CHIEF COMPLAINT: renal failure

PRESENT ILLNESS: 53 year old man with h/o AML s/p allo cord transplant (now day
+516) complicated by chronic GVHD with arthritis, BOOP, who
presented to the BMT floor from clinic with worsening renal
function(2.3) and hyperkalemia, and worsening odynophagia on
[**2185-4-20**].

MEDICAL HISTORY: Past Medical History (taken from previous notes)
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+334. Day 100 bone marrow biopsy showed no
siagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy

MEDICATION ON ADMISSION: -Acyclovir 400 [**Hospital1 **]
-Carvedilol 12.5 [**Hospital1 **]
-Cyanocobalamin 1000mcg IM 1xmonth
-Nexium 20mg PO BID
-Furosemide 40mg PO BID
-Gabapentin 300 cap 3caps tid
-Insulin Novolog 4xday, sliding scale
-Glargine 10u qhs
-Lisinopril 5mg daily
-Montelukast 10mg PO daily
-Morphine 15mg PO q6-8 hrs prn pain
-MMF 500mg TID
-Nitro 0.3mg tab SL
-zofran 4-8mg q8 hrs prn nausea
-Oxycodone SR 10mg PO BID
-Prednisone 20mg daily
-Bactrim 800-160 MWF
-Voriconazole 200mg tab, 1.5 tab q12h
-AA Magnesium Sulfate OTC 1tab daily
-Vit C 500mg tab daily
-Aspirin 81 mg tab Enteric coated
-Cal Carb 1000mg tab [**Hospital1 **]
-Vit D3 400u daily
-Hexavitamin 1 tab daily
-Miconazole 2% powder to affected areas [**Hospital1 **]
-Thiamine 50mg PO daily
-Docusate 100mg PO BID
-Senna 1 tab [**Hospital1 **] prn

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: GENERAL: Middle-aged, Cushingoid, overweight man in NAD
HEENT: EOMI, PERRLA, mucous membranes moist, no cervical LAD, no
JVD, neck supple w/out tenderness
CARDIAC: RRR no m/g/r, S1, S2 nl
CHEST: kyphotic
LUNG: few bilateral crackles at bases, no wheezes, rhonchi
ABDOMEN: obese, soft, NT, ND, unable to appreciate HSM [**2-14**] body
habitus, no rebound or guarding
EXT: warm, + bilateral 2+ pitting edema to knees, DP+
bilaterally, no cyanosis - L elbow medial epicondyle tenderness
w/ effusion, no joint erythema or effusion
NEURO: CNII-XII intact, motor symmetric strength, hyperesthetic
sensation bilateral LE/feet, no evidence of toe nail erythema
DERM: ecchymoses on abdomen [**2-14**] insulin, no other lesions.
Psych: Mood liabile, affect appropriate, intermittently tearing
up to labs draws, movement to ICU

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 econdary to AML
and GVHD. Lives with wife, teenage son. Past tobacco use, but
non currently.
Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Chronic graft-versus-host disease,Other transfusion reaction,Cushing's syndrome,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Abnormal involuntary movements,Syncope and collapse,Tension headache,Esophageal reflux,Other specified gastritis, without mention of hemorrhage,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified hereditary and idiopathic peripheral neuropathy,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Pure hypercholesterolemia,Personal history of tobacco use,Constipation, unspecified,Family history of ischemic heart disease,Family history of diabetes mellitus,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
Acute kidney failure NOS,Ac myl leuk wo achv rmsn,Chronc graft-vs-host dis,Transfusion reaction NEC,Cushing's syndrome,Hyperpotassemia,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Alveol pneumonopathy NEC,Abn involun movement NEC,Syncope and collapse,Tension headache,Esophageal reflux,Oth spf gstrt w/o hmrhg,Adv eff corticosteroids,Idio periph neurpthy NOS,Adv eff antineoplastic,Pure hypercholesterolem,History of tobacco use,Constipation NOS,Fam hx-ischem heart dis,Fam hx-diabetes mellitus,Meth resis Staph carrier
Admission Date:  [**2185-4-20**]              Discharge Date:   [**2185-4-23**]

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

Service: MEDICINE

Allergies:
Benadryl Allergy / Ambisome / Flomax

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
renal failure

Major Surgical or Invasive Procedure:
None


History of Present Illness:
53 year old man with h/o AML s/p allo cord transplant (now day
+516) complicated by chronic GVHD with arthritis, BOOP, who
presented to the BMT floor from clinic with worsening renal
function(2.3) and hyperkalemia, and worsening odynophagia on
[**2185-4-20**].

On arrival to the BMT floor, as he was transitioning into the
bed, he became mom[**Name (NI) 11711**] unresponsive to verbal stimuli and
physical stimuli. No jerking movements or incontience were
noted. A code blue was called. On arrival of the code team, BP
124/80, Hr 70s, satting 100% on 5L NC. He was responsive to
verbal stimuli and answering questions appropriately. He does
not recall only seconds of the entire episode; wife notes that
his eyes were closed. 1 amp of D50, 10units regular insulin, and
abuterol nebs were given for known hyperkalemia. An EKG was
obtained which showed isolated peaked T waves. CXR showed no
interval change when accounted for technique from prior in the
day. During this time, he did experience a headache that was
located in the forhead, temples and described as a pressure /
squeeze that he has experienced with prior tension headaches.
He was then transferred to the [**Hospital Unit Name 153**] for further cardiac
monitoring. During this time, he was also noted to have some
tremors in hands and legs, but this was not associated with any
loss of consciousness or loss of consciousness. These episodes
will occur for only seconds at a time and tend to occur when he
is holding objects in his hands / intention tremor. He has not
had formal workup for this, but there was no clear etiology to
this tremor (which has been present intermittently over the past
2 years) to date.
His wife also relays the presence of intermittent episodes of
unresponsiveness over the past x2 years ago at a frequency of
1-2x per week lasting only seconds at a time. This has not been
formally evaluated to date.


Past Medical History:
Past Medical History (taken from previous notes)
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+334. Day 100 bone marrow biopsy showed no
siagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy

Social History:
Formerly worked as auto mechanic, now disabled econdary to AML
and GVHD. Lives with wife, teenage son. Past tobacco use, but
non currently.

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:
GENERAL: Middle-aged, Cushingoid, overweight man in NAD
HEENT: EOMI, PERRLA, mucous membranes moist, no cervical LAD, no
JVD, neck supple w/out tenderness
CARDIAC: RRR no m/g/r, S1, S2 nl
CHEST: kyphotic
LUNG: few bilateral crackles at bases, no wheezes, rhonchi
ABDOMEN: obese, soft, NT, ND, unable to appreciate HSM [**2-14**] body
habitus, no rebound or guarding
EXT: warm, + bilateral 2+ pitting edema to knees, DP+
bilaterally, no cyanosis - L elbow medial epicondyle tenderness
w/ effusion, no joint erythema or effusion
NEURO: CNII-XII intact, motor symmetric strength, hyperesthetic
sensation bilateral LE/feet, no evidence of toe nail erythema
DERM: ecchymoses on abdomen [**2-14**] insulin, no other lesions.
Psych: Mood liabile, affect appropriate, intermittently tearing
up to labs draws, movement to ICU


Pertinent Results:
CBC:
[**2185-4-20**] 11:11AM BLOOD WBC-5.3 RBC-2.84* Hgb-9.3* Hct-29.3*
MCV-103* MCH-32.7* MCHC-31.7 RDW-15.2 Plt Ct-101*
[**2185-4-23**] 06:10AM BLOOD WBC-2.5* RBC-2.79* Hgb-9.2* Hct-29.1*
MCV-104* MCH-33.1* MCHC-31.7 RDW-15.3 Plt Ct-88*
[**2185-4-20**] 11:11AM BLOOD Neuts-84.9* Lymphs-4.7* Monos-7.5 Eos-2.9
Baso-0
[**2185-4-23**] 06:10AM BLOOD Neuts-70.4* Lymphs-11.9* Monos-13.8*
Eos-3.7 Baso-0.2

Chemistries:
[**2185-4-20**] 11:11AM BLOOD Glucose-156* UreaN-91* Creat-2.3* Na-137
K-5.5* Cl-103 HCO3-22 AnGap-18
[**2185-4-20**] 07:49PM BLOOD Glucose-108* UreaN-74* Creat-2.1* Na-136
K-4.8 Cl-126* HCO3-18* AnGap--3*
[**2185-4-21**] 04:18AM BLOOD Glucose-112* UreaN-83* Creat-2.2* Na-137
K-5.7* Cl-108 HCO3-23 AnGap-12
[**2185-4-21**] 08:18AM BLOOD Na-139 K-6.8* Cl-109*
[**2185-4-21**] 08:18AM BLOOD Na-142 K-5.6* Cl-110*
[**2185-4-21**] 02:12PM BLOOD Na-140 K-5.7* Cl-108
[**2185-4-22**] 05:14AM BLOOD Glucose-88 UreaN-72* Creat-2.0* Na-142
K-4.8 Cl-108 HCO3-24 AnGap-15
[**2185-4-23**] 06:10AM BLOOD Glucose-88 UreaN-61* Creat-1.9* Na-142
K-4.0 Cl-108 HCO3-26 AnGap-12

LFTs:
[**2185-4-20**] 11:11AM BLOOD ALT-35 AST-28 LD(LDH)-246 AlkPhos-189*
TotBili-0.2
[**2185-4-21**] 04:18AM BLOOD ALT-33 AST-27 CK(CPK)-17* AlkPhos-168*
TotBili-0.1

Cardiac Enzymes:
[**2185-4-20**] 06:29PM BLOOD CK-MB-3 cTropnT-<0.01
[**2185-4-21**] 04:18AM BLOOD CK-MB-3 cTropnT-<0.01

[**2185-4-20**] 11:11AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.6
[**2185-4-23**] 06:10AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.2

Antibody Titers:
[**2185-4-20**] 11:11AM BLOOD IgG-412* IgA-54* IgM-17*

ABG:
[**2185-4-20**] 06:30PM BLOOD Type-ART pO2-134* pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Intubat-NOT INTUBA
[**2185-4-20**] 06:30PM BLOOD Glucose-442* Lactate-1.7 Na-132* K-6.5*
Cl-100
[**2185-4-20**] 06:30PM BLOOD freeCa-1.13

Blood and urine cultures from [**4-20**] negative.

Head CT ([**4-21**]):
IMPRESSION: No acute intracranial hemorrhage. Paranasal sinus
disease in the left maxillary and sphenoid sinus, as described
above.

CXR: ([**4-21**]) :
FINDINGS: Allowing for differences in technique there has been
no interval
change in appearance of the chest since the recent study with no
acute
cardiopulmonary abnormality identified.


Brief Hospital Course:
Summary of Hospital Course: 53 year old man with h/o AML s/p
allo cord transplant (day +516 on admission) complicated by
chronic GVHD with arthritis, BOOP, who now presents to clinic
with acute on chronic renal failure. Hospital course complicated
by syncopal episode the day of admission resulting in Code Blue
and hyperkalemia, requiring brief ICU admission.

#Syncope: Patient had syncopal episode the day of admission,
where he was unresponsive for ~1 minute while lying flat.
Unclear etiology, possible due to orthostatic hypotension (noted
to have orthostatic physiology in the ICU and on the floor) vs
arrythmia vs seizure activity. Of note, (per wife), patient has
had many of these episodes recently (~2 years, ~1-2 episodes per
week). Patient denied any heralding symptoms and was not
post-ictal afterwards, but was noted to have a resting tremor in
the MICU. His history of tremor is not consistent wtih seizure
activity. It appears to be an intention tremor that gets worse
when holding on to objects and is low in amplitude while high in
frequency, bilateral and not associated with change in
consciousness or incontinence.

Noted to be hyperkalemic during the code, given amp D50 and 10 U
insulin peri-code and kayexalate in the ICU, with drop in
potassium down to 4.0 on discharge.   Neurology consulted on
patient who recommended EEG and possible midodrine or fluorinef
support. Held patient's lisinopril, but continued him on his
carvedilol 12.5 mg PO BID as this was recently decreased in the
setting of light headedness/dizziness by his cardiologist on
[**3-21**], although informed him not to take the medication if he had
any pre-syncopal symptoms. Medication can be decreased at the
discretion of his cardiologist. Patient had no further syncopal
episodes or events on telemetry in the ICU or on the floor.
Neurology was consulted who recommended an EEG, possible blood
pressure support with midodrine or fluorinef, at the discretion
of the patient's outpatient oncologist and nephrologist. Was
noted to not have any telemetry events or syncopal events while
ambulating, with appropriate increase in pulse and blood
pressure. and requested to be discharged with outpatient syncope
work-up. Outpatient TTE, EEG, carotid U/S, and holter monitering
were arranged prior to discharge.

#Acute on chronic renal failure: Noted to have mildly elevated
Cre to 2.3 in clinic the day of admission. Creatine has
fluctuated over the past two years, with several episodes of
acute renal failure while hospitalized. Followed by nephrology
as an outpatient. Per outpatient notes, etiology of CKD thought
to be [**2-14**] ATN that has not resolved, medication effect in the
setting of bactrim, voriconazole, lisinopril, or AIN. Less
likely due to AML infiltration of kidneys (very rare) or
chemotherapy. Unlikely progressive glomerular disease given
patient only has scant proteinuria. Patient has refused renal
biopsy in the past. Baseline Cre has been 1.4-2.0 over the past
few months.  Lisinopril was held. Cellcept was decreased to
[**Telephone/Fax (3) 39636**] as GFR was ~30. Oral fluid intake encouraged. Renal
failure resolved to baseline creatinine (1.9) on discharge.
Renal did not have chance to formally consult on patient since
he requested discharge, but stated informally that they had no
further recommendations as an inpatient since he was refusing
renal biopsy, and he could be accommodated very soon in renal
clinic with his current outpatient nephrologist.

#Congestive Heart Failure: Euvolemic to mildly hypervolemic on
exam. Requested TTE as outpatient. Continued home meds including
aspirin, beta-blocker. Held ACEI due to hyperkalemia.

#AML: allo SCT +519 days. counts stable. continued prophylactic
medications. Arranged to follow up with outpatient oncologist.

#Epigastric discomfort: Gastritis, likely in setting of
prednisone. Patient has tried and failed Nexium, reporting it
has not helped his gastritis for 3 months. Relieved with
protonix, which was added to med list on discharge. Can obtain
prior authorization from PCP [**Name Initial (PRE) 5564**].

Medications on Admission:
-Acyclovir 400 [**Hospital1 **]
-Carvedilol 12.5 [**Hospital1 **]
-Cyanocobalamin 1000mcg IM 1xmonth
-Nexium 20mg PO BID
-Furosemide 40mg PO BID
-Gabapentin 300 cap 3caps tid
-Insulin Novolog 4xday, sliding scale
-Glargine 10u qhs
-Lisinopril 5mg daily
-Montelukast 10mg PO daily
-Morphine 15mg PO q6-8 hrs prn pain
-MMF 500mg TID
-Nitro 0.3mg tab SL
-zofran 4-8mg q8 hrs prn nausea
-Oxycodone SR 10mg PO BID
-Prednisone 20mg daily
-Bactrim 800-160 MWF
-Voriconazole 200mg tab, 1.5 tab q12h
-AA Magnesium Sulfate OTC 1tab daily
-Vit C 500mg tab daily
-Aspirin 81 mg tab Enteric coated
-Cal Carb 1000mg tab [**Hospital1 **]
-Vit D3 400u daily
-Hexavitamin 1 tab daily
-Miconazole 2% powder to affected areas [**Hospital1 **]
-Thiamine 50mg PO daily
-Docusate 100mg PO BID
-Senna 1 tab [**Hospital1 **] prn


Discharge Medications:
1. Acyclovir 200 mg Capsule [**Hospital1 **]: Two (2) Capsule PO Q12H (every
12 hours).
2. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO three times
a day.
3. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Prednisone 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
7. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet [**Hospital1 **]: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
9. Oxycodone 10 mg Tablet Sustained Release 12 hr [**Hospital1 **]: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
10. Morphine 15 mg Tablet [**Hospital1 **]: One (1) Tablet PO every 6-8 hours
as needed for pain.
11. Voriconazole 200 mg Tablet [**Hospital1 **]: 1.5 Tablets PO Q12H (every
12 hours).
12. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
14. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Thiamine HCl 100 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).

16. Nitroglycerin 0.3 mg Tablet, Sublingual [**Hospital1 **]: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

17. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
18. Carvedilol 12.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day: HOLD if patient loses consciousness or has systolic blood
pressure less than 100.
19. Hexavitamin     Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
20. Vitamin D-3 400 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
21. Vitamin C 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
22. Insulin Aspart 100 unit/mL Solution [**Hospital1 **]: One (1) as directed
Subcutaneous four times a day: per sliding scale.
23. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1) syringe
Subcutaneous at bedtime: 10 Units at bedtime.
24. Zofran 4 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
25. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: Two (2) Capsule PO
BID (2 times a day).
26. Mycophenolate Mofetil 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily): please administer at noon  .


Discharge Disposition:
Home

Discharge Diagnosis:
1' Diagnosis
Acute on Chronic Renal Failure
Hyperkalemia
Syncope

2' Diagnosis
Congestive Heart Failure
Hypertension
Acute Myelogenous Leukemia


Discharge Condition:
afebrile, hemodynamically stable, without syncopal episode x48
hours

Discharge Instructions:


You were admitted with a diagnosis of acute on chronic renal
failure, high potassium levels, and syncope. Your kidney
function resolved back to it's baseline, and your potassium
levels normalized with some kayexalate. We wanted to run some
lab tests to evaluate the reason for your syncope, but you felt
well and wanted to go home and have the testing done as an
outpatient.

Please take your medications as directed
- Please hold your lisinopril as this medication can cause
elevated potassium levels. Please restart at the discretion of
your PCP or cardiologist.
- Your Cellcept was decreased as noted on the medication list.
- We started you on protonix for your heart burn in place of the
Nexium. You may need prior authorization from your primary care
physician or oncologist for this medications.

Please return to the hospital if you have fever > 100.4, any
further fainting episodes, chest pain, palpitations, or any
other symptoms not listed here concerning enough to warrant
physician [**Name Initial (PRE) 2742**].

Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 5-HEM ONC 7F [**Name Initial (NameIs) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2185-4-25**] 2:00
Provider: [**Name10 (NameIs) 3310**],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-7F
Date/Time:[**2185-4-25**] 2:00

with your cardiologist as an outpatient. The phone number is
[**Telephone/Fax (1) 62**].

with renal as an outpatient. Please call ([**Telephone/Fax (1) 773**] to make
an appointment.

to get your trans-thoracic echocardiogram, your carotid
ultrasound, your holter monitoring, and your EEG. They have all
been ordered and your outpatient oncologist should follow up on
the results.
- Please call [**Telephone/Fax (1) 327**] to schedule your carotid ultrasound.
- Please call [**Telephone/Fax (1) 62**] to schedule your trans-thoracic
ultrasound.
- Please call [**Telephone/Fax (1) 3104**] to schedule your holter monitoring.
- Please call [**Telephone/Fax (1) 5285**] to schedule your EEG.



Completed by:[**2185-4-25**]
{"Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Chronic graft-versus-host disease,Other transfusion reaction,Cushing's syndrome,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Abnormal involuntary movements,Syncope and collapse,Tension headache,Esophageal reflux,Other specified gastritis, without mention of hemorrhage,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified hereditary and idiopathic peripheral neuropathy,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Pure hypercholesterolemia,Personal history of tobacco use,Constipation, unspecified,Family history of ischemic heart disease,Family history of diabetes mellitus,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus"}


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: renal failure

PRESENT ILLNESS: 53 year old man with h/o AML s/p allo cord transplant (now day
+516) complicated by chronic GVHD with arthritis, BOOP, who
presented to the BMT floor from clinic with worsening renal
function(2.3) and hyperkalemia, and worsening odynophagia on
[**2185-4-20**].

MEDICAL HISTORY: Past Medical History (taken from previous notes)
1) AML, M5b diagnosed 07/[**2182**].
- Received induction chemotherapy with 7 + 3(ARA-C and
idarubicin)-[**2182-7-23**] until [**2182-8-22**]. The patient achieved a
CR after this therapy.
- High-dose ARA-C x 2 cycles from [**2182-8-28**] until [**2182-9-27**].
- Pt found to have relapsing dz and reinduced with Mitoxantrone
and Ara-C [**Date range (1) 39624**]. Pt was found to have relapsing dz on
bone marrow bx [**2183-9-2**] with 16% blasts, then was admitted
between [**Date range (1) 39625**] for Mitoxantrone, Etopiside and Cytarabine.
- s/p myeloablative sequential unrelated double cord blood
transplant, now D+334. Day 100 bone marrow biopsy showed no
siagnostic morphologic features of involvement by acute
leukemia, with cytogenetics revealing karyotype 46XX, consistent
with that of female donor.
2) hepatic insufficiency due to secondary hemochromatosis and
steatosis
3) Aspergillosis of the sinus/nares on voriconazole.
4) Bacillary angiomatosis
5) Acute appendicitis deep into his nadir during transplant that
was successfully treated with daptomycin, meropenem, levofloxain
and metronidazole
6) Incidental HHV6 IgG-positive, without disease
7) Hx of post chemo-induced cardiomyopathy; TTE [**6-19**] with
preserved EF.
8) Sarcoid - diagnosed in [**2172**], received intermittent steroids
9) GERD
10) HTN
11) Hypercholesterolemia
12) s/p cholecystectomy in [**6-/2180**] complicated by sinus
tract to the abdominal wall
13) Hepatic and splenic microabscesses/candidiasis ([**8-/2182**])
14) BOOP requiring extended ICU/hospital course in [**3-/2184**] and
home oxygen
15) Peripheral neuropathy

MEDICATION ON ADMISSION: -Acyclovir 400 [**Hospital1 **]
-Carvedilol 12.5 [**Hospital1 **]
-Cyanocobalamin 1000mcg IM 1xmonth
-Nexium 20mg PO BID
-Furosemide 40mg PO BID
-Gabapentin 300 cap 3caps tid
-Insulin Novolog 4xday, sliding scale
-Glargine 10u qhs
-Lisinopril 5mg daily
-Montelukast 10mg PO daily
-Morphine 15mg PO q6-8 hrs prn pain
-MMF 500mg TID
-Nitro 0.3mg tab SL
-zofran 4-8mg q8 hrs prn nausea
-Oxycodone SR 10mg PO BID
-Prednisone 20mg daily
-Bactrim 800-160 MWF
-Voriconazole 200mg tab, 1.5 tab q12h
-AA Magnesium Sulfate OTC 1tab daily
-Vit C 500mg tab daily
-Aspirin 81 mg tab Enteric coated
-Cal Carb 1000mg tab [**Hospital1 **]
-Vit D3 400u daily
-Hexavitamin 1 tab daily
-Miconazole 2% powder to affected areas [**Hospital1 **]
-Thiamine 50mg PO daily
-Docusate 100mg PO BID
-Senna 1 tab [**Hospital1 **] prn

ALLERGIES: Benadryl Allergy / Ambisome / Flomax

PHYSICAL EXAM: GENERAL: Middle-aged, Cushingoid, overweight man in NAD
HEENT: EOMI, PERRLA, mucous membranes moist, no cervical LAD, no
JVD, neck supple w/out tenderness
CARDIAC: RRR no m/g/r, S1, S2 nl
CHEST: kyphotic
LUNG: few bilateral crackles at bases, no wheezes, rhonchi
ABDOMEN: obese, soft, NT, ND, unable to appreciate HSM [**2-14**] body
habitus, no rebound or guarding
EXT: warm, + bilateral 2+ pitting edema to knees, DP+
bilaterally, no cyanosis - L elbow medial epicondyle tenderness
w/ effusion, no joint erythema or effusion
NEURO: CNII-XII intact, motor symmetric strength, hyperesthetic
sensation bilateral LE/feet, no evidence of toe nail erythema
DERM: ecchymoses on abdomen [**2-14**] insulin, no other lesions.
Psych: Mood liabile, affect appropriate, intermittently tearing
up to labs draws, movement to ICU

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 econdary to AML
and GVHD. Lives with wife, teenage son. Past tobacco use, but
non currently. 

### Response:
{"Acute kidney failure, unspecified,Acute myeloid leukemia, without mention of having achieved remission,Chronic graft-versus-host disease,Other transfusion reaction,Cushing's syndrome,Hyperpotassemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Abnormal involuntary movements,Syncope and collapse,Tension headache,Esophageal reflux,Other specified gastritis, without mention of hemorrhage,Adrenal cortical steroids causing adverse effects in therapeutic use,Unspecified hereditary and idiopathic peripheral neuropathy,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Pure hypercholesterolemia,Personal history of tobacco use,Constipation, unspecified,Family history of ischemic heart disease,Family history of diabetes mellitus,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus"}
