CHIEF COMPLAINT: High WBC count (relapsed AML)

PRESENT ILLNESS: Mr. [**Known lastname 20904**] is a 78 yo Cantonese speaking man with AML s/p 7+3
induction chemotherapy in [**2194-2-16**], who presents from clinic
with relapsed AML. He had been in peripheral remission for about
3 months. Patient interview was conducted with the help of
interpreter via telephone.
.
He was diagnosed with AML in [**2194-2-16**] when he presented to the
hospital with dizziness. He was found to be neutropenic and
anemic, and BM biopsy was consistent with AML. His 6[**Hospital **]
hospital stay included a brief ICU stay for respiratory distress
while receiving idarubicin for 7+3 induction, and then his
post-chemo course was complicated by C. [**Hospital 563**] candidemia.
Echo and eye exam were normal. He was initially started on
Micafungin for the candidemia, however LFTs were noted to rise
with a new abdominal pain. MRI was performed which ruled out
hepatosplenic involvement. Although it was felt unlikely that
micafungin caused the LFT elevation, it was switched to
anidlofungin per ID recs and was discharged home with 2 more
weeks of anidlofungin.
.
Since discharge from the hospital in [**2194-3-16**], pt reports
feeling "okay." His lower back has been bothering him since he
"fell back in the winter time," and he feels weak in the legs on
prolonged ambulation. He also endorses swelling in the lower
legs, but it's not new. Otherwise, his ROS is negative;
specifically, he denies fevers, chills, URI symptoms, nausea,
vomiting, abdominal pain, diarrhea, dysuria.

MEDICAL HISTORY: 1. AML as above
2. Diabetes Mellitus; followed by Dr. [**First Name (STitle) 3636**] at [**Hospital **] Clinic; was
started on insulin during last admission in Efb [**2194**] however it
was stopped on [**2194-5-13**] per patient request (did not like the
[**Last Name (un) **] of checking FS and giving injections)
3. HTN

MEDICATION ON ADMISSION: Doxazosin 2 mg QHS
Glyburide 10 mg QDay
Lamivudine 100 mg QDay
Omeprazole 20 mg QDay
Aspirin 325 mg QDay

ALLERGIES: Cytarabine

PHYSICAL EXAM: Vitals: T: 97.8 BP: 123/70  HR: 97  RR: 20  O2: 94% RA
Appearance: NAD
Eyes: EOMI, PERRL, dentures in place, no oral lesions. MMM
Neck: supple. No thyromegaly
Lymph node: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy
Heart: Borderline tachycardic, no murmurs/rubs/gallops
Lungs: CTAB no rhonchi, crackles or wheezes
Abd: Soft, NDNT. +normoactive bowel sounds
Ext: [**1-17**]+ pitting edema bilaterally to upper ankles
Neuro: Alert and oriented x3, no focal deficits
Skin: warm, no rash, no ulcer

FAMILY HISTORY: No one in family has hx of cancer/blood disorders

SOCIAL HISTORY: Lives with wife. Married for 30+ years. Denies smoking, alcohol
or drug use history ever.
Acute myeloid leukemia, without mention of having achieved remission,Defibrination syndrome,Acute diastolic heart failure,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Other pulmonary insufficiency, not elsewhere classified,Paroxysmal ventricular tachycardia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Stomatitis and mucositis, unspecified,Oliguria and anuria,Pain in joint, shoulder region,Other specified visual disturbances,Fever presenting with conditions classified elsewhere
Ac myl leuk wo achv rmsn,Defibrination syndrome,Ac diastolic hrt failure,Hpt B chrn wo cm wo dlta,Other pulmonary insuff,Parox ventric tachycard,DMII wo cmp nt st uncntr,Hypertension NOS,Chr pulmon heart dis NEC,Stomatitis/mucositis NOS,Oliguria & anuria,Joint pain-shlder,Visual disturbances NEC,Fever in other diseases
Admission Date:  [**2194-6-6**]              Discharge Date:   [**2194-6-21**]

Date of Birth:  [**2115-9-30**]             Sex:   M

Service: MEDICINE

Allergies:
Cytarabine

Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
High WBC count (relapsed AML)

Major Surgical or Invasive Procedure:
Placement and subsequent removal of pheresis line


History of Present Illness:
Mr. [**Known lastname 20904**] is a 78 yo Cantonese speaking man with AML s/p 7+3
induction chemotherapy in [**2194-2-16**], who presents from clinic
with relapsed AML. He had been in peripheral remission for about
3 months. Patient interview was conducted with the help of
interpreter via telephone.
.
He was diagnosed with AML in [**2194-2-16**] when he presented to the
hospital with dizziness. He was found to be neutropenic and
anemic, and BM biopsy was consistent with AML. His 6[**Hospital **]
hospital stay included a brief ICU stay for respiratory distress
while receiving idarubicin for 7+3 induction, and then his
post-chemo course was complicated by C. [**Hospital 563**] candidemia.
Echo and eye exam were normal. He was initially started on
Micafungin for the candidemia, however LFTs were noted to rise
with a new abdominal pain. MRI was performed which ruled out
hepatosplenic involvement. Although it was felt unlikely that
micafungin caused the LFT elevation, it was switched to
anidlofungin per ID recs and was discharged home with 2 more
weeks of anidlofungin.
.
Since discharge from the hospital in [**2194-3-16**], pt reports
feeling "okay." His lower back has been bothering him since he
"fell back in the winter time," and he feels weak in the legs on
prolonged ambulation. He also endorses swelling in the lower
legs, but it's not new. Otherwise, his ROS is negative;
specifically, he denies fevers, chills, URI symptoms, nausea,
vomiting, abdominal pain, diarrhea, dysuria.


Past Medical History:
1. AML as above
2. Diabetes Mellitus; followed by Dr. [**First Name (STitle) 3636**] at [**Hospital **] Clinic; was
started on insulin during last admission in Efb [**2194**] however it
was stopped on [**2194-5-13**] per patient request (did not like the
[**Last Name (un) **] of checking FS and giving injections)
3. HTN


Social History:
Lives with wife. Married for 30+ years. Denies smoking, alcohol
or drug use history ever.


Family History:
No one in family has hx of cancer/blood disorders

Physical Exam:
Vitals: T: 97.8 BP: 123/70  HR: 97  RR: 20  O2: 94% RA
Appearance: NAD
Eyes: EOMI, PERRL, dentures in place, no oral lesions. MMM
Neck: supple. No thyromegaly
Lymph node: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy
Heart: Borderline tachycardic, no murmurs/rubs/gallops
Lungs: CTAB no rhonchi, crackles or wheezes
Abd: Soft, NDNT. +normoactive bowel sounds
Ext: [**1-17**]+ pitting edema bilaterally to upper ankles
Neuro: Alert and oriented x3, no focal deficits
Skin: warm, no rash, no ulcer


Pertinent Results:
Admission labs
135  98  14
-------------- glu not done
4.3  27  0.9
Ca: 9.0
ALT: 55 AP: 189 Tbili: 0.3
AST: 51 LDH: 846
WBC 107.2 (N:1 Band:0 L:0 M:1 E:0 Bas:0 Other (blasts): 98)
Hbg 12.8
Hct 38.8
Plt 71

[**6-11**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. There is mild global
left ventricular hypokinesis (LVEF = 50 %). There is no
ventricular septal defect. Right ventricular chamber size is
normal with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-17**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is no pericardial effusion.

Compared with the prior study (images reviewed) of [**2194-4-4**],
biventricular systolic function is now borderline/mildly
depressed. The degree of MR has slightly increased. Pulmonary
hypertension is now detected.


Brief Hospital Course:
Pt was admitted in good condition despite WBC count of 100,000
until ~ 6 pm on [**6-7**] when he started to become dyspneic, hypoxic
to 88% on RA with drop in UOP. There was a concern for
leukostasis and pt was transferred to MICU for urgent pheresis.

MICU course:  On [**6-6**] he spiked a temperature to 102.8F
overnight, with SVT to the 140's responsive to diltiazem, and
cefepime was started given functional neutropenia. He was doing
well on [**6-7**] with heart rates ~100, sats 92-95% on room air, and
respiratory rates in the 20's, until 6pm, when he was noted to
be more tachypneic (to the 30's), tachycardic (to the 150's),
and hypoxic (88% on room air). His urine output dropped off, and
a chest xray showed mild hilar prominence. LDH had doubled, and
white count had not dropped substantially. Given concern for
leukostasis, preparations for initiation of pheresis were made.
Given his likely tumor lysis, early DIC, likely leukostasis, and
tenuous respiratory and hemodynamic status, he was transferred
to the [**Hospital Unit Name 153**].

In the ICU, constellation of symptoms, including low urine
output and worsening respiratory status concerning for
leukostasis. Pheresis line was placed and leukoreduction therapy
undertaken.  Hypoxia was thought to be secondary to leukostasis,
and he maintained his O2 Sat on 2L NC.  Hydroxeaurea and
hydration were contineud to protect against tumor lysis. He was
afebrile but was given levaquin + vancomycin + zosyn for recent
fevers and functional neutropenia.

Pt underwent pheresis without incident and was transferred to
the floor. He was continued on Decitabine chemo per protocol
(total 5 days) and high dose hydroxyurea. He was on allopurinol
to reduce risk of hyperuricemia. Tumor lysis and DIC labs were
checked frequently. The patient appeared to be in early DIC
during the acute stage of needing leukopheresis however it did
not progress further. Pt had occasional fevers with no evidence
of infection. He was continued on Vanc, Cefepime, Acyclovr and
Fluconazole as he was neutropenic, but his fevers were thought
to be most likely due to disease process.

Summary of other issues:
# SVT/ Flash Pulm Edema: Pt went into SVT especially when
febrile. It responded well on Dilt IV (5 mg very slowly as BP
would transiently drop). Pt was maintained on Dilt 30 mg PO QID
with holding parameters. Lasix IV bolus was effective in
managing his respiratory distress. As his home hospice service
was unable to provide this, he was discharged on daily po lasix.
.
# Diabetes: He is followed by [**Last Name (un) **]. Pt was deemed to require
insulin however pt refused it at home due to the rigors of
checking blood sugars and giving appropriate doses of insulin.
Thus he was on glyburide instead at home.
- Held glyburide during hospital stay.
- FS QID and HISS
.
# Past hepatitis B exposure: HBV surface antigen negative, HBV
surface antibody positive, HBV core antibody (IGM) positive
- Pt was started on Lamivudine for concern of HBV reactivation
during prior admission. It was continued.

=======================================

GOALS OF CARE:
Several meetings were held with the team and the patient and his
family to discuss goals of care given his advanced age and grave
prognosis. The decision was made to make pt DNR/DNI, but to
complete a course of decitabine. On the BMT service, his WBC
initially seemed to respond to this therapy, but his peripheral
counts ulitmately demonstrated a recurrence of his disease. This
was discussed with him and his family; they chose to make him
CMO and be discharged home with hospice.


Medications on Admission:
Doxazosin 2 mg QHS
Glyburide 10 mg QDay
Lamivudine 100 mg QDay
Omeprazole 20 mg QDay
Aspirin 325 mg QDay


Discharge Medications:
1. Roxanol Concentrate 20 mg/mL Solution Sig: 5-15 mg PO q2-3h
as needed for pain/shortness of breath.
Disp:*30 ML* Refills:*0*
2. MED
LIQUID ATIVAN; GIVE 0.5mg po/SL Q4H prn anxiety. dispense 50mg.
3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: One (1)
Sublingual every four (4) hours as needed for secretions.
Disp:*50 tablets* Refills:*3*
4. Acetaminophen 650 mg Suppository Sig: One (1)  Rectal every
four (4) hours.
Disp:*50 suppositiories* Refills:*2*
5. Compazine 25 mg Suppository Sig: One (1)  Rectal every eight
(8) hours as needed for nausea.
Disp:*50 Suppository* Refills:*3*
6. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
9. Dulcolax 10 mg Suppository Sig: One (1)  Rectal once a day as
needed for constipation.
Disp:*30 Suppository* Refills:*0*
10. OXYGEN
oxygen 2L nasal cannula PRN
11. LINE FLUSH
10cc saline flush and 2cc 10% heparin flush DAILY and PRN in
each PICC port


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2188**]

Discharge Diagnosis:
Acute Myelogenous Leukemia


Discharge Condition:
Hemodynamically stable. Poor Oncologic prognosis. Comfort
measures only.


Discharge Instructions:
Dear Mr. [**Known lastname 20904**],

You were admitted to [**Hospital1 18**] for treatment of your leukemia.
Unfortunately, this treatment was not effective. As per
discussion with you and your family, we focused on making you
comfortable. Arrangements were made for you to receive hospice
care at home.

You and your family should now that if it becomes too difficult
to take care of you when you become more ill at home, you are
welcome to return to the hospital.

Followup Instructions:
None



Completed by:[**2194-6-25**]
{'Acute myeloid leukemia, without mention of having achieved remission,Defibrination syndrome,Acute diastolic heart failure,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Other pulmonary insufficiency, not elsewhere classified,Paroxysmal ventricular tachycardia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Stomatitis and mucositis, unspecified,Oliguria and anuria,Pain in joint, shoulder region,Other specified visual disturbances,Fever presenting with conditions classified elsewhere'}


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: High WBC count (relapsed AML)

PRESENT ILLNESS: Mr. [**Known lastname 20904**] is a 78 yo Cantonese speaking man with AML s/p 7+3
induction chemotherapy in [**2194-2-16**], who presents from clinic
with relapsed AML. He had been in peripheral remission for about
3 months. Patient interview was conducted with the help of
interpreter via telephone.
.
He was diagnosed with AML in [**2194-2-16**] when he presented to the
hospital with dizziness. He was found to be neutropenic and
anemic, and BM biopsy was consistent with AML. His 6[**Hospital **]
hospital stay included a brief ICU stay for respiratory distress
while receiving idarubicin for 7+3 induction, and then his
post-chemo course was complicated by C. [**Hospital 563**] candidemia.
Echo and eye exam were normal. He was initially started on
Micafungin for the candidemia, however LFTs were noted to rise
with a new abdominal pain. MRI was performed which ruled out
hepatosplenic involvement. Although it was felt unlikely that
micafungin caused the LFT elevation, it was switched to
anidlofungin per ID recs and was discharged home with 2 more
weeks of anidlofungin.
.
Since discharge from the hospital in [**2194-3-16**], pt reports
feeling "okay." His lower back has been bothering him since he
"fell back in the winter time," and he feels weak in the legs on
prolonged ambulation. He also endorses swelling in the lower
legs, but it's not new. Otherwise, his ROS is negative;
specifically, he denies fevers, chills, URI symptoms, nausea,
vomiting, abdominal pain, diarrhea, dysuria.

MEDICAL HISTORY: 1. AML as above
2. Diabetes Mellitus; followed by Dr. [**First Name (STitle) 3636**] at [**Hospital **] Clinic; was
started on insulin during last admission in Efb [**2194**] however it
was stopped on [**2194-5-13**] per patient request (did not like the
[**Last Name (un) **] of checking FS and giving injections)
3. HTN

MEDICATION ON ADMISSION: Doxazosin 2 mg QHS
Glyburide 10 mg QDay
Lamivudine 100 mg QDay
Omeprazole 20 mg QDay
Aspirin 325 mg QDay

ALLERGIES: Cytarabine

PHYSICAL EXAM: Vitals: T: 97.8 BP: 123/70  HR: 97  RR: 20  O2: 94% RA
Appearance: NAD
Eyes: EOMI, PERRL, dentures in place, no oral lesions. MMM
Neck: supple. No thyromegaly
Lymph node: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy
Heart: Borderline tachycardic, no murmurs/rubs/gallops
Lungs: CTAB no rhonchi, crackles or wheezes
Abd: Soft, NDNT. +normoactive bowel sounds
Ext: [**1-17**]+ pitting edema bilaterally to upper ankles
Neuro: Alert and oriented x3, no focal deficits
Skin: warm, no rash, no ulcer

FAMILY HISTORY: No one in family has hx of cancer/blood disorders

SOCIAL HISTORY: Lives with wife. Married for 30+ years. Denies smoking, alcohol
or drug use history ever. 

### Response:
{'Acute myeloid leukemia, without mention of having achieved remission,Defibrination syndrome,Acute diastolic heart failure,Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta,Other pulmonary insufficiency, not elsewhere classified,Paroxysmal ventricular tachycardia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other chronic pulmonary heart diseases,Stomatitis and mucositis, unspecified,Oliguria and anuria,Pain in joint, shoulder region,Other specified visual disturbances,Fever presenting with conditions classified elsewhere'}
