CHIEF COMPLAINT: SOB, CP, n/v

PRESENT ILLNESS: HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 36 year old female with history of recently
diagnosed ALL, who came to the oncology clinic to receive her
chemothrapy and complained of worsening shortness of breath and
chest pain for a few days, and was referred to ED for further
evaluation and treatment. Per patient, she has been experiencing
worsening dyspnea for the past week when she had to increase the
number of pillows from 2 to 4 due to shortness of breath when
she slept.  States a [**6-14**] midsternal chest pain that radiates
circumferentialy around the ribs to the back that started a few
days ago. Pain is gradual and constant and worse with
inspiration, gets better when she is sits up.  Has a productive
cough with white/clear phelegm.  Denies any fevers/chills/night
sweats.
.
She has also been experiencing severe nausea and vomiting for
the past week where she has been unable to hold any food down.
Her weight has been fluctuating but no big weight loss recently.
She does endorse dizziness since yesterday when she stands up,
relieved when she sits or lies down.
.
With her hx of asthma, she only uses her inhalers. Has not been
to the ED for any exacerbations. States an increased frequency
of use of her inhalers in the past few weeks.
.
Of note, patient recently presented to ED on [**2172-8-11**] with some
RUE weaknesa and parethesia, and was found to have a WBC of
140K, and emergently leukopheresed, and was diagnosed with ALL.
She was discharged on [**2172-9-22**], and has been receiving
chemotherapy regularly. Today is her phase II day 25 therapy.
.
In the ED, patient's initial vitals were: Afebrile, T98.2 BP
154/120 HR 138 RR 18 SPO297% on R/A. Sat's: off oxygen 93%, 97%
on 4L (depends on position). She was slightly tachypneic, RR
25-30s, and it hurts for her to breath in.  She underwent CTA to
rule out PE. Her scan demonstrated large bilateral pleural
effusions and a small pericardial effusion. bedside US showed no
tamponade, and small effusion. She was given 1 gram of Cefepime,
500-1000cc of normal saline, had 200cc urine (no foley). No
change in HR was seen after receiving morphine or IVF. The
oncology fellow was notified of the patient's planned admission
and course. per onc fellow, no urgent need to tap, but may need
to tap overnight if pt is very symptomatic from the pleural
effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management.
.
On the floor, she continued to complain of shortness of breath
while lying down, and is sitting up while talking. She continued
to complain of nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied any palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- ALL
- Asthma: uses inhalers
- HTN
- Cervical Intraepithelial neoplasia

MEDICATION ON ADMISSION: Medications: (confirmed by [**2172-10-15**] hem/onc note)
ACYCLOVIR - 200 mg Capsule - 2 Capsule(s) by mouth three times a
day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL by mouth
once a day
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth twice a
daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhaled twice a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
puffs po four times a day as needed for prn
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for Nausea
MERCAPTOPURINE - 50 mg Tablet - 2 Tablet(s) by mouth once daily.
Bring to appointment on Monday [**2172-9-21**].
METOCLOPRAMIDE - 5 mg Tablet - [**2-7**] Tablet(s) by mouth every 8
hours as needed for Nausea
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth every 8
hours as needed for Nausea
OXYCODONE -  (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for Pain
TRAMADOL - 50 mg Tablet - [**2-7**] Tablet(s) by mouth every six (6)
hours as needed for headache

ALLERGIES: Prochlorperazine

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T: 98.7  HR: 131  BP 158/122   RR 30   Sat 100% on 4L
Pulsus paradoxus was 5.
GENERAL: No acute distress. She is alert and oriented x3 in good
mood and affect.
HEENT: Pupils are equal and reactive to light.  Conjunctivae are
pink.  Oropharynx is dry. There are no specific lesions on lips,
teeth, or gums.
NECK:  Supple, with no thyromegaly, and no palpable mass.
JVP=10cm
LYMPH NODES:  There is no palpable lower cervical,
supraclavicular, axillary, or groin lymphadenopathy.
LUNGS:  Decreased breath sounds bilaterally. Poor airway entry.
Diffuse crackles and wheezes
ABDOMEN:  Soft, nontender, nondistended with no
hepatosplenomegaly and no masses.
EXTREMITIES:  There is no lower extremity edema.
SKIN:  There are no rashes and no palpable lesions.

FAMILY HISTORY: FAMILY HISTORY:
No family h/o leukemia and lymphoma

SOCIAL HISTORY: SOCIAL HISTORY: Lives at home with aunt and sister.  [**Name (NI) **] 2
children (7, 17).  Denies alcohol, tobacco, illicit drugs.  Was
previously employed at [**Company 59330**], hasn't been working since being
diagnosed with ALL in [**Month (only) 205**]. She hopes to go back to work. Denies
any recent travel. Her son has been sick with a cold, but hasn't
been with her since he got sick.
Acute combined systolic and diastolic heart failure,Acute respiratory failure,Acute lymphoid leukemia, without mention of having achieved remission,Asthma, unspecified type, unspecified,Esophageal reflux,Unspecified essential hypertension,Neutropenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Nausea with vomiting,Chest pain, unspecified
Ac syst/diastol hrt fail,Acute respiratry failure,Ac lym leuk wo achv rmsn,Asthma NOS,Esophageal reflux,Hypertension NOS,Neutropenia NOS,Anemia NOS,Adv eff antineoplastic,Nausea with vomiting,Chest pain NOS
Admission Date:  [**2172-10-15**]              Discharge Date:   [**2172-10-23**]

Date of Birth:  [**2135-11-15**]             Sex:   F

Service: MEDICINE

Allergies:
Prochlorperazine

Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
SOB, CP, n/v

Major Surgical or Invasive Procedure:
None


History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 36 year old female with history of recently
diagnosed ALL, who came to the oncology clinic to receive her
chemothrapy and complained of worsening shortness of breath and
chest pain for a few days, and was referred to ED for further
evaluation and treatment. Per patient, she has been experiencing
worsening dyspnea for the past week when she had to increase the
number of pillows from 2 to 4 due to shortness of breath when
she slept.  States a [**6-14**] midsternal chest pain that radiates
circumferentialy around the ribs to the back that started a few
days ago. Pain is gradual and constant and worse with
inspiration, gets better when she is sits up.  Has a productive
cough with white/clear phelegm.  Denies any fevers/chills/night
sweats.
.
She has also been experiencing severe nausea and vomiting for
the past week where she has been unable to hold any food down.
Her weight has been fluctuating but no big weight loss recently.
She does endorse dizziness since yesterday when she stands up,
relieved when she sits or lies down.
.
With her hx of asthma, she only uses her inhalers. Has not been
to the ED for any exacerbations. States an increased frequency
of use of her inhalers in the past few weeks.
.
Of note, patient recently presented to ED on [**2172-8-11**] with some
RUE weaknesa and parethesia, and was found to have a WBC of
140K, and emergently leukopheresed, and was diagnosed with ALL.
She was discharged on [**2172-9-22**], and has been receiving
chemotherapy regularly. Today is her phase II day 25 therapy.
.
In the ED, patient's initial vitals were: Afebrile, T98.2 BP
154/120 HR 138 RR 18 SPO297% on R/A. Sat's: off oxygen 93%, 97%
on 4L (depends on position). She was slightly tachypneic, RR
25-30s, and it hurts for her to breath in.  She underwent CTA to
rule out PE. Her scan demonstrated large bilateral pleural
effusions and a small pericardial effusion. bedside US showed no
tamponade, and small effusion. She was given 1 gram of Cefepime,
500-1000cc of normal saline, had 200cc urine (no foley). No
change in HR was seen after receiving morphine or IVF. The
oncology fellow was notified of the patient's planned admission
and course. per onc fellow, no urgent need to tap, but may need
to tap overnight if pt is very symptomatic from the pleural
effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management.
.
On the floor, she continued to complain of shortness of breath
while lying down, and is sitting up while talking. She continued
to complain of nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied any palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.


Past Medical History:
PAST MEDICAL HISTORY:
- ALL
- Asthma: uses inhalers
- HTN
- Cervical Intraepithelial neoplasia

Social History:
SOCIAL HISTORY: Lives at home with aunt and sister.  [**Name (NI) **] 2
children (7, 17).  Denies alcohol, tobacco, illicit drugs.  Was
previously employed at [**Company 59330**], hasn't been working since being
diagnosed with ALL in [**Month (only) 205**]. She hopes to go back to work. Denies
any recent travel. Her son has been sick with a cold, but hasn't
been with her since he got sick.


Family History:
FAMILY HISTORY:
No family h/o leukemia and lymphoma


Physical Exam:
PHYSICAL EXAMINATION:
VS: T: 98.7  HR: 131  BP 158/122   RR 30   Sat 100% on 4L
Pulsus paradoxus was 5.
GENERAL: No acute distress. She is alert and oriented x3 in good
mood and affect.
HEENT: Pupils are equal and reactive to light.  Conjunctivae are
pink.  Oropharynx is dry. There are no specific lesions on lips,
teeth, or gums.
NECK:  Supple, with no thyromegaly, and no palpable mass.
JVP=10cm
LYMPH NODES:  There is no palpable lower cervical,
supraclavicular, axillary, or groin lymphadenopathy.
LUNGS:  Decreased breath sounds bilaterally. Poor airway entry.
Diffuse crackles and wheezes
ABDOMEN:  Soft, nontender, nondistended with no
hepatosplenomegaly and no masses.
EXTREMITIES:  There is no lower extremity edema.
SKIN:  There are no rashes and no palpable lesions.


Pertinent Results:
LABORATORIES:

WBC 0.5  Hgb 8.9  Hct 26.3, plt 16 MCV 85 N:23.0 L:74.7 M:1.4
E:0.7 Bas:0.2
Gran-Ct: 161 , repeat 80  --> by discharge the ANC was 1580

On discharge, the pt's WBC's were 4.9, h/h 8.2/24.7 and plts 9

142  105  10
-------------123
3.6  27  0.7

Chems were normal through admission, normal renal function,
except for phosphorous which had the tendency to run high, was
4.8 on d/c.

CK's normal through admission.
Tbili 1.7 (1.3 indirect and 0.4 direct) on admission, trended
down to 1.0 on d/c.
ALT/AST 44/27 on admit, 43/24 on d/c.
LDH 273 on admit and 265 on d/c.
AlkP normal through admission
Alb 3.7

CK MB was normal through admission [**7-12**]
TropT slightly elevated at 0.09-0.11 then trended slightly more
to 0.14-0.17, however not thought to be due to ACS

BNP 5007 on admission

PT: 14.1  PTT: 24.3  INR: 1.2
UA: neg

BCx negative x2

IMAGING:
- CXR ([**2172-10-15**])
IMPRESSION: New interstitial edema and moderate bilateral
pleural effusions with adjacent atelectasis.
.
- TTE [**2172-10-16**]:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.

Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
- CTA report [**2172-10-15**]: FINDINGS: There is no evidence of
pulmonary embolism, aortic dissection, or
pneumothorax. The thoracic aorta is normal in caliber.

There are bilateral moderate new pleural effusions with adjacent
atelectasis
in the lower lobes bilaterally. There are scattered noncalcified
pulmonary
nodules, which are new compared to the recent prior study of
[**9-19**]. Small-
to-moderate pericardial effusion is present. There is diffuse
interstitial
septal thickening, compatible with edema. The airways are patent
to the
subsegmental levels bilaterally. There is no hilar, mediastinal
or axillary adenopathy.

This study is not optimized for subdiaphragmatic evaluation.
Known liver mass in segment VI is not imaged on this study.

IMPRESSION:
1. New large bilateral pleural effusions, small-to-moderate
pericardial
effusion, and interstitial septal thickening, compatible with
edema.

2. Bilateral noncalcified pulmonary nodules. Short interval
development
since the prior study favors infectious/inflammatory etiology,
progression of
the disease less likely.

.
EKG on admission ([**2172-10-15**]):
rate 127, sinus rhythm. normal axis. pr, qrs and qt intervals
within normal range. low amplitude qrs in limb leads. t wave
flattening in limb leads.  less than 0.5mm ST depression in V5,
V6.
.
ECHO [**2172-10-16**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis (LVEF = XX %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size is normal. with severe
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.
.
Compared with the prior study (images reviewed) of [**2172-8-12**],
global biventricular systolic dysfunction is new. The
pericardial effusion is new.
.
EKG [**2172-10-16**]
Sinus tachycardia with slowing of the rate compared to the
previous tracing
of [**2172-10-15**]. The T waves are biphasic in leads I, II aVL, aVF and
V3-V6, similar
to that recorded on [**2172-9-19**] though not as prominent. Followup
and clinical
correlation are suggested.
.
CXR [**2172-10-16**]
FINDINGS: Cardiomediastinal silhouette appears unchanged from
previous study.
Bilateral pleural effusions are seen with bibasilar atelectasis
and mild
pulmonary edema. There is no pneumothorax.
.
ECHO  [**2172-10-20**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis (LVEF = 30%). There is no
ventricular septal defect. The right ventricular cavity is
mildly dilated with focal hypokinesis of the apical free wall.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. There is mild
pulmonary artery systolic hypertension. There is a small
pericardial effusion. The effusion appears circumferential.

IMPRESSION: Moderate global left ventricular systolic
dysfunction. Mild regional right ventricular systolic
dysfunction. Mild mitral regurgitation. Mild pulmonary
hypertension. Small pericardial effusion.

Compared with the prior study (images reviewed) of [**2172-10-16**],
right ventricular cavity is slightly larger, although both RV
and LV overall systolic function has improved. Pericardial
effusion size and other findings are similar.

CXR [**2172-10-21**]
Lung volumes have improved, possibly because of deeper
inspiration. Moderate
bilateral pleural effusions persist. Bibasilar atelectasis is
improved.
Upper lungs clear. Moderate enlargement of the cardiac
silhouette is
unchanged. There is no distention of mediastinal veins to
suggest particular
elevation of central venous pressure.


Brief Hospital Course:
36yo newly Dx'd ALL in [**8-13**], currently getting E2993 Tx, phase
II day+26 admitted for SOB, orthopnea, n/v found to have heart
failure with EF 15-20% with bilateral pleural effusions and
small pericardial effusion, pancytopenic.
.
1. Heart [**Name (NI) 94059**] pt was admitted to the ICU and Dx'd with
acute heart failure, which was thought to be due to Daunorubicin
therapy in the past several months VS myocarditis/pericarditis.
She was tachycardic and HTN, had a CTA without PE or dissection
and had a TTE showing EF of 15-20%, global hypokinesis of LV,
hypokinesis of free wall of RV, and small pericardial effusion.
Given IV Lasix diuresis with good response, hemodynamically
stabilized and called out to the floor where she was continued
on IV Lasix diuresis, then switched to PO diuresis. Cards was
consulted and recommended a heart failure regimen of Lasix 40mg
PO qday, Metoprolol 25mg PO bid, Lisinopril 5mg POqd, and
Aldactone 25mg PO qday, which the pt was started on and
tolerated well. The pt then had a repeat echo the day after she
developed some acute CP (see below) which showed an improvement
in her EF to 30%, improvement in systolic fxn of both
ventricles, no increase in pericardial effusion. By the time of
discharge, the pt's vitals had stabilized and bp's were in the
low 100's-110's and pulse 80's-90's, and her weight had
decreased down to pre-admission weight. The pt will be d/c'd on
her current HF regimen and will need to be reassessed, including
her heart failure meds and repeat echo in the future.
.
2. Chest pain--Pt c/o substernal pleuritic type pain on
admission, and had one acute episode of SOB and substernal chest
pain on the floor, pleuritic in nature, for which an EKG was
obtained which was significant for small voltage QRS complexes
in V3-V6 (no ST changes), a CXR was obtained which showed
continued pleural effusions, and cardiac enzymes were drawn. The
pt received a dose of 40mg IV Lasix and had good UOP overnight,
and the CP/SOB resolved uneventfully. Pt was not given any ASA
during the admission due to low platelet count.
.
Several EKG's were recorded through her admission, all without
ST changes, and CE's were trended through admission. CKMB's
where flat, however there was a small increase in her Troponins
ranging from 0.09 to 0.17. This small increase was thought to be
due to either demand ischemia or to a possible myo/pericarditis
picture, for which Cards recommended doing an oupt cardiac MR in
the future is still clinically warranted.
.
3. [**Name (NI) 94060**] pt had crackles on PE, was requiring O2 via NC, and
had CXR showing pleural effusions. She was started on her home
asthma regimen and occasionally given prn Xopenx nebs, Alubterol
being avoided due to tachycardia at the time. She was weaned off
the O2 as her HF resolved and by time of d/c was satting well on
room air, not tachypneic, not having difficulty breathing.
.
4. [**Name (NI) 94061**] pt was neutropenic on admission and started
on empiric Cefipime, despite being afebrile. The pt never spiked
a fever through admission and Cefipime was discontinued. All
cultures were negative through admission. The pt was started on
Neupogen with appropriate response, which was then d/c'd. The pt
will be discharged on her home regimen of prophylactic ABx
including Atovaquone and Acyclovir.
.
5. [**Name (NI) 94062**] pt was anemic but felt to be at baseline. Did
receive 1U PRBC's through admission but Hct remained stable
through rest of admission.
.
6. [**Name (NI) 94063**] pt was thrombocytopenic with plts 21 on
admission and received 5U plts during admission, with minimal
response. It was felt that the pt had many platelet antibodies
as a result of a long platelet transfusion history and
considering that she was being followed for future
transplantation, that further platelet transfusions would
increase her antibodies and make transplantation more difficult.
Therefore, a lower platelet count was tolerated and aggressive
transfusion was not pursued. She had no clinical evidence of
bleeding, her Hct remained stable, and her tachycardia trended
down as her volume overload and heart failure resolved.
.
7. Pericardial effusion--There was some concern for a
hemorrhagic pericarditis, with a small pericardial effusion seen
on echo and her platelets being low and low voltage QRS
complexes seen on an EKG once. She did not have a rub or pulsus
paradoxus on PE. She received a follow up echo showing that the
pericardial effusion had not increased in size.
.
8. [**Name (NI) 94064**] pt was complaining of a headache on admission
that she said was consistent with what she described as a
history of migraines, however she did not have phonophobia,
photophobia, or an aura. She did however appear to be in pain.
She was started on her home dose of Ultram and she refused any
narcotic pain meds. She occasionally c/o this h/a during
admission but they spontaneously resolved without any
complications with conservative Ultram management.

Medications on Admission:
Medications: (confirmed by [**2172-10-15**] hem/onc note)
ACYCLOVIR - 200 mg Capsule - 2 Capsule(s) by mouth three times a
day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL by mouth
once a day
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth twice a
daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhaled twice a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
puffs po four times a day as needed for prn
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for Nausea
MERCAPTOPURINE - 50 mg Tablet - 2 Tablet(s) by mouth once daily.
Bring to appointment on Monday [**2172-9-21**].
METOCLOPRAMIDE - 5 mg Tablet - [**2-7**] Tablet(s) by mouth every 8
hours as needed for Nausea
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth every 8
hours as needed for Nausea
OXYCODONE -  (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for Pain
TRAMADOL - 50 mg Tablet - [**2-7**] Tablet(s) by mouth every six (6)
hours as needed for headache

Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*3*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*3*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
Disp:*30 Tablet(s)* Refills:*3*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
6. Atovaquone 750 mg/5 mL Suspension Sig: One (1)  PO BID (2
times a day).
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) as needed for nausea.
9. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
12. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation twice a day as needed for shortness of breath
or wheezing.


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
1. ALL
2. Heart failure


Discharge Condition:
By the time of discharge, the pt's volume overload was much
improved, heart function had slightly improved as seen by heart
ultrasound, had good oxygen saturation on room air and vital
signs were stable, had been stabilized on a medicine regimen,
and was medically clear for discharge.


Discharge Instructions:
You were admitted to [**Hospital1 18**] and found to be in heart failure. You
were stabilized in the intensive care unit and given medicines
to draw off extra fluids from your body. Cardiology was
consulted and recommended a regimen to treat your heart failure.
You had a repeat ultrasound of your heart which showed some
improvement.

You were started on 4 new medicines which will be very important
to continue after discharge: Lasix, Metoprolol, Lisinopril, and
Aldactone. You will need to follow up with your physician to
assess your heart function and the necessity of continuing these
medicines. It is very important to take these medicines as
prescribed as your heart is still not up to its full strength.

Please return to the hospital or to a health care provider if
you experience fevers, chills, or night sweats, continued
shortness of breath, difficulty breathing, swelling of your
legs, chest pain, or any other concern.

Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on Monday [**2172-10-26**] at 2pm on [**Hospital Ward Name 23**] [**Location (un) 436**].


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

Completed by:[**2172-10-27**]
{'Acute combined systolic and diastolic heart failure,Acute respiratory failure,Acute lymphoid leukemia, without mention of having achieved remission,Asthma, unspecified type, unspecified,Esophageal reflux,Unspecified essential hypertension,Neutropenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Nausea with vomiting,Chest pain, unspecified'}


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: SOB, CP, n/v

PRESENT ILLNESS: HISTORY OF PRESENT ILLNESS:
Ms. [**Known lastname **] is a 36 year old female with history of recently
diagnosed ALL, who came to the oncology clinic to receive her
chemothrapy and complained of worsening shortness of breath and
chest pain for a few days, and was referred to ED for further
evaluation and treatment. Per patient, she has been experiencing
worsening dyspnea for the past week when she had to increase the
number of pillows from 2 to 4 due to shortness of breath when
she slept.  States a [**6-14**] midsternal chest pain that radiates
circumferentialy around the ribs to the back that started a few
days ago. Pain is gradual and constant and worse with
inspiration, gets better when she is sits up.  Has a productive
cough with white/clear phelegm.  Denies any fevers/chills/night
sweats.
.
She has also been experiencing severe nausea and vomiting for
the past week where she has been unable to hold any food down.
Her weight has been fluctuating but no big weight loss recently.
She does endorse dizziness since yesterday when she stands up,
relieved when she sits or lies down.
.
With her hx of asthma, she only uses her inhalers. Has not been
to the ED for any exacerbations. States an increased frequency
of use of her inhalers in the past few weeks.
.
Of note, patient recently presented to ED on [**2172-8-11**] with some
RUE weaknesa and parethesia, and was found to have a WBC of
140K, and emergently leukopheresed, and was diagnosed with ALL.
She was discharged on [**2172-9-22**], and has been receiving
chemotherapy regularly. Today is her phase II day 25 therapy.
.
In the ED, patient's initial vitals were: Afebrile, T98.2 BP
154/120 HR 138 RR 18 SPO297% on R/A. Sat's: off oxygen 93%, 97%
on 4L (depends on position). She was slightly tachypneic, RR
25-30s, and it hurts for her to breath in.  She underwent CTA to
rule out PE. Her scan demonstrated large bilateral pleural
effusions and a small pericardial effusion. bedside US showed no
tamponade, and small effusion. She was given 1 gram of Cefepime,
500-1000cc of normal saline, had 200cc urine (no foley). No
change in HR was seen after receiving morphine or IVF. The
oncology fellow was notified of the patient's planned admission
and course. per onc fellow, no urgent need to tap, but may need
to tap overnight if pt is very symptomatic from the pleural
effusion.
.
She was transferred to the [**Hospital Unit Name 153**] for further management.
.
On the floor, she continued to complain of shortness of breath
while lying down, and is sitting up while talking. She continued
to complain of nausea.
.
Review of sytems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied any palpitations. Denied diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- ALL
- Asthma: uses inhalers
- HTN
- Cervical Intraepithelial neoplasia

MEDICATION ON ADMISSION: Medications: (confirmed by [**2172-10-15**] hem/onc note)
ACYCLOVIR - 200 mg Capsule - 2 Capsule(s) by mouth three times a
day
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth daily
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 mL by mouth
once a day
CIPROFLOXACIN - 250 mg Tablet - 1 Tablet(s) by mouth twice a
daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
inhaled twice a day
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation Aerosol -
2
puffs po four times a day as needed for prn
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth every 6 hours as
needed for Nausea
MERCAPTOPURINE - 50 mg Tablet - 2 Tablet(s) by mouth once daily.
Bring to appointment on Monday [**2172-9-21**].
METOCLOPRAMIDE - 5 mg Tablet - [**2-7**] Tablet(s) by mouth every 8
hours as needed for Nausea
OLANZAPINE [ZYPREXA] - 2.5 mg Tablet - 1 Tablet(s) by mouth
twice
a day
OMEPRAZOLE -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth daily
ONDANSETRON HCL - 8 mg Tablet - one Tablet(s) by mouth every 8
hours as needed for Nausea
OXYCODONE -  (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for Pain
TRAMADOL - 50 mg Tablet - [**2-7**] Tablet(s) by mouth every six (6)
hours as needed for headache

ALLERGIES: Prochlorperazine

PHYSICAL EXAM: PHYSICAL EXAMINATION:
VS: T: 98.7  HR: 131  BP 158/122   RR 30   Sat 100% on 4L
Pulsus paradoxus was 5.
GENERAL: No acute distress. She is alert and oriented x3 in good
mood and affect.
HEENT: Pupils are equal and reactive to light.  Conjunctivae are
pink.  Oropharynx is dry. There are no specific lesions on lips,
teeth, or gums.
NECK:  Supple, with no thyromegaly, and no palpable mass.
JVP=10cm
LYMPH NODES:  There is no palpable lower cervical,
supraclavicular, axillary, or groin lymphadenopathy.
LUNGS:  Decreased breath sounds bilaterally. Poor airway entry.
Diffuse crackles and wheezes
ABDOMEN:  Soft, nontender, nondistended with no
hepatosplenomegaly and no masses.
EXTREMITIES:  There is no lower extremity edema.
SKIN:  There are no rashes and no palpable lesions.

FAMILY HISTORY: FAMILY HISTORY:
No family h/o leukemia and lymphoma

SOCIAL HISTORY: SOCIAL HISTORY: Lives at home with aunt and sister.  [**Name (NI) **] 2
children (7, 17).  Denies alcohol, tobacco, illicit drugs.  Was
previously employed at [**Company 59330**], hasn't been working since being
diagnosed with ALL in [**Month (only) 205**]. She hopes to go back to work. Denies
any recent travel. Her son has been sick with a cold, but hasn't
been with her since he got sick. 

### Response:
{'Acute combined systolic and diastolic heart failure,Acute respiratory failure,Acute lymphoid leukemia, without mention of having achieved remission,Asthma, unspecified type, unspecified,Esophageal reflux,Unspecified essential hypertension,Neutropenia, unspecified,Anemia, unspecified,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Nausea with vomiting,Chest pain, unspecified'}
