CHIEF COMPLAINT: Fever, hypotension

PRESENT ILLNESS: This is a 56 year old male with a history of AML s/p double cord
bone marrow transplant over three years ago, COP who presents
with one day of sore throat, nose pain/sinus pain, headache, and
fever to 103.2 this morning. He also endorses 2 episodes of
vomiting (without nausea), cough, chills, and rigors. He was in
his usual state of health until last evening when he started to
feel unwell, and started experiencing malaise, and headache.
This morning things worsened to the point where he was unable to
get himself into the car because of fatigue/weakness. He has
history of apnea requiring intubation 3 years ago. Also, patient
is on 2L home O2 (use with a lot of activity but not at rest)
for COP.
.
He has not ahd any recent history of travel, hiking, or sick
contacts. His wife states they had a vacation planned, but
haven't done anything recently because he has been unwell. He
has chronic arthralgias from GVHD, but they have been well
controlled and they have been able to wean his prednisone down
to 3mg. He also has had a decrease in his pain requirement and
is now only on oxycontin.
.
Of note prior admission in [**Month (only) **] with fever, malaise,
vomiting. He was afebrile during his admission. He was started
on cipro for possible GI source and his voriconazole (for
aspergillus sinusitis) was discontinued given interaction with
Cipro.
.
In the ED, initial VS were: 100.2 120 109/56 20 94%. CXR with
?LLL infiltrate. Looked dry, IVC collapsible on beside U/S.
Started on IVF and ceftx, azithromycin. SBP down to 79, given
hydrocort 25mg. With persistent hypotension, broadened with
vancomycin and ceftazidime, as well as another hydrocort 75mg.
Awaiting oseltamivir. Now on 3rd and 4th L IVF. Pt notes wanting
to avoid CVL. Rapid flu negative, nasal swab pending. Labs
notable for WBC 11.8, CKD (at baseline), elevated BNP. Currently
alert and appropriate, maintaining airway, breathing
comfortably. Access is 18g and 20g PIV. Current VS: 90 94/44 12
100,4L.
.
On the floor, He is lethargic, but appropriate. He wakes to
voice, and follows commands appropriately. Answering questions,
oriented.

MEDICAL HISTORY: -AML M5B
 -- S/p idarubicin, Ara-C, mitoxantrone, etoposide and
cytarabine
 -- S/p double cord transplant in [**2184**]
 -- Prior GVHD, specifically myalgias, arthralgias, Fe overload,
peripheral neuropathy
-Chemotherapy-associated cardiomyopathy, LVEF 50%
-CKD
-DM due to prednisone
-Hemochromatosis with chronic liver disease
-Aspergillus of the sinuses and nares
-Sarcoid diagnosed in [**2172**] on intermittent steroids
-Hypertension
-GERD
-Hypercholesterolemia
-BOOP in [**2184-3-13**] on occasional home oxygen

MEDICATION ON ADMISSION: acyclovir 400 mg PO TID
allopurinol 100 mg PO Daily
carvedilol 12.5 mg PO BID
escitalopram [Lexapro] 10 mg PO daily
furosemide 40 mg PO daily only as needed for weight gain of 3
lbs**  He has not used this med in some time
gabapentin 300 mg PO TID
mycophenolate mofetil [CellCept] 500 mg PO bid
nitroglycerin 0.3 mg SL** Has not needed
oxycodone 5-10 mg PO Q4-6H prn pain** Not currently requiring
oxycontin 10 mg PO BID
pantoprazole [Protonix] 40 mg PO daily
Colace 100mg PO TID
Miralax PRN constipation
prednisone 3 mg PO daily
Sulfamethoxazole-trimethoprim 800 mg-160 mg PO MWF
ascorbic acid [Vitamin C] 500 mg PO daily
calcium carbonate 1,000 mg PO daily
cholecalciferol (vitamin D3) 2,000 unit PO daily
Aspirin 81 mg PO daily
loratadine [Claritin]
multivitamin with iron-mineral PO daily
thiamine HCl 50 mg PO daily

ALLERGIES: Benadryl Allergy / AmBisome / Flomax / Tacrolimus

PHYSICAL EXAM: ON ADMISSION:

FAMILY HISTORY: Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

SOCIAL HISTORY: Formerly worked as auto mechanic, now disabled secondary to AML
and GVHD. Lives with wife and son. Past tobacco use, but non
currently.
- Tobacco: Prior to AML diagnosis, he was a smoker, but quit 5
years
- Alcohol:  only very occassionally
- Illicits:  None
Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Bone marrow replaced by transplant,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diarrhea,Other dependence on machines, supplemental oxygen,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Other hemochromatosis,Dehydration,Examination of participant in clinical trial,Personal history of tobacco use,Chronic kidney disease, Stage III (moderate),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Thrombocytopenia, unspecified
Pneumonia, organism NOS,Ac myl leuk wo achv rmsn,Trnspl status-bne marrow,Acute kidney failure NOS,Systolic hrt failure NOS,Diarrhea,Depend-supplement oxygen,Hy kid NOS w cr kid I-IV,Pure hypercholesterolem,Hemochromatosis NEC,Dehydration,Exam-clincal trial,History of tobacco use,Chr kidney dis stage III,Adv eff antineoplastic,Thrombocytopenia NOS
Admission Date:  [**2187-3-30**]              Discharge Date:   [**2187-4-6**]

Date of Birth:  [**2131-3-30**]             Sex:   M

Service: MEDICINE

Allergies:
Benadryl Allergy / AmBisome / Flomax / Tacrolimus

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Fever, hypotension


Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 56 year old male with a history of AML s/p double cord
bone marrow transplant over three years ago, COP who presents
with one day of sore throat, nose pain/sinus pain, headache, and
fever to 103.2 this morning. He also endorses 2 episodes of
vomiting (without nausea), cough, chills, and rigors. He was in
his usual state of health until last evening when he started to
feel unwell, and started experiencing malaise, and headache.
This morning things worsened to the point where he was unable to
get himself into the car because of fatigue/weakness. He has
history of apnea requiring intubation 3 years ago. Also, patient
is on 2L home O2 (use with a lot of activity but not at rest)
for COP.
.
He has not ahd any recent history of travel, hiking, or sick
contacts. His wife states they had a vacation planned, but
haven't done anything recently because he has been unwell. He
has chronic arthralgias from GVHD, but they have been well
controlled and they have been able to wean his prednisone down
to 3mg. He also has had a decrease in his pain requirement and
is now only on oxycontin.
.
Of note prior admission in [**Month (only) **] with fever, malaise,
vomiting. He was afebrile during his admission. He was started
on cipro for possible GI source and his voriconazole (for
aspergillus sinusitis) was discontinued given interaction with
Cipro.
.
In the ED, initial VS were: 100.2 120 109/56 20 94%. CXR with
?LLL infiltrate. Looked dry, IVC collapsible on beside U/S.
Started on IVF and ceftx, azithromycin. SBP down to 79, given
hydrocort 25mg. With persistent hypotension, broadened with
vancomycin and ceftazidime, as well as another hydrocort 75mg.
Awaiting oseltamivir. Now on 3rd and 4th L IVF. Pt notes wanting
to avoid CVL. Rapid flu negative, nasal swab pending. Labs
notable for WBC 11.8, CKD (at baseline), elevated BNP. Currently
alert and appropriate, maintaining airway, breathing
comfortably. Access is 18g and 20g PIV. Current VS: 90 94/44 12
100,4L.
.
On the floor, He is lethargic, but appropriate. He wakes to
voice, and follows commands appropriately. Answering questions,
oriented.

Past Medical History:
-AML M5B
 -- S/p idarubicin, Ara-C, mitoxantrone, etoposide and
cytarabine
 -- S/p double cord transplant in [**2184**]
 -- Prior GVHD, specifically myalgias, arthralgias, Fe overload,
peripheral neuropathy
-Chemotherapy-associated cardiomyopathy, LVEF 50%
-CKD
-DM due to prednisone
-Hemochromatosis with chronic liver disease
-Aspergillus of the sinuses and nares
-Sarcoid diagnosed in [**2172**] on intermittent steroids
-Hypertension
-GERD
-Hypercholesterolemia
-BOOP in [**2184-3-13**] on occasional home oxygen


Social History:
Formerly worked as auto mechanic, now disabled secondary to AML
and GVHD. Lives with wife and son. Past tobacco use, but non
currently.
- Tobacco: Prior to AML diagnosis, he was a smoker, but quit 5
years
- Alcohol:  only very occassionally
- Illicits:  None


Family History:
Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

Physical Exam:
ON ADMISSION:

General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, unable to see
posterior pharynx
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles bilaterally at the bases to the mid lungs
otherwise clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Somewhat distant heart sounds, Regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis,
trace edema
Neuro: PERRL, EOMI, strength 5/5
.
ON DISCHARGE:
Stable from admission exam with exception of clear lung exam,
and improved hypotension.

Pertinent Results:
ADMISSION LABS:

[**2187-3-30**] 11:30AM BLOOD WBC-11.8* RBC-3.59* Hgb-11.9* Hct-36.1*
MCV-101* MCH-33.1* MCHC-32.9 RDW-13.6 Plt Ct-131*
[**2187-3-30**] 11:30AM BLOOD Neuts-86* Bands-0 Lymphs-4* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-0
[**2187-3-30**] 11:30AM BLOOD PT-14.6* PTT-28.4 INR(PT)-1.3*
[**2187-3-30**] 11:30AM BLOOD Glucose-110* UreaN-43* Creat-2.1* Na-141
K-5.3* Cl-107 HCO3-22 AnGap-17
[**2187-3-30**] 11:30AM BLOOD ALT-23 AST-18 LD(LDH)-145 AlkPhos-199*
TotBili-0.3
[**2187-3-30**] 11:30AM BLOOD proBNP-2580*
[**2187-3-30**] 11:30AM BLOOD Albumin-4.0 Calcium-8.7 Phos-2.0*# Mg-1.7
[**2187-3-30**] 12:14PM BLOOD Lactate-2.1*
[**2187-3-30**] 02:10PM BLOOD Lactate-1.2
.
DISCHARGE LABS

[**2187-4-6**] 07:40AM BLOOD WBC-6.6 RBC-3.23* Hgb-10.5* Hct-33.4*
MCV-103* MCH-32.4* MCHC-31.4 RDW-13.3 Plt Ct-142*
[**2187-4-6**] 07:40AM BLOOD Neuts-77.0* Lymphs-7.5* Monos-8.0
Eos-7.3* Baso-0.3
[**2187-4-6**] 07:40AM BLOOD PT-13.8* PTT-28.7 INR(PT)-1.2*
[**2187-4-6**] 07:40AM BLOOD Glucose-89 UreaN-14 Creat-1.2 Na-143
K-4.3 Cl-110* HCO3-23 AnGap-14
[**2187-4-6**] 07:40AM BLOOD ALT-49* AST-22 LD(LDH)-131 AlkPhos-140*
TotBili-0.2
[**2187-4-6**] 07:40AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6
.
MICRO:
Blood culture [**3-30**]: NEG
Urine culture [**3-30**]: NEG
Respiratory viral screen: NEG
CMV viral load: non-detecable
Stool culture [**4-2**]: NEG
C Diff: NEG x2
Legionella urinary antigen: NEG
Aspergilus galactomannan: 0.1 (ref <0.5)
C Diff PCR: PENDING ON DISCHARGE
.
URINE:
[**2187-3-30**] 02:45PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2187-3-30**] 02:45PM URINE RBC-4* WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2187-3-30**] 02:45PM URINE CastHy-3*
[**2187-3-30**] 02:45PM URINE AmorphX-FEW
[**2187-3-30**] 02:45PM URINE Mucous-RARE
[**2187-3-30**] 02:45PM URINE Hours-RANDOM UreaN-608 Na-39 K-73 Cl-47
[**2187-3-30**] 02:45PM URINE Osmolal-453
.
CXR [**2187-3-30**]:
The cardiac, mediastinal and hilar contours are normal. The
pulmonary vascularity is not engorged. Patchy opacity is noted
within the left lung base. The right lung is grossly clear.  No
pleural effusion or pneumothorax is present. There are mild
degenerative changes in the thoracic spine. Right-sided rib
excrescences are again demonstrated.

IMPRESSION:
Patchy opacity in left lung base which may be infectious in
etiology.


Brief Hospital Course:
56 year old male with a h/o AML, CKD, and possible COP, now s/p
double cord transplant over three years ago who presents with a
1 day history of fever, cough, malaise, and hypotensive in the
ED.
.
# Fever/Pneumonia:  On admission, pt found to have LLL pneumonia
likely explaining fevers with leukocytosis to 11.8.  Respiratory
viral culture, CMV viral load, urine culture, and blood cultures
were all negative.  Pt was started on vanc/ceftazidime which he
tolerated well.  Fevers resolved and patient became
hemodynamically stable and was transferred to the floor.  IV
antibiotics were changed to levofloxacin on HOD # 5 and
SOB/cough continued to improve.  He was discharged on
levofloxacin to complete a total 14 day course of antibiotics.
He was provided with tesslon perels for his cough on discharge
though this had almost entirely improved.
.
# Hypotension: Pt was hypotensive upon admission to the ICU.  He
met SIRS criteria with fever and leukocytosis, though was not
bacteremic.  He was likely dehydrated with poor PO intake in the
days leading up to admission, along with possible adrenal
insufficiency in setting of chronic steroids.  He was fluid
resuscitated with 4L NS in the ED and given Hydrocortisone 100
mg IV.  He was given antibiotics as above, and his lactate
decreased from 2.1 on admission to 1.2 the next day.  He was
switched back to his home dose of Prednisone 3 mg PO daily.  His
BP steadily improved and he was restarted on his home Carvedilol
12.5 mg PO BID, which had been held on admission.  He remained
normotensive upon transfer to the floor and through discharge.
.
# Diarrhea:  Pt developed diarrhea on HOD #5, with up to 5 loose
BMs/day.  Fecal culture and C. diff negative x2, though C. Diff
PCR was sent and pending on discharge.  He was started on fluids
which were eventually stopped once PO intake improved.  He was
also started empirically on PO flagyl for C. Diff which he will
continue for 14 day course.  Diarrhea was much improved on
discharge with only 1 episode the morning of discharge.
.
# AOCRF:  Cr was 2.1 on admission (recent baseline of ~2).  Was
likely a pre-renal state given hypotension and dehydration.
Improved with fluids and PO intake to 1.2 on discharge.
.
# AML S/P double cord transplant: Stable. Continued
immunosuppression and treatment of GVHD with Prednisone and
Cellcept.
.
# GERD: Continued home Pantoprazole 40 mg PO daily.
.
# Follow up issues/Transitional:
-Patient set up with follow up with oncologist for 1 week after
discharge
-C. Diff PCR pending on discharge and should be followed


Medications on Admission:
acyclovir 400 mg PO TID
allopurinol 100 mg PO Daily
carvedilol 12.5 mg PO BID
escitalopram [Lexapro] 10 mg PO daily
furosemide 40 mg PO daily only as needed for weight gain of 3
lbs**  He has not used this med in some time
gabapentin 300 mg PO TID
mycophenolate mofetil [CellCept] 500 mg PO bid
nitroglycerin 0.3 mg SL** Has not needed
oxycodone 5-10 mg PO Q4-6H prn pain** Not currently requiring
oxycontin 10 mg PO BID
pantoprazole [Protonix] 40 mg PO daily
Colace 100mg PO TID
Miralax PRN constipation
prednisone 3 mg PO daily
Sulfamethoxazole-trimethoprim 800 mg-160 mg PO MWF
ascorbic acid [Vitamin C] 500 mg PO daily
calcium carbonate 1,000 mg PO daily
cholecalciferol (vitamin D3) 2,000 unit PO daily
Aspirin 81 mg PO daily
loratadine [Claritin]
multivitamin with iron-mineral PO daily
thiamine HCl 50 mg PO daily


Discharge Medications:
1. acyclovir 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8
hours).
2. allopurinol 100 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
3. escitalopram 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day as
needed for weight gain greater than 3 pounds.
5. gabapentin 300 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID (3
times a day).
6. mycophenolate mofetil 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO
BID (2 times a day).
7. oxycodone 5 mg Tablet [**Month/Day/Year **]: 1-2 Tablets PO every 4-6 hours as
needed for pain.
8. OxyContin 10 mg Tablet Extended Release 12 hr [**Month/Day/Year **]: One (1)
Tablet Extended Release 12 hr PO twice a day.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. docusate sodium 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO TID
(3 times a day).
11. prednisone 1 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO DAILY
(Daily).
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Month/Day/Year **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
13. ascorbic acid 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
14. calcium carbonate 200 mg (500 mg) Tablet, Chewable [**Month/Day/Year **]: Two
(2) Tablet, Chewable PO DAILY (Daily).
15. cholecalciferol (vitamin D3) 2,000 unit Capsule [**Month/Day/Year **]: One (1)
Capsule PO once a day.
16. aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
17. loratadine  Oral
18. multivitamin with iron-mineral     Tablet [**Month/Day/Year **]: One (1)
Tablet PO once a day.
19. carvedilol 12.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2
times a day).
20. Miralax 17 gram/dose Powder [**Month/Day/Year **]: One (1)  PO once a day as
needed for constipation.
21. thiamine HCl 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.

22. benzonatate 100 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO BID (2
times a day) as needed for cough.
Disp:*20 Capsule(s)* Refills:*0*
23. levofloxacin 750 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily) for 3 days: to be completed [**2187-4-9**].
Disp:*3 Tablet(s)* Refills:*0*
24. metronidazole 500 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H
(every 8 hours) for 13 days: to be completed [**2187-4-19**].
Disp:*39 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
-Pneumonia
-Antibiotic associated diarrhea

Secondary:
-History of Acute Myeloid Leukemia


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


Discharge Instructions:
Mr. [**Known lastname 39623**],

You were admitted to the hospital for fevers and weakness.  You
were found to have a pneumonia on chest XRAY, and were started
on IV antibiotics.  You spent 1 night in the ICU and then got
transferred to the floor.

Your pneumonia has improved and you are tolerating oral
antibiotics well.  You did develop some diarrhea which we feel
is likely related to your antibiotics.  Your C. diff testing was
negative, but we would like to continue your treatment for this
given your good response.

We made the following changes to your medications:

STARTED: Levofloxacin (levoquin) 750mg by mouth once daily to be
completed [**2187-4-9**].
STARTED: Metronidazole (flagyl) 500mg by mouth every 8 hours.
You should complete your last dose on the evening of [**2187-4-19**]

Please note your follow up appointments below.

It was a pleasure participating in your care

Followup Instructions:
Department: [**Date Range **]/BMT
When: FRIDAY [**2187-4-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital Ward Name **]/BMT
When: FRIDAY [**2187-4-13**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3310**], PA [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2187-5-2**] at 11:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Bone marrow replaced by transplant,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diarrhea,Other dependence on machines, supplemental oxygen,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Other hemochromatosis,Dehydration,Examination of participant in clinical trial,Personal history of tobacco use,Chronic kidney disease, Stage III (moderate),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,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: Fever, hypotension

PRESENT ILLNESS: This is a 56 year old male with a history of AML s/p double cord
bone marrow transplant over three years ago, COP who presents
with one day of sore throat, nose pain/sinus pain, headache, and
fever to 103.2 this morning. He also endorses 2 episodes of
vomiting (without nausea), cough, chills, and rigors. He was in
his usual state of health until last evening when he started to
feel unwell, and started experiencing malaise, and headache.
This morning things worsened to the point where he was unable to
get himself into the car because of fatigue/weakness. He has
history of apnea requiring intubation 3 years ago. Also, patient
is on 2L home O2 (use with a lot of activity but not at rest)
for COP.
.
He has not ahd any recent history of travel, hiking, or sick
contacts. His wife states they had a vacation planned, but
haven't done anything recently because he has been unwell. He
has chronic arthralgias from GVHD, but they have been well
controlled and they have been able to wean his prednisone down
to 3mg. He also has had a decrease in his pain requirement and
is now only on oxycontin.
.
Of note prior admission in [**Month (only) **] with fever, malaise,
vomiting. He was afebrile during his admission. He was started
on cipro for possible GI source and his voriconazole (for
aspergillus sinusitis) was discontinued given interaction with
Cipro.
.
In the ED, initial VS were: 100.2 120 109/56 20 94%. CXR with
?LLL infiltrate. Looked dry, IVC collapsible on beside U/S.
Started on IVF and ceftx, azithromycin. SBP down to 79, given
hydrocort 25mg. With persistent hypotension, broadened with
vancomycin and ceftazidime, as well as another hydrocort 75mg.
Awaiting oseltamivir. Now on 3rd and 4th L IVF. Pt notes wanting
to avoid CVL. Rapid flu negative, nasal swab pending. Labs
notable for WBC 11.8, CKD (at baseline), elevated BNP. Currently
alert and appropriate, maintaining airway, breathing
comfortably. Access is 18g and 20g PIV. Current VS: 90 94/44 12
100,4L.
.
On the floor, He is lethargic, but appropriate. He wakes to
voice, and follows commands appropriately. Answering questions,
oriented.

MEDICAL HISTORY: -AML M5B
 -- S/p idarubicin, Ara-C, mitoxantrone, etoposide and
cytarabine
 -- S/p double cord transplant in [**2184**]
 -- Prior GVHD, specifically myalgias, arthralgias, Fe overload,
peripheral neuropathy
-Chemotherapy-associated cardiomyopathy, LVEF 50%
-CKD
-DM due to prednisone
-Hemochromatosis with chronic liver disease
-Aspergillus of the sinuses and nares
-Sarcoid diagnosed in [**2172**] on intermittent steroids
-Hypertension
-GERD
-Hypercholesterolemia
-BOOP in [**2184-3-13**] on occasional home oxygen

MEDICATION ON ADMISSION: acyclovir 400 mg PO TID
allopurinol 100 mg PO Daily
carvedilol 12.5 mg PO BID
escitalopram [Lexapro] 10 mg PO daily
furosemide 40 mg PO daily only as needed for weight gain of 3
lbs**  He has not used this med in some time
gabapentin 300 mg PO TID
mycophenolate mofetil [CellCept] 500 mg PO bid
nitroglycerin 0.3 mg SL** Has not needed
oxycodone 5-10 mg PO Q4-6H prn pain** Not currently requiring
oxycontin 10 mg PO BID
pantoprazole [Protonix] 40 mg PO daily
Colace 100mg PO TID
Miralax PRN constipation
prednisone 3 mg PO daily
Sulfamethoxazole-trimethoprim 800 mg-160 mg PO MWF
ascorbic acid [Vitamin C] 500 mg PO daily
calcium carbonate 1,000 mg PO daily
cholecalciferol (vitamin D3) 2,000 unit PO daily
Aspirin 81 mg PO daily
loratadine [Claritin]
multivitamin with iron-mineral PO daily
thiamine HCl 50 mg PO daily

ALLERGIES: Benadryl Allergy / AmBisome / Flomax / Tacrolimus

PHYSICAL EXAM: ON ADMISSION:

FAMILY HISTORY: Father- CAD s/p CABG. Type II Diabetes
Mother- Type [**Name (NI) **] Diabetes.
Multiple paternal uncles with heart disease.
2 siblings in good health.

SOCIAL HISTORY: Formerly worked as auto mechanic, now disabled secondary to AML
and GVHD. Lives with wife and son. Past tobacco use, but non
currently.
- Tobacco: Prior to AML diagnosis, he was a smoker, but quit 5
years
- Alcohol:  only very occassionally
- Illicits:  None 

### Response:
{'Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Bone marrow replaced by transplant,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diarrhea,Other dependence on machines, supplemental oxygen,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pure hypercholesterolemia,Other hemochromatosis,Dehydration,Examination of participant in clinical trial,Personal history of tobacco use,Chronic kidney disease, Stage III (moderate),Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Thrombocytopenia, unspecified'}
