CHIEF COMPLAINT: Malaise, hypotension

PRESENT ILLNESS: 73 yo M with h/o CMV, prostate ca s/p XRT and hormonal therapy,
DM, presenting with 3 months of worsening fatigue,
constitutional symptoms, and recent hypotension.

MEDICAL HISTORY: Lymphadenopathy
Cytomegalovirus disease
DM
Hypercholesterolemia
HTN
HLD
cardiomyopathy
OA

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Furosemide 20 mg PO DAILY
2. tadalafil *NF* 20 mg Oral qwk
3. NIFEdipine CR 30 mg PO DAILY
4. ValGANCIclovir 900 mg PO Q24H
5. 70/30 30 Units Breakfast
70/30 20 Units Bedtime
6. Tamsulosin 0.4 mg PO HS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, SOB
8. Aspirin 325 mg PO DAILY

ALLERGIES: simvastatin

PHYSICAL EXAM: ADMISSION EXAM
Vitals:  100.6, 100, 110/58, 21, 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present,
splenomegaly, but no hepatomegaly, nontender on palpation
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: Mother: breast ca, DM, HTN lived to 90s
Father: prostate ca, DM, HTN
no family hx of hematologic malginancy

SOCIAL HISTORY: Worked as a pastor, lives with wife, denies smoking, EtOH or
drug abuse.
Mycosis fungoides, unspecified site, extranodal and solid organ sites,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Other pancytopenia,Personal history of malignant neoplasm of prostate,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hypocalcemia
Mycs fng unsp xtrndl org,SIRS-noninf w ac org dys,Ac kidny fail, tubr necr,Acute necrosis of liver,Hyposmolality,Prim cardiomyopathy NEC,Other pancytopenia,Hx-prostatic malignancy,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Hypertension NOS,Neutropenia NOS,Fever in other diseases,Hypocalcemia
Admission Date:  [**2132-9-9**]              Discharge Date:   [**2132-9-25**]

Date of Birth:  [**2059-9-3**]             Sex:   M

Service: MEDICINE

Allergies:
simvastatin

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Malaise, hypotension


Major Surgical or Invasive Procedure:
none

History of Present Illness:
73 yo M with h/o CMV, prostate ca s/p XRT and hormonal therapy,
DM, presenting with 3 months of worsening fatigue,
constitutional symptoms, and recent hypotension.

Pt was interviewed with the presence of his wife, who helped to
answer much of the questions.  Pt stated that in [**Month (only) 547**], he noted
vision changes, as diagnosed with CMV retinitis.  He was started
on valganciclovir, with improvement of vision changes, but later
had worsening malaise.  Pt attributed his symptoms to the
medication and stopped valgancilovir three weeks ago.
Reportedly, pt had undetectable CMV viral load in the blood
prior to d/c'ing the medication.  Pt continued to have chill,
malaise, night sweats, ~10 lbs weight loss in last month,
anorexia, and intermittent diarrhea.  There was however no
fever, rigor, abdomminal pain, upper or lower GIB.

In [**2128**], pt had similar symptoms per PCP note, although pt could
not recall these history.  He reportedly had a axillar lymph
node biopsy, and was found to have CMV lymphadenitis with no
[**Doctor Last Name **]-Sternberg cells and negative flow cytometry.  In [**Month (only) 958**]
[**2132**], a CT abd showed splenomegaly to 14 cm, which in [**2132-8-10**]
has increased to 17.5 with mediastinal lymphadenopathy,
periaortic lymphadenopathy and a 2.9X3.8 splenic mass.

In the ED, initial VS were:  98.7 87 78/49 16 100% RA. Lab was
notable for WBC 1.8 with 29% neutrophil, mild anemia with HCT
33.4, transaminitis with ALT 211, AST 451, ALP 829, T-bili 6.5,
normal coag, and Alb 3.1, hyponatremia to 128, and lactate 2.4.
He had normal CXR and normal RUQ US.  He was given Vancomycin,
Cefepime and hydrocortisone 100 mg, and 1 liter IVF.  His blood
pressure improved to SBP ~110 after the 1 liter IVF. Because of
hypotension and transaminitis, he was transferred to the ICU.

On arrival to the MICU, patient's VS were 100.6, 100, 110/58,
21, 99% on RA

Review of systems:
(+) Per HPI
(-) Denies fever, Denies headache, sinus tenderness, rhinorrhea
or congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, dark or bloody stools.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.


Past Medical History:
Lymphadenopathy
Cytomegalovirus disease
DM
Hypercholesterolemia
HTN
HLD
cardiomyopathy
OA


Social History:
Worked as a pastor, lives with wife, denies smoking, EtOH or
drug abuse.


Family History:
Mother: breast ca, DM, HTN lived to 90s
Father: prostate ca, DM, HTN
no family hx of hematologic malginancy


Physical Exam:
ADMISSION EXAM
Vitals:  100.6, 100, 110/58, 21, 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present,
splenomegaly, but no hepatomegaly, nontender on palpation
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.


Pertinent Results:
ADMISSION LABS
[**2132-9-9**] 02:35PM BLOOD WBC-1.8* RBC-3.92* Hgb-10.6* Hct-33.4*
MCV-85 MCH-
                       27.0 MCHC-31.7 RDW-18.1* Plt Ct-154

[**2132-9-9**] 02:35PM BLOOD PT-12.3 PTT-37.7* INR(PT)-1.1

[**2132-9-9**] 02:35PM BLOOD Glucose-62* UreaN-22* Creat-0.9 Na-128*
K-6.2* Cl-
                 101 HCO3-23 AnGap-10
[**2132-9-9**] 02:35PM BLOOD Albumin-3.1* Calcium-8.2* Phos-3.4 Mg-2.4

DISCHARGE LABS

LABS PENDING

PERTINENT MICRO

PERTINENT IMAGING

RUQ U/S ([**9-9**]): no evidence of stones or ductal dilation
CT ABD/Pelv ([**2132-9-10**]):

CT OF THE CHEST WITH INTRAVENOUS CONTRAST:  Numerous enlarged
lymph nodes are seen in the left axillary and subpectoral
region, with the largest node
measuring 34 x 24 mm (3:24).  Small right axillary lymph nodes
measuring less than a centimeter do not meet criteria for
significant adenopathy.  Additional prominent scattered lymph
nodes are seen in the mediastinum in the prevascular,
pretracheal regions, with the largest in the right paratracheal
region measuring 10 mm (3:23).  The imaged portion of the
thyroid gland is normal.  The airways are patent to subsegmental
levels bilaterally.  The lungs are clear, without suspicious
pulmonary nodules or masses.  Small pleural calcifications are
seen anteriorly in the left lung (3:25).  Small bilateral simple
pleural effusions are seen.  There is no pericardial effusion.
The heart is normal in size.  Moderate-to-severe coronary
arterial calcifications are noted.  Mild atherosclerotic
calcification is seen in the thoracic aorta.  The pulmonary
arteries are unremarkable.

CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST:  No focal liver
lesions are
identified.  There is no intra- or extra-hepatic biliary
dilatation.  Mild
gallbladder wall edema in the setting of a decompressed
gallbladder likely
relates to third spacing.  The adrenal glands are normal.  The
pancreas is
normal in appearance.  The spleen is enlarged measuring 15.8 cm.
 Both kidneys enhance and excrete contrast symmetrically without
hydronephrosis or renal masses. A 6.5 cm simple renal cortical
cyst is seen in the interpolar region of the left kidney.
Additional smaller renal cysts are seen in both kidneys.
Small scattered retroperitoneal lymph nodes are seen, with the
largest node in the left paraaortic region measuring 10 mm
(3:72).  There is a small amount of perihepatic ascites and fat
stranding in the right paracolic gutter.  The stomach, small and
large bowel loops are normal.  The abdominal aorta has moderate
atherosclerotic calcification, without aneurysmal dilation.

CT OF THE PELVIS WITH INTRAVENOUS CONTRAST:  The urinary bladder
is
decompressed with mild bladder wall thickening, which may relate
to prior
radiation treatment or outlet obstruction.  Multiple
brachytherapy seeds are seen within the prostate.  The rectum
and sigmoid colon are normal.  A small amount of simple ascites
is seen within the pelvis.  No significant pelvic adenopathy is
seen. A small fat-containing left inguinal hernia is present.

BONES AND SOFT TISSUES:  No bone lesions suspicious for
infection or
malignancy are detected.  Moderate degenerative changes are seen
in the facet joints of L4-L5 and L5-S1 levels.

IMPRESSION:
1.  Numerous axillary lymphadenopathy (largest in left axilla
measuring 3.4 x 2.4cm) and splenomegaly.  These findings are
concerning for lymphoproliferative disorder.  Borderline
mediastinal lymph nodes.
2.  Bilateral small simple pleural effusions and a small amount
of abdominal ascites.


Brief Hospital Course:
MICU COURSE

# T Cell Lymphoma / Lymphadenopathy:  Patient has history of
axillary adenopathy which had been biopsied in [**2128**], with
results consistent with CMV-lymphadenitis, negative for
[**Doctor Last Name **]-[**Doctor Last Name 93840**] cells, negative flow cytometry.  As per the
outpatient Atrius records, patient was evaluated for
lymphadenopathy recently by Oncologist, who was planning to
arrange for a PET-CT.  He was seen by the inpatient Atrius
Oncology service, who recommended a lymph node biopsy.  He
underwent full excisional lymph node biopsy on [**9-12**] by general
surgery.  Results of the pathology were c/w T cell lymphoma.
Patient developed liver and kidney failure, thought likely to be
secondary to infiltrative disease. Patient underwent one
treatment with etoposide, with little improvement. Patient was
found to have worsening mental status. CT scan was performed
which did not show evidence of bleed or malignancy. Potential
hepatorenal syndrome was considered, but urine sodium > 10 was
not consistent with HRS. Renal was consulted, who recommended
attempting volume resuscitation for likely ATN. This was
attempted but with little success, with patient still nearly
anuric. Conversation was held with family, and patient was made
CMO. Ativan, morphine, and scopolamine were started.  He passed
away early morning of [**2132-9-25**] with family at the bedside.
Family consented to autopsy with nocturnist who pronounced his
death.

# Hypotension: This was responsive to fluid boluses in the ED.
Patient was started on Vanc/Cefipime for concern for febrile
neutropenia/sepsis.  Patient was given maintenance fluids on the
floor and his pressures remained between 90s-110s systolic,
without the need for pressors.

# Fevers: Differential included sepsis vs. disseminated CMV
infection vs. lymphoma.  Patient had a transaminitis with
obstructive hyperbilirubinemia but RUQ u/s did not show concern
for cholecystis or biliary obstruction. Patient had history of
fevers secondary to CMV, for which he was taking valgancyclovir.
 He had recently stopped before this admission due to side
effects.  He was cultured and covered for febrile neutropenia in
the ED with Vanc and Cefepime because his white count came back
at 1.8 with 28% bands.  Patient had a temp to 100.6 on transfer
to the floor.  On D2 of his MICU stay, he spiked temps to 102.
Blood cultures remained negative.  He had an extensive ID
workup, including CMV viral load, HepB/C AG, Hep B/C viral load,
cryptococcal antigen, HIV viral load, RPR, as well as
cryptococcal antigen, which all came back negative.  His blood
cultures remained negative.  He was started on Acyclovir ppx.
given his low white count and positive EBV titers.  After
diagnosis of T cell lymphoma, these constitutional symptoms were
thought to be secondary to his underlying malignancy as opposed
to active infection.

# Obstructive jaundice: He had elevated liver enzymes with an
elevated direct biliribin, consistent with an obstructive
process.  RUQ ultrasound failed to reveal biliary duct dilation
or stones.  CT abdomen/pelv with contrast failed to show focal
liver disease or intra or extra hepatic biliary dilation.
Hepatitis studies as well as [**Doctor First Name **] and AMA were negative.  The
cause was thought to be due liver infiltration by malignancy.

# CMV retinitis: The patient was placed on valgancylovir
initially for concern for CMV reactivation.  Outside records
were obtained, which showed that he was diagnosed with CMV
retinitis in [**2132-4-10**] after experiencing worsening vision
in his left eye.  He was followed by [**Hospital 13128**], who
prescribed systemic valgancyclovir with resolution of his ocular
symptoms.  His valgancyclovir was halted for a few weeks prior
to admission for concern for marrow suppression.  His
valgancyclovir was discontinued on D3 of admission after an
ophthalmology evaluation revealed no retinitis and his CMV load
was negative.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Furosemide 20 mg PO DAILY
2. tadalafil *NF* 20 mg Oral qwk
3. NIFEdipine CR 30 mg PO DAILY
4. ValGANCIclovir 900 mg PO Q24H
5. 70/30 30 Units Breakfast
70/30 20 Units Bedtime
6. Tamsulosin 0.4 mg PO HS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, SOB
8. Aspirin 325 mg PO DAILY


Discharge Medications:
Patient expired [**2132-9-25**]

Discharge Disposition:
Expired

Discharge Diagnosis:
T cell lymphoma

Discharge Condition:
Expired in hospital
{'Mycosis fungoides, unspecified site, extranodal and solid organ sites,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Other pancytopenia,Personal history of malignant neoplasm of prostate,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hypocalcemia'}


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: Malaise, hypotension

PRESENT ILLNESS: 73 yo M with h/o CMV, prostate ca s/p XRT and hormonal therapy,
DM, presenting with 3 months of worsening fatigue,
constitutional symptoms, and recent hypotension.

MEDICAL HISTORY: Lymphadenopathy
Cytomegalovirus disease
DM
Hypercholesterolemia
HTN
HLD
cardiomyopathy
OA

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Furosemide 20 mg PO DAILY
2. tadalafil *NF* 20 mg Oral qwk
3. NIFEdipine CR 30 mg PO DAILY
4. ValGANCIclovir 900 mg PO Q24H
5. 70/30 30 Units Breakfast
70/30 20 Units Bedtime
6. Tamsulosin 0.4 mg PO HS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze, SOB
8. Aspirin 325 mg PO DAILY

ALLERGIES: simvastatin

PHYSICAL EXAM: ADMISSION EXAM
Vitals:  100.6, 100, 110/58, 21, 99% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present,
splenomegaly, but no hepatomegaly, nontender on palpation
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

FAMILY HISTORY: Mother: breast ca, DM, HTN lived to 90s
Father: prostate ca, DM, HTN
no family hx of hematologic malginancy

SOCIAL HISTORY: Worked as a pastor, lives with wife, denies smoking, EtOH or
drug abuse. 

### Response:
{'Mycosis fungoides, unspecified site, extranodal and solid organ sites,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Acute kidney failure with lesion of tubular necrosis,Acute and subacute necrosis of liver,Hyposmolality and/or hyponatremia,Other primary cardiomyopathies,Other pancytopenia,Personal history of malignant neoplasm of prostate,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Hypocalcemia'}
