CHIEF COMPLAINT: Scheduled admission for chemotherapy

PRESENT ILLNESS: Ms. [**Known lastname **] is a 50 year old woman with history of AML, allogenic
transplant in [**2110-8-4**], and recent admissions for right-sided
hydronephrosis ([**Month (only) 116**]), donor lymphocyte infusion in (discharged
[**8-24**]), and left-sided hydronephrosis (discharged [**10-4**]). She
has been admitted for chemotherapy in preparation for donor
lymphocyte infusion vs. second bone marrow transplant.
.
She reports feeling "lousy" for the past several weeks, with
feelings of fatigue and lack of stamina. She has had increased
bruising. Her steroids were increased last Friday to 40mg daily
from 30mg daily. She reports a headache and fever to 100.5 last
night which came down with Tylenol.

MEDICAL HISTORY: ONCOLOGY HX:
- Acute myelogenous leukemia s/p allo transplant
- [**2110-8-4**]: 5 of 6 matched family member allogenic BMT for AML.
Father was her donor. She has remained in complete remission; no
GVHD.  Her performance status was 100%.
- mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of relapsed AML, planning for DLI
.
PMH:
1. AML- as above
2. Allergic rhinitis
3. Depression

MEDICATION ON ADMISSION: Ciprofloxacin 250mg [**Hospital1 **]
Ritalin 20mg QD
Citalopram 20mg QD
Loratadine 20mg QD
Beclonase [**Hospital1 **]
Fluconazole 200mg QD
Acyclovir 400mg [**Hospital1 **]
Protonix 40mg [**Hospital1 **]
Sudafed 30 mg QD
Potassium 20mEq powder
Fluconazole QD
Prednisone 40mg (increased on Friday)

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

PHYSICAL EXAM: Vitals: T 98.6  BP 107/67  P 98  RR 18  O2sat 98%
Gen: Well-appearing, no acute distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: No LAD
Card: RRR, normal S1/S2, no m/r/g
Pulm: CTA bilaterally
Back: No CVAT, mild tenderness around percutaneous nephrostomy
insertion site, ecchymoses
Abd: Soft, non-distended, RUQ and epigastric tenderness
Ext: No clubbing or cyanosis, 1+ non-pitting edema bilaterally,
2+ pulses bilaterally
Skin: Some ecchymoses, no rashes
Neuro: A&Ox3, responds appropriately

FAMILY HISTORY: Both parents living. Mother with HTN, MI, SLE; father with HTN.
Father (donor) recently had MI. Siblings with hypertension.

SOCIAL HISTORY: Married, lives with her husband and three children ages 13, 8,
6. Works as a controller. No tobacco or EtOH.
Encounter for antineoplastic chemotherapy,Acute myeloid leukemia, without mention of having achieved remission,Bacteremia,Bone marrow replaced by transplant,Stricture or kinking of ureter,Peritoneal effusion (chronic),Stomatitis and mucositis, unspecified,Ulcer of anus and rectum,Hypotension, unspecified,Rash and other nonspecific skin eruption,Neutropenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Anemia in neoplastic disease,Unspecified drug or medicinal substance causing adverse effects in therapeutic use
Antineoplastic chemo enc,Ac myl leuk wo achv rmsn,Bacteremia,Trnspl status-bne marrow,Stricture of ureter,Peritoneal effusion,Stomatitis/mucositis NOS,Rectal & anal ulcer,Hypotension NOS,Nonspecif skin erupt NEC,Neutropenia NOS,Other anaerobes,Anemia in neoplastic dis,Adv eff medicinal NOS
Admission Date:  [**2114-10-22**]              Discharge Date:   [**2114-11-16**]

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

Service: MEDICINE

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

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Scheduled admission for chemotherapy


Major Surgical or Invasive Procedure:
s/p antegrade nephrostogram
s/p PICC line placement


History of Present Illness:
Ms. [**Known lastname **] is a 50 year old woman with history of AML, allogenic
transplant in [**2110-8-4**], and recent admissions for right-sided
hydronephrosis ([**Month (only) 116**]), donor lymphocyte infusion in (discharged
[**8-24**]), and left-sided hydronephrosis (discharged [**10-4**]). She
has been admitted for chemotherapy in preparation for donor
lymphocyte infusion vs. second bone marrow transplant.
.
She reports feeling "lousy" for the past several weeks, with
feelings of fatigue and lack of stamina. She has had increased
bruising. Her steroids were increased last Friday to 40mg daily
from 30mg daily. She reports a headache and fever to 100.5 last
night which came down with Tylenol.

Past Medical History:
ONCOLOGY HX:
- Acute myelogenous leukemia s/p allo transplant
- [**2110-8-4**]: 5 of 6 matched family member allogenic BMT for AML.
Father was her donor. She has remained in complete remission; no
GVHD.  Her performance status was 100%.
- mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of relapsed AML, planning for DLI
.
PMH:
1. AML- as above
2. Allergic rhinitis
3. Depression

Social History:
Married, lives with her husband and three children ages 13, 8,
6. Works as a controller. No tobacco or EtOH.

Family History:
Both parents living. Mother with HTN, MI, SLE; father with HTN.
Father (donor) recently had MI. Siblings with hypertension.

Physical Exam:
Vitals: T 98.6  BP 107/67  P 98  RR 18  O2sat 98%
Gen: Well-appearing, no acute distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: No LAD
Card: RRR, normal S1/S2, no m/r/g
Pulm: CTA bilaterally
Back: No CVAT, mild tenderness around percutaneous nephrostomy
insertion site, ecchymoses
Abd: Soft, non-distended, RUQ and epigastric tenderness
Ext: No clubbing or cyanosis, 1+ non-pitting edema bilaterally,
2+ pulses bilaterally
Skin: Some ecchymoses, no rashes
Neuro: A&Ox3, responds appropriately

Pertinent Results:
Urine cytology : NEGATIVE FOR MALIGNANT CELLS.
.
RUQ U/S [**10-23**]: Mildly distended gallbladder. Mildly distended
common bile duct. Negative [**Doctor Last Name 515**] sign. HIDA can be performed
for further evaluation if clinically warranted.
.
CT Abd/Pelvis [**10-23**]: 1. Ascites and edema of the small and large
bowel. The appearances may be consistent with enteritis or a
graft versus host disease. 2. No evidence of perforation. 3.
Left nephrostomy tube. 4. Moderate dilation of right kidney. 5.
Unchanged appearance of low attenuation lesions in pancreas and
liver.
.
Abd X-Ray [**10-23**]: FINDINGS: Left nephrostomy tube is present. No
dilated bowel loops are identified. Stool and air is present in
the colon. The osseous structures are unremarkable. IMPRESSION:
No obstruction.
.
[**2114-11-5**] BONE MARROW CORE BIOPSY:
DIAGNOSIS: Markedly hypocellular bone marrow with extensive
fibrosis and focal increased blasts, see note.
Note: The aspirate material is aspicular. The core biopsy shows
extensive areas of grade 3 reticulin fibrosis. An
immunohistochemical stain for CD34 highlights a focal area with
increased interstitial blasts within the extensively fibrotic
background, which likely represents minimal residual disease.
This was reviewed in consultation with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] who concurs.
Compared to the previous biopsy, the current biopsy shows a
marked reduction in cellularity.
MICROSCOPIC DESCRIPTION.
Peripheral Blood Smears:
Red blood cells show hypochromasia and anisopoikilocytosis with
rare microcytes, red cell fragments and dacrocytes.
The white blood cell count appears markedly decreased. Platelet
count appears markedly decreased.  Large/giant forms are not
seen.
A limited 25 cell differential shows   100% lymphocytes.
Aspirate Smears:
The aspirate material is inadequate for evaluation due to a lack
of spicules, hemodilution, and clotted sample.
Clot Section and Biopsy Slides:
The biopsy material is fragmented, but adequate for evaluation.
One bony piece is  hypocellular with new bone formation and
likely represents previous biopsy site.
A second bony core fragment contains diffuse background fibrosis
occupying more than half the length of this piece. In the
remaining half, the cellularity is variable (overall 10%) and is
comprised predominantly of plasma cells, lymphocytes, and
hemosiderin-laden macrophages.  A small lymphoid aggregate is
seen.  Maturing myeloid and erythroid precursors are extremely
scant.
A CD34 immunohistochemical stain is performed to better assess
presence of blasts, given the architectural distortion by
background fibrosis. The CD34 stain highlights scattered
interstitial mononuclear cells within the fibrotic areas overall
comprising ~10% of marrow cellularity (the remaining being
lymphocytes and plasma cells).
Special Stains:
Iron stain is inadequate for evaluation due to lack of spicules.

Reticulin stain shows extensive Grade 3 reticulin fibrosis.
Trichrome stain does not show any collagen fibrosis.

ADDENDUM: Additional immunohistochemical studies with antibodies
against favor VIII-related antigen highlights endothelial cells.
Definite staining amongst blasts is not seen, however, scant
tissue remains on deeper sections used for immunohistochemical
staining.
.
Renal U/S: IMPRESSION: No definite evidence of hydronephrosis.
Left-sided nephrostomy tube is seen in place. Likely right-sided
ureteral jet. No left ureteral jet identified.
.
[**2114-11-15**] Antegrade Nephrostogram:IMPRESSION: Persistent
narrowing of the distal left ureter, probably from the extrinsic
compression, unchanged from the study from one month ago


Brief Hospital Course:
#) AML. She was admitted for scheduled MEC with initial plans
for either second DLI vs. second BMT. She tolerated MEC, but her
course was complicated by severe mucositis. pain was controlled
with Fentanyl PCA. She also developed diarrhea (C. diff and
other stool cultures negative and symptomatically treated with
immodium).
Day 14 marrow revealed markedly hypocellular bone marrow with
extensive fibrosis and focal increased blasts. On discharge, she
is to follow-up with her outpatient oncologist for a repeat bone
marrow bx and further discussion of additional chemotherapy/mini
transplant.
.
#) Abdominal pain: Patient was admitted with complaints of mild
abdominal discomfort. Then, on AM of [**10-23**], developed worsening
abdominal pain, diffuse, worse in LLQ. KUB negative for free air
and obstruction. She was given lorazepam 1g IV for anxiety and
sent for CT abd/pelvis without contrast. After returning from
CT, BP was found to be 70/40 with continued progression of her
pain. She also had some associated nausea. She was mentating
normally throughout. She was given a 1L NS bolus with transient
improvement of her blood pressure to 95/50s. She was also given
aztreonam 2g IV, vancomycin 1g IV, and metronidazole 500mg IV.
She also received morphine 1mg IV for pain with little relief.
Surgery was consulted and she was transferred to the ICU. Abd CT
revealed ascites and edema of the small and large bowel. The
appearances may be consistent with enteritis or a graft versus
host disease with no evidence of perforation. Ultimately, this
was felt not to be an acute surgical abdomen. Once her blood
pressure stabilized and she was aggressively diuresed. Following
diuresis, her abdominal pain also subsided. By the time of
discharge, she was feeling well without abdominal discomfort.
.
#) Hypotension: In the setting of severe abdominal pain, she was
found to have SBP in 80's, which responded well to fluid
boluses. Initially, there was concern for sepsis, and she was
started on stress dose steroids, which were ultimately tapered
down. Afterwards, her BP remained stable. She was discharged on
a tapered down dose of 5 mg prednisone QD.
.
#) Fevers: Beginning on [**11-7**], she developed fevers to 101. She
was empirically covered with aztreonam, vancomycin and
caspofungin. There was concern for a line infection from her
left IJ, which waspulled. The tip was sent for culture, but no
organisms grew. Blood cx subsequently grew out Lactobacillus X3.
ID was consulted and suggested starting meropenam. Given she has
a hx of hives to penicillins, she was premedicated and tolerated
the meropenam without incident. She was discharged to complete a
total of 14 day course of meropenam. Ertapenam as QD antibiotic
was discussed, but as there was no literature to support its
efficacy against lactobacillus, she was discharged with VNA
services to help administer her IV meropenam.  By dicharge, she
had been afebrile for greater than 72 hours.
.
#) Hydronephrosis: Patient has a history of obstruction of her
ureters. The etiology remains unclear as the ureters behave as
if there is external compression, but there are no compressing
masses seen on any imaging. She was s/p urgent placement of L
nephrostomy tube, and had been responding well. On [**11-10**], she
developed R flank pain (very mild and intermittent) as well as
decreased urine output. There was concern for right ureteral
obstruction as well, but Abd U/S revealed normal flow through R
ureter. Urology was consulted regarding taking out her left
nephrostomy tube prior to discharge. She had a antegrade
nephrostogram, which revealed essentially unchanged partial
obstruction of left ureter with only minimal and slow flow. the
decision was made for her to follow-up with her urologist, Dr.
[**Last Name (STitle) 770**], as an outpatient to further assess in 2 weeks.
.
#) F/E/N: IVF, bolus as needed, replete electrolytes as needed.
She was started on TPN for nutrition given her abdominal pain
and was gradually weaned off. By discharge, she was tolerating
PO's.


Medications on Admission:
Ciprofloxacin 250mg [**Hospital1 **]
Ritalin 20mg QD
Citalopram 20mg QD
Loratadine 20mg QD
Beclonase [**Hospital1 **]
Fluconazole 200mg QD
Acyclovir 400mg [**Hospital1 **]
Protonix 40mg [**Hospital1 **]
Sudafed 30 mg QD
Potassium 20mEq powder
Fluconazole QD
Prednisone 40mg (increased on Friday)

Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Loratadine 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Methylphenidate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Beclomethasone Diprop Monohyd 42 mcg (0.042 %) Aerosol, Spray
Sig: One (1)  Nasal [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO Q4H (every 4
hours) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*1*
9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
10. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  Q8H (every 8 hours) for 7 days: Please premedicate
with Tylenol.
Disp:*21 Recon Soln(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1)  PO once a
day.
Disp:*30 packets* Refills:*2*
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Line care
Please flush and care for line as per IV network protocol


Discharge Disposition:
Home With Service

Facility:
VNS of [**Location (un) 7188**] and [**Location (un) 16221**] County

Discharge Diagnosis:
Primary:
AML
lactobacillus bacteremia
ureteral stricture


Discharge Condition:
good


Discharge Instructions:
You have AML and received induction chemotherapy during this
admission. During this hospital course, you have some narrowing
of your left ureter requiring the nephrostomy tube to be in
place. You will need to address this issue with your urologist,
Dr. [**Last Name (STitle) 770**]. Also, you have a bacteria called Lactobacillus
growing in your blood. To treat this bacteria, you will need to
take an antibiotic called Meropenam IV every 8hours for one
week.

Please attend all follow-up appointments and take all
medications as prescribed.

Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] at [**Hospital1 18**] [**2114-11-19**] at
12:30.
.
Also, please follow-up with your urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]
to discuss when you can have your nephrostomy tube removed. Your
appointment with him is on [**2114-11-29**] 2:50PM in [**Hospital Ward Name 23**] Building
[**Location (un) 436**], [**Hospital1 18**] [**Hospital Ward Name **].
{'Encounter for antineoplastic chemotherapy,Acute myeloid leukemia, without mention of having achieved remission,Bacteremia,Bone marrow replaced by transplant,Stricture or kinking of ureter,Peritoneal effusion (chronic),Stomatitis and mucositis, unspecified,Ulcer of anus and rectum,Hypotension, unspecified,Rash and other nonspecific skin eruption,Neutropenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Anemia in neoplastic disease,Unspecified drug or medicinal substance causing adverse effects in therapeutic use'}


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: Scheduled admission for chemotherapy

PRESENT ILLNESS: Ms. [**Known lastname **] is a 50 year old woman with history of AML, allogenic
transplant in [**2110-8-4**], and recent admissions for right-sided
hydronephrosis ([**Month (only) 116**]), donor lymphocyte infusion in (discharged
[**8-24**]), and left-sided hydronephrosis (discharged [**10-4**]). She
has been admitted for chemotherapy in preparation for donor
lymphocyte infusion vs. second bone marrow transplant.
.
She reports feeling "lousy" for the past several weeks, with
feelings of fatigue and lack of stamina. She has had increased
bruising. Her steroids were increased last Friday to 40mg daily
from 30mg daily. She reports a headache and fever to 100.5 last
night which came down with Tylenol.

MEDICAL HISTORY: ONCOLOGY HX:
- Acute myelogenous leukemia s/p allo transplant
- [**2110-8-4**]: 5 of 6 matched family member allogenic BMT for AML.
Father was her donor. She has remained in complete remission; no
GVHD.  Her performance status was 100%.
- mid-[**7-10**] found to have peripheral blasts and host cells in
marrow, suggestive of relapsed AML, planning for DLI
.
PMH:
1. AML- as above
2. Allergic rhinitis
3. Depression

MEDICATION ON ADMISSION: Ciprofloxacin 250mg [**Hospital1 **]
Ritalin 20mg QD
Citalopram 20mg QD
Loratadine 20mg QD
Beclonase [**Hospital1 **]
Fluconazole 200mg QD
Acyclovir 400mg [**Hospital1 **]
Protonix 40mg [**Hospital1 **]
Sudafed 30 mg QD
Potassium 20mEq powder
Fluconazole QD
Prednisone 40mg (increased on Friday)

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

PHYSICAL EXAM: Vitals: T 98.6  BP 107/67  P 98  RR 18  O2sat 98%
Gen: Well-appearing, no acute distress
HEENT: PERRL, EOMI, OP clear, MMM
Neck: No LAD
Card: RRR, normal S1/S2, no m/r/g
Pulm: CTA bilaterally
Back: No CVAT, mild tenderness around percutaneous nephrostomy
insertion site, ecchymoses
Abd: Soft, non-distended, RUQ and epigastric tenderness
Ext: No clubbing or cyanosis, 1+ non-pitting edema bilaterally,
2+ pulses bilaterally
Skin: Some ecchymoses, no rashes
Neuro: A&Ox3, responds appropriately

FAMILY HISTORY: Both parents living. Mother with HTN, MI, SLE; father with HTN.
Father (donor) recently had MI. Siblings with hypertension.

SOCIAL HISTORY: Married, lives with her husband and three children ages 13, 8,
6. Works as a controller. No tobacco or EtOH. 

### Response:
{'Encounter for antineoplastic chemotherapy,Acute myeloid leukemia, without mention of having achieved remission,Bacteremia,Bone marrow replaced by transplant,Stricture or kinking of ureter,Peritoneal effusion (chronic),Stomatitis and mucositis, unspecified,Ulcer of anus and rectum,Hypotension, unspecified,Rash and other nonspecific skin eruption,Neutropenia, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other anaerobes,Anemia in neoplastic disease,Unspecified drug or medicinal substance causing adverse effects in therapeutic use'}
