CHIEF COMPLAINT: Admitted for Cycle 1 of MEC

PRESENT ILLNESS: 61 yo woman with history of breast CA and subsequent development
of AML s/p allo HSCT on [**2115-10-4**] who recently had episodes of
back pain X2months and MRI revealed an L2 lesion that was found
to be a chloroma, concerning for extramedullary relapse. Bone
marrow done last week on prelim read was also positive for AML.
She had been scheduled for radiation to the spine and planned
DLI. However, with positive bone marrow, she is now being
admitted for MEC. Patient with lower back pain, hip pain (R>L)
radiating down the legs. No numbness or tingling typically. Pain
is intermittent, but constant since last night. Gait feels
unsteady. Denies fevers, chills, no weight loss >2 pounds. Not
sure if having night sweats. Appetite decreased but eating
normally currently. No changes in BMs.
.
Of note, patient with tooth pain recently. 1st molar on left
painful after biting into a tums. Now right first molar also
sensitive. Pain in L>R. No HA, double vision. H/o possible TMJ.
.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias, rashes.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- [**2102**] TAH/BSO showed stage IIB ovarian Ca adjuvant treatment
with six cycles of carboplatin and Taxol
- [**2113-12-7**] had mammogram that showed a poorly
differentiated invasive ductal carcinoma, 8 mm in largest
diameter, without LVI. ER/PR/HER-2 negative. FNA of a palpable
right axillary lymph node was consistent with malignancy.
Imaging showed right axillary, subpectoral, and deep cervical
lymph node involvement.
- [**2114-2-4**] treated with Adriamycin and Cytoxan followed by
Taxol at the [**Company 2860**] followed by bilateral mastectomies(right
modified radical mastectomy and left simple mastectomy) at [**Hospital1 2025**].
Pathology from the right breast demonstrated LCIS, chemotherapy
changes, and no evidence of residual IDC. Zero of 24 right
axillary lymph nodes were positive for disease. There was no
evidence of cancer in the left breast.
- genetic testing negative for BRCA-1 and 2 mutations.
- [**2115-4-4**], she developed new lower back pain while undergoing
planning for bilateral breast reconstruction surgery. Initially
managed conservatively. Her pain progressed, and on [**2115-6-4**], she presented to the emergency room at [**Hospital3 **]. Blood work at the hospital demonstrated a CBC that was
notable for
white blood cell count of 19, hematocrit 23, and a platelet
count
of 12. White blood cell count differential was notable for 11%
blasts. At that time, she endorsed easy bruising, but denied
fevers, chills, night sweats, weight loss, or recurrent
infections. She was subsequently transferred to [**Hospital1 18**] where she

MEDICATION ON ADMISSION: acyclovir
albuterol
atovaquone
azelastine
folic acid
lidocaine patch
oxycodone
posaconazole
potassium chloride
vitamin D
colace
senna
magnesium oxide

ALLERGIES: Prochlorperazine / Sulfa (Sulfonamide Antibiotics) / Betadine
Viscous Gauze / Vancomycin / Meropenem / Zosyn / cefepime

PHYSICAL EXAM: Admission Exam:
VS: T 99.5, BP 110/70, HR 86, RR 18, SpO2 98%RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. 1st
molars look intact, without erythema or fluctuance at the gums.
Teeth are not cracked, no obvious cavities.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: tender to palpation along lumbar and sacral spine.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+.  tender to palpation along right iliac crest and groin.
nontender along left.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait - walked with a right
limp.

FAMILY HISTORY: Her father had a large CVA in his early 50s. MGM with ovarian
cancer. MGF with colon cancer. Sister with uterine cancer.
Maternal aunt with breast cancer. Type 2 DM in mother and
father.

SOCIAL HISTORY: Denies tobacco ever, EtOH (not now, was a social drinker years
back), drug use.
She lives in [**Location 3493**] ([**Hospital3 **]) w/ husband, 2 cats.
Self-employed consultant.
Encounter for antineoplastic chemotherapy,Septicemia due to escherichia coli [E. coli],Severe sepsis,Septic shock,Antineoplastic chemotherapy induced pancytopenia,Bloodstream infection due to central venous catheter,Peripheral stem cells replaced by transplant,Acute myeloid leukemia, in relapse,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Rash and other nonspecific skin eruption,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple,Personal history of malignant neoplasm of ovary,Acquired absence of both cervix and uterus
Antineoplastic chemo enc,E coli septicemia,Severe sepsis,Septic shock,Antin chemo indcd pancyt,Blood inf dt cen ven cth,Trspl sts-perip stm cell,Act myel leuk in relapse,Adv eff antineoplastic,Neutropenia NOS,Fever in other diseases,Nonspecif skin erupt NEC,Asthma NOS,Hx of breast malignancy,Acq absnce breast/nipple,Hx of ovarian malignancy,Acq absnce cervix/uterus
Admission Date:  [**2116-10-2**]              Discharge Date:   [**2116-11-15**]

Date of Birth:  [**2055-2-23**]             Sex:   F

Service: MEDICINE

Allergies:
Prochlorperazine / Sulfa (Sulfonamide Antibiotics) / Betadine
Viscous Gauze / Vancomycin / Meropenem / Zosyn / cefepime

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Admitted for Cycle 1 of MEC

Major Surgical or Invasive Procedure:
PICC line placement [**2116-10-2**]
Right IJ placement [**2116-10-16**]


History of Present Illness:
61 yo woman with history of breast CA and subsequent development
of AML s/p allo HSCT on [**2115-10-4**] who recently had episodes of
back pain X2months and MRI revealed an L2 lesion that was found
to be a chloroma, concerning for extramedullary relapse. Bone
marrow done last week on prelim read was also positive for AML.
She had been scheduled for radiation to the spine and planned
DLI. However, with positive bone marrow, she is now being
admitted for MEC. Patient with lower back pain, hip pain (R>L)
radiating down the legs. No numbness or tingling typically. Pain
is intermittent, but constant since last night. Gait feels
unsteady. Denies fevers, chills, no weight loss >2 pounds. Not
sure if having night sweats. Appetite decreased but eating
normally currently. No changes in BMs.
.
Of note, patient with tooth pain recently. 1st molar on left
painful after biting into a tums. Now right first molar also
sensitive. Pain in L>R. No HA, double vision. H/o possible TMJ.
.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias, rashes.

Past Medical History:
PAST ONCOLOGIC HISTORY:
- [**2102**] TAH/BSO showed stage IIB ovarian Ca adjuvant treatment
with six cycles of carboplatin and Taxol
- [**2113-12-7**] had mammogram that showed a poorly
differentiated invasive ductal carcinoma, 8 mm in largest
diameter, without LVI. ER/PR/HER-2 negative. FNA of a palpable
right axillary lymph node was consistent with malignancy.
Imaging showed right axillary, subpectoral, and deep cervical
lymph node involvement.
- [**2114-2-4**] treated with Adriamycin and Cytoxan followed by
Taxol at the [**Company 2860**] followed by bilateral mastectomies(right
modified radical mastectomy and left simple mastectomy) at [**Hospital1 2025**].
Pathology from the right breast demonstrated LCIS, chemotherapy
changes, and no evidence of residual IDC. Zero of 24 right
axillary lymph nodes were positive for disease. There was no
evidence of cancer in the left breast.
- genetic testing negative for BRCA-1 and 2 mutations.
- [**2115-4-4**], she developed new lower back pain while undergoing
planning for bilateral breast reconstruction surgery. Initially
managed conservatively. Her pain progressed, and on [**2115-6-4**], she presented to the emergency room at [**Hospital3 **]. Blood work at the hospital demonstrated a CBC that was
notable for
white blood cell count of 19, hematocrit 23, and a platelet
count
of 12. White blood cell count differential was notable for 11%
blasts. At that time, she endorsed easy bruising, but denied
fevers, chills, night sweats, weight loss, or recurrent
infections. She was subsequently transferred to [**Hospital1 18**] where she

underwent bone marrow biopsy on [**2115-6-7**], with findings
consistent with AML with monocytic differentiation. On [**2115-6-8**], she began induction chemotherapy with 7+3. Her treatment
course was complicated by prolonged neutropenic fevers,
multifocal pneumonia requiring lung biopsy that demonstrated
evidence of BOOP. She was subsequently treated with steroids.
Bone marrow biopsy performed on day +14 and day +24 showed
residual blasts in the marrow, and she was treated with one
cycle
of HiDAC. Bone marrow biopsy on [**2115-7-16**], showed no
evidence of blasts. She was subsequently discharged, but had
several short stays in the hospital for difficulties with
infections. On [**2115-9-27**], she was admitted to [**Hospital1 18**] for

ablative allogeneic stem cell transplant from a matched
unrelated
donor. She underwent conditioning with fludarabine, busulfan,
and ATG. Her transplant was on [**2115-10-4**]. She did well
following the transplant, with no evidence of recurrent disease

or graft-versus-host disease. In [**2116-7-3**], she once again began

to develop low back pain with occasional radiation down her
legs.
An L-spine MRI on [**2116-7-31**], demonstrated a new enhancing L2

spinous process mass with associated soft tissue component and
no
spinal canal involvement. There was also new heterogeneous
marrow signal noted in the iliac bone and sacrum. Pelvis MRI on

[**2116-8-6**], once again demonstrated diffuse marrow signal
abnormality with near complete homogenous replacement of the
right posterior ilium to SI joint, and marrow replacement of the
left femur to the mid diaphysis. There were also bilateral
sacral insufficiency fractures noted. On [**2116-8-17**], she
underwent bone marrow biopsy, which demonstrated a mildly
hypocellular marrow with no evidence of AML. Flow cytometry was

negative for evidence of blasts. On [**2116-8-25**], she
underwent an FNA of this newly identified left spinous process
mass. Pathology demonstrated skeletal muscle and soft tissue
with an atypical mononuclear infiltrate consistent with myeloid

sarcoma. Immunohistochemistry staining was positive for CD4, 15,
33, 43, and 68 (similar to her previous AML). This was felt to
represent an extramedullary relapse of her AML.
-Bone marrow biopsy last week ([**9-/2116**]) was positive for AML.
-patient is being admitted for MEC chemo therapy given extent of
relapse

OTHER MEDICAL HISTORY:
relapsed AML
ovarian cancer [**2102**]
breast cancer [**2113**]

Social History:
Denies tobacco ever, EtOH (not now, was a social drinker years
back), drug use.
She lives in [**Location 3493**] ([**Hospital3 **]) w/ husband, 2 cats.
Self-employed consultant.


Family History:
Her father had a large CVA in his early 50s. MGM with ovarian
cancer. MGF with colon cancer. Sister with uterine cancer.
Maternal aunt with breast cancer. Type 2 DM in mother and
father.


Physical Exam:
Admission Exam:
VS: T 99.5, BP 110/70, HR 86, RR 18, SpO2 98%RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. 1st
molars look intact, without erythema or fluctuance at the gums.
Teeth are not cracked, no obvious cavities.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: tender to palpation along lumbar and sacral spine.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+.  tender to palpation along right iliac crest and groin.
nontender along left.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait - walked with a right
limp.

Discharge Exam:
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric, pale conjunctiva. PERRL, EOMI.
MMM, OP clear, dentition normal.
CV: RRR with normal S1, S2. No M/R/G.
Chest: CTAB without crackles, wheezes or rhonchi. No use of
accessory muscles.
Abd: normoactive bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: nontender, full ROM.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+. Nontender to palpation.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait WNL.

Pertinent Results:
Labs on admission:
[**2116-10-2**] 02:27PM BLOOD WBC-5.7 RBC-3.60* Hgb-11.2* Hct-33.5*
MCV-93 MCH-31.2 MCHC-33.6 RDW-14.6 Plt Ct-115*
[**2116-10-2**] 02:27PM BLOOD Neuts-74* Bands-1 Lymphs-8* Monos-8 Eos-4
Baso-0 Atyps-1* Metas-3* Myelos-1*
[**2116-10-2**] 02:27PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2116-10-1**] 01:07PM BLOOD PT-13.0 PTT-23.9 INR(PT)-1.1
[**2116-10-2**] 02:27PM BLOOD Glucose-96 UreaN-14 Creat-0.8 Na-141
K-3.7 Cl-103 HCO3-30 AnGap-12
[**2116-10-2**] 02:27PM BLOOD ALT-25 AST-19 LD(LDH)-[**2007**]* AlkPhos-141*
TotBili-0.2
[**2116-10-2**] 02:27PM BLOOD Calcium-9.3 Phos-3.6 Mg-2.0

Labs on discharge:
[**2116-11-15**] 07:20AM BLOOD WBC-1.3* RBC-2.93* Hgb-9.2* Hct-27.6*
MCV-94 MCH-31.3 MCHC-33.2 RDW-17.1* Plt Ct-236
[**2116-11-15**] 07:20AM BLOOD Neuts-50 Bands-1 Lymphs-20 Monos-26*
Eos-1 Baso-1 Atyps-0 Metas-0 Myelos-1* NRBC-1*
[**2116-11-15**] 07:20AM BLOOD PT-10.8 PTT-24.7 INR(PT)-0.9
[**2116-11-15**] 07:20AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-27 AnGap-12
[**2116-11-15**] 07:20AM BLOOD ALT-24 AST-18 LD(LDH)-230 AlkPhos-139*
TotBili-0.2
[**2116-11-15**] 07:20AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9

Pertint Micro Results:
URINE CULTURE (Final [**2116-10-5**]):
      GRAM POSITIVE BACTERIA.    10,000-100,000 ORGANISMS/ML..
         Alpha hemolytic colonies consistent with alpha
streptococcus or
         Lactobacillus sp.
      GRAM POSITIVE BACTERIA.    10,000-100,000 ORGANISMS/ML..
         UNABLE TO FURTHER IDENTIFY
Blood Culture, Routine (Final [**2116-10-21**]):
      THIS IS A CORRECTED REPORT 0802 [**2116-10-19**].
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (un) **] ([**Numeric Identifier **]) 0802
[**2116-10-19**].
      ENTEROCOCCUS GALLINARUM.
         PREVIOUSLY REPORTED AS BURKHOLDERIA (PSEUDOMONAS)
CEPACIA ON
         [**2116-10-18**].  FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
         gentamicin. Screen predicts possible synergy with
selected
         penicillins or vancomycin. Consult ID for details.
         HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
         streptomycin.  Screen predicts possible synergy with
selected
         penicillins or vancomycin.  Consult ID for details..
         Daptomycin = 2 MCG/ML.
         Daptomycin Sensitivity testing performed by Etest.
         VANCOMYCIN Sensitivity testing confirmed by Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS GALLINARUM
                             |
AMPICILLIN------------   <=2 S
DAPTOMYCIN------------       S
LINEZOLID-------------     2 S
PENICILLIN G----------     1 S
VANCOMYCIN------------     8 I
.
Blood Culture, Routine (Final [**2116-10-27**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
         AZTREONAM & [**Last Name (NamePattern1) 92908**] SUSCEPTIBILITIES REQUESTED BY
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
         #[**Numeric Identifier 8022**].  RESISTANT TO AZTREONAM MIC >=32 MCG/ML.
         SENSITIVE TO [**Numeric Identifier 92908**] MIC <=1 MCG/ML.
         [**Numeric Identifier 92908**] MIC interpretations are based on
manufacturer's
         guidelines that are FDA approved.
         AZTREONAM AND [**Numeric Identifier 92908**] sensitivity testing performed
by
         Microscan.
      ESCHERICHIA COLI.    SECOND MORPHOLOGY.  FINAL
SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
         AZTREONAM & [**Last Name (NamePattern1) 92908**] SUSCEPTIBILITIES REQUESTED BY
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**]
         #[**Numeric Identifier 8022**].  RESISTANT TO AZTREONAM MIC >= 32 MCG/ML.
         SENSITIVE TO [**Numeric Identifier 92908**] MIC <=1 MCG/ML.
         [**Numeric Identifier 92908**] MIC interpretations are based on
manufacturer's
         guidelines that are FDA approved.
         AZTREONAM AND [**Numeric Identifier 92908**] sensitivity testing performed
by
         Microscan.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          ESCHERICHIA COLI
                             |          |
AMPICILLIN------------  =>32 R     =>32 R
AMPICILLIN/SULBACTAM--    16 I       16 I
CEFAZOLIN-------------  =>64 R     =>64 R
CEFEPIME--------------  =>64 R     =>64 R
CEFTAZIDIME-----------    16 R       16 R
CEFTRIAXONE-----------  =>64 R     =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
PIPERACILLIN/TAZO-----       S          S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R        8 R
.

PATH:
.
[**2116-9-29**] Bone Marrow Biopsy: HYPERCELLULAR BONE MARROW WITH
EXTENSIVE NECROSIS AND EVIDENCE OF RELAPSED ACUTE MYELOID
LEUKEMIA. Note: There is extensive zonal confluent necrosis
alternating with sheets of blasts with abundant pink cytoplasm.
The histological and cytological features are virtually
identical to those seen at first diagnosis.
.
[**2116-11-11**]: Bone Marrow Biopsy: Mildly hypocellular for age
erythroid dominant bone marrow.  No definitive morphological
evidence of acute leukemia, see note.
Note:  While rare blasts and left shifted myeloids are seen
along with atypical monocytes in peripheral blood. However,
there is differentiation. Please correlate with clinical
findings and progression, flow cytometry ([**-1/4753**]) and
karyotype studies, to exclude minimal residual disease.

IMAGING:

[**2116-10-2**] Panorex: pending report
[**2116-10-2**] Echo: The left atrium and right atrium are normal in
cavity size. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF 70%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2115-8-29**], a pericardial effusion is no longer seen.
[**2116-10-3**] CXR: Left PICC line tip is at the level of mid SVC.
Heart size and mediastinum are unremarkable. Lungs are
essentially clear. No pleural effusion or pneumothorax is noted.
Right apical opacity is unchanged since the prior examination
dating back to [**2116-7-3**] and reflects a focal area of
consolidation seen back on [**2115-10-20**] radiograph and most
likely represents a residua of the cryptogenic organizing
pneumonia.
[**2116-10-16**] Limited son[**Name (NI) **] of left arm demonstrated likely
non-occlusive thrombus in the mid brachial vein. The PICC was
not placed.
[**2116-10-17**] Bone Marrow Biopsy: Hypocellular bone marrow consistent
with chemotherapeutic ablation. No diagnostic morphologic
features of acute leukemia seen.
[**2116-10-18**] CXR: IMPRESSION: No evidence of acute pneumonia.
[**2116-10-24**] CT abdomen/pelvis:
1. Within limits of a noncontrast examination, no etiology for
patient's
fever within the limitation of this unenhanced CT. No drainable
fluid
collection.
2. No retroperitoneal hematoma.
[**2116-10-26**]  ECHO: IMPRESSION: Mild-moderate mitral regurgitation
without evidence of discrete vegetation. Preserved global and
regional biventricular systolic function. Compared with the
prior study (images reviewed) of [**2116-10-2**], the severity of
mitral regurgitation and estimated PA systolic pressure are
increased. If the clinical suspicion for endocarditis is
moderate or high, a TEE would be better able to define the
mitral valve morphology for possible vegetation.
[**2116-10-26**] LUE U/S: No evidence of deep venous thrombosis in the
left upper
extremity.
[**2116-11-9**] RUQ U/S:
1. Mildly coarse liver. This is a nonspecific finding but could
reflect
diffuse liver disease. Ultrasound cannot exclude [**Last Name (un) **]-occlusive
disease.
2. Small 3-mm gallbladder polyp is unchanged.


Brief Hospital Course:
61 yo F with h/o breast CA and subsequent development of AML s/p
allo HSCT (on [**2115-10-4**]) found to have a relapse of her AML with
positive BM biopsy and chloroma of the L2 spine, admitted for C1
of MEC (started [**2116-10-3**]).
.
# Relapsed AML: [**2116-9-29**] BM biopsy showed HYPERCELLULAR BONE
MARROW WITH EXTENSIVE NECROSIS AND EVIDENCE OF RELAPSED ACUTE
MYELOID LEUKEMIA. Additionally tissue sample of L2 lesion was
found to be a chloroma. Patient had been scheduled for radiation
to the spine and planned DLI. However, given her positive BM, it
was decided she should have MEC. Baseline Echo on admission WNL,
with EF>70%. MEC and allopurinol administered, patient tolerated
it well. Patient became neutropenic on D7. Acyclovir and
atovaquone were continued for prohylaxis (home regimen).  She
was previously on posaconazole for fungal ppx, however this was
changed to voriconazole for a few weeks for neutropenic fevers,
but changed back to posaconazole before discharge. Patient
required several transfusions of PRBCs and platelets during
admission. CBC, Gran Count monitored closely. She experienced
prolonged pancytopenia, but her counts eventually began trending
up around day 35.  She had a repeat bone marrow biopsy on
[**2116-11-11**] (day 40) which showed no evidence of her leukemia (3%
blasts). Her counts continued to trend up, and ANC was 650 on
the day of discharge (day 44 after MEC).
.
# Fever: Patient became febrile several days into MEC therapy,
prior to neutropenia.  She was started on cefepime on [**10-5**], and
remained afebrile for >1week. CXR on [**10-3**] clear except for focal
area of consolidation in right apice, thought to be residua of
cryptogenic PNA from previous admission. Pt without cough,
sputum production, SOB. Urine culture negative. Blood cultures
negative from [**10-3**], [**10-5**]. PICC line was pulled for slight
erythema, nonocclusive thrombus found at that time, so PICC
could not be replaced. Instead, right IJ was placed on [**2116-10-16**].
[**10-15**] and [**10-16**] blood clutures negative. Patient again began
having fevers on [**10-17**] without localizing symptoms, with 1 out
of 2 blood cultures growing enterococcus galinerum, sensitive to
daptomycin. Cefepime was discontinued on [**2116-10-20**] for diffuse
rash. ID consulted given patient's many allergies (i.e.
meropenem and vancomycin). Treated with daptomycin, aztreonam
and ciprofloxacin. RIJ was left in place, as patient has
difficult access (cannot place line in right arm [**2-5**] lymphedema
from previous mastectomy and now with clot in left arm from
previous PICC). Daily blood cultures were negative. Patient
developed fever to 103.5F, [**10-22**] Blood culture grew E Coli while
on atreonam and ciproflozacin. She became hypotensive, minimally
responsive to fluids and was transferred to the [**Hospital Unit Name 153**].  She
stayed there for two days and was stabilized with fluids, never
requiring pressors.  The E coli in her blood cultures was found
to be sensitive only to gentamicin and zosyn, so she was started
on these two antibiotics.  She was stable enough to be sent back
to the floor after 2 days in the ICU.  She soon developed a rash
which was consistent with a drug rash and attributed to the
zosyn (given her many penicillin-family allergies).  Sensitivity
testing found the E Coli to be sensative to [**Last Name (LF) **], [**First Name3 (LF) **] she
was started on this in addition to the gentamicin.  Her IJ was
pulled at this time, a new left IJ was placed.  Multiple
surveillance cultures were drawn and had no growth.  She
remained afebrile for the last 14+ days of her hospital stay and
did not have any more positive cultures.  Her intravenous abx
were stopped a few days prior to discharge, and she remained
stable with no evidence of infection.  She was sent home with
prophylactic antibiotics only-- acyclovir, posaconazole, and
atovaquone.
.
# Sepsis: Patient transferred to ICU with concern for septic
shock, with hypotension initally not responsive to IVF's.
Etiology thought to be due to E coli found on blood cx on [**10-22**]
and [**10-23**], likely from gut translocation. Patient's BP recovered
with volume expansion including 2units pRBC. Patient was never
pressor dependent. After conferring with ID, abx were narrowed
to daptomycin for previously documented VRE, and
zosyn/gentamicin for empiric GNR coverage. Patient was
maintained on voriconazole, acyclovir, and atovaquone ppx. CDiff
antigen was negative and no blood cx returned positive since
[**10-23**].
.
# L PICC line assoc blood clot: Patient found on US to have a
nonocclusive thrombus from her left PICC. Instead of replacing
PICC, IR placed a right IJ for access. No anticoagulation needed
as plts are low. LUE ultrasound was repeated 1-2 weeks later and
found that the clot had resovled.
.
# Transaminitis: LFTs rose abruptly on [**11-9**] from normal
baseline. RUQ US showed a "coarse liver", non-specific but could
signify liver disease/inflammation. Thought to be due to
voriconazole, which was DC'd [**11-9**].  Her LFTs then trended back
down to baseline/normal values.  It would be reasonable to
obtain a future repeat RUQ US to assess for resolution of liver
inflammation and rule out occult, ongoing process.
.
# Rashes: Developed Started out as erythamtous, blanching
0.5-1cm papules over flank, back, inner thighs. Minimally
puritic, but worsening, becoming more diffuse over arms, chest,
abdomen, thighs, and back over 2 days. No complaints, no trouble
breathing. Pt with h/o meropenem allergy. Developed 13 days
after starting cefepime. Derm consulted and felt this was a drug
reaction to cefepime, recommended triamcinilone. ID agreed.
Cefepime discontinued 2 days after rash first developed. Got
worse for several days, and then began to to improve.  While
this rash was clearing, she was started on zosyn
(pipericillin-tazobactam) and developed a new, separate rash
across her arms and some puffiness in her face.  Initially
dermatology and ID felt it was possible to treat through this
reaction (given the need for zosyn for her E. coli bacteremia),
however when she developed swelling of her lips and itching of
her throat, the medication was stopped.  At this point, her rash
and swelling began to subside and resolved within a week.
.
# Tooth pain: On admission, patient had been complaining of
bilateral lower 1st molar tooth pain for the past week, worse on
the left than the right. There was minimal concern for infection
on exam, and pain resolved within two days of admission. Panorex
xray of teeth was performed to evaluate for infectious process,
however report was pending at time of discharge.
.
# Back Pain: Patient presented with lower back and right hip
pain, tender to palpation and limiting the range of motion of
her back and right hip. Likely related to her chloroma at the L2
level. Patient required a lidocaine patch for pain on the first
day of her admission, however pain resolved by day 2. Patient
was also written for oxycodone prn, however she did not require
it.
.
# Transient visual changes: Patient c/o visual changes, most
notably increased floaters in right eye and 'light dimming'.
Opthomology was consulted who examined the retina, and found
only a small cotton wool spot on right macula. Unlikely to be
contributing to visual symptoms.
.
# Asthma - Stable, managed with home medications: prn albuterol,
astepro.


Medications on Admission:
acyclovir
albuterol
atovaquone
azelastine
folic acid
lidocaine patch
oxycodone
posaconazole
potassium chloride
vitamin D
colace
senna
magnesium oxide

Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q8H (every 8 hours) as needed for
wheezing, SOB.
2. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml (1500 mg)
PO DAILY (Daily).
3. Astepro 0.15 % (205.5 mcg) Spray, Non-Aerosol Sig: Two (2)
puffs Nasal [**Hospital1 **] (2 times a day) as needed.
4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-5**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for dyspepsia.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Ten (10)
ml (200 mg) PO Q 12H (Every 12 Hours).
12. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-5**] Sprays Nasal
TID (3 times a day) as needed for nasal irritation.
13. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Relapsed acute myelogenous leukemia
Chemotherapy-induced pancytopenia
Neutropenic fever
Sepsis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mrs. [**Known lastname **],

It was a pleasure taking care of you in the hospital.  You were
admitted for your first cycle of MEC chemotherapy, started on
[**2116-10-3**]. You became neutropenic 7 days after starting
chemotherapy.  Your time in the hospital was complicated by two
bloodstream infections, both of which were treated with
antibiotics and eventually resolved.  Your white blood cell
counts increased slowly but surely, and a repeat bone marrow
biopsy showed no leukemia cells.

Changes to your medication regimen:
STOP potassium chloride
STOP magnesium oxide
(you no longer need these medications)

Followup Instructions:
Please come to 7 [**Hospital Ward Name 1826**] outpatient area on Monday, [**11-16**] for
bloodwork and to make a follow up appointment with Dr. [**Last Name (STitle) **]
{'Encounter for antineoplastic chemotherapy,Septicemia due to escherichia coli [E. coli],Severe sepsis,Septic shock,Antineoplastic chemotherapy induced pancytopenia,Bloodstream infection due to central venous catheter,Peripheral stem cells replaced by transplant,Acute myeloid leukemia, in relapse,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Rash and other nonspecific skin eruption,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple,Personal history of malignant neoplasm of ovary,Acquired absence of both cervix and uterus'}


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: Admitted for Cycle 1 of MEC

PRESENT ILLNESS: 61 yo woman with history of breast CA and subsequent development
of AML s/p allo HSCT on [**2115-10-4**] who recently had episodes of
back pain X2months and MRI revealed an L2 lesion that was found
to be a chloroma, concerning for extramedullary relapse. Bone
marrow done last week on prelim read was also positive for AML.
She had been scheduled for radiation to the spine and planned
DLI. However, with positive bone marrow, she is now being
admitted for MEC. Patient with lower back pain, hip pain (R>L)
radiating down the legs. No numbness or tingling typically. Pain
is intermittent, but constant since last night. Gait feels
unsteady. Denies fevers, chills, no weight loss >2 pounds. Not
sure if having night sweats. Appetite decreased but eating
normally currently. No changes in BMs.
.
Of note, patient with tooth pain recently. 1st molar on left
painful after biting into a tums. Now right first molar also
sensitive. Pain in L>R. No HA, double vision. H/o possible TMJ.
.
.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias, rashes.

MEDICAL HISTORY: PAST ONCOLOGIC HISTORY:
- [**2102**] TAH/BSO showed stage IIB ovarian Ca adjuvant treatment
with six cycles of carboplatin and Taxol
- [**2113-12-7**] had mammogram that showed a poorly
differentiated invasive ductal carcinoma, 8 mm in largest
diameter, without LVI. ER/PR/HER-2 negative. FNA of a palpable
right axillary lymph node was consistent with malignancy.
Imaging showed right axillary, subpectoral, and deep cervical
lymph node involvement.
- [**2114-2-4**] treated with Adriamycin and Cytoxan followed by
Taxol at the [**Company 2860**] followed by bilateral mastectomies(right
modified radical mastectomy and left simple mastectomy) at [**Hospital1 2025**].
Pathology from the right breast demonstrated LCIS, chemotherapy
changes, and no evidence of residual IDC. Zero of 24 right
axillary lymph nodes were positive for disease. There was no
evidence of cancer in the left breast.
- genetic testing negative for BRCA-1 and 2 mutations.
- [**2115-4-4**], she developed new lower back pain while undergoing
planning for bilateral breast reconstruction surgery. Initially
managed conservatively. Her pain progressed, and on [**2115-6-4**], she presented to the emergency room at [**Hospital3 **]. Blood work at the hospital demonstrated a CBC that was
notable for
white blood cell count of 19, hematocrit 23, and a platelet
count
of 12. White blood cell count differential was notable for 11%
blasts. At that time, she endorsed easy bruising, but denied
fevers, chills, night sweats, weight loss, or recurrent
infections. She was subsequently transferred to [**Hospital1 18**] where she

MEDICATION ON ADMISSION: acyclovir
albuterol
atovaquone
azelastine
folic acid
lidocaine patch
oxycodone
posaconazole
potassium chloride
vitamin D
colace
senna
magnesium oxide

ALLERGIES: Prochlorperazine / Sulfa (Sulfonamide Antibiotics) / Betadine
Viscous Gauze / Vancomycin / Meropenem / Zosyn / cefepime

PHYSICAL EXAM: Admission Exam:
VS: T 99.5, BP 110/70, HR 86, RR 18, SpO2 98%RA
Gen: Elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM, OP clear. 1st
molars look intact, without erythema or fluctuance at the gums.
Teeth are not cracked, no obvious cavities.
Neck: Supple, No cervical lymphadenopathy.
CV: RRR with normal S1, S2. No M/R/G.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly or
masses.
Back: tender to palpation along lumbar and sacral spine.
Musculoskeletal: WWP. No C/C/E. Distal pulses intact radial 2+,
PT 2+.  tender to palpation along right iliac crest and groin.
nontender along left.
Skin: No rashes, ulcers, or other lesions.
Neuro: CN II-XII grossly intact. Gait - walked with a right
limp.

FAMILY HISTORY: Her father had a large CVA in his early 50s. MGM with ovarian
cancer. MGF with colon cancer. Sister with uterine cancer.
Maternal aunt with breast cancer. Type 2 DM in mother and
father.

SOCIAL HISTORY: Denies tobacco ever, EtOH (not now, was a social drinker years
back), drug use.
She lives in [**Location 3493**] ([**Hospital3 **]) w/ husband, 2 cats.
Self-employed consultant. 

### Response:
{'Encounter for antineoplastic chemotherapy,Septicemia due to escherichia coli [E. coli],Severe sepsis,Septic shock,Antineoplastic chemotherapy induced pancytopenia,Bloodstream infection due to central venous catheter,Peripheral stem cells replaced by transplant,Acute myeloid leukemia, in relapse,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Neutropenia, unspecified,Fever presenting with conditions classified elsewhere,Rash and other nonspecific skin eruption,Asthma, unspecified type, unspecified,Personal history of malignant neoplasm of breast,Acquired absence of breast and nipple,Personal history of malignant neoplasm of ovary,Acquired absence of both cervix and uterus'}
