CHIEF COMPLAINT: Dyspnea on Exertion, Fatigue, Low grade fever

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 52 year old man with no major medical problems
who presented to the emergency room with shortness of breath and
worsening dyspnea on exertion. For the past month, he has
noticed increased bruising, and for the past week, he has
noticed nosebleeds at night and bleeding gums, as well as
ulcerations on his tongue. He developed progressive dyspnea on
exertion, which prompted an admission to [**Hospital **] Hospital, at
which time his hematocrit was noted to be 16. He received 4
units of pRBC's and his bone marrow was aspirated (results
pending). He was discharged home and told his bone marrow
results would be available on Tuesday. The day prior to
admission at [**Hospital1 18**], he complained of worsened dyspnea and
band-like chest pain across his chest, at which time his wife
insisted that he come to [**Hospital1 18**].
.
He denies recent weight loss, but has noticed a low-grade
temperature over the past week, along with night sweats, chills,
and diffuse abdominal pain (no associated nausea, vomiting,
diarrhea). He has had a headache which responds to ibuprofen.
During his hospitalization at [**Hospital **] Hospital, he developed a
rash after receiving a blood transfusion. He has also noticed a
non-tender ulceration on his penis, which developed within the
last week. His wife notes that his color has improved
dramatically since receiving the blood transfusions.

MEDICAL HISTORY: s/p multiple back surgeries, including cervical spinal fusion
s/p basal cell carcinoma removal
Nephrolithiasis
Hypercholesterolemia
Had cardiac cath in [**2134**] (per report, was "clean", after failing
multiple thallium stress tests)
Chronic numbness and neuropathic pain of left upper
extremity/chest

MEDICATION ON ADMISSION: Meds:
Multivitamin
Lipitor 20mg daily
.
Discharged from [**Location (un) **] on the following:
Augmentin 875-125mg daily
Ciprofloxacin 500mg [**Hospital1 **]
Folate 1mg daily

ALLERGIES: Cefepime

PHYSICAL EXAM: Vitals: T 97.9, BP 122/72, HR 67, RR 18, Sat 94% on 2L
(documented, but when seen he was off oxygen)
Gen: Pale appearing, no acute distress
HEENT: EOMI, PERRL, ?petechiae on uvula
Neck: Supple, no thyromegaly
Nodes: No cervical, supraclavicular or subclavicular
lympahdenopathy appreciated; shottly inguinal lymphadenopathy
L>R
Heart: RRR, normal S1/S2, no m/r/g
Lungs: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended, normal bowel sounds; no
hepatosplenomegaly appreciated
Back: No spinal tenderness, no costovertebral angle tenderness
GU: Painless chancre on left side of penis, between shaft and
head of penis, draining purulent material
Ext: No clubbing/cyanosis/edema
Neuro: A&O x 3

FAMILY HISTORY: Mother died suddenly in her 70's, father died of cancer, unknown
type (with visible tumors across his body). One sister with
thyroid cancer, brother with diabetes, sister with [**Name (NI) 5895**]
Disease.

SOCIAL HISTORY: Lives in [**Location 14840**] with his wife. They have three children (ages
24, 22, and 18). He works as a technician for [**Company 22957**], with some
exposure to lead; crawls around office buildings and below
houses and may have had asbestos exposure. + tobacco history (1
ppd x "many" years, not currently). Social EtOH, no drugs.
Sexually active with one partner, wife, no extramarital sexual
exposures. No previous STD's.
Acute myeloid leukemia, without mention of having achieved remission,Pneumonia in other systemic mycoses,Acute pericarditis, unspecified,Other and unspecified mycoses,Unspecified protein-calorie malnutrition,Secondary malignant neoplasm of pleura,Ulcer of heel and midfoot,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Neutropenia, unspecified,Nonspecific abnormal results of function study of liver,Other specified disorders of penis,Stomatitis and mucositis, unspecified,Unspecified disorder of kidney and ureter
Ac myl leuk wo achv rmsn,Pneum in oth sys mycoses,Acute pericarditis NOS,Mycoses NEC & NOS,Protein-cal malnutr NOS,Second malig neo pleura,Ulcer of heel & midfoot,Drug dermatitis NOS,Adv eff cephalosporin,Neutropenia NOS,Abn liver function study,Disorder of penis NEC,Stomatitis/mucositis NOS,Renal & ureteral dis NOS
Admission Date:  [**2143-3-31**]              Discharge Date:   [**2143-5-31**]

Date of Birth:  [**2090-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Dyspnea on Exertion, Fatigue, Low grade fever

Major Surgical or Invasive Procedure:
R-CVL by IR
Pericardiocentesis
Bone marrow biopsies x4
R neck biopsy
L PICC line placement
diagnostic thorocentesis by IP
bronchoscopy x2


History of Present Illness:
Mr. [**Known lastname 47367**] is a 52 year old man with no major medical problems
who presented to the emergency room with shortness of breath and
worsening dyspnea on exertion. For the past month, he has
noticed increased bruising, and for the past week, he has
noticed nosebleeds at night and bleeding gums, as well as
ulcerations on his tongue. He developed progressive dyspnea on
exertion, which prompted an admission to [**Hospital **] Hospital, at
which time his hematocrit was noted to be 16. He received 4
units of pRBC's and his bone marrow was aspirated (results
pending). He was discharged home and told his bone marrow
results would be available on Tuesday. The day prior to
admission at [**Hospital1 18**], he complained of worsened dyspnea and
band-like chest pain across his chest, at which time his wife
insisted that he come to [**Hospital1 18**].
.
He denies recent weight loss, but has noticed a low-grade
temperature over the past week, along with night sweats, chills,
and diffuse abdominal pain (no associated nausea, vomiting,
diarrhea). He has had a headache which responds to ibuprofen.
During his hospitalization at [**Hospital **] Hospital, he developed a
rash after receiving a blood transfusion. He has also noticed a
non-tender ulceration on his penis, which developed within the
last week. His wife notes that his color has improved
dramatically since receiving the blood transfusions.


Past Medical History:
s/p multiple back surgeries, including cervical spinal fusion
s/p basal cell carcinoma removal
Nephrolithiasis
Hypercholesterolemia
Had cardiac cath in [**2134**] (per report, was "clean", after failing
multiple thallium stress tests)
Chronic numbness and neuropathic pain of left upper
extremity/chest

Social History:
Lives in [**Location 14840**] with his wife. They have three children (ages
24, 22, and 18). He works as a technician for [**Company 22957**], with some
exposure to lead; crawls around office buildings and below
houses and may have had asbestos exposure. + tobacco history (1
ppd x "many" years, not currently). Social EtOH, no drugs.
Sexually active with one partner, wife, no extramarital sexual
exposures. No previous STD's.


Family History:
Mother died suddenly in her 70's, father died of cancer, unknown
type (with visible tumors across his body). One sister with
thyroid cancer, brother with diabetes, sister with [**Name (NI) 5895**]
Disease.

Physical Exam:
Vitals: T 97.9, BP 122/72, HR 67, RR 18, Sat 94% on 2L
(documented, but when seen he was off oxygen)
Gen: Pale appearing, no acute distress
HEENT: EOMI, PERRL, ?petechiae on uvula
Neck: Supple, no thyromegaly
Nodes: No cervical, supraclavicular or subclavicular
lympahdenopathy appreciated; shottly inguinal lymphadenopathy
L>R
Heart: RRR, normal S1/S2, no m/r/g
Lungs: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended, normal bowel sounds; no
hepatosplenomegaly appreciated
Back: No spinal tenderness, no costovertebral angle tenderness
GU: Painless chancre on left side of penis, between shaft and
head of penis, draining purulent material
Ext: No clubbing/cyanosis/edema
Neuro: A&O x 3


Pertinent Results:
.
CXR [**3-31**]: CHEST, TWO VIEWS: No prior for comparisons. Cardiac,
mediastinal, and hilar contours are within normal limits. Linear
atelectasis is seen at the left lung base. Mild blunting of the
left costophrenic angle is also seen. Right costophrenic angle
appears clear. Splenic shadow is not well identified. No
pneumothorax. No fractures are seen. IMPRESSION: Linear
atelectasis left lung base and probable tiny left pleural
effusion.
.
CXR [**4-1**]: Comparison with the previous study done on [**2143-3-31**].
Minimally increased streaky density at the left base appears
more confluent than on the earlier study. The heart and
mediastinal structures are unremarkable in appearance as before.
The bony thorax is grossly intact. IMPRESSION: Minimally
increased density at the left base which may represent evolving
pneumonia. Follow up recommended.

Brief Hospital Course:
Mr. [**Known lastname 47367**] is a 52 year old male with no major past medical
history who presented with dyspnea on exertion, fatigue, and
easy bruisability, and was found to be pancytopenic.  He was
intially admitted to the general medicine team. The morning
after admission the pt triggered for a drop in SaO2 to 83% RA.
He came up to 95% on 4L. CXR showed possible LLL PNA. The pt was
started on cefepime. As his peripheral smear showed blasts, he
was then transferred to the BMT service.  On the day of
admission to the BMT service ([**2143-4-3**]) he complained of chest
pain and had diffuse ST elevations on EKG. Stat ECHO showed a
pericardial effusion although he had no pulsus paradoxus.  He
was dgiven oxygen and transferred to the cath lab for urgent
pericardiocentesis. They removed over 300mL of fluid and those
cultures were negative.  He then recovered in the MICU. His
pericardial drain was removed the next day.  He was then
transferred back to the BMT service.

# pericardial effusion/tamponade:  As described above, ECHO
showed these results. He underwent a pericardiocentesis to drain
the fluid and it did not reacumulate based on several
surveillence ECHOs.

# pleural effusion: left sided.  This was thought to be related
to malignancy and to his initially pericardial effusion. The
pleural effusion persisted throughout admission.  He had a
diagnostic thorocentesis by IP which removed 30ml of bloody
fluid.  No infectious source was found in the fluid.

# AML: (M7). He was intially given 7+3 idarubicin and cytarabine
chemotherapy to induce remission with the plan to have a donor
allo transplant.  His day 14 bone marrow showed continued
hypercellular marrow.  He was reinduced with HIDAC on [**4-22**].
His counts continued to remain very low for an extended period
of time.  His course was complicated by febrile neutropenia.  He
was started on cefepime but developed a rash. This was biopsied
by dermatology and found to be a drug rash.  He was switched to
aztreonam and continued to spike temps. More antibiotics were
added including vancomycin, levofloxacin and several different
antifungals including caspofungin, micafungin, voriconazole,
posaconazole, ambisome.  He had several reactions to these
antifungals including rash (likely with caspofungin and
micafungin) and elevated LFTs. As his counts returned, a repeat
bone marrow preliminarily showed a sick marrow but no obvious
evidence of leukemia.  The antibiotics were pealed back and he
was discharged on voriconazole alone (see details below).  He
also developed mucositis which required morphine PCA and TPN for
malnutrition.  On the day of discharge, he was told that a bone
marrow donor was likely found.

# suspected fungal pneumonia: He continued to spike temperatures
on several antibiotics. All of his cultures were negative. His
chest CT and xrays showed patchy infiltrates.  A beta glucan
retured at 161; galactomanin was negative. Pulmonary and ID were
following as consult teams. THe patient had a BAL which was
negative except for 3 colonies of yeast among large amounts of
oral flora. The yeast was thought to be contamination per
pathology.  Given the elevated beta glucan and the fact that he
defervesced on antifungal therapy, it was thought that he likely
had a fungal infection and was discharged on voriconazole.

#) Elevated LFTs:  This was attributed to his antifungal
therapies.  He seemed to have elevations with posaconazole and
ambisome the most. He was sent out on voriconazole. He had two
MRIs of the liver (one while still neutropenic and one after his
counts recovered) to rule out obvious fungal infections in the
liver; both were negative.  He should have his LFTs monitored
closely as an outpatient while on voriconazole.

# Chest Pain: He has a history of cervical spinal fusion surgery
and chronic left-sided chest pain. He was intially ruled out for
AMI with negative cardiac enzymes and had a negative CTA to rule
out PE.  His chest pain persisted throughout admission and moved
around his chest, was pleuritic in nature.  This was thought to
be related to resolving pleural effusions as well as a suspected
fungal pneumonia especially after his counts returned.

# Penile ulceration. No history of extramarital affairs, no
previous STD's. Differential included primary syphilis,
lymphogranulosum venereum (although very rare), skin ulceration
secondary to trauma and worsened by neutropenia. This last
diagnosis was likely the cause.  All infectious test were
negative (RPR, GC/chlamydia). He was treated with a course of
ciprofloxacin and azithromycin and the ulcer healed.

# renal lesion: Incidentally found on chest CT initially and a
renal ultrasound also could not characterize it will. Radiology
felt it might appear to be a papillary RCC, but recommended a
renal MRI to fully evaluate. This needs to be followed up as an
outpatient.

Follow up:
-Monitor LFTs
-Follow up final bone marrow results
-Follow up donor information
-Renal MRI to evaluate renal lesion

Medications on Admission:
Meds:
Multivitamin
Lipitor 20mg daily
.
Discharged from [**Location (un) **] on the following:
Augmentin 875-125mg daily
Ciprofloxacin 500mg [**Hospital1 **]
Folate 1mg daily


Discharge Medications:
1. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours.
Disp:*60 Tablet(s)* Refills:*0*
2. MS Contin 15 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO every twelve (12) hours.
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for nausea or insomnia.
Disp:*30 Tablet(s)* Refills:*0*
6. PICC line care
PICC line care per CCS protocol
7. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
Disp:*30 Tablet(s)* Refills:*0*
9. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ensure Plus     Liquid Sig: One (1)  PO four times a day.
Disp:*120 * Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Primary diagnosis:
AML s/p 2 cycles of 7+3 induction and HIDAC reinduction
pericardial effusion/tamponade
febrile neutropenia
suspected fungal pneumonia
pleural effusion
penile ulceration
abnormal LFTs
malnutrition


Discharge Condition:
vital signs stable. Oxygen saturation above 92% on RA.
Tolerating oral intake.


Discharge Instructions:
You were admitted with AML and have received chemotherapy. You
white blood cell counts have returned.  Your course was
complicated by fevers and a suspected fungal infection in your
lungs. You are being sent out on voriconazole antifungal
medication to take twice a day. Please discuss with Dr. [**Last Name (STitle) **]
when you should stop taking this medication. You will likely
need another CAT scan of your chest to evaluate the pneumonia.

You have also been given pain medications to take. You should
take 30mg of MS contin twice a day and hydromorphone for
breakthrough pain. As your pain improves, you should decrease
the MS contin to 15mg twice a day- please speak to your doctor
about tapering this down. Do not drive while on this medication.

Pain medications can cause constipation. You are being given
some suggestions to help control constipation: docusate stool
softner, senna or bisacodyl as laxatives.

You should NOT take your lipitor (atorvastatin) because your
liver enzymes are elevated and this medication can interact with
the liver.

You should notify your physician or go to the emergency room if
you have fevers >101, chills, shortness of breath, chest pain,
nausea or vomiting, lightheadedness, bleeding in the gums or
blood in the urine or stool or black or tarry stools or any
other symptoms which are concerning to you.

Followup Instructions:
Please follow up Monday on the 7 [**Hospital Ward Name 1826**] outpatient clinic at
10:30AM.

Dr. [**Last Name (STitle) **] will see you on Monday in 7 [**Hospital Ward Name 1826**] and schedule
your next appointment at that time.



Completed by:[**2143-6-2**]
{'Acute myeloid leukemia, without mention of having achieved remission,Pneumonia in other systemic mycoses,Acute pericarditis, unspecified,Other and unspecified mycoses,Unspecified protein-calorie malnutrition,Secondary malignant neoplasm of pleura,Ulcer of heel and midfoot,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Neutropenia, unspecified,Nonspecific abnormal results of function study of liver,Other specified disorders of penis,Stomatitis and mucositis, unspecified,Unspecified disorder of kidney and ureter'}


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: Dyspnea on Exertion, Fatigue, Low grade fever

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 52 year old man with no major medical problems
who presented to the emergency room with shortness of breath and
worsening dyspnea on exertion. For the past month, he has
noticed increased bruising, and for the past week, he has
noticed nosebleeds at night and bleeding gums, as well as
ulcerations on his tongue. He developed progressive dyspnea on
exertion, which prompted an admission to [**Hospital **] Hospital, at
which time his hematocrit was noted to be 16. He received 4
units of pRBC's and his bone marrow was aspirated (results
pending). He was discharged home and told his bone marrow
results would be available on Tuesday. The day prior to
admission at [**Hospital1 18**], he complained of worsened dyspnea and
band-like chest pain across his chest, at which time his wife
insisted that he come to [**Hospital1 18**].
.
He denies recent weight loss, but has noticed a low-grade
temperature over the past week, along with night sweats, chills,
and diffuse abdominal pain (no associated nausea, vomiting,
diarrhea). He has had a headache which responds to ibuprofen.
During his hospitalization at [**Hospital **] Hospital, he developed a
rash after receiving a blood transfusion. He has also noticed a
non-tender ulceration on his penis, which developed within the
last week. His wife notes that his color has improved
dramatically since receiving the blood transfusions.

MEDICAL HISTORY: s/p multiple back surgeries, including cervical spinal fusion
s/p basal cell carcinoma removal
Nephrolithiasis
Hypercholesterolemia
Had cardiac cath in [**2134**] (per report, was "clean", after failing
multiple thallium stress tests)
Chronic numbness and neuropathic pain of left upper
extremity/chest

MEDICATION ON ADMISSION: Meds:
Multivitamin
Lipitor 20mg daily
.
Discharged from [**Location (un) **] on the following:
Augmentin 875-125mg daily
Ciprofloxacin 500mg [**Hospital1 **]
Folate 1mg daily

ALLERGIES: Cefepime

PHYSICAL EXAM: Vitals: T 97.9, BP 122/72, HR 67, RR 18, Sat 94% on 2L
(documented, but when seen he was off oxygen)
Gen: Pale appearing, no acute distress
HEENT: EOMI, PERRL, ?petechiae on uvula
Neck: Supple, no thyromegaly
Nodes: No cervical, supraclavicular or subclavicular
lympahdenopathy appreciated; shottly inguinal lymphadenopathy
L>R
Heart: RRR, normal S1/S2, no m/r/g
Lungs: Clear to auscultation bilaterally
Abd: Soft, non-tender, non-distended, normal bowel sounds; no
hepatosplenomegaly appreciated
Back: No spinal tenderness, no costovertebral angle tenderness
GU: Painless chancre on left side of penis, between shaft and
head of penis, draining purulent material
Ext: No clubbing/cyanosis/edema
Neuro: A&O x 3

FAMILY HISTORY: Mother died suddenly in her 70's, father died of cancer, unknown
type (with visible tumors across his body). One sister with
thyroid cancer, brother with diabetes, sister with [**Name (NI) 5895**]
Disease.

SOCIAL HISTORY: Lives in [**Location 14840**] with his wife. They have three children (ages
24, 22, and 18). He works as a technician for [**Company 22957**], with some
exposure to lead; crawls around office buildings and below
houses and may have had asbestos exposure. + tobacco history (1
ppd x "many" years, not currently). Social EtOH, no drugs.
Sexually active with one partner, wife, no extramarital sexual
exposures. No previous STD's. 

### Response:
{'Acute myeloid leukemia, without mention of having achieved remission,Pneumonia in other systemic mycoses,Acute pericarditis, unspecified,Other and unspecified mycoses,Unspecified protein-calorie malnutrition,Secondary malignant neoplasm of pleura,Ulcer of heel and midfoot,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Neutropenia, unspecified,Nonspecific abnormal results of function study of liver,Other specified disorders of penis,Stomatitis and mucositis, unspecified,Unspecified disorder of kidney and ureter'}
