CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.  Acute myelogenous leukemia
diagnosed in [**2180-1-8**], status post Idarubicin, and ARA-C
times two, with consolidation chemotherapy on [**2180-5-1**].
2.  Hypertension.  3.  Carotid stenosis.  4.  History of
alcohol abuse.  5.  Acoustic neuroma.  6.  Benign prostatic
hypertrophy.

MEDICATION ON ADMISSION: Zoloft 125 mg p.o. q.d., Norvasc,
Atenolol, Flomax, Lipitor.

ALLERGIES: The patient on admission had no known drug
allergies but was found to be allergic to Ceftazidime.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in [**Hospital3 4634**].  He
has been sober for the past six months.  He has an 80
pack-year history of smoking.  He is a retired electrician.
Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission
Other anaphylactic react,Adv eff cephalosporin,React-oth vasc dev/graft,Bacteremia,Cellulitis of leg,Act myl leuk w rmsion
Admission Date:  [**2180-5-15**]       Discharge Date:  [**2180-6-8**]

Date of Birth:   [**2117-1-6**]       Sex:  M

Service:  BONE MARROW TRANSPLANT
male with a history of acute myelogenous leukemia diagnosed
in [**2180-1-8**] status post two cycles of Idarubicin and
ARA-C on [**2-22**] and [**3-21**], with consolidation
chemotherapy on [**2180-5-1**], who was admitted from the
vomiting, and neutropenia.
The patient has complained of feeling "terrible" since the
evening prior to admission.  His only specific complaint was
low back pain radiating down both legs.  He denied any cough,
shortness of breath, chest pain, abdominal pain, headache,
bright red blood per rectum, or melena.
The patient was given one dose of Ceftazidime in the clinic.
On transfer to the floor, he was noted to be increasingly
diffuse, confluent, erythematous papular rash over his
extremities, trunk, groin, and legs.  He was noted to be
tachycardia to the 150s with a temperature of 102??????.  The
patient complained of pruritus and was given Benadryl IV.  He
continued to complain of low back pain, but did not have any
other complaints.

Given the patient's persistent hypotension despite
intravenous fluid, the MICU Team was called to evaluate him.
At this time, he was given a second dose of intravenous
Benadryl, Solu-Medrol 80 mg IV x 1, Vancomycin 1 g IV, and
was transferred to the MICU for further care.

PAST MEDICAL HISTORY:  1.  Acute myelogenous leukemia
diagnosed in [**2180-1-8**], status post Idarubicin, and ARA-C
times two, with consolidation chemotherapy on [**2180-5-1**].
2.  Hypertension.  3.  Carotid stenosis.  4.  History of
alcohol abuse.  5.  Acoustic neuroma.  6.  Benign prostatic
hypertrophy.

ALLERGIES:  The patient on admission had no known drug
allergies but was found to be allergic to Ceftazidime.

MEDICATIONS ON ADMISSION:  Zoloft 125 mg p.o. q.d., Norvasc,
Atenolol, Flomax, Lipitor.

SOCIAL HISTORY:  The patient lives in [**Hospital3 4634**].  He
has been sober for the past six months.  He has an 80
pack-year history of smoking.  He is a retired electrician.

PHYSICAL EXAMINATION:  Vital signs:  Temperature 102??????, blood
pressure 70/40, pulse 130-150s, respirations 30, oxygen
saturation 94-99% on 5 L oxygen by nasal cannula.  General:
He was awake, alert, and pale, but was noted to be
interacting appropriately.  HEENT:  Pupils equal, round and
reactive to light.  Extraocular movements intact.  Oropharynx
was dry.  Neck:  Supple.  No lymphadenopathy or jugular
venous distention.  Chest:  He had wheezes bilaterally, right
greater than left.  Cardiovascular:  Sinus tachycardia with
no murmurs.  Abdomen:  Normoactive bowel sounds.  Soft,
nontender, nondistended.  No hepatosplenomegaly.
Extremities:  Cool without cyanosis, clubbing, or edema.  He
did not have any flank ecchymosis.  Neurological:  The
patient was interacting appropriately.  He was seen to move
all four extremities.  Ski:  The patient was noted to have a
diffuse erythematous confluent papular rash over his
extremities, trunk, groin, and proximal legs.

LABORATORY DATA:  The patient had a white blood cell count of
0.2, hematocrit 21.8, platelet count 15, 90% neutrophils, 0%
lymphs, 2% eosinophils; INR 1.2, PTT 27.5; fibrinogen 611;
sodium 133, potassium 3.9, chloride 98, CO2 18, BUN 25,
creatinine 1.4, glucose 270; AST 9, ALT 27, LDH 87, alkaline
phosphatase 103, total bilirubin 1.2, direct bilirubin 0.6,
magnesium 1.1, phosphate 2.7.

Electrocardiogram revealed sinus tachycardia at 150 beats per
minute.  He had a normal axis and intervals without any overt
ischemic ST or T-wave changes.

On chest x-ray the patient was noted to have possible mild
congestive heart failure with small pleural effusions and
question of evolving pneumonia at the right lung base.

HOSPITAL COURSE:  This is a 63-year-old male with a history
of acute myelogenous leukemia who is day 14 of consolidation
chemotherapy who presented with fever and neutropenia.  The
patient developed a rash, tachycardia, and hypotension after
receiving one dose of Ceftazidime.  Our initial suspicion was
that the hypotension was multifactorial, likely due secondary
to sepsis, as well as anaphylaxis to the Ceftazidime.

The patient was initially admitted to the MICU.  Here, he was
started on an epinephrine drip.  He was treated empirically
with Vancomycin and ................... and continued on
Solu-Medrol 80 mg q.8  for probable anaphylaxis.

The patient remained hemodynamically stable over night and
was called out to the Bone Marrow Transplant Unit on the
following day.

1.  Anaphylaxis following Ceftazidime:  Upon discharge from
the Medical Intensive Care Unit, the patient was noted to be
hemodynamically stable.  At this time, he was switched to an
oral Prednisone at taper and was continued on Benadryl and
Zantac.  An Allergy consult was obtained, and they concurred
that the anaphylaxis was most likely secondary to the
Ceftazidime.  They recommended decreasing the patient's
steroids to Prednisone 60 mg q.d. and then discontinuing it
after 24 hours.  They also instructed us to avoid to all
penicillins and cephalosporins, although Vancomycin and
.................... were thought to be appropriate.

2.  Infectious disease:  On hospital day #3, the patient had
2 out of 2 blood cultures grow gram positive cocci in pairs
and clusters.  He was continued on his Vancomycin, as well as
..................  The organism was subsequently speciated
as MRSA.  His urine culture subsequently grew coag-negative
staph as well.  The patient subsequently was continued only
on Vancomycin, as well as Gentamicin times four days for
augmentation.  The patient subsequently had a CT scan of his
chest which revealed multiple inflammatory foci within his
lungs, as well as bilateral small pleural effusions.  These
results were discussed with both the pulmonary service, as
well as the Infectious Disease team.  Their consensus was
that these nodules most likely represented infected foci with
MRSA.  The initial plan was to continue to treat the patient
with Vancomycin and to subsequently reimage after a short
duration of antibiotic therapy.

The patient was subsequently noted to have diffuse erythema
and induration over his right deltoid.  This was noted to be
distinct from the diffuse macular papular rash that he
presented with which was noted to be resolving.

The patient was seen by the Dermatology Service who obtained
a biopsy of his right deltoid for pathologic analysis and
culture.  The patient subsequently had a CT of his right
shoulder which revealed .................. of his fat planes
with nearby inflammation and edema.  The Dermatology Service
felt that these findings were most consistent with a drug
eruption, likely a residual response to the Ceftazidime.

Given his degree of MRSA bacteremia, the patient had a TTE to
rule out endocarditis.  No vegetations were noted.  The
patient subsequently had an MRI of his abdomen to rule out
hepatosplenic candidiasis after his liver function tests were
noted to be mildly elevated.  This revealed a 5.2 x 4.5 cm
cystic lesion with rim enhancement over the right psoas.
This was felt to be consistent with abscess.  The patient was
subsequently noted to have a tender, inflamed right calf.
The right deltoid edema and erythema that he had were noted
to be worse.  These were all felt to likely represent
abscess.  The patient subsequently underwent a CT-guided
placement of a pigtail catheter over the right psoas abscess.
He underwent ultrasound-guided aspiration of right shoulder,
as well as the left calf.  Subsequent cultures from these
fluid collections grew MRSA.  After the procedure, the
patient drained over 100 cc from the right psoas.  His right
deltoid and left calf continued to be tender, indurated, and
erythematous.

We were concerned about probable reaccumulation.  At this
point, we involved the General Surgery Service.  The patient
underwent incision and drainage of the right deltoid and left
calf fluid collections.  This procedure was done on [**6-1**]
by Dr. [**Last Name (STitle) **] from General Surgery.  The patient tolerated
the procedure well.  He did not have any reaccummulation in
either the deltoid or the calf.  He subsequently had a repeat
CAT scan to evaluate for interval change in the pulmonary
nodules and psoas collection.  The pulmonary nodules were
noted to be decreased in size but not number.  This was still
felt to be consistent with a therapeutic response.  Of note,
the psoas collection was noted to have resolved, and the
pigtail catheter was removed.

At the time of this dictation, the recommendation of the
Infectious Disease team is for a total of 12 weeks of
Vancomycin therapy.  We will dose the Vancomycin only for
trough levels of under 20 given his acute on chronic renal
insufficiency.

3.  Oncologic:  The patient was initially noted to be
neutropenic.  He was continued on Neupogen 480 mcg subcue
q.d.  During his hospital course, his white blood cell count
returned to the normal range.  Thus far, his platelets have
been somewhat slower to respond.  They have remained in the
40,000 range.  The patient underwent a repeat bone marrow
aspiration to evaluate for response after consolidation
chemotherapy.  The bone marrow aspirate was consistent with
remission.

The patient will follow with his primary oncologist Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] for continuation of his chemotherapy.

4.  Renal:  After the patient's repeat chest and abdomen CT
scan, his creatinine increased to 2.0.  This was felt to be
most consistent with contrast ATN.  The patient had a FENa of
approximately 4% which was more consistent with an intrinsic
renal etiology.  We hydrated the patient gently.  We dosed
his Vancomycin only for trough levels of less than 20.  We
anticipate that his creatinine will improve gradually.

DISPOSITION:  The patient was seen by the Physical Therapy
Service who have recommended an acute inpatient
rehabilitation stay.

DISCHARGE DIAGNOSIS:
1.  Anaphylactic reaction to Ceftazidime.
2.  Methicillin resistant staphylococcus aureus sepsis with
multiple abscess foci status post drainage.
3.  Acute myelogenous leukemia in remission.
4.  Benign prostatic hypertrophy.
5.  Hypertension.
6.  Depression.
7.  History of carotid insufficiency.

DISCHARGE MEDICATIONS:  Pending at the time of this discharge
summary.






                           [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.

Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36

D:  [**2180-6-6**]  14:07
T:  [**2180-6-6**]  14:13
JOB#:  [**Job Number 101388**]


Admission Date:  [**2180-5-15**]       Discharge Date: [**2180-6-7**]

Date of Birth:   [**2117-1-6**]       Sex:  M


DISCHARGE MEDICATIONS: The patient's discharge medications
are as follows:
1.  Atenolol 25 milligrams po q day.
2.  Zoloft 125 milligrams po q day.
4.  Vancomycin 1 gram IV q day, dose only for a trough level
of less than 20. The patient will receive this through [**2180-8-14**].
5.  Flomax 0.4 milligrams po q day.
6.  Multi vitamin one po q day.
7.  Reglan 10 milligrams po qid.
8.  Oxycodone 5 to 10 milligrams po q four to six hours prn.
deltoid and left calf.
10. Protonix 40 milligrams po q day.

DISCHARGE CONDITION: Stable. Discharged to acute
rehabilitation facility.

DISCHARGE FOLLOW UP: The patient is to follow up with his
primary oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].


                          DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-438



Dictated By:[**Last Name (NamePattern1) 11732**]
MEDQUIST36

D:  [**2180-6-7**]  09:55
T:  [**2180-6-7**]  10:10
JOB#:  [**Job Number **]
{'Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission'}


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: 

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.  Acute myelogenous leukemia
diagnosed in [**2180-1-8**], status post Idarubicin, and ARA-C
times two, with consolidation chemotherapy on [**2180-5-1**].
2.  Hypertension.  3.  Carotid stenosis.  4.  History of
alcohol abuse.  5.  Acoustic neuroma.  6.  Benign prostatic
hypertrophy.

MEDICATION ON ADMISSION: Zoloft 125 mg p.o. q.d., Norvasc,
Atenolol, Flomax, Lipitor.

ALLERGIES: The patient on admission had no known drug
allergies but was found to be allergic to Ceftazidime.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in [**Hospital3 4634**].  He
has been sober for the past six months.  He has an 80
pack-year history of smoking.  He is a retired electrician. 

### Response:
{'Other anaphylactic reaction,Cephalosporin group causing adverse effects in therapeutic use,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Cellulitis and abscess of leg, except foot,Acute myeloid leukemia, in remission'}
