CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: Ms. [**Known lastname **] is a 79-year-old woman with hx of CVA, HTN,
hypothyroidism newly diagnosed Diffuse large B-Cell Non-Hodgkins
Lymphoma who presents with fever, malaise, poor appetite. She
recently underwent exploratory laparotomy with tumor biopsy
[**2146-5-25**] for evaluation of a pelvic mass with placement of
bilaterel ureteral stents. The surgery was complicated by acute
renal failure with creat up to 2.6 from baseline 1.5 suspectedly
due to ATN from ureteral obstruction although renal US revealed
no clear obstruction and she was discharged [**5-29**] with creat
improved to 1.9. She initially was feeling well but over the
next 2 days developed worsening fevers, nausea w/o vomiting and
decreased urine output. She continued to take all of her
medications as prescribed. On the day of admission she developed
a fever to 102 with night sweats on the night prior with
worsening confusion and was brought to the ED. She denied cough,
has mild abdominal discomfort and had no BM. She denies dysuria
but did report some mild bilateral flank pain.
.
In the ED she was found to be in acute on chronic RF with
elevated lactate to 7.6 and positive UA. Abd CT revealed left
sided mild hydronephrosis with no asymmetric stranding and
diffuse lymphomatous involvment of the retroperitoneum extending
up the ureters and involving the renal pelvises as well. Sepsis
line placed and she was started on vancomycin, levofloxacin and
flagyl and given 3l NS for hydration with vital signs stable.
She was also evaluated by Ob/gyn who agreed that admission to
ICU for sepsis was appropriate.

MEDICAL HISTORY: B-cell NHL- presented with three to four months of appetite
loss, nausea, and back pain.  CT scan performed on [**2146-5-6**]
revealed extensive ascites and peritoneal masses concerning for
ovarian cancer.  Also, noted were bilateral ureteral
irregularities close to obstruction, both on the left and the
right.
CVA- no residual deficit
R carotid artery occlusion
Melanoma- (~[**2140**]) Left eye localized involvement, s/p proton
beam tx without evidence of recurrence
hypertension
hypercholesterolemia
hypothyroidism
gout
.
Psurg:
Appendectomy

MEDICATION ON ADMISSION: Percocoet 5/325 mg 1-2T q4-6h
Alprazolam 0.5 mg qd
allopurinol 10 mg qd
Lipitor 10 mg qd
Nexium 40 mg qd
aspirin 81 mg qd
Levothyroxine 125 mcg qd
clopidogrel 75 mg qd
triamterene 37.5/25 qd
atenolol 50 mg qd
motrin prn
colace 100mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ED:T 102   HR 90    BP  170/85  RR 16
Vitals on Admit to ICU: T  99.0  HR 90  BP 98/65 RR 16 O2sat 98%
[**Female First Name (un) **]
Gen:NAD, A and Ox3
HEENT:PERRL, MMdry, upper full dentures lower bridge, no elev
JVP
NEck:supple
CV:RRR, nS1S2 no MRG
PULM:fine crackles at bases bilat
Abd:bilat mild CVA tenderness, severe tenderness around
incision, fullness to left side of incision with no fluctuance,
mild erythema along staple line
Extrem:2+ rad and dp pulses, 2+ LE edema worse on left
Neuro:CNII-XII intact, [**6-11**] UE and LE strength except for [**5-12**] in
hip flexers bilat, distal sensation intact

FAMILY HISTORY: She has one cousin with history of breast cancer
and daughter had renal cell cancer.

SOCIAL HISTORY: married, lived with her husband in [**Name (NI) 1268**] until her most
recent hospitalization.  No current tobacco, or illicits. Drinks
2 glasses of wine per week.  smoking 20+ years ago.  Not
currently working.  She has 6 children who live in the area and
daughter in law who is a nurse.
Septicemia due to escherichia coli [E. coli],Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites,Hydronephrosis,Other mechanical complication of genitourinary device, implant, and graft,Sepsis,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Personal history of other diseases of circulatory system,Hypotension, unspecified
E coli septicemia,Brkt tmr unsp xtrndl org,Hydronephrosis,Malfunc gu dev/graft NEC,Sepsis,Hypertension NOS,Hypothyroidism NOS,Hx-circulatory dis NEC,Hypotension NOS
Admission Date:  [**2146-6-5**]              Discharge Date:   [**2146-6-16**]

Date of Birth:  [**2066-9-20**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Fevers

Major Surgical or Invasive Procedure:
Ureteral stent revision

History of Present Illness:
 Ms. [**Known lastname **] is a 79-year-old woman with hx of CVA, HTN,
hypothyroidism newly diagnosed Diffuse large B-Cell Non-Hodgkins
Lymphoma who presents with fever, malaise, poor appetite. She
recently underwent exploratory laparotomy with tumor biopsy
[**2146-5-25**] for evaluation of a pelvic mass with placement of
bilaterel ureteral stents. The surgery was complicated by acute
renal failure with creat up to 2.6 from baseline 1.5 suspectedly
due to ATN from ureteral obstruction although renal US revealed
no clear obstruction and she was discharged [**5-29**] with creat
improved to 1.9. She initially was feeling well but over the
next 2 days developed worsening fevers, nausea w/o vomiting and
decreased urine output. She continued to take all of her
medications as prescribed. On the day of admission she developed
a fever to 102 with night sweats on the night prior with
worsening confusion and was brought to the ED. She denied cough,
has mild abdominal discomfort and had no BM. She denies dysuria
but did report some mild bilateral flank pain.
.
In the ED she was found to be in acute on chronic RF with
elevated lactate to 7.6 and positive UA. Abd CT revealed left
sided mild hydronephrosis with no asymmetric stranding and
diffuse lymphomatous involvment of the retroperitoneum extending
up the ureters and involving the renal pelvises as well. Sepsis
line placed and she was started on vancomycin, levofloxacin and
flagyl and given 3l NS for hydration with vital signs stable.
She was also evaluated by Ob/gyn who agreed that admission to
ICU for sepsis was appropriate.


Past Medical History:
B-cell NHL- presented with three to four months of appetite
loss, nausea, and back pain.  CT scan performed on [**2146-5-6**]
revealed extensive ascites and peritoneal masses concerning for
ovarian cancer.  Also, noted were bilateral ureteral
irregularities close to obstruction, both on the left and the
right.
CVA- no residual deficit
R carotid artery occlusion
Melanoma- (~[**2140**]) Left eye localized involvement, s/p proton
beam tx without evidence of recurrence
hypertension
hypercholesterolemia
hypothyroidism
gout
.
Psurg:
Appendectomy

Social History:
married, lived with her husband in [**Name (NI) 1268**] until her most
recent hospitalization.  No current tobacco, or illicits. Drinks
2 glasses of wine per week.  smoking 20+ years ago.  Not
currently working.  She has 6 children who live in the area and
daughter in law who is a nurse.

Family History:
She has one cousin with history of breast cancer
and daughter had renal cell cancer.

Physical Exam:
ED:T 102   HR 90    BP  170/85  RR 16
Vitals on Admit to ICU: T  99.0  HR 90  BP 98/65 RR 16 O2sat 98%
[**Female First Name (un) **]
Gen:NAD, A and Ox3
HEENT:PERRL, MMdry, upper full dentures lower bridge, no elev
JVP
NEck:supple
CV:RRR, nS1S2 no MRG
PULM:fine crackles at bases bilat
Abd:bilat mild CVA tenderness, severe tenderness around
incision, fullness to left side of incision with no fluctuance,
mild erythema along staple line
Extrem:2+ rad and dp pulses, 2+ LE edema worse on left
Neuro:CNII-XII intact, [**6-11**] UE and LE strength except for [**5-12**] in
hip flexers bilat, distal sensation intact

Pertinent Results:
[**2146-6-4**] 08:20PM   WBC-21.7*# RBC-3.79* HGB-11.6* HCT-34.2*
MCV-90 MCH-30.6 MCHC-33.9 RDW-15.3
[**2146-6-4**] 08:20PM   GLUCOSE-94 UREA N-24* CREAT-2.0* SODIUM-138
POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-18* ANION GAP-26*
[**2146-6-4**] 08:20PM   CALCIUM-10.9* PHOSPHATE-2.6* MAGNESIUM-1.5*
[**2146-6-4**] 08:20PM   ALT(SGPT)-12 AST(SGOT)-28 ALK PHOS-84
AMYLASE-25 TOT BILI-0.7
[**2146-6-4**] 11:13PM   LACTATE-7.5*
.
CXR ([**2146-6-5**]): There has been interval withdrawal of the right
IJ line, with the tip now in the distal SVC.  The remainder of
the study has not significantly changed in comparison to the
prior exam.  Again seen are NU stents overlying the abdomen.
.
CT abd/pelvis ([**2146-6-5**]): 1.  Bilateral NU stents.  Left
proximal NU stent is in the proximal left ureter, and there is
associated hydronephrosis.  There is extensive soft tissue
around both ureters, which may reflect extension of the
patient's known lymphoma.  Additionally, there is soft tissue
stranding around the left ureter, and associated forniceal
rupture cannot be excluded. 2.  Extensive soft tissue in the
pelvis, which likely reflects a combination of the uterus, the
known lymphoma, and unopacified loops of bowel, though subacute
hemorrhage cannot be excluded.  The stent position is not well
evaluated without IV contrast.  There is extension into the
retroperitoneum (including around the ureters), and extensive
mesenteric lymphadenopathy.  Tiny foci of air within this, and
also likely small extraluminal air, likely reflect changes
related to prior biopsy and recent surgery.  These findings are
consistent with patient's known lymphoma. 3.  Diverticulosis
without definite diverticulitis. 4.  Small amount of fluid along
the anterior abdominal wall incision. 5.  Foley catheter
positioned within the vagina. 6.  Two pulmonary nodules, largest
measuring 16 mm in the right middle lobe.
.
.
SPINAL FLUIDS:
[**2146-6-13**] 06:21PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-44 Monos-56
[**2146-6-13**] 06:21PM CEREBROSPINAL FLUID (CSF) TotProt-30 Glucose-84
LD(LDH)-23
.
RENAL ULTRASOUND:
IMPRESSION:
1.  No evidence of hydronephrosis.  Two tiny right renal cysts.
2.  Small volume ascites.
.
DISCHARGE LABS:
.
[**2146-6-16**] 12:00AM BLOOD WBC-0.4* RBC-2.96* Hgb-9.2* Hct-26.5*
MCV-90 MCH-31.2 MCHC-34.9 RDW-13.7 Plt Ct-97*
[**2146-6-16**] 12:00AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-135
K-4.0 Cl-101 HCO3-30 AnGap-8
[**2146-6-16**] 12:00AM BLOOD ALT-13 AST-21 LD(LDH)-398* AlkPhos-51
TotBili-0.3
[**2146-6-16**] 12:00AM BLOOD Albumin-2.5* Calcium-7.8* Phos-2.1*
Mg-1.8

Brief Hospital Course:
The patient was admitted with fevers, leukocytosis, acute renal
failure and hypotension. She was felt to have signs of
urosepsis. She was started on broad antibiotic coverage for gram
negative rods in the blood. The etiology of the patient's
urosepsis is likely ureteral obstruction. CT confirmed
hydronephrosis. The patient underwent a failed trial at IR
placement of a percutaneous nephrostomy tube. She successfully
underwent a urologic procedure with re-stenting of the ureters.
The GNR's in the blood speciated to pan-sensitive E. Coli. The
patient's antibiotic regimen was narrowed to ceftriaxone.
Subsequent blood and urine cultures were without growth. The
patient was initiated on solumedrol daily in hopes of shrinking
her abdominal mass. The patient was transferred to the oncology
service for likely chemotherapy.
.
BMT COURSE:
The patient began chemotherapy on [**2146-6-7**]. She received cytoxan,
prednisone, vincristine, and intrathecal methotrexate. She
tolerated the chemo well. She developed tumor lysis syndrome
which was treated with high rates of IVF and diuresis to keep
her urine output up. She did not develop complications, and
tumor lysis resolved.
.
She continued to have hematuria, the etiology of which was felt
to be ureteral irritation by both the tumor mass and the several
urologic procedures for stenting of her occluded ureters. Her
foley catheter was pulled and she diruesed well and urinated
well. Her hematocrit and coagulation studies were normal. She
will be discharged with follow up with Dr. [**First Name (STitle) **] to evaluate for
the need for continued uretheral stenting. Any concerns of
ongoing hematuria can also be addressed to him. A renal
ultrasound was performed on the day prior to discharge to eval
for resolution of hydronephrosis. It showed no evidence for
hydronephrosis.
.
On discharge, her WBC was beginning to drop as expected and she
began GCSF treatment. She was not febrile. She is to see Dr.
[**First Name (STitle) 1557**] on Monday in follow up.

Medications on Admission:
Percocoet 5/325 mg 1-2T q4-6h
Alprazolam 0.5 mg qd
allopurinol 10 mg qd
Lipitor 10 mg qd
Nexium 40 mg qd
aspirin 81 mg qd
Levothyroxine 125 mcg qd
clopidogrel 75 mg qd
triamterene 37.5/25 qd
atenolol 50 mg qd
motrin prn
colace 100mg [**Hospital1 **]

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).

11. Saliva Substitution Combo No.2     Solution Sig: [**2-8**]  Mucous
membrane qid () as needed for mouth sores.
12. Filgrastim 480 mcg/1.6 mL Solution Sig: Four [**Age over 90 11578**]y
(480) mcg Injection Q24H (every 24 hours): adminitration should
continue until instructed by Dr. [**First Name (STitle) 1557**] to d/c.
13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Morphine Sulfate 2 mg IV Q4H:PRN
16. Ceftriaxone 1 g Recon Soln Sig: One (1) gram Intravenous
once a day: To be discontiued when WBC counts are increased adn
instructed to discontinue by Dr. [**First Name (STitle) 1557**].
17. Heparin Flush Port (10units/ml) 5 ml IV DAILY:PRN
10 ml NS followed by 5 ml of 10 Units/ml heparin (50 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
18. Ondansetron 4-8 mg IV Q8H:PRN
19. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name 533**] Centre for Extended Care

Discharge Diagnosis:
Burkitt's Lymphoma
Ureteral Obstruction
Hematuria
Hypertension


Discharge Condition:
ambulating with assist, good oxygen saturations, tolerating POs


Discharge Instructions:
Please take all medications as prescribed. Please attend all
follow up appointments. If you develop fever, chills please
contact your health care providers right away.
.
You had stents placed in your ureturs as they were obstructed by
the tumor. This is the cause of the blood in your urine. You
have a follow up appointment with the Urologist Dr. [**First Name (STitle) **] in 3
months time to address the need for the continuation or removal
of these stents. If have continued hematuria, problems making
urine, or pain associated with decreased urine output, please
contact the office of Dr. [**First Name (STitle) **]: [**Telephone/Fax (1) 6317**]

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-6-20**] 3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-6-20**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 7614**]
Date/Time:[**2146-6-27**] 11:15
{"Septicemia due to escherichia coli [E. coli],Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites,Hydronephrosis,Other mechanical complication of genitourinary device, implant, and graft,Sepsis,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Personal history of other diseases of circulatory system,Hypotension, 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 lastname **] is a 79-year-old woman with hx of CVA, HTN,
hypothyroidism newly diagnosed Diffuse large B-Cell Non-Hodgkins
Lymphoma who presents with fever, malaise, poor appetite. She
recently underwent exploratory laparotomy with tumor biopsy
[**2146-5-25**] for evaluation of a pelvic mass with placement of
bilaterel ureteral stents. The surgery was complicated by acute
renal failure with creat up to 2.6 from baseline 1.5 suspectedly
due to ATN from ureteral obstruction although renal US revealed
no clear obstruction and she was discharged [**5-29**] with creat
improved to 1.9. She initially was feeling well but over the
next 2 days developed worsening fevers, nausea w/o vomiting and
decreased urine output. She continued to take all of her
medications as prescribed. On the day of admission she developed
a fever to 102 with night sweats on the night prior with
worsening confusion and was brought to the ED. She denied cough,
has mild abdominal discomfort and had no BM. She denies dysuria
but did report some mild bilateral flank pain.
.
In the ED she was found to be in acute on chronic RF with
elevated lactate to 7.6 and positive UA. Abd CT revealed left
sided mild hydronephrosis with no asymmetric stranding and
diffuse lymphomatous involvment of the retroperitoneum extending
up the ureters and involving the renal pelvises as well. Sepsis
line placed and she was started on vancomycin, levofloxacin and
flagyl and given 3l NS for hydration with vital signs stable.
She was also evaluated by Ob/gyn who agreed that admission to
ICU for sepsis was appropriate.

MEDICAL HISTORY: B-cell NHL- presented with three to four months of appetite
loss, nausea, and back pain.  CT scan performed on [**2146-5-6**]
revealed extensive ascites and peritoneal masses concerning for
ovarian cancer.  Also, noted were bilateral ureteral
irregularities close to obstruction, both on the left and the
right.
CVA- no residual deficit
R carotid artery occlusion
Melanoma- (~[**2140**]) Left eye localized involvement, s/p proton
beam tx without evidence of recurrence
hypertension
hypercholesterolemia
hypothyroidism
gout
.
Psurg:
Appendectomy

MEDICATION ON ADMISSION: Percocoet 5/325 mg 1-2T q4-6h
Alprazolam 0.5 mg qd
allopurinol 10 mg qd
Lipitor 10 mg qd
Nexium 40 mg qd
aspirin 81 mg qd
Levothyroxine 125 mcg qd
clopidogrel 75 mg qd
triamterene 37.5/25 qd
atenolol 50 mg qd
motrin prn
colace 100mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ED:T 102   HR 90    BP  170/85  RR 16
Vitals on Admit to ICU: T  99.0  HR 90  BP 98/65 RR 16 O2sat 98%
[**Female First Name (un) **]
Gen:NAD, A and Ox3
HEENT:PERRL, MMdry, upper full dentures lower bridge, no elev
JVP
NEck:supple
CV:RRR, nS1S2 no MRG
PULM:fine crackles at bases bilat
Abd:bilat mild CVA tenderness, severe tenderness around
incision, fullness to left side of incision with no fluctuance,
mild erythema along staple line
Extrem:2+ rad and dp pulses, 2+ LE edema worse on left
Neuro:CNII-XII intact, [**6-11**] UE and LE strength except for [**5-12**] in
hip flexers bilat, distal sensation intact

FAMILY HISTORY: She has one cousin with history of breast cancer
and daughter had renal cell cancer.

SOCIAL HISTORY: married, lived with her husband in [**Name (NI) 1268**] until her most
recent hospitalization.  No current tobacco, or illicits. Drinks
2 glasses of wine per week.  smoking 20+ years ago.  Not
currently working.  She has 6 children who live in the area and
daughter in law who is a nurse. 

### Response:
{"Septicemia due to escherichia coli [E. coli],Burkitt's tumor or lymphoma, unspecified site, extranodal and solid organ sites,Hydronephrosis,Other mechanical complication of genitourinary device, implant, and graft,Sepsis,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Personal history of other diseases of circulatory system,Hypotension, unspecified"}
