CHIEF COMPLAINT: Fevers and rigors

PRESENT ILLNESS: 66 year old male with history of refractory AML now on Dacogen
therapy (chronic neutropenia) with new onset of fever and
rigors.  He has felt unwell for 10 days prior to presenting to
his [**Hospital 3242**] clinic appointment on the day of admission.  He has been
complaining about a large mouth sore, abdominal discomfort,
constipation, perirectal pressure, loss of appetite and weight
loss.  During his appointment, he was receiving a blood
transfusion (RBCs and platelets) and developed rigors, SBP to
180, HR to 160 (has hx of SVT), RR >40, O2 100% only 10 minutes
before infusion was to end. He was given 50 mg hydrocortisone
for bronchspasm (+wheezing on exam), 50 mg total of Demerol for
rigors, 25 mg of Benadryl for ?transfusion reaction and 2 grams
cefepime for febrile neutropenia.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
-[**Doctor First Name **] presented in [**7-4**] with pancytopenia.
-Bone marrow on [**2158-7-14**] was consistent with AML, FAB M1-M2.
FLT3/NPM1 were both negative.
-[**2158-7-14**] Tx'ed with Cytarabine/Daunorubicin (7+3)
-[**2158-8-2**] Reinduction with MEC He did achieve remission after this

MEDICATION ON ADMISSION: 1. fexofenadine 180 mg daily
2. ondansetron 4 mg q8h PRN
3. omeprazole 20 mg daily
4. metoprolol tartrate 25 mg [**Hospital1 **]
5. fluconazole 200 mg daily
6. acyclovir 400 mg q8h
7. multivitamin daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 100.7, BP: 104/54 P: 22 RR: 29  SpO2: 97% on 2L
General: Alert, oriented, no acute distress, jaundiced
HEENT: PERRL, sclera icteric with sublingual jaundice, dry MM,
healing sore on inside of lower lip; oropharynx clear
Neck: supple, JVD to 7-8cm, no LAD
Lungs: mildly decreased BS to bases bilaterally, no wheezes,
rales, rhonchi
CV: tachycardic, regular rate and rhythm, normal S1/S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no [**Doctor Last Name 515**] sign, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Left oral erosion. Nonbleeding. No other
mucositis. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: Tachycardic. S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, good breath sounds, expiratory
wheezes BL.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.

FAMILY HISTORY: Negative for any known hematologic malignancies.

SOCIAL HISTORY: He is unmarried and lives alone in [**Location (un) **]. He is a retired
fireman and a US Marine core veteran. He does not smoke, does
not drink alcohol and has never used drugs. He takes frequent
trips to [**State 15946**], but none recently.
Streptococcal septicemia,Other specified aplastic anemias,Acute myeloid leukemia, without mention of having achieved remission,Unspecified essential hypertension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
Streptococcal septicemia,Aplastic anemias NEC,Ac myl leuk wo achv rmsn,Hypertension NOS,Adv eff antineoplastic
Admission Date:  [**2159-6-29**]              Discharge Date:   [**2159-7-4**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
Fevers and rigors


Major Surgical or Invasive Procedure:
attempted central line placement ([**2159-6-29**])
PICC removal ([**2159-6-29**])
PICC placement


History of Present Illness:
66 year old male with history of refractory AML now on Dacogen
therapy (chronic neutropenia) with new onset of fever and
rigors.  He has felt unwell for 10 days prior to presenting to
his [**Hospital 3242**] clinic appointment on the day of admission.  He has been
complaining about a large mouth sore, abdominal discomfort,
constipation, perirectal pressure, loss of appetite and weight
loss.  During his appointment, he was receiving a blood
transfusion (RBCs and platelets) and developed rigors, SBP to
180, HR to 160 (has hx of SVT), RR >40, O2 100% only 10 minutes
before infusion was to end. He was given 50 mg hydrocortisone
for bronchspasm (+wheezing on exam), 50 mg total of Demerol for
rigors, 25 mg of Benadryl for ?transfusion reaction and 2 grams
cefepime for febrile neutropenia.

Of note, he does have a history of bacteremia on multiple
occasions (CoNS, Klebsiella), with several ICU admissions for
septic shock, known to become ill very quickly, per BMT.

In the ED, initial vs were: 103.6 152 108/50 22 94% 2L Nasal
Cannula. Labs were sent for fibrinogen, LDH, Coombs, FDP, and
blood cultures: 2 peripheral, 1 from picc line.  CVL placement
was attempted at right subclavian, but was unsuccessful and
followed by a RIJ attempt that coiled upwards.  Upon removal of
this line, CXR showed that the PICC line appears to have been
pulled back as well.  He was given Vancomycin in addition to
Cefepime for concern for line infection.  He received a total of
6L NS IVF with persistent tachycardic to 130s (down from 150s),
1g tylenol with no change in fever.  U/A clear and CXR shows
symmetric pulmonary vascular congestion.  Vitals on transfer:
103.3 138 123/70 23 99% 2L
.
In the ICU, the patient is mildly tachypneic and jaundiced, but
feels more relaxed.  He does not require any supplemental O2.
.
On arrival to BMT, VS were 97.8, 101, 122/70, 25, 96%. Patient
states that he is feeling good. He denies SOB, cough, fevers,
chills, nausea, abd pain, diarrhea. He endorses some
constipation. He has no rash. He does have a small oral erosion
that is healing.

Past Medical History:
ONCOLOGIC HISTORY:
-[**Doctor First Name **] presented in [**7-4**] with pancytopenia.
-Bone marrow on [**2158-7-14**] was consistent with AML, FAB M1-M2.
FLT3/NPM1 were both negative.
-[**2158-7-14**] Tx'ed with Cytarabine/Daunorubicin (7+3)
-[**2158-8-2**] Reinduction with MEC He did achieve remission after this

therapy.
-[**2158-12-4**] Tx'd with Cyatarbine x 5 days(completed [**2158-12-8**])
-[**2159-2-22**] Tx'd with cycle 2 MEC
- [**2159-4-3**] Dacogen for refractory leukemia
.
PMH:
- Osteoarthritis - [**2147**]
- s/p L TKA - [**2155**]
- s/p R THA - [**2154**]
- Seasonal allergies - x 30 years
- Hypertension - [**2151**]
- h/o colonoscopy [**2154**] negative
- GERD - [**2155**]
- R 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**]
- Herniated disks with chronic back pain- [**2135**]

PSH:
Left knee surgery
Right hip surgery


Social History:
He is unmarried and lives alone in [**Location (un) **]. He is a retired
fireman and a US Marine core veteran. He does not smoke, does
not drink alcohol and has never used drugs. He takes frequent
trips to [**State 15946**], but none recently.


Family History:
Negative for any known hematologic malignancies.

Physical Exam:
Admission Physical Exam:
Vitals: T: 100.7, BP: 104/54 P: 22 RR: 29  SpO2: 97% on 2L
General: Alert, oriented, no acute distress, jaundiced
HEENT: PERRL, sclera icteric with sublingual jaundice, dry MM,
healing sore on inside of lower lip; oropharynx clear
Neck: supple, JVD to 7-8cm, no LAD
Lungs: mildly decreased BS to bases bilaterally, no wheezes,
rales, rhonchi
CV: tachycardic, regular rate and rhythm, normal S1/S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no [**Doctor Last Name 515**] sign, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Left oral erosion. Nonbleeding. No other
mucositis. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: Tachycardic. S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, good breath sounds, expiratory
wheezes BL.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.

Pertinent Results:
Admission Labs:
[**2159-6-29**] 11:30AM   WBC-1.6*# RBC-2.70* HGB-7.2* HCT-21.8*
MCV-81* MCH-26.7* MCHC-33.1 RDW-18.4*
[**2159-6-29**] 11:30AM   NEUTS-0 BANDS-0 LYMPHS-10* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-90*
[**2159-6-29**] 11:30AM   HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
ELLIPTOCY-1+
[**2159-6-29**] 11:30AM   UREA N-28* CREAT-1.1 SODIUM-134 POTASSIUM-4.6
CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
[**2159-6-29**] 11:30AM   ALT(SGPT)-58* AST(SGOT)-40 LD(LDH)-290* ALK
PHOS-490* TOT BILI-1.9* DIR BILI-0.9* INDIR BIL-1.0
[**2159-6-29**] 11:30AM   CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2159-6-29**] 05:52PM   PT-14.9* PTT-24.3 INR(PT)-1.3*
[**2159-6-29**] 11:30AM   GRAN CT-0*
.
Microbiology:
- [**2159-6-29**] 12:00 pm BLOOD CULTURE
   Blood Culture, Routine (Preliminary):
      GRAM NEGATIVE ROD(S).
      STREPTOCOCCUS SPECIES.

- [**2159-6-29**] 5:52 pm BLOOD CULTURE      #1.
   Blood Culture, Routine (Preliminary):
      STREPTOCOCCUS SPECIES.    PRELIMINARY SENSITIVITY.
         These preliminary susceptibility results are offered to
help guide
         treatment; interpret with caution as final
susceptibilities may
         change. Check for final susceptibility results in 24
hours.
                              SENSITIVITIES: MIC expressed in
MCG/ML
                               STREPTOCOCCUS SPECIES
                             |
CLINDAMYCIN-----------       S
ERYTHROMYCIN----------       S
VANCOMYCIN------------       S

- blood culture ([**6-29**]): E. coli, pan sensitive
- urine culture ([**6-29**]): Negative
- PICC catheter tip ([**6-29**]): Negative
- blood culture ([**7-1**]): Negative
.
Imaging:
- CT abdomen/pelvis ([**6-29**]):
IMPRESSION: 1. Minimal intrahepatic biliary ductal dilation,
without definite etiology, though in the setting of gallbladder
sludge. Overall, the biliary system could be further evaluated
via MRCP if clinical concern persists.
2. New left lower lobe pulmonary nodular opacity. Given the
short-interval appearance, this is likely infectious or
inflammatory, though a dedicated CT of the chest is recommended
in three months' time in order to exclude an underlying lesion.
3. Mild area of fat stranding surrounding a segment of sigmoid
colon with relative mural thickening. Overall, this finding is
nonspecific and though there is no evidence of diverticulosis, a
mild uncomplicated diverticulitis may have this appearance
versus focal uncomplicated colitis. Nevertheless, recommend
correlation to colonoscopy upon cessation of symptoms in order
to exclude an underlying mass.
4. Small hiatal hernia.
5. Unchanged renal cysts and splenomegaly.
.
CXR ([**6-29**]):  IMPRESSION: No acute cardiopulmonary process.
Bibasilar atelectasis.
CXR ([**6-30**]):  IMPRESSION: Left basilar opacity. Followup is
suggested.
CXR ([**7-1**]):  IMPRESSION: Bibasilar infiltrate left greater than
right. Previously noted edema has resolved.
CXR ([**7-2**]): Small left pleural effusion has developed since
[**6-29**], and there is mild
left lower lobe atelectasis. The new left basal lung nodule
detected on
[**6-29**] abdomen CT is not large enough to be seen on chest
radiographs,
particularly when performed bedside. Finding was discussed with
the ICU
clinical team as presumed focal infection. Lungs are otherwise
clear. Heart
size is normal.

TTE ([**7-3**]): IMPRESSION: No valvular vegetations or
clinically-significant valvular disease seen. Symmetric left
ventricular hypertrophy with normal global and regional
biventricular systolic function.
.
CXR post PICC placement: FINDINGS: As compared to the previous
radiograph, the patient has received a
left-sided PICC line. The course of the PICC line is
unremarkable. The tip
of the line projects over the mid SVC. No evidence of
pneumothorax or other
complications. Unchanged left retrocardiac atelectasis. No other
changes.
.
Discharge Labs:

[**2159-7-4**] 05:45AM BLOOD WBC-1.2* RBC-2.77* Hgb-7.9* Hct-23.6*
MCV-85 MCH-28.5 MCHC-33.4 RDW-17.5* Plt Ct-14*
[**2159-7-4**] 05:45AM BLOOD Neuts-0 Bands-0 Lymphs-33 Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Blasts-60* NRBC-7*
[**2159-7-4**] 05:45AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-2+
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+ Burr-OCCASIONAL
Stipple-1+ Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 12850**]2+
[**2159-7-4**] 06:25PM BLOOD PT-15.0* PTT-26.7 INR(PT)-1.3*
[**2159-7-4**] 05:45AM BLOOD Gran Ct-0*
[**2159-7-4**] 05:45AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-138
K-3.6 Cl-107 HCO3-21* AnGap-14
[**2159-7-4**] 05:45AM BLOOD ALT-23 AST-18 LD(LDH)-163 AlkPhos-259*
TotBili-1.5 DirBili-0.9* IndBili-0.6
[**2159-7-4**] 05:45AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.8 Mg-1.7

Brief Hospital Course:
66 year old male with refractory AML on Dacogen therapy with
chronic neutropenia, presenting with fevers and rigors in the
setting of RBC/platelets transfusions and history of multiple
admissions for sepsis. The patient's fevers continued
post-transfusion and infectious workup was initiated.

# Neutropenic Fevers/rigors with tachycardia:  Given the timing
of his fevers/rigors, a transfusion reaction was considered, but
ruled out. A previous transfusion reaction in [**2159-3-25**] was
characterized by urticaria and not this clinical picture. He
remained febrile for several days following the reaction.  His
symptoms were considered more likely to be of infectious origin.
 He had multiple sites that could contribute to infection,
including a mouth sore, a PICC line, and abdominal pain of
unknown etiology.  Lactate was low and reassuring.  As patient
is neutropenic, vancomycin, cefepime, and Flagyl were started to
treat the potential infecious sources.  The PICC line was
removed and the tip cultured and had no growth.  Anti-fungal
coverage was changed from fluconazole to micafungin to treat a
possible fungal infection of the mouth and/or rectal area.  CT
abdomen/pelvis revealed both a LLL opacity in the lung and a
possible colitis vs. diverticulitis in the sigmoid.  Given
clinical improvement, the patient was transferred from the ICU
to the BMT service on [**2159-7-2**]. ID was consulted after blood
cultures grew Strep viridans and E. coli, both of which were
pan-sensitive. We switched the patient off broad spectrum ABX to
ceftriaxone based on ID recs. The patient remained afebrile on
this regimen. Also, the patient was switched from micafungin
back to his fluconazole prophylaxis. The patient's blood
cultures had cleared by [**7-1**]. He received a new PICC line on the
day of discharge and was sent home on a 14 day course of
ceftriaxone 2 g Q24hrs.
.
# Direct hyperbilirubinemia: On presentation, the patient had an
elevated bilirubin at 1.9, with direct of 0.9 and an AP of 490;
all mildly elevated from prior baseline.  Transaminases were
also slightly elevated.  Differential for this includes a
biliary process (obstruction) vs. hemolysis (less likely due to
increased direct bilirubin fraction).  LFTs were followed and
rapidly resolved with hydration.  Flagyl was included in
antibiotic coverage (as noted above) for possible
biliary/abdominal process.  A RUQ ultrasound was normal. The
patient's LFTs and bili trended down during admission.
.
# ST depressions in anterolateral leads: On presentation there
were some EKG changes that were concerning for possible
ischemia.  EKG was repeated once the patient was less
tachycardic and these changes resolved.  Cardiac enzymes were
negative.  This was determined to be rate-related.
.
# Pancytopenia: Patient is transfusion dependent due to
chemotherapy.  His transfusion threshold of Hct < 24 and Plt <
10 was maintained during this admission.  He required
transfusions of both throughout his stay.

# Refractory AML: Currently receiving Dacogen (C4) infusions,
last administered on [**6-20**], with chronic neutropenia (ANC=0).
Blasts at 92% represents poorly controlled disease.  The patient
will follow-up with his primary oncologist to determine his next
course of treatment.


Medications on Admission:
1. fexofenadine 180 mg daily
2. ondansetron 4 mg q8h PRN
3. omeprazole 20 mg daily
4. metoprolol tartrate 25 mg [**Hospital1 **]
5. fluconazole 200 mg daily
6. acyclovir 400 mg q8h
7. multivitamin daily


Discharge Medications:
1. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
4. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*0*
5. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours) for 9 days: Last
dose on [**7-13**].
Disp:*QS QS* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*0*
7. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day.



Discharge Disposition:
Home With Service

Facility:
VNA of [**Hospital1 487**]

Discharge Diagnosis:
Bloodstream Infection
AML


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital with fever and shaking chills
after receiving a blood transfusion in clinic. Your temperature
on admission was 103 F. You were admitted to the ICU for close
monitoring of your pulse, blood pressure, and temperature. You
were transfered to the floor when your condition improved. We
initially put you on strong antibiotics, but then we changed
this to ceftriaxone once the culture sensitivities returned.
Your blood cultures drawn on admission grew 2 types of bacteria:
E coli and Strep. We consulted the infectious disease
specialists who agreed with our decision to treat you with 14
days of IV ceftriaxone.
.
Your PICC line was removed on admission in order to eliminate
sources of infection. You received a new PICC on discharge.
Also, we took an ultrasound of your heart to look for bacteria,
but this was negative.
.
We monitored your counts due to your leukemia. You required
blood transfusions as well as platelets on your stay. We made
f/u appointments for you in clinic.
.
Please take all meds as prescribed.

Followup Instructions:
Department: BMT CHAIRS & ROOMS
When: FRIDAY [**2159-7-6**] at 10:30 AM

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2159-7-6**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2159-7-6**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
{'Streptococcal septicemia,Other specified aplastic anemias,Acute myeloid leukemia, without mention of having achieved remission,Unspecified essential hypertension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}


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 and rigors

PRESENT ILLNESS: 66 year old male with history of refractory AML now on Dacogen
therapy (chronic neutropenia) with new onset of fever and
rigors.  He has felt unwell for 10 days prior to presenting to
his [**Hospital 3242**] clinic appointment on the day of admission.  He has been
complaining about a large mouth sore, abdominal discomfort,
constipation, perirectal pressure, loss of appetite and weight
loss.  During his appointment, he was receiving a blood
transfusion (RBCs and platelets) and developed rigors, SBP to
180, HR to 160 (has hx of SVT), RR >40, O2 100% only 10 minutes
before infusion was to end. He was given 50 mg hydrocortisone
for bronchspasm (+wheezing on exam), 50 mg total of Demerol for
rigors, 25 mg of Benadryl for ?transfusion reaction and 2 grams
cefepime for febrile neutropenia.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
-[**Doctor First Name **] presented in [**7-4**] with pancytopenia.
-Bone marrow on [**2158-7-14**] was consistent with AML, FAB M1-M2.
FLT3/NPM1 were both negative.
-[**2158-7-14**] Tx'ed with Cytarabine/Daunorubicin (7+3)
-[**2158-8-2**] Reinduction with MEC He did achieve remission after this

MEDICATION ON ADMISSION: 1. fexofenadine 180 mg daily
2. ondansetron 4 mg q8h PRN
3. omeprazole 20 mg daily
4. metoprolol tartrate 25 mg [**Hospital1 **]
5. fluconazole 200 mg daily
6. acyclovir 400 mg q8h
7. multivitamin daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: 100.7, BP: 104/54 P: 22 RR: 29  SpO2: 97% on 2L
General: Alert, oriented, no acute distress, jaundiced
HEENT: PERRL, sclera icteric with sublingual jaundice, dry MM,
healing sore on inside of lower lip; oropharynx clear
Neck: supple, JVD to 7-8cm, no LAD
Lungs: mildly decreased BS to bases bilaterally, no wheezes,
rales, rhonchi
CV: tachycardic, regular rate and rhythm, normal S1/S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no [**Doctor Last Name 515**] sign, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Physical Exam:
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Left oral erosion. Nonbleeding. No other
mucositis. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: Tachycardic. S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, good breath sounds, expiratory
wheezes BL.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.

FAMILY HISTORY: Negative for any known hematologic malignancies.

SOCIAL HISTORY: He is unmarried and lives alone in [**Location (un) **]. He is a retired
fireman and a US Marine core veteran. He does not smoke, does
not drink alcohol and has never used drugs. He takes frequent
trips to [**State 15946**], but none recently. 

### Response:
{'Streptococcal septicemia,Other specified aplastic anemias,Acute myeloid leukemia, without mention of having achieved remission,Unspecified essential hypertension,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}
