CHIEF COMPLAINT: Neutropenic fever and Hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is 50 yo F with AML s/p allo-BMT in [**2110**], now with
relapsed AML awaiting repeat SCT, currently s/p high-dose ARA-C
on [**11-29**], who presented to [**Hospital 7188**] Hospital with diarrhea (on
Flagy ~1 week) and fatigue. At the OSH, she was found to be
hypotensive with SBP's 60's-70's and had temp of 100.3. She got
2-3L of IVF, meropenem, vancomycin, and was tran, and was then
transferred to the [**Hospital1 18**] ED. In the ED, she received 1L NS, and
SBP improved from the 70's to low 100's. She was admitted to the
[**Hospital Unit Name 153**]. She was continued on meropenem, vanco, given 2L NS and
started on stress dose steroids. She spiked to 101.7 so blood
cultures were again drawn and she was started on Flagyl for
possible Cdiff. Blood Cx from OSH came back positive for coag
negative staph. Her blood pressures improved and her temperature
curve decreased until prior to transfer to the floor when she
was 101.
She remained HD stable so was transferred.
.
At the time of interview, the patient felt hot, sweaty, and
fatigued. She denied chills. She denied chest pain, shortness of
breath, cough. She noted only 2 episodes of diarrhea with
lomotil. She denied melena, hematochezia. She denied HA, sinus
congestion. She denied dysuria, urinary urgency or frequency.
.
ROS: otherwise negative. no lightheadedness, palpitations. no
mouth pain. no myalgia/arthralgia.
.
ONC HISTORY:
Acute myelogenous leukemia - status post allogenic transplant
[**2110-8-4**]: 5 of 6 matched family member (father) allogenic BMT.
Mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of AML. MEC protocol started [**2114-7-29**]. She
tolerated the chemo well. Of note she was found to have anti HLA
B7 and B27 antibodies so required matched platelet transfusions
during her nadir. She underwent DLI on [**2114-9-4**]. She relapsed with
cytogenetically different AML (monosomy 7). She then underwent
reinduction with MEC in [**10-10**]. She received high-dose ARA-C
starting [**2114-11-29**]. She currently has a matched donor and is
awaiting transplant.

MEDICAL HISTORY: - Allergic rhinitis
- Depression
- Right-sided hydronephrosis secondary to fibroid
uterus/retroperitneal fibrosis thought secondary to
paraneoplastic syndrome, status post stent [**6-9**], removed [**8-9**]

MEDICATION ON ADMISSION: Fluconazole 200mg q12h
Acyclovir 400mg q12h
Citalopram 20mg qd
Methylphenidate 10mg qam
Loratadine 10mg qd
Olanzapine 5mg [**Hospital1 **] prn
Prednisone 30mg qd
Levoflox 500mg qd (day #[**9-13**])
Beconase AQ 42mcg [**2-5**] sprays prn
Loperamide 2mg q4h prn
Meropenem (reportedly had one dose at OSH)

ALLERGIES: Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol /
Vicodin / Percocet

PHYSICAL EXAM: Vitals: T 99.4 BP 108/68 HR 100 RR 18 O2 99% 1L NC
Gen: Sleepy, nontoxic, flushed
HEENT: PERRL. sclera anicteric. MMM. No oral lesions.
Neck: JVD 7 cm. No LAD.
CV: tachycardic, regular, nl s1, s2, no m/r/g
Resp: CTAB
Abd: soft, NTND, +BS, no rebound/guarding. L nephrostomy tube in
place - no drainage, d/c or tenderness.
Ext: no c/c/e
Skin: no rash
Neuro: A&Ox3

FAMILY HISTORY: Both parents living. Mother with hypertension, myocardial
infarction, systemic lupus. Father (donor) with hypertension,
recently had myocardial infarction. Siblings with hypertension.

SOCIAL HISTORY: Married, lives with her husband (who is a nurse) and three
children ages 14, 9, 7. Worked as a controller. No tobacco or
alcohol use.
Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Septic shock,Acute myeloid leukemia, without mention of having achieved remission,Volume depletion, unspecified,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other ureteric obstruction
React-oth vasc dev/graft,Staphylcocc septicem NEC,Severe sepsis,Septic shock,Ac myl leuk wo achv rmsn,Volume depletion NOS,Diarrhea,Adv eff antineoplastic,Ureteric obstruction NEC
Admission Date:  [**2114-12-15**]              Discharge Date:   [**2114-12-26**]

Date of Birth:  [**2064-6-13**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol /
Vicodin / Percocet

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Neutropenic fever and Hypotension

Major Surgical or Invasive Procedure:
Peripherally Inserted Central Venous Catheter removal.
Tunneled central venous line insertion.
Nephrostogram and nephrostomy tube replacement/capping.


History of Present Illness:
Ms. [**Known lastname **] is 50 yo F with AML s/p allo-BMT in [**2110**], now with
relapsed AML awaiting repeat SCT, currently s/p high-dose ARA-C
on [**11-29**], who presented to [**Hospital 7188**] Hospital with diarrhea (on
Flagy ~1 week) and fatigue. At the OSH, she was found to be
hypotensive with SBP's 60's-70's and had temp of 100.3. She got
2-3L of IVF, meropenem, vancomycin, and was tran, and was then
transferred to the [**Hospital1 18**] ED. In the ED, she received 1L NS, and
SBP improved from the 70's to low 100's. She was admitted to the
[**Hospital Unit Name 153**]. She was continued on meropenem, vanco, given 2L NS and
started on stress dose steroids. She spiked to 101.7 so blood
cultures were again drawn and she was started on Flagyl for
possible Cdiff. Blood Cx from OSH came back positive for coag
negative staph. Her blood pressures improved and her temperature
curve decreased until prior to transfer to the floor when she
was 101.
She remained HD stable so was transferred.
.
At the time of interview, the patient felt hot, sweaty, and
fatigued. She denied chills. She denied chest pain, shortness of
breath, cough. She noted only 2 episodes of diarrhea with
lomotil. She denied melena, hematochezia. She denied HA, sinus
congestion. She denied dysuria, urinary urgency or frequency.
.
ROS: otherwise negative. no lightheadedness, palpitations. no
mouth pain. no myalgia/arthralgia.
.
ONC HISTORY:
Acute myelogenous leukemia - status post allogenic transplant
[**2110-8-4**]: 5 of 6 matched family member (father) allogenic BMT.
Mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of AML. MEC protocol started [**2114-7-29**]. She
tolerated the chemo well. Of note she was found to have anti HLA
B7 and B27 antibodies so required matched platelet transfusions
during her nadir. She underwent DLI on [**2114-9-4**]. She relapsed with
cytogenetically different AML (monosomy 7). She then underwent
reinduction with MEC in [**10-10**]. She received high-dose ARA-C
starting [**2114-11-29**]. She currently has a matched donor and is
awaiting transplant.


Past Medical History:
- Allergic rhinitis
- Depression
- Right-sided hydronephrosis secondary to fibroid
uterus/retroperitneal fibrosis thought secondary to
paraneoplastic syndrome, status post stent [**6-9**], removed [**8-9**]

- Left-sided hydronephrosis, status post nephrostomy tube
placement [**2114-10-4**]
- History of Lactobacillus bacteremia treated with Meropenem
during admission [**Date range (3) 48091**]
- Gastroesophageal reflux disease
- Chronic fatigue


Social History:
Married, lives with her husband (who is a nurse) and three
children ages 14, 9, 7. Worked as a controller. No tobacco or
alcohol use.


Family History:
Both parents living. Mother with hypertension, myocardial
infarction, systemic lupus. Father (donor) with hypertension,
recently had myocardial infarction. Siblings with hypertension.

Physical Exam:
Vitals: T 99.4 BP 108/68 HR 100 RR 18 O2 99% 1L NC
Gen: Sleepy, nontoxic, flushed
HEENT: PERRL. sclera anicteric. MMM. No oral lesions.
Neck: JVD 7 cm. No LAD.
CV: tachycardic, regular, nl s1, s2, no m/r/g
Resp: CTAB
Abd: soft, NTND, +BS, no rebound/guarding. L nephrostomy tube in
place - no drainage, d/c or tenderness.
Ext: no c/c/e
Skin: no rash
Neuro: A&Ox3


Pertinent Results:
[**2114-12-25**] 12:00AM BLOOD WBC-1.6* RBC-3.46* Hgb-10.5* Hct-30.1*
MCV-87 MCH-30.3 MCHC-34.8 RDW-15.9* Plt Ct-91*
[**2114-12-25**] 12:00AM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-10*
[**2114-12-25**] 07:00AM BLOOD PT-12.8 PTT-89.2* INR(PT)-1.1
[**2114-12-25**] 12:00AM BLOOD Gran Ct-1270*
[**2114-12-24**] 12:05AM BLOOD Gran Ct-1260*
[**2114-12-23**] 12:10AM BLOOD Gran Ct-1090*
[**2114-12-25**] 12:00AM BLOOD Glucose-210* UreaN-16 Creat-0.5 Na-139
K-4.0 Cl-99 HCO3-29 AnGap-15
.
Percutaneous Nephrostogram-
Left-sided nephrostography was performed over-the-guide wire,
which depicted a normal right-sided pelvocaliceal tree. The left
ureter is seen to be patent to the urinary bladder. No
intraluminal filling defect is seen. The caudal third of the
ureter demonstrates a moderate segmental stenosis and lateral
displacement of the course of the ureter seemingly draped along
a mass located medial to the lower third of the ureters course.
The upper two thirds of the ureter appears unremarkable.

Based upon the nephrostogram obtained, decision was made to
exchange the nephrostomy tube. The preexistent tube was then
removed over the guidewire leaving the guidewire in situ in
exchanged for a new 8-French nephrostomy tube. The retention
pigtail was formed within the left renal pelvis and locked in
place. The catheter was secured using an 0-silk retention suture
at the skin entry site, reinforced with an 8-French StatLock
device. The puncture site in the drainage catheter was dressed
with drain sponges, overlaid with Tegaderm transparent
semi-occlusive dressing patches. The estimated blood loss was
minimal. No complications were encountered.

The catheter was capped and left in place.

IMPRESSION.
1. Segmental stenosis of caudal [**2-6**] of left ureter. No
obstruction of the left ureter is observed.
2. Status post over-the-wire exchange of left-sided 8-French
nephrostomy tube, which was left capped.
3. No hydronephrosis.


Brief Hospital Course:
Mrs. [**Known lastname **] is a 50 yo woman with AML who is s/p allogenic BMT
five years ago, and presented recently with a donor cell AML and
is s/p reinduction with MEC and then HIDAC on [**11-29**] who was
admitted with hypotension and gram positive sepsis.
.
#) Hypotension/[**Name (NI) 15305**] Pt was admitted with SBP's in low 80's
responsive to IV fluid boluses. She was admitted to the [**Hospital Ward Name 1826**]
Intensive Care Unit for close monitoring of her volume status.
Given the patient's chronic steroid use and hypotension she was
started on stress dose steroids for relative adrenal
insufficiency. Her symptoms of diarrhea and abdominal pain
raised suspicion for an intrabdominal source, however her R PICC
line was notably painful and erythematous and therefore thought
to be the most likely source of infection. Her right axillary
vein PICC line was removed on admission. And she was started on
Vancomycin IV Serial blood cultures later grew coagulase
positive Staphylococcus sp sensitive to vancomycin. She was
transferred to the BMT floor where an upper extremity doppler
ultrasound revealed total occlusion of the axillary vein
extending into the cephalic vein. The patient was transfused HLA
matched platelets for goal greater than 50,000 and
anticoagulated with heparin gtt. She was continued on vancomycin
IV after reviewing senstivities and speciation data. She
conituned to have fevers to 103 thought secondary to poor
antibiotic penetration into the infected thrombus. Her
antifungal coverage was broadened to voriconazole. TTE was
obtained and did not reveal any valvular vegetations. Once
afebrile for 48hrs she was switched to PO linezolid. She was
changed back to fluconazole for antifungal prophylaxis.
.
#) Nephrostomy-
Extensive discussion between providers of risks and benefits of
nephrostomy tube going into transplant. Etiology of ureteral
obstruction was thought secondary to fibroid uterus vs.
retroperitoneal fibrosis as paraneoplastic syndrome. Urology
consultation recommended leaving the nephrostomy in place. Prior
to discharge, a nephrostogram revealed caudal stenosis, and was
the tube was capped and left in place. Pt tolerated capping of
tube overnight and was discharged with instruction that if she
tolerated the capping that it could be removed in 48-72hrs at
the discretion of her primary oncologist in consultation with
the urology and interventional radiology services.
.
#) Diarrhea-
Thought to be due to chemotherapy. Improved with loperamide. C.
difficile negative x 3. Stool cultures were negative for
cyptococcus, giardia, microsporidia. CT scan revealed
perinephric fat stranding
.
#) AML-
Patient is status post HIDAC on [**11-29**]. Awaiting matched
unrelated donor transplant. Bone marrow aspirate revealed wide
spread infiltration with blast cells and peripheral smear prior
to discharge revealed 10% blast cells. The patient was
discharged with plan for further chemotherapy within a few days
of discharge, with a second attempt at allogenic transplant to
follow.
.
#) Heme- found to have anti-HLA B7 and B27 antibodies and
required matched platelet transfusions. Pt did respond to 1 unit
of unmatched platelets given prior to he central venous catheter
insertion. Pt was transfused with 1 unit HLA matched platelets
prior to discharge.
.
#) Depression: continued celexa
.
#) Chronic fatigue: continued ritalin.
.
#) F/E/N-
Started on TPN during admission + neutropenic diet. Advanced to
regular low bacteria. Given regular IVF's.
.
#) Intravenous [**Name (NI) 12010**]
Pt has very difficult venous access. peripheral IV's only lasted
<24hrs. A repeat PICC line was attempted on the left arm, but
was unsuccessful due to vasospasm. She was later given a left
subclavian triple lumen catheter. Two days prior to discharge
with negative surveillance blood cultures and after being
afebrile for 48hrs a left sided tunneled internal jugular venous
catheter was placed.
.
#) Communication: husband [**Name (NI) **] ([**Name2 (NI) **]) ([**Telephone/Fax (1) 48092**],
([**Telephone/Fax (1) 48093**], Cell ([**Telephone/Fax (1) 48094**]


Medications on Admission:
Fluconazole 200mg q12h
Acyclovir 400mg q12h
Citalopram 20mg qd
Methylphenidate 10mg qam
Loratadine 10mg qd
Olanzapine 5mg [**Hospital1 **] prn
Prednisone 30mg qd
Levoflox 500mg qd (day #[**9-13**])
Beconase AQ 42mcg [**2-5**] sprays prn
Loperamide 2mg q4h prn
Meropenem (reportedly had one dose at OSH)


Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. Loratadine 10 mg Tablet Sig: One (1) Tablet PO daily ().
5. Beconase AQ 42 mcg (0.042 %) Aerosol, Spray Sig: One (1)
Nasal [**2-5**] sprays [**Hospital1 **] ().
6. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Mupirocin Calcium 2 % Cream Sig: One (1)  Topical  QD ().
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*10 Tablet(s)* Refills:*0*
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
12. Hickman Catheter Care
Central venous catheter care per protocol
13. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO PT [**Month (only) **] SELF
DOSE UP TO 12MG PER DAY ().


Discharge Disposition:
Home With Service

Facility:
IV Clinical Network of [**Doctor Last Name **]

Discharge Diagnosis:
Primary: Central Venous Line Infection

Secondary:
Acute Myelogenous leukemia


Discharge Condition:
Stable.


Discharge Instructions:
You were admitted for a central venous line infection following
treatment for acute myelogenous leukemia.

Please take all of your medications as prescribed.

Call Dr. [**First Name (STitle) 1557**] or 911 if you experience any fever, uncontrolled
bleeding, worsening diarrhea or abdominal pain, back pain,
decreased urine output or any other concerning symptoms.

Followup Instructions:
You should follow up with Dr. [**First Name (STitle) 1557**] on Monday. Please call his
office at anytime with any other questions.
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Septic shock,Acute myeloid leukemia, without mention of having achieved remission,Volume depletion, unspecified,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other ureteric obstruction'}


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: Neutropenic fever and Hypotension

PRESENT ILLNESS: Ms. [**Known lastname **] is 50 yo F with AML s/p allo-BMT in [**2110**], now with
relapsed AML awaiting repeat SCT, currently s/p high-dose ARA-C
on [**11-29**], who presented to [**Hospital 7188**] Hospital with diarrhea (on
Flagy ~1 week) and fatigue. At the OSH, she was found to be
hypotensive with SBP's 60's-70's and had temp of 100.3. She got
2-3L of IVF, meropenem, vancomycin, and was tran, and was then
transferred to the [**Hospital1 18**] ED. In the ED, she received 1L NS, and
SBP improved from the 70's to low 100's. She was admitted to the
[**Hospital Unit Name 153**]. She was continued on meropenem, vanco, given 2L NS and
started on stress dose steroids. She spiked to 101.7 so blood
cultures were again drawn and she was started on Flagyl for
possible Cdiff. Blood Cx from OSH came back positive for coag
negative staph. Her blood pressures improved and her temperature
curve decreased until prior to transfer to the floor when she
was 101.
She remained HD stable so was transferred.
.
At the time of interview, the patient felt hot, sweaty, and
fatigued. She denied chills. She denied chest pain, shortness of
breath, cough. She noted only 2 episodes of diarrhea with
lomotil. She denied melena, hematochezia. She denied HA, sinus
congestion. She denied dysuria, urinary urgency or frequency.
.
ROS: otherwise negative. no lightheadedness, palpitations. no
mouth pain. no myalgia/arthralgia.
.
ONC HISTORY:
Acute myelogenous leukemia - status post allogenic transplant
[**2110-8-4**]: 5 of 6 matched family member (father) allogenic BMT.
Mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of AML. MEC protocol started [**2114-7-29**]. She
tolerated the chemo well. Of note she was found to have anti HLA
B7 and B27 antibodies so required matched platelet transfusions
during her nadir. She underwent DLI on [**2114-9-4**]. She relapsed with
cytogenetically different AML (monosomy 7). She then underwent
reinduction with MEC in [**10-10**]. She received high-dose ARA-C
starting [**2114-11-29**]. She currently has a matched donor and is
awaiting transplant.

MEDICAL HISTORY: - Allergic rhinitis
- Depression
- Right-sided hydronephrosis secondary to fibroid
uterus/retroperitneal fibrosis thought secondary to
paraneoplastic syndrome, status post stent [**6-9**], removed [**8-9**]

MEDICATION ON ADMISSION: Fluconazole 200mg q12h
Acyclovir 400mg q12h
Citalopram 20mg qd
Methylphenidate 10mg qam
Loratadine 10mg qd
Olanzapine 5mg [**Hospital1 **] prn
Prednisone 30mg qd
Levoflox 500mg qd (day #[**9-13**])
Beconase AQ 42mcg [**2-5**] sprays prn
Loperamide 2mg q4h prn
Meropenem (reportedly had one dose at OSH)

ALLERGIES: Penicillins / Sulfur / Demerol / Amphotericin B / Allopurinol /
Vicodin / Percocet

PHYSICAL EXAM: Vitals: T 99.4 BP 108/68 HR 100 RR 18 O2 99% 1L NC
Gen: Sleepy, nontoxic, flushed
HEENT: PERRL. sclera anicteric. MMM. No oral lesions.
Neck: JVD 7 cm. No LAD.
CV: tachycardic, regular, nl s1, s2, no m/r/g
Resp: CTAB
Abd: soft, NTND, +BS, no rebound/guarding. L nephrostomy tube in
place - no drainage, d/c or tenderness.
Ext: no c/c/e
Skin: no rash
Neuro: A&Ox3

FAMILY HISTORY: Both parents living. Mother with hypertension, myocardial
infarction, systemic lupus. Father (donor) with hypertension,
recently had myocardial infarction. Siblings with hypertension.

SOCIAL HISTORY: Married, lives with her husband (who is a nurse) and three
children ages 14, 9, 7. Worked as a controller. No tobacco or
alcohol use. 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Other staphylococcal septicemia,Severe sepsis,Septic shock,Acute myeloid leukemia, without mention of having achieved remission,Volume depletion, unspecified,Diarrhea,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other ureteric obstruction'}
