by ortho (appx 2 ccs) [4500 WBC, 83% polys, no orgs on GS or
culture] and the final by IR (appx 10cc), which showed 2+ polys
and no organisms on gram stain or culture. The patient became
and remained afebrile after the third tap. He was continued on
nafcillin with a planned antibiotic course of 6 weeks.
.
#. Narrow-complex Tachycardia: Patient had sporadic bouts of SVT
while in the ICU, reaching rates of about 200 bpms.  Usually
broke SVT on own, but on ICU day #3 had an early morning bout of
SVT to 180's.  Given 5 mg IV metoprolol and carotid massage,
bringing HR down to 100.  Thought to be due to fevers.  BMT
concerned of possible intracrdiac/valvular infection which may
be affecting conduction system.  No signs of infectious
collection seen on imaging.  Started on low dose beta blocker
12.5 mg metoprolol [**Hospital1 **] for baseline rate control on ICU day #4.
The patient's heart rate was better controlled for the remainder
of his hospitalization and he was discharged on this medication.
.
#. Right calf nodule- Patient with small erythematous macule on
lateral right calf which progressed to a non tender erythematous
nodule. Derm was consulted and did not feel that this was a
manifestation of septic emboli; they felt it was more likely a
resolving inflammatory process. Given location of nodule and
patient already on optimal therapy, biopsy was not performed.
.
#. Hypertension: Patient with history of hypertension on
amlodipine at home. This medication was discontinued on
admission secondary to his low blood pressures in the setting of
sepsis. Following his ICU stay, he was normotensive off of
amlodipine and on metoprolol. He was discharged on metoprolol
and amlodipine was discontinued.
.
# Hyperbilirbuinemia:  Bilirubin slowly trending up from <1.0 to
2.7 on ICU day #4.  [**Month (only) 116**] be due to recent transfusions he
previously received on ICU admission.  RUQ US did not show any
cholangitic or hepatic process/obstruction. This trended down
during the rest of his hospitalization.

Medications on Admission:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**11-26**] Tablet,
Rapid Dissolves PO three times a day as needed for nausea.


Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams
Intravenous Q4H (every 4 hours).
4. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]

Discharge Diagnosis:
Acute myelogenous leukemia
Methicillin sensitive staphylococcus aureus bacteremia
Right shoulder infection


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital with fatigue and right
shoulder pain. You were found to have bacteria growing in your
blood and required a stay in the intensive care unit. Your
infection was treated with antibiotics and your condition
improved. The source of your infection was believed to be your
shoulder- an MRI showed inflammation and tear of the muscles as
well as fluid in the joints. Some of this fluid was drained and
your fevers resolved. Please continue to take the antibiotics
for six weeks.

We made the following changes to your medications:
- START taking nafcillin for your infection
- START taking metoprolol for your heart rate and blood pressure
- START taking fluconazole to prevent fungal infection
- CHANGE your dose of acyclovir to 400 mg every eight hours
- STOP taking amlodipine for your blood pressure

Followup Instructions:
Please follow up at the appointments below:

Department: INFECTIOUS DISEASE
When: MONDAY [**2158-11-27**] at 9:50 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-11-27**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2158-11-27**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12633**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

Completed by:[**2158-11-10**]
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic pulmonary embolism,Septic shock,Other specified aplastic anemias,Pyogenic arthritis, shoulder region,Acute myeloid leukemia, without mention of having achieved remission,Jaundice, unspecified, not of newborn,Disorders of bursae and tendons in shoulder region, unspecified,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Effusion of joint, shoulder region,Other atopic dermatitis and related conditions,Severe sepsis,Other fluid overload'}


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: Fever

PRESENT ILLNESS: Mr. [**Known lastname 86903**] is a 66 yo man with AML M1-2 s/p induction currently
C1D16 on HIDAC consolidation who presents with R shoulder pain
and fatigue. Seen at 7Feldberg outpatient clinic for count check
yesterday; he complained of feeling very poorly and requested to
come in early, gait was unstable & he used a wheelchair. He
states that since sleeping on his R shoulder on Sunday night, he
has had [**8-4**] pain in the shoulder and difficulty moving it
secondary to pain. States that he was unable to sleep at all the
past two nights secondary to the pain. His vital signs at clinic
the day prior to admission were BP 129/86, HR 116 T 98.2 RR 18
O2 Sat%: 98%. His labs were wbc 0.1 hgb.7.8/hct.21.8 and
platelets 5; he was transfused with 2u prbc and 1 bag of
platelets.
.
Today the patient reports that he was feeling extremely fatigued
and so called an ambulance. He was taken to an outside hospital
where he received vancomycin and zosyn. He was then transferred
to [**Hospital1 18**] for further management and found to have T 103.3,
tachycardia to 120s, and SBP 94. Blood cultures were sent and he
was started on vanc/cefepime.

MEDICAL HISTORY: Oncologic History:
His induction chemotherapy was complicated by acute kidney
injury and neutropenic fever.  Induction with 3+7 was
unsuccessful, so he was re-induced with MEC, which resulted in
prolonged cytopenias and a brief ICU stay for respiratory
difficulty.  His only sibling is not a match and a search for a
matched unrelated donor has not been fruitful. He has therefore
enrolled in a dendritic fusion vaccine trial (protocol 09-014)
with PT1 and is now starting consolidation.
.
ROS: He reports extreme fatigue, R shoulder pain, blood tinged
mucus from right nostril. Denies wght loss, headache, dizziness,
visual changes, chest pain, dyspnea, cough, abd pain, back pain,
constipation, diarrhea, hematochezia, hematuria, other urinary
symptoms, or rash.
.
Past Medical History:
- AML M1-2, normal cytogenetics, NPM-1 negative, FLT3 negative,
s/p 3+7 induction, MEC re-induction, complicated by acute kidney

MEDICATION ON ADMISSION: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: 100.8 105 102/65 76 96%3L nc.
Gen: NAD
HEENT: MM dry, OP clear without lesions, exudate, or erythema.
CV: Tachy S1+S2.
Pulm: Bibasilar crackles (R>L)
Abd: S/NT/ND _bs
Ext: Trace edema bilaterally.
MSK: Right shoulder pain to active and passive motion.
Neuro: AOx3, CN II-XII intact.

FAMILY HISTORY: Thinks he had an uncle w/ liver cancer.  Father died of AAA,
mother of ?CHF.  Multiple family members w/ CVA as cause of
death.  No known h/o hematologic malignancies.

SOCIAL HISTORY: Never married, no children.  Lives alone.  Retired fireman.
U.S.M.C. veteran during [**Country 3992**], stationed in Okinawa.  He is a
never smoker, denies alcohol and illicit drug use.  He
frequently travels to the southwest (e.g. [**State 15946**]). 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Septic pulmonary embolism,Septic shock,Other specified aplastic anemias,Pyogenic arthritis, shoulder region,Acute myeloid leukemia, without mention of having achieved remission,Jaundice, unspecified, not of newborn,Disorders of bursae and tendons in shoulder region, unspecified,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Effusion of joint, shoulder region,Other atopic dermatitis and related conditions,Severe sepsis,Other fluid overload'}
