CHIEF COMPLAINT: petechiae, dyspnea

PRESENT ILLNESS: 36 year old female with hx anemia (baseline HCT 32 in [**2127**]),
hypothyroidism, and alopecia who presented to clinic today with
recent oral mucosal bleeding, mild dyspnea on exertion, and new
petecchial rash.  For the last 1-2 weeks, patient has been
experiencing nausea, and some pressure in her fingertips, for
which she was recently seen in the [**Hospital1 18**] ED and discharged.
Patient soon after noticed a petechial rash over her lower
extremities and on her chest. 3-4 days prior to admission, the
patient was noted to have increasing yellowing of face and eyes
that has since resolved.  She also noted some bleeding from her
gums over the last 1-2 days. She has had continued nausea and
vomiting, with some diffuse abdominal pain. Patient also notes
some shortness of breath on exertion over the last few days.
Lab work following clinic revealed new thrombocytopenia (12K)
and worsening anemia (24.8). Heme-onc fellow on-call who
suggested patient be sent to ED for expedited work-up (and to
r/o early TTP).  Of note, the patient had diffuse rash with
alopecia and malar distribution one year ago. [**Doctor First Name **] checked by
physician at that time elevated.
.
On admission to ED, VS: 97.8 106 114/83 16 100%.  Patient
complained of dyspnea on exertion.  She was put on oxygen b/c
subjective SOB.  She was seen by heme/onc and renal who
recommended urgent pheresis.
.
On the floor, patient denies abdominal pain, nausea, dyspnea.
She is very fatigued.  She continues to have petechiae.
.
ROS:  No fevers, chills, change in weight.  Patient endorses a
headache.  No confusion.  No cough.  No diarrhea/constipation.
No rectal bleeding.  No focal weakness or numbness.  She
endorses shortness of breath, esepcially on exertion. No focal
numb/tingling.

MEDICAL HISTORY: -Hypothyroidism
-Acne
-Alopecia areata

MEDICATION ON ADMISSION: minoxidil 5 % Topical Soln
Synthroid 100 mcg Tab
Retin-A 0.01 % Topical Gel

ALLERGIES: Latex

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
36.4  112/69  78  18  92% RA
Gen:  Alert, oriented, laying comfortably in bed in NAD
HEENT:  sclera non-icteric, MMM, few palatal petichiae,
petichial lesion on left lower lip and right corner of lips;  no
lymphadenopathy
Card:  Nl S1, S2, no murmurs, rubs or gallops
Lungs:  Clear to auscultation bilaterally
Abdomen:  soft, mildly tender to palpation, non-distended
Skin:  Scattered non-blanching pinpoint macular lesions on chest
and anterior aspect of shins.  Shin lesions intermixed with
raised, non-blanching lesions.
Neuro:  CN II- XII intact;  Strength 5/5 bilaterally, sensation
intact.

FAMILY HISTORY: On her mother's side, there is hypothyroidism and alopecia.  On
her father's side, there is ovarian and prostate cancer.  There
is no alopecia in her father's side. There is no family history
of early colon cancer or early
coronary artery disease.

SOCIAL HISTORY: Dentist. No substance abuse.  Lived in [**Location **] different places.
And workups in many different places.
Thrombotic microangiopathy,Unspecified acquired hypothyroidism,Alopecia areata,Other abnormal glucose,Adrenal cortical steroids causing adverse effects in therapeutic use,Allergy to latex,Headache,Urticaria, unspecified
Thrombot microangiopathy,Hypothyroidism NOS,Alopecia areata,Abnormal glucose NEC,Adv eff corticosteroids,Hx-latex allergy,Headache,Urticaria NOS
Admission Date:  [**2130-9-1**]              Discharge Date:   [**2130-9-6**]

Date of Birth:  [**2094-8-24**]             Sex:   F

Service: MEDICINE

Allergies:
Latex

Attending:[**First Name3 (LF) 14689**]
Chief Complaint:
petechiae, dyspnea

Major Surgical or Invasive Procedure:
Central Venous Line Placement , plasmapheresis

History of Present Illness:
36 year old female with hx anemia (baseline HCT 32 in [**2127**]),
hypothyroidism, and alopecia who presented to clinic today with
recent oral mucosal bleeding, mild dyspnea on exertion, and new
petecchial rash.  For the last 1-2 weeks, patient has been
experiencing nausea, and some pressure in her fingertips, for
which she was recently seen in the [**Hospital1 18**] ED and discharged.
Patient soon after noticed a petechial rash over her lower
extremities and on her chest. 3-4 days prior to admission, the
patient was noted to have increasing yellowing of face and eyes
that has since resolved.  She also noted some bleeding from her
gums over the last 1-2 days. She has had continued nausea and
vomiting, with some diffuse abdominal pain. Patient also notes
some shortness of breath on exertion over the last few days.
Lab work following clinic revealed new thrombocytopenia (12K)
and worsening anemia (24.8). Heme-onc fellow on-call who
suggested patient be sent to ED for expedited work-up (and to
r/o early TTP).  Of note, the patient had diffuse rash with
alopecia and malar distribution one year ago. [**Doctor First Name **] checked by
physician at that time elevated.
.
On admission to ED, VS: 97.8 106 114/83 16 100%.  Patient
complained of dyspnea on exertion.  She was put on oxygen b/c
subjective SOB.  She was seen by heme/onc and renal who
recommended urgent pheresis.
.
On the floor, patient denies abdominal pain, nausea, dyspnea.
She is very fatigued.  She continues to have petechiae.
.
ROS:  No fevers, chills, change in weight.  Patient endorses a
headache.  No confusion.  No cough.  No diarrhea/constipation.
No rectal bleeding.  No focal weakness or numbness.  She
endorses shortness of breath, esepcially on exertion. No focal
numb/tingling.

Past Medical History:
-Hypothyroidism
-Acne
-Alopecia areata



Social History:
Dentist. No substance abuse.  Lived in [**Location **] different places.
And workups in many different places.

Family History:
On her mother's side, there is hypothyroidism and alopecia.  On
her father's side, there is ovarian and prostate cancer.  There
is no alopecia in her father's side. There is no family history
of early colon cancer or early
coronary artery disease.

Physical Exam:
ADMISSION PHYSICAL EXAM:
36.4  112/69  78  18  92% RA
Gen:  Alert, oriented, laying comfortably in bed in NAD
HEENT:  sclera non-icteric, MMM, few palatal petichiae,
petichial lesion on left lower lip and right corner of lips;  no
lymphadenopathy
Card:  Nl S1, S2, no murmurs, rubs or gallops
Lungs:  Clear to auscultation bilaterally
Abdomen:  soft, mildly tender to palpation, non-distended
Skin:  Scattered non-blanching pinpoint macular lesions on chest
and anterior aspect of shins.  Shin lesions intermixed with
raised, non-blanching lesions.
Neuro:  CN II- XII intact;  Strength 5/5 bilaterally, sensation
intact.

DISCHARGE PHYSICAL EXAM:
97.2  119/80  73  18  100% RA
Gen:  Alert, oriented, laying comfortably in bed in NAD
HEENT: NC/AT, sclera non-icteric, MMM, oropharynx clear
NECK: Soft, supple, no lymphadenopathy
Card:  Nl S1, S2, no murmurs, rubs or gallops
Lungs:  Clear to auscultation bilaterally
Abdomen: Soft, ND/NT, NABS, no organomegaly
Skin:  Currently clear, no evidence of hives or petechiae
Neuro:  CN II- XII intact;  Strength 5/5 bilaterally, sensation
intact.

Pertinent Results:
ADMISSION LABS:
.
Blood Counts
[**2130-8-31**] 04:29PM BLOOD WBC-5.4 RBC-3.32* Hgb-8.3* Hct-24.8*
MCV-75* MCH-25.0* MCHC-33.5 RDW-17.8* Plt Ct-12*#
[**2130-9-1**] 05:05PM BLOOD WBC-5.9 RBC-3.19* Hgb-8.2* Hct-23.2*
MCV-73* MCH-25.7* MCHC-35.3* RDW-17.8* Plt Ct-22*
[**2130-9-2**] 05:57PM BLOOD WBC-6.7 RBC-3.05* Hgb-7.9* Hct-22.5*
MCV-74* MCH-26.0* MCHC-35.1* RDW-18.2* Plt Ct-50*#

Chemistry
[**2130-8-31**] 04:29PM BLOOD UreaN-22* Creat-0.7 Na-140 K-3.8 Cl-106
HCO3-24 AnGap-14
[**2130-9-2**] 05:57PM BLOOD Glucose-161* UreaN-14 Creat-0.8 Na-140
K-3.9 Cl-106 HCO3-23 AnGap-15

Hemolysis / Anemia
[**2130-8-31**] 04:29PM BLOOD LD(LDH)-1204* TotBili-2.6*
[**2130-9-1**] 05:25AM BLOOD LD(LDH)-492* TotBili-1.4
[**2130-9-1**] 05:05PM BLOOD LD(LDH)-455* TotBili-1.9*
[**2130-8-31**] 04:29PM BLOOD calTIBC-346 Hapto-<5* Ferritn-742*
TRF-266
[**2130-9-1**] 02:50AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 dsDNA-NEGATIVE
[**2130-9-1**] 02:50AM BLOOD C3-169 C4-29
[**2130-9-1**] 02:50AM BLOOD ESR-60*
.
PERTINENT LABS:
.
[**2130-8-31**] 04:29PM BLOOD WBC-5.4 RBC-3.32* Hgb-8.3* Hct-24.8*
MCV-75* MCH-25.0* MCHC-33.5 RDW-17.8* Plt Ct-12*#
[**2130-9-6**] 06:30AM BLOOD WBC-10.7 RBC-2.99* Hgb-8.0* Hct-23.4*
MCV-78* MCH-26.7* MCHC-34.1 RDW-18.5* Plt Ct-289
[**2130-9-1**] 09:58AM BLOOD Fibrino-302
[**2130-9-1**] 02:50AM BLOOD ESR-60*
[**2130-9-4**] 06:35AM BLOOD Ret Aut-3.5*
[**2130-8-31**] 04:29PM BLOOD ALT-24 AST-51* LD(LDH)-1204* AlkPhos-42
TotBili-2.6*
[**2130-9-3**] 06:37AM BLOOD calTIBC-315 VitB12-326 Hapto-63
Ferritn-299* TRF-242
[**2130-8-31**] 04:29PM BLOOD TSH-3.1
[**2130-9-1**] 02:50AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:40 dsDNA-NEGATIVE
[**2130-9-1**] 02:50AM BLOOD C3-169 C4-29
[**2130-9-1**] 05:05PM BLOOD HIV Ab-NEGATIVE
[**2130-9-1**] 09:44AM BLOOD Lactate-1.4
.
DISCHARGE LABS:
.
[**2130-9-6**] 06:30AM BLOOD WBC-10.7 RBC-2.99* Hgb-8.0* Hct-23.4*
MCV-78* MCH-26.7* MCHC-34.1 RDW-18.5* Plt Ct-289
[**2130-9-6**] 06:30AM BLOOD Glucose-83 UreaN-15 Creat-0.6 Na-137
K-3.8 Cl-103 HCO3-27 AnGap-11
[**2130-9-6**] 06:30AM BLOOD LD(LDH)-204 TotBili-0.3
[**2130-9-6**] 06:30AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.7
.
MICRO:
.
MRSA SCREEN (Final [**2130-9-3**]):    No MRSA isolated.
BCx ([**2130-9-3**]): NGTD x 4 days
UCx ([**2130-9-5**]): NGTD x 2 days
.
IMAGING: None

Brief Hospital Course:
HOSPITAL COURSE
36yo F PMHx anemia (baseline HCT 32 in [**2127**]), hypothyroidism,
and alopecia who presented to clinic with recent oral mucosal
bleeding, mild dyspnea on exertion, and new petecchial rash.
.
ACTIVE DIAGNOSES:
.
#Thrombotic Thrombocytopenia Purpura:  Patient presented with
patechiae, found to have microcytic anemia, thrombocytopenia,
markedly elevated LDH, low haptoglobin.  Smear consistent with
microangiopathic hemolytic anemia.  No evidence of HUS given
lack of fever, renal failure, AMS but she did have significant
headaches. She was admitted to the ICU and diagnosed as having
TTP of unclear etiology and transfered to [**Name (NI) 2035**] following
stabilization.  [**Doctor First Name **] equivocal, ADAMTS13 studies sent and
pending.  Patient was evaluated by hematology service and
recommended for PO steroids and plasmapheresis.  Pheresis was
complicated by mild urticaria, controlled with prn benadryl but
otherwise well tolerated and her calcium was repleted prn. She
had a terrific response to the treatment with her platelet count
on admission of 12 rising to 289 on the day of discharge. She
did not suffer from any catostrophic vascular complications such
as strokes, infarcts, or renal compromise. She was ultimately
discharged home with follow-up set up with the pheresis team
(her pheresis line was left in place) with transfer of care
ultimately to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to ultimately occur.
.
# Steroid-Induced Hyperglycemia: Pt developed moderately
elevated finger sticks likely [**2-22**] initiation of steroids (no
history of DM). She was managed with HISS. Tapering of her oral
steroids was deferred to the outpatient setting with the
pheresis team.
.
# Latex Allergy: Note, patient has latex allergy which has made
ordering medications (heparin, calcium, dextrose, insulin)
complex and has required discussion with pharmacy
.
Chronic Diagnoses:
.
#Hypothyroidism: Stable. She was continued on her home
levothyroxine.
.
#Alopecia: Stable and no apparent areas of alopecia on exam. Her
combination minoxidil, steroid, and retinoid topical solution
was held given concern of minoxidil as possible exacerbating
factor in her TTP. She was instructed to follow-up with her
dermatologist as an outpatient for continued management.
.
Transitional Issues:
She was set up with frequent outpatient follow-up with the
pheresis team for line maintainence, lab draws, and clinic
visits. She was also set up with an appointment with Dr. [**Last Name (STitle) **]
with the intent that he would be assuming her long-term
care/maintenance for TTP.

Medications on Admission:
minoxidil 5 % Topical Soln
Synthroid 100 mcg Tab
Retin-A 0.01 % Topical Gel

Discharge Medications:
1. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*1 bottle* Refills:*0*
3. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for urticaria.
Disp:*1 bottle* Refills:*0*
4. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
Disp:*1 bottle* Refills:*0*
6. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*1 bottle* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
-Thrombotic thrombocytopenia purpura
Secondary:
-Hypothyroidism
-Alopecia areata


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


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure taking care of you. You were admitted to [**Hospital1 1535**] for evaluation and treatment of
TTP (thrombotic thrombocytopenia purpura). You were treated with
high-dose steroids as well as plasmapheresis. Your condition
improved dramatically and your platelet counts returned to
[**Location 213**].

The following changes have been made to your medications:
-START Prednisone 60mg by mouth once daily (Dr. [**First Name (STitle) 805**] and Dr.
[**Last Name (STitle) **] will be in charge of slowly tapering down the dose of this
medication)
-START Tylenol 500mg 1-2 tablets by mouth every 6 hours as
needed for pain (do not take more than 4 grams daily)
-START Benadryl 25mg by mouth every 6 hours as needed for itch
-START Sarna Lotion apply to affected areas 4 times daily as
needed for itch
-START Vitamin B12 250mcg by mouth once daily (this can be a
lower dose if that's what's available at the pharmacy)
-STOP your topical minoxidil, steroid, retinoid solution (We
recommend speaking with your dermatologist and Dr. [**Last Name (STitle) **] before
resuming use)

We wish you a speedy recovery and hope you feel better. Please
follow-up with the appointments listed below.

Followup Instructions:
You will follow-up in the pheresis unit on Friday for flushing
of your pheresis line and lab draw. You will then follow-up with
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] in clinic on Monday who follow you short-term.
You will then see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in his clinic on the day and
time below for long-term follow-up of your condition.
.
Department: INFUSION/PHERESIS UNIT
When: FRIDAY [**2130-9-8**] at 8:15 AM [**Telephone/Fax (1) 14067**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) **]
Campus: EAST     Best Parking: Main Garage

Department: [**Hospital3 249**]
When: MONDAY [**2130-9-18**] at 11:00 AM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**] in the [**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 250**]
Notes: This appointment is with a hospital-based doctor as part
of your transition from the hospital back to your primary care
provider.  [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2130-10-5**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) 10341**] MD [**MD Number(2) 14690**]

Completed by:[**2130-9-28**]
{'Thrombotic microangiopathy,Unspecified acquired hypothyroidism,Alopecia areata,Other abnormal glucose,Adrenal cortical steroids causing adverse effects in therapeutic use,Allergy to latex,Headache,Urticaria, 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: petechiae, dyspnea

PRESENT ILLNESS: 36 year old female with hx anemia (baseline HCT 32 in [**2127**]),
hypothyroidism, and alopecia who presented to clinic today with
recent oral mucosal bleeding, mild dyspnea on exertion, and new
petecchial rash.  For the last 1-2 weeks, patient has been
experiencing nausea, and some pressure in her fingertips, for
which she was recently seen in the [**Hospital1 18**] ED and discharged.
Patient soon after noticed a petechial rash over her lower
extremities and on her chest. 3-4 days prior to admission, the
patient was noted to have increasing yellowing of face and eyes
that has since resolved.  She also noted some bleeding from her
gums over the last 1-2 days. She has had continued nausea and
vomiting, with some diffuse abdominal pain. Patient also notes
some shortness of breath on exertion over the last few days.
Lab work following clinic revealed new thrombocytopenia (12K)
and worsening anemia (24.8). Heme-onc fellow on-call who
suggested patient be sent to ED for expedited work-up (and to
r/o early TTP).  Of note, the patient had diffuse rash with
alopecia and malar distribution one year ago. [**Doctor First Name **] checked by
physician at that time elevated.
.
On admission to ED, VS: 97.8 106 114/83 16 100%.  Patient
complained of dyspnea on exertion.  She was put on oxygen b/c
subjective SOB.  She was seen by heme/onc and renal who
recommended urgent pheresis.
.
On the floor, patient denies abdominal pain, nausea, dyspnea.
She is very fatigued.  She continues to have petechiae.
.
ROS:  No fevers, chills, change in weight.  Patient endorses a
headache.  No confusion.  No cough.  No diarrhea/constipation.
No rectal bleeding.  No focal weakness or numbness.  She
endorses shortness of breath, esepcially on exertion. No focal
numb/tingling.

MEDICAL HISTORY: -Hypothyroidism
-Acne
-Alopecia areata

MEDICATION ON ADMISSION: minoxidil 5 % Topical Soln
Synthroid 100 mcg Tab
Retin-A 0.01 % Topical Gel

ALLERGIES: Latex

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
36.4  112/69  78  18  92% RA
Gen:  Alert, oriented, laying comfortably in bed in NAD
HEENT:  sclera non-icteric, MMM, few palatal petichiae,
petichial lesion on left lower lip and right corner of lips;  no
lymphadenopathy
Card:  Nl S1, S2, no murmurs, rubs or gallops
Lungs:  Clear to auscultation bilaterally
Abdomen:  soft, mildly tender to palpation, non-distended
Skin:  Scattered non-blanching pinpoint macular lesions on chest
and anterior aspect of shins.  Shin lesions intermixed with
raised, non-blanching lesions.
Neuro:  CN II- XII intact;  Strength 5/5 bilaterally, sensation
intact.

FAMILY HISTORY: On her mother's side, there is hypothyroidism and alopecia.  On
her father's side, there is ovarian and prostate cancer.  There
is no alopecia in her father's side. There is no family history
of early colon cancer or early
coronary artery disease.

SOCIAL HISTORY: Dentist. No substance abuse.  Lived in [**Location **] different places.
And workups in many different places. 

### Response:
{'Thrombotic microangiopathy,Unspecified acquired hypothyroidism,Alopecia areata,Other abnormal glucose,Adrenal cortical steroids causing adverse effects in therapeutic use,Allergy to latex,Headache,Urticaria, unspecified'}
