CHIEF COMPLAINT: Neutropenic fever / epigastric pain

PRESENT ILLNESS: 38 y/o female with history of ALL, diagnosed [**9-23**], status post
complete remission induced by five cycles of chemotherapy but
with recent relapse by bone marrow biopsy [**2135-6-13**] status post
admission for reinduction chemotherapy [**Date range (1) 18555**] who presented to
the ED from home with epigastric pain and fevers.
.
Her admission was prompted first by a call to the [**Date range (1) 3242**] floor at
approx 9pm on [**6-29**] with concerns that she was not feeling well.
She noted epigastric pain for approximately three days
associated with diarrhea and nausea. She was directed to call
the [**Month/Year (2) 3242**] fellow on call, and when she mentioned fever to 100.2
associated with chills and rigors, she was directed to the ED
for evaluation.
.
In the ED her vitals with T 99.1 orally, HR 109, BP 128/87, RR
16, and satting 100% on RA. She received 2gm cefepime, IV
dilaudid, and was pan-cultured. CXR was without evidence for
pneumonia. She was guiac negative. No CT scan was performed.
.
On review of systems, she denies cough, shortness of breath, or
diaphoresis. Her diarrhea has resolved, but her abdominal pain
continues.  She notes it has been occurring since tuesday, is
worse with eating, and is constant all day and evening.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
# Her ALL was diagnosed in [**9-23**], [**Location (un) 5622**] chromosome
negative.  She underwent 4 cycles of part A and part B hyperCVAD
and 1 cycle of maintenance therapy.  As above, she had a recent
relapse of her disease by bone marrow biopsy on [**2135-6-13**] and had
re-induction chemotherapy on [**6-17**] with plans to undergo matched
un-related allogeneic stem cell transplantation if a donor
becomes available. Her treatment course has been complicated by
-F+N, low back pain, C diff,
-surgical debridement and extraction of a tooth on [**2135-2-11**] due
to dentoalveolar abscess to bone
-vaginal Herpes outbreak while in hospital [**Date range (1) 18555**].
.
OTHER PAST MEDICAL HISTORY:
# DMII
# HTN
# s/p tonsillectomy
# s/p cholecystectomy
# s/p tooth #12 flap, fistulectomy and debridement [**2134-12-26**]
# s/p upper left tooth extraction on [**2135-2-11**]
# vaginal herpes

MEDICATION ON ADMISSION: Metoprolol 37.5mg po qday
Acyclovir 400mg po Q 8 hours
Glimepiride 2mg po BID
Lantus/Humalog sliding scale

ALLERGIES: Penicillins / Aspirin / Amoxicillin / Omeprazole

PHYSICAL EXAM: On admission

FAMILY HISTORY: ? sickle cell train in sister.  + for HTN in parents and for DM
in both sets of grandparents.

SOCIAL HISTORY: Lives alone in [**Location (un) 669**]. Originally from [**Country 3515**]. Previously
worked as a financial aid officer in a bank. No EtOH, no
tobacco.
Acute lymphoid leukemia, without mention of having achieved remission,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Streptococcal septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified disease of pericardium,Unspecified protein-calorie malnutrition,Pneumonia, organism unspecified,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Thrombocytopenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Infection with microorganisms without mention of resistance to multiple drugs,Cardiac arrest,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other specified noninflammatory disorders of vagina
Ac lym leuk wo achv rmsn,Acute pancreatitis,Int inf clstrdium dfcile,Streptococcal septicemia,Severe sepsis,Acute respiratry failure,Acute kidney failure NOS,Pericardial disease NOS,Protein-cal malnutr NOS,Pneumonia, organism NOS,Neutropenia NOS,Fever in other diseases,Thrombocytopenia NOS,Anemia NOS,Adv eff antineoplastic,Inf mcr rst ot drg nt ml,Cardiac arrest,Chr blood loss anemia,DMII wo cmp nt st uncntr,Hypertension NOS,Noninflam dis vagina NEC
Admission Date:  [**2135-6-30**]              Discharge Date:   [**2135-9-18**]

Date of Birth:  [**2097-2-6**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Aspirin / Amoxicillin / Omeprazole

Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Neutropenic fever / epigastric pain

Major Surgical or Invasive Procedure:
Bone marrow biopsy.
PICC line removal.
Tunneled line placement.
Bone marrow biopsy.

History of Present Illness:
38 y/o female with history of ALL, diagnosed [**9-23**], status post
complete remission induced by five cycles of chemotherapy but
with recent relapse by bone marrow biopsy [**2135-6-13**] status post
admission for reinduction chemotherapy [**Date range (1) 18555**] who presented to
the ED from home with epigastric pain and fevers.
.
Her admission was prompted first by a call to the [**Date range (1) 3242**] floor at
approx 9pm on [**6-29**] with concerns that she was not feeling well.
She noted epigastric pain for approximately three days
associated with diarrhea and nausea. She was directed to call
the [**Month/Year (2) 3242**] fellow on call, and when she mentioned fever to 100.2
associated with chills and rigors, she was directed to the ED
for evaluation.
.
In the ED her vitals with T 99.1 orally, HR 109, BP 128/87, RR
16, and satting 100% on RA. She received 2gm cefepime, IV
dilaudid, and was pan-cultured. CXR was without evidence for
pneumonia. She was guiac negative. No CT scan was performed.
.
On review of systems, she denies cough, shortness of breath, or
diaphoresis. Her diarrhea has resolved, but her abdominal pain
continues.  She notes it has been occurring since tuesday, is
worse with eating, and is constant all day and evening.

Past Medical History:
PAST ONCOLOGIC HISTORY:
# Her ALL was diagnosed in [**9-23**], [**Location (un) 5622**] chromosome
negative.  She underwent 4 cycles of part A and part B hyperCVAD
and 1 cycle of maintenance therapy.  As above, she had a recent
relapse of her disease by bone marrow biopsy on [**2135-6-13**] and had
re-induction chemotherapy on [**6-17**] with plans to undergo matched
un-related allogeneic stem cell transplantation if a donor
becomes available. Her treatment course has been complicated by
-F+N, low back pain, C diff,
-surgical debridement and extraction of a tooth on [**2135-2-11**] due
to dentoalveolar abscess to bone
-vaginal Herpes outbreak while in hospital [**Date range (1) 18555**].
.
OTHER PAST MEDICAL HISTORY:
# DMII
# HTN
# s/p tonsillectomy
# s/p cholecystectomy
# s/p tooth #12 flap, fistulectomy and debridement [**2134-12-26**]
# s/p upper left tooth extraction on [**2135-2-11**]
# vaginal herpes

Social History:
Lives alone in [**Location (un) 669**]. Originally from [**Country 3515**]. Previously
worked as a financial aid officer in a bank. No EtOH, no
tobacco.

Family History:
? sickle cell train in sister.  + for HTN in parents and for DM
in both sets of grandparents.

Physical Exam:
On admission

VS: 99.5   99  16  120/88  97%RA
GEN: Well appearing, in no acute distress
HEENT: moist mucus membranes, no oral ulcers. Some subtle
whitening
CV:  RRR s1, s2,  no M/G/R
RESP: CTA bilaterally
ABD: soft - most tender to palpation in mid epigastrum. no
rebound or guarding
EXT: no ulcers, no edema, no foot lesions, good sensation

Pertinent Results:
LABS AT ADMISSION:
.
[**2135-6-30**] 06:03AM   GLUCOSE-174* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-10
[**2135-6-30**] 06:03AM   ALT(SGPT)-57* AST(SGOT)-49* LD(LDH)-223 ALK
PHOS-72 AMYLASE-41 TOT BILI-0.5
[**2135-6-30**] 06:03AM   LIPASE-27
[**2135-6-30**] 06:03AM   ALBUMIN-4.0 CALCIUM-8.3* PHOSPHATE-3.8
MAGNESIUM-1.8
[**2135-6-30**] 06:03AM   WBC-0.1* RBC-3.01* HGB-9.0* HCT-26.0* MCV-86
MCH-30.0 MCHC-34.7 RDW-13.4
[**2135-6-30**] 06:03AM   NEUTS-30* BANDS-0 LYMPHS-45* MONOS-5 EOS-10*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-10*
[**2135-6-30**] 06:03AM   HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL OVALOCYT-2+
TEARDROP-2+
[**2135-6-30**] 06:03AM   PLT SMR-LOW PLT COUNT-34*
[**2135-6-30**] 06:03AM   PT-14.5* PTT-31.5 INR(PT)-1.3*
[**2135-6-30**] 03:00AM   COMMENTS-GREEN TOP
[**2135-6-30**] 03:00AM   LACTATE-0.7
[**2135-6-30**] 02:40AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2135-6-30**] 02:40AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2135-6-29**] 12:00PM   GLUCOSE-239* UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-13
[**2135-6-29**] 12:00PM   WBC-0.1*# RBC-3.16* HGB-9.7* HCT-27.0* MCV-85
MCH-30.6 MCHC-35.8* RDW-13.6
[**2135-6-29**] 12:00PM   NEUTS-18.2* BANDS-3.0 LYMPHS-51.5*
MONOS-15.2* EOS-12.1* BASOS-0
[**2135-6-29**] 12:00PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
TEARDROP-1+
[**2135-6-29**] 12:00PM   PLT SMR-VERY LOW PLT COUNT-37*
[**2135-6-29**] 12:00PM   GRAN CT-27*
..
MICROBIOLOGY:
[**6-30**]: [**11-19**] blood cultures positive for coag neg staphylococcus.
..
STUDIES
.
CT CHEST ([**2135-7-13**]):
New bilateral pleural effusions are very tiny. Dependent
ground-glass opacity in both bases clears in inspiration and
prone imaging and are due to air trapping. One 9 x 7 mm bulla in
right lower lobe is unchanged (4A:106). Lungs are otherwise
clear. There is no lymph node enlargement using CT criteria.
There is no pericardial effusion. Airways are patent to the
subsegmental level. This study was not tailored for
subdiaphragmatic evaluation except to note clips in the upper
abdomen. Bones are normal.
IMPRESSION:
1. New very tiny bilateral pleural effusions.
2. Otherwise, normal exam. No findings of infection.
.
RUQ ULTRASOUND ([**2135-7-7**]):
The liver is diffusely echogenic. No focal liver lesions are
identified. There is no intrahepatic biliary ductal dilation.
The CBD is likely nondilated, though could not be specifically
identified. Portal venous flow is hepatopetal. The kidneys are
normal without hydronephrosis. The aorta is normal caliber. The
spleen and pancreas are normal.
IMPRESSION: Echogenic liver most likely fatty infiltration. More
severe forms of liver disease such as cirrhosis and fibrosis
cannot be excluded on the basis of this examination.
.
PELVIC ULTRASOUND ([**2135-7-7**]):
IMPRESSION:
1. Heterogeneous 9 mm enodmetrium with possible focal
endometrial lesion.
Follow up or son[**Name (NI) 18556**] could be performed if desired,
for further
evaluation of the endometrium.
2. 9 mm right adnexal cyst which today has the appearance of a
paraovarian
cyst.
4. Enlarging fibroids (largest 2.8 cm).
.
LUE ULTRASOUND [**7-6**]:
No evidence of DVT involving the left upper extremity.
.
BONE MARROW BIOPSY [**7-6**]:
DIAGNOSIS:
Relapsed B-acute lymphoblastic leukemia.  The biopsy material is
adequate for evaluation.  The bone marrow cellularity is 80-90%.
 Bony trabecula are focally thickened.  There is an interstitial
infiltrate of immature cells consistent with blasts occurring in
sheets occupying 90% of marrow cellularity.   In the remaining
hematopoiesis, the M:E ratio estimate is decreased.  Erythroid
precursors are decreased and exhibit maturation.  Myeloid
elements are markedly decreased and exhibit maturation.
Megakaryocytes are decreased.  Abnormal forms are not seen.
Focal loose clustering is noted.   Compared to a previous
M08-407, S08-[**Numeric Identifier 18557**], the current biopsy shows greater cellularity
comprised mostly of blasts with similar morphology to those seen
on the prior biopsy.
.
TTE [**7-19**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
Bone marrow biopsy [**8-1**]:
The biopsy material is adequate for evaluation and reveals a
markedly hypercellular bone marrow (90% cellularity).  There is
an interstitial infiltrate of immature cells consistent with
blasts occupying 90% of marrow cellularity.  By
immunohistochemistry, the blasts are not immunoreactive for CD4
or CD68 (histiocytes staining).


Brief Hospital Course:
In summary, this is a 38 year-old woman with [**Location (un) 5622**]
chromosome negative ALL, previously on chemo-therapy status post
induced remission with relapse of disease on bone marrow biopsy
[**2135-6-13**] status post reinduction chemotherapy as inpatient
[**Date range (1) 18555**] presenting with abdominal pain, fever and neutropenia.

# Acute Lymphoblastic Leukemia:  Because the infectious work-up
was negative, we decided to perform bone marrow biopsy to assess
for ALL disease recurrence.  The path report is provided above;
it showed 80% blasts.  Reinduction chemotherapy with hyperCVAD
part B was started (D+1 was [**2135-7-12**]).  There were no
complications during the chemotherapy.  She was kept on
allopurinol and sodium bicarbonate IV hydration to prevent
methotrexate-related renal toxicity.  She was started on
filgrastim.  The decision was made by her outpatient oncologist
to pursue an allogenic bone marrow transplant, so screening for
bone marrow transplantation was undertaken she had a TTE, PFTs
and an HIV test.  ID also evaluated her as part of the
pre-transplant workup.  Unfortunately she started to have
recurrent fevers as described above and her bone marrow biopsy
on [**8-1**] showed relapse so it was decided to treat her with
clofarabine to attempt to induce remission so she could undergo
a transplant in the near future.

# Neutropenic fever:  Granulocyte count was 18 on night of
admission.  As above, patient received one 2 mg dose of IV
cefepime in the ED.  When she arrived on the floor there was no
clear source of infection; CXR and urine culture were negative
and physical exam was remarkable only for mild epigastric
tenderness.  Blood cultures were drawn; one of four samples grew
gram positive cocci so she was started on IV vancomycin.
Speciation returned as coagulase negative staph; vanco was
stopped but her coverage was later broadened to cefepime and
caspofungin due to her persistent fevers and low white counts.
Her PICC line was removed and cultured.  This was negative.
Blood cultures remained negative on broad spectrum antibiotics
but she continued to spike fevers overnight.  No infectious
source was identified.  She was restarted on IV vancomycin for
continued fevers and also developed diarrhea and was found to be
C. diff positive and so was started on po flagyl.  She stopped
having fevers for a while, however they began again on [**7-26**].  A
CT of her chest showed no active disease, a CT of her sinuses
showed no sinusitis, cultures were all negative and it was
thought that the fevers were due to her ALL so a bone marrow
biopsy was done on [**8-1**] which showed a packed marrow.  She
continued to have fevers while being treated with clofarabine,
however her fevers resolved a few days after her course of
clofarabine was completed.

Approximately two weeks after clofarabine completion on [**8-16**],
with an ANC of 0, the patient again developed fevers.  Her PICC
was pulled.  Chest and abdominal CT did not show any source.
Blood cultures grew vancomycin-resistant enterococcus.
Linezolid was initially started but switched to daptomycin out
of concern for linezolid-induced bone marrow suppression.

# Tachypnea:  The patient was noted to be increasingly
tachypneic in the context of VRE bacteremia.  CT chest was
consistent with volume overload, and she was tentatively
diuresed given pericardial effusion (below).  On [**8-18**], her
tachypnea was worsening, and she was transferred to the ICU for
further management.

# Acute Pancreatitis:  A few days after completing clofarabine
she developed persistent abdominal pain.  She had had a MRI to
evaluate a possible new nodule seen on abdominal US, however the
MRI showed no liver pathology except for iron deposition.  An
abdominal CT showed pancreatitis so she was made NPO and given
aggressive IV hydration and dilaudid for pain control.  TPN was
started for nutrition.  Flagyl was stopped as this could
exacerbate pancreatitis.  After 6 days when she was still
experiencing significant pain, abdominal CT was done to evaluate
for complications, and it was negative for abscess or necrosis.


# C.diff infection: The patient developed diarrhea and was found
to be C.diff positive on [**7-18**].  She was started on po flagyl and
her diarrhea resolved.  She was continued on flagyl as she
remained neutropenic on broad spectrum antibiotics.  She was
switched to po vancomycin when she developed pancreatitis.

# Vaginal Bleeding:  On HD 2, she started her menses.  She had
received an injection of medroxyprogesterone acetate in clinic 2
months prior to admission(this is a q3 month injection), but
this was ineffective.  When her bleeding and fevers continued,
GYN was consulted for recs regarding additional progesterone
therapy and work-up for gynecologic cause of fevers and
abdominal / suprapubic pain.  Pelvic exam was negative for
cervical motion tenderness.  Pelvic U/S showed possible
endometrial polyp versus intrauterine clot, two uterine
fibroids, and stable right hydrosalpinx versus ovarian cyst.
There was no pathology to account for her fevers.
Progesterone/estrogen injections as well as GnRH analogues were
deferred due to the thromboembolic risks and the low liklihood
of any benefit to be had from either therapy in the setting of
recent progesterone therapy.  Her platelets and red cells were
repleted as needed; platelets were transfused to keep levels
greater than 30 to minimize menstrual blood loss.  Her menstrual
bleeding continued until GYN returned for a reevaluation and
recommended using a low-dose estradiol patch.  After wearing the
patch for 2 weeks with an increase in the dose, her menstrual
bleeding stopped and she was taken off the estradiol patch.
Several days later, she again started bleeding.  Gynecology
again saw the patient and restarted an estradiol patch.

# Initial epigastric pain:  Differential diagnosis for abdominal
pain at presentation included peptic ulcer disease,
pancreatitis, or gastritis (viral or chemical).  She had been on
protonix, but still may have developed gastric ulcerations or
mucosal lesions secondary to steroids (per chemo), viral ulcers,
or infection.  We continued her pantoprazole and treated her
pain with PO dilaudid.  H. pylori serology and RUQ ultrasound
were negative.  We could not perform upper endoscopy due to her
thrombocytopenia.  Further work-up could be pursued as
outpatient when her cell counts recover; however, her epigastric
pain resolved during the hospital course.

# Genital Herpes:  Shortly before presentation, she was
diagnosed with vaginal herpes for which she was being treated
with acyclovir.  This was continued for the duration of the
hospitalization.

# Hypertension:  The patient was initally on her outpatient
metoprolol dose, however she had elevated pressures while
hospitalized and so had her metoprolol increased to 50 mg daily
and 5 mg of amlodipine added.  Her BP medications were held
during her pancreatitis as she was NPO.  She was hypertensive in
this setting and was treated with hydralazine and metoprolol IV.

# Diabetes:  We held her glimepiride and started her on a
humalog insulin sliding scale for tighter glucose control.  Her
home glargine was decreased from 20U to 18U qPM as she had a few
episode of midnighttime hypoglycemia.  Her lantus was decreased
during her episode of pancreatitis as she was on TPN.  Insulin
in the TPN was titrated upward, with adequate control of
hyperglycemia.

# Pericardial effusion:  TTE showed pericardial effusion with
diastolic collapse of the right ventricle consistent with
tamponade physiology.  Cardiology saw the patient and advised
volume resuscitation.  This recommendation was balanced with her
respiratory distress and anasarca in response to aggressive
fluids.
____________________________________________________________
[**Hospital Unit Name **] course [**2135-8-18**]- [**2135-9-18**]

The pt was transferred to the [**Hospital Ward Name 332**] ICU [**2135-8-18**] for persistent
febrile neutropenia and sepsis. In the [**Hospital Unit Name 153**], she had a long
course with recurrent fevers and infections. Infectious disease
and the [**Hospital Unit Name 3242**] team were both involved extensively. Nephrology was
also involved as the pt was put on CVVH for renal failure. She
needed extensive blood and platelet transfusions for persistent
anemia and thrombocytopenis. She was intubated for several weeks
due to respiratory failure. She did recieve tube feedings and
TPN for nutritional support. She was eventually made DNR/DNI on
[**9-15**] and, despite use of multiple pressors, succumbed to septic
infection on [**2135-9-18**].

Medications on Admission:
Metoprolol 37.5mg po qday
Acyclovir 400mg po Q 8 hours
Glimepiride 2mg po BID
Lantus/Humalog sliding scale

Discharge Medications:
Pt expired on [**2135-9-18**].

Discharge Disposition:
Expired

Discharge Diagnosis:
Pt expired.

Discharge Condition:
.

Discharge Instructions:
.

Followup Instructions:
.


Completed by:[**2137-1-17**]
{'Acute lymphoid leukemia, without mention of having achieved remission,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Streptococcal septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified disease of pericardium,Unspecified protein-calorie malnutrition,Pneumonia, organism unspecified,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Thrombocytopenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Infection with microorganisms without mention of resistance to multiple drugs,Cardiac arrest,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other specified noninflammatory disorders of vagina'}


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: Neutropenic fever / epigastric pain

PRESENT ILLNESS: 38 y/o female with history of ALL, diagnosed [**9-23**], status post
complete remission induced by five cycles of chemotherapy but
with recent relapse by bone marrow biopsy [**2135-6-13**] status post
admission for reinduction chemotherapy [**Date range (1) 18555**] who presented to
the ED from home with epigastric pain and fevers.
.
Her admission was prompted first by a call to the [**Date range (1) 3242**] floor at
approx 9pm on [**6-29**] with concerns that she was not feeling well.
She noted epigastric pain for approximately three days
associated with diarrhea and nausea. She was directed to call
the [**Month/Year (2) 3242**] fellow on call, and when she mentioned fever to 100.2
associated with chills and rigors, she was directed to the ED
for evaluation.
.
In the ED her vitals with T 99.1 orally, HR 109, BP 128/87, RR
16, and satting 100% on RA. She received 2gm cefepime, IV
dilaudid, and was pan-cultured. CXR was without evidence for
pneumonia. She was guiac negative. No CT scan was performed.
.
On review of systems, she denies cough, shortness of breath, or
diaphoresis. Her diarrhea has resolved, but her abdominal pain
continues.  She notes it has been occurring since tuesday, is
worse with eating, and is constant all day and evening.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
# Her ALL was diagnosed in [**9-23**], [**Location (un) 5622**] chromosome
negative.  She underwent 4 cycles of part A and part B hyperCVAD
and 1 cycle of maintenance therapy.  As above, she had a recent
relapse of her disease by bone marrow biopsy on [**2135-6-13**] and had
re-induction chemotherapy on [**6-17**] with plans to undergo matched
un-related allogeneic stem cell transplantation if a donor
becomes available. Her treatment course has been complicated by
-F+N, low back pain, C diff,
-surgical debridement and extraction of a tooth on [**2135-2-11**] due
to dentoalveolar abscess to bone
-vaginal Herpes outbreak while in hospital [**Date range (1) 18555**].
.
OTHER PAST MEDICAL HISTORY:
# DMII
# HTN
# s/p tonsillectomy
# s/p cholecystectomy
# s/p tooth #12 flap, fistulectomy and debridement [**2134-12-26**]
# s/p upper left tooth extraction on [**2135-2-11**]
# vaginal herpes

MEDICATION ON ADMISSION: Metoprolol 37.5mg po qday
Acyclovir 400mg po Q 8 hours
Glimepiride 2mg po BID
Lantus/Humalog sliding scale

ALLERGIES: Penicillins / Aspirin / Amoxicillin / Omeprazole

PHYSICAL EXAM: On admission

FAMILY HISTORY: ? sickle cell train in sister.  + for HTN in parents and for DM
in both sets of grandparents.

SOCIAL HISTORY: Lives alone in [**Location (un) 669**]. Originally from [**Country 3515**]. Previously
worked as a financial aid officer in a bank. No EtOH, no
tobacco. 

### Response:
{'Acute lymphoid leukemia, without mention of having achieved remission,Acute pancreatitis,Intestinal infection due to Clostridium difficile,Streptococcal septicemia,Severe sepsis,Acute respiratory failure,Acute kidney failure, unspecified,Unspecified disease of pericardium,Unspecified protein-calorie malnutrition,Pneumonia, organism unspecified,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Thrombocytopenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Infection with microorganisms without mention of resistance to multiple drugs,Cardiac arrest,Iron deficiency anemia secondary to blood loss (chronic),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other specified noninflammatory disorders of vagina'}
