CHIEF COMPLAINT: Pancytopenia

PRESENT ILLNESS: 66yo M w/ PMH s/f HTN, seasonal allergies, osteoarthritis s/p L
TKA and R THA who is transferred from outside hospital with
pancytopenia, recent weight loss (semi-intentional), and found
to have blasts on peripheral smear by OSH hematologist. He
reports feeling mostly well prior to admission. He developed
headache last weekend that he felt was related to his sinuses,
given his h/o seasonal allergies. He then developed a sore
throat earlier this week. He went to the VA to be evaluated for
possible sinusitis/URI and CBC was checked which revealed WBC of
1.8. He was referred to OSH for further management. He was
evaluated in the ED and a hematologist was consulted who
examined the peripheral smear. Smear showed 50% lymphocytes, 28%
blasts, 2% metamyelocytes, 5% NRBCs. No clear cut Auer rods but
some blasts with significant granularity. Patient was transfused
2u PRBCs, started on allopurinol, 1/2NS w/ bicarb and K at OSH
and transferred here for further diagnostic workup. Of note, pt.
travels often to West Coast and spent 10 weeks in [**State 15946**] this
spring, returning [**2158-2-23**]. He reports allergic symptoms and
lots of dust. Also of note, pt. reports trying to lose weight
recently with 9-10lb weight loss in last 1-2 months. Denies
fever, chills, night sweats, fatigue, unintentional weight loss,
lymphadenopathy. Denies rash, joint pain, nausea, vomiting,
productive cough, diarrhea, BRBPR, melena.

MEDICAL HISTORY: Osteoarthritis, s/p L TKA, R THA
h/o negative colonoscopy-last [**2154**]
Hypertension
Seasonal Allergies
GERD

MEDICATION ON ADMISSION: Home:
Diovan 80mg PO daily
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Multiple vitamins, incl. MVI, B complex
.
On transfer:
Allopurinol 300mg PO daily
Ambien 5mg PO QHS prn insomnia
Colace 100mg PO BID
Dulcolax 10mg PO QAM prn constipation
Milk of Magnesia Q6h prn constipation
Mylanta 30ml PO Q4h prn
Procardia XL 30mg PO daily
Protonix 40mg PO daily
Reglan 10mg IV Q6h prn nausea
Robitussin 10mL PO Q4h prn cough
Tylenol 650mg PO Q6h prn
Zofran 4mg IV Q8h prn nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.4 132/90 115 18 94%RA 231lbs
Gen: alert, anxious M appearing stated age in NAD
HEENT: NC/AT, PERRL, EOMI, OP w/o exudate/erythema, MM moist, no
oral lesions, good dentition, no scleral pallor
Neck: supple, no submental, submandibular, supraclavicular,
ant/post cervical, pre/post auricular LAD
Skin: No rash, well healed vertical incision over L knee,
bandaid over L chest
Cor: Tachycardic but regular, no murmurs/rubs/gallops, +S1/S2
Lungs: CTAB, good air entry b/l, no rales/rhonchi/wheezes
Abd: slightly firm, nontender, nondistended, +BS, no
hepatosplenomegaly, no rebound or guarding
Extremities: warm, no clubbing or edema, +onychomycosis on all
toenails

FAMILY HISTORY: Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.

SOCIAL HISTORY: Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran. Denies ever smoking, no EtOH, no illicits.
Travelled to [**State 15946**] for 10 weeks, returning 4/[**2157**].
Encounter for antineoplastic chemotherapy,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Hemorrhage of gastrointestinal tract, unspecified,Hydronephrosis,Acute kidney failure, unspecified,Other specified disorders of skin,Esophageal reflux,Displacement of lumbar intervertebral disc without myelopathy,Other and unspecified hyperlipidemia,Knee joint replacement,Drug induced neutropenia,Fever presenting with conditions classified elsewhere,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Other specified periodontal diseases,Other constipation,Cough,Tachycardia, unspecified,Chronic ethmoidal sinusitis,Hypoxemia,Dysthymic disorder,Other abnormal blood chemistry,Hematuria, unspecified,Lesion of ulnar nerve
Antineoplastic chemo enc,Acute respiratry failure,Ac myl leuk wo achv rmsn,Gastrointest hemorr NOS,Hydronephrosis,Acute kidney failure NOS,Skin disorders NEC,Esophageal reflux,Lumbar disc displacement,Hyperlipidemia NEC/NOS,Joint replaced knee,Drug induced neutropenia,Fever in other diseases,Adv eff antineoplastic,Crnry athrscl natve vssl,Thrombocytopenia NOS,Anemia in neoplastic dis,Periodontal disease NEC,Constipation NEC,Cough,Tachycardia NOS,Chr ethmoidal sinusitis,Hypoxemia,Dysthymic disorder,Abn blood chemistry NEC,Hematuria NOS,Ulnar nerve lesion
Admission Date:  [**2158-7-13**]              Discharge Date:   [**2158-8-31**]

Date of Birth:  [**2092-6-29**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Pancytopenia

Major Surgical or Invasive Procedure:
Subclavian central venous catheter placement and removal
Bone marrow biopsies
- Right subclavian triple lumen central venous catheter
placement and removal
- Bone marrow biopsies (three)
- Lumbar puncture and intrathecal methotrexate


History of Present Illness:
66yo M w/ PMH s/f HTN, seasonal allergies, osteoarthritis s/p L
TKA and R THA who is transferred from outside hospital with
pancytopenia, recent weight loss (semi-intentional), and found
to have blasts on peripheral smear by OSH hematologist. He
reports feeling mostly well prior to admission. He developed
headache last weekend that he felt was related to his sinuses,
given his h/o seasonal allergies. He then developed a sore
throat earlier this week. He went to the VA to be evaluated for
possible sinusitis/URI and CBC was checked which revealed WBC of
1.8. He was referred to OSH for further management. He was
evaluated in the ED and a hematologist was consulted who
examined the peripheral smear. Smear showed 50% lymphocytes, 28%
blasts, 2% metamyelocytes, 5% NRBCs. No clear cut Auer rods but
some blasts with significant granularity. Patient was transfused
2u PRBCs, started on allopurinol, 1/2NS w/ bicarb and K at OSH
and transferred here for further diagnostic workup. Of note, pt.
travels often to West Coast and spent 10 weeks in [**State 15946**] this
spring, returning [**2158-2-23**]. He reports allergic symptoms and
lots of dust. Also of note, pt. reports trying to lose weight
recently with 9-10lb weight loss in last 1-2 months. Denies
fever, chills, night sweats, fatigue, unintentional weight loss,
lymphadenopathy. Denies rash, joint pain, nausea, vomiting,
productive cough, diarrhea, BRBPR, melena.

Past Medical History:
Osteoarthritis, s/p L TKA, R THA
h/o negative colonoscopy-last [**2154**]
Hypertension
Seasonal Allergies
GERD

Social History:
Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran. Denies ever smoking, no EtOH, no illicits.
Travelled to [**State 15946**] for 10 weeks, returning 4/[**2157**].


Family History:
Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.

Physical Exam:
VS: 99.4 132/90 115 18 94%RA 231lbs
Gen: alert, anxious M appearing stated age in NAD
HEENT: NC/AT, PERRL, EOMI, OP w/o exudate/erythema, MM moist, no
oral lesions, good dentition, no scleral pallor
Neck: supple, no submental, submandibular, supraclavicular,
ant/post cervical, pre/post auricular LAD
Skin: No rash, well healed vertical incision over L knee,
bandaid over L chest
Cor: Tachycardic but regular, no murmurs/rubs/gallops, +S1/S2
Lungs: CTAB, good air entry b/l, no rales/rhonchi/wheezes
Abd: slightly firm, nontender, nondistended, +BS, no
hepatosplenomegaly, no rebound or guarding
Extremities: warm, no clubbing or edema, +onychomycosis on all
toenails

Pertinent Results:
Admission Labs:

[**2158-7-13**] 05:48PM BLOOD WBC-2.3* RBC-3.69* Hgb-10.5* Hct-31.8*
MCV-86 MCH-28.4 MCHC-32.9 RDW-17.1* Plt Ct-30*
[**2158-7-13**] 05:48PM BLOOD Neuts-16* Bands-1 Lymphs-20 Monos-0 Eos-2
Baso-0 Atyps-1* Metas-0 Myelos-0 Blasts-60* NRBC-5* Other-0
[**2158-7-13**] 05:48PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+
Ovalocy-2+
[**2158-7-13**] 05:48PM BLOOD PT-13.2 PTT-24.6 INR(PT)-1.1
[**2158-7-13**] 05:48PM BLOOD Fibrino-665*
[**2158-7-21**] 12:04AM BLOOD Fibrino-607*
[**2158-7-14**] 03:30PM BLOOD ESR-45*
[**2158-7-17**] 12:00AM BLOOD Gran Ct-163*
[**2158-7-13**] 05:48PM BLOOD Glucose-102* UreaN-25* Creat-1.0 Na-141
K-4.4 Cl-102 HCO3-31 AnGap-12
[**2158-7-13**] 05:48PM BLOOD ALT-47* AST-37 LD(LDH)-396* AlkPhos-125
TotBili-1.1
[**2158-7-13**] 05:48PM BLOOD Albumin-4.3 Calcium-9.6 Phos-4.3 Mg-2.1
UricAcd-5.2
[**2158-7-14**] 06:00AM BLOOD TSH-1.5
[**2158-7-14**] 06:00AM BLOOD [**Doctor First Name **]-NEGATIVE
.
Discharge Labs:

.
Pathology:
[**7-13**] Flow cytometry:
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD2, CD3, CD4,
CD5, CD7, CD8, CD10, CD13, CD14, CD15, CD19, CD20, CD33, CD34,
CD41, CD11c, CD56, CD64, HLA-DR, KAPPA, LAMBDA, CD71, GlycA,
CD45, CD117.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast yield.
An abnormal population of events cluster within the blast gate.
They comprise of approximately 37% of all events. These 'blasts'
express CD7, CD34, CD13 (dim), CD33, CD11c(dim) and CD71. CD19
expression is equivocal. They are negative for CD20, CD10, CD3
(and other T-cell markers except CD7), CD64, CD14 and CD56.
Lymphoid gated events are unremarkable.
INTERPRETATION
Increased blasts with predominantly myeloid markers, consistent
with acute myeloid leukemia.  Morphological review shows blasts
(~58%) with high N:C ratio, rare Auer rods, scant paucigranular
cytoplasm, irregular nuclear contours, and open chromatin.
Findings discussed with Dr. [**Last Name (STitle) **] on [**2158-7-14**].
.
- [**7-14**] Bone Marrow:  By morphology and immunophenotype, the
blasts appear to be of early myeloid differentiation (FAB M1-2).
However, cytogenetics and other molecular findings are necessary
and should be correlated for an appropriate current WHO based
classification.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation.  Erythrocytes are
decreased in number and are normochromic and normocytic with
mild anisopoikilocytosis.  Occasional ovalocytes, dacrocytes and
polychromatophilic cells seen, 2 nucleated RBCs, 100 nucleated
cells seen.   The white blood cell count appears decreased.
There is a predominance of large, immature forms with high
nuclear cytoplasm ratio, scant agranular cytoplasm, prominent
nucleoli and fine chromatin consistent with blast forms.  Rare
Auer rod identified.  Platelet count appears decreased.  Large
forms are seen.  Giant forms are not present.  Differential
shows   6% neutrophils,  0% bands,  0% monocytes,  28%
lymphocytes,  2% eosinophils,  0% basophils, 63% blasts seen.
- Aspirate Smear:
The aspirate material is adequate for evaluation.  The M:E ratio
is 1.9:1.  Erythroid precursors show normoblastic maturation
with occasional megaloblastoid forms, irregular nuclear
contours, and rare nuclear buds.  Myeloid precursors consist of
a predominance of blast forms.  Megakaryocytes are present in
decreased numbers; abnormal forms are seen and include small
hypolobated forms.  Differential shows:  62% Blasts,  0%
Promyelocytes, <1% Myelocytes, 0% Metamyelocytes, 0%
Bands/Neutrophils, <1% Plasma cells,  3% Lymphocytes, 33%
Erythroid.
Blasts comprise 62% of the aspirate and are large with fine
chromatin, prominent nucleoli and scant cytoplasm.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation.  Prominent
aspiration artifact is present.  The overall cellularity of ~
70% with 80% blasts.  The M:E ratio estimate is normal.
Erythroid precursors are decreased and exhibit normoblastic
maturation.  Myeloid elements are decreased and consist of
predominantly blasts, without maturing hematopoiesis.
Megakaryocytes are markedly decreased.
Marrow clot section is similar to the biopsy.
Special Stains:
Iron stain is adequate for evaluation.  Storage iron is normal.
Sideroblasts are present.  Ringed sideroblasts are absent.
.
- [**7-14**] Cytogenetics: KARYOTYPE: 46,XY[20]
INTERPRETATION:
No cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
Mosaicism and small chromosome anomalies may not be
detectable using the standard methods employed.
-------------------INTERPHASE FISH ANALYSIS, 100-300
CELLS-------------------
nuc ish(D5S23,D5S721,EGR1)x2[100],(D7Z1,D7S522)x2[100],
(D20S108x2)[100]
FISH evaluation for a 5q deletion was performed with the
Vysis LSI EGR1/D5S23, D5S721 Dual Color Probe ([**Doctor Last Name 7594**]
Molecular) for EGR1 at 5q31 and D5S721/D5S23 at 5p15.2 and
is interpreted as NORMAL. Two EGR1 hybridization signals
were observed in 100/100 nuclei examined, which is within
the normal range established for this probe in the
Cytogenetics Laboratory at [**Hospital1 18**]. Up to 3% of cells in
normal samples can show apparent 5q deletion using this
probe set. A normal EGR1 FISH finding can result from
absence of a 5q deletion, from a 5q deletion that does not
involve the region to which this probe hybridizes, or from
an insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 7q deletion was performed with the
Vysis D7S522/CEP7 Dual Color Probe ([**Doctor Last Name 7594**] Molecular) for
D7S522 at 7q31 and CEP7 (D7Z1) (chromosome 7 alpha
satellite DNA) at 7p11.1-q11.1 and is interpreted as
NORMAL. Two D7S522 hybridization signals were observed in
100/100 nuclei, which is within the normal range
established for this probe in the Cytogenetics Laboratory
at [**Hospital1 18**]. Up to 3% of cells in normal samples can show
apparent 7q deletion using this probe set. A normal
D7S522 FISH finding can result from the absence of a 7q
deletion, from a 7q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
FISH evaluation for a 20q deletion was performed with the
Vysis LSI D20S108 Probe ([**Doctor Last Name 7594**] Molecular) at 20q12 and is
interpreted as NORMAL. Two hybridization signals were
observed in 98/100 nuclei examined, which is within the
normal range established for this probe in the Cytogenetics
Laboratory at [**Hospital1 18**]. Up to 8% of cells in normal samples
can show apparent 20q deletion using this probe set. A
normal 20q FISH finding can result from absence of a 20q
deletion, from a 20q deletion that does not involve the
region to which this probe hybridizes, or from an
insufficient number of neoplastic cells in the specimen.
.
Bone marrow [**2158-7-27**]: Peripheral Blood Smear:
The smear is adequate. Erythrocytes are decreased and exhibit
moderate anisocytosis and poikilocytosis. Scattered microcytes,
echinocytes, elliptocytes, dacrocytes and red cell fragments are
seen. Rare shistocytes are seen on scanning. The white blood
cell count appears markedly decreased and includes large
immature myeloid forms consistent with blasts. Lymphocytes
include small mature and large reactive forms. Platelet count
appears moderately decreased. Large forms are seen. Differential
count shows 0% neutrophils, 0% bands, 4% monocytes, 89%
lymphocytes, 0% eosinophils, 7% blasts.
Aspirate Smear: The aspirate material is adequate for evaluation
and is predominantly comprised of large atypical myeloid forms
with one to several prominent nucleoli consistent with blasts.
Erythroid precursors are markedly decreased. Rare maturing forms
are present. Maturing myeloid precursors are greatly decreased
in number. Megakaryocytes are present in normal numbers.
Differential (300 cells) shows:  72% Blasts, 2% Promyelocytes,
<1% Myelocytes, <1% Metamyelocytes, <1% Bands/Neutrophils, 3%
Plasma cells, 18% Lymphocytes, 5% Erythroid.
Clot Section and Biopsy Slides: The biopsy material is adequate
for evaluation. The overall cellularity is approximately 40% and
is comprised almost entirely of large blast forms present in
large clusters. The blasts comprise 70-80% of overall marrow
cellularity. The remainder of the cellular components are made
up of lymphocytes, plasma cells and rare maturing myeloid and
erythroid precursors. Megakaryocytes are present.
.
- Bone marrow [**2158-8-16**]: <<<<      >>>

.
Imaging:
- [**7-14**] TTE: The left atrium is elongated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets are mildly thickened (?#). There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. No mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Biatrial dilation.
.
- [**7-14**] CXR:  No previous images. There is some apparent
hyperexpansion of the
lungs suggesting some chronic pulmonary disease. However, no
evidence of
acute pneumonia, vascular congestion, or pleural effusion.
Right subclavian PICC line extends to the mid portion of the
SVC. No evidenceof pneumothorax.
.
- [**7-20**] CXR: Aside from atelectasis in the left base the lungs
are clear. There are low lung volumes. Cardiomediastinal
contours are normal. Right PICC tip is in the mid SVC.
.
- [**7-24**] CT Chest w/o con: 4.5-mm right lower lobe nodule. Suggest
repeat examination in six months.Multifocal subsegmental
atelectasis, not obstructive. Coronary calcification.
.
- [**2158-7-28**] CT chest/abd/pelvis: No abnormal interstitial lung
process or site of infection identified. Interval increase in
number of mediastinal nodes extensively, but no single
pathologically enlarged lymph node.
.
- [**2158-7-30**] CTA chest: 1. Limited CT examination due to respiratory
artifact. No proximal or segmental pulmonary emboli identified.
More distal branches obscured due to poor filling and breathing
artifact. If a high clinical concern for embolus, a dedicated
V/Q scan could be obtained if patient is able to tolerate as the
lungs. Slightly increased linear atelectasis. 2. Unchanged small
mediastinal lymph nodes of uncertain etiology. 3.
Atherosclerotic calcification within the coronary vessels.
Small-to-moderate hiatal hernia. 4. Stable right-sided pulmonary
nodules as detailed above; can be followed in six months as
suggested on initial [**2158-7-24**] CT chest.
.
- [**2158-8-15**] CT abdomen/pelvis: Mild delayed right nephrogram with
high-density filling defect within the posterior calices of the
right upper pole, most consistent with underlying clot. There is
mild right hydronephrosis and proximal-mid hydroureter with
abrupt cutoff of contras column in the mid-distal ureter. This
may reflect more distal intraureteral clot, although a focal
obstructing lesion cannot be
completely excluded. Can consider correlation with follow up CT
or further
evaluation with dedicated MR urogram or ureteroscopy as needed.

-[**2158-8-16**] Bone marrow biopsy: MARKEDLY HYPOCELLULAR BONE MARROW
WITH FEATURES CONSISTENT WITH CHEMOTHERAPY-INDUCE MARROW
ABLATION. THERE IS NO MORPHOLOGIC EVIDENCE OF INVOLVEMENT BY
ACUTE MYELOID LEUKEMIA.

-[**2158-8-23**] Renal u/s: Mild to moderate right and mild left
hydronephrosis.

-[**2158-8-24**] MRI C and T spine, brachial plexus: No abnormal
cervical or thoracic spine enhancement.  Limited study by
motion, but grossly normal MR appearance of the brachial plexus
bilaterally.

-[**2158-8-26**] CT chest w/o contrast: Redemonstration of tiny
pulmonary nodules as detailed above, the largest of which is
approximately 5 mm. Would recommend repeat evaluation with a
dedicated CT of the chest in approximately six months.

-[**2158-8-27**] Bone marrow biopsy: Hypocellular marrow with erythroid
dominant elements. Diagnostic features of involvement by acute
myeloid leukemia are not seen,  By immunohistochemical stains,
CD34 reactive blasts comprised <5% of overall marrow
cellularity.  E-cadherin expression is present in scattered
clusters of early erythroid precursors, while Glycophorin A
highlights numerous maturing erythroid forms.

-[**2158-8-28**] Urine cytology: Rare cluster of atypical but
degenerated urothelial cells.


Brief Hospital Course:
66yo M w/ unrelated PMH presented to OSH, found to have
pancytopenia w/ blasts in smear, transferred and found to have
AML on flow cytometry and bone marrow biopsy.
.
# AML: Patient was admitted and found to be pancytopenic but
asymptomatic except a chronic non-productive cough that was
attributed to seasonal allergies. He underwent TTE which showed
normal LVEF. He underwent bone marrow biopsy on [**7-14**] which
confirmed diagnosis of AML. A triple lumen subclavian CVL was
placed on [**7-14**]. He was started on 7+3 induction therapy on [**7-14**].
He tolerated the infusion well and his ANC fell to 0 on [**7-22**]. He
was thrombocytopenic and developed gingival bleeding with PLT in
the 30s and was transfused as needed. He was also anemic and
transfused as needed. Repeat bone marrow showed
hypercellularity. Patient was started on MEC therapy and
tolerated it well. His ANC remained 0. Repeat bone marrow on D14
of MEC showed hypocellularity. His counts gradually increased
and antibiotics were discontinued, he had been on broad coverage
with vancomycin, cefepime, and ambisome (spent a lot of time in
[**State 15946**]) and remained on these antibiotics until he was no
longer neutropenic or febrile.  Counts continued to increase and
at the time of discharge pt was no longer neutropenic and WBC
was 4.1.  Bone marrow biopsy on [**2158-8-28**] showed no clonal
cytogenetic aberrations and <5% blasts.  However, skin biopsy
for a purple-pink papular rash on both forearms with biopsy was
consistent with leukemia cutis.  Considering his bone marrow
response and the resolution of this rash, it was thought to be
rseolved.  He will followup with Dr. [**Last Name (STitle) **] for futher
treatment.
.
# Febrile Neutropenia: As counts decreased, the patient was
febrile without obvious source in urine or lungs and was started
on cefepime and vancomycin and levofloxacin which had been
prescribed for cough was discontinued. Given the concern for
hemorrhoids and possible minor anal mucosal tear, see below,
Flagyl was added. Micafungin was added on day 4 after first
spike given continued fevers. Pt. felt well and was ambulatory,
taking PO during this time. Patient clinically improved, but
then developed high fevers, rigors, and whole-body rash,
respiratory distress (see ICU course below). He was pan-scanned
again, and CT sinus showed sinusitis. Coccidio, beta-glucan,
galactmannan, histoplasmosis, legionella, blood fungal cultures
were sent and were all eventually negative. ID was consulted and
suggested removing cefepime and micafungin as they might cause
rash. He was placed on vancomycin, meropenem, and ambisome (for
aspergillus and coccidiomycosis coverage). Patient had risen
LFTs which eventually trended down. He improved clinically and
antibiotic coverage was stopped on [**8-26**] when patient had been
afebrile for several days and ANC >1000.  Beta glucan from [**8-26**]
was >500.  ID was consulted again and advised to recheck beta
glucan, as it may have been an erroneous result, since he was
asymptomatic and had stable lesions on chest CT from [**8-26**], and
also requested a mycoF/lytic culture.  These results are to be
followed up as an outpatient and no antifungal coverage or
liver/spleen imaging were advised unlses the he spiked a fever,
which he did not do.
.
# Guaiac positive stool: Patient reported hard and painful BM
during induction therapy. Bloody streaks were seen on stool,
minimal blood in toilet. Platelets transfused, Hct stable. Bowel
regimen increased and further BMs were guaiac neg and soft for
the rest of his hospital course.

#hematuria: noted to have hematuria [**8-15**] in the setting of
thrombocytopenia.  CT abd/pelvis showed mild R hydronephrosis
and proximal-mid hydroureter on [**8-15**].  Hematuria resolved as
thrombocytopenia resolved, platelets were transfused for <10.
F/u ultrasound showed bilateral hydronephrosis in the setting of
increasing creatinine, urology was consulted concerning the
hydronephrosis and advised that he follow up as an outpatient
for a hematuria workup.
.
#Thrombocytopenia: pt had low platelets as expected and was
transfused PRN for platelets <10.  On [**8-20**], had urticarial
reaction to crossmatched platelets that improved with tylenol,
PRA assay positive.  Thrombocytopenia improved without
intervention as the rest of counts went up as well.

#Acute kidney injury: Patient's creatinine was elevated starting
[**8-24**] from baseilne of 0.9 to 1.8 on [**8-29**] despite removal of
nephrotoxic vancomycin and ambisome on [**8-26**].  Renal was
consulted and considering FeNa of 2.1, was thought to be due to
AIN, although it is unclear which medication caused this.  He
did have a drug rash earlier in his hospital course, thought to
be related to micafungin or meropenem, but it is unclear what
caused the AIN.  He will followup with renal service as an
outpatient.

#L 4th and 5th finger numbness: Patient had noted this
consistently for a week and mentioned it on [**2158-8-24**].  MRI T and
C spine and brachail plexus were ordered to eval for CNS spread
of disease, in addition LP was done.  No lesions on MRI and no
evidence of CNS disease.  Numbness may be [**12-27**] ulnar neuropathy,
he will follow up in neurology clinic and may get an EMG.
.
ICU Course ([**Date range (1) 29638**])
Hypoxia: Pt with increased O2 demand and some respiratory
distress which lead to his brief transfer from the onc service
to the [**Hospital Unit Name 153**]. Pt was initially given nebs, changed from NC to
facemask, and given IV lasix. He was redosed with lasix with
good urine output. CXR showed no change and ECHO was obtained.
Pt O2 requirement stabilized and he was titrated down to lower
dose nasal cannula.
.
Febrile Neutropenia: Temp of 101.4 at time of ICU transfer.
Broad spectrum antibiotics were continued but elevated LFTs
raised concern over the administration of fluconazole. Because
of the pts significant travel history to some fungal endemic
regions it was determined to treat emperically with Ambisome so
this was started and Fluconazole D/Ced. Near the end of the
first Ambisome infusion pt spiked a fever above 104 and had
chills/rigors. This calmed down with demerol and tylenol and was
thought likely due to the infusion vs an infectious cause.
.
Pancytopenia: This was thought [**12-27**] to AML and chemo with Hgb low
on ICU presentation. Over brief ICU course 1 unit of PRBC was
initially given followed by 2 units PRBC the next day. Pt had
mild temp at time of beginning of the 2nd transfusion but it was
administered in spite of this. Hct responded appropriately to
these infusions.
.


Medications on Admission:
Home:
Diovan 80mg PO daily
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Multiple vitamins, incl. MVI, B complex
.
On transfer:
Allopurinol 300mg PO daily
Ambien 5mg PO QHS prn insomnia
Colace 100mg PO BID
Dulcolax 10mg PO QAM prn constipation
Milk of Magnesia Q6h prn constipation
Mylanta 30ml PO Q4h prn
Procardia XL 30mg PO daily
Protonix 40mg PO daily
Reglan 10mg IV Q6h prn nausea
Robitussin 10mL PO Q4h prn cough
Tylenol 650mg PO Q6h prn
Zofran 4mg IV Q8h prn nausea

Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
3. nifedipine 30 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
4. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
Acute Myelogenous Leukemia


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


Discharge Instructions:
Mr. [**Known lastname 86903**], you were admitted to the [**Hospital1 827**] because you had low blood count. We obtained a
bone marrow biopsy which showed that you had acute myelogenous
leukemia. You were started on chemotherapy. Your cell counts
dropped as expected, and you developed a fever. We did CT scans
of your sinus, chest, and abdomen to look for a source of
infeciton. We treated you with many antibiotics. One of the
antibiotics gave you a rash, which resolved after we stopped it.
You had a repeat bone marrow biopsy which still showed leukemia,
so you underwent a second round of chemotherapy. While you white
blood cell counts were at their nadir, you have difficulty
breathing and spiked high fevers with rigors for many days. We
continued with medications to treat bacterial or fungal
infections. You eventually got better and did not have any more
fevers and your white blood cell counts increased (including
neutrophil count) and we stopped your antibiotics.  We did a
final bone marrow biopsy which showed <5% blasts, indicating a
good response.  You will follow up with Dr. [**Last Name (STitle) **] on Friday
to discuss the next steps in your treatment.

Your creatinine was increasing (number that shows kidney
function), which we think is likely due to acute interstitial
nephritis (allergic reaction in your kidneys likely from
medications).  You should follow up with urology clinic and
renal clinic about this and the blood in your urine you had a
couple of weeks ago.  You should also follow up in neurology
clinic so they can check on the numbness in your left hand.
Your sutures can be taken out in one week (around [**9-7**]), this
can be done at clinic.
.
We made the following changes to your medications:
stop taking diovan
start taking nifedipine (procardia)
start taking acyclovir

Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 162**] & [**Hospital1 **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2158-10-2**] 4:00  (neurology-finger numbness)

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2158-9-25**] 3:00 (renal-kidneys)

Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-9-1**] 2:00 (oncologist-leukemia)

[**2158-11-3**]  02:00p   [**Last Name (LF) **],[**First Name3 (LF) 275**] C. (urology, for blood in your
urine)



Completed by:[**2158-9-1**]
{'Encounter for antineoplastic chemotherapy,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Hemorrhage of gastrointestinal tract, unspecified,Hydronephrosis,Acute kidney failure, unspecified,Other specified disorders of skin,Esophageal reflux,Displacement of lumbar intervertebral disc without myelopathy,Other and unspecified hyperlipidemia,Knee joint replacement,Drug induced neutropenia,Fever presenting with conditions classified elsewhere,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Other specified periodontal diseases,Other constipation,Cough,Tachycardia, unspecified,Chronic ethmoidal sinusitis,Hypoxemia,Dysthymic disorder,Other abnormal blood chemistry,Hematuria, unspecified,Lesion of ulnar nerve'}


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: Pancytopenia

PRESENT ILLNESS: 66yo M w/ PMH s/f HTN, seasonal allergies, osteoarthritis s/p L
TKA and R THA who is transferred from outside hospital with
pancytopenia, recent weight loss (semi-intentional), and found
to have blasts on peripheral smear by OSH hematologist. He
reports feeling mostly well prior to admission. He developed
headache last weekend that he felt was related to his sinuses,
given his h/o seasonal allergies. He then developed a sore
throat earlier this week. He went to the VA to be evaluated for
possible sinusitis/URI and CBC was checked which revealed WBC of
1.8. He was referred to OSH for further management. He was
evaluated in the ED and a hematologist was consulted who
examined the peripheral smear. Smear showed 50% lymphocytes, 28%
blasts, 2% metamyelocytes, 5% NRBCs. No clear cut Auer rods but
some blasts with significant granularity. Patient was transfused
2u PRBCs, started on allopurinol, 1/2NS w/ bicarb and K at OSH
and transferred here for further diagnostic workup. Of note, pt.
travels often to West Coast and spent 10 weeks in [**State 15946**] this
spring, returning [**2158-2-23**]. He reports allergic symptoms and
lots of dust. Also of note, pt. reports trying to lose weight
recently with 9-10lb weight loss in last 1-2 months. Denies
fever, chills, night sweats, fatigue, unintentional weight loss,
lymphadenopathy. Denies rash, joint pain, nausea, vomiting,
productive cough, diarrhea, BRBPR, melena.

MEDICAL HISTORY: Osteoarthritis, s/p L TKA, R THA
h/o negative colonoscopy-last [**2154**]
Hypertension
Seasonal Allergies
GERD

MEDICATION ON ADMISSION: Home:
Diovan 80mg PO daily
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Multiple vitamins, incl. MVI, B complex
.
On transfer:
Allopurinol 300mg PO daily
Ambien 5mg PO QHS prn insomnia
Colace 100mg PO BID
Dulcolax 10mg PO QAM prn constipation
Milk of Magnesia Q6h prn constipation
Mylanta 30ml PO Q4h prn
Procardia XL 30mg PO daily
Protonix 40mg PO daily
Reglan 10mg IV Q6h prn nausea
Robitussin 10mL PO Q4h prn cough
Tylenol 650mg PO Q6h prn
Zofran 4mg IV Q8h prn nausea

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.4 132/90 115 18 94%RA 231lbs
Gen: alert, anxious M appearing stated age in NAD
HEENT: NC/AT, PERRL, EOMI, OP w/o exudate/erythema, MM moist, no
oral lesions, good dentition, no scleral pallor
Neck: supple, no submental, submandibular, supraclavicular,
ant/post cervical, pre/post auricular LAD
Skin: No rash, well healed vertical incision over L knee,
bandaid over L chest
Cor: Tachycardic but regular, no murmurs/rubs/gallops, +S1/S2
Lungs: CTAB, good air entry b/l, no rales/rhonchi/wheezes
Abd: slightly firm, nontender, nondistended, +BS, no
hepatosplenomegaly, no rebound or guarding
Extremities: warm, no clubbing or edema, +onychomycosis on all
toenails

FAMILY HISTORY: Thinks he had an uncle w/ liver cancer. Father died of AAA,
mother of ?CHF. Multiple family members w/ CVA as cause of
death. No known h/o hematologic malignancies.

SOCIAL HISTORY: Never married, no children. Lives alone. Retired fireman.
U.S.M.C. veteran. Denies ever smoking, no EtOH, no illicits.
Travelled to [**State 15946**] for 10 weeks, returning 4/[**2157**]. 

### Response:
{'Encounter for antineoplastic chemotherapy,Acute respiratory failure,Acute myeloid leukemia, without mention of having achieved remission,Hemorrhage of gastrointestinal tract, unspecified,Hydronephrosis,Acute kidney failure, unspecified,Other specified disorders of skin,Esophageal reflux,Displacement of lumbar intervertebral disc without myelopathy,Other and unspecified hyperlipidemia,Knee joint replacement,Drug induced neutropenia,Fever presenting with conditions classified elsewhere,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Coronary atherosclerosis of native coronary artery,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Other specified periodontal diseases,Other constipation,Cough,Tachycardia, unspecified,Chronic ethmoidal sinusitis,Hypoxemia,Dysthymic disorder,Other abnormal blood chemistry,Hematuria, unspecified,Lesion of ulnar nerve'}
