CHIEF COMPLAINT: Chief Complaint: Fatigue
.
Reason for MICU transfer: Hypotension

PRESENT ILLNESS: 67 year old male with relapsed AML on chemo who presents with
fatigue and weakness.

MEDICAL HISTORY: AML, dx'ed [**7-4**].  Treated with 7+3 induction and then
reinduction with MEC [**2-2**].  Refractory leukemia [**4-4**], started
Dacogen.  Recently completed cycle of dacogen [**7-25**].
Osteoarthritis
S/p L TKA - [**2155**]
S/p R THA - [**2154**]
Seasonal allergies - x 30 years
Hypertension - [**2151**]
H/o colonoscopy [**2154**] negative
GERD - [**2155**]
Right septic shoulder - [**10/2158**]
MSSA sepsis - [**10/2158**]
SVT while in ICU - [**10/2158**]
R calf nodule - [**11/2158**]
Hyperbilirubinemia - [**2158-10-25**]
Pulmonary nodules - [**11/2158**] (stable or resolved since thattime
aside from 6 mm LLL nodule on [**5-/2159**] scan)
Herniated disks with chronic back pain - [**2135**]

MEDICATION ON ADMISSION: Cipro XR 500mg po daily x 7 days (last day [**2159-8-8**])
Voriconazole 400mg po q12h
Metoprolol tartrate 25mg po bid
Omeprazole 20mg po daily
Acyclovir 400mg po q8h
Multivitamin 1 tab po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 96.2 110 98/63 23 100%3L
General: Alert, oriented, diaphoretic and mildly tachypne
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, right IJ in place, no LAD
CV: Regular rate and rhythm with hyperdynamic heart sounds,
normal S1 + S2, no murmurs, rubs, gallops
Lungs: Few crackles at the bases, no wheezes, rales, ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: cool extremities, 1+ pulses, no edema.

FAMILY HISTORY: Father was obese and a heavy smoker, unknown cause of death.
Mother suffered from rheumatoid arthritis and died at age 59.
No known family history of pulmonary disease.

SOCIAL HISTORY: Patient lives alone.  Retired firefighter and Marine Corp
member.  Photographer and car enthusiast.  Never smoker, no
alcohol or other drug use.
Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Septic shock,Acute respiratory failure,Acute myeloid leukemia, in relapse,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Fever presenting with conditions classified elsewhere,Severe sepsis,Other specified cardiac dysrhythmias
E coli septicemia,Pneumonia, organism NOS,Septic shock,Acute respiratry failure,Act myel leuk in relapse,Drug induced neutropenia,Adv eff antineoplastic,Fever in other diseases,Severe sepsis,Cardiac dysrhythmias NEC
Admission Date:  [**2159-8-7**]              Discharge Date:   [**2159-8-13**]

Date of Birth:  [**2092-6-29**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Chief Complaint: Fatigue
.
Reason for MICU transfer: Hypotension

Major Surgical or Invasive Procedure:
mechanical ventilation/intubation

History of Present Illness:
67 year old male with relapsed AML on chemo who presents with
fatigue and weakness.

He was recently admitted [**Date range (1) 86908**]/11 with febrile neutropenia.
At that time, he was treated for multifocal pneumonia with a
course of vanc/meropenem, and it was ultimately felt that he had
aspergillosis and was started on voriconazole.  He was also
discharged on a 7 day course of cipro.  Also had a recent
admission for strep viridens and E Coli bacteremia.

He had been feeling well at home until 2 days ago.  He was seen
in onc clinic at that time and had a low grade fever that
self-resolved.  Then started to feel chills the next day and
decided to come in for evaluation.  Denies cough, SOB, nausea,
vomiting, abdominal pain, diarrhea, dysuria, and headache

In the ED, he triggered for tachycardia with rate 156 on
arrival, temp 103.5.  He was rigoring and very warm to the
touch. Denied nuchal rigidity.  Labs were significant for WBC
1.3 with 88% blasts, platelets 17, and elevated LFTs.  Lactate
2.0.  CXR showed irregular density in the superior aspect of the
RLL, increased compared to prior, concerning for worsening
infectious process.  He was given vanc, cefepime, levofloxacin,
and acetaminophen.  RUQ ultrasound was normal.  BP was in the
80's after 2L IVF and right IJ CVL was placed.  Levophed was
then started, and subsequently neosynephrine was added for
refractory hypotension.  Shock ultrasound showed a trace
pericardial effusion.  CVP was measured to be 12.  BP now 93/56
and close to being maxed out on neo.  Did get stress dose
steroids in ED.  Given 7L IV fluids total in ED.  Tachypneic in
mid 20's to 40's.  Full code.
.
On arrival to the MICU, he reports feeling very discouraged and
fatigued.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
AML, dx'ed [**7-4**].  Treated with 7+3 induction and then
reinduction with MEC [**2-2**].  Refractory leukemia [**4-4**], started
Dacogen.  Recently completed cycle of dacogen [**7-25**].
Osteoarthritis
S/p L TKA - [**2155**]
S/p R THA - [**2154**]
Seasonal allergies - x 30 years
Hypertension - [**2151**]
H/o colonoscopy [**2154**] negative
GERD - [**2155**]
Right septic shoulder - [**10/2158**]
MSSA sepsis - [**10/2158**]
SVT while in ICU - [**10/2158**]
R calf nodule - [**11/2158**]
Hyperbilirubinemia - [**2158-10-25**]
Pulmonary nodules - [**11/2158**] (stable or resolved since thattime
aside from 6 mm LLL nodule on [**5-/2159**] scan)
Herniated disks with chronic back pain - [**2135**]

Social History:
Patient lives alone.  Retired firefighter and Marine Corp
member.  Photographer and car enthusiast.  Never smoker, no
alcohol or other drug use.


Family History:
Father was obese and a heavy smoker, unknown cause of death.
Mother suffered from rheumatoid arthritis and died at age 59.
No known family history of pulmonary disease.

Physical Exam:
Vitals: 96.2 110 98/63 23 100%3L
General: Alert, oriented, diaphoretic and mildly tachypne
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, right IJ in place, no LAD
CV: Regular rate and rhythm with hyperdynamic heart sounds,
normal S1 + S2, no murmurs, rubs, gallops
Lungs: Few crackles at the bases, no wheezes, rales, ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: cool extremities, 1+ pulses, no edema.


Pertinent Results:
WBC 1.3 (12L 88blasts 15 NRBCs) Hgb 9.2 Hct 26.4 Plt 17
Na 137 K 4.0 Cl 102 Bicarb 22 BUN 25 Creat 1.1 Gluc 124
ALT 48 AST 44 AlkP 537 TB 2.3 LDH 450
Lactate 2.0
UA sm blood, <1RBC, <1 epi, otherwise negative

[**2159-8-12**] 02:47AM BLOOD WBC-21.3* RBC-3.29* Hgb-9.6* Hct-27.5*
MCV-84 MCH-29.1 MCHC-34.8 RDW-16.7* Plt Ct-11*
[**2159-8-6**] 10:44PM BLOOD WBC-1.3* RBC-3.27* Hgb-9.2* Hct-26.4*
MCV-81* MCH-28.2 MCHC-34.9 RDW-15.9* Plt Ct-17*
[**2159-8-12**] 02:47AM BLOOD Neuts-0 Bands-0 Lymphs-2* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-98* NRBC-1*
[**2159-8-6**] 10:44PM BLOOD Neuts-0 Bands-0 Lymphs-12* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-88* NRBC-15*
[**2159-8-12**] 02:47AM BLOOD Plt Smr-RARE Plt Ct-11*
[**2159-8-12**] 02:47AM BLOOD Glucose-103* UreaN-38* Creat-1.3* Na-139
K-3.6 Cl-111* HCO3-18* AnGap-14
[**2159-8-6**] 10:44PM BLOOD Glucose-124* UreaN-25* Creat-1.1 Na-137
K-4.0 Cl-102 HCO3-22 AnGap-17
[**2159-8-12**] 02:47AM BLOOD ALT-13 AST-22 LD(LDH)-526* AlkPhos-144*
TotBili-8.3* DirBili-6.2* IndBili-2.1
[**2159-8-6**] 10:44PM BLOOD ALT-48* AST-44* LD(LDH)-450* AlkPhos-537*
TotBili-2.3*
[**2159-8-10**] 11:02PM BLOOD CK-MB-3 cTropnT-0.02*
[**2159-8-12**] 02:47AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9
[**2159-8-7**] 07:54AM BLOOD Albumin-2.8* Calcium-6.9* Phos-3.9
Mg-1.3*
[**2159-8-9**] 11:16PM BLOOD Tobra-2.1*
[**2159-8-12**] 03:18AM BLOOD Type-ART Temp-36.5 pO2-138* pCO2-37
pH-7.33* calTCO2-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED
[**2159-8-12**] 03:18AM BLOOD Lactate-1.3
[**2159-8-10**] 08:27AM BLOOD O2 Sat-98
[**2159-8-12**] 03:18AM BLOOD freeCa-1.17
[**2159-8-8**] 06:40PM BLOOD VORICONAZOLE-Test Name
[**2159-8-7**] 07:54AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test

IMAGING:

[**8-6**] CXR: Increasing conspicuous irregular opacity of right
lower lobe,
likely represents worsening infectious process though cannot
exclude
malignancy. Strongly advise imaging to resolution.

[**8-7**] RUQ US:
Normal right upper quadrant ultrasound, except for simple right
renal cyst.

[**8-7**] CT chest/abd/pelvis:
1. Progression of pulmonary opacities in bilateral lower lobes
of the lungs with non-enhancing wedge like opacity in the right
lung, and nodular opacities in the right upper lobe likely
inflammatory or infectious in nature. Associated likely reactive
mediastinal lymphadenopathy.
2. No acute intrabdominal process.
3. Mild periportal edema suggesting third spacing.
3. Bilateral cortical and parapelvic renal cysts.
4. Splenomegaly.
5. Lumbar spine and left hip DJD.

[**8-8**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is low normal (LVEF
50-55%). The right ventricular cavity is mildly dilated with
borderline normal free wall function. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a prominent fat pad.

[**8-8**] Hip xray: 1. No evidence of joint effusion.
2. Right total hip arthroplasty without hardware complications.
3. Left hip degenerative changes.

[**8-8**] Knee xray:
Left total knee arthroplasty without hardware complications.
Small suprapatellar effusion.


Brief Hospital Course:
Primary Reason for Hospitalization: 67 year old male with
relapsed AML on chemo who presented with septic shock from
multiple organisms and who passed away in the MICU.

#. Septic Shock/Neutropenic Fever: The patient had positive
blood cultures with E. coli as well as VRE. He also appeared to
have a severe pulmonary process which was thought to be a
progression of his recent pulmonary aspergillosis. He was
treated with broad spectrum antibiotics and antifungals in
consulation with the infectious disease team but he continued to
decompensate. He required multiple pressors to maintain his
blood pressure. He began to have increased respiratory distress
and required intubation. As the patient's prognosis began to
look worse a family meeting was called with ICU and Oncology
Attendings present with the patient's brother [**Name (NI) **] [**Name (NI) 86903**](HCP)
and his wife. [**Name (NI) **] reported that the patient would not want a
long drawn out course if his condition was terminal. He reported
that the patient would want to be comfortable in his last hours.
The patient was made CMO. He was left on mechanical ventilation
but measures not supporting comfort were withdrawn. He passed
away on [**2159-8-13**] at 1420
.
#. Refractory AML: Was receiving palliative Dacogen infusions,
last dose 8/31 with chronic neutropenia with ANC=0 and blast 88%
of WBC. On admission he had a WBC count of 1.3 w ANC of 0 and
90% blasts, but throughout the course of his stay and
progression of his infection his WBC count rose to 20 w 98%
blasts. He was followed by Heme/Onc during his stay, who briefly
started him on hydroxyurea, however his prognosis remained
dismal.  Following a goals of care discussion between his
family, ICU staff, and the heme/onc team, he was made CMO and
passed away.
.
#. Respiratory Failure: Grew increasingly tachypneic during his
hospital course due to compensation for significant metabolics
acidosis from his sepsis with underlying parenchymal
disease/infection.  He eventually began to tire and had trouble
keeping up an adequate minute [**Last Name (LF) 86909**], [**First Name3 (LF) **] he required
intubation on [**8-9**].  He was still on the ventillator when he was
made CMO, and the decision was made to wait to extubate until he
passed from cardiac death.  He was extubated following his
death.

# Acute renal insuffiency:  Creatinine slightly elevated to 1.1
on admission from baseline 0.8-1.0, rose to 1.3 during
admission.  This was attributed to low flow state due to sepsis
as well as effect of some obligate nephrotoxins with
antibiotics.  This was managed with treatment of his underlying
sepsis and care to avoid any other unnecessary nephrotoxins.
.
#. Abnormal LFTs: Elevated bili to 2.3 with alk phos of 537.
Has had similar abnormalities on prior admissions for sepsis
which typically resolved with hydration.
Bilirubin continued to rise throughout his hospital stay, but
alk phos fell to nearly normal levels.  No clear etiology, RUQ
US was unrevealing.  Repeat abdominal imaging was considered,
however he never was stable enough to leave the floor for the
study.


Medications on Admission:
Cipro XR 500mg po daily x 7 days (last day [**2159-8-8**])
Voriconazole 400mg po q12h
Metoprolol tartrate 25mg po bid
Omeprazole 20mg po daily
Acyclovir 400mg po q8h
Multivitamin 1 tab po daily


Discharge Medications:
expired


Discharge Disposition:
Expired

Discharge Diagnosis:
expired


Discharge Condition:
expired


Discharge Instructions:
expired

Followup Instructions:
expired
{'Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Septic shock,Acute respiratory failure,Acute myeloid leukemia, in relapse,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Fever presenting with conditions classified elsewhere,Severe sepsis,Other specified cardiac dysrhythmias'}


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: Chief Complaint: Fatigue
.
Reason for MICU transfer: Hypotension

PRESENT ILLNESS: 67 year old male with relapsed AML on chemo who presents with
fatigue and weakness.

MEDICAL HISTORY: AML, dx'ed [**7-4**].  Treated with 7+3 induction and then
reinduction with MEC [**2-2**].  Refractory leukemia [**4-4**], started
Dacogen.  Recently completed cycle of dacogen [**7-25**].
Osteoarthritis
S/p L TKA - [**2155**]
S/p R THA - [**2154**]
Seasonal allergies - x 30 years
Hypertension - [**2151**]
H/o colonoscopy [**2154**] negative
GERD - [**2155**]
Right septic shoulder - [**10/2158**]
MSSA sepsis - [**10/2158**]
SVT while in ICU - [**10/2158**]
R calf nodule - [**11/2158**]
Hyperbilirubinemia - [**2158-10-25**]
Pulmonary nodules - [**11/2158**] (stable or resolved since thattime
aside from 6 mm LLL nodule on [**5-/2159**] scan)
Herniated disks with chronic back pain - [**2135**]

MEDICATION ON ADMISSION: Cipro XR 500mg po daily x 7 days (last day [**2159-8-8**])
Voriconazole 400mg po q12h
Metoprolol tartrate 25mg po bid
Omeprazole 20mg po daily
Acyclovir 400mg po q8h
Multivitamin 1 tab po daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 96.2 110 98/63 23 100%3L
General: Alert, oriented, diaphoretic and mildly tachypne
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, right IJ in place, no LAD
CV: Regular rate and rhythm with hyperdynamic heart sounds,
normal S1 + S2, no murmurs, rubs, gallops
Lungs: Few crackles at the bases, no wheezes, rales, ronchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley in place
Ext: cool extremities, 1+ pulses, no edema.

FAMILY HISTORY: Father was obese and a heavy smoker, unknown cause of death.
Mother suffered from rheumatoid arthritis and died at age 59.
No known family history of pulmonary disease.

SOCIAL HISTORY: Patient lives alone.  Retired firefighter and Marine Corp
member.  Photographer and car enthusiast.  Never smoker, no
alcohol or other drug use. 

### Response:
{'Septicemia due to escherichia coli [E. coli],Pneumonia, organism unspecified,Septic shock,Acute respiratory failure,Acute myeloid leukemia, in relapse,Drug induced neutropenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Fever presenting with conditions classified elsewhere,Severe sepsis,Other specified cardiac dysrhythmias'}
