CHIEF COMPLAINT: Cough, SOB

PRESENT ILLNESS: 37 year old female with a history of ALL, s/p allo SCT [**1-13**] c/b
neutropenic fever and skin GVHD, presents with one day of
shortness of breath and cough.
.
Patient has had a chronic cough for several months. She also had
some mild GGO on prior CTs, followed monthly, stable from
[**Month (only) 404**] through [**2173-4-16**]. This morning, she woke up feeling short
of breath, with worsening cough productive of green sputum. She
felt progressively fatigued throughout the day. She presented to
oncology clinic where she was found to have a fever of 100.4.
She initially had an oxygen saturation of 94 on RA in clinic.
Blood cultures were drawn, nasal swab sent for viral screen, and
she was given cefepime IV 2g and admitted for fever.

MEDICAL HISTORY: - Allogenic Double Cord Blood SCT on [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD.
- ALL
- Asthma
- HTN
- Cervical Intraepithelial neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity 9/[**2172**].

MEDICATION ON ADMISSION: acyclovir 400mg PO tid
atovaquone 1500mg PO daily
enzonatate 100mg PO tid
carvedilol 37.5 mg PO bid
advair 500/50 INH [**Hospital1 **]
Folic Acid 1mg PO daily
Cellcept 250mg PO bid
Omeprazole 20mg PO daily
Prednisone 10mg PO daily
Tacrolimus 0.25mg PO bid
Voriconazole 200mg PO q 12
Mag Oxide 133mg PO tid
MVI 1 tab daily

ALLERGIES: Prochlorperazine

PHYSICAL EXAM: VS: T 101.0 BP 136/94 HR 109 RR 40 SpO2 86/RA -> 94%/4L
General: African American Female in moderate distress,
tachypneic
CV: RRR, no m/r/g, JVP not elevated, 2+ pulses DP
Resp: diffuse rhonchi bilaterally, worse at right base
Abd: NT, ND, BS+
Ext: No edema, warm well perfused
Neuro: AAO x 3, speech fluent, no pronator drift

FAMILY HISTORY: Mother had gastric cancer

SOCIAL HISTORY: Smoke: never
EtOH: Occassional in past, none currently
Drugs: Never
Lives/works: Single, has two children (ages 7 and 18). Lives in
Pneumonia due to Pseudomonas,Complications of transplanted bone marrow,Acute lymphoid leukemia, in relapse,Other primary cardiomyopathies,Acute graft-versus-host disease,Chronic systolic heart failure,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dysplasia of cervix, unspecified,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypoxemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus
Pseudomonal pneumonia,Compl marrow transplant,Act lymp leuk in relapse,Prim cardiomyopathy NEC,Ac graft-versus-host dis,Chr systolic hrt failure,Abn react-procedure NEC,Dysplasia of cervix NOS,Asthma NOS,Hypertension NOS,Hypoxemia,Migrne unsp wo ntrc mgrn
Admission Date:  [**2173-5-31**]              Discharge Date:   [**2173-6-9**]

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

Service: MEDICINE

Allergies:
Prochlorperazine

Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Cough, SOB

Major Surgical or Invasive Procedure:
None

History of Present Illness:
37 year old female with a history of ALL, s/p allo SCT [**1-13**] c/b
neutropenic fever and skin GVHD, presents with one day of
shortness of breath and cough.
.
Patient has had a chronic cough for several months. She also had
some mild GGO on prior CTs, followed monthly, stable from
[**Month (only) 404**] through [**2173-4-16**]. This morning, she woke up feeling short
of breath, with worsening cough productive of green sputum. She
felt progressively fatigued throughout the day. She presented to
oncology clinic where she was found to have a fever of 100.4.
She initially had an oxygen saturation of 94 on RA in clinic.
Blood cultures were drawn, nasal swab sent for viral screen, and
she was given cefepime IV 2g and admitted for fever.


Past Medical History:
- Allogenic Double Cord Blood SCT on [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD.
- ALL
- Asthma
- HTN
- Cervical Intraepithelial neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity 9/[**2172**].

PAST ONCOLOGIC HISTORY:

Presented to ED with right chest and right upper extremity pain

and paresthesias and visual blurriness. CBC demonstrated WBC
149,000. Leukapheresis --> WBC 35,000. Admitted to BMT. Started

Hydrea.
-Aspirate Smear: >90% cellularity, interstitial infiltrate of
immature cells consistent with blasts in sheets occupying 95% of

marrow cellularity.
-Special Stains: MPO-negative, PAS-positive with cytoplasmic
granular pattern.
-Immunophenotyping (Flow cytometry:)
Positive: CD34 (subset 32%,) HLA-DR, TdT, 19
CD15 (subset 52%)
Negative: CD20, CD10
CD13, CD33, CD14, CD117, CD64, CD11c and CD56
-Dx = Precursor B-cell ALL
-Cytogenetics:
--Some aberrations (including trisomy 22) seen in single
metaphase.
--FISH: Ph-negative, abnormal pattern in 60/100 cells
indicative of trisomy 22, abnormal MLL rearrangement in 90/100
cells
INDUCTION:
Phase I, weeks [**2-8**], day 1 = [**2172-8-13**]
Daunorubicin 60 mg/m2 iv day 1, 8, 15 and 22
Vincristine 1.4 mg/m2 iv day 1, 8, 15 and 22
Dexamethasone 10 mg iv tid day [**3-4**]
L-Asparaginase 10,000 IU day 17-28
MTX 12.5 mg IT day 8 (instead of day 15)
-CSF = rare atypical mononuclear cells, favor atypical
lymphocytes.
Phase II, weeks [**6-12**], day 1 = [**2172-9-21**]
Cyclophosphamide 650 mg/m2 = 1160 mg IV days 1, 15 and 29.
Cytarabine 75 mg/m2 = 130 mg IV Days [**2-8**], [**9-15**], 15-18, 22-25
Mercaptopurine 60 mg/m2 = 100 mg Day [**3-4**]
MTX 12.5 mg IT Days 1, 8, 15, 22
Response Evaluation: Bone Marrow Aspirate/Biopsy on [**10-26**]
CR: -No morphologic evidence of residual leukemia
-Normal cytogenetics, negative FISH for MLL
Intensification Therapy
3 cycles of HD-MTX 3 g/m2 days 1 ([**11-26**]-given), 8, and 22
Standard Leucovorin rescue
L-asparaginase 10,000 IU days 2 ([**11-27**]-given,) 9, and 23
Allogenic Double Cord Blood SCT
Conditioning was achieved with Fludarabine, and Ara-C
and TBI. During the conditioning phase, nausea control was
achieved with Dexamethasone, Lorazepam, Zofran PRN.
Ciprofloxacin, Fluticasone and Acyclovir were initiated for
prophylaxis as per protocol. Course complicated by neutropenic
fever and acute skin GVHD.

Social History:
Smoke: never
EtOH: Occassional in past, none currently
Drugs: Never
Lives/works: Single, has two children (ages 7 and 18). Lives in

[**Location (un) 686**], her aunt is living with her. Was previously employed

at [**Last Name (un) 59330**], hasn't been working since being diagnosed with ALL in

[**2172-8-5**].


Family History:
Mother had gastric cancer

Physical Exam:
VS: T 101.0 BP 136/94 HR 109 RR 40 SpO2 86/RA -> 94%/4L
General: African American Female in moderate distress,
tachypneic
CV: RRR, no m/r/g, JVP not elevated, 2+ pulses DP
Resp: diffuse rhonchi bilaterally, worse at right base
Abd: NT, ND, BS+
Ext: No edema, warm well perfused
Neuro: AAO x 3, speech fluent, no pronator drift


Pertinent Results:
Admission Labs:

Chemistries:
UREA N-9 CREAT-1.0 SODIUM-143 POTASSIUM-3.7 CHLORIDE-107 TOTAL
CO2-28 ANION GAP-12 ALT(SGPT)-9 AST(SGOT)-21 ALK PHOS-84 TOT
BILI-1.0
CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-1.6
tacroFK-8.8

CBC:
WBC-8.4 RBC-2.88* HGB-9.1* HCT-28.5* MCV-99* MCH-31.6 MCHC-32.0
RDW-16.4*
Diff: NEUTS-64 BANDS-0 LYMPHS-26 MONOS-9 EOS-1 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-2+
MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-2+
PLT SMR-LOW PLT COUNT-104*

[**2173-6-1**] 1:40 am BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2173-6-17**]**

   GRAM STAIN (Final [**2173-6-1**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2173-6-3**]):
      10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
      PSEUDOMONAS AERUGINOSA.    ~[**2163**]/ML.  FURTHER WORKUP ON
REQUEST ONLY.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.  ID AND SUSCEPTIBILITY REQUESTED BY [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] [**2173-6-2**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------     2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------   <=1 S

   LEGIONELLA CULTURE (Final [**2173-6-8**]):    NO LEGIONELLA
ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2173-6-1**]):
      This is a low yield procedure based on our in-house
studies.
      TEST REQUESTED BY [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 63576**] #[**Numeric Identifier 63577**] [**2173-6-1**].
      NO FUNGAL ELEMENTS SEEN.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2173-6-1**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2173-6-17**]):    NO FUNGUS ISOLATED.

Cytology from BAL:

  NEGATIVE FOR MALIGNANT CELLS.

  Reactive bronchial cells, pulmonary macrophages, and
  squamous cells.

  Note: No viral inclusions or fungal forms seen by routine
  stain. See also corresponding microbiology studies.

CT chest with and without contrast [**2173-5-31**]:

IMPRESSION:
1. No evidence of pulmonary embolism.
2. Extensive bilateral alveolar opacities, the pattern suggests
generalized
infection, PCP and bacteria should be included in the
differential diagnosis.
3. Small bilateral pleural effusions.
4. Mild pericardial effusion.
5. Two small splenules, borderline size of the left adrenal.

The referring physician, [**Last Name (NamePattern4) **]. [**Known lastname **] was contact[**Name (NI) **] by telephone
at the time of dictation.

CXR [**2173-6-1**]:
1. Extensive bilateral alveolar opacities are concerning for
generalized
infectious process. PCP and bacterial pneumonia are included in
the
differential diagnosis.
2. Bilateral small pleural effusions.
3. Left PICC tip projects over the mid/lower SVC.

The study and the report were reviewed by the staff radiologist.




Brief Hospital Course:
#. Pseudomonas PNA - On admission, was believed to be a likely
infectious process given fever, hypoxia and productive cough.
Given h/o CHF, this could be contributing, but she has no
clinical signs of HF.  She has a h/o GGO opacities with multiple
infections in the past. Upon admission to the floor, she was
transferred to the MICU for ongoing respiratory distress and
urgent bronchoscopy with extensive infiltrates seen on CT Chest.
She received vancomycin and cefepime prior to admission to the
ICU and also underwent a CTA chest that was negative for PE.
Bronchoscopy was performed. She was continued on vancomycin and
cefepime. In the MICU, the patient was transiently on
caspofungin, given that she had been on voriconazole for
prophylaxis. She was started on bactrim IV as empiric PCP
[**Name Initial (PRE) 31304**]. Considering she was on bactrim, her atovaquone was
held. She improved overnight with decreased O2 requirement and,
on the day following her transfer to the [**Hospital Unit Name 153**], she was
transferred back to the floor.  BAL culture grew Psudomonas
aerginoasa sensitive to Cefepime and CIprofloxacin. She was
switched to a combination of Cefepime and Ciprofloxacin for
double Abx coverage for Pseudomonas. The patient was also
continued on PO Voriconazole in place of Caspofungin.  The
patient was also switched back to Atovaquone for PCP [**Name Initial (PRE) 5**].  The
patient continued to show significant symptomatic improvement
over the next several days, with no further fevers and no longer
had an oxygen requirement.  She was able to ambulate with good
O2 sats.  She is being discharged home to complete a 14 day
total Abx course of Cefepime and Ciprofloxacin.  The patient was
also administered IVIG prior to discharge as her IgG level was
low.  She will continue Prednisone at 10mg daily upon discharge
and will follow-up with her oncologist Dr. [**Last Name (STitle) **].

VISION CHANGES: description of blurry vision on admission,
incideous in onset, was initially concerning for fungal or
intracranial process while the patient was in MICU. However, the
symptoms resolved shortly thereafter.

HEADACHE: the patient with a history of migraines.  The headache
on admission was consistent with migraine HA. No meningismus.
Not related to vision changes temporally.  The symptoms resolved
by hospital day 3 and the patient remained free of headaches.

ALLO SCT w/ SKIN GVHD: we continued Cellcept, Prednisone, and
Tacrolimus. We also continued folic acid.

CHRONIC SYSTOLIC CHF: no signs of acute exacerbation or change
in baseline status. cont home BB, daily weights and heart
healthy diet.

ASTHMA: cont ADVAIR, and nebs as above

HTN: hypertensive on admission, we continued carvedilol.

GERD: reports occoasional symptoms for which she takes
omeprazole daily, which was continued while in hospital

Medications on Admission:
acyclovir 400mg PO tid
atovaquone 1500mg PO daily
enzonatate 100mg PO tid
carvedilol 37.5 mg PO bid
advair 500/50 INH [**Hospital1 **]
Folic Acid 1mg PO daily
Cellcept 250mg PO bid
Omeprazole 20mg PO daily
Prednisone 10mg PO daily
Tacrolimus 0.25mg PO bid
Voriconazole 200mg PO q 12
Mag Oxide 133mg PO tid
MVI 1 tab daily


Discharge Medications:
1. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 6 days: Last day = [**2173-6-15**] in AM.
Disp:*12 Recon Soln(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Until directed otherwise by Dr. [**Last Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*2*
3. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 9 days: Last day = [**2173-6-18**].
Disp:*12 Tablet(s)* Refills:*0*
4. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Tacrolimus 0.5 mg Capsule Sig: 0.5 Capsule PO Q12H (every 12
hours).
7. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
8. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO DAILY
(Daily).
11. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Carvedilol 12.5 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
13. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Magnesium Oxide 84.5 mg (140 mg) Capsule Sig: One (1)
Capsule PO three times a day.
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 disk* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary: pneumonia

Secondary: ALL status post allogeneic stem cell trasnplant


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital because you developed
shortness of breath, cough, fevers, and were found to have a
pneumonia.  We performed a procedure called bronchosopy to
evaluate the cause of your pneumonia.  We found that it was
caused by a bacterium known as Pseudomonas.  We gave you
appropriate antibiotics and your symptoms improved.  At this
time, you no longer require oxygen and are able to walk without
getting short of breath.

We also gave you IVIG because your antibody levels were low.

You will need to complete a course of antibiotics as follows:

We STARTED you on Cefepime 2 grams IV every 12 hours.  You will
need to get infusions of this antibiotic until

We STARTED you on Ciprofloxacin.  Please take 750mg every 12
hours until .

We DECREASED your dose of Advair to 250/50 to one inhalation
twice a day.

Please continue to take all your other medications as
prescribed.

You will need to follow up with your oncologist Dr. [**Last Name (STitle) **] as
shown below.

Please call BMT fellow on call or come back to the hospital
right away if you develop fevers, worsening cough, shortness of
breath, nasal congestion, or any other concerning symptoms.

Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.


Followup Instructions:
You have you an appointment this Friday [**2173-6-11**] at 8:30 am in
[**Hospital 3242**] clinic with Dr. [**Last Name (STitle) **].  You will also have your labs
drawn at that time.

You also have the following appointments:

Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2173-7-19**]
1:00 PM
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2173-7-19**]
2:00 PM
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2173-7-21**] 3:30 PM


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

Completed by:[**2173-7-26**]
{'Pneumonia due to Pseudomonas,Complications of transplanted bone marrow,Acute lymphoid leukemia, in relapse,Other primary cardiomyopathies,Acute graft-versus-host disease,Chronic systolic heart failure,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dysplasia of cervix, unspecified,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypoxemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus'}


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: Cough, SOB

PRESENT ILLNESS: 37 year old female with a history of ALL, s/p allo SCT [**1-13**] c/b
neutropenic fever and skin GVHD, presents with one day of
shortness of breath and cough.
.
Patient has had a chronic cough for several months. She also had
some mild GGO on prior CTs, followed monthly, stable from
[**Month (only) 404**] through [**2173-4-16**]. This morning, she woke up feeling short
of breath, with worsening cough productive of green sputum. She
felt progressively fatigued throughout the day. She presented to
oncology clinic where she was found to have a fever of 100.4.
She initially had an oxygen saturation of 94 on RA in clinic.
Blood cultures were drawn, nasal swab sent for viral screen, and
she was given cefepime IV 2g and admitted for fever.

MEDICAL HISTORY: - Allogenic Double Cord Blood SCT on [**2173-1-11**], course
complicated by neutropenic fever and acute skin GVHD.
- ALL
- Asthma
- HTN
- Cervical Intraepithelial neoplasia
- C-section in [**2165**]
- Cardiomyopathy due to early anthracycline-related
cardiotoxicity 9/[**2172**].

MEDICATION ON ADMISSION: acyclovir 400mg PO tid
atovaquone 1500mg PO daily
enzonatate 100mg PO tid
carvedilol 37.5 mg PO bid
advair 500/50 INH [**Hospital1 **]
Folic Acid 1mg PO daily
Cellcept 250mg PO bid
Omeprazole 20mg PO daily
Prednisone 10mg PO daily
Tacrolimus 0.25mg PO bid
Voriconazole 200mg PO q 12
Mag Oxide 133mg PO tid
MVI 1 tab daily

ALLERGIES: Prochlorperazine

PHYSICAL EXAM: VS: T 101.0 BP 136/94 HR 109 RR 40 SpO2 86/RA -> 94%/4L
General: African American Female in moderate distress,
tachypneic
CV: RRR, no m/r/g, JVP not elevated, 2+ pulses DP
Resp: diffuse rhonchi bilaterally, worse at right base
Abd: NT, ND, BS+
Ext: No edema, warm well perfused
Neuro: AAO x 3, speech fluent, no pronator drift

FAMILY HISTORY: Mother had gastric cancer

SOCIAL HISTORY: Smoke: never
EtOH: Occassional in past, none currently
Drugs: Never
Lives/works: Single, has two children (ages 7 and 18). Lives in 

### Response:
{'Pneumonia due to Pseudomonas,Complications of transplanted bone marrow,Acute lymphoid leukemia, in relapse,Other primary cardiomyopathies,Acute graft-versus-host disease,Chronic systolic heart failure,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Dysplasia of cervix, unspecified,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Hypoxemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus'}
