CHIEF COMPLAINT: Hypotension, cough

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant
for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx
of PE on coumadin.
.
He presents to his [**Hospital 3242**] clinic with fatigue for several days, and
anorexia, with about 12-16 hours of worsening shortness of
breath.
.
Endorses increased cough with yellow sputum production and
chills, but no fever. This morning, he reported an acute episode
of dyspnea that did not rapidly improved, and occured with
little amounts of activity and somewhat improved with rest. No
PND/orthopnea. No hemoptysis.
.
He has had no new rashes, and has not had documented fevers. He
has no diarrhea, but has been nauseated without vomiting. He
reports mild epigastric pain. He has a mild headache made
somewhat worse with light, but he feels that this is very
consistent with flares of GVH and not different (has occured he
estimates about 8 times).
.
In clinic SBP 70's, and he was given saline with improvement,
but then the BP decreased down to the 80's. Labs from clinic
showed that Cr increased to 2.9 (baseline 1.1). WBC increased
somewhat. He was transferred to the ED for further evaluation.
.
In the ED, initial vs were: 4 97.6 72 105/73 18 99%  He was
given total of 3L of saline, and recent vital signs were 98.8
129/85 80 16 96% on 2L at time of transfer. A bedside "shock"
ultrasound US in ED showed no cardiac effusion, no evidence of
gross RV overload. EKG was not significantly changed. Her INR
was 3.0. Of note, he was also complaining of left sided
shoulder/neck pain associated with shortness of breath and
diaphoresis.
.
For interventions, he received 1 gm vanc and 1gm aztreonam, 40
mg medrol, and 2 L IVF in clinic, and another liter in the ED.

MEDICAL HISTORY: - AML-M7: s/p matched unrelated allogenic transplant on
[**2143-6-24**]
- Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**]
consistent with GVHD, managed with cyclosporine, steroids,
periodic CellCept, and has received 1 cycle of Rituxan.
- Type 2 DM
- Hyperlipidemia
- H/o AVN bilateral hips
- HTN
- H/o nephrolithiasis, lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
- h/o left interpolar renal lesion, followed with MRs
- h/o BCC s/p excision
- h/o SCC left cheek, s/p Mohs' [**5-/2144**]
- h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware)
- h/o anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]
- Chronic numbness, neuropathic pain in left upper extremity.
- Multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4.
- h/o pulmonary embolism [**11/2144**] on anticoagulated from
[**11/2144**]-present
- h/o RSV [**11/2144**] requiring ICU admission
- h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**]

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUDESONIDE [ENTOCORT EC] -  (Dose adjustment - no new Rx) - 3 mg
Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice
a day
FOLIC ACID -  (Dose adjustment - no new Rx) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**]
hours as needed for pain
INSULIN LISPRO [HUMALOG] - SS
LISINOPRIL -  (Dose adjustment - no new Rx) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three)
Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20
mg) and 3 tablets every evening (60 mg)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once day
PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
Apply to upper torso once daily
WARFARIN [COUMADIN] -  (Dose adjustment - no new Rx) - 2.5 mg
Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] -  (Dose adjustment - no
new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily)
INSULIN NPH HUMAN RECOMB -  (Prescribed by Other Provider) - 100
unit/mL Suspension - 12 units twice a day Please take first dose
in the morning and the second dose at bedtime

ALLERGIES: Cefepime / Cipro

PHYSICAL EXAM: Tmax: 36.7 ??????C (98.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 85 (85 - 85) bpm
BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg
RR: 11 (11 - 11) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mild RUQ->mid epigastrium tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema . No calf or thigh tenderness.
Skin: depigmentation on hands, redness of neck, but no notable
skin changes otherwise. No rashes.

FAMILY HISTORY: Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and one of children, worked as a [**Company 22957**]
technician until [**Month (only) 547**] when he took early retirement and he is
no longer working.  Tob: previously smoked 1ppd for many years
but quit 2.5 years ago
EtOH: h/o social use; none recently
Unspecified septicemia,Acute kidney failure, unspecified,Glucocorticoid deficiency,Acute myeloid leukemia, in remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Severe sepsis,Adrenal cortical steroids causing adverse effects in therapeutic use,Acute bronchitis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of steroids
Septicemia NOS,Acute kidney failure NOS,Glucocorticoid deficient,Act myl leuk w rmsion,Compl marrow transplant,Chronc graft-vs-host dis,Severe sepsis,Adv eff corticosteroids,Acute bronchitis,Abn react-org transplant,Hx-ven thrombosis/embols,DMII wo cmp nt st uncntr,Long-term use steroids
Admission Date:  [**2145-9-7**]              Discharge Date:   [**2145-9-12**]

Date of Birth:  [**2090-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Cefepime / Cipro

Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypotension, cough

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant
for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx
of PE on coumadin.
.
He presents to his [**Hospital 3242**] clinic with fatigue for several days, and
anorexia, with about 12-16 hours of worsening shortness of
breath.
.
Endorses increased cough with yellow sputum production and
chills, but no fever. This morning, he reported an acute episode
of dyspnea that did not rapidly improved, and occured with
little amounts of activity and somewhat improved with rest. No
PND/orthopnea. No hemoptysis.
.
He has had no new rashes, and has not had documented fevers. He
has no diarrhea, but has been nauseated without vomiting. He
reports mild epigastric pain. He has a mild headache made
somewhat worse with light, but he feels that this is very
consistent with flares of GVH and not different (has occured he
estimates about 8 times).
.
In clinic SBP 70's, and he was given saline with improvement,
but then the BP decreased down to the 80's. Labs from clinic
showed that Cr increased to 2.9 (baseline 1.1). WBC increased
somewhat. He was transferred to the ED for further evaluation.
.
In the ED, initial vs were: 4 97.6 72 105/73 18 99%  He was
given total of 3L of saline, and recent vital signs were 98.8
129/85 80 16 96% on 2L at time of transfer. A bedside "shock"
ultrasound US in ED showed no cardiac effusion, no evidence of
gross RV overload. EKG was not significantly changed. Her INR
was 3.0. Of note, he was also complaining of left sided
shoulder/neck pain associated with shortness of breath and
diaphoresis.
.
For interventions, he received 1 gm vanc and 1gm aztreonam, 40
mg medrol, and 2 L IVF in clinic, and another liter in the ED.

Past Medical History:
- AML-M7: s/p matched unrelated allogenic transplant on
[**2143-6-24**]
- Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**]
consistent with GVHD, managed with cyclosporine, steroids,
periodic CellCept, and has received 1 cycle of Rituxan.
- Type 2 DM
- Hyperlipidemia
- H/o AVN bilateral hips
- HTN
- H/o nephrolithiasis, lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
- h/o left interpolar renal lesion, followed with MRs
- h/o BCC s/p excision
- h/o SCC left cheek, s/p Mohs' [**5-/2144**]
- h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware)
- h/o anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]
- Chronic numbness, neuropathic pain in left upper extremity.
- Multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4.
- h/o pulmonary embolism [**11/2144**] on anticoagulated from
[**11/2144**]-present
- h/o RSV [**11/2144**] requiring ICU admission
- h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**]

Social History:
Lives with his wife, and one of children, worked as a [**Company 22957**]
technician until [**Month (only) 547**] when he took early retirement and he is
no longer working.  Tob: previously smoked 1ppd for many years
but quit 2.5 years ago
EtOH: h/o social use; none recently

Family History:
Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].


Physical Exam:
Tmax: 36.7 ??????C (98.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 85 (85 - 85) bpm
BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg
RR: 11 (11 - 11) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mild RUQ->mid epigastrium tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema . No calf or thigh tenderness.
Skin: depigmentation on hands, redness of neck, but no notable
skin changes otherwise. No rashes.

Pertinent Results:
[**9-9**] CT chest without contrast
IMPRESSION:
1. Mostly resolved parenchymal opacities, leaving several
parenchymal bands which are felt most likely to represent
residua of a prior infectious or inflammatory process.
2. Subacute to chronic rib fractures, including along the right
posterior
seventh rib, where there is faint but suspicious sclerosis
extending further laterally than would usually be expected in
the setting of an uncomplicated rib fracture. In the setting of
prior treated hematological malignancy, the finding of vague
sclerosis raises concern for a bone marrow abnormality such as
myelofibrosis or potentially a form of disease recurrence.
Mostly, however, the bones appear within normal limits.
.
[**9-9**] PFT's
SPIROMETRY
       Pre drug                 Post drug
       Actual Pred %Pred        Actual %Pred %chg
FVC    3.86   5.05   76         3.83     76   -1
FEV1   2.83   3.60   79         2.69     75   -5
FEV1/FVC 73   71     103        70       98   -4
.
[**9-8**] RUQ US
IMPRESSION:
1. Polyp at neck of gallbladder (1.2cm), which was also seen on
prior
ultrasound scan [**2145-2-9**]. This has not changed significantly
since prior
ultrasound scan, but followup imaging is advised.
.
[**9-8**] Echo
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
.
Micro:
[**9-8**] CMV VL negative
[**9-8**] sputum: oropharyngeal flora
[**9-8**] urine cx negative
[**9-8**] viral screen and cx negative
[**9-7**] blood cx negative
.
ON ADMISSION:
[**2145-9-7**] 01:05PM BLOOD WBC-11.1* RBC-4.39* Hgb-16.0 Hct-49.0
MCV-112* MCH-36.5* MCHC-32.7 RDW-14.9 Plt Ct-264
[**2145-9-7**] 01:05PM BLOOD Neuts-85.1* Lymphs-7.0* Monos-5.2 Eos-2.5
Baso-0.3
[**2145-9-7**] 01:05PM BLOOD PT-30.5* INR(PT)-3.0*
[**2145-9-7**] 01:05PM BLOOD UreaN-28* Creat-2.9*# Na-140 K-4.4 Cl-101
HCO3-29 AnGap-14
[**2145-9-7**] 01:05PM BLOOD ALT-24 AST-20 LD(LDH)-201 CK(CPK)-37*
AlkPhos-155* TotBili-0.3
[**2145-9-7**] 01:05PM BLOOD cTropnT-0.05*
[**2145-9-7**] 01:05PM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.6* Mg-2.4
[**2145-9-7**] 08:13PM BLOOD Lactate-1.9
.
ON DISCHARGE:
[**2145-9-12**] 05:40AM BLOOD WBC-7.2 RBC-3.45* Hgb-12.5* Hct-38.3*
MCV-111* MCH-36.2* MCHC-32.7 RDW-15.0 Plt Ct-211
[**2145-9-12**] 05:40AM BLOOD Neuts-68.8 Lymphs-17.2* Monos-7.9
Eos-5.7* Baso-0.4
[**2145-9-12**] 05:40AM BLOOD Plt Ct-211
[**2145-9-12**] 05:40AM BLOOD Glucose-80 UreaN-18 Creat-0.9 Na-143
K-3.7 Cl-104 HCO3-30 AnGap-13
[**2145-9-12**] 05:40AM BLOOD ALT-25 AST-18 LD(LDH)-181 AlkPhos-112
TotBili-0.2
[**2145-9-12**] 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 UricAcd-4.6

Brief Hospital Course:
55 y/o male with ?viral syndrome vs. other atypical infection
with hypotension that is suspected to be hypovolemia or adrenal
insufficiency, with acute renal failure.
.
# Lethargy: concern for viral syndrome, including activation of
CMV, or a respiratory virus. He has been known EBV+ in the past.
This could also be related to sensation of dyspnea that he has
been having, and warranted further cardiovascular and pulmonary
work-up in parallel with the infectious work-up. In the ICU,
continued broad spectrum antibiotics of vancomycin and aztreonam
(given allergy).  Infectious workup largely negative including
CMV VL, respiratory panel, EBV VL, fungal markers, blood
cultures, urine cultures, CT chest. Pt's lethargy improved with
IVFs, antibiotics, and stress dose steroids. Did not ever need
pressors.
.
# Dyspnea/Cough: Concern for infectious process. Regarding VTE,
his risk should be reduced with therapeutic INR, though the
concern for coumadin failure merits consideration, though would
be unlikely and he has no other signs and symptoms of DVT. PFTs
completed [**9-9**], with official report pending at time of this
summary. CT chest showing resolving parenchymal processes,
resolving infectious/inflammatory process. Continued broad
spectrum antibiotics initially. When no infiltrate noted on CXR,
decreased ABX to 5 days of azithromycin for treatment of
bronchitis.
.
# Hypotension: A bedside "shock" ultrasound US in ED showed no
cardiac effusion, no evidence of gross RV overload. EKG
unchanged. Patient's hypotension was fluid/stress dose steroids
responsive. Initially given stress dose steroids with plans to
resume home dose.  Also given IVF repletion. BPs normalized.
Likely etiology was slight adrenal insufficiency in setting of
viral syndrome despite negative infectious workup. Patient
discharged with prednisone 7.5 mg daily.
.
# Acute Renal Failure: Likely pre-renal azotemia. Improved with
IVFs. Cr 0.9 on discharge.
.
# Mild epigastric/RUQ tenderness: No laboratory e/o hepatitis.
RUQ US showing polyp at neck of gallbladder (1.2cm), which was
also seen on prior ultrasound scan [**2145-2-9**]. No other findings
to explain epigastric pain. This pain has resolved on discharge.
.
# Pulmonary Embolism [**11-23**]: continued coumadin with INR goal
[**1-19**].

# Diabetes: Continued NPH 12 units [**Hospital1 **], with close sugar
monitoring and diabetic diet.

Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUDESONIDE [ENTOCORT EC] -  (Dose adjustment - no new Rx) - 3 mg
Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice
a day
FOLIC ACID -  (Dose adjustment - no new Rx) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**]
hours as needed for pain
INSULIN LISPRO [HUMALOG] - SS
LISINOPRIL -  (Dose adjustment - no new Rx) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three)
Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20
mg) and 3 tablets every evening (60 mg)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once day
PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
Apply to upper torso once daily
WARFARIN [COUMADIN] -  (Dose adjustment - no new Rx) - 2.5 mg
Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] -  (Dose adjustment - no
new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily)
INSULIN NPH HUMAN RECOMB -  (Prescribed by Other Provider) - 100
unit/mL Suspension - 12 units twice a day Please take first dose
in the morning and the second dose at bedtime

Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
5. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day: QAM and QPM.
6. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO once a day: at 1400 every day.

7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
8. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO twice a day.
9. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): For total 7.5 mg daily.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: On
Saturdays.
13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet
Transdermal once a day: Apply to upper torso once daily as
directed.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous twice a day.
15. Insulin Lispro 100 unit/mL Solution Sig: Varied units
Subcutaneous four times a day: As per home sliding scale.

Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
Hypotension/adrenal insufficiency
Bronchitis
Acute renal failure
.
Secondary diagnosis:
AML s/p MUD allogeneic SCT [**6-/2143**]
Chronic GVHD of skin/liver
h/o PE
Diabetes mellitus


Discharge Condition:
Stable, afebrile, BP 113/76, RR 16, sats 96% on RA, INR 1.8.


Discharge Instructions:
You were admitted with fatigue, shortness of breath, cough, low
blood pressure and acute renal failure. We were concerned for
early sepsis and you were in the ICU initially. You received
broad spectrum antibiotics and stress dose steroids, but a full
workup (including viral swabs, cultures, ECHO, and CT chest)
were unrevealing. CT chest showed resolving infiltrates and your
symptoms improved so the antibiotics were switched to
azithromycin for presumed bronchitis. Your prednisone was
increased due to presumed mild adrenal insufficiency.
.
The following medication changes were made:
1) Prednisone increased to 7.5mg daily
2) Azithromycin (antibiotic) started, to be completed as
outpatient
3) Your lisinopril (blood pressure medication) and metoprolol
were discontinued. Do NOT resume these medications until
speaking to Dr. [**Last Name (STitle) **].
.
You need to have your INR checked on Tuesday, [**2145-9-14**]. You also
need to follow up with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] within the
next week. Please call their office tomorrow to make this
appointment.
.
of the following symptoms: fever, chills, shortness of breath,
difficulty breathing, abdominal pain, cough, flu symptoms, or
any other worrisome symptoms.


Followup Instructions:
You need to have your INR checked on Tuesday, [**2145-9-14**].
.
Please call Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 72254**] office to make an
appointment to be seen later this week. They can be reached at
[**Telephone/Fax (1) 3241**].



Completed by:[**2145-9-17**]
{'Unspecified septicemia,Acute kidney failure, unspecified,Glucocorticoid deficiency,Acute myeloid leukemia, in remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Severe sepsis,Adrenal cortical steroids causing adverse effects in therapeutic use,Acute bronchitis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of steroids'}


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: Hypotension, cough

PRESENT ILLNESS: Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant
for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx
of PE on coumadin.
.
He presents to his [**Hospital 3242**] clinic with fatigue for several days, and
anorexia, with about 12-16 hours of worsening shortness of
breath.
.
Endorses increased cough with yellow sputum production and
chills, but no fever. This morning, he reported an acute episode
of dyspnea that did not rapidly improved, and occured with
little amounts of activity and somewhat improved with rest. No
PND/orthopnea. No hemoptysis.
.
He has had no new rashes, and has not had documented fevers. He
has no diarrhea, but has been nauseated without vomiting. He
reports mild epigastric pain. He has a mild headache made
somewhat worse with light, but he feels that this is very
consistent with flares of GVH and not different (has occured he
estimates about 8 times).
.
In clinic SBP 70's, and he was given saline with improvement,
but then the BP decreased down to the 80's. Labs from clinic
showed that Cr increased to 2.9 (baseline 1.1). WBC increased
somewhat. He was transferred to the ED for further evaluation.
.
In the ED, initial vs were: 4 97.6 72 105/73 18 99%  He was
given total of 3L of saline, and recent vital signs were 98.8
129/85 80 16 96% on 2L at time of transfer. A bedside "shock"
ultrasound US in ED showed no cardiac effusion, no evidence of
gross RV overload. EKG was not significantly changed. Her INR
was 3.0. Of note, he was also complaining of left sided
shoulder/neck pain associated with shortness of breath and
diaphoresis.
.
For interventions, he received 1 gm vanc and 1gm aztreonam, 40
mg medrol, and 2 L IVF in clinic, and another liter in the ED.

MEDICAL HISTORY: - AML-M7: s/p matched unrelated allogenic transplant on
[**2143-6-24**]
- Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**]
consistent with GVHD, managed with cyclosporine, steroids,
periodic CellCept, and has received 1 cycle of Rituxan.
- Type 2 DM
- Hyperlipidemia
- H/o AVN bilateral hips
- HTN
- H/o nephrolithiasis, lithotripsy and previous nephrostomy tube
and emergent surgery to repair ureteral damage
- h/o left interpolar renal lesion, followed with MRs
- h/o BCC s/p excision
- h/o SCC left cheek, s/p Mohs' [**5-/2144**]
- h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and
cervical spine fusion (bone graft, no hardware)
- h/o anterior cervical diskectomy and instrument arthrodesis at
C5-C6 and C6-C7 for degenerative cervical spondylitic disease
with spinal cord compression and foraminal stenosis at C5-C6 and
C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]
- Chronic numbness, neuropathic pain in left upper extremity.
- Multilevel compression fractures T11, T12, L1 and mild
compression L3 and L4.
- h/o pulmonary embolism [**11/2144**] on anticoagulated from
[**11/2144**]-present
- h/o RSV [**11/2144**] requiring ICU admission
- h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**]

MEDICATION ON ADMISSION: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUDESONIDE [ENTOCORT EC] -  (Dose adjustment - no new Rx) - 3 mg
Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice
a day
FOLIC ACID -  (Dose adjustment - no new Rx) - 1 mg Tablet - 1
(One) Tablet(s) by mouth once a day
HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**]
hours as needed for pain
INSULIN LISPRO [HUMALOG] - SS
LISINOPRIL -  (Dose adjustment - no new Rx) - 5 mg Tablet - 1
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth
twice a day
OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three)
Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20
mg) and 3 tablets every evening (60 mg)
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once day
PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a
day
RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday
TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet -
Apply to upper torso once daily
WARFARIN [COUMADIN] -  (Dose adjustment - no new Rx) - 2.5 mg
Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] -  (Dose adjustment - no
new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily)
INSULIN NPH HUMAN RECOMB -  (Prescribed by Other Provider) - 100
unit/mL Suspension - 12 units twice a day Please take first dose
in the morning and the second dose at bedtime

ALLERGIES: Cefepime / Cipro

PHYSICAL EXAM: Tmax: 36.7 ??????C (98.1 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 85 (85 - 85) bpm
BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg
RR: 11 (11 - 11) insp/min
SpO2: 97%
Heart rhythm: SR (Sinus Rhythm)
.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: mild RUQ->mid epigastrium tenderness
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema . No calf or thigh tenderness.
Skin: depigmentation on hands, redness of neck, but no notable
skin changes otherwise. No rashes.

FAMILY HISTORY: Mother died suddenly in her 70s. Father died of unknown cancer
with tumors visible across body. One sister has thyroid cancer.
One brother has diabetes and kidney stones. One sister has
[**Name (NI) 5895**].

SOCIAL HISTORY: Lives with his wife, and one of children, worked as a [**Company 22957**]
technician until [**Month (only) 547**] when he took early retirement and he is
no longer working.  Tob: previously smoked 1ppd for many years
but quit 2.5 years ago
EtOH: h/o social use; none recently 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Glucocorticoid deficiency,Acute myeloid leukemia, in remission,Complications of transplanted bone marrow,Chronic graft-versus-host disease,Severe sepsis,Adrenal cortical steroids causing adverse effects in therapeutic use,Acute bronchitis,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Personal history of venous thrombosis and embolism,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of steroids'}
