CHIEF COMPLAINT: Recurrent Large B-Cell Lymphoma admitted for autologous stem
cell transplant.

PRESENT ILLNESS: The patient is admitted for an autologous stem cell
transplantation s/p BM harvesting as she did not have an
adequate peripheral collection.
The paitent was diagnosed in [**2156-9-16**] after presenting
with abdominal pain. Disease confined to the abdomin, stage
IIIB. She is s/p 6 cycles of R-CHOP (last treatment
[**2157-1-6**]),She relapsed 2 months following RCHOP.She was
treated with  R-CHOP x 2 with minimal response, s/p ICE in [**6-21**]
and [**7-21**]. She also was admitted on [**8-2**] for cytoxan and
neupogen for stem cell mobilization. Three peripheral
collections were attempted without sufficient cells. She
ultimately underwent a BM harvest in the OR with successful
colelction of sufficient cells for an attempted autologous stem
cell transplantation.

MEDICAL HISTORY: Oncology History
1. Large cell lymphoma diagnosed in [**8-/2156**] after she presented
with abdominal pain. At that time, she was found to have a bulky
intraabdominal mass. CT-guided biopsy complicated by
intraabdominal bleeding. Disease confined to the abdomen, stage
IIIB. Relapsed after initial therapy with 6 cycles of R-CHOP
(last treatment on [**2157-1-6**], vincristine held secondary to
peripheral neuropathy), s/p Rituxan x 2, s/p R-CHOP x 2, and s/p
recent ICE [**6-21**] and [**7-21**].
.
Other Past Medical History:
1. Hypertension, not on any meds
2. s/p ovarian cystectomy of 7cm benign left ovarian
cyst in [**2147**] at [**Hospital 189**] Hosp
3. s/p D&C for menometrorrhagia [**2147**]
4. s/p post-partum tubal ligation

MEDICATION ON ADMISSION: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4

ALLERGIES: Penicillins / Diphenhydramine / Percocet / Meropenem

PHYSICAL EXAM: VS T:98.2 HR:110 RR:18 BP:108/65 O2:100%RA
GEN: A/O, pleasant, in NAD
HEENT: NCAT, no oral ulcers, no rashes
NECK: No LAD
CV: RRR s1, s2, no M/G/R
RESP: CTA bl
ABD: Soft, NT/ND, no masses
EXT: no rashes, + pulses distally

FAMILY HISTORY: Her sister has recently been diagnosed with metastatic cervical
cancer. Great aunt with breast cancer. Son with schizophrenia

SOCIAL HISTORY: She lives with her husband in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MA. They have 2 grown
children.
schizophrenia which is well-controlled. She doesn't smoke or
drink alcohol.
Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Unspecified schizophrenia, unspecified,Cystitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Atrial fibrillation,Foreign body in larynx,Unspecified essential hypertension,Epistaxis,Mucositis (ulcerative) due to antineoplastic therapy,Family history of malignant neoplasm of breast,Family history of malignant neoplasm of other genital organs,Family history of psychiatric condition
Oth lymp unsp xtrndl org,Acute kidney failure NOS,Bacterial pneumonia NOS,Schizophrenia NOS-unspec,Cystitis NOS,Adv eff antineoplastic,Atrial fibrillation,Foreign body in larynx,Hypertension NOS,Epistaxis,Mucosits d/t antineo rx,Family hx-breast malig,Fm hx genital malig NEC,Fam hx-psychiatric cond
Admission Date:  [**2157-10-11**]              Discharge Date:   [**2157-11-30**]

Date of Birth:  [**2096-8-13**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Diphenhydramine / Percocet / Meropenem

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Recurrent Large B-Cell Lymphoma admitted for autologous stem
cell transplant.


Major Surgical or Invasive Procedure:
autologous stem cell transplant

History of Present Illness:
The patient is admitted for an autologous stem cell
transplantation s/p BM harvesting as she did not have an
adequate peripheral collection.
The paitent was diagnosed in [**2156-9-16**] after presenting
with abdominal pain. Disease confined to the abdomin, stage
IIIB. She is s/p 6 cycles of R-CHOP (last treatment
[**2157-1-6**]),She relapsed 2 months following RCHOP.She was
treated with  R-CHOP x 2 with minimal response, s/p ICE in [**6-21**]
and [**7-21**]. She also was admitted on [**8-2**] for cytoxan and
neupogen for stem cell mobilization. Three peripheral
collections were attempted without sufficient cells. She
ultimately underwent a BM harvest in the OR with successful
colelction of sufficient cells for an attempted autologous stem
cell transplantation.


Past Medical History:
Oncology History
1. Large cell lymphoma diagnosed in [**8-/2156**] after she presented
with abdominal pain. At that time, she was found to have a bulky
intraabdominal mass. CT-guided biopsy complicated by
intraabdominal bleeding. Disease confined to the abdomen, stage
IIIB. Relapsed after initial therapy with 6 cycles of R-CHOP
(last treatment on [**2157-1-6**], vincristine held secondary to
peripheral neuropathy), s/p Rituxan x 2, s/p R-CHOP x 2, and s/p
recent ICE [**6-21**] and [**7-21**].
.
Other Past Medical History:
1. Hypertension, not on any meds
2. s/p ovarian cystectomy of 7cm benign left ovarian
cyst in [**2147**] at [**Hospital 189**] Hosp
3. s/p D&C for menometrorrhagia [**2147**]
4. s/p post-partum tubal ligation


Social History:
She lives with her husband in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MA. They have 2 grown
children.
schizophrenia which is well-controlled. She doesn't smoke or
drink alcohol.


Family History:
Her sister has recently been diagnosed with metastatic cervical
cancer. Great aunt with breast cancer. Son with schizophrenia

Physical Exam:
VS T:98.2 HR:110 RR:18 BP:108/65 O2:100%RA
GEN: A/O, pleasant, in NAD
HEENT: NCAT, no oral ulcers, no rashes
NECK: No LAD
CV: RRR s1, s2, no M/G/R
RESP: CTA bl
ABD: Soft, NT/ND, no masses
EXT: no rashes, + pulses distally


Pertinent Results:
[**2157-10-11**] 11:38AM   GRAN CT-[**2091**]*
[**2157-10-11**] 11:38AM   PLT COUNT-124*#
[**2157-10-11**] 11:38AM   HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+
[**2157-10-11**] 11:38AM   NEUTS-69.9 LYMPHS-18.5 MONOS-9.8 EOS-1.5
BASOS-0.3
[**2157-10-11**] 11:38AM   WBC-2.8* RBC-3.72* HGB-11.8* HCT-35.0* MCV-94
MCH-31.6 MCHC-33.6 RDW-21.8*
[**2157-10-11**] 11:38AM   ALBUMIN-4.6 CALCIUM-9.5 PHOSPHATE-3.5
MAGNESIUM-2.4
[**2157-10-11**] 11:38AM   ALT(SGPT)-14 AST(SGOT)-21 LD(LDH)-216 ALK
PHOS-108 TOT BILI-0.5 DIR BILI-0.2 INDIR BIL-0.3
[**2157-10-11**] 11:38AM   GLUCOSE-102 UREA N-8 CREAT-0.6 SODIUM-143
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-30 ANION GAP-12
[**2157-10-11**] 03:32PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2157-10-11**] 03:32PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
.
CHEST (PORTABLE AP)  [**2157-10-12**] 11:42 PM
The heart, mediastinal and hilar contours are unchanged when
compared to prior study. There is a new right lower lobe patchy
opacity that could represent early pneumonia. It is very subtle
and was not seen in the prior study. Since it could be from
overlying breast, lateral view is recommended.
IMPRESSION: Possible right lower lobe pneumonia. Lateral view
recommended for further evaluation.
.
CHEST (PORTABLE AP)  [**2157-10-23**] 4:47 PM
The previously seen patchy density in the right lower lobe is
markedly improved and almost completely resolved. On one
projection, slight increased density was noted.The bilateral
central venous lines remain in place and there is no
pneumothorax. Pulmonary vascular markings, cardiac and
mediastinal contours are normal.
-Marked improvement versus prior with only minimal residual RLL
vague density appreciated.
.
ABDOMEN (SUPINE & ERECT)  [**2157-11-4**] 10:12 AM
Supine and upright plain radiograph of the abdomen and pelvis
were obtained. The bowel gas pattern is unremarkable and there
is no evidence of free air or obstruction. There is no evidence
of organomegaly. Rounded calcifications within the pelvis likely
represent phleboliths. Osseous structures are unremarkable.
-No evidence of obstruction.
.
CT PELVIS W/CONTRAST  [**2157-11-6**] 2:24 PM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
CHEST: There is no morphologically significant mediastinal or
hilar lymphadenopathy. There is no pericardial or pleural
effusion. In the lung window, note is made of atelectatic
opacities in the lung bases, however, no other consolidation is
noted. The central airways are patent. The evaluation of the
lung parenchyma is somewhat limited due to a motion artifact.
ABDOMEN: Again note is made of 1.7 cm low-density lesion in the
right lobe of the liver, unchanged since prior study, most
likely representing liver cyst. Note is made of small amount of
gallbladder edema with normal enhancement of the mucosa, with a
nondistended gallbladder. Spleen, pancreas, adrenal glands, and
the visualized portion of the large and small intestines are
within normal limits. No significant lymphadenopathy. No
ascites. Again note is made of a low-density lesion in the right
kidney, unchanged since prior study.
PELVIS: The visualized portion of large and small intestines are
within normal limits. There is no ascites or lymphadenopathy.
There is no suspicious lytic or blastic lesion in skeletal
structures.
IMPRESSION:
1. NO evidence of pneumonica or abdominal abscess.
2. Mild edema surrounding nondistended gallbladder. Clinical
correlation is recommended.
3. Liver cyst and renal cyst.
4. Basilar atelectasis.
.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST  [**2157-11-9**] 3:45 PM
There are patent nasal-antral ostia, bilaterally. Uncinate
processes are intact, however, and there are no signs of
post-surgical change. The appearance is smooth and symmetric,
suggesting that the appearance may be congenital, or perhaps,
related to remote inflammation. There is minimal mucosal
thickening in the ethmoid sinuses, with slight circumferential
mucosal thickening in the sphenoid sinus. The maxillary and
frontal sinuses are clear. There are no air-fluid levels to
suggest acute sinusitis. There is a large bony spur associated
with mild leftward deviation of the nasal septum, but the middle
meatus is widely patent. The orbits and surrounding soft tissue
structures are unremarkable. The osseous structures are within
normal limits.
IMPRESSION:
1. Minimal sphenoid and ethmoid sinus mucosal thickening,
without air-fluid levels to suggest acute sinusitis.
2. Patent maxillary sinus secondary ostia, most likely
congenital.
.
CT CHEST W/O CONTRAST  [**2157-11-18**] 3:59 PM
New right middle lobe consolidation. Given the fast appearance
during the last 10 days it most likely represents bacterial
pneumonia. Other sources of infection in a neutropenic patient
such as fungal infection, for example aspergillosis or
mucormycosis cannot be excluded. These findings were
communicated to Dr. [**Last Name (STitle) 10351**] during dictation of this exam.
.
[**11-27**] BAL
GRAM STAIN (Final [**2157-11-27**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final [**2157-11-29**]):
      Test cancelled by laboratory due to lack of branching gram
positive
      rods in the gram stain.
      Gram stain is an equally sensitive means of detecting
Nocardia in a
      primary specimen.
      Culture may be a more sensitive means of detecting
Nocardia and
      should be considered.
      PATIENT CREDITED.

   RESPIRATORY CULTURE (Final [**2157-11-29**]):    NO GROWTH, <1000
CFU/ml.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2157-11-28**]):
      PNEUMOCYSTIS CARINII NOT SEEN.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2157-11-28**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):

   NOCARDIA CULTURE (Preliminary):    NO NOCARDIA ISOLATED.


Brief Hospital Course:
61 y/o F admitted for Autologous Bone marrow transplant with CBV
regimen for treatment of large B-cell lymphoma. She is status
post multiple chemotherapy regimens and a BM harvest in the OR
after failed peripheral blood stem cell collection
.
Lymphoma: The patient was admitted to undergo autologous stem
cell transplantation with high dose chemotherapy with CBV
therapy. Admitted Day-7 and began chemotherapy D-7. Etoposide,
Cytoxan, MESNA, BCNU given with last dose 9/30. Day -2 started
acyclovir, ursodiol.  PBCS given during course of chemo. [**10-17**]-
Day -1 patient complained of severe nausea with emesis. [**10-18**], on
day 0 stem cells given with gross hematuria during. Hematuria
prior considered hemorrhagic cystitis related to cytoxan.
Patient vigorously hydrated. Course complicated by severe
nausea, emesis, severe mucositis, and prolonged neutropenia.
Mucositis severe with difficulty swallowing secretions,
hematocrit and platelets monitored and patient made NPO with TPN
and fentanyl PCA for pain. Mucositis greatly improved by [**10-31**],
but unfortunately patient did not engraft as of day +17, ANC
150, with very slow progression of WBC, though given bone marrow
would expect slower recovery.
.
Fever: Pt developed a fever to 100.9 on [**10-12**]. Cultures sent,
Chest x-ray with likely pneumonia. Penicillin allergy, pt unsure
if cephalasporin as well. Treated with levofloxacin and
vancomycin. Continued with chemo. Concerning given for
autologous SCT 3 days of chemo with new pneumonia, though
patient asymptomatic and not dramatic picture on CXR. With
persistence of low grade temps cefepime also started [**10-15**].
Patient completed seven day course for CAP on [**10-15**]. line site
with erythema, pt still febrile, added flagyl to already broad
coverage of cefepime, vanc, caspo.
cefepime started [**10-19**], DC [**10-25**]. flagyl started [**10-24**], DC [**10-25**].
meropenem started [**10-25**], given nausea. caspo started [**10-21**]. [**10-26**]
pulled subclavian line on right. Pt febrile despite being on
meropenem, vancomycin, caspofungin, acyclovir, with no blood
cultures or catheter tip cultures positive to date. Of note
patient neutropenic with ANC 150 day +17.
.
Dysphagia- onset [**10-18**] in relation to severe mucositis,
etiologies to consider primarily musositis, though viral
bacterial, fungal infection, [**Doctor First Name 329**] [**Doctor Last Name **] tear from severe
wretching all possibilities. Patient kept NPO, TPN started,
acyclovir, cefepime, and fentanyl PCA. Improved by day +15, and
patient able to tolerate PO, though with emesis.
.
Anemia, thrombocytopenia- epistaxis. Platelets and PRBC
transfusions throughout course of stay.
.
nausea- zofran, ativan, and anzemet with chemo. scopolamine
patch attempted in addition to decadron 4 mg [**Hospital1 **]. Patient
continued to have severe nausea which dissipated one into
treatment but returned three weeks into treatment once patient
attempted to restart PO intake. Emesis shortly after eating with
no associated cramping. Patient with bowel movements and passing
flatus. KUB negative for obtruction and patient encouraged to
start slow with PO to advance as tolerated.
.
ICU COURSE:
Patient transferred to ICU on [**2157-11-27**] after found to have a
worsening RML consolidation, occluded RML bronchus, and
bilateral effusions. Pt underwent bronchoscopy, had new O2
requirement (94% on 6L) after the procedure. She was
subsequently placed on BiPAP, progressively worsening SOB and O2
requirement, and became more SOB requiring 60% FM with 6L NC to
maintain O2 sat in the 90's. Pt transferred to the [**Hospital Unit Name 153**] for
closer monitoring. She had repeat bronchoscopy. Large mucous
plug noted in RML bronchus, unable to be removed.
.
Ultimately, her SOB/hypoxia felt possibly an infectious etiology
although no identified source after 3 BALs. Pt with significant
lung pathology (RML consolidation, RML bronchus occlusion, and
BL pleural effusions) as well as RLL involvment. She had three
total bronchs without bug isolated. Abx regimen: levoflox,
flagyl, caspo, Posaconazle later switched to ambisome, and
Minocylcine. Minocycline for coverage of some Nocardia species
(other options cause marrow suppression including Bactrim,
Linezolid). Meropenem was attempted; however, after
desensitization, patient developed A-fib after dose. It was
unclear and unlikely that the afib was related to the meropenam.

.
During her ICU course, she also developed Afib with RVR. Started
on Procainamide, per cards recs. She continued metoprolol 25mg
PO BID, discontinued digoxin. Her hemondynamic status was
unstable and metoprolol was then stopped. Then, she was noted to
have several episodes of V tach, which resolved prior to
requiring pads. Her QTc was monitored while on Procainamide.
.
On [**2157-11-30**], her cardiac status had not improved. She also
became hypotensive and bradycardic, ultimately requiring
dobutamine and levophed with minimal improvement in MAP. UOP
declined, lactate rose to 14.
.
Family meeting with patients family and oncologists on [**2157-11-30**].
Family ultimately decided that patient should have no further
escalation of care. Later that evening, patient's BP and HR
began to decline, and she passed away peacefully with family by
bedside. Family agreed to an autopsy to shed light on the cause
for her hypoxia/pulmonary dysfunction as well as for the
subacute worsening of hemodynamic status, decreased UOP, and
elevated lactate.

Medications on Admission:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4

to 6 hours) as needed.
2. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
3. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:

Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.

5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day


Discharge Disposition:
Expired

Discharge Diagnosis:
deceased
hypoxia
cardiac arrest
acute renal failure

Discharge Condition:
deceased
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Unspecified schizophrenia, unspecified,Cystitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Atrial fibrillation,Foreign body in larynx,Unspecified essential hypertension,Epistaxis,Mucositis (ulcerative) due to antineoplastic therapy,Family history of malignant neoplasm of breast,Family history of malignant neoplasm of other genital organs,Family history of psychiatric condition'}


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: Recurrent Large B-Cell Lymphoma admitted for autologous stem
cell transplant.

PRESENT ILLNESS: The patient is admitted for an autologous stem cell
transplantation s/p BM harvesting as she did not have an
adequate peripheral collection.
The paitent was diagnosed in [**2156-9-16**] after presenting
with abdominal pain. Disease confined to the abdomin, stage
IIIB. She is s/p 6 cycles of R-CHOP (last treatment
[**2157-1-6**]),She relapsed 2 months following RCHOP.She was
treated with  R-CHOP x 2 with minimal response, s/p ICE in [**6-21**]
and [**7-21**]. She also was admitted on [**8-2**] for cytoxan and
neupogen for stem cell mobilization. Three peripheral
collections were attempted without sufficient cells. She
ultimately underwent a BM harvest in the OR with successful
colelction of sufficient cells for an attempted autologous stem
cell transplantation.

MEDICAL HISTORY: Oncology History
1. Large cell lymphoma diagnosed in [**8-/2156**] after she presented
with abdominal pain. At that time, she was found to have a bulky
intraabdominal mass. CT-guided biopsy complicated by
intraabdominal bleeding. Disease confined to the abdomen, stage
IIIB. Relapsed after initial therapy with 6 cycles of R-CHOP
(last treatment on [**2157-1-6**], vincristine held secondary to
peripheral neuropathy), s/p Rituxan x 2, s/p R-CHOP x 2, and s/p
recent ICE [**6-21**] and [**7-21**].
.
Other Past Medical History:
1. Hypertension, not on any meds
2. s/p ovarian cystectomy of 7cm benign left ovarian
cyst in [**2147**] at [**Hospital 189**] Hosp
3. s/p D&C for menometrorrhagia [**2147**]
4. s/p post-partum tubal ligation

MEDICATION ON ADMISSION: 1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4

ALLERGIES: Penicillins / Diphenhydramine / Percocet / Meropenem

PHYSICAL EXAM: VS T:98.2 HR:110 RR:18 BP:108/65 O2:100%RA
GEN: A/O, pleasant, in NAD
HEENT: NCAT, no oral ulcers, no rashes
NECK: No LAD
CV: RRR s1, s2, no M/G/R
RESP: CTA bl
ABD: Soft, NT/ND, no masses
EXT: no rashes, + pulses distally

FAMILY HISTORY: Her sister has recently been diagnosed with metastatic cervical
cancer. Great aunt with breast cancer. Son with schizophrenia

SOCIAL HISTORY: She lives with her husband in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MA. They have 2 grown
children.
schizophrenia which is well-controlled. She doesn't smoke or
drink alcohol. 

### Response:
{'Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Acute kidney failure, unspecified,Bacterial pneumonia, unspecified,Unspecified schizophrenia, unspecified,Cystitis, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Atrial fibrillation,Foreign body in larynx,Unspecified essential hypertension,Epistaxis,Mucositis (ulcerative) due to antineoplastic therapy,Family history of malignant neoplasm of breast,Family history of malignant neoplasm of other genital organs,Family history of psychiatric condition'}
