CHIEF COMPLAINT: Diarrhea, SOB, and cough

PRESENT ILLNESS: Mr. [**Known lastname 6483**] is a 52 year old with a PMHx s/f AML s/p SCT
(recently completed dapogen, still on hydroxyurea), C.diff,
babesosis, and HTN who presented today to the ED with a chief
complaints of fevers, diarrhea, and  sob. He was in his usual
state of health until yesterday afternoon when he began to
experience copious liquid stools which kept him up for [**2-12**] of
the night, and experience subjective fevers. He also noted a dry
cough which has been worsening overnight and dyspnea. He also
noted one episode of nonbilious/nonbloody emesis. Prior to this
exacerbation, he denies any fevers/chills/cough/SOB.
.
In the ED, initial vs were: T:102.0 (by temporal artery scanner)
P:128 BP:109/64 R:40 O2 sat:94% RA. Patient was given 1gm of
tylenol, 3L NS, vancomycin and zosyn. ABG demonstrated
7.51/31/58/26 on RA.

MEDICAL HISTORY: AML s/p SCT on [**5-17**], with relapse
C diff colitis in [**3-22**] on chronic oral vancomycin (negative pcr
in may)
HTN
Previous babesosis

MEDICATION ON ADMISSION: not applicable

ALLERGIES: Cefepime / Levaquin

PHYSICAL EXAM: Initial ICU Admission Exam [**2176-8-12**]:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: expiratory wheezing on R lower fields, no  rales,
occassional ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no CVA tenderness
Ext: L wrist in cast s/p fracture, warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema

FAMILY HISTORY: Cousin: Leukemia s/p transplant
Father: lung cancer

SOCIAL HISTORY: Social History:
- Tobacco:  quit 5 years ago, previous 30 pack-year
- Alcohol: none
- Illicits:  None
- Previously stocked shelves at [**Date Range **]'s. Currently not working.
Complications of transplanted bone marrow,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Acidosis,Candidiasis of mouth,Other secondary thrombocytopenia,Neutropenia, unspecified,Atrial fibrillation,Acute bronchiolitis due to other infectious organisms,Graft-versus-host disease, unspecified,Diarrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fever presenting with conditions classified elsewhere,Personal history of tobacco use,Hypoxemia,Anemia in neoplastic disease,Do not resuscitate status,Unspecified essential hypertension
Compl marrow transplant,Ac kidny fail, tubr necr,Pneumonia, organism NOS,Ac myl leuk wo achv rmsn,Acidosis,Thrush,Sec thrombocytpenia NEC,Neutropenia NOS,Atrial fibrillation,Acu brnchlts d/t oth org,Graft-versus-host NOS,Diarrhea,Abn react-procedure NEC,Fever in other diseases,History of tobacco use,Hypoxemia,Anemia in neoplastic dis,Do not resusctate status,Hypertension NOS
Admission Date:  [**2176-8-12**]              Discharge Date:   [**2176-9-6**]

Date of Birth:  [**2124-2-28**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime / Levaquin

Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Diarrhea, SOB, and cough

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 6483**] is a 52 year old with a PMHx s/f AML s/p SCT
(recently completed dapogen, still on hydroxyurea), C.diff,
babesosis, and HTN who presented today to the ED with a chief
complaints of fevers, diarrhea, and  sob. He was in his usual
state of health until yesterday afternoon when he began to
experience copious liquid stools which kept him up for [**2-12**] of
the night, and experience subjective fevers. He also noted a dry
cough which has been worsening overnight and dyspnea. He also
noted one episode of nonbilious/nonbloody emesis. Prior to this
exacerbation, he denies any fevers/chills/cough/SOB.
.
In the ED, initial vs were: T:102.0 (by temporal artery scanner)
P:128 BP:109/64 R:40 O2 sat:94% RA. Patient was given 1gm of
tylenol, 3L NS, vancomycin and zosyn. ABG demonstrated
7.51/31/58/26 on RA.

On the floor,  Mr. [**Known lastname 6483**] was found to have T100.8, HR117, BP
of 102/44, RR 19-35, SpO2 98% on 10L shovel mask. Desaturates to
89-91 on RA.


Past Medical History:
AML s/p SCT on [**5-17**], with relapse
C diff colitis in [**3-22**] on chronic oral vancomycin (negative pcr
in may)
HTN
Previous babesosis

Social History:
Social History:
- Tobacco:  quit 5 years ago, previous 30 pack-year
- Alcohol: none
- Illicits:  None
- Previously stocked shelves at [**Date Range **]'s. Currently not working.

Family History:
Cousin: Leukemia s/p transplant
Father: lung cancer


Physical Exam:
Initial ICU Admission Exam [**2176-8-12**]:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: expiratory wheezing on R lower fields, no  rales,
occassional ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no CVA tenderness
Ext: L wrist in cast s/p fracture, warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema

ICU Admission Exam [**2176-8-30**]:
Vitals: T 98.6, BP 117/85, HR 114, RR 25, SpO2 99% on NRB
General: Alert, moderate distress and appears uncomfortable
HEENT: Sclera anicteric, pale conjunctive, MMM
Neck: JVP not elevated, no LAD
Lungs: Coarse breath sounds with upper respiratory fluid sounds.
 No wheezes or crackles
CV: Regular tachycardia. Normal S1, S2.  No murmurs, rubs,
gallops.
Abdomen: Moderately distended and diffusely tender to palpation.
 Tympanic in central area.  Flexiseal in place with green liquid
stool.
GU: Foley draining dark urine.
Ext: Warm, 2+ pulses. Lower extremity edema 2+ bilaterally and
symmetric.

Discharge: deceased

Pertinent Results:
[**2176-8-11**] 08:40AM   GRAN CT-286*
[**2176-8-11**] 08:40AM   PLT SMR-RARE PLT COUNT-12*#
[**2176-8-11**] 08:40AM   HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+ TEARDROP-1+
[**2176-8-11**] 08:40AM   NEUTS-26* BANDS-0 LYMPHS-36 MONOS-18* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-20*
[**2176-8-11**] 08:40AM   WBC-1.1*# RBC-2.55* HGB-8.7* HCT-24.7* MCV-97
MCH-34.0* MCHC-35.1* RDW-18.2*
[**2176-8-11**] 08:40AM   CALCIUM-9.3 PHOSPHATE-4.3 MAGNESIUM-1.7
[**2176-8-11**] 08:40AM   ALT(SGPT)-36 AST(SGOT)-24 ALK PHOS-78 TOT
BILI-0.4
[**2176-8-11**] 08:40AM   UREA N-24* CREAT-1.1 SODIUM-144 POTASSIUM-3.6
CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2176-8-11**] 11:33AM   PLT COUNT-37*#
[**2176-8-12**] 12:05PM   PT-12.0 PTT-20.8* INR(PT)-1.0
[**2176-8-12**] 12:05PM   PLT SMR-VERY LOW PLT COUNT-29*
[**2176-8-12**] 12:05PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL OVALOCYT-1+
TEARDROP-1+ BITE-OCCASIONAL
[**2176-8-12**] 12:05PM   NEUTS-10* BANDS-0 LYMPHS-45* MONOS-11 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 BLASTS-34* NUC RBCS-2*
[**2176-8-12**] 12:05PM   WBC-1.7*# RBC-3.12* HGB-10.9*# HCT-30.0*
MCV-96 MCH-34.9* MCHC-36.4* RDW-18.5*
[**2176-8-12**] 12:05PM   ALBUMIN-3.8
[**2176-8-12**] 12:05PM   LIPASE-17

Brief Hospital Course:
Mr. [**Known lastname 6483**] is a 52 year old with AML s/p SCT and relapse who
was admitted from the ED to the ICU for neutropenic fever and
hypoxemia. He suffered from multiple medical problems, including
untreatable acute myelocytic leukemia, severe graft vs host
disease, acute kidney injury, and hypoxia likely due to
pneumonia. He passed away in the early morning of [**2176-9-6**]. The
paragraphs below describe in detail the course of his several
medical issues.
.
#Hypoxemia: Pt presented with hypoxemia with O2 sats 89-93% on
50% ventimask, and hypoxia continued to be a problem throughout
this hospitalization. The etiology of this hypoxemia was thought
to be secondary to pneumonia (see below), PE, graft versus host
disease, leukemic infiltration or transfusion related acute lung
injury. Gradual improvement while on stress dose steroids and
broad spectrum antibiotics pointed towards leukemic
infiltration, GVHD or pneumonia as the cause. As pt denied chest
pain, did not clinically have a DVT, and improved with the above
interventions, PE was seen as less likely. Anticoagulation was
never begun in this patient given his thrombocytopenia. Chest CT
showed central bronchial wall thickening, consistent with small
airway disease. No consolidations noted. On exam the patient
continued to have wheezes and he was treated symptomatically
with [**Date Range 1988**] nebulizers and supplemental oxygen. Within the
first 24h sats improved to 94%/6L xNC with frequent duonebs.
After respiratory status improved (and other issues stabilized)
the pt was discharged to [**Date Range 3242**], but later re-presented to the ICU
for worsening hypoxia and increased oxygen requirement. At that
time, WBC bumped from 10 to 15 with predominantly lymphocytes
and monocyte lineages changing, which was suspicious for
leukemic infiltration. Antibiotics were broadened to meropenem
but again cultures were negative. O2 sats were >90% on high-flow
oxygen by facemask. [**Date Range 3242**] and ID consult services continued to
follow. O discharge from the [**Hospital Unit Name 153**], the patient remained on a
high-flow oxygen by facemask until time of death.
.
#Possible PNA. Pt was without PNA on imaging but persistent
hypoxia and cough in this chronically immunosuppresed patient
led to agressive antibiotic therapy for possible pneumonia and
pneumonia prophylaxis. Received ongoing Vanc, Zosyn, and
Micofungin. Also received a course of acyclovir and
pentaminidine nebulizer as HSV and PCP prophylaxis,
respectively. Induced sputums were collected multiple times but
cultures were consistently negative, apart from one sputum
culture growing yeast (subsequently negative). He did have
positive beta-glucan and galactomannan labs but these were
difficult to interpret as pt was on zosyn at the time, which can
make these labs falsely positive. The patient became acutely
hypoxic on his most recent stay in the [**Hospital Unit Name 153**] after an episode of
emesis. CXR was concernign for aspiration, and the patient's
antibiotic coverage was broadened to include meorpenem.
.
#GVHD: Patient has suspected intestinal GVHD, with copious
volume (100cc/hour) guaiac-negative liquid stool. Antibiotic
therapy for C diff was started prophylactically. Repletion with
D5 1/2 NS with 20 mEq KCl and 20 mEq HCO3- was begun at 100
cc/hour to make up for his diarrheal losses. This was
discontinued when pt became fluid overloaded with bibasilar
crackles and elevated JVD. Given presentation with large-volume
liquid stools and cultures negative for shigella, campylobacter,
yersinia, and c diff toxin, he was started on stress-dose
solumedrol 60mg [**Hospital1 **], made NPO and TPN was initiated for bowel
rest. Loperamide and opium tincture were startedv for
symptomatic control. CT scan of the abdomen showed submucosal
fat-deposition and/or edema involving a long segment of
mid-to-distal small bowel and ascending colon, consistent with
graft-versus-host disease. CellCept was started with minimal
improvement in diarrhea; stool volume only slowed noticeably
after starting twice-weekly etanercept during initial transfer
to the [**Hospital1 3242**] service. Aside from the patient's diarrhea, he had no
other manifestations of GvHD. He was continued on
Methylprednisolone, CellCept, and etancercept during his second
stay in the ICU, plus prophylactic Flagyl given risk of
developing C diff colitis.
.
#AML: The patient was followed by the [**Hospital1 3242**] service during his
stay in the [**Hospital Unit Name 153**]. Daily CBCs with diff were drawn daily. Blasts
were present on the differential throughout the patient's stay
in the [**Hospital Unit Name 153**]. [**Hospital Unit Name 3242**] again was actively involved in the management
of the patient's underlying leukemia. He was on allupurinol,
hydroxyurea and ursodiol during his first ICU stay but these
were held per [**Hospital Unit Name 3242**] recommendations upon his second ICU admission.
No active chemotherapy was begun given the patient's clinical
status.
.
#ARF: On admission, the patient had a normal sCr. However, while
in the [**Hospital Unit Name 153**], the patient developed ARF. Urine lytes suggested a
pre-renal state [**3-13**] profuse diarrhea. Renal was consulted. A
urine sediment also showed crystals on the urine which were
concerning given that the patient was on acyclovir for HSV
prophylaxis. Acyclovir was stopped. The patient also had an
elevated urine Protein:Creatine ratio of 0.3, suggesting an
intrarenal cause for the patient's ARF. His creatinine gradually
rose to 3.8, with no improvement despite fluid resuscitation and
TPN. Renal consult service followed and determined not to pursue
dialysis given overall clinical picture, thrombocytopenia, and
family preference.
.
#AMS: The patient acutely developed waxing/[**Doctor Last Name 688**] mental status,
occasionally oriented only to person and sometimes moaning in
response to questions. Early during admission, given his
thrombocytopenia, he had a head CT to evaluation for
intracranial bleed but this was not seen. At time of transfer
from the ICU to [**Doctor Last Name 3242**], following IVF administration, his mental
status had improved and he was able to keep converation and
answer questions appropriately. However, during ICU readmission
his mental status was once again low-baseline, moaning with
exhalation and unable to communicate with ICU staff.
.
#Afib with RVR: The patient initially presented to the [**Hospital Unit Name 153**] in
Afib with RVR. The patient's rate was mostly sinus tachycardia,
but would intermittently convert to atrial fibrillation or
atrial flutter. He was started on oral diltiazem 30mg QID; rate
was eventually controlled on low-dose metoprolol. For episodes
of sinus tachycardia, the patient received 1L boluses of fluid
in the setting of his fluid losses from diarrhea. For episodes
of atrial fibrillation or atrial flutter,
he patient intermittently received IV diltiazem or metoprolol.
.
#Neutropenia: On neutropenic precautions for absolute
neutropenia on admission but developed only low-grade
temperatures. Antibiotics as above. To review: initially given
Vancomycin/Zosyn for possible neutropenic fever with a suspected
pulmonary source. And given recent history of cdiff and copious
diarrhea, PO vancomycin and IV flagyl started as empiric therapy
for severe C diff and continued after stool cultures negative
x3. Prophylaxis with acyclovir and fluconazole continued;
fluconazole later switched to Micafungin. Acyclovir had to be
stopped in the setting of ARF with urine showing crystals. ID
was also consulted. They recommended adding on Tobramycin for
ESBL coverage to the patient's antibiotic regimen. Tobramycin
was never added in part due to the patient's acute renal failure
and his clinical picture: he did not develop fever. ANCs
steadily rose throughout his first ICU stay; during the second
ICU admission labs showed an elevated white count without
neutropenia.
.
#Thrombocytopenia: Secondary to leukemia. Platelets monitored
daily with CBCs. Patient had a transfusion threshold of >10. He
received three platelet transfusions (on [**8-16**] and [**8-26**] and [**9-2**]).
No signs of active bleeding.
.
#Anemia: Secondary to leukemia. Hgb/Hct monitored with daily
labs. Red cell transfusion threshold 25. He received two PRBC
transfusions ([**8-13**], [**8-27**]).
.
#Goals of care: Frequently family meetings were held with family
and, when his mental status allowed, with the patient himself.
Health care proxy is brother [**Name (NI) **] [**Name (NI) 6483**]; mother [**Name (NI) 13788**]
[**Name (NI) 6483**] also very involved in pt's care (and is documented in
OMR as being HCP). [**Name (NI) 3242**] service participated in these meetings.
Family (brother and mother) changed pt's code status from Full
Code to DNR/DNI on [**2176-9-1**] in context of worsening unexplained
hypoxia on broad-spectrum antibiotics, poor mental status, and
worsening leukemia prognosis.

Medications on Admission:
not applicable

Discharge Medications:
deceased

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased

Discharge Condition:
deceased

Discharge Instructions:
not applicable

Followup Instructions:
not applicable
{'Complications of transplanted bone marrow,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Acidosis,Candidiasis of mouth,Other secondary thrombocytopenia,Neutropenia, unspecified,Atrial fibrillation,Acute bronchiolitis due to other infectious organisms,Graft-versus-host disease, unspecified,Diarrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fever presenting with conditions classified elsewhere,Personal history of tobacco use,Hypoxemia,Anemia in neoplastic disease,Do not resuscitate status,Unspecified essential hypertension'}


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: Diarrhea, SOB, and cough

PRESENT ILLNESS: Mr. [**Known lastname 6483**] is a 52 year old with a PMHx s/f AML s/p SCT
(recently completed dapogen, still on hydroxyurea), C.diff,
babesosis, and HTN who presented today to the ED with a chief
complaints of fevers, diarrhea, and  sob. He was in his usual
state of health until yesterday afternoon when he began to
experience copious liquid stools which kept him up for [**2-12**] of
the night, and experience subjective fevers. He also noted a dry
cough which has been worsening overnight and dyspnea. He also
noted one episode of nonbilious/nonbloody emesis. Prior to this
exacerbation, he denies any fevers/chills/cough/SOB.
.
In the ED, initial vs were: T:102.0 (by temporal artery scanner)
P:128 BP:109/64 R:40 O2 sat:94% RA. Patient was given 1gm of
tylenol, 3L NS, vancomycin and zosyn. ABG demonstrated
7.51/31/58/26 on RA.

MEDICAL HISTORY: AML s/p SCT on [**5-17**], with relapse
C diff colitis in [**3-22**] on chronic oral vancomycin (negative pcr
in may)
HTN
Previous babesosis

MEDICATION ON ADMISSION: not applicable

ALLERGIES: Cefepime / Levaquin

PHYSICAL EXAM: Initial ICU Admission Exam [**2176-8-12**]:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: expiratory wheezing on R lower fields, no  rales,
occassional ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no CVA tenderness
Ext: L wrist in cast s/p fracture, warm, well perfused, 2+
pulses, no clubbing, cyanosis or edema

FAMILY HISTORY: Cousin: Leukemia s/p transplant
Father: lung cancer

SOCIAL HISTORY: Social History:
- Tobacco:  quit 5 years ago, previous 30 pack-year
- Alcohol: none
- Illicits:  None
- Previously stocked shelves at [**Date Range **]'s. Currently not working. 

### Response:
{'Complications of transplanted bone marrow,Acute kidney failure with lesion of tubular necrosis,Pneumonia, organism unspecified,Acute myeloid leukemia, without mention of having achieved remission,Acidosis,Candidiasis of mouth,Other secondary thrombocytopenia,Neutropenia, unspecified,Atrial fibrillation,Acute bronchiolitis due to other infectious organisms,Graft-versus-host disease, unspecified,Diarrhea,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Fever presenting with conditions classified elsewhere,Personal history of tobacco use,Hypoxemia,Anemia in neoplastic disease,Do not resuscitate status,Unspecified essential hypertension'}
