CHIEF COMPLAINT: Admission for transplant

PRESENT ILLNESS: 69 y/o F with hx of AML with FLT3 mutation diagnosed in [**Month (only) 404**]
of [**2145**] after she presented to [**Hospital1 18**] [**Location (un) 620**] with fatigue. She
is s/p chemotherapy (7 + 3 induction) Day +141. She is being
admitted for nonmyeloablative allogeneic double cord transplant
with Fludarabine, Melphalan and ATG conditioning regimen.
.
Currently, patient reports that she feels well, has no
complaints and is anxious to start the treatment protocol.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
ONCOLOGICAL HISTORY:
From OMR admission note:
Ms. [**Known lastname 20281**] is a 69-year-old woman with a past medical history
significant for aortic valvular replacement for aortic stenosis
in [**2143**] and venous occlusion of the retinal vein in [**10/2144**], who
presented on [**2145-1-27**] to the [**Hospital 18**] [**Hospital 620**] campus with
increasing fatigue and shortness of breath. She had no fevers,
chills, or night sweats, but noted some easy bruising. She also
had some visual changes with diplopia and blurry vision due to
recent retinal vein occlusion. At [**Hospital1 18**] [**Location (un) 620**], Ms. [**Known lastname 20281**] was
found of a white blood count of 300,000 with 94% blasts. She was
started on IV fluids with
bicarbonate and was transferred to [**Hospital1 18**] for further management.
Flow cytometry on [**2145-1-27**] from her peripheral blood showed a
majority of the cells in the CD45 intermediate low side scatter
blast region. The cells expressed CD33 along with dim CD4 and
dim CD19. Cells were negative for CD34 and HLA-DR. [**Last Name (STitle) 20282**] were
negative for other myeloid markers including CD13, CD14, CD15,
CD41, CD64, glycolphorin, CD17. Immunophenotyping findings were
consistent with involvement by acute myeloid leukemia with a
peripheral smear revealing cup-like nuclei. Cytogenetics were
notable for FLT3 and NPM positivity. Echocardiogram showed a
left ejection fraction of greater than 65%. Because of her high
white count, Ms. [**Known lastname 20281**] [**Last Name (Titles) 1834**] leukophoresis and initially
received hydroxyurea. On [**2145-1-28**], she was initiated on 7 and
3 induction regimen with idarubicin and ara-C. Her course was
complicated by fever and neutropenia. She also was noted for a
drop in her ejection fraction to 20-25% on [**2145-2-14**], which was
felt due to anthracycline use. She has been managed medically
initially with spironolactone, furosemide, lisinopril, and
metoprolol and is followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP as an outpatient. She is currently on spironolactone,
furosemide, diovan, and metoprolol. Her lisinopril was
discontinued due to cough which has since resolved. Ms. [**Known lastname 20283**]
course was complicated by her deconditioning and depression
regarding her diagnosis and conditioning. She was followed by
psychiatry while an inpatient and was discharged on [**2145-3-3**]
to [**Hospital1 **] House Rehabilitation in order to improve her strength
before moving forward with further therapy. Her cardiomyopathy
also limited her ability to receive further chemotherapy.

MEDICAL HISTORY: 1. AML, cup-like.
2: Aortic valve replacement in [**4-/2143**] secondary to aortic
stenosis.
3. Hypertension.
4. Hypercholesterolemia.
5. History of hepatic cyst (noted on a preoperative workup for
AVR and stable on imaging) - was concerning for an echinococcal
cyst, and treated empirically with albendazole in [**10/2143**];
repeat CT from [**2145-2-16**] notes the cyst to be markedly smaller at
10.6 x 10.1 mm from 8.5 x 6.2 cm.
6. Cholelithiasis.
7. History of dysfunctional uterine bleeding.
8. Appendectomy.
9. Left retinal vein occlusion [**10/2144**] thought to be in setting
of leukocytosis [**2-22**] AML
10. Typhilitis during induction chemotherapy

MEDICATION ON ADMISSION: Furosemide 20 mg qd
Metoprolol Tartrate 50 mg tid
Mirtazapine 15 mg qhs
Sertraline 25mg qd
Spironolactone 12.5mg qd
Valsartan 80 mg [**Hospital1 **]
Acetaminophen 325 mg q6h prn pain
Multivitamin 1 tab qd

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals - T:97.9 BP:128/82 HR:79 RR:18 02 sat:100% on RA
GENERAL: NAD, elderly female, well appearing, thinned hair
HEENT: OP clear, no lesions or evidence of thrush, EOMI, PERRL
on R side, L pupil very sluggish-non-reactive has known L
retinal occlusion
CARDIAC: regular rate, 3/6 SEM throughout precordium, loudest at
LLSB, no heave
LUNG: CTAB, no wheezes, rhonchi or rales
ABDOMEN: +bs, well healed surgical scars from appendectomy and
aortic valve replacement surgery
EXT: 1+ non pitting edema, mild chronic venous stasis changes,
2+ DP pulses
NEURO: alert and oriented to person, place, time and purpose,
strength 5/5 UE/LE bilaterally, sensation intact throughtout, CN
[**3-4**] intact
DERM: no lesions appreciated

FAMILY HISTORY: Sister recently passed away of "unknown causes" while she was in

SOCIAL HISTORY: Married, lives with her husband in [**Name (NI) 620**], originally from
[**Name (NI) **], has 4 children, some live locally. Lifelong
non-smoker, very rare EtOH.
Acute myeloid leukemia, without mention of having achieved remission,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Acute on chronic combined systolic and diastolic heart failure,Bacteremia,Other primary cardiomyopathies,Atrial fibrillation,Dysthymic disorder,Pure hypercholesterolemia,Unspecified essential hypertension,Heart valve replaced by other means
Ac myl leuk wo achv rmsn,Ac kidny fail, tubr necr,Acute respiratry failure,Acidosis,Ac/chr syst/dia hrt fail,Bacteremia,Prim cardiomyopathy NEC,Atrial fibrillation,Dysthymic disorder,Pure hypercholesterolem,Hypertension NOS,Heart valve replac NEC
Admission Date:  [**2145-5-20**]              Discharge Date:   [**2145-6-28**]

Date of Birth:  [**2075-7-5**]             Sex:   F

Service: EMERGENCY

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Admission for transplant

Major Surgical or Invasive Procedure:
Tunnelled Central Line Placement

History of Present Illness:
 69 y/o F with hx of AML with FLT3 mutation diagnosed in [**Month (only) 404**]
of [**2145**] after she presented to [**Hospital1 18**] [**Location (un) 620**] with fatigue. She
is s/p chemotherapy (7 + 3 induction) Day +141. She is being
admitted for nonmyeloablative allogeneic double cord transplant
with Fludarabine, Melphalan and ATG conditioning regimen.
.
Currently, patient reports that she feels well, has no
complaints and is anxious to start the treatment protocol.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
ONCOLOGICAL HISTORY:
From OMR admission note:
Ms. [**Known lastname 20281**] is a 69-year-old woman with a past medical history
significant for aortic valvular replacement for aortic stenosis
in [**2143**] and venous occlusion of the retinal vein in [**10/2144**], who
presented on [**2145-1-27**] to the [**Hospital 18**] [**Hospital 620**] campus with
increasing fatigue and shortness of breath. She had no fevers,
chills, or night sweats, but noted some easy bruising. She also
had some visual changes with diplopia and blurry vision due to
recent retinal vein occlusion. At [**Hospital1 18**] [**Location (un) 620**], Ms. [**Known lastname 20281**] was
found of a white blood count of 300,000 with 94% blasts. She was
started on IV fluids with
bicarbonate and was transferred to [**Hospital1 18**] for further management.
Flow cytometry on [**2145-1-27**] from her peripheral blood showed a
majority of the cells in the CD45 intermediate low side scatter
blast region. The cells expressed CD33 along with dim CD4 and
dim CD19. Cells were negative for CD34 and HLA-DR. [**Last Name (STitle) 20282**] were
negative for other myeloid markers including CD13, CD14, CD15,
CD41, CD64, glycolphorin, CD17. Immunophenotyping findings were
consistent with involvement by acute myeloid leukemia with a
peripheral smear revealing cup-like nuclei. Cytogenetics were
notable for FLT3 and NPM positivity. Echocardiogram showed a
left ejection fraction of greater than 65%. Because of her high
white count, Ms. [**Known lastname 20281**] [**Last Name (Titles) 1834**] leukophoresis and initially
received hydroxyurea. On [**2145-1-28**], she was initiated on 7 and
3 induction regimen with idarubicin and ara-C. Her course was
complicated by fever and neutropenia. She also was noted for a
drop in her ejection fraction to 20-25% on [**2145-2-14**], which was
felt due to anthracycline use. She has been managed medically
initially with spironolactone, furosemide, lisinopril, and
metoprolol and is followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP as an outpatient. She is currently on spironolactone,
furosemide, diovan, and metoprolol. Her lisinopril was
discontinued due to cough which has since resolved. Ms. [**Known lastname 20283**]
course was complicated by her deconditioning and depression
regarding her diagnosis and conditioning. She was followed by
psychiatry while an inpatient and was discharged on [**2145-3-3**]
to [**Hospital1 **] House Rehabilitation in order to improve her strength
before moving forward with further therapy. Her cardiomyopathy
also limited her ability to receive further chemotherapy.

As an outpatient, Ms. [**Known lastname 20281**] was noted for a drop in her platelet
count. She had noted a superficial saphenous vein clot and was
started on Lovenox approximately two weeks prior to this. Her
Lovenox had been stopped due to her decreasing platelet count.
However, she was found to have a positive HIT antibody and was
admitted for initiation of Argatroban therapy on [**2145-3-22**].
Followup testing with serotonin releasing assay was negative,
thereby making HIT diagnosis unlikely. It was decided to stop
Argatroban. She had a repeat bone marrow aspirate and biopsy
done on [**2145-3-18**] and [**2145-3-26**], both showing no evidence for
patient's known leukemia, although the specimen on [**2145-3-26**]
showed megakaryocytic hypoplasia. Repeat testing for FLT3
mutation and NPM mutation were sent on [**2145-3-27**] and were
negative. Ms. [**Known lastname 20281**] was further evaluated with a repeat
ultrasound which continued to shows a superficial clot in the
saphenous vein, but there was no evidence for deep vein
thrombosis, so she did not require any further anticoagultion,
which would have been difficult as her platelet count has
remained low. She also was reevaluated with echocardiogram which
showed improvement in her left ventricular ejection fraction to
50-55%. Ms. [**Known lastname 20281**] was initially discharged to home on
[**2145-3-31**], but fell. She was readmitted overnight. CT of the
head was negative, and she was discharged to [**Location (un) 1036**] for
further rehabilitation. She has been followed in the outpatient
setting for transfusion support.

Over the past 4 - 6 weeks, Ms. [**Known lastname 20281**] has received periodic
transfusion support but her counts have slowly recovered. She
had a repeat bone marrow aspirate and biopsy on [**2145-4-23**] which
showed a hypocellular erythroid dominant bone marrow with
trilineage hematopoiesis whit no evidence for acute leukemia.
Her FLT3 mutation and NPM mutation have remained negative. Ms.
[**Known lastname 20281**] has also been transitioned to home with physical therapy.
She has increased her strength and conditioning and remains
independent in her care and is walking without issues. She has
increased her activity. This is also in the setting of improved
cardiomyopathy. Because of her known mutations, she is at high
risk for recurrent leukemia and is in need of n allogeneic
transplant. She is being admitted today for her nonmyeloablative
allogeneic double cord transplant with Fludarabine, Melphalan
and ATG conditioning regimen.


Past Medical History:
1. AML, cup-like.
2: Aortic valve replacement in [**4-/2143**] secondary to aortic
stenosis.
3. Hypertension.
4. Hypercholesterolemia.
5. History of hepatic cyst (noted on a preoperative workup for
AVR and stable on imaging) - was concerning for an echinococcal
cyst, and treated empirically with albendazole in [**10/2143**];
repeat CT from [**2145-2-16**] notes the cyst to be markedly smaller at
10.6 x 10.1 mm from 8.5 x 6.2 cm.
6. Cholelithiasis.
7. History of dysfunctional uterine bleeding.
8. Appendectomy.
9. Left retinal vein occlusion [**10/2144**] thought to be in setting
of leukocytosis [**2-22**] AML
10. Typhilitis during induction chemotherapy


Social History:
Married, lives with her husband in [**Name (NI) 620**], originally from
[**Name (NI) **], has 4 children, some live locally. Lifelong
non-smoker, very rare EtOH.

Family History:
Sister recently passed away of "unknown causes" while she was in

a NH. Sister had diabetes. No FH of cardiac disease. No history
of leukemia or lymphoma.


Physical Exam:
Vitals - T:97.9 BP:128/82 HR:79 RR:18 02 sat:100% on RA
GENERAL: NAD, elderly female, well appearing, thinned hair
HEENT: OP clear, no lesions or evidence of thrush, EOMI, PERRL
on R side, L pupil very sluggish-non-reactive has known L
retinal occlusion
CARDIAC: regular rate, 3/6 SEM throughout precordium, loudest at
LLSB, no heave
LUNG: CTAB, no wheezes, rhonchi or rales
ABDOMEN: +bs, well healed surgical scars from appendectomy and
aortic valve replacement surgery
EXT: 1+ non pitting edema, mild chronic venous stasis changes,
2+ DP pulses
NEURO: alert and oriented to person, place, time and purpose,
strength 5/5 UE/LE bilaterally, sensation intact throughtout, CN
[**3-4**] intact
DERM: no lesions appreciated


Pertinent Results:
LABS ON ADMISSION:
[**2145-5-19**] 09:35AM BLOOD Neuts-60.2 Lymphs-29.9 Monos-7.2 Eos-2.0
Baso-0.8
[**2145-5-19**] 09:35AM BLOOD WBC-2.9* RBC-2.91* Hgb-10.0* Hct-28.3*
MCV-97 MCH-34.2* MCHC-35.2* RDW-21.3* Plt Ct-126*
[**2145-5-19**] 09:35AM BLOOD PT-12.1 PTT-21.9* INR(PT)-1.0
[**2145-5-20**] 09:45AM BLOOD Fibrino-482*
[**2145-5-22**] 12:00AM BLOOD Gran Ct-9120*
[**2145-5-19**] 09:35AM BLOOD ALT-20 AST-24 LD(LDH)-216 AlkPhos-76
TotBili-0.5 DirBili-0.1 IndBili-0.4
[**2145-5-19**] 09:35AM BLOOD Albumin-4.2 Calcium-9.3 Phos-4.0 Mg-2.2
.
URINE:
[**2145-5-20**] 04:46PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
[**2145-5-20**] 04:46PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2145-5-31**] 11:40AM URINE RBC-3* WBC-5 Bacteri-FEW Yeast-NONE
Epi-29 TransE-10
.
MICROBIO:
Bl Cx - [**6-3**] - E. coli
Bl Cx - [**2061-6-11**] Enterococcus faecium
IV Cath tip - [**6-13**] E. faecium
C. diff negative
Urine cx - negative
.
CARDIOLOGY:
TTE ([**6-13**]):
Conclusions
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is mildly depressed (LVEF= 40 %). A
bioprosthetic aortic valve prosthesis is present. The aortic
valve prosthesis leaflets appear to move normally. No masses or
vegetations are seen on the aortic valve, but cannot be fully
excluded due to suboptimal image quality. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but cannot be fully excluded due to suboptimal
image quality. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Emergent on-call
echocardiogram. Mild left ventricular systolic dysfunction.
Aortic valve bioprosthesis without obvious vegetations. Mild
mitral regurgitation.
If clinically indicated, a TEE will better assess for valvular
vegetations, especially in the presence of a prosthetic valve.
Compared with the prior study (images reviewed) of [**2145-5-7**],
left ventricular systolic function is less vigorous.
.
NEURO:
EEG ([**5-/2145**]):
This is an abnormal routine EEG due to a slow and poorly
modulated background indicative of a moderate to severe
encephalopathy.
Medications, metabolic disturbances, and infection are among the
most
common causes. There are no areas of prominent focal slowing
although
encephalopathies can obscure focal findings. There are no
epileptiform
features.
.
RADIOLOGY:
MRI Brain [**6-24**]:
IMPRESSION:
1. No acute infarction.
2. Diffuse bilateral mastoid air cells disease, mucosal
thickening and/or
fluid and also in the pneumatized petrous apices. While the
presence of
mucosal thickening and fluid does not by itself mean
mastoiditis, to
correlate clinically and with ENT examination to exclude
infective mastoiditis and if necessary LP, based on clinical
examination.
MRV without contrast can also be considered to assess Venous
sinuses.
3. The left internal carotid artery flow void in the carotid
canal is not
clearly identifiable on the present study unclear if this is
abnormal or
related to the oblique orientation of the head. MR angiogram of
the head
without IV contrast can be considered.

Brief Hospital Course:
Pt was admitted for allo-double cord transplant. On expiration
she was on day 31 of transplant. Her course was complicated by
prolonged MICU course as follows.

MICU course:
.
This is a 69 year old woman with AML, s/p 7+3, day 15 of
non-myeloablative allogeneic double cord transplant, with PMH of
bioprosthetic aortic valve, now in the ICU with worsening mental
status, increasing oxygen needs, and evident fluid overload in
the setting of acute renal failure and likely chronic heart
failure as well as recent VRE bacteremia.
.
HYPOXIA:  Gradual increase in O2 requirement before transfer to
MICU, with increasing evidence of fluid overload. Repeat
echocardiogram showed EF newly depressed to 30%. She was given
high-dose Lasix followed by Lasix drip with minimal urine
output. O2 requirement continued to increase, and she was
intubated.  CVVH was begun to remove volume. CVVH was continued
throughout her course. She was unable to be extubated.
.
CHF:  EF newly depressed to 25-30% as seen on TTE the day of
transfer to MICU.  Possibly secondary to prior chemotherapy.
Milrinone gtt was started with standing metoprolol to decrease
heart rate.  SvO2s  improved and milrinone was weaned. On later
echo EF improved to 35-40%. However, on day of expiration EF was
reduced to less 10% and she appeared to have cardiogenic shock.
.
ATRIAL FIBRILLATION: The patient developed atrial fibrillation
with a rate of 140s, compromising her forward flow and resulting
blood pressure.  She received unsuccessful cardioversion but
then converted to NSR after two amiodarone loads.  Amiodarone
was started and then discontinued after milrinone was stopped.
She had intermittent afib throughout her stay and was restarted
on metoprolol. In the last 24 hours her afib with RVR returned
when her BP dropped. She was given IVF boluses that temporarily
improved her HR before her final decompensation.
.
HYPOTENSION: This was likely secondary to atrial fibrillation as
well as a diffuse inflammatory response from engraftment causing
mixed cardiogenic and distributive shock. She required
phenylephrine in addition to milrinone initially.  With the
administration of steroids and rate correction, the patient??????s
hemodynamics markedly improved. However, on day of death
hypotension returned and was not responsive to multiple pressors
and IVF. At that time it appeared to be cardiogenic and septic
in nature.
.
VRE BACTEREMIA:  Linezolid was continued.  No evidence of
vegetation on TTE or TEE.
.
ACUTE RENAL FAILURE:  She had granular casts in urine and
presumably ATN.  She was increasingly volume overloaded and
oliguric.   During the first day in the ICU, she failed to
respond to 160 mg of Lasix followed by a Lasix gtt at 20mg/h as
well as metolazone.  A temporary line was placed and CVVH
initiated. She remained on CVVH. On her last 2 days she has 6
liters of fluid removed per day. She was anuric at the time.
.
ALTERED MENTAL STATUS:  Prior to intubation the patient was
altered in excess of her baseline anxiety.  Differential
diagnosis includes bacteremia, sepsis, renal failure/uremia,
underlying malignancy, med effect, delirium of the critically
ill. MS did not improve during her course. She only would open
her eyes and blink in a non-responsive manner. She had a gag
reflex. MR of the head did not show a source. LP was attempted
at bedside but not able to be completed.
.
FEVER (WITH NEUTROPENIA):  Cefepime, Flagyl, and micafungin for
empiric coverage of earlier fevers. Vancomycin had been started
before VRE was identified. Given this, continuing linezolid for
VRE. Filgrastim was continued. Three days prior to death
linezolid was changed to daptomycin due to suppressed cell
counts. Pt appeared to have a septic component on her final day.
.
AML:  Tacrolimus was held and levels checked.  CellCept was
continued. Methylprednisolone was started for likely engraftment
syndrome.  Filgrastim was continued per BMT recs. She was on day
31 at time of death. Her WBC was still 0.1 without change.
.
Coagulopathy: INR trended up slowly. She was given vitamin K.
Seems out of proportion to liver impairment. Likely contribution
from poor nutritional status
.
Transaminitis: LFTs increased slightly from yesterday, unclear
significance but not likely hypoxic/shock, no new infections or
toxic medication effect.
Events of 24 hours proceeding expiration:
Pt had CVVH with 6 liters removed. Became hypotensive and had
afib with RVR. Given fluid, 3 liters of NS, but BP only
temporarily responded. SBP in 60s, started Neo-Synephrine and
required addition of Levophed. BP continued to  be labile. IVF
boluses were continued. Stat echo showed EF of less than 10%. Pt
had code blue with hypoxia and PEA arrest. Briefly on Epi gtt.
Had <1 minute of compressions. Hypoxia and hypotension continued
once pulse returned. Primary oncologist also present during
events. Discussion with family and pt was made CMO. Pt expired.
Family declined autopsy.


Medications on Admission:
Furosemide 20 mg qd
Metoprolol Tartrate 50 mg tid
Mirtazapine 15 mg qhs
Sertraline 25mg qd
Spironolactone 12.5mg qd
Valsartan 80 mg [**Hospital1 **]
Acetaminophen 325 mg q6h prn pain
Multivitamin 1 tab qd


Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired


Completed by:[**2145-7-1**]
{'Acute myeloid leukemia, without mention of having achieved remission,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Acute on chronic combined systolic and diastolic heart failure,Bacteremia,Other primary cardiomyopathies,Atrial fibrillation,Dysthymic disorder,Pure hypercholesterolemia,Unspecified essential hypertension,Heart valve replaced by other means'}


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: Admission for transplant

PRESENT ILLNESS: 69 y/o F with hx of AML with FLT3 mutation diagnosed in [**Month (only) 404**]
of [**2145**] after she presented to [**Hospital1 18**] [**Location (un) 620**] with fatigue. She
is s/p chemotherapy (7 + 3 induction) Day +141. She is being
admitted for nonmyeloablative allogeneic double cord transplant
with Fludarabine, Melphalan and ATG conditioning regimen.
.
Currently, patient reports that she feels well, has no
complaints and is anxious to start the treatment protocol.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
ONCOLOGICAL HISTORY:
From OMR admission note:
Ms. [**Known lastname 20281**] is a 69-year-old woman with a past medical history
significant for aortic valvular replacement for aortic stenosis
in [**2143**] and venous occlusion of the retinal vein in [**10/2144**], who
presented on [**2145-1-27**] to the [**Hospital 18**] [**Hospital 620**] campus with
increasing fatigue and shortness of breath. She had no fevers,
chills, or night sweats, but noted some easy bruising. She also
had some visual changes with diplopia and blurry vision due to
recent retinal vein occlusion. At [**Hospital1 18**] [**Location (un) 620**], Ms. [**Known lastname 20281**] was
found of a white blood count of 300,000 with 94% blasts. She was
started on IV fluids with
bicarbonate and was transferred to [**Hospital1 18**] for further management.
Flow cytometry on [**2145-1-27**] from her peripheral blood showed a
majority of the cells in the CD45 intermediate low side scatter
blast region. The cells expressed CD33 along with dim CD4 and
dim CD19. Cells were negative for CD34 and HLA-DR. [**Last Name (STitle) 20282**] were
negative for other myeloid markers including CD13, CD14, CD15,
CD41, CD64, glycolphorin, CD17. Immunophenotyping findings were
consistent with involvement by acute myeloid leukemia with a
peripheral smear revealing cup-like nuclei. Cytogenetics were
notable for FLT3 and NPM positivity. Echocardiogram showed a
left ejection fraction of greater than 65%. Because of her high
white count, Ms. [**Known lastname 20281**] [**Last Name (Titles) 1834**] leukophoresis and initially
received hydroxyurea. On [**2145-1-28**], she was initiated on 7 and
3 induction regimen with idarubicin and ara-C. Her course was
complicated by fever and neutropenia. She also was noted for a
drop in her ejection fraction to 20-25% on [**2145-2-14**], which was
felt due to anthracycline use. She has been managed medically
initially with spironolactone, furosemide, lisinopril, and
metoprolol and is followed by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], NP as an outpatient. She is currently on spironolactone,
furosemide, diovan, and metoprolol. Her lisinopril was
discontinued due to cough which has since resolved. Ms. [**Known lastname 20283**]
course was complicated by her deconditioning and depression
regarding her diagnosis and conditioning. She was followed by
psychiatry while an inpatient and was discharged on [**2145-3-3**]
to [**Hospital1 **] House Rehabilitation in order to improve her strength
before moving forward with further therapy. Her cardiomyopathy
also limited her ability to receive further chemotherapy.

MEDICAL HISTORY: 1. AML, cup-like.
2: Aortic valve replacement in [**4-/2143**] secondary to aortic
stenosis.
3. Hypertension.
4. Hypercholesterolemia.
5. History of hepatic cyst (noted on a preoperative workup for
AVR and stable on imaging) - was concerning for an echinococcal
cyst, and treated empirically with albendazole in [**10/2143**];
repeat CT from [**2145-2-16**] notes the cyst to be markedly smaller at
10.6 x 10.1 mm from 8.5 x 6.2 cm.
6. Cholelithiasis.
7. History of dysfunctional uterine bleeding.
8. Appendectomy.
9. Left retinal vein occlusion [**10/2144**] thought to be in setting
of leukocytosis [**2-22**] AML
10. Typhilitis during induction chemotherapy

MEDICATION ON ADMISSION: Furosemide 20 mg qd
Metoprolol Tartrate 50 mg tid
Mirtazapine 15 mg qhs
Sertraline 25mg qd
Spironolactone 12.5mg qd
Valsartan 80 mg [**Hospital1 **]
Acetaminophen 325 mg q6h prn pain
Multivitamin 1 tab qd

ALLERGIES: Lisinopril

PHYSICAL EXAM: Vitals - T:97.9 BP:128/82 HR:79 RR:18 02 sat:100% on RA
GENERAL: NAD, elderly female, well appearing, thinned hair
HEENT: OP clear, no lesions or evidence of thrush, EOMI, PERRL
on R side, L pupil very sluggish-non-reactive has known L
retinal occlusion
CARDIAC: regular rate, 3/6 SEM throughout precordium, loudest at
LLSB, no heave
LUNG: CTAB, no wheezes, rhonchi or rales
ABDOMEN: +bs, well healed surgical scars from appendectomy and
aortic valve replacement surgery
EXT: 1+ non pitting edema, mild chronic venous stasis changes,
2+ DP pulses
NEURO: alert and oriented to person, place, time and purpose,
strength 5/5 UE/LE bilaterally, sensation intact throughtout, CN
[**3-4**] intact
DERM: no lesions appreciated

FAMILY HISTORY: Sister recently passed away of "unknown causes" while she was in

SOCIAL HISTORY: Married, lives with her husband in [**Name (NI) 620**], originally from
[**Name (NI) **], has 4 children, some live locally. Lifelong
non-smoker, very rare EtOH. 

### Response:
{'Acute myeloid leukemia, without mention of having achieved remission,Acute kidney failure with lesion of tubular necrosis,Acute respiratory failure,Acidosis,Acute on chronic combined systolic and diastolic heart failure,Bacteremia,Other primary cardiomyopathies,Atrial fibrillation,Dysthymic disorder,Pure hypercholesterolemia,Unspecified essential hypertension,Heart valve replaced by other means'}
