CHIEF COMPLAINT: diarrhea

PRESENT ILLNESS: 59 y/o man with a history of AML diagnosed [**1-21**] s/p 7+3
induction on [**2175-2-4**] with persistent blasts w/o maturation in
repeat marrow bx, s/p reinduction with HIDAC on [**2176-3-2**], now day
#215 s/p allo stem cell transplant (HLA matched sibling-brother)
in [**7-20**], presents with a 3.5 week h/o diarrhea.  The pt states
the diarrhea began [**3-10**], with watery brown semi-solid to solid
BMs, up to 10-12 per day.  He felt that he occasionally could
not make it to the bathroom.  No blood or mucus in the stool.
He tried to limit his lactose intake, but this did not improve
his diarrhea.  He has not had any sick contacts, foreign travel
(only recently went to [**Location (un) 7349**]), no camping. No changes in
medications or new antibiotics recently.  He did have a "skin
rash" recently at [**Hospital **] Hospital, thought [**1-18**] levaquin.  The
pt was hospitalized [**Date range (1) 61436**] at [**Location (un) **], and stated that he was
given IVF hydration, stool studies sent, he underwent flex
sigmoidoscopy showing "rectal ulcers" that were biopsied, with
path pending per pt.  He says their workup was "unrevealing."
During his hospitalization, he was given flagyl and levaquin,
and hydrocortisone.  His diarrhea has continued despite these
measures.  He has no abd pain, no nausea or vomiting. + low
grade fevers but  chills. No dark urine.  No night sweats. He
notes a 13 lb weight loss since [**2-29**].  Decreased energy. Poor po
intake (b/c he fears that it will 'go right through him.'
Eating boost tid, with soups mainly.  + bloating, and the
sensation of "having to have a bm" that can be as severe as a
[**5-25**], but is usually a [**1-26**].  He has not taken any meds for the
bloating or diarrhea until recently, when Dr. [**First Name (STitle) 1557**] told him to
take Imodium.

MEDICAL HISTORY: Past Oncologic History:
#. [**1-21**]: Initial presentation of malignancy:  Pt had a routine
physcial at his PCP's office that showed pancytopenia. His last
CBC was one year earlier and WNL. He was admitted to [**Hospital **]
hospital where a bone marrow showed acute myelogenous leukemia.
The patient was referred to Dr. [**First Name (STitle) 1557**] for further treatment.
Prior to seeing his PCP he felt completely well. He had not
noticed any bleeding, fevers, chills, night sweats, HA, weight
loss, or shortness of breath.
.
#. AML - Hospitalization at [**Hospital1 18**]: [**Date range (1) 61437**]: Initial bone
marrow biopsy showed marrow involvement by AML evolving in a
background of myelodysplastic syndrome. 90% blasts were seen on
aspirate. Cytogenetics were abnormal with multiple structural
and numerical aberrations. Among these are a missing 7 and 21, a
deletion of 5q, additional material of undetermined origin on
17q, and 4 to 5 structurally abnormal markers. The patient was
started on 7+3 therapy on [**2-4**]. He tolerated the induction well
with only the development of fevers. However on day +13 of
induction, he underwent repeat bone marrow which demonstrated
persistent leukemia. A repeat marrow on day +20 showed a
hypocellular marrow with young cells that were thought to be of
normal maturation. His peripheral smear demonstrated few blasts,
also thought to represent early cells of normal maturation. His
peripheral smear continued to show blasts and on day +28, his
marrow was re-biopsied. This showed a increase in the number of
blast forms without maturation. He underwent reinduction with
HIDAC starting [**2175-3-3**]. He had no mucositis or CNS dysfunction
His repeat marrow on day +14 of re-induction showed 95% cellular

MEDICATION ON ADMISSION: 1.  CellCept [**Pager number **] mg b.i.d.
2.  Ursodiol 300mg po bid
3.  Multivitamin
4.  Folic acid 800mcg po qd
5.  Lopressor 12.5mg po bid
6.  Lexapro 20mg po qd
7.  Desipramine 100mg po qd
8.  Ritalin 10mg po qAM and qNoon
9.  Acyclovir 400mg po tid
10. Magnesium supplement
11. Alprazolam 0.5mg po qd prn
12. Meds he has not taken in weeks: Prep H, Peptobismol, TUMS

ALLERGIES: Caspofungin / Levaquin

PHYSICAL EXAM: Vitals: temp: 98.9 BP: 104/68 P: 89 RR: 14 O2sat: 99% RA. Wt 130
lbs, 66 inches.
General: Thin CM in NAD. Breathing comfortably on RA. Well
spoken. AOX3. Appropriate. + bitemporal wasting.
HEENT: PERRL EOMI. MM dry, OP clear w/o lesions
Neck: No lad, no jvd
Lungs: CTAB
CV: RRR S1 and S2 audible w/o m/r/g
Abd: Soft, NT, ND, NABS, No masses. No HSM.
P. vasc: 2+ DP pulses b/l. Dry skin. No cyanosis/clubbing.
Neuro: CN 2-12 intact. Motor [**4-19**] throughout. Sensory [**4-19**]
throughout. Gait WNL.

FAMILY HISTORY: No fHX of Leukemia or lymphoma.  Mother- bone cancer of unknown
etiology. Father- 3 vessel bypass graft, HTN

SOCIAL HISTORY: no tobacco, though smoked pipes in college X 2 years,
no etoh, no IVDA.  Lives in [**Location **] with wife.  [**Name (NI) **] is a retired
finance professor, originally worked at [**University/College **], now working at the
[**Last Name (un) 61441**].
Enteritis due to rotavirus,Bacterial pneumonia, unspecified,Bone marrow replaced by transplant,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute myeloid leukemia, in remission,Cytomegaloviral disease,Unspecified disorder of kidney and ureter,Dysthymic disorder,Dermatophytosis of the body
Intes infec rotavirus,Bacterial pneumonia NOS,Trnspl status-bne marrow,Hypoxemia,Hyp kid NOS w cr kid V,Act myl leuk w rmsion,Cytomegaloviral disease,Renal & ureteral dis NOS,Dysthymic disorder,Dermatophytosis of body
Admission Date:  [**2176-4-3**]              Discharge Date:   [**2176-4-23**]

Date of Birth:  [**2116-9-5**]             Sex:   M

Service: MEDICINE

Allergies:
Caspofungin / Levaquin

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
diarrhea

Major Surgical or Invasive Procedure:
none


History of Present Illness:
59 y/o man with a history of AML diagnosed [**1-21**] s/p 7+3
induction on [**2175-2-4**] with persistent blasts w/o maturation in
repeat marrow bx, s/p reinduction with HIDAC on [**2176-3-2**], now day
#215 s/p allo stem cell transplant (HLA matched sibling-brother)
in [**7-20**], presents with a 3.5 week h/o diarrhea.  The pt states
the diarrhea began [**3-10**], with watery brown semi-solid to solid
BMs, up to 10-12 per day.  He felt that he occasionally could
not make it to the bathroom.  No blood or mucus in the stool.
He tried to limit his lactose intake, but this did not improve
his diarrhea.  He has not had any sick contacts, foreign travel
(only recently went to [**Location (un) 7349**]), no camping. No changes in
medications or new antibiotics recently.  He did have a "skin
rash" recently at [**Hospital **] Hospital, thought [**1-18**] levaquin.  The
pt was hospitalized [**Date range (1) 61436**] at [**Location (un) **], and stated that he was
given IVF hydration, stool studies sent, he underwent flex
sigmoidoscopy showing "rectal ulcers" that were biopsied, with
path pending per pt.  He says their workup was "unrevealing."
During his hospitalization, he was given flagyl and levaquin,
and hydrocortisone.  His diarrhea has continued despite these
measures.  He has no abd pain, no nausea or vomiting. + low
grade fevers but  chills. No dark urine.  No night sweats. He
notes a 13 lb weight loss since [**2-29**].  Decreased energy. Poor po
intake (b/c he fears that it will 'go right through him.'
Eating boost tid, with soups mainly.  + bloating, and the
sensation of "having to have a bm" that can be as severe as a
[**5-25**], but is usually a [**1-26**].  He has not taken any meds for the
bloating or diarrhea until recently, when Dr. [**First Name (STitle) 1557**] told him to
take Imodium.


Past Medical History:
Past Oncologic History:
#. [**1-21**]: Initial presentation of malignancy:  Pt had a routine
physcial at his PCP's office that showed pancytopenia. His last
CBC was one year earlier and WNL. He was admitted to [**Hospital **]
hospital where a bone marrow showed acute myelogenous leukemia.
The patient was referred to Dr. [**First Name (STitle) 1557**] for further treatment.
Prior to seeing his PCP he felt completely well. He had not
noticed any bleeding, fevers, chills, night sweats, HA, weight
loss, or shortness of breath.
.
#. AML - Hospitalization at [**Hospital1 18**]: [**Date range (1) 61437**]: Initial bone
marrow biopsy showed marrow involvement by AML evolving in a
background of myelodysplastic syndrome. 90% blasts were seen on
aspirate. Cytogenetics were abnormal with multiple structural
and numerical aberrations. Among these are a missing 7 and 21, a
deletion of 5q, additional material of undetermined origin on
17q, and 4 to 5 structurally abnormal markers. The patient was
started on 7+3 therapy on [**2-4**]. He tolerated the induction well
with only the development of fevers. However on day +13 of
induction, he underwent repeat bone marrow which demonstrated
persistent leukemia. A repeat marrow on day +20 showed a
hypocellular marrow with young cells that were thought to be of
normal maturation. His peripheral smear demonstrated few blasts,
also thought to represent early cells of normal maturation. His
peripheral smear continued to show blasts and on day +28, his
marrow was re-biopsied. This showed a increase in the number of
blast forms without maturation. He underwent reinduction with
HIDAC starting [**2175-3-3**]. He had no mucositis or CNS dysfunction
His repeat marrow on day +14 of re-induction showed 95% cellular

bone marrow comprised almost exclusively of immature cells,
consistent with myeloblasts. His counts were monitored closely
to see if he would return with MDS or persistent AML. As his
counts began to return he had noted 10% blasts in the periphery.
It was felt that this could represent persistent AML versus
early recovering marrow.  He also developed a PNA during this
admission.
.
ORIGINAL CYTOGENETICS:
#. [**2175-2-17**] cytogenetics:
49,[**Last Name (LF) **],[**First Name3 (LF) **](5)(q11.2q33),-7,add(17)(q25),-21,+[**2-18**][cp19]/46,XY[1];
This abnormal karyotype shows multiple structural and numerical
aberrations. Among these are a missing 7 and 21, a deletion of
5q, additional material of undetermined origin on 17q, and 4 to
5 structurally abnormal marker
.
#. 8/22/05-10/05 Hospitalization at [**Hospital1 18**]: allo transplant from
brother, did well.
.
#. [**Hospital1 18**]: Patient was admitted [**Date range (3) 61438**] for neutropenic
fever. He was discharged from that hospitalization on
levofloxacin. No fever source was identified on that admission.
.
#. [**Date range (1) 61439**]/05: Hospitalization at [**Location (un) **]: febrile
neutropenia
.
#. [**Date range (1) 61440**]/05: Hospitalization at [**Location (un) **]: [**1-18**] ?Klebsiella
from GI tract? per pt, febrile neutropenia
.
#. end of [**2175-11-16**]: Hospitaliz. at [**Location (un) **]: Staph epi
bacteremia, on Vanco/Cefepime, febrile neutropenia
.
#. The patient had a positive CMV viral load on [**2175-10-11**] at
1,600 copies (previous negative on [**10-7**]). CMV VL on [**2176-2-29**] was
undetectable.
.
#. As of [**2-19**], the pt remains in clinical complete remission.
.
1.  AML (multiple cytogentic aberrations)- diagnosed [**1-21**], S/P
2.  alloSCT from sibling donor
3.  Depression, well controlled on medication per pt.
4.  HSV-2, only 1 flare in 3 years
5.  Tonsillectomy and Adenoidectomy - [**2121**]
6.  HTN, well controlled on medic per pt.
7.  Pulm Aspergillus
8.  CMV viremia


Social History:
no tobacco, though smoked pipes in college X 2 years,
no etoh, no IVDA.  Lives in [**Location **] with wife.  [**Name (NI) **] is a retired
finance professor, originally worked at [**University/College **], now working at the
[**Last Name (un) 61441**].


Family History:
No fHX of Leukemia or lymphoma.  Mother- bone cancer of unknown
etiology. Father- 3 vessel bypass graft, HTN

Physical Exam:
Vitals: temp: 98.9 BP: 104/68 P: 89 RR: 14 O2sat: 99% RA. Wt 130
lbs, 66 inches.
General: Thin CM in NAD. Breathing comfortably on RA. Well
spoken. AOX3. Appropriate. + bitemporal wasting.
HEENT: PERRL EOMI. MM dry, OP clear w/o lesions
Neck: No lad, no jvd
Lungs: CTAB
CV: RRR S1 and S2 audible w/o m/r/g
Abd: Soft, NT, ND, NABS, No masses. No HSM.
P. vasc: 2+ DP pulses b/l. Dry skin. No cyanosis/clubbing.
Neuro: CN 2-12 intact. Motor [**4-19**] throughout. Sensory [**4-19**]
throughout. Gait WNL.


Pertinent Results:
MARROWS DURING INTITIAL DX:
#. [**2175-2-22**] BM Bx: Cellular myeloid-dominant marrow with markedly
left-shifted myelopoiesis and increased myeloblasts (day 20
status post myeloblative chemotherapy) Note: Although
myeloblasts appear increased on the hemodilute aspirate smear,
an accurate count can not be determined due to poor specimen
quality. Re-biopsy is recommended if clinically indicated.
.
[**2175-3-2**] BM Bx: C/W AML. Immunophenotypic findings c/w
involvement by AML w/an immature phenotype.
.
[**3-18**] BM Bx: biopsy consists of blood, cortical bone, and a few
fragments of > 95% cellular bone marrow comprised almost
exclusively of immature cells, consistent with myeloblasts.
.
MOST RECENT ECHO [**7-20**] EF >60%.
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Trace aortic regurgitation is seen.
.
Imaging:
[**2176-4-3**]: CXR
CHEST, PA AND LATERAL: An opacity is present in the left lower
lobe. The remaining lungs are clear. The mediastinal and hilar
contours are
unremarkable. The heart is normal size. No pleural effusions are
visualized. The surrounding soft tissue and osseous structures
are unremarkable.
IMPRESSION: Left lower lobe pneumonia.
.
[**2176-4-8**]:
AP CHEST RADIOGRAPH:
Left sided PICC line is seen with tip overlying the distal SVC.
Cardiac, mediastinal, and hilar contours appear unchanged.
Pulmonary vascularity remains within normal limits. Compared to
prior study, the left lower lobe opacity appears slightly worse.
There has also been interval increase in right lower lobe
opacity, consistent with pneumonia.
IMPRESSION: Bibasilar pneumonia, slightly worsened in the
interval.
.
[**4-9**] CXR
IMPRESSION: AP chest compared to [**4-4**] and 24:
Bibasilar pneumonia is clearing. Upper lungs are clear. Heart
size is
normal. There is no appreciable pleural effusion. Tip of a
left-sided
central venous line projects over the SVC. Mediastinal widening
at the thoracic inlet due to combination of adenopathy and fat
deposition and tortuous vessels is longstanding.
.
CTA [**4-9**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Persistent bilateral lower lobe consolidations, also with
patchy lingular
involvement. The degree of consolidation is increased at the
right base.
.
CT ABD [**4-9**]
IMPRESSION:
1. Diffuse edema of the descending colon, sigmoid colon, and
rectum with consistent with colitis. This finding is
non-specific and may represent infectious etiology. A drug
reaction if the patient is on chemotherapy could give this
appearance. Less likely is ischemia as the abdominal vasculature
is widely patent. Inflammatory bowel disease is also less
likely. Clinical correlation is recommended.
2. No evidence for pulmonary embolus. Bilateral airspace
consolidation within the lower lobes, left greater than right,
consistent with pneumonia.
3. Cholelithiasis without evidence for cholecystitis with mild
central biliary ductal dilatation.
4. Multiple rounded low-attenuation foci within the kidneys
bilaterally, which cannot be definitively characterized as
simple renal cysts. A renal ultrasound is recommended for
definitive characterization.
.
CT HEAD [**4-9**]
FINDINGS: There is no evidence of acute intracranial hemorrhage.
No mass effect. No shift of normally midline structures.
Bilateral ventricles are symmetric and not dilated. Note is made
of right carotid artery calcification. There is fluid in
bilateral ethmoid sinuses, representing sinusitis. Calcified
dural plaques are seen.
IMPRESSION: No acute intracranial hemorrhage. Ethmoid sinusitis.

.
CT CHEST [**4-19**]
IMPRESSION: Improving of the bilateral lower lobe consolidation


Brief Hospital Course:
59 y/o gentleman with h/o AML day 217 post allo SCT (HLA matched
sibling) presents with 3.5 week h/o diarrhea, 13 lb weight loss,
decr po intake.  His course was complicated by bilateral lower
lobe PNA requiring an admission to the ICU.
.
#. [**Hospital Unit Name 153**] course for desaturation/acute respiratory distress:  The
pt's course was complicated by PNA.  On admission CXR, the pt
demonstrated a LLL infiltrate.  He was started on levaquin,
however, his PNA worsened with chest CT the following day
showing bilateral lower lobe consolidations.  His coverage was
broadened to include Vanco, Flagyl and Ganciclovir to cover for
CMV PNA.  His voriconazole was continued throughout this time.
He did not require intubation.  Pt's sats remained stable on
face mask, now weaned down to 50% Fio2, upper 90s sats.  He was
suctioned and given chest PT in the ICU.  His Vancomycin was
discontinued, and azithromycin was added empirically for
Legionella coverage (although urinary antigen negative).  ID
consultants continued to follow pt in the [**Hospital Unit Name 153**], and recommended
sending EBV VL, 2 more sputums for PCP, [**Name10 (NameIs) **] continuing the
current regimen of Cefepime (started [**4-5**]), Flagyl (started
[**4-4**]), Azithro (added [**4-10**]) and Ganciclovir (started [**4-4**]),
keeping a low threshold for bronch.  However, the pt did not
require bronchoscopy. EBV and PCP were negative. Respiratory
status improved and patient was transferred back to 7 [**Hospital Ward Name 1826**]
for further care. He was maintained on Albuterol/Atrovent nebs
and supplemental oxygen was weaned as tolerated. Repeat Chest CT
on [**2176-4-19**] showed interval improvement in pneumonia.
.
#. Bilateral lower lobe PNA:  being covered with
Cefepime/Flagyl/Voriconazole.  Pt most likely has bacterial PNA
given appearance with air bronchograms/consolidation seen on
Chest CT.  Less likely CMV PNA or MRSA PNA, although was
recently hospitalized in [**Location (un) **], CT.  Vancomycin discontinued
and added back X 2, but now discontinued.  He was being covered
with Azithro for Legionella PNA though Legionella urinary ag
negative while in the ICU but this was discontinued [**4-12**] after
[**Hospital Unit Name 153**] call out.  His PCP DFA was negative.  His CMV VL was
negative X 3, but do not suspect CMV PNA.  Serum galactomannan
negative.  He was weaned from face mask to nasal cannula and
saturated well with nebs and nasal cannula. Albuterol nebs and
supplemental oxygen were weaned. Patient did well on room air
and was followed by physical therapy. At time of discharge,
patient was doing well on room air without ambulatory
desaturation below 94-95%. He was discharged home on Cefpodoxime
to complete 3 week course of antibiotics from time of clinical
improvement. Continued Voriconazole for antifungal coverage.
.
#.  Diarrhea, improved: DDX includes Rotavirus in
immunosuppressed individual, GVHD, CMV colitis, other
infectious.  Less likely osmotic diarrhea, medication induced,
or inflammatory.  OSH report showing rectal ulcerations, biopsy:
no cytopathic effect. CMV VL at OSH neg, CMV VL here negative X
3.  He was given IVIg the morning after admission.  The pt was
on Ganciclovir IV for several days, however this was stopped
after he demonstrated improvement in diarrhea. GI was consulted
for possible colonoscopy with biopsy, but given improvement in
diarrhea, colonoscopy was deferred. Repeat CMV VL was sent which
was positive but not within detectable range, and patient was
re-started on Ganciclovir; he received treatment dose for 4 days
and then converted to Valganciclovir maintenance dose. At time
of discharge, patient having [**1-19**] formed BMs/day, marked
improvement from admission condition. Weaned down to Prednisone
10mg, to be tapered as outpatient.
.
# Anxiety/Depression: Continued on outpatient Ritalin,
Desipramine, and Escitilopram
.
#. HTN: Patient with long-standing history of HTN, which
improved after chemotherapy. Outpatient Metoprolol was continued
and titrated up to 25mg TID.
.
#. Incidentaloma: CT Chest on [**2176-4-19**] showed low-density right
kidney lesion which should be evaluated with ultrasound to
exclude the possibility of complex cyst or malignancy. Findings
were emailed to oncologist, to follow-up as outpatient. Patient
without flank pain or renal insufficiency.

#. FULL CODE

Medications on Admission:
1.  CellCept [**Pager number **] mg b.i.d.
2.  Ursodiol 300mg po bid
3.  Multivitamin
4.  Folic acid 800mcg po qd
5.  Lopressor 12.5mg po bid
6.  Lexapro 20mg po qd
7.  Desipramine 100mg po qd
8.  Ritalin 10mg po qAM and qNoon
9.  Acyclovir 400mg po tid
10. Magnesium supplement
11. Alprazolam 0.5mg po qd prn
12. Meds he has not taken in weeks: Prep H, Peptobismol, TUMS

Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO once a
day: 1 tablet in the morning
1 tablet at noon.
Disp:*60 Tablet(s)* Refills:*0*
3. Desipramine 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*100 Tablet(s)* Refills:*0*
4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
5. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day for 10 days.
Disp:*1 trade size* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*0*
8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*14 Tablet(s)* Refills:*1*
9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Flushes
Heparin and saline flushes for PICC per protocol
12. Dressing
PICC dressing care and changes per protocol


Discharge Disposition:
Home With Service

Facility:
[**Hospital 5065**] Healthcare

Discharge Diagnosis:
Bilateral lower lobe pneumonia, presumed bacterial
Diarrhea post-transplant
CMV
Hypertension


Discharge Condition:
diarrhea resolved, sat'ing well on room air


Discharge Instructions:
1. Take all medications as prescribed and make all follow-up
appointments.
2. If you experience fevers, chills, diarrhea, difficulty
breathing, or any other concerning signs/symptoms, please
contact the BMT fellow or report to the Emergency Department

Followup Instructions:
As instructed, please report to 7Feldberg on Thursday at 10 AM
to meet with Dr. [**First Name (STitle) 1557**].



Completed by:[**2176-4-27**]
{'Enteritis due to rotavirus,Bacterial pneumonia, unspecified,Bone marrow replaced by transplant,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute myeloid leukemia, in remission,Cytomegaloviral disease,Unspecified disorder of kidney and ureter,Dysthymic disorder,Dermatophytosis of the body'}


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: diarrhea

PRESENT ILLNESS: 59 y/o man with a history of AML diagnosed [**1-21**] s/p 7+3
induction on [**2175-2-4**] with persistent blasts w/o maturation in
repeat marrow bx, s/p reinduction with HIDAC on [**2176-3-2**], now day
#215 s/p allo stem cell transplant (HLA matched sibling-brother)
in [**7-20**], presents with a 3.5 week h/o diarrhea.  The pt states
the diarrhea began [**3-10**], with watery brown semi-solid to solid
BMs, up to 10-12 per day.  He felt that he occasionally could
not make it to the bathroom.  No blood or mucus in the stool.
He tried to limit his lactose intake, but this did not improve
his diarrhea.  He has not had any sick contacts, foreign travel
(only recently went to [**Location (un) 7349**]), no camping. No changes in
medications or new antibiotics recently.  He did have a "skin
rash" recently at [**Hospital **] Hospital, thought [**1-18**] levaquin.  The
pt was hospitalized [**Date range (1) 61436**] at [**Location (un) **], and stated that he was
given IVF hydration, stool studies sent, he underwent flex
sigmoidoscopy showing "rectal ulcers" that were biopsied, with
path pending per pt.  He says their workup was "unrevealing."
During his hospitalization, he was given flagyl and levaquin,
and hydrocortisone.  His diarrhea has continued despite these
measures.  He has no abd pain, no nausea or vomiting. + low
grade fevers but  chills. No dark urine.  No night sweats. He
notes a 13 lb weight loss since [**2-29**].  Decreased energy. Poor po
intake (b/c he fears that it will 'go right through him.'
Eating boost tid, with soups mainly.  + bloating, and the
sensation of "having to have a bm" that can be as severe as a
[**5-25**], but is usually a [**1-26**].  He has not taken any meds for the
bloating or diarrhea until recently, when Dr. [**First Name (STitle) 1557**] told him to
take Imodium.

MEDICAL HISTORY: Past Oncologic History:
#. [**1-21**]: Initial presentation of malignancy:  Pt had a routine
physcial at his PCP's office that showed pancytopenia. His last
CBC was one year earlier and WNL. He was admitted to [**Hospital **]
hospital where a bone marrow showed acute myelogenous leukemia.
The patient was referred to Dr. [**First Name (STitle) 1557**] for further treatment.
Prior to seeing his PCP he felt completely well. He had not
noticed any bleeding, fevers, chills, night sweats, HA, weight
loss, or shortness of breath.
.
#. AML - Hospitalization at [**Hospital1 18**]: [**Date range (1) 61437**]: Initial bone
marrow biopsy showed marrow involvement by AML evolving in a
background of myelodysplastic syndrome. 90% blasts were seen on
aspirate. Cytogenetics were abnormal with multiple structural
and numerical aberrations. Among these are a missing 7 and 21, a
deletion of 5q, additional material of undetermined origin on
17q, and 4 to 5 structurally abnormal markers. The patient was
started on 7+3 therapy on [**2-4**]. He tolerated the induction well
with only the development of fevers. However on day +13 of
induction, he underwent repeat bone marrow which demonstrated
persistent leukemia. A repeat marrow on day +20 showed a
hypocellular marrow with young cells that were thought to be of
normal maturation. His peripheral smear demonstrated few blasts,
also thought to represent early cells of normal maturation. His
peripheral smear continued to show blasts and on day +28, his
marrow was re-biopsied. This showed a increase in the number of
blast forms without maturation. He underwent reinduction with
HIDAC starting [**2175-3-3**]. He had no mucositis or CNS dysfunction
His repeat marrow on day +14 of re-induction showed 95% cellular

MEDICATION ON ADMISSION: 1.  CellCept [**Pager number **] mg b.i.d.
2.  Ursodiol 300mg po bid
3.  Multivitamin
4.  Folic acid 800mcg po qd
5.  Lopressor 12.5mg po bid
6.  Lexapro 20mg po qd
7.  Desipramine 100mg po qd
8.  Ritalin 10mg po qAM and qNoon
9.  Acyclovir 400mg po tid
10. Magnesium supplement
11. Alprazolam 0.5mg po qd prn
12. Meds he has not taken in weeks: Prep H, Peptobismol, TUMS

ALLERGIES: Caspofungin / Levaquin

PHYSICAL EXAM: Vitals: temp: 98.9 BP: 104/68 P: 89 RR: 14 O2sat: 99% RA. Wt 130
lbs, 66 inches.
General: Thin CM in NAD. Breathing comfortably on RA. Well
spoken. AOX3. Appropriate. + bitemporal wasting.
HEENT: PERRL EOMI. MM dry, OP clear w/o lesions
Neck: No lad, no jvd
Lungs: CTAB
CV: RRR S1 and S2 audible w/o m/r/g
Abd: Soft, NT, ND, NABS, No masses. No HSM.
P. vasc: 2+ DP pulses b/l. Dry skin. No cyanosis/clubbing.
Neuro: CN 2-12 intact. Motor [**4-19**] throughout. Sensory [**4-19**]
throughout. Gait WNL.

FAMILY HISTORY: No fHX of Leukemia or lymphoma.  Mother- bone cancer of unknown
etiology. Father- 3 vessel bypass graft, HTN

SOCIAL HISTORY: no tobacco, though smoked pipes in college X 2 years,
no etoh, no IVDA.  Lives in [**Location **] with wife.  [**Name (NI) **] is a retired
finance professor, originally worked at [**University/College **], now working at the
[**Last Name (un) 61441**]. 

### Response:
{'Enteritis due to rotavirus,Bacterial pneumonia, unspecified,Bone marrow replaced by transplant,Hypoxemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acute myeloid leukemia, in remission,Cytomegaloviral disease,Unspecified disorder of kidney and ureter,Dysthymic disorder,Dermatophytosis of the body'}
