CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: Ms. [**Known firstname **] [**First Name4 (NamePattern1) 2431**] [**Known lastname **] is a 38yo F ALL s/p double cord blood
SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease, well-known to the [**Year (4 digits) 3242**]
service who was just discharged yesterday ([**2174-8-10**]) after a
prolonged hospital course for acute on chronic CHF thought be be
due to cardiac GVHD and acute on chronic renal failure. She was
discharged home with daily infusions of IV torsamide and
methylprednisolone. She came to clinic today fopr follow-up
where she was found to be febrile to 102 and up 0.5lbs from her
discharge weight. CXR was done and cardiac silloette was
increased, concerning for pleural effusion. Blood (PICC and
peripheral) and urine cultures were sent, and she was started on
empiric meropenem.
.
On arrival to the floor, pt has no complaints. She spent an hour
outside yesterday and was otherwise at home resting. She does
nto recal any bug bites. She did not feel subjectively febrile.
She has some cough, but no different or worse than prior to
discharge. She has some pedal [**Last Name (un) **],a put attributes this to
being up and walking around today. No calf pain. Otherwise, ROS
is negative. Per her sister, the pt got her torsemide and
methyprednisolone in clinic today. [**Name6 (MD) **] outpatient NP, pt's
weight was 137# today, up slightly from 136.5# on the day of
discharge.

MEDICAL HISTORY: ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

MEDICATION ON ADMISSION: -acyclovir 400 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) Neb Inhalation every six (6) hours as needed for SOB,
wheezing
-digoxin 125 mcg Tablet One (1) Tablet by mouth EVERY OTHER DAY.
-ergocalciferol (vitamin D2)50,000 unit Capsule One (1) Capsule
by mouth 1X/week
-lorazepam 0.5 mg Tablet One (1) Tablet by mouth every six (6)
hours as needed for anxiety/nausea.
-methylprednisolone sodium succ Sixty (60) mg Intravenous once a
day.
-metoprolol succinate 50 mg Tablet Extended Release 24 hr, One
(1) Tablet Extended Release 24 hr by mouth once a day
-morphine [MS Contin]15 mg Tablet Extended Release One (1)
Tablet Extended Release by mouth twice a day.
-mycophenolate mofetil 500 mg Tablet Two (2) Tablet by mouth
twice a day.
-nifedipine 60 mg Tablet Extended Release One (1) Tablet
Extended Release by mouth once a day in the evening.
-NPH insulin human recomb Ten (10) units Subcutaneous twice a
day: Please administer 10 units before breakfast and 10 units
before dinner.
-omeprazole 40 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth once a day.
-ondansetron 4 mg Tablet, Rapid Dissolve [**2-6**] Tablet, Rapid
Dissolves by mouth three times a day as needed for nausea.
-oxycodone 5 mg Tablet One (1) Tablet by mouth every 4-6 hours
as needed for pain.
-sildenafil 20 mg Tablet Four (4) Tablet by mouth three times a
day.
-sulfamethoxazole-trimethoprim 400-80 mg Tablet One (1) Tablet
by mouth DAILY (Daily).
-torsemide 20 mg/2 mL (10 mg/mL) Solution Forty (40) mg
Intravenous once a day.
-voriconazole 200 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.

ALLERGIES: Prochlorperazine / Heparin Agents

PHYSICAL EXAM: Physical Exam on Admission:
VS: T97.9/Tm 102, BP 110/67, HR 86, RR 18, 94% on 2L
GEN: AOx3, NAD
HEENT: Pupil equal and round. Sclera and conjunctiva clear. MMM.

FAMILY HISTORY: Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

SOCIAL HISTORY: She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis. Lifelong nonsmoker, but not currently. Denies
illicits or EtOH.
Complications of transplanted bone marrow,Pneumonia in cytomegalic inclusion disease,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,End stage renal disease,Cytomegaloviral disease,Acute lymphoid leukemia, in relapse,Secondary cardiomyopathy, unspecified,Chronic systolic heart failure,Acute pericarditis, unspecified,Cardiac tamponade,Acute kidney failure, unspecified,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic graft-versus-host disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of steroids,Hypoxemia,Thrombocytopenia, unspecified
Compl marrow transplant,Pneum w cytomeg incl dis,Acute respiratry failure,Septicemia NOS,Severe sepsis,Septic shock,End stage renal disease,Cytomegaloviral disease,Act lymp leuk in relapse,Second cardiomyopath NOS,Chr systolic hrt failure,Acute pericarditis NOS,Cardiac tamponade,Acute kidney failure NOS,Acidosis,Hyp kid NOS w cr kid V,Chronc graft-vs-host dis,Abn react-procedure NEC,Accident in place NEC,Asthma NOS,Chr pulmon heart dis NEC,Adv eff antineoplastic,Long-term use steroids,Hypoxemia,Thrombocytopenia NOS
Admission Date:  [**2174-8-11**]              Discharge Date:   [**2174-8-24**]

Date of Birth:  [**2135-11-15**]             Sex:   F

Service: MEDICINE

Allergies:
Prochlorperazine / Heparin Agents

Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Fevers

Major Surgical or Invasive Procedure:
Pericardiocentesis

History of Present Illness:
Ms. [**Known firstname **] [**First Name4 (NamePattern1) 2431**] [**Known lastname **] is a 38yo F ALL s/p double cord blood
SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease, well-known to the [**Year (4 digits) 3242**]
service who was just discharged yesterday ([**2174-8-10**]) after a
prolonged hospital course for acute on chronic CHF thought be be
due to cardiac GVHD and acute on chronic renal failure. She was
discharged home with daily infusions of IV torsamide and
methylprednisolone. She came to clinic today fopr follow-up
where she was found to be febrile to 102 and up 0.5lbs from her
discharge weight. CXR was done and cardiac silloette was
increased, concerning for pleural effusion. Blood (PICC and
peripheral) and urine cultures were sent, and she was started on
empiric meropenem.
.
On arrival to the floor, pt has no complaints. She spent an hour
outside yesterday and was otherwise at home resting. She does
nto recal any bug bites. She did not feel subjectively febrile.
She has some cough, but no different or worse than prior to
discharge. She has some pedal [**Last Name (un) **],a put attributes this to
being up and walking around today. No calf pain. Otherwise, ROS
is negative. Per her sister, the pt got her torsemide and
methyprednisolone in clinic today. [**Name6 (MD) **] outpatient NP, pt's
weight was 137# today, up slightly from 136.5# on the day of
discharge.

Past Medical History:
ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

Social History:
She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis. Lifelong nonsmoker, but not currently. Denies
illicits or EtOH.

Family History:
Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

Physical Exam:
Physical Exam on Admission:
VS: T97.9/Tm 102, BP 110/67, HR 86, RR 18, 94% on 2L
GEN: AOx3, NAD
HEENT: Pupil equal and round. Sclera and conjunctiva clear. MMM.

No oral lesions or exudates.
Cards: S1/S1, S3. RRR.
Pulm: Bibasilar crackles
Abd: soft, NT, ND
Extremities: wwp, edema of the feet and distal ankles B/L
Skin: no rashes or bruising
Neuro: nonfocal
Pulsus paradoxus 2mmHg
.
Physical Exam on Discharge:
Patient expired.


Pertinent Results:
[**2174-8-11**] 02:07PM   UREA N-82* CREAT-2.7* SODIUM-129*
POTASSIUM-4.4 CHLORIDE-90* TOTAL CO2-27 ANION GAP-16
[**2174-8-11**] 02:07PM   ALT(SGPT)-23 AST(SGOT)-75* LD(LDH)-1186* ALK
PHOS-540* TOT BILI-1.9* DIR BILI-1.4* INDIR BIL-0.5
[**2174-8-11**] 02:07PM   ALBUMIN-3.6 CALCIUM-8.3* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2174-8-11**] 02:07PM   WBC-4.1 RBC-2.62* HGB-8.8* HCT-24.4* MCV-93
MCH-33.7* MCHC-36.3* RDW-23.7*
[**2174-8-11**] 02:07PM   NEUTS-86* BANDS-0 LYMPHS-6* MONOS-7 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-5*
[**2174-8-11**] 02:07PM   PLT SMR-VERY LOW PLT COUNT-24*
[**2174-8-11**] 02:07PM   GRAN CT-3543
.
IMAGING:
CXR ([**2174-8-11**]):
AP single view of the chest has been obtained with patient in
upright position. Comparison is made with the next preceding PA
and lateral
chest examination of [**2174-8-3**]. The heart size has increased
further in
size. There is no typical configurational abnormality. The
rather general
increase of the heart shadow is suggestive of pericardial
effusion. Previously described right-sided PICC line remains in
unchanged position.
Pulmonary vascular congestive pattern has not changed
significantly; however, the previously described patchy and
partially confluenting parenchymal densities persist and
apparently have progressed further. They are most marked in the
mid lung field on the right side and the lateral upper lobe area
on the left. Lateral pleural sinuses are partially concealed by
the described parenchymal densities. Conclusive evidence of
pleural effusion is not present, and major pleural effusion is
unlikely as it did not exist on the lateral view on the
preceding chest examination.
.
Progression of bilateral pulmonary infiltrates in this patient
on stem cell
transplant therapy.
.
Echo ([**2174-8-12**]):  Moderate ?partially loculated pericardial
effusion without definite evidence for tamponade physiology.
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2174-8-4**],
the pericardial effusion is larger. Serial evaluation is
suggested.
.
Echo ([**2174-8-18**]):
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF 65%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal. with borderline normal free wall function. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is a
small to moderate sized pericardial effusion. The effusion
appears circumferential. There are no echocardiographic signs of
tamponade.
.
Echo ([**2174-8-23**]):
The left atrium appears extrinsically compressed (mildly)
posteriorly, possibly by a consolidated posterior pericardial
effusion. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is unusually small. Overall left
ventricular systolic function is low normal (LVEF 50%). The
right ventricular free wall is hypertrophied. with depressed
free wall contractility. The epicardial surface of the right
ventricle as well as atria appears to be encased in a layer of
echodense material (epicardial fat vs consolidated effusive
material). No evidence of cardiac tamponade seen.
.
RUQ ([**2174-8-23**]):
1. No evidence of acute cholecystitis, as clinically queried.
2. Reversed flow in the main portal vein, could be secondary to
cardiac
tamponade or tricuspid regurgitation.
3. Redemonstration of FNH in the right hepatic lobe.
4. Moderate-sized bilateral pleural effusions and a small amount
of ascites


Brief Hospital Course:
38 year old female with ALL s/p cord blood transplant
complicated by multi-organ GVHD admitted directly to the ICU for
recurrent fever and increased pulmonary infiltrates on CXR.

#Sepsis:
Patient presented to the clinic with fevers to 102; CXR showed
increased pulmonary infiltrates and heart size. She received a
dose of meropenem, blood and urine cultures were sent, and she
was admitted directly to the ICU. After transfer to the ICU she
was given IV fluids and continued on broad-spectrum antibiotics
(vancomycin, cefepime), antifungal (voriconazole) and antiviral
(gancyclovir). Bronchoscopy lavage fluid was sent for
pan-culture, pneumocystis smear, and CMV screen. CMV pneumonitis
was suspected given previous BAL CMV+. Hypoxia and work of
breathing worsening and she required intubation for ventilation
(see below). Microbiology revealed parainfluenza 3, but no other
pathogens: sputum bacterial and fungal cultures + BAL
cultures/stains/labs were all negative, including negative PCRs
for PCP and CMV. She received vancomycin, cefepime, ganciclovir,
voriconazole, and amphotericin B for broad anti-bacterial,
anti-fungal, and anti-viral coverage. She also received four
doses of IVIG.
.
# Hypoxia:
Serial CXRs showed diffuse bilateral infiltrates. Microbiology
as above. Patient arrived in the ICU unintubated but was
intubated on the day after transfer for increasing respiratory
effort and somnolence. She was sedated on fentanyl and versed
due to agitation and discomfort on the vent. She was difficult
to wean from 80% Fi02 and 14 PEEP. She required mechanical
ventilation at an Fi02 of 100% O2 until the time of expiration.
In addition to infection, there was concern for ARDS. The
patient expired on the ventilator.
.
#Pericardial Effusion: Admission CXR showed increased heart
size, and the echo done on [**2174-8-12**] showed increase in pericardial
effusion without evidence of tamponade. Patient's primary
cardiologist, Dr. [**First Name (STitle) 437**] was alerted and recommended follow up
with echo on [**2174-8-15**]. Follow-up echo showed worsening
moderate-to-large pericardial effusion, which was drained by
bedside pericardiocentesis. Pericardial fluid included 30%
lymphocytes and 60% macrocytes, cultures negative. Although she
does not carry a diagnosis of cardiac GVHD, this was suspected.
A third follow-up echo showed normal LVEF.
.
#Congestive heart failure with systolic dysfunction:
Patient has known CHF with systolic dysfunction from chemo, XRT
and suspected cardiac GVHD. Considered whether patient's recent
CHF lability might contribute to current respiratory acuity. She
was euvolemic to slightly volume up on exam with lower extremity
pitting edema. Daily weights showed her to be under her recent
discharge weight of 136.5 lb. She was on torsemide on arrival,
but this was held in the context of hypovolemia (see below).
NiCOM maneuvers were performed and a transesophageal Balloon was
placed for pleural pressure monitoring. Following
pericardiocentesis her cardiac output improved, repeat Echo was
performed, and congestive heart failure was thought not to be
the cause of her declining clinical picture. A repeat ECHO did
show worsening right ventricular function. Despite being on
three pressors, the patient's clinical picture declined and she
developed hypotension.

#Chronic Kidney Disease: Patient baseline creatinine 2.5 - 3.0
with admission Cr of 2.7. Creatinine continued to rise from 3.0
to 3.7 despite IVF. Renal service followed. Pt was hypocalcemic
to 5.9 (requiring standing supplementation) and
hyperphosphatemic, both likely secondary to renal failure. She
became anuric and was started on CVVHD. CVVHD was discontinued
as the patient developed hypotension despite being on three
pressors.
.
#ALL: Pt is s/p double cord blood SCT [**1-/2173**] complicated by
GVHD on immunosuppression, recently discharged on mycophenolate,
IV solumedrol and bactrim/acyclovir for prophylaxis. Her
mycophenolate dose was changed to 500 mg PO BID and she was
continued on this plus 60 mg IV solumedrol daily. She was on
Bactrim prophylaxis prior to admission, and this was increased
to therapeutic dosing while in the ICU.

#Hypotension. She was transiently IV fluid and pressor-dependent
with hypotension to 85/45 but maintained BP through most of her
ICU stay. Home nifedipine and lopressor were held.

#Anemia. Transfused 1U PRBC for Hct 22 on ICU day 2;
post-transfusion Hct 27.

# Hyponatremia. She was hyponatremic, likely due to diuresis
(which was stopped). No mental status changes prior to
intubation. Free water restricted.

# LFT abnormalities. Stable transaminases, with normal ALT and
AST mildly elevated. Unclear etiology, likely secondary to
hypoxia and end-organ underperfusion.

# Thrombocytopenia. Platelet count remained low but patient did
not show signs of coagulopathy.

Medications on Admission:
-acyclovir 400 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) Neb Inhalation every six (6) hours as needed for SOB,
wheezing
-digoxin 125 mcg Tablet One (1) Tablet by mouth EVERY OTHER DAY.
-ergocalciferol (vitamin D2)50,000 unit Capsule One (1) Capsule
by mouth 1X/week
-lorazepam 0.5 mg Tablet One (1) Tablet by mouth every six (6)
hours as needed for anxiety/nausea.
-methylprednisolone sodium succ Sixty (60) mg Intravenous once a
day.
-metoprolol succinate 50 mg Tablet Extended Release 24 hr, One
(1) Tablet Extended Release 24 hr by mouth once a day
-morphine [MS Contin]15 mg Tablet Extended Release One (1)
Tablet Extended Release by mouth twice a day.
-mycophenolate mofetil 500 mg Tablet Two (2) Tablet by mouth
twice a day.
-nifedipine 60 mg Tablet Extended Release One (1) Tablet
Extended Release by mouth once a day in the evening.
-NPH insulin human recomb Ten (10) units Subcutaneous twice a
day: Please administer 10 units before breakfast and 10 units
before dinner.
-omeprazole 40 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth once a day.
-ondansetron 4 mg Tablet, Rapid Dissolve [**2-6**] Tablet, Rapid
Dissolves by mouth three times a day as needed for nausea.
-oxycodone 5 mg Tablet One (1) Tablet by mouth every 4-6 hours
as needed for pain.
-sildenafil 20 mg Tablet Four (4) Tablet by mouth three times a
day.
-sulfamethoxazole-trimethoprim 400-80 mg Tablet One (1) Tablet
by mouth DAILY (Daily).
-torsemide 20 mg/2 mL (10 mg/mL) Solution Forty (40) mg
Intravenous once a day.
-voriconazole 200 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.

Discharge Medications:
Deceased

Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Deceased

Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased
{'Complications of transplanted bone marrow,Pneumonia in cytomegalic inclusion disease,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,End stage renal disease,Cytomegaloviral disease,Acute lymphoid leukemia, in relapse,Secondary cardiomyopathy, unspecified,Chronic systolic heart failure,Acute pericarditis, unspecified,Cardiac tamponade,Acute kidney failure, unspecified,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic graft-versus-host disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of steroids,Hypoxemia,Thrombocytopenia, unspecified'}


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: Fevers

PRESENT ILLNESS: Ms. [**Known firstname **] [**First Name4 (NamePattern1) 2431**] [**Known lastname **] is a 38yo F ALL s/p double cord blood
SCT [**1-/2173**] c/b GVHD, severe left ventricular systolic
dysfunction attributed to chemotherapy for ALL as well as XRT
for [**Year (4 digits) 3242**] (EF 15-20%), embolic CVA now on coumadin, asthma,
hypertension and chronic kidney disease, well-known to the [**Year (4 digits) 3242**]
service who was just discharged yesterday ([**2174-8-10**]) after a
prolonged hospital course for acute on chronic CHF thought be be
due to cardiac GVHD and acute on chronic renal failure. She was
discharged home with daily infusions of IV torsamide and
methylprednisolone. She came to clinic today fopr follow-up
where she was found to be febrile to 102 and up 0.5lbs from her
discharge weight. CXR was done and cardiac silloette was
increased, concerning for pleural effusion. Blood (PICC and
peripheral) and urine cultures were sent, and she was started on
empiric meropenem.
.
On arrival to the floor, pt has no complaints. She spent an hour
outside yesterday and was otherwise at home resting. She does
nto recal any bug bites. She did not feel subjectively febrile.
She has some cough, but no different or worse than prior to
discharge. She has some pedal [**Last Name (un) **],a put attributes this to
being up and walking around today. No calf pain. Otherwise, ROS
is negative. Per her sister, the pt got her torsemide and
methyprednisolone in clinic today. [**Name6 (MD) **] outpatient NP, pt's
weight was 137# today, up slightly from 136.5# on the day of
discharge.

MEDICAL HISTORY: ALL:
- initially presented in [**2172-8-5**] right chest and right upper
extremity pain and paresthesias and visual blurriness. WBC
149,000; received leukapheresis, started on hydroxyurea.
Diagnosed with precursor B-cell ALL.
- underwent phase I induction with daunorubicin, vincristine,
dexamethasone, L-asparaginase, MTX; phase II with
cyclophosphamide, cytarabine, mercaptopurine, MTX
- Bone Marrow Aspirate/Biopsy on [**2172-10-26**] showed no morphologic
evidence of residual leukemia
- underwent allo double cord blood SCT [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD
- subsequent course has been complicated by pseudomonas
pneumonia
in [**5-15**], empiric treatment of CMV pericarditis in [**7-15**], chronic
nausea and vomiting which has been treated as GVHD with steroids
though colonoscopies in [**8-14**] and [**11-14**] were negative for GVHD.
.
OTHER MEDICAL HISTORY:
- Embolic stroke in [**3-/2174**] on coumadin
- Asthma
- Hypertension
- Cervical Intraepithelial Neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity [**10/2172**]
- Chronic kidney disease stage III/IV, baseline creatinine ~2.0
- Chronic abdominal pain: Her workup so far has included EGD
[**2173-9-5**], [**2173-11-5**] with mild signs of gastritis, no GVHD.
Colonoscopy [**2173-8-5**], unremarkable with biospy negative for
GVHD, CMV.  UGI and SBFT [**4-/2174**] was mostly unremarkable.  She
has had multiple CT scans which have demonstrated moderate
ascites with interval increase, no drainable fluid collection,
diverticulosis, small fat-containing umbilical hernia with mild
fat stranding, no bowel obstruction.  RUQ ultrasound revealed
ascites, gallbladder wall edema presumably from third spacing,
and no biliary duct dilatation.

MEDICATION ON ADMISSION: -acyclovir 400 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.
-albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization
One (1) Neb Inhalation every six (6) hours as needed for SOB,
wheezing
-digoxin 125 mcg Tablet One (1) Tablet by mouth EVERY OTHER DAY.
-ergocalciferol (vitamin D2)50,000 unit Capsule One (1) Capsule
by mouth 1X/week
-lorazepam 0.5 mg Tablet One (1) Tablet by mouth every six (6)
hours as needed for anxiety/nausea.
-methylprednisolone sodium succ Sixty (60) mg Intravenous once a
day.
-metoprolol succinate 50 mg Tablet Extended Release 24 hr, One
(1) Tablet Extended Release 24 hr by mouth once a day
-morphine [MS Contin]15 mg Tablet Extended Release One (1)
Tablet Extended Release by mouth twice a day.
-mycophenolate mofetil 500 mg Tablet Two (2) Tablet by mouth
twice a day.
-nifedipine 60 mg Tablet Extended Release One (1) Tablet
Extended Release by mouth once a day in the evening.
-NPH insulin human recomb Ten (10) units Subcutaneous twice a
day: Please administer 10 units before breakfast and 10 units
before dinner.
-omeprazole 40 mg Capsule, Delayed Release(E.C.) One (1)
Capsule, Delayed Release(E.C.) by mouth once a day.
-ondansetron 4 mg Tablet, Rapid Dissolve [**2-6**] Tablet, Rapid
Dissolves by mouth three times a day as needed for nausea.
-oxycodone 5 mg Tablet One (1) Tablet by mouth every 4-6 hours
as needed for pain.
-sildenafil 20 mg Tablet Four (4) Tablet by mouth three times a
day.
-sulfamethoxazole-trimethoprim 400-80 mg Tablet One (1) Tablet
by mouth DAILY (Daily).
-torsemide 20 mg/2 mL (10 mg/mL) Solution Forty (40) mg
Intravenous once a day.
-voriconazole 200 mg Tablet One (1) Tablet by mouth every twelve
(12) hours.

ALLERGIES: Prochlorperazine / Heparin Agents

PHYSICAL EXAM: Physical Exam on Admission:
VS: T97.9/Tm 102, BP 110/67, HR 86, RR 18, 94% on 2L
GEN: AOx3, NAD
HEENT: Pupil equal and round. Sclera and conjunctiva clear. MMM.

FAMILY HISTORY: Mother with history of gastric cancer, died at age 40.  Father
with hypertension.

SOCIAL HISTORY: She is single with a daughter and a son. Lives in [**Location 686**].
Previously employed at [**Company 59330**] though has not worked since her
diagnosis. Lifelong nonsmoker, but not currently. Denies
illicits or EtOH. 

### Response:
{'Complications of transplanted bone marrow,Pneumonia in cytomegalic inclusion disease,Acute respiratory failure,Unspecified septicemia,Severe sepsis,Septic shock,End stage renal disease,Cytomegaloviral disease,Acute lymphoid leukemia, in relapse,Secondary cardiomyopathy, unspecified,Chronic systolic heart failure,Acute pericarditis, unspecified,Cardiac tamponade,Acute kidney failure, unspecified,Acidosis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic graft-versus-host disease,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in other specified places,Asthma, unspecified type, unspecified,Other chronic pulmonary heart diseases,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Long-term (current) use of steroids,Hypoxemia,Thrombocytopenia, unspecified'}
