CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: 56 woman with [**Location (un) 5622**] chromosone positive ALL in remission
presented to clinic with fever to 103 and BP 92/58. She was
initially diagnosed by her PCP [**Last Name (NamePattern4) **] [**3-/2128**] after presenting with
weakness. She  underwent induction therapy with daunorubicin,
vincristine, l-
asparaginase, and prednisone and responded well. In the past 15
months, she has received gleevec, hyper CVAD, desatinib,
rituxan, and pulse dose steroids to maintain her clinical and
cytological remission. Recently, she has been on velcade and
cytoxan, with most recent dose 4/9.

MEDICAL HISTORY: ) borderline hypothyroidism
2) Osteopenia
3) L fibula fx [**11-4**]
4) Chronic constipation
5) Chronic HA's
6) Right basilic vein thrombosis [**7-6**]
7) Lung nodules, presumed aspergillus, as above
8) Anxiety
9) C. Difficile infection [**7-6**]
10) Contrast nephropathy in [**7-6**]
11) VRE bacteremia [**8-5**]
12) Neuropathy secondary to vincristine
13) cardiomyopathy secondary to anthracycline

MEDICATION ON ADMISSION: Sprycel (Dasatinib) 70 mg p.o. b.i.d., pretreat with Benadryl 25
mg
Acyclovir 400 mg p.o. b.i.d.
Decadron taper, took 8 mg yesterday (for use with velcade)
prednisone 10 mg p.o. daily
Celexa 20 mg p.o. daily
Lisinopril 2.5 mg p.o. daily
folic acid 1 mg p.o. daily
Magnesium b.i.d.
Protonix 40 mg p.o. daily
Vitamin B12 500 mcg daily
Toprol XL 75 mg mg p.o. daily
Lasix 20 mg PO PRN ~2x/week
vancocin 250 [**Hospital1 **]

ALLERGIES: Cefepime / Latex / Mycostatin

PHYSICAL EXAM: T 98.1 BP 78/52 HR 75 O2 93% on RA
Gen: pleasant cooperative NAD
HEENT: dry MM, no thrush/mucositis
Neck: supple, without LAD
Pulm: CTAB no crackles
Chest: left sided port, no erythema or exudates
Cor: RRR I/VI systolic murmur
Abd: soft, NT ND decreased BS
Ext: WWP, radial/DP 2+ bilaterally, no pedal edema
skin: no rashes

FAMILY HISTORY: no one with ALL. Father: died of emphysema from tobacco abuse at
65yo. Mother:Alive and has emphesema from tobacco abuse. sister:
1, alive, healthy.

SOCIAL HISTORY: denies tobacco/EtOH. Lives with husband, has 2 children.
Pneumocystosis,Acute lymphoid leukemia, without mention of having achieved remission,Hyperpotassemia,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Hypotension, unspecified,Anemia in neoplastic disease,Disorder of bone and cartilage, unspecified,Hypoxemia
Pneumocystosis,Ac lym leuk wo achv rmsn,Hyperpotassemia,Thrombocytopenia NOS,CHF NOS,Hypotension NOS,Anemia in neoplastic dis,Bone & cartilage dis NOS,Hypoxemia
Admission Date:  [**2129-5-10**]              Discharge Date:   [**2129-5-24**]

Date of Birth:  [**2072-7-24**]             Sex:   F

Service: MEDICINE

Allergies:
Cefepime / Latex / Mycostatin

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

Major Surgical or Invasive Procedure:
None


History of Present Illness:
56 woman with [**Location (un) 5622**] chromosone positive ALL in remission
presented to clinic with fever to 103 and BP 92/58. She was
initially diagnosed by her PCP [**Last Name (NamePattern4) **] [**3-/2128**] after presenting with
weakness. She  underwent induction therapy with daunorubicin,
vincristine, l-
asparaginase, and prednisone and responded well. In the past 15
months, she has received gleevec, hyper CVAD, desatinib,
rituxan, and pulse dose steroids to maintain her clinical and
cytological remission. Recently, she has been on velcade and
cytoxan, with most recent dose 4/9.

Of note, the patient complains of fevers and drenching night
sweats for the last 3 weeks. She also had a CT scan in [**Month (only) 958**]
[**2129**] to discover the etiology of her fevers. It showed ground
glass opacities and she then underwent a bronchoscopy that was
unrevealing.
.
In clinic, she was given 100mg IV hydrocortisone, Ertapenem 1gm
IV, tylenol 650mg po after blood and urine cultures obtained.
.
ROS: denies SOB, pedal edema, hematuria, hematochezia, nausea,
vomitting, anorexia aside from today, weight loss, dysuria,
polyuria, cough, chest pain, abd. pain, sick contacts, diarrhea,
[**Name2 (NI) 11756**]. Admits to fevers x 3 weeks.


Past Medical History:
) borderline hypothyroidism
2) Osteopenia
3) L fibula fx [**11-4**]
4) Chronic constipation
5) Chronic HA's
6) Right basilic vein thrombosis [**7-6**]
7) Lung nodules, presumed aspergillus, as above
8) Anxiety
9) C. Difficile infection [**7-6**]
10) Contrast nephropathy in [**7-6**]
11) VRE bacteremia [**8-5**]
12) Neuropathy secondary to vincristine
13) cardiomyopathy secondary to anthracycline


Social History:
denies tobacco/EtOH. Lives with husband, has 2 children.

Family History:
no one with ALL. Father: died of emphysema from tobacco abuse at
65yo. Mother:Alive and has emphesema from tobacco abuse. sister:
1, alive, healthy.

Physical Exam:
T 98.1 BP 78/52 HR 75 O2 93% on RA
Gen: pleasant cooperative NAD
HEENT: dry MM, no thrush/mucositis
Neck: supple, without LAD
Pulm: CTAB no crackles
Chest: left sided port, no erythema or exudates
Cor: RRR I/VI systolic murmur
Abd: soft, NT ND decreased BS
Ext: WWP, radial/DP 2+ bilaterally, no pedal edema
skin: no rashes


Pertinent Results:
[**2129-5-9**] 10:45AM BLOOD WBC-2.6* RBC-3.03* Hgb-9.5* Hct-27.7*
MCV-92 MCH-31.3 MCHC-34.2 RDW-21.1* Plt Ct-26*
[**2129-5-9**] 10:45AM BLOOD Neuts-75.3* Bands-1.0 Lymphs-4.1*
Monos-10.3 Eos-0 Baso-0 Atyps-6.2* Myelos-3.1*
[**2129-5-9**] 10:45AM BLOOD Plt Smr-VERY LOW Plt Ct-26*
[**2129-5-9**] 10:45AM BLOOD Glucose-86 UreaN-35* Creat-1.0 Na-141
K-3.8 Cl-106 HCO3-25 AnGap-14
[**2129-5-9**] 10:45AM BLOOD ALT-78* AST-47* LD(LDH)-402* AlkPhos-82
TotBili-0.3

Brief Hospital Course:
56 woman with [**Location (un) 5622**] chromosone positive ALL in remission
presented to clinic with hypotension and fevers.
.
Hypotension: The patient presented with systolic blood pressure
in the high 70s to 80s that was minimally responsive to fluids.
She received stress dose steroids (hydrocortisone 100 mg IV q8)
and spent one night in the ICU, not requiring pressors. She did
not have symptoms of lightheadedness or change in mental status
and over the course of her stay her blood pressure returned to
her baseline of 90s to low 100s.
.
Fever: The patient presented with high spiking fevers to 102s.
These fevers continued for a full week into her stay and were
often accompanied by severe chills, fatigue and in general a
"toxic" looking appearance. Although she was not neutropenic,
she was started on broad antibiotic coverage, including
vancomycin, cefepime, flagyl given her history of C.Diff, and
caspofungin. She was also receiving her standing prophylactic
dose of oral vanco and had been receiving monthly pentamidine.
Her admission CT chest actually showed an improvement in her
ground glass lung opacities from previously and given that she
had had a negative BAL within the last month, PCP was [**Name9 (PRE) 1801**]
thought to be a low probability.
Given the lack of improvement on antibiotics and the negative
cultures, the fevers were thought most likely due to either
Velcade (last dose on [**5-9**]) or desatinib. However, the duration
and lack of improvement was thought unusual for Velcade and the
fevers did not improve when her desatinib was held for 4 days.
Eventually a b-glucan test was found to be significantly
positive, when tests from previous hospitalizations had only
been "intermediate." She then had a repeat CT of the chest which
showed worsening ground glass in the upper lobes. She was
started on treatment dose Bactrim and her Fevers immediately
subsided (see ID).
.
ID: ID consult service was involved and based on beta-glucan and
CT findings and resolution of fevers on Bactrim, determined that
the diagnosis could be made without doing another bronchoscopy.
She was started on Bactrim 2 DS tabs TID and prednisone 40 mg
[**Hospital1 **]. Within two days of starting the bactrim, her LFTs had
climbed from a normal level to a maximum of ALT 433, AST 336
(the LFTs continued to rise for a day after the bactrim had been
stopped). On discharge the LFTs had trended downward for 48
hours and on discharge were ALT 317, AST 150. She was switched
from the Bactrim to Clindamycin Q6 and primaquine 15 mg QD
dosing and had been on these medications for >48hrs prior to
discharge with no fevers. She was discharged on a three week
course of this regimen, with an increase in her PO vanco to 125
Q6H given her past history of Cdiff. The patient was also
discharged on a quick taper of steroids from 10 mg [**Hospital1 **] to a
standing dose of 10 mg QD, to be continued on an ongoing basis
until further adjusted by her outpatient oncologist. A longer
taper of high dose steroids was not considered necessary given
her good O2 sats, no desatting on ambulation, and not as much
data on this protocol in non-HIV patients.
.
ALL: The patient had her Dasatinib held for roughly 4 days to
rule out drug related fever but was discharged on her normal
dose of 70 mg [**Hospital1 **].
.
CHF: The patient's cardiac medications, metoprolol and
lisinopril, were held when she presented with hypotension. These
were not restarted on her discharge from the hospital, as she
had relatively low blood pressures (<120) and was still being
actively treated for infection. These long-term benefit
medications could be restarted as desired by her outpatient
HCPs.

access: port
.

Medications on Admission:
Sprycel (Dasatinib) 70 mg p.o. b.i.d., pretreat with Benadryl 25
mg
Acyclovir 400 mg p.o. b.i.d.
Decadron taper, took 8 mg yesterday (for use with velcade)
prednisone 10 mg p.o. daily
Celexa 20 mg p.o. daily
Lisinopril 2.5 mg p.o. daily
folic acid 1 mg p.o. daily
Magnesium b.i.d.
Protonix 40 mg p.o. daily
Vitamin B12 500 mcg daily
Toprol XL 75 mg mg p.o. daily
Lasix 20 mg PO PRN ~2x/week
vancocin 250 [**Hospital1 **]


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. SPRYCEL 70 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO twice a day.

4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO four times
a day for 20 days.
Disp:*80 Capsule(s)* Refills:*1*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day: Do not take at same time as Sprycel.
10. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day) as needed.
11. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. Atrovent HFA 17 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*1*
13. Primaquine 26.3 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 20 days.
Disp:*20 Tablet(s)* Refills:*0*
14. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 20 days.
Disp:*240 Capsule(s)* Refills:*0*
15. Prednisone 10 mg Tablet Sig: tapered dose Tablet PO see
instructions: Take 10 mg twice a day for three days starting on
[**5-26**] (ending on [**5-28**]). Then take 10 mg once a day for 7 days and
consult your physician about further tapering of the dose. Do
NOT stop taking this medication abruptly.
Disp:*15 Tablet(s)* Refills:*1*
16. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO twice a day
for 3 doses: Take 15 mg of prednisone the evening of [**5-24**] and in
the morning and evening of [**5-25**]. .
Disp:*9 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Pneumocystis carinii infection
Acute leukocytic leukemia
.


Discharge Condition:
Good


Discharge Instructions:
Please call your physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] to make sure that
you still have your appointment as scheduled.
.
You were admitted with high fevers. Based on your CT scan and
one of your blood tests, there is a high chance that these
fevers were caused by an infection called Pneumocystis or "PCP".
.
You were started on two medications called Primaquine and
Clindamycin for treatment of your PCP. [**Name10 (NameIs) **] should take these
medications as directed.
.
You should take oral Vancomycin daily as directed to ensure that
you do not develop a C. Diff infection.
.
For the PCP, [**Name10 (NameIs) **] have been started on a prednisone taper as
follows:
15 mg for your evening dose on [**5-24**] and in the morning and
evening on [**5-25**]. Then 10 mg twice a day for three days following
([**Date range (1) 11757**]). Then 10 mg once a day after that. Please consult
your oncologist for further instructions on the taper. He may
also decide to change this taper. Please refer all questions
about the prednisone taper to your oncologist.
.
It is important that you meet your appointments in order to have
your liver function tests, your kidney function tests, and your
platelet level tested.
.
If you have any fevers or other concerns about your health, call
your physician.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2129-5-26**] 10:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3237**]
Date/Time:[**2129-5-26**] 10:00
Provider: [**Name10 (NameIs) 3242**] CHAIR 6  Date/Time:[**2129-5-26**] 10:00



Completed by:[**2129-5-26**]
{'Pneumocystosis,Acute lymphoid leukemia, without mention of having achieved remission,Hyperpotassemia,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Hypotension, unspecified,Anemia in neoplastic disease,Disorder of bone and cartilage, unspecified,Hypoxemia'}


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

PRESENT ILLNESS: 56 woman with [**Location (un) 5622**] chromosone positive ALL in remission
presented to clinic with fever to 103 and BP 92/58. She was
initially diagnosed by her PCP [**Last Name (NamePattern4) **] [**3-/2128**] after presenting with
weakness. She  underwent induction therapy with daunorubicin,
vincristine, l-
asparaginase, and prednisone and responded well. In the past 15
months, she has received gleevec, hyper CVAD, desatinib,
rituxan, and pulse dose steroids to maintain her clinical and
cytological remission. Recently, she has been on velcade and
cytoxan, with most recent dose 4/9.

MEDICAL HISTORY: ) borderline hypothyroidism
2) Osteopenia
3) L fibula fx [**11-4**]
4) Chronic constipation
5) Chronic HA's
6) Right basilic vein thrombosis [**7-6**]
7) Lung nodules, presumed aspergillus, as above
8) Anxiety
9) C. Difficile infection [**7-6**]
10) Contrast nephropathy in [**7-6**]
11) VRE bacteremia [**8-5**]
12) Neuropathy secondary to vincristine
13) cardiomyopathy secondary to anthracycline

MEDICATION ON ADMISSION: Sprycel (Dasatinib) 70 mg p.o. b.i.d., pretreat with Benadryl 25
mg
Acyclovir 400 mg p.o. b.i.d.
Decadron taper, took 8 mg yesterday (for use with velcade)
prednisone 10 mg p.o. daily
Celexa 20 mg p.o. daily
Lisinopril 2.5 mg p.o. daily
folic acid 1 mg p.o. daily
Magnesium b.i.d.
Protonix 40 mg p.o. daily
Vitamin B12 500 mcg daily
Toprol XL 75 mg mg p.o. daily
Lasix 20 mg PO PRN ~2x/week
vancocin 250 [**Hospital1 **]

ALLERGIES: Cefepime / Latex / Mycostatin

PHYSICAL EXAM: T 98.1 BP 78/52 HR 75 O2 93% on RA
Gen: pleasant cooperative NAD
HEENT: dry MM, no thrush/mucositis
Neck: supple, without LAD
Pulm: CTAB no crackles
Chest: left sided port, no erythema or exudates
Cor: RRR I/VI systolic murmur
Abd: soft, NT ND decreased BS
Ext: WWP, radial/DP 2+ bilaterally, no pedal edema
skin: no rashes

FAMILY HISTORY: no one with ALL. Father: died of emphysema from tobacco abuse at
65yo. Mother:Alive and has emphesema from tobacco abuse. sister:
1, alive, healthy.

SOCIAL HISTORY: denies tobacco/EtOH. Lives with husband, has 2 children. 

### Response:
{'Pneumocystosis,Acute lymphoid leukemia, without mention of having achieved remission,Hyperpotassemia,Thrombocytopenia, unspecified,Congestive heart failure, unspecified,Hypotension, unspecified,Anemia in neoplastic disease,Disorder of bone and cartilage, unspecified,Hypoxemia'}
