CHIEF COMPLAINT: AML requiring induction chemotherapy

PRESENT ILLNESS: Mr. [**Known lastname 9025**] is a 65 year old gentleman with a history of CMML
and recurrent AML who presents for induction chemotherapy.
Patient underwent induction chemotherapy in [**2151-8-20**],
complicated by renal failure and need for hemodialysis for
several weeks.  Patient was in remission for over a year and was
found to have recurred by labs in clinic.  Dr. [**Last Name (STitle) **]
preferred that he be admitted tonight in case his counts rapidly
increase.  He continues on Hydrea daily and allopurinol. He
feels well now.
.
On review of systems, patient has persistent dry cough since
[**Month (only) 956**].  He also notes reflux symptoms exacerbated by
movement, actively sitting up or lying down. He does note that
his fatigue has been worsening over the last couple of weeks,
though he is still able to care for himself independently at
home.  He notes that he has chronic post-nasal drip for years
which has not affected his cough in the past.  He denies fevers,
chills, sweats, congestion, dyspnea, dyspnea on exertion, chest
pain, palpitations, nausea, vomiting,
diarrhea, rashes, bleeding, easy bruising, weight changes.

MEDICAL HISTORY: - Chronic Monocytic Myelogenous Leukemia
- Acute Myelogenous Leukemia s/p induction [**10/2151**] and
re-induction therapy
- Chronic renal insufficiency with baseline creatinine 3.0-3.5,
required temporary hemodialysis while on induction therapy with
7+3 in [**2151**]
- Non-obstructive nephrolithiasis --> ?Urate Nephropathy
- Brief hospitalization in [**2151**] for [**Last Name (un) **] and gross hematuria
- Right sided inguinal hernia - per CT, contains predominantly
fat, not bowel
- Splenomegaly
- GERD - duodenitis
- Eczema - severe
- Asthmatic bronchitis, diagnosed in [**2139**]
- Herpes zoster, [**2144**].
- Erectile dysfunction beginning in [**2139**] with
hypotestosteronemia.
- S/p removal of a "lump" from right arm, at dorsal site where
elbow rubs tableside.
- Basal cell cancer, removed from his nose in Spring [**2148**].
.

MEDICATION ON ADMISSION: ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
HYDROXYUREA - 500 mg Capsule - 1 Capsule(s) by mouth once a day
Medications - OTC
SODIUM BICARBONATE -  (Prescribed by Other Provider) - 650 mg
Tablet - 1 Tablet(s) by mouth twice a day --> ( Patient does not
take this b/c it makes him nauseated )
OMEPRAZOLE - dosage uncertain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS: 99.0   93/48  77  18  97%RA
GENERAL:  lying supine, easily able to sit up, in no acute
distress.
HEENT: Oropharynx clear, no ulcerative lesions noted
NECK:  Supple, diffuse bilateral cervical lymphadenopathy,
particularly posteriorly L>R.
CHEST: Lung sounds clear to auscultation bilaterally without
rhonchi, rales, or wheezes.
HEART:  Regular rhythm (irregular rhythm on EKG) normal rate,
+systolic murmur loudest at LUSB
ABDOMEN:  Soft, nontender, nondistended with normoactive bowel
sounds, +massive splenomegaly
EXTREMITIES:  No peripheral edema, good DP pulses
SKIN:  Warm, dry. Mild brownish bruising on left forearm.

FAMILY HISTORY: No family history of hematologic disorders. Mother died of colon
cancer at 58. Father died from cardiovascular disease at 72.

SOCIAL HISTORY: The patient formerly worked as a transportation coordinator in
his 60s, has not been working recently.   Prior to that he
worked in high-tech sales. He has a bachelors in engineering and
an MBA.  There isno history of smoking, illicit drug use, or
alcohol abuse. He has a 15 year old daughter.  [**Name (NI) **] lives with his
wife, daughter and their dog.
Acute myeloid leukemia, without mention of having achieved remission,Abscess of lung,Pneumonia due to parainfluenza virus,Pneumonia in aspergillosis,Septicemia due to pseudomonas,Sepsis,Aspergillosis,Calculus of ureter,Hydronephrosis,Acidosis,Chronic kidney disease, Stage IV (severe),Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Fever presenting with conditions classified elsewhere,Hypersplenism,Contact dermatitis and other eczema, unspecified cause,Asthma, unspecified type, unspecified,Esophageal reflux
Ac myl leuk wo achv rmsn,Abscess of lung,Parinfluenza viral pneum,Pneum in aspergillosis,Pseudomonas septicemia,Sepsis,Aspergillosis,Calculus of ureter,Hydronephrosis,Acidosis,Chr kidney dis stage IV,Unilat inguinal hernia,Fever in other diseases,Hypersplenism,Dermatitis NOS,Asthma NOS,Esophageal reflux
Admission Date:  [**2153-6-16**]              Discharge Date:   [**2153-7-28**]

Date of Birth:  [**2086-12-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
AML requiring induction chemotherapy

Major Surgical or Invasive Procedure:
PICC line placement, PICC line removal
Lumbar Puncture
Hemodialysis
Several blood and platelet transfusions


History of Present Illness:
Mr. [**Known lastname 9025**] is a 65 year old gentleman with a history of CMML
and recurrent AML who presents for induction chemotherapy.
Patient underwent induction chemotherapy in [**2151-8-20**],
complicated by renal failure and need for hemodialysis for
several weeks.  Patient was in remission for over a year and was
found to have recurred by labs in clinic.  Dr. [**Last Name (STitle) **]
preferred that he be admitted tonight in case his counts rapidly
increase.  He continues on Hydrea daily and allopurinol. He
feels well now.
.
On review of systems, patient has persistent dry cough since
[**Month (only) 956**].  He also notes reflux symptoms exacerbated by
movement, actively sitting up or lying down. He does note that
his fatigue has been worsening over the last couple of weeks,
though he is still able to care for himself independently at
home.  He notes that he has chronic post-nasal drip for years
which has not affected his cough in the past.  He denies fevers,
chills, sweats, congestion, dyspnea, dyspnea on exertion, chest
pain, palpitations, nausea, vomiting,
diarrhea, rashes, bleeding, easy bruising, weight changes.

Past Medical History:
- Chronic Monocytic Myelogenous Leukemia
- Acute Myelogenous Leukemia s/p induction [**10/2151**] and
re-induction therapy
- Chronic renal insufficiency with baseline creatinine 3.0-3.5,
required temporary hemodialysis while on induction therapy with
7+3 in [**2151**]
- Non-obstructive nephrolithiasis --> ?Urate Nephropathy
- Brief hospitalization in [**2151**] for [**Last Name (un) **] and gross hematuria
- Right sided inguinal hernia - per CT, contains predominantly
fat, not bowel
- Splenomegaly
- GERD - duodenitis
- Eczema - severe
- Asthmatic bronchitis, diagnosed in [**2139**]
- Herpes zoster, [**2144**].
- Erectile dysfunction beginning in [**2139**] with
hypotestosteronemia.
- S/p removal of a "lump" from right arm, at dorsal site where
elbow rubs tableside.
- Basal cell cancer, removed from his nose in Spring [**2148**].
.

ONCOLOGIC HISTORY:
CMML
- [**7-/2146**]-sumer [**2151**] followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
- [**2151**] summer - transformation to AML and rise in baseline Cr
--> care transferred to Dr. [**Last Name (STitle) **], started on Hydrea
- [**2151-8-20**] - induction chemotherapy w idarubicin and ARA-C
(7+3), cut short [**2-20**] worsening renal dysfunction, requiring HD
for several weeks; renal dysfunction [**2-20**] tumor lysis syndrome vs
tumor infiltration vs ATN
- Re-induction chemotherapy [**2-20**] persistent AML upon restaging
marrow; re-induction done while still on HD in [**2151**]
- [**2152-2-20**] - subsequent bone marrow biopsy showed continued CMML
and remission of AML ; started on Hydrea, which he has been
taking intermittently
- persistent renal insufficiency not requiring HD
- [**2152-4-4**] -- hospitalized w abd pain, constipation, CT showed
hydronephrosis and stones --> likely Urate Nephropathy, was
started on allopurinol ; [**2153-4-10**] ultrasound showed slight
improvement of hydronephrosis ; pt followed by nephrology as
outpatient ; [**4-11**] returned for gross hematuria
- new lymphadenopathy per CT scan in [**Month (only) **]
- [**2153-4-6**] Bone Marrow consistent with CMML, still in remission
for AML
- Allogenic transplant and post-remission chemotherapy were
deffered in setting of renal failure
.
With Induction therapy,
patient received the following doses of Idarubicin:
[**2151-7-28**]: 9mg/m2=18mg
[**2151-7-29**]: 6mg/m2=12mg
.
[**2151-9-7**]: 12mg/m2=23mg
[**2151-9-8**]: 12mg/m2=23mg
[**2151-9-9**]: 12mg/m2=23mg
.
Total Cumulative dose=51mg/m2

Social History:
The patient formerly worked as a transportation coordinator in
his 60s, has not been working recently.   Prior to that he
worked in high-tech sales. He has a bachelors in engineering and
an MBA.  There isno history of smoking, illicit drug use, or
alcohol abuse. He has a 15 year old daughter.  [**Name (NI) **] lives with his
wife, daughter and their dog.

Family History:
No family history of hematologic disorders. Mother died of colon
cancer at 58. Father died from cardiovascular disease at 72.

Physical Exam:
VITAL SIGNS: 99.0   93/48  77  18  97%RA
GENERAL:  lying supine, easily able to sit up, in no acute
distress.
HEENT: Oropharynx clear, no ulcerative lesions noted
NECK:  Supple, diffuse bilateral cervical lymphadenopathy,
particularly posteriorly L>R.
CHEST: Lung sounds clear to auscultation bilaterally without
rhonchi, rales, or wheezes.
HEART:  Regular rhythm (irregular rhythm on EKG) normal rate,
+systolic murmur loudest at LUSB
ABDOMEN:  Soft, nontender, nondistended with normoactive bowel
sounds, +massive splenomegaly
EXTREMITIES:  No peripheral edema, good DP pulses
SKIN:  Warm, dry. Mild brownish bruising on left forearm.

Patient was examined on day of discharge. Compared to admission,
the pt was weaker, deconditioned, with 3+ edema of the ankles
and mild crackles throughout lung fields.

Pertinent Results:
[**2153-6-16**] 03:27PM   GLUCOSE-110* UREA N-61* CREAT-3.7* SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-20* ANION GAP-16
[**2153-6-16**] 03:27PM   estGFR-Using this
[**2153-6-16**] 03:27PM   ALT(SGPT)-18 AST(SGOT)-15 LD(LDH)-200 ALK
PHOS-37* TOT BILI-0.5
[**2153-6-16**] 03:27PM   ALBUMIN-4.2 CALCIUM-8.2* PHOSPHATE-4.8*
MAGNESIUM-2.1 URIC ACID-7.9*
[**2153-6-16**] 03:27PM   NEUTS-26* BANDS-19* LYMPHS-5* MONOS-16* EOS-3
BASOS-0 ATYPS-1* METAS-4* MYELOS-11* PROMYELO-1* BLASTS-5*
OTHER-9*
[**2153-6-16**] 03:27PM   HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
BURR-OCCASIONAL STIPPLED-1+ TEARDROP-2+
[**2153-6-16**] 03:27PM   PLT SMR-NORMAL PLT COUNT-17*
[**2153-6-16**] 03:27PM   PT-16.9* PTT-34.9 INR(PT)-1.5*
[**2153-6-16**] 03:27PM   FIBRINOGE-234
[**2153-7-9**] 06:36PM BLOOD VORICONAZOLE-Test
[**2153-7-28**] 12:00AM BLOOD Glucose-118* UreaN-56* Creat-2.1* Na-137
K-4.6 Cl-108 HCO3-19* AnGap-15

Brief Hospital Course:
Mr. [**Known lastname 9025**] is a 66-year-old man with CMML with recurrent AML,
presenting for another round of induction chemotherapy.
.
Patient has been in remission for one year after induction and
re-induction chemotherapy.  Bone Marrow biopsy was performed by
Dr. [**Last Name (STitle) **] on [**6-15**] to reassess disease.  Spleen is massive
in size. Patient has lifetime limit of anthracycline dosing
which should allow for MEC induction therapy. CBC Diff shows
~14% blasts which is elevated from prior, but counts 4 days ago
showed 12% blasts.  Concern by outpatient hematologist that
patient may develop urgent need for chemotherapy in next couple
of days, which is why he was admitted today rather than on
Monday night. Pt started induction chemotherapy on Tuesday
[**2153-6-19**] with MEC which was dose reduced and given with HD support
with the renal team. He was incidentally found to have
asymptomatic coag neg staph bacteremia in multiple BCx bottles
and his chemo was stopped so he only received 3/5 doses. This
was concerning as his counts dropped but still was noted to have
blasts in his peripheral blood, concerning for inadequate chemo
dose. His line was pulled and he was treated with vanc. Another
line was placed and the pt was doing well until on [**6-30**] he
developed acute neutropenic sepsis with 3/3 bottles of
pan-sensitive pseudomonas. Due to hypotension and fevers >103 he
was sent to the ICU overnight with broad spectrum abx and
pressors. He was sent back to the floor the next day and
improved. Per ID he was on vanc, cefepime, vori at this time
(d/c'd cipro as no need for double coverage for pansens
pseudomonas). he was improving until [**7-7**] when he was found to
have acute mental status changes characterized by difficulty
with word finding, perseveration, AOx1. The remainder of his
neuro exam was nonfocal. The pt is normally very intelligent so
these changes are considered profound. Neuro was consulted. He
underwent CT head noncon which was neg for bleed or acute
process. An LP was performed which only showed RBCs with minimal
WBCs (however given the pt's neutropenia it is unclear that he
would mount a response). He was started on treatment dose IV
acyclovir for HSV consideration, although leukemic involvement
was also concerning given the pt's suboptimal chemo regimen due
to premature interruption as noted above. His viral studies,
Cxs, and flow were non contributory, acyclovir was switched back
to prophylactic dosing. He continued on Vanc, Cefepime, and Vori
and slowly improved mental status until he was considered to be
at baseline. On [**7-13**] he spiked a neutropenic fever and was found
to be +parainfluenza type 3. Once he had completed more than the
full course for F+N and had been afebrile x several days and was
no longer neutropenic, the vanc and cefepime were discontinued
and the patient remained afebrile for the remainder of his
admission. Vori was continued due to history of lung nodules and
necrotizing PNA concerning for aspergillus. On discharge the
patient was afebrile, non-neutropenic, without signs of
infection other than a mild cough. He did have persistence of
blasts. He was deconditioned and evaluated by PT who felt he was
capable of going home with 24h guardianship and home PT
services. On discharge he continued to be platelet and blood
transfusion dependent, and will have frequent followups and
count checks in outpatient clinic to transfuse as necessary.
.
# Cough/Reflux
Patient had RSV pneumonia in [**2153-2-19**] and has persistent dry
cough with mild sputum production occasionally. Prior to
starting chemotherapy, will need to ensure that patient is
stable without infection. Cough sounds GERD related by history,
as he has significant reflux and may actually be at risk for
Barrett's esophagus. Pulm was initially consulted as the pt was
noted to have small nodules in his chest CT that were read as
concern for 'acute infx' although per pulm consult team and ID
it was thought to be low likely. He was started on ppx vori and
no bronch/BAL was done due to neutropenia and low yield study.
Fungal markers were neg. The pt's cough was stable and he was
continued on his home PPI as well as Voriconazole.
.
# Chronic Renal Failure
Cr at 3.7 on admission. Patient's basline creatinine 3.0-3.5
after temporarily requiring dialysis with previous induction
therapy for AML in [**2151**].  He does have known nephrolithiasis
with secondary hydropnephrosis, likely also contributing to
renal failure. With MEC chemotherapy regimen, there was concern
for further nephtoxicity. Non-gap acidosis, likely secondary to
renal failure -- pt not taking sodium bicarbonate tablets at
home as prescribed because it makes him nauseated.  Follows with
Dr. [**Last Name (STitle) 1187**]. As noted above the pt had HD support with his MEC
doses which were also renally dosed. After this, his Cr actually
stabilized to around 2.5-2.7 improved from his prior baseline.
At one point the cr increased from 2.7 to 3.1 and acyclovir was
changed to PO dosing after which cr returned to 2.7. Creatinine
continued to drop and was at 2.2 on the day of discharge.
.


Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
HYDROXYUREA - 500 mg Capsule - 1 Capsule(s) by mouth once a day
Medications - OTC
SODIUM BICARBONATE -  (Prescribed by Other Provider) - 650 mg
Tablet - 1 Tablet(s) by mouth twice a day --> ( Patient does not
take this b/c it makes him nauseated )
OMEPRAZOLE - dosage uncertain

Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation q4h-prn as needed for sob, wheeze.
Disp:*1 inhaler* Refills:*2*
8. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*2*
9. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary Diagnosis:
Acute Myelogenous Leukemia

Secondary Diagnoses:
Chronic renal insufficiency, bacteremia, pseudomonal sepsis,
parainfluenza infection, altered mental status-resolved
Chronic Monocytic Myelogenous Leukemia
Splenomegaly
Gastroesophageal Reflux Disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 9025**],
You were admitted to the hospital because you had a recurrence
of your AML, you received 3/5 doses of induction chemotherapy
which was stopped due to a blood infection. Your admission was
further complicated by another blood infection that caused you
to be septic, a viral respiratory infection, and an acute
alteration of your mental status which has now resolved. You are
currently improved clinically but are still deconditioned and
require frequent platelet and blood transfusions. After
discharge, you will require continued transfusions and physical
therapy.

You will be seen for follow-up blood counts and likely
transfusion Monday [**7-30**] at 2pm in 7-[**Hospital Ward Name 1826**], please arrive
early.

Please call if you become febrile, experience uncontrolled
bleeding,

Followup Instructions:
Provider: [**Name Initial (NameIs) 455**] 6-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2153-7-30**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2153-8-2**] 2:30
Provider: [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 3240**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2153-8-2**]
2:30
{'Acute myeloid leukemia, without mention of having achieved remission,Abscess of lung,Pneumonia due to parainfluenza virus,Pneumonia in aspergillosis,Septicemia due to pseudomonas,Sepsis,Aspergillosis,Calculus of ureter,Hydronephrosis,Acidosis,Chronic kidney disease, Stage IV (severe),Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Fever presenting with conditions classified elsewhere,Hypersplenism,Contact dermatitis and other eczema, unspecified cause,Asthma, unspecified type, unspecified,Esophageal reflux'}


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: AML requiring induction chemotherapy

PRESENT ILLNESS: Mr. [**Known lastname 9025**] is a 65 year old gentleman with a history of CMML
and recurrent AML who presents for induction chemotherapy.
Patient underwent induction chemotherapy in [**2151-8-20**],
complicated by renal failure and need for hemodialysis for
several weeks.  Patient was in remission for over a year and was
found to have recurred by labs in clinic.  Dr. [**Last Name (STitle) **]
preferred that he be admitted tonight in case his counts rapidly
increase.  He continues on Hydrea daily and allopurinol. He
feels well now.
.
On review of systems, patient has persistent dry cough since
[**Month (only) 956**].  He also notes reflux symptoms exacerbated by
movement, actively sitting up or lying down. He does note that
his fatigue has been worsening over the last couple of weeks,
though he is still able to care for himself independently at
home.  He notes that he has chronic post-nasal drip for years
which has not affected his cough in the past.  He denies fevers,
chills, sweats, congestion, dyspnea, dyspnea on exertion, chest
pain, palpitations, nausea, vomiting,
diarrhea, rashes, bleeding, easy bruising, weight changes.

MEDICAL HISTORY: - Chronic Monocytic Myelogenous Leukemia
- Acute Myelogenous Leukemia s/p induction [**10/2151**] and
re-induction therapy
- Chronic renal insufficiency with baseline creatinine 3.0-3.5,
required temporary hemodialysis while on induction therapy with
7+3 in [**2151**]
- Non-obstructive nephrolithiasis --> ?Urate Nephropathy
- Brief hospitalization in [**2151**] for [**Last Name (un) **] and gross hematuria
- Right sided inguinal hernia - per CT, contains predominantly
fat, not bowel
- Splenomegaly
- GERD - duodenitis
- Eczema - severe
- Asthmatic bronchitis, diagnosed in [**2139**]
- Herpes zoster, [**2144**].
- Erectile dysfunction beginning in [**2139**] with
hypotestosteronemia.
- S/p removal of a "lump" from right arm, at dorsal site where
elbow rubs tableside.
- Basal cell cancer, removed from his nose in Spring [**2148**].
.

MEDICATION ON ADMISSION: ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
HYDROXYUREA - 500 mg Capsule - 1 Capsule(s) by mouth once a day
Medications - OTC
SODIUM BICARBONATE -  (Prescribed by Other Provider) - 650 mg
Tablet - 1 Tablet(s) by mouth twice a day --> ( Patient does not
take this b/c it makes him nauseated )
OMEPRAZOLE - dosage uncertain

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS: 99.0   93/48  77  18  97%RA
GENERAL:  lying supine, easily able to sit up, in no acute
distress.
HEENT: Oropharynx clear, no ulcerative lesions noted
NECK:  Supple, diffuse bilateral cervical lymphadenopathy,
particularly posteriorly L>R.
CHEST: Lung sounds clear to auscultation bilaterally without
rhonchi, rales, or wheezes.
HEART:  Regular rhythm (irregular rhythm on EKG) normal rate,
+systolic murmur loudest at LUSB
ABDOMEN:  Soft, nontender, nondistended with normoactive bowel
sounds, +massive splenomegaly
EXTREMITIES:  No peripheral edema, good DP pulses
SKIN:  Warm, dry. Mild brownish bruising on left forearm.

FAMILY HISTORY: No family history of hematologic disorders. Mother died of colon
cancer at 58. Father died from cardiovascular disease at 72.

SOCIAL HISTORY: The patient formerly worked as a transportation coordinator in
his 60s, has not been working recently.   Prior to that he
worked in high-tech sales. He has a bachelors in engineering and
an MBA.  There isno history of smoking, illicit drug use, or
alcohol abuse. He has a 15 year old daughter.  [**Name (NI) **] lives with his
wife, daughter and their dog. 

### Response:
{'Acute myeloid leukemia, without mention of having achieved remission,Abscess of lung,Pneumonia due to parainfluenza virus,Pneumonia in aspergillosis,Septicemia due to pseudomonas,Sepsis,Aspergillosis,Calculus of ureter,Hydronephrosis,Acidosis,Chronic kidney disease, Stage IV (severe),Inguinal hernia, without mention of obstruction or gangrene, unilateral or unspecified (not specified as recurrent),Fever presenting with conditions classified elsewhere,Hypersplenism,Contact dermatitis and other eczema, unspecified cause,Asthma, unspecified type, unspecified,Esophageal reflux'}
