CHIEF COMPLAINT: Sepsis and anemia

PRESENT ILLNESS: This is a 72 year-old female with history of marginal cell
lymphoma and aplastic anemia who was admitted with concerns for
sepsis and severe anemia. She had presented to oncology clinic
for an appointment the day of admission at which time she was
noted to be hypoxic, febrile, and hypotensive.  In the emergency
room, she received vancomycin, aztreonam, and gentamycin. She
was transfused 2 units of red cells and received six liters of
saline.  Given her persistent hypotension, she was started on a
levophed drip. Her urine culture from [**10-28**] grew strep bovis and
coag negative staph, for which she was treated with
levofloxacin.  She had a repeat urine culture on admission that
was growing coag negative staph.

MEDICAL HISTORY: 1. Marginal zone lymphoma- She had six chemotherapy treatments
with protocol 03-294 including fludarabine and rituximab. She
completed this treatment in 04/[**2148**]. Her treatment course was
complicated by pneumonitis felt to be due to her fludarabine.
Her last PFTs were on [**2149-9-29**]. These were significant for a
FVC of 106% predicted, FEV1 of 108% predicted, and FEV1/FVC of
102% predicted. The DLCO is 1:46. The isolated reduction in
diffusing capacity suggests perfusion limitation.
2. Cold agglutinin syndrome- She is transfusion dependant. Prior
to admission, her last transfusion was on [**2149-10-29**]. She
requires her blood to be warmed to avoid hemolysis. She also
received retuxin at that time without complication.
3. Hypertension
4. Status post TAH and BSO
5. Status post appendectomy
6. Status post cholecystectomy
7. Lactose intolerance
8. Status post resection of parotid tumor- [**2130**]
9. Status post hernia repair in setting of strangulated hernia-
[**11/2148**]

MEDICATION ON ADMISSION: 1. Prednisone 20 mg daily
2. Atenolol 50 mg daily
3. Norvasc 5 mg daily
4. Diovan-HCTZ 160/12.5 mg daily
5. Folic acid 1 mg daily

ALLERGIES: Penicillins / Bactrim Ds

PHYSICAL EXAM: Vitals: Temperature:98.5 Blood Pressure:108/70 Pulse:80
Respiratory rate:18 Oxygen saturation:90% on Room air and 95% on
2L nasal cannula.
General: Lying in bed in no acute distress.
HEENT: Pupils equal and reactive, oropharynx clear, moist mucous
membranes
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Resp: Bibasilar crackles
Abd: Soft, nontender, distended upper abdomen with palpable
mass, normoactive bowel sounds, no rebound or guarding.
Ext: Warm and well perfused without cyanosis or edema
Neuro: Alert and oriented.  Moving all extremeties. Grossly
non-focal exam

FAMILY HISTORY: Her father had a stroke and age 69.

SOCIAL HISTORY: She lives with her husband and had family in area.  She has a 25
pack-year history of tobacco and quit 4 months ago.  She does
not drink alcohol.
Unspecified septicemia,Acute respiratory failure,Urinary tract infection, site not specified,Autoimmune hemolytic anemias,Infection and inflammatory reaction due to other vascular device, implant, and graft,Candidal esophagitis,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other specified viral meningitis,Other specified non-arthropod-borne viral diseases of central nervous system,Other pulmonary embolism and infarction,Unspecified pleural effusion,Pneumonia, organism unspecified,Alkalosis,Severe sepsis,Esophageal reflux,Atrial fibrillation,Long-term (current) use of steroids,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use
Septicemia NOS,Acute respiratry failure,Urin tract infection NOS,Autoimmun hemolytic anem,React-oth vasc dev/graft,Candidal esophagitis,Oth lymp unsp xtrndl org,Viral meningitis NEC,Viral encephalitis NEC,Pulm embol/infarct NEC,Pleural effusion NOS,Pneumonia, organism NOS,Alkalosis,Severe sepsis,Esophageal reflux,Atrial fibrillation,Long-term use steroids,Adv eff antineoplastic
Admission Date:  [**2149-11-4**]              Discharge Date:   [**2149-12-31**]

Date of Birth:  [**2077-2-2**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Bactrim Ds

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Sepsis and anemia

Major Surgical or Invasive Procedure:
Central line placement
Upper endoscopy

History of Present Illness:
This is a 72 year-old female with history of marginal cell
lymphoma and aplastic anemia who was admitted with concerns for
sepsis and severe anemia. She had presented to oncology clinic
for an appointment the day of admission at which time she was
noted to be hypoxic, febrile, and hypotensive.  In the emergency
room, she received vancomycin, aztreonam, and gentamycin. She
was transfused 2 units of red cells and received six liters of
saline.  Given her persistent hypotension, she was started on a
levophed drip. Her urine culture from [**10-28**] grew strep bovis and
coag negative staph, for which she was treated with
levofloxacin.  She had a repeat urine culture on admission that
was growing coag negative staph.

Past Medical History:
1. Marginal zone lymphoma- She had six chemotherapy treatments
with protocol 03-294 including fludarabine and rituximab. She
completed this treatment in 04/[**2148**]. Her treatment course was
complicated by pneumonitis felt to be due to her fludarabine.
Her last PFTs were on [**2149-9-29**]. These were significant for a
FVC of 106% predicted, FEV1 of 108% predicted, and FEV1/FVC of
102% predicted. The DLCO is 1:46. The isolated reduction in
diffusing capacity suggests perfusion limitation.
2. Cold agglutinin syndrome- She is transfusion dependant. Prior
to admission, her last transfusion was on [**2149-10-29**]. She
requires her blood to be warmed to avoid hemolysis. She also
received retuxin at that time without complication.
3. Hypertension
4. Status post TAH and BSO
5. Status post appendectomy
6. Status post cholecystectomy
7. Lactose intolerance
8. Status post resection of parotid tumor- [**2130**]
9. Status post hernia repair in setting of strangulated hernia-
[**11/2148**]

Social History:
She lives with her husband and had family in area.  She has a 25
pack-year history of tobacco and quit 4 months ago.  She does
not drink alcohol.


Family History:
Her father had a stroke and age 69.

Physical Exam:
Vitals: Temperature:98.5 Blood Pressure:108/70 Pulse:80
Respiratory rate:18 Oxygen saturation:90% on Room air and 95% on
2L nasal cannula.
General: Lying in bed in no acute distress.
HEENT: Pupils equal and reactive, oropharynx clear, moist mucous
membranes
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Resp: Bibasilar crackles
Abd: Soft, nontender, distended upper abdomen with palpable
mass, normoactive bowel sounds, no rebound or guarding.
Ext: Warm and well perfused without cyanosis or edema
Neuro: Alert and oriented.  Moving all extremeties. Grossly
non-focal exam


Pertinent Results:
Admission Labs:
0.2>24.9<72
N:0 L:92 Atyps:8
Reticulocytes:0.4
.
[**Age over 90 **]|96|36/158
3.9|27|0.7\
Ca:8.7 Mg:2.1
.
ALT:57 AST:55 AP:107 LDH:808 Tbili:1.4 Dbili:0.4 Alb:3.6
.
Chest x-ray: Volume overload, probably right lower lobe
infiltrate, right IJ catheter in place.

Brief Hospital Course:
72 year-old female with past medical history signficant for
marginal zone lymphoma and aplastic anemia who was admitted with
sepsis and pancytopenia.
.
1. Sepsis: On admission, she had coagulase negative staph
growing in her urine.  She had a torso CT scan that demostrated
a dilated esophagus.  Subsequently, an upper endoscopy with
ultrasound showed severe [**Female First Name (un) **] esophagitis and enlarged
mediastinal lymph nodes without abnormal esophageal thickening.
She was initially treated with ambisome and voriconazole for
severe [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 99813**]; however, the voriconazole was
stopped secondary to elevated alkaline phosphatase.  Since she
was febrile and neutropenic, she was also covered broadly for
febrile neutropenia with aztreonam, daptomycin, and flagyl.  She
was also continued on Acyclovir for zoster prophylaxis. Bactrim
was started for nocardia coverage, but stopped due to nausea and
vomiting.  She initially received stress-dose steroids when she
was admitted to the ICU, however, these were tapered during the
admission.  For further infectious work-up, she had a chest
x-ray and CT that showed multifactorial pulmonary nodules.
However, a serum galactomannin, urinary legionella, and sputum
PCP were negative.  Once she was stabalized hemodynamically, she
was transfered to the floor.  She later developed a VRE
bactermia.  She was intially treated with daptomycin and
gentamicin for the VRE and was later switched to linezolid when
she was not clearing the bacteria.  Her bacteremia persisted for
about 13 days.  When she began having mental status changes with
somnolence and unresponsiveness, an LP was performed that showed
[**Male First Name (un) 2326**] virus on PCR.  She was continued on linezolid, aztreonam,
flagyl, acyclovir, caspofungin empirically throughout the
admission since she remained febrile and neutropenic.
.
2. Pancytopenia: She had pancytopenia on admission, which was
thought to be secondary to aplastic anemia from her fludarabine
treatment.  She also had a cold agglutinin syndrome, which was
treated with several doses of rituxan.  She had several drops in
her hematocrit while she wsa hypothermic, and these drops were
attributed with cold agglutinin syndrome.  Therefore, red cells
were warmed prior to transfusion.  IVIG treatment was attempted
for treatment of hemolytic anemia, but she had a febrile and
hypertensive reaction to it.  She subsequently was treated with
rabbit anti-thymocyte globulin (ATG) for her aplastic anemia;
however, she had a hypersensitivity reaction that required
emergent intubation for 2 days.  Since she had persistent VRE
bacteremia and remained neutropenic, it was decided to pursue
ATG desensitization to treat her aplastic anemia.  She underwent
ATG desensitization in the ICU.  She received 4 days on ATG per
protocol.  After treatment with ATG, she continued to have VRE
bacteremia and was also found to have [**Male First Name (un) 2326**] virus in her CSF.  As a
bridge until the ATG took effect, she had 5 granulocyte
transfusions.  She tolerated these well.  Unfortunately, the ATG
did not take effect, and she remained neutropenic and
pancytopenic.  She was maintained on supportive red cell and
platelet transfusions.  She was maintained on G-CSF for
neutropenia.
.
3. Marginal zone lymphoma: She had a bone marrow biopsy on
[**2149-10-6**] that showed that she was in remission.
.
4. Mental Status Change: On one occasion, she became somnolent
and unresponsive to voice and painful stimuli.  An MRI was
negative for mass effect or structural brain lesion.  EEG was
negative for seizure activity.  Neurology was consulted and felt
that the change in mental status likely secondary to
toxic/metabolic causes.  Her mental status eventually improved.
However, later, she had a second episode of somnolence and
unresponsiveness.  Again an MRI was negative and an EEG was
negative for seizure activity.  An LP at that time showed [**Male First Name (un) 2326**]
virus in her CSF.  Therefore, her unresponsiveness was likely
secondary to the [**Male First Name (un) 2326**] virus infection.  She did not recover her
mental status and remained unresponsive to painful stimuli.  She
did have some spontaneous movements.
.
5. Hypertension: Initially, her antihypertensives were held in
the setting of sepsis.  These were restarted once she was no
longer hypotensive.
.
6. Respiratory alkalosis: On several occasions, she had 2
episodes of paradoxical breathing in which an ABG showed a
respiratory alkalosis.  There was concern for intracranial
pathology; however, head CT was negative.   Her respiratory
status subsequently improved without intervention on several
occasions.  However, one episode of paradoxical breathing
required intubation and mechanical ventilation for 5 days.  It
was unclear the cause of the respiratory alkalosis.  In
retrospect, her paradoxical breathing pattern was likely
secondary to the [**Male First Name (un) 2326**] virus infection.
.
7. Atrial Fibrillation: She was found to have atrial
fibrillation during her second period of unresponsiveness.  This
new atrial fibrillation was though to be related to
toxic/metabolic causes.  Her cardiac enzymes were negative.  She
 responded well to diltiazam for rate control.  She was
transitioned to lopressor for both rate control and blood
pressure control.
.
8. Pulmonary Embolism: Pulmonary embolism: An Echocardigram
showed RV dilation.  A CTA at that time showed a pulmonary
embolism that was thought to be from her catheter [**Male First Name (un) **]
thrombus from her right IJ catheter. She was intially started on
heparin; however, after further discussions with the family, it
was decided that the risks of anticoagulation were not worth the
benefits.  Therefore, the heparin was stopped.
.
9) Rectal bleeding: In the middle of her admission, she had
isolated episode of rectal bleeding.  She remained
hemodynamically stable and did not have a drop in her
hematocrit.  However, at the end of her hospital stay, she had
persistent rectal bleeding.  She was transfused as needed to
keep platelets and hematocrit up.
.
10) FEN: She was initially on neutropenic diet.  Once her mental
status changed, she was maintained on TPN.
.
11) Access: She had several central lines placed and replaced
during her period of persistent bacteremia.
.
12) Code: She was intially full code.  However, once she
remained unresponsive and was found to have persistent
infections in the setting of neutropenia, she was transitioned
to DNR/DNI.  A family meeting was held and it was decided to
continued supportive measures with antibiotics and TPN to see if
her immune system could recover to counter the [**Male First Name (un) 2326**] virus and
other infections.  She did not improve and there was no
indication that her counts would return.  Therefore, her family
decided to make the goal of care comfort only.  She expired on
[**2149-12-31**] at 2:50 AM.

Medications on Admission:
1. Prednisone 20 mg daily
2. Atenolol 50 mg daily
3. Norvasc 5 mg daily
4. Diovan-HCTZ 160/12.5 mg daily
5. Folic acid 1 mg daily


Discharge Medications:
NA

Discharge Disposition:
Expired

Discharge Diagnosis:
Aplastic anemia
Cold agglutinin hemolytic anemia
VRE sepsis
[**Male First Name (un) 2326**] virus infection

Discharge Condition:
Expired

Discharge Instructions:
NA

Followup Instructions:
NA


Completed by:[**2149-12-31**]
{'Unspecified septicemia,Acute respiratory failure,Urinary tract infection, site not specified,Autoimmune hemolytic anemias,Infection and inflammatory reaction due to other vascular device, implant, and graft,Candidal esophagitis,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other specified viral meningitis,Other specified non-arthropod-borne viral diseases of central nervous system,Other pulmonary embolism and infarction,Unspecified pleural effusion,Pneumonia, organism unspecified,Alkalosis,Severe sepsis,Esophageal reflux,Atrial fibrillation,Long-term (current) use of steroids,Antineoplastic and immunosuppressive drugs 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: Sepsis and anemia

PRESENT ILLNESS: This is a 72 year-old female with history of marginal cell
lymphoma and aplastic anemia who was admitted with concerns for
sepsis and severe anemia. She had presented to oncology clinic
for an appointment the day of admission at which time she was
noted to be hypoxic, febrile, and hypotensive.  In the emergency
room, she received vancomycin, aztreonam, and gentamycin. She
was transfused 2 units of red cells and received six liters of
saline.  Given her persistent hypotension, she was started on a
levophed drip. Her urine culture from [**10-28**] grew strep bovis and
coag negative staph, for which she was treated with
levofloxacin.  She had a repeat urine culture on admission that
was growing coag negative staph.

MEDICAL HISTORY: 1. Marginal zone lymphoma- She had six chemotherapy treatments
with protocol 03-294 including fludarabine and rituximab. She
completed this treatment in 04/[**2148**]. Her treatment course was
complicated by pneumonitis felt to be due to her fludarabine.
Her last PFTs were on [**2149-9-29**]. These were significant for a
FVC of 106% predicted, FEV1 of 108% predicted, and FEV1/FVC of
102% predicted. The DLCO is 1:46. The isolated reduction in
diffusing capacity suggests perfusion limitation.
2. Cold agglutinin syndrome- She is transfusion dependant. Prior
to admission, her last transfusion was on [**2149-10-29**]. She
requires her blood to be warmed to avoid hemolysis. She also
received retuxin at that time without complication.
3. Hypertension
4. Status post TAH and BSO
5. Status post appendectomy
6. Status post cholecystectomy
7. Lactose intolerance
8. Status post resection of parotid tumor- [**2130**]
9. Status post hernia repair in setting of strangulated hernia-
[**11/2148**]

MEDICATION ON ADMISSION: 1. Prednisone 20 mg daily
2. Atenolol 50 mg daily
3. Norvasc 5 mg daily
4. Diovan-HCTZ 160/12.5 mg daily
5. Folic acid 1 mg daily

ALLERGIES: Penicillins / Bactrim Ds

PHYSICAL EXAM: Vitals: Temperature:98.5 Blood Pressure:108/70 Pulse:80
Respiratory rate:18 Oxygen saturation:90% on Room air and 95% on
2L nasal cannula.
General: Lying in bed in no acute distress.
HEENT: Pupils equal and reactive, oropharynx clear, moist mucous
membranes
Cardiac: Regular rate and rhythm without murmurs, rubs, or
gallops.
Resp: Bibasilar crackles
Abd: Soft, nontender, distended upper abdomen with palpable
mass, normoactive bowel sounds, no rebound or guarding.
Ext: Warm and well perfused without cyanosis or edema
Neuro: Alert and oriented.  Moving all extremeties. Grossly
non-focal exam

FAMILY HISTORY: Her father had a stroke and age 69.

SOCIAL HISTORY: She lives with her husband and had family in area.  She has a 25
pack-year history of tobacco and quit 4 months ago.  She does
not drink alcohol. 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Urinary tract infection, site not specified,Autoimmune hemolytic anemias,Infection and inflammatory reaction due to other vascular device, implant, and graft,Candidal esophagitis,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Other specified viral meningitis,Other specified non-arthropod-borne viral diseases of central nervous system,Other pulmonary embolism and infarction,Unspecified pleural effusion,Pneumonia, organism unspecified,Alkalosis,Severe sepsis,Esophageal reflux,Atrial fibrillation,Long-term (current) use of steroids,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use'}
