CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 71 year old man with a history notable for
hypertrophic non-obstructive cardiomyopathy, Afib, and Stage IIB
squamous cell lung cancer on chemo, s/p VATS RLL lobectomy
[**2146-7-25**], now C1D10 cisplatin/taxotere adjuvant chemotherapy, who
presents from heme/onc clinic with febrile neutropenia,
tachycardia, and hypotension. The patient had his first dose of
adjuvant chemo on [**9-6**] and felt well until Saturday [**9-10**]. Then,
he began to experience nausea, fatigue, poor appetite, and
diarrhea. He also felt dizzy and lightheaded occasionally. He
denied vomiting or bloody stools. His wife takes his temperature
at home and it had never been abolve 98.6.

MEDICAL HISTORY: Hypertrophic Obstructive Cardiomyopathy (Cardiol Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 696**])
HTN
CHF (EF 55%)
Bicuspid AV
Mild AS ([**Location (un) 109**] 1.7 cm2)
Dilated ascending aorta
Cholecystectomy
Hypercholesterolemia
Pneumonia ([**2139**])
Left leg claudication
Left inguinal hernia repair ([**2142**])
Colonic polyps (proximal descending colon; distal sigmoid
colon; [**2138**] colonoscopy)
Right rotator cuff injury
Atrial fibrillation ([**5-/2146**]) s/p DCCV [**2146-6-16**]
Right lung nodule

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID
2. Disopyramide CR 240 mg PO Q12H
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Metoprolol Succinate XL 50 mg PO Q12H
5. Pravastatin 80 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ondansetron 4-8 mg PO Q8H:PRN nausea
8. Prochlorperazine 5-10 mg PO Q6H:PRN nausea

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals:  98.2  84  95/60  17  95%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at RUSB, no extra heart sounds. JVP 10-12 cm, +HJR.
Lungs: Rales on left 1/3 up, absent breath sounds R base.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: His parents are both deceased (father - unknown;
mother 85; colon cancer).  He has two brothers (64 - CAD,
obesity; 72 - CAD, CVA). He has 4 children - 42, 46 year old
sons
- one with prior melanoma; 47 and 49 year-old daughters.

SOCIAL HISTORY: He previously worked at Polaroid.  He is now also retired
from bartending and delivering car parts. He has 4 children - 2
sons (both live in [**Name (NI) 108**]) and 2 daughters (live locally).
He continues to refrain from smoking (80 pack years; quit [**2143**]).
Atrial fibrillation,Urinary tract infection, site not specified,Malignant neoplasm of lower lobe, bronchus or lung,Chronic diastolic heart failure,Congenital insufficiency of aortic valve,Hyposmolality and/or hyponatremia,Hypertrophic obstructive cardiomyopathy,Other and unspecified Escherichia coli [E. coli],Neutropenia, unspecified,Hypotension, unspecified,Dizziness and giddiness,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Aortic valve disorders,Thoracic aortic ectasia,Peripheral vascular disease, unspecified,Personal history of antineoplastic chemotherapy,Personal history of colonic polyps,Personal history of tobacco use
Atrial fibrillation,Urin tract infection NOS,Mal neo lower lobe lung,Chr diastolic hrt fail,Cong aorta valv insuffic,Hyposmolality,Hyprtrophc obst cardiomy,E.coli infection NEC/NOS,Neutropenia NOS,Hypotension NOS,Dizziness and giddiness,Adv eff antineoplastic,Hyperlipidemia NEC/NOS,Aortic valve disorder,Thoracic aortic ectasia,Periph vascular dis NOS,Hx antineoplastic chemo,Prsnl hst colonic polyps,History of tobacco use
Admission Date:  [**2146-9-15**]              Discharge Date:   [**2146-9-20**]

Date of Birth:  [**2075-7-3**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3977**]
Chief Complaint:
Fevers

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 174**] is a 71 year old man with a history notable for
hypertrophic non-obstructive cardiomyopathy, Afib, and Stage IIB
squamous cell lung cancer on chemo, s/p VATS RLL lobectomy
[**2146-7-25**], now C1D10 cisplatin/taxotere adjuvant chemotherapy, who
presents from heme/onc clinic with febrile neutropenia,
tachycardia, and hypotension. The patient had his first dose of
adjuvant chemo on [**9-6**] and felt well until Saturday [**9-10**]. Then,
he began to experience nausea, fatigue, poor appetite, and
diarrhea. He also felt dizzy and lightheaded occasionally. He
denied vomiting or bloody stools. His wife takes his temperature
at home and it had never been abolve 98.6.

He presented today to his oncologist's office for a routine
visit, where he was found to be neutropenic (WBC 1.6, N:7%) and
febrile to 100.8. He was also tachycardic to the 130s. He was
referred to [**Hospital1 18**] ED for further management.

In the ED, initial VS were:  100.8 131 133/82 16 98%. His EKG
showed rapid Afib. He had a CXR that showed a RLL opacity,
consistent with mucoid impaction. He was given vamcomycin and
cefepime. He was given tylenol 1g PO. For Afib, he was given 4L
NS, diltiazem 10mg IV, metoprolol 50mg PO, and digoxin IV 0.5mg
x1, 0.25mg Q6H x2 doses, but were unable to break his rapid
Afib. His BP was as low as 89/76 and his HR was as high as 170.

On arrival to the MICU, patient's VS: 98.2  84  95/60  17
95%/RA.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
Hypertrophic Obstructive Cardiomyopathy (Cardiol Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 696**])
HTN
CHF (EF 55%)
Bicuspid AV
Mild AS ([**Location (un) 109**] 1.7 cm2)
Dilated ascending aorta
Cholecystectomy
Hypercholesterolemia
Pneumonia ([**2139**])
Left leg claudication
Left inguinal hernia repair ([**2142**])
Colonic polyps (proximal descending colon; distal sigmoid
colon; [**2138**] colonoscopy)
Right rotator cuff injury
Atrial fibrillation ([**5-/2146**]) s/p DCCV [**2146-6-16**]
Right lung nodule

Social History:
He previously worked at Polaroid.  He is now also retired
from bartending and delivering car parts. He has 4 children - 2
sons (both live in [**Name (NI) 108**]) and 2 daughters (live locally).
He continues to refrain from smoking (80 pack years; quit [**2143**]).

He has beer on the weekends. Denies drugs.  Wife recently
underwent surgery for brain aneurysm.



Family History:
His parents are both deceased (father - unknown;
mother 85; colon cancer).  He has two brothers (64 - CAD,
obesity; 72 - CAD, CVA). He has 4 children - 42, 46 year old
sons
- one with prior melanoma; 47 and 49 year-old daughters.


Physical Exam:
ADMISSION EXAM:
Vitals:  98.2  84  95/60  17  95%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at RUSB, no extra heart sounds. JVP 10-12 cm, +HJR.
Lungs: Rales on left 1/3 up, absent breath sounds R base.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.


Pertinent Results:
ADMISSION LABS
[**2146-9-15**] 09:40AM BLOOD WBC-1.6*# RBC-4.74 Hgb-13.6* Hct-39.5*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.2 Plt Ct-206
[**2146-9-15**] 09:40AM BLOOD Neuts-7* Bands-1 Lymphs-64* Monos-24*
Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2146-9-15**] 09:40AM BLOOD UreaN-19 Creat-0.9 Na-132* K-4.7 Cl-98
HCO3-29 AnGap-10
[**2146-9-15**] 09:40AM BLOOD ALT-27 AST-19 CK(CPK)-46* AlkPhos-61
TotBili-0.3
[**2146-9-15**] 09:40AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.9 Cholest-165
[**2146-9-15**] 09:40AM BLOOD Triglyc-204* HDL-37 CHOL/HD-4.5
LDLcalc-87
[**2146-9-15**] 01:54PM BLOOD Lactate-1.8

CXR [**2146-9-15**]:
FINDINGS:  Frontal and lateral views of the chest were obtained.
 The heart is of top normal size with stable cardiomediastinal
contours.  The right lung base linear opacity is similar to
multiple prior examinations, compatible with chronic mucoid
impaction.  Known right lower lobe nodule is not clearly
visualized on this exam.  Small right pleural effusion is
present, similar to prior.  No radiopaque foreign body.
Multilevel thoracic spine degenerative changes.

IMPRESSION:  Right lower lung linear opacity, similar to prior
and likely
reflects chronic mucoid impaction.  Small right pleural effusion
is also
similar to prior.

DISCHARGE LABS
[**2146-9-20**] 07:20AM BLOOD WBC-34.1* RBC-4.04* Hgb-11.6* Hct-34.6*
MCV-86 MCH-28.9 MCHC-33.6 RDW-15.7* Plt Ct-196
[**2146-9-19**] 08:05AM BLOOD UreaN-6 Creat-0.8 Na-139 K-3.7 Cl-104
HCO3-26 AnGap-13
[**2146-9-20**] 07:20AM BLOOD UreaN-10 Creat-0.9
[**2146-9-19**] 04:00PM BLOOD CK(CPK)-47
[**2146-9-18**] 07:00AM BLOOD ALT-19 AST-21 AlkPhos-100 TotBili-0.2
[**2146-9-19**] 08:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0

Brief Hospital Course:
71 year old man with hypertrophic cardiomyopathy, AFib, squamous
cell lung cancer on adjuvant chemo C1D15 on day of discharge,
cis/docetaxel who presented with febrile neutropenia, Afib with
RVR, and hypotension.
.
At time of discharge, pt was clinically stable with resolution
of neutropenia. He had a dose of Neulasta at time of admission.
He remains in sinus rhythm, with adjustments to his medications
this admission. Other details below:
.
# Afib with RVR:
- The patient has a history of Afib s/p DCCV in [**5-/2146**] and is on
disopyramide for rhythm control and metoprolol for rate control.
Fever and neutropenia likely precipitating factors. Metoprolol
has been held. Dig loaded initially. No role for cardioversion
unless pt is hemodynamcially unstable.
- Med changes per discussion with cardiology:
 - [**9-18**] - stopped digoxin 0.25mg daily. Metoprolol changed to
long acting 50 mg po daily. Stopped heparin gtt and started back
on outpt [**Month/Year (2) **].
 - Change to longacting diltiazem.
- Continue disopyramide. (see discharge meds for regimen) In
sinus rhythm with this regimen.
- telemetry; reviewed EKG with cardiology, who reports no acute
issues with EKG findings.
.
# Hypotension: resolved with IVF and rate control; maybe
associated with infection.
.
# Febrile neutropenia: Resolved [**2146-9-17**].
- [**2146-9-18**] WBC 19, leukocytosis now - Patient received outpt
Neulasta on [**2146-9-15**].
- Likely urinary source with e coli (essentially pan-sensitive)
in urine. Blood cultures no growth to date. Patient has had ANC
of 112 initially.
- Had cefepime 2g q8h  (started [**2146-9-16**], had 5 day course); Will
change to cefpodoxime to continue additional 3 days of therapy.
 - vancomycin started [**9-16**], stopped [**9-19**] to tailor therapy.
- unlikely cxr findings are PNA. Post VATS CXR shows RLL field
opacity, likely associated with resection. Exam has been normal
thus far. Monitor closely.
.
# Hyponatremia: Resolved due to hypovolemia.
.
# Squamous cell lung cancer: Cycle 1 of adjuvant chemo. When
stable will start C2 in [**1-24**] weeks as outpatient.
.
# Hypertrophic cardiomyopathy: Stable. Followed cards recs.
.
# Hyperlipidemia
- continue pravastatin

Patient will follow up with oncology and cardiology as
instructed.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID
2. Disopyramide CR 240 mg PO Q12H
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Metoprolol Succinate XL 50 mg PO Q12H
5. Pravastatin 80 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ondansetron 4-8 mg PO Q8H:PRN nausea
8. Prochlorperazine 5-10 mg PO Q6H:PRN nausea


Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 3 Days
RX *cefpodoxime 200 mg 1 tablet(s) by mouth q12 h Disp #*6
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID
4. Disopyramide CR 200 mg PO Q12H
RX *disopyramide [Norpace CR] 100 mg 2 capsule(s) by mouth twice
a day Disp #*120 Capsule Refills:*1
5. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
6. Pravastatin 80 mg PO DAILY
7. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*1
8. Ondansetron 4-8 mg PO Q8H:PRN nausea
9. Prochlorperazine 5-10 mg PO Q6H:PRN nausea
10. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1


Discharge Disposition:
Home

Discharge Diagnosis:
Atrial Fibrillation with RVR
Neutropenic Fever
Urinary Tract Infection
Hypotension
Hyponatremia
Squamous Cell Lung Cancer


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted due to infection from having a low immune
system due to the chemotherapy for lung cancer. You also had
complications of a rapid heart rate due to atrial fibrillation.
A urine source of infection was discovered and you were treated
with appropriate IV antibiotics, and you will complete an
additional 3 day course of oral antibiotics while at home. Your
heart rate was also very fast and needed aggressive intervention
with multiple medications. You had a brief stay in the ICU. The
heart doctors helped in your management and you are now on a
good regimen that controls your heart rate. It is in SINUS
RHYTHM. You will go home for recovery with close follow up with
your outpatient providers.

TRANSITION ISSUES:
1. Start taking antibiotics either tonite or tomorrow morning
and finish taking pills.
2. Need to discuss with your cardiologist about HEART MEDICATION
management.
3. Follow up with your ONCOLOGIST for further care.


Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2146-9-27**] at 9:30 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD (And Dr [**Last Name (STitle) **] [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2146-9-27**] at 11:00 AM
With: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN [**Telephone/Fax (1) 9644**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

CARDIOLOGY
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**]
Department: [**Hospital **] MEDICAL GROUP
When: WEDNESDAY [**2146-9-28**] at 10:45 AM
With: DR. [**First Name (STitle) 569**] PASTOR [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS     Best Parking: On Street Parking

Department: CARDIAC SERVICES
When: THURSDAY [**2147-1-12**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
*The office has sent Dr. [**Last Name (STitle) 696**] an email seeing if they can get
you a sooner appointment. The office has also put you on
cancellation list, they will contact you at home if a sooner
appointment becomes available. If you have any questions or
concerns please call the office.
{'Atrial fibrillation,Urinary tract infection, site not specified,Malignant neoplasm of lower lobe, bronchus or lung,Chronic diastolic heart failure,Congenital insufficiency of aortic valve,Hyposmolality and/or hyponatremia,Hypertrophic obstructive cardiomyopathy,Other and unspecified Escherichia coli [E. coli],Neutropenia, unspecified,Hypotension, unspecified,Dizziness and giddiness,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Aortic valve disorders,Thoracic aortic ectasia,Peripheral vascular disease, unspecified,Personal history of antineoplastic chemotherapy,Personal history of colonic polyps,Personal history of tobacco use'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Fevers

PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 71 year old man with a history notable for
hypertrophic non-obstructive cardiomyopathy, Afib, and Stage IIB
squamous cell lung cancer on chemo, s/p VATS RLL lobectomy
[**2146-7-25**], now C1D10 cisplatin/taxotere adjuvant chemotherapy, who
presents from heme/onc clinic with febrile neutropenia,
tachycardia, and hypotension. The patient had his first dose of
adjuvant chemo on [**9-6**] and felt well until Saturday [**9-10**]. Then,
he began to experience nausea, fatigue, poor appetite, and
diarrhea. He also felt dizzy and lightheaded occasionally. He
denied vomiting or bloody stools. His wife takes his temperature
at home and it had never been abolve 98.6.

MEDICAL HISTORY: Hypertrophic Obstructive Cardiomyopathy (Cardiol Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 696**])
HTN
CHF (EF 55%)
Bicuspid AV
Mild AS ([**Location (un) 109**] 1.7 cm2)
Dilated ascending aorta
Cholecystectomy
Hypercholesterolemia
Pneumonia ([**2139**])
Left leg claudication
Left inguinal hernia repair ([**2142**])
Colonic polyps (proximal descending colon; distal sigmoid
colon; [**2138**] colonoscopy)
Right rotator cuff injury
Atrial fibrillation ([**5-/2146**]) s/p DCCV [**2146-6-16**]
Right lung nodule

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**].
1. [**Name2 (NI) 62055**] Etexilate 150 mg PO BID
2. Disopyramide CR 240 mg PO Q12H
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Metoprolol Succinate XL 50 mg PO Q12H
5. Pravastatin 80 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Ondansetron 4-8 mg PO Q8H:PRN nausea
8. Prochlorperazine 5-10 mg PO Q6H:PRN nausea

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals:  98.2  84  95/60  17  95%/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur at RUSB, no extra heart sounds. JVP 10-12 cm, +HJR.
Lungs: Rales on left 1/3 up, absent breath sounds R base.
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: His parents are both deceased (father - unknown;
mother 85; colon cancer).  He has two brothers (64 - CAD,
obesity; 72 - CAD, CVA). He has 4 children - 42, 46 year old
sons
- one with prior melanoma; 47 and 49 year-old daughters.

SOCIAL HISTORY: He previously worked at Polaroid.  He is now also retired
from bartending and delivering car parts. He has 4 children - 2
sons (both live in [**Name (NI) 108**]) and 2 daughters (live locally).
He continues to refrain from smoking (80 pack years; quit [**2143**]). 

### Response:
{'Atrial fibrillation,Urinary tract infection, site not specified,Malignant neoplasm of lower lobe, bronchus or lung,Chronic diastolic heart failure,Congenital insufficiency of aortic valve,Hyposmolality and/or hyponatremia,Hypertrophic obstructive cardiomyopathy,Other and unspecified Escherichia coli [E. coli],Neutropenia, unspecified,Hypotension, unspecified,Dizziness and giddiness,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Aortic valve disorders,Thoracic aortic ectasia,Peripheral vascular disease, unspecified,Personal history of antineoplastic chemotherapy,Personal history of colonic polyps,Personal history of tobacco use'}
