CHIEF COMPLAINT: R arm pain and febrile neutropenia

PRESENT ILLNESS: 50y/o F with relapsed Ph+ pre-B cell ALL presents with
fever/neutropenia and chest pain. Pain started in her R arm
(site of PICC). Pt states that chest pain began about 2 days
ago, getting worse. Dull, all across chest, no radiation. No
exacerbating or alleviating factors. No associated SOB, N/V, or
diaphoresis. Not pleuritic. Has had this pain previously, when
admitted to hospital. Pain now resolved with morphine.
.
Pt noticed rash on inner aspect of R arm, for the last few days,
near PICC line. PICC being used for TPN and abx. Pt denies SOB,
worsening cough, N/V, abdominal pain, diarrhea, dysuria, or
fevers at home. No odynophagia or pain with chewing.
.
In [**Name (NI) **], pt rec'd cefepime 2g, vancomycin 1g, tylenol 1g,
phenergan 12.5mg, anzemet 12.5mg, and morphine 12mg.

MEDICAL HISTORY: Onc Hx: Pt initially dx'ed in [**2-22**], s/p chemo - induction with
doxorubicin, asparaginase, vincristine, cytoxan, and prednisone;
s/p XRT cranial x12 fractions, and intrathecal MTX. Relaped in
[**2-23**] while still rec'ing maintenance therapy. [**4-22**]: MTX,
vincristine, prednisone. [**2126**]: ALL relapsed, rec'd chemo.
[**Location (un) 5622**] chromosome positive. Now being Rx'ed with Gleevec,
prednisone, and vincristine.
.
PMH:
ALL as above
pulmonary aspergillosis on lung bx [**9-23**]
multiple sclerosis
[**Month/Year (2) 862**] d/o (last [**Month/Year (2) 862**] 20 years ago)
DVT [**12-22**]
echo [**2126-11-5**] EF >55%

MEDICATION ON ADMISSION: voriconazole 200mg IV bid
prednisone
ambisome 450mg IV MWF
gleevec 400mg [**Hospital1 **]
megace 400mg daily
morphine sustained release 15mg [**Hospital1 **]
morphine 15mg po q4-6hrprn
zoloft 75mg daily
levofloxacin 500mg po daily

ALLERGIES: Depakote / Hydromorphone / Carbamazepine Derivatives

PHYSICAL EXAM: VS: 97.3 133 112/70 24 100%on 4L
Gen: ill appearing, alopecia, appears in respiratory distress.
HEENT: PERRL, EOMI, MM dry,
Neck: no LAD, no JVD
CV: tachycardic, RRR nl S1-S2
Pulm: bibasilar crackles, R > L, otherwise CTAB
Abd: soft, NT/ND, +BS, no masses
Ext: R PICC with erythematous rash and mild skin breakdown more
proximal;R arm warm, firm and painful, 1+ edema in LE
bilaterally, symmetric; ppp
Neuro: resting tremor, CN II-XII intact, strength and sensory
grossly intact
Perirectal area: no evidence of abscess

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home.  Son [**Name (NI) **] is NOK and HCP (he is an only
child).  Husband died 22 years ago from ALL (at [**Hospital1 18**]).
Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute pericarditis, unspecified,Unspecified septicemia,Acute lymphoid leukemia, without mention of having achieved remission,Aspergillosis,Other convulsions,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Severe sepsis,Pneumonia in aspergillosis,Multiple sclerosis,Cellulitis and abscess of upper arm and forearm,Encephalopathy, unspecified
React-oth vasc dev/graft,Acute pericarditis NOS,Septicemia NOS,Ac lym leuk wo achv rmsn,Aspergillosis,Convulsions NEC,Ac kidny fail, tubr necr,Acute respiratry failure,Severe sepsis,Pneum in aspergillosis,Multiple sclerosis,Cellulitis of arm,Encephalopathy NOS
Admission Date:  [**2126-12-2**]              Discharge Date:   [**2126-12-12**]

Date of Birth:  [**2076-2-13**]             Sex:   F

Service: MEDICINE

Allergies:
Depakote / Hydromorphone / Carbamazepine Derivatives

Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
R arm pain and febrile neutropenia

Major Surgical or Invasive Procedure:
Pericardial window
CT guided lung bx
Central line placement
bone marrow bx
lumbar puncture


History of Present Illness:
50y/o F with relapsed Ph+ pre-B cell ALL presents with
fever/neutropenia and chest pain. Pain started in her R arm
(site of PICC). Pt states that chest pain began about 2 days
ago, getting worse. Dull, all across chest, no radiation. No
exacerbating or alleviating factors. No associated SOB, N/V, or
diaphoresis. Not pleuritic. Has had this pain previously, when
admitted to hospital. Pain now resolved with morphine.
.
Pt noticed rash on inner aspect of R arm, for the last few days,
near PICC line. PICC being used for TPN and abx. Pt denies SOB,
worsening cough, N/V, abdominal pain, diarrhea, dysuria, or
fevers at home. No odynophagia or pain with chewing.
.
In [**Name (NI) **], pt rec'd cefepime 2g, vancomycin 1g, tylenol 1g,
phenergan 12.5mg, anzemet 12.5mg, and morphine 12mg.


Past Medical History:
Onc Hx: Pt initially dx'ed in [**2-22**], s/p chemo - induction with
doxorubicin, asparaginase, vincristine, cytoxan, and prednisone;
s/p XRT cranial x12 fractions, and intrathecal MTX. Relaped in
[**2-23**] while still rec'ing maintenance therapy. [**4-22**]: MTX,
vincristine, prednisone. [**2126**]: ALL relapsed, rec'd chemo.
[**Location (un) 5622**] chromosome positive. Now being Rx'ed with Gleevec,
prednisone, and vincristine.
.
PMH:
ALL as above
pulmonary aspergillosis on lung bx [**9-23**]
multiple sclerosis
[**Month/Year (2) 862**] d/o (last [**Month/Year (2) 862**] 20 years ago)
DVT [**12-22**]
echo [**2126-11-5**] EF >55%


Social History:
Lives at home.  Son [**Name (NI) **] is NOK and HCP (he is an only
child).  Husband died 22 years ago from ALL (at [**Hospital1 18**]).


Family History:
Non-contributory

Physical Exam:
VS: 97.3 133 112/70 24 100%on 4L
Gen: ill appearing, alopecia, appears in respiratory distress.
HEENT: PERRL, EOMI, MM dry,
Neck: no LAD, no JVD
CV: tachycardic, RRR nl S1-S2
Pulm: bibasilar crackles, R > L, otherwise CTAB
Abd: soft, NT/ND, +BS, no masses
Ext: R PICC with erythematous rash and mild skin breakdown more
proximal;R arm warm, firm and painful, 1+ edema in LE
bilaterally, symmetric; ppp
Neuro: resting tremor, CN II-XII intact, strength and sensory
grossly intact
Perirectal area: no evidence of abscess


Pertinent Results:
[**2126-12-2**] 02:19AM BLOOD WBC-0.1* RBC-3.21* Hgb-9.9* Hct-28.6*
MCV-89 MCH-30.9 MCHC-34.6 RDW-14.0 Plt Ct-20*#
[**2126-12-9**] 04:15AM BLOOD WBC-0.3* RBC-3.29* Hgb-9.9* Hct-27.7*
MCV-84 MCH-30.2 MCHC-35.9* RDW-16.7* Plt Ct-30*
[**2126-12-3**] 07:20AM BLOOD Neuts-40* Bands-20* Lymphs-20 Monos-20*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2126-12-7**] 05:11PM BLOOD Neuts-43* Bands-43* Lymphs-0 Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-7*
[**2126-12-2**] 02:19AM BLOOD PT-14.4* PTT-25.1 INR(PT)-1.4
[**2126-12-2**] 02:19AM BLOOD Plt Ct-20*#
[**2126-12-9**] 04:15AM BLOOD Plt Ct-30*
[**2126-12-9**] 04:15AM BLOOD PT-16.0* PTT-26.5 INR(PT)-1.8
[**2126-12-2**] 02:19AM BLOOD Gran Ct-50*
[**2126-12-9**] 04:15AM BLOOD Gran Ct-230*
[**2126-12-2**] 02:19AM BLOOD Glucose-130* UreaN-18 Creat-0.4 Na-135
K-4.0 Cl-103 HCO3-19* AnGap-17
[**2126-12-9**] 04:15AM BLOOD Glucose-79 UreaN-153* Creat-3.1* Na-148*
K-3.8 Cl-112* HCO3-14* AnGap-26*
[**2126-12-2**] 02:19AM BLOOD ALT-50* AST-20 CK(CPK)-4* AlkPhos-505*
Amylase-8 TotBili-1.9*
[**2126-12-9**] 04:15AM BLOOD ALT-23 AST-23 LD(LDH)-371* AlkPhos-308*
TotBili-1.1
[**2126-12-2**] 02:19AM BLOOD Lipase-10
[**2126-12-2**] 02:19AM BLOOD CK-MB-NotDone
[**2126-12-2**] 02:19AM BLOOD cTropnT-<0.01
[**2126-12-2**] 04:30PM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-12-2**] 02:19AM BLOOD TotProt-5.2* Albumin-2.8* Globuln-2.4
Calcium-7.9* Phos-3.2 Mg-1.9 UricAcd-1.2*
[**2126-12-9**] 04:15AM BLOOD Calcium-7.2* Phos-7.4* Mg-2.6
.
[**12-2**] RUE U/S: No right upper extremity DVT.
.
[**12-2**] CXR: No acute cardiopulmonary process. Stable appearance
of chest since [**2126-11-18**].
.
[**12-2**] CTA Chest: 1. No evidence of pulmonary embolism.
2. Interval stable appearance of bilateral nodules, and patchy
areas of consolidation within the lungs.
3. Previously noted mild splenomegaly is no longer appreciated,
possibly related to slice selection.
.
[**12-4**] Echo: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a moderate sized pericardial effusion.
There is sustained right atrial collapse, consistent with low
filling pressures or tamponade. There is right ventricular
diastolic collapse, consistent with impaired fillling/tamponade
physiology. There is significant, accentuated respiratory
variation in mitral/tricuspid valve inflows, consistent with
impaired ventricular filling.
No vegetation seen (cannot definitively exclude)
Compared with the prior study (tape reviewed) of [**2126-11-5**], the
pericardial effusion is now larger.
.
[**12-4**] Cath: 1.  Limited resting hemodynamics demonstrated an
elevated mean right filling pressure along with a magnified
right atrial "x" descent along with an attenuated "y" descent.
Additionally the mean right atrial
pressure approatched the PCWP.  The pericardial pressure and
waveform
matched the RA pressure and waveform.
2.  Following pericardiocentesis (removal of over 320cc of
non-bloody fluid) the pericardial pressure dropped to zero with
no
change in the right atrial pressure or cardiac output.
FINAL DIAGNOSIS:
1. Moderate pericardial tamponade.
.
[**12-5**] CXR: The patient is status post pericardiocentesis. There
is a catheter overlying the cardiac silhouette.
There is continued bilateral multifocal opacity indicating
invasive aspergillosis this patient with leukemia and
neutropenia. The previously identified pulmonary edema has been
slightly improving. There is continued small right pleural
effusion. There is continued enlargement of the cardiac
silhouette. No evidence of pneumothorax is identified. The right
subclavian IV catheter remains in place.
.
[**12-5**] Abd U/S: No evidence of dilatation of the bile ducts.
Unremarkable gallbladder. Echogenic right kidney suggestive of
diffuse chronic parenchymal renal disease.
.
[**12-6**] KUB: A limited portable supine AP view of the abdomen at
22:15 hours show no evidence of dilated bowel loops to suggest
intestinal obstruction. Small amount of gas is seen throughout
the colon.
.
[**12-6**] MRI Brain: IMPRESSION: This examination is slightly
limited by motion. Mild periventricular hyperintensities due to
small vessel disease. No enhancing lesions seen. Findings
discussed with Dr. [**First Name (STitle) 3640**].
MRV OF THE HEAD: Normal MRV of the head.
IMPRESSION: Normal MRA of the head.
.
[**12-6**] CT head: No intracranial hemorrhage or mass effect. No
change since [**2126-10-20**].
.
[**12-6**] EEG: This is a markedly abnormal EEG due to the presence
of
abnormal background rhythms in predominantly the theta frequency
range
with superimposed delta and theta frequency slowing seen
periodically in
generalized bursts. No sharp or epileptiform features were
associated
with this slowing. The findings are most consistent with an
encephalopathy. Common causes of encephalopathy include
metabolic
causes, medications, and infections. No focal or epileptiform
features
were seen.
.
[**12-6**] Echo: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 60%). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is a small
posterior pericardial effusion. The effusion is echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2126-12-4**], a small consolidated effusion (posterior)
is now evident.
.
[**12-7**] CXR: No significant change in bilateral parenchymal
opacities related to pulmonary aspergillosis.
.
[**12-7**] KUB: A single supine portable abdominal film is compared
to previous examination a day ago. The abdomen appears gasless
with fecal material in left hemicolon. The linear lucencies in
the splenic flexure and descending colon is felt to be
intraluminal rather than within the wall of the colon.
The tip of the NG tube is not visualized in distal esophagus and
stomach.
.
[**12-7**] Renal U/S: No hydronephrosis or hydroureter bilaterally.
Exam of the left kidney was technically limited.
.
[**12-9**] MR [**Name13 (STitle) 430**]: Unusual generalized focal FLAIR hyperintensities
and possible coincident enhancement. Although motion artifact or
possibly another unusual artifact may be responsible for the
apparent sulcal enhancement, meningitis of infectious or
neoplastic etiology should be considered in the given clinical
scenario.
.
[**12-9**] Spinal fluid cytology: negative for malignant cells.
.
[**12-9**] Bone Marrow Bx: Bone marrow aspirate and core biopsy:
Markedly hypocellular bone marrow with rare maturing erythroid
precursors and interstitial eosinophilic material consistent
with post-chemotherapy aplasia.
MICROSCOPIC DESCRIPTION
PERIPHERAL SMEAR
Smear quality is acceptable.
Red cells show anisopoikilocytosis with rare schistocyte.
WBC count is decreased.
A 42-cell count differential shows:  60% segmented neutrophils,
17% bands, 7% monocytes, 2% lymphocytes, 14% basophils.
Platelet count appears decreased; giant forms are not present.
ASPIRATE SMEARS:
          Inadequate for evaluation due to lack of spicules.
CLOT SECTION AND BIOPSY SLIDES
The marrow biopsy is virtually acellular (<5%) and contains only
are small clusters populated by maturing erythroid precursors.
Myeloid precursors and megakaryocytes are not seen.
The remainder of the cellularity is composed of stromal cells,
plasma cells, lymphocytes, and macrophages.
No tumor, granuloma, lymphoma, lymphoid, or aggregate is seen.
There is a small amount of interstitial eosinophilic material
consistent with prior chemotherapy.
Marrow clot section is not submitted.
Touch prep is not submitted.
SPECIAL STAINS
Iron stain is inadequate for evaluation because it does not
contain marrow spicules.
Clinical:  [**Location (un) 5622**] positive, ALL.
Gross:  The specimen is received in B+ Fixative labeled with
"[**Known lastname 62516**], [**Known firstname **]",  the medical record number and "MO5-659", and
consists of a core biopsy of bone marrow measuring 1.7 cm in
length.  The specimen is entirely submitted in A.

Brief Hospital Course:
50y/o F with ALL, fever/neutropenia, and R arm pain.
.
   After treatment in the emergency department with cefepime and
vancomycin for febrile neutropenia, the patient was admitted to
the oncology service for further care.  She was continued on
cefepime and vancomycin, and the doses of her antifungal
medication for known aspergillus infection were increased.
   The patient developed a new murmur and increased dyspnea and
chest pain, and on [**12-4**] an echocardiogram revealed a
pericardial effusion and tamponade physiology.  She was
transferred to the CCU for placement of a pericardial drain and
for post-procedural care.  320cc of yellow fluid was removed via
the pericardial drain.  On [**12-5**] the patient developed renal
failure.  Her ambisome dose was therefore decreased and her
voriconazole was changed to the PO formulation.  On [**12-6**] the
patien's mental status deteriorated and she became aphasic and
less interactive.  Neurology was consulted, and they were
concerned for an intracranial process vs. toxic/metabolic
etiology.  A head CT without contrast was negative for any acute
abnormality.  EEG was consistent with encephalopathy.  MRI was
negative for acute infarct, and MRA was negative for any
vascular abnormality.  An LP was done which showed an opening
pressure of 42; however, this was felt to be falsely elevated
due to patient positioning.  Laboratory studies were not
consistent with infection, and cultures were negative.  Not
enough fluid was obtained to send for cytology.
   The patient was then transferred to the ICU for further care.
 Shortly thereafter, a family meeting was held in which the
patient's code status was changed to DNR/DNI.  A bone marrow
biopsy was done on [**12-9**] to determine the status of the
patient's leukemia.  The marrow was hypocellular with no
evidence of active leukemia.  The patient's mental status did
not improve, and so a repeat LP was done on [**12-9**] to confirm the
opening pressure (which was again 40) and to obtain fluid for
cytology.  (CSF cytology was negative for malignant cells.)
After the LP the patient was noted to be in severe respiratory
distress and tachycardic to the 170s.  EKG revealed sinus
tachycardia with no ischemic changes.  ABG at that time was
7.16/46/83/17.  The patient's son was [**Name (NI) 653**], and he
reiterated that he did not wish for his mother to be intubated.
The patient's son and sister came to the bedside soon thereafter
and requested that the patient be made comfortable.  Her status
was therefore changed to Comfort Measures Only and she was
started on a morphine drip for comfort.  On the morning of [**12-10**]
the patient was noted to have [**Date Range 862**] activity.  This was
treated with ativan and resolved.  The patient was then
transferred out of the ICU to the floor for further care.
   On the BMT floor she was maintained on morphine and ativan
drips that was titrated to her comfort.  On the morning after
transfer, she went into status epilepticus.  This was terminated
with 10mg of ativan given as 4mg, 4mg, and 2mg.  She was again
breathing comfortably after this intervention but expired
90minutes afterwards.  The family was [**Date Range 653**] who professed
gratitude with her care at [**Hospital1 18**] and refused autopsy.

Medications on Admission:
voriconazole 200mg IV bid
prednisone
ambisome 450mg IV MWF
gleevec 400mg [**Hospital1 **]
megace 400mg daily
morphine sustained release 15mg [**Hospital1 **]
morphine 15mg po q4-6hrprn
zoloft 75mg daily
levofloxacin 500mg po daily


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
ALL
Multiple sclerosis
Acute renal failure
pericardial tamponade
encephalopathy


Discharge Condition:
Expired


Discharge Instructions:
None

Followup Instructions:
None
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute pericarditis, unspecified,Unspecified septicemia,Acute lymphoid leukemia, without mention of having achieved remission,Aspergillosis,Other convulsions,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Severe sepsis,Pneumonia in aspergillosis,Multiple sclerosis,Cellulitis and abscess of upper arm and forearm,Encephalopathy, 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: R arm pain and febrile neutropenia

PRESENT ILLNESS: 50y/o F with relapsed Ph+ pre-B cell ALL presents with
fever/neutropenia and chest pain. Pain started in her R arm
(site of PICC). Pt states that chest pain began about 2 days
ago, getting worse. Dull, all across chest, no radiation. No
exacerbating or alleviating factors. No associated SOB, N/V, or
diaphoresis. Not pleuritic. Has had this pain previously, when
admitted to hospital. Pain now resolved with morphine.
.
Pt noticed rash on inner aspect of R arm, for the last few days,
near PICC line. PICC being used for TPN and abx. Pt denies SOB,
worsening cough, N/V, abdominal pain, diarrhea, dysuria, or
fevers at home. No odynophagia or pain with chewing.
.
In [**Name (NI) **], pt rec'd cefepime 2g, vancomycin 1g, tylenol 1g,
phenergan 12.5mg, anzemet 12.5mg, and morphine 12mg.

MEDICAL HISTORY: Onc Hx: Pt initially dx'ed in [**2-22**], s/p chemo - induction with
doxorubicin, asparaginase, vincristine, cytoxan, and prednisone;
s/p XRT cranial x12 fractions, and intrathecal MTX. Relaped in
[**2-23**] while still rec'ing maintenance therapy. [**4-22**]: MTX,
vincristine, prednisone. [**2126**]: ALL relapsed, rec'd chemo.
[**Location (un) 5622**] chromosome positive. Now being Rx'ed with Gleevec,
prednisone, and vincristine.
.
PMH:
ALL as above
pulmonary aspergillosis on lung bx [**9-23**]
multiple sclerosis
[**Month/Year (2) 862**] d/o (last [**Month/Year (2) 862**] 20 years ago)
DVT [**12-22**]
echo [**2126-11-5**] EF >55%

MEDICATION ON ADMISSION: voriconazole 200mg IV bid
prednisone
ambisome 450mg IV MWF
gleevec 400mg [**Hospital1 **]
megace 400mg daily
morphine sustained release 15mg [**Hospital1 **]
morphine 15mg po q4-6hrprn
zoloft 75mg daily
levofloxacin 500mg po daily

ALLERGIES: Depakote / Hydromorphone / Carbamazepine Derivatives

PHYSICAL EXAM: VS: 97.3 133 112/70 24 100%on 4L
Gen: ill appearing, alopecia, appears in respiratory distress.
HEENT: PERRL, EOMI, MM dry,
Neck: no LAD, no JVD
CV: tachycardic, RRR nl S1-S2
Pulm: bibasilar crackles, R > L, otherwise CTAB
Abd: soft, NT/ND, +BS, no masses
Ext: R PICC with erythematous rash and mild skin breakdown more
proximal;R arm warm, firm and painful, 1+ edema in LE
bilaterally, symmetric; ppp
Neuro: resting tremor, CN II-XII intact, strength and sensory
grossly intact
Perirectal area: no evidence of abscess

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home.  Son [**Name (NI) **] is NOK and HCP (he is an only
child).  Husband died 22 years ago from ALL (at [**Hospital1 18**]). 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute pericarditis, unspecified,Unspecified septicemia,Acute lymphoid leukemia, without mention of having achieved remission,Aspergillosis,Other convulsions,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Severe sepsis,Pneumonia in aspergillosis,Multiple sclerosis,Cellulitis and abscess of upper arm and forearm,Encephalopathy, unspecified'}
