CHIEF COMPLAINT: Nausea, vomiting diarrhea and fever

PRESENT ILLNESS: 59 year old female 170 days post allogenic BMT for myelodyspasia
presents with sudden nausea and vomiting, found to be
hypotensive in Dr.[**Name (NI) 6168**] clinic to 60/p, AF with RVR to 150s.
Ext warm, pt mentating. Received hydrocort 100mg. In the ED, BP
initally responded to 113/91 after 2L NS. However, pt remained
hypotensive after 6L. Temp was 101.8. MUST protocol was
activated. Started on cefipime & flagyl empirically after
blood/urine cx's taken. Lactate=1.5. Pt started on dopamine and
transitioned to levophed. Pt converted to NSR spontaneously with
stabalization of blood pressure. Pressors changed from dopa to
levophed in ED.  Vanco and gent dose given for broader
covergage.  Initial CXR was negative, but repeat CXR on [**4-10**]
showed LLL hazy opacity (effusion vs. pna). CT abd/pelvis showed
no acute process; enlarged GB without evidence of cholecystitis.
Blood, urine and stool cx are negative to date. CMV level
pending. In MICU, started on stress dose steroids, prednisone
held, cellcept held. Levophed was weaned off. Pt was ruled out
for MI. Bedside echo without signs of tampanade.
.
Pt is now afebrile. Pt has not had any more diarrhea since
admission, until this morning, when she had 3 episodes of watery
diarrhea. She had had abdominal crampy pain throughout
hospitaliziation, which she feels is getting better. No other
localizing complaints of cough, dysuria.

MEDICAL HISTORY: 1. Polycythemia [**Doctor First Name **] with subsequent myelofibrosis s/p
non-myelo-ablative alloBMT in [**9-30**]
2. Hx paroxysmal AFib in [**2152**], s/p cardioversion (successful for
only 72 hrs), was on amiodarone for some time, is now only on
digoxin

MEDICATION ON ADMISSION: Prednisone 25 mg po qd
Cellcept = 500 mg po tid
ursodiol 300 mg
bactrim MWF
protonix
ativan
ambien
acyclovir
folic acid
benadryl

ALLERGIES: Aspirin / Nsaids

PHYSICAL EXAM: 101.6, 125, 77/28- in clinic on [**2155-4-7**] BP = 122/74, CVP = 9,
RR =25, SaO2 = 100%3L NC
P.E. Ill appearing, NAD pleasant
VS: 101.6, 125,
HEENT: dry MMM, JVP,
Neck: supple
Lungs: CTAB
Heart: hyperdynamic, irregular
Abd: Soft, diffuse mild tenderness, lower > upper
Ext: 2+DPP, no demema
Neuro: grossly inctac
Skin: Multiple non-blanching punctate erythematous rash

FAMILY HISTORY: 4 brothers who were [**6-2**] HLA matches

SOCIAL HISTORY: No tobacco, rare glass of wine with dinner, married and lives
with husband on [**Hospital3 **].  3 children all healthy.
Unspecified septicemia,Complications of transplanted bone marrow,Unspecified myeloid leukemia, without mention of having achieved remission,Septic shock,Atrial fibrillation,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diarrhea,Polycythemia vera,Severe sepsis,Ulceration of intestine,Chronic ulcer of other specified sites
Septicemia NOS,Compl marrow transplant,Uns my leu wo ach rmsn,Septic shock,Atrial fibrillation,Abn react-org transplant,Diarrhea,Polycythemia vera,Severe sepsis,Ulceration of intestine,Chronic skin ulcer NEC
Admission Date:  [**2155-4-8**]              Discharge Date:   [**2155-4-25**]

Date of Birth:  [**2095-11-29**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Nsaids

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Nausea, vomiting diarrhea and fever

Major Surgical or Invasive Procedure:
1.  colonoscopy
2.  placement of right IJ
3.  placement of PICC


History of Present Illness:
59 year old female 170 days post allogenic BMT for myelodyspasia
presents with sudden nausea and vomiting, found to be
hypotensive in Dr.[**Name (NI) 6168**] clinic to 60/p, AF with RVR to 150s.
Ext warm, pt mentating. Received hydrocort 100mg. In the ED, BP
initally responded to 113/91 after 2L NS. However, pt remained
hypotensive after 6L. Temp was 101.8. MUST protocol was
activated. Started on cefipime & flagyl empirically after
blood/urine cx's taken. Lactate=1.5. Pt started on dopamine and
transitioned to levophed. Pt converted to NSR spontaneously with
stabalization of blood pressure. Pressors changed from dopa to
levophed in ED.  Vanco and gent dose given for broader
covergage.  Initial CXR was negative, but repeat CXR on [**4-10**]
showed LLL hazy opacity (effusion vs. pna). CT abd/pelvis showed
no acute process; enlarged GB without evidence of cholecystitis.
Blood, urine and stool cx are negative to date. CMV level
pending. In MICU, started on stress dose steroids, prednisone
held, cellcept held. Levophed was weaned off. Pt was ruled out
for MI. Bedside echo without signs of tampanade.
.
Pt is now afebrile. Pt has not had any more diarrhea since
admission, until this morning, when she had 3 episodes of watery
diarrhea. She had had abdominal crampy pain throughout
hospitaliziation, which she feels is getting better. No other
localizing complaints of cough, dysuria.


Past Medical History:
1. Polycythemia [**Doctor First Name **] with subsequent myelofibrosis s/p
non-myelo-ablative alloBMT in [**9-30**]
2. Hx paroxysmal AFib in [**2152**], s/p cardioversion (successful for
only 72 hrs), was on amiodarone for some time, is now only on
digoxin


Social History:
No tobacco, rare glass of wine with dinner, married and lives
with husband on [**Hospital3 **].  3 children all healthy.

Family History:
4 brothers who were [**6-2**] HLA matches

Physical Exam:
101.6, 125, 77/28- in clinic on [**2155-4-7**] BP = 122/74, CVP = 9,
RR =25, SaO2 = 100%3L NC
P.E. Ill appearing, NAD pleasant
VS: 101.6, 125,
HEENT: dry MMM, JVP,
Neck: supple
Lungs: CTAB
Heart: hyperdynamic, irregular
Abd: Soft, diffuse mild tenderness, lower > upper
Ext: 2+DPP, no demema
Neuro: grossly inctac
Skin: Multiple non-blanching punctate erythematous rash

Pertinent Results:
Admission Labs:
*
CBC: WBC-3.5* RBC-4.14* HGB-13.4 HCT-37.0 MCV-90 PLT 111
*
LFTs: ALT(SGPT)-32 AST(SGOT)-18 LD(LDH)-143 ALK PHOS-187* TOT
BILI-1.3 DIR BILI-0.6 INDIR BIL-0.7
*
CHEM: GLUCOSE-115* UREA N-17 CREAT-0.9 SODIUM-137 POTASSIUM-3.2*
CHLORIDE-101 TOTAL CO2-27 ALBUMIN-3.4 CALCIUM-7.9* MAGNESIUM-1.6
*
LACTATE-1.5
*
U/A: BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
*
Admission abdominal CT:
1. No evidence of colitis, or intraabdominal pathology. The
appendix is visualized within the right lower quadrant and
appears normal.
2. Enlarged gallbladder without evidence of acute cholecystitis.
3. Ossifications within the spleen consistent with prior
granulomatous infection.
*
Admission Chest X ray: Negative
*
Micro:
[**4-8**] Urine Cx: <10,000 organisms
[**4-8**] Blood Cx: Negative
[**4-10**] Stool Cx: Negative
[**4-11**] Stool Cx: Negative
[**4-12**] Stool Cx: Negative
[**4-9**] CMV VL: Not detected
[**4-14**] CMV VL: Not detected
[**4-14**] stool Cx: no C diff
[**4-15**] stool Cx: no C diff
[**4-19**] tissue CMV culture pending
*
CT abdomen/pelvis [**4-16**]:
1. Unremarkable appearance of the bowel. Specifically, no
evidence of infectious or ischemic colitis.
2. Unchanged appearance of gallbladder distention. This can be
an expected finding in a fasting patient. There is no
pericholecystic fluid or gallbladder wall edema. Please
correlate with patient's clinical symptoms.
3. 2-cm aneurysmal dilatation of the splenic artery.
*
Colonoscopy [**2155-4-18**]:
Erythema and granularity in the ascending colon (biopsy).
Ulcers in the terminal ileum (biopsy).
Otherwise normal colonoscopy to terminal ileum.
.
Biopsy results:
A. Terminal ileum biopsy: Fragments of  granulation tissue with
acute and chronic inflammation consistent with ulceration and a
fragment of ileal mucosa with reactive and atrophic changes.
B. Right colon biopsies: Colonic mucosa with focal atrophic and
reactive changes.
C. Left colon biopsies: No significant pathology.
D. Rectal biopsies: No significant pathology.
Note: The changes are not specific. Ulceration may be seen in
chronic graft versus host disease but may also be seen in
ischemia, infection, inflammatory bowel disease, etc. Clinical
correlation is needed. An occasional apoptotic cell is seen.
Immunostains for CMV are negative with appropriate positive
control, and no viral inclusions were seen on routine sections.
Special stains for fungi and AFB are negative with appropriate
positive controls.


Brief Hospital Course:
59 yo woman with PCV s/p mini allo-BMT on [**9-30**] , admitted with
sepsis now resolved, w/ persistent diarrhea. See HPI for ICU
course prior to transfer to BMT. A brief problem based course is
outlined below.

1. Hypotension/sepsis - On transfer to BMT her hypotension had
resolved. She had initially presented with hypotensive episode
(60's systolic), which resolved after IV fluids, pressors and
stress dose steroids in the ICU. No clear source was identified,
with initial blood cx, urine cx, and CXR all negative. Initial
lactate was 1.5. A GI source of sepsis was suspected, which
could have been predisposed by gut GVHD, through a cytokine
mediated event. Other potential etiologies were considered
including dehydrational state from emesis/diarrhea vs adrenal
insufficiency, or a combination of factors. In either case, she
subsequently stabilized on broad antibiotics, which were
continued on admission to the transplant service. Stress dose
steroids were stopped, and she was re-started on a GVHD
treatment regimen of cellcept and solumedrol as outlined below.
She remained hemodynamically stable off pressors, and off stress
dose steroids.

2. Diarrhea - Unclear etiology. The differential included CMV
infection, gut GVHD, or other infectious etiology. Factors
supporting a "late" acute GVHD were her recent skin changes of
GVHD and precipitation of diarrhea (>500cc/day) when cellcept
and solumedrol were abruptly held in the ICU. In addition,
symptoms improved following re-initiation of these meds. Other
infectious etiologies were searched for, including CMV, which
was negative by viral load testing. C diff, campylobacter and
shigella stool cultures were also negative. CT scan was
performed which was negative for intra-abdominal pathology. No
evidence for micro-perforation, ischemia, or colitis was seen.
The GI service was consulted, and plan was made for potential
biopsy if diarrhea continued to evaluate for GVHD vs. CMV.  Pt's
diarrhea improved but then got worse when she began to advance
her diet.  She therefore underwent colonoscopy as her abdominal
pain and diarrhea were persistent and worsening.  This showed a
nonspecific acute on chronic inflammatory process, particularly
in the terminal ileum, which could be consistent with acute on
chronic GVHD versus infection versus IBD.  Of note, IHC for CMV
was negative.  GI was reconsulted; ursodiol was stopped, as this
could induce a bile-acid diarrhea.  It was thought that perhaps
the inflammation in the terminal ileum was preventing bile acid
reabsorption in the enterohepatic circulation, causing diarrhea.
 Pt began to improve somewhat and increased her ambulation,
which also seemed to result in improvement of abdominal pain.
Her diet was advanced, and her abdominal pain got better.  Pt
still had diarrhea on discharge, but stool output was only about
200cc/day.

3. POLYCYTHEMIA [**Doctor First Name **] S/P ALLO-BMT [**9-30**] - >100 days out.
Continued with GVHD medications, including solumedrol and
cell-cept. She was well-engrafted, with WBC >1500, Plt >100K,
and stable hematocrit. Donor/Patient same blood type=O+.  Pt's
Solumedrol was ultimately changed to prednisone 20mg po daily,
which can be tapered as tolerated as an outpatient.

4. CAD - Presented wtih lateral changes on EKG with rapid afib.
Pt was ruled out for MI. Remained chest pain free throughout her
admission. Bedside echo in unit was without tamponade signs.  Pt
had no further cardiac issues after the resolution of her
sepsis.

5. atrial fibrillation - Presented with Afib with RVR in ED in
setting of fever, hypovolemia. Now in sinus rhythm, with no
further issues.

6. FEN - Pt was begun on TPN as her albumin was in the 2's, and
it was thought that she would likely not be able to manage
adequate nutrition in the setting of continued abdominal pain
and diarrhea.  She was discharged on TPN, as well, and she will
continue to advance her diet as tolerated.  Of note, she
required calcium and phosphorus repletion to the point that she
may need extra infusions of these, as the Ca x phos product is
greater than what can be given in the TPN solution.  Pt had PICC
line placed in R arm in interventional radiology on the day of
discharge.

7.  Code - full


Medications on Admission:
Prednisone 25 mg po qd
Cellcept = 500 mg po tid
ursodiol 300 mg
bactrim MWF
protonix
ativan
ambien
acyclovir
folic acid
benadryl

Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).

2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
4. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
7. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at
bedtime) as needed.
8. Budesonide 3 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO tid ().
Disp:*90 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
1.  diarrhea
2.  graft versus host disease
3.  atrial fibrillation with rapid ventricular response in
setting of sepsis


Discharge Condition:
stable, tolerating po, ambulating

Discharge Instructions:
Please keep all of your appointments and take all of your
medications.  If your abdominal pain or diarrhea get worse,
please go to the emergency room or call your primary care
doctor.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2155-5-2**] 11:30
{'Unspecified septicemia,Complications of transplanted bone marrow,Unspecified myeloid leukemia, without mention of having achieved remission,Septic shock,Atrial fibrillation,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diarrhea,Polycythemia vera,Severe sepsis,Ulceration of intestine,Chronic ulcer of other specified sites'}


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: Nausea, vomiting diarrhea and fever

PRESENT ILLNESS: 59 year old female 170 days post allogenic BMT for myelodyspasia
presents with sudden nausea and vomiting, found to be
hypotensive in Dr.[**Name (NI) 6168**] clinic to 60/p, AF with RVR to 150s.
Ext warm, pt mentating. Received hydrocort 100mg. In the ED, BP
initally responded to 113/91 after 2L NS. However, pt remained
hypotensive after 6L. Temp was 101.8. MUST protocol was
activated. Started on cefipime & flagyl empirically after
blood/urine cx's taken. Lactate=1.5. Pt started on dopamine and
transitioned to levophed. Pt converted to NSR spontaneously with
stabalization of blood pressure. Pressors changed from dopa to
levophed in ED.  Vanco and gent dose given for broader
covergage.  Initial CXR was negative, but repeat CXR on [**4-10**]
showed LLL hazy opacity (effusion vs. pna). CT abd/pelvis showed
no acute process; enlarged GB without evidence of cholecystitis.
Blood, urine and stool cx are negative to date. CMV level
pending. In MICU, started on stress dose steroids, prednisone
held, cellcept held. Levophed was weaned off. Pt was ruled out
for MI. Bedside echo without signs of tampanade.
.
Pt is now afebrile. Pt has not had any more diarrhea since
admission, until this morning, when she had 3 episodes of watery
diarrhea. She had had abdominal crampy pain throughout
hospitaliziation, which she feels is getting better. No other
localizing complaints of cough, dysuria.

MEDICAL HISTORY: 1. Polycythemia [**Doctor First Name **] with subsequent myelofibrosis s/p
non-myelo-ablative alloBMT in [**9-30**]
2. Hx paroxysmal AFib in [**2152**], s/p cardioversion (successful for
only 72 hrs), was on amiodarone for some time, is now only on
digoxin

MEDICATION ON ADMISSION: Prednisone 25 mg po qd
Cellcept = 500 mg po tid
ursodiol 300 mg
bactrim MWF
protonix
ativan
ambien
acyclovir
folic acid
benadryl

ALLERGIES: Aspirin / Nsaids

PHYSICAL EXAM: 101.6, 125, 77/28- in clinic on [**2155-4-7**] BP = 122/74, CVP = 9,
RR =25, SaO2 = 100%3L NC
P.E. Ill appearing, NAD pleasant
VS: 101.6, 125,
HEENT: dry MMM, JVP,
Neck: supple
Lungs: CTAB
Heart: hyperdynamic, irregular
Abd: Soft, diffuse mild tenderness, lower > upper
Ext: 2+DPP, no demema
Neuro: grossly inctac
Skin: Multiple non-blanching punctate erythematous rash

FAMILY HISTORY: 4 brothers who were [**6-2**] HLA matches

SOCIAL HISTORY: No tobacco, rare glass of wine with dinner, married and lives
with husband on [**Hospital3 **].  3 children all healthy. 

### Response:
{'Unspecified septicemia,Complications of transplanted bone marrow,Unspecified myeloid leukemia, without mention of having achieved remission,Septic shock,Atrial fibrillation,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diarrhea,Polycythemia vera,Severe sepsis,Ulceration of intestine,Chronic ulcer of other specified sites'}
