CHIEF COMPLAINT: hyponatremia, n/v

PRESENT ILLNESS: 48 y/o F with h/o sjogrens, cryoglobulinemia, transferred from
[**Location (un) **] [**Location (un) **] with hyponatremia to 112. Felt poorly for
several weeks feeling weak, tired. Started vomiting (non-bloody,
non-bilious) on wednesday with decreased apetite, nausea. No
associated headache, abdominal pain, diarrhea, or fevers.
However, also did have a non-productive cough with episode of
bronchitis 5 weeks ago. She reports no similar prior episodes
like this. Of note ,symptoms worsened after starting a trial of
doxcycline on wednesday. She stopped after one day due to the
N/V. No associated rash.

MEDICAL HISTORY: sjogren's disease
h/o cryoglobulinemia

MEDICATION ON ADMISSION: doxycycline- stopped
multivitamins
melatonin

ALLERGIES: Codeine

PHYSICAL EXAM: 98.3, BP 134/70, HR 79, RR 16, 94% RA, 134 lb
gen- awake, alert, pleasant, NAD
heent- dry eyes, mouth. + swollen 2-3 cm, non-tender salivary
glands b/l at angle of jaw b/l.
neck- supple. no add'l swollen glands/lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND, NABS, no bruits auscultated
ext- no rash, no edema, warm, 2+ pulses
neuro- alert and oriented x 3. CNII-XII intact. motor strength
full. normal sensation
skin- no hyperpigmentation, no jaundice
affect- normal

FAMILY HISTORY: no fh of auto-immune disease. brother with gout

SOCIAL HISTORY: denies tobacco, occ ETOH. no IVDU. denies HIV risk factors. no
tattoos. Works at a private high school. Irish descent, lives in
[**Location 246**] now.
Other paraproteinemias,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Anemia, unspecified,Sicca syndrome
Paraproteinemia NEC,Acute kidney failure NOS,Hyposmolality,Nephritis NOS,Anemia NOS,Sicca syndrome
Admission Date:  [**2101-4-3**]              Discharge Date:   [**2101-4-16**]

Date of Birth:  [**2052-4-8**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
hyponatremia, n/v

Major Surgical or Invasive Procedure:
plasmaphoresis with hemodialysis
temporary HD/plasmapheresis catheter placement


History of Present Illness:
48 y/o F with h/o sjogrens, cryoglobulinemia, transferred from
[**Location (un) **] [**Location (un) **] with hyponatremia to 112. Felt poorly for
several weeks feeling weak, tired. Started vomiting (non-bloody,
non-bilious) on wednesday with decreased apetite, nausea. No
associated headache, abdominal pain, diarrhea, or fevers.
However, also did have a non-productive cough with episode of
bronchitis 5 weeks ago. She reports no similar prior episodes
like this. Of note ,symptoms worsened after starting a trial of
doxcycline on wednesday. She stopped after one day due to the
N/V. No associated rash.

She has a long history of sjogrens for which she has chronic dry
eyes and dry mouth. She also has a history of cryoglubinemia for
which she required cytoxan and plasmapheresis in [**2092**]. It was
diagnosed after her toe went numb. She denies N/V at that time
and reports no kidney involvement as far as she knows. And she
has had no further problems since then. She says she was told
her Na runs low, but she does not know her baseline levels. she
went to her PCP where she was found to have a Na of 117, so she
was sent to [**Hospital3 **]. There, her Na was 112, Cr 1.9,
bicarb 19, k 4.3. Rec'd 800cc NS and transferred to [**Hospital1 18**]. Of
note ,patient has never been here. Normally seen at [**Hospital **],
where her PCP [**Last Name (NamePattern4) **]. [**Name10 (NameIs) 3081**] she admits she has never need
hospital admission before. Even during her cytoxan treatments
for cryoglobulinemia it was all outpatient.

Of note, she reports being tested for hepb/c and was negative.
Denies HIV risk factors. no history of thyroid disease or
adrenal insufficiency that she knows of.

In ER  here, na 113, bicarb 17, cr 1.8. Given 3L NS in ER.
Zofran 4mg IV. U/A with 21-50 RBC, large blood, 500 protein;
serum osm 252, urine osm 245, urine Na 10

Admit to medicine

ROS: on arrival pt denies abd pain, no current n/v, f/c. no
headache. +dry mouth, dry eyes. still feels mildly dehydrated,
but at her baseline. denies changes in her urine. + decrease in
apetite, fatigue over last several weeks. no rash, bruising,
bleeding. + numbness in her left pinky that was transient, now
gone. no cp, sob, lh, dizziness


Past Medical History:
sjogren's disease
h/o cryoglobulinemia

Social History:
denies tobacco, occ ETOH. no IVDU. denies HIV risk factors. no
tattoos. Works at a private high school. Irish descent, lives in
[**Location 246**] now.

Family History:
no fh of auto-immune disease. brother with gout

Physical Exam:
98.3, BP 134/70, HR 79, RR 16, 94% RA, 134 lb
gen- awake, alert, pleasant, NAD
heent- dry eyes, mouth. + swollen 2-3 cm, non-tender salivary
glands b/l at angle of jaw b/l.
neck- supple. no add'l swollen glands/lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND, NABS, no bruits auscultated
ext- no rash, no edema, warm, 2+ pulses
neuro- alert and oriented x 3. CNII-XII intact. motor strength
full. normal sensation
skin- no hyperpigmentation, no jaundice
affect- normal


Pertinent Results:
admission labs:
-------------
[**2101-4-2**] 09:50PM   WBC-6.6 RBC-3.12* HGB-9.8* HCT-25.8* MCV-83
MCH-31.4 MCHC-37.8* RDW-13.1
[**2101-4-2**] 09:50PM   NEUTS-83.1* LYMPHS-9.1* MONOS-6.5 EOS-1.3
BASOS-0.1
[**2101-4-2**] 09:50PM   PT-12.8 PTT-32.5 INR(PT)-1.1
[**2101-4-2**] 09:50PM   OSMOLAL-252*
[**2101-4-2**] 09:50PM   PHOSPHATE-4.9* MAGNESIUM-2.1
[**2101-4-2**] 09:50PM   ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-59
AMYLASE-38 TOT BILI-0.7
[**2101-4-2**] 09:50PM   GLUCOSE-86 UREA N-41* CREAT-1.8* SODIUM-113*
POTASSIUM-4.3 CHLORIDE-88* TOTAL CO2-17* ANION GAP-12
[**2101-4-3**] 12:30AM URINE  RBC-21-50* WBC-[**2-23**] BACTERIA-FEW
YEAST-NONE EPI-1
[**2101-4-3**] 12:30AM URINE  HYALINE-[**2-23**]*
[**2101-4-3**] 12:30AM URINE  BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2101-4-3**] 12:30AM URINE  OSMOLAL-245
[**2101-4-3**] 12:30AM URINE  HOURS-RANDOM SODIUM-10 POTASSIUM-39
CHLORIDE-11

Reports-
EKG- w/ NSR, normal axis, TWI V1. No acute ST changes

CXR: CHEST, PA AND LATERAL: The cardiac and mediastinal contours
are within normal limits. The lungs are clear. There are no
pleural effusions. Pulmonary vasculature is within normal
limits. There is slight widening of the AP diameter of the chest
which may indicate underlying obstructive lung disease.

IMPRESSION: No acute cardiopulmonary disease.
--------------
CT ABDOMEN W/O CONTRAST  [**2101-4-14**] 9:18 AM

CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST

Reason: eval for hematoma from prior renal biopsy

[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with cryo, resolving ARF on plasmaphoresis
with worsening anemia.
REASON FOR THIS EXAMINATION:
eval for hematoma from prior renal biopsy
CONTRAINDICATIONS for IV CONTRAST: ARF;ARF

INDICATION: 49-year-old woman with acute renal failure on
plasmapheresis and worsening anemia. Please evaluate for
hematoma from prior renal biopsy.

TECHNIQUE: Axial MDCT images were obtained from lung bases to
pubic symphysis with no IV or oral contrast administration.
Sagittal and coronal reformatted images were then obtained.

CT OF THE ABDOMEN WITHOUT IV CONTRAST: The visualized portion of
the lung bases demonstrate moderate bilateral pleural effusions.
Dependent atelectatic changes are also noted at both lung bases.
The visualized part of the heart and great vessels appear
normal. There are CT signs of anemia with relative increased
density of the septum compared to the intraventricular contents.

The liver, spleen, and the adrenal glands are normal. The
gallbladder demonstrates diffuse wall thickening. The kidneys
demonstrate normal appearance with no stone, mass, or
hydronephrosis. There is a 1.3 x 2.5 x 2.1 cm perinephric
hematoma around the left kidney. Small subcapsular hematoma is
also identified. The stomach, duodenum, loops of small bowel and
large bowel have normal appearance. No free or fluid is noted
within the abdomen.

CT OF THE PELVIS WITHOUT IV CONTRAST: The urinary bladder,
distal ureters, uterus and adnexa, and rectum and sigmoid colon
have normal appearance. Small amount of free fluid is noted
within the pelvis.

BONE WINDOWS: No concerning lytic or sclerotic lesion is
identified.

IMPRESSION:
1. Small perinephric hematoma measuring approximately 1.3 x 2.5
x 2.1 cm and tiny subcapsular hematoma. These are are not
uncommon after uncomplicated renal biopsy and do not explain the
patient's severe anemia.

2. Diffuse gallbladder wall thickening with no evidence of
cholecystitis.

3. Moderate bilateral pleural effusion and dependent atelectatic
changes at both lung bases.

4. Small amount of fluid is noted within the pelvis consistent
with ascites.

5. CT signs of anemia.
---------------
SPECIMEN SUBMITTED: Native renal biopsy.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2101-4-4**] [**2101-4-4**] [**2101-4-12**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/mrr??????



DIAGNOSIS:



Renal biopsy, needle: Cryoglobulinemic nephropathy, see note.



Note:

Light Microscopy: The specimen consists of renal cortex,
containing approximately 27 glomeruli, of which 4 are globally
sclerotic. The remainder show varying degrees of endocapillary
proliferation and double contour formation accompanied by
numerous PAS positive "hyalin thrombi". No cellular crescents
are noted. CD68 highlights many macrophages in the glomeruli.



There is mild interstitial fibrosis and tubular atrophy. Mild
chronic inflammation accompanies the scarring. Intact
tubulointerstitium shows minimal inflammation.



Arteries show mild intimal fibroplasia.

Arterioles show mild mural thickening, with some hyaline change.
Occasional arterioles show "hyalin thrombi", some with an
associated inflammatory vasculitis.



Immunofluorescence:  The specimen consists of renal cortex only,
containing approximately 8 glomeruli, of which 1 is globally
sclerotic. There is intraluminal "thrombus" and granular
peripheral capillary loop (and to a less extent mesangial)
staining for IgG (2+), IgA (1+), IgM (2+), C3 (3+), kappa (3+)
and lambda (1+). Vascular positivity is seen for IgM and fibrin,
but not IgG.  C1q is negative.

Albumin is non-contributory.



Electron microscopy:  Findings will be issued in an addendum.



Comment: The amount of "hyalin thrombi" present is striking.
Focal vasculitis is seen.

ELECTRON MICROSCOPY (C-4849):

Fine structural studies of three similar and representative
glomeruli reveal widespread foot process effacement. No
subepithelial deposits are noted. Endocapillary cellularity is
increased, and widespread mesangial interposition is noted.
Subendothelial/endocapillary/mesangial electron dense deposits
are easily identified, and most show cryoglobulin type
substructure. Only focal areas of subendothelial electron
lucency, in association with the cryoglobulin type deposits, are
seen. Many capillaries show prominent cryoglobulin "thrombi".
Rare fibrin tactoids are seen in association with the deposits.
No definite tubuloreticular structures are noted.

A vessel wall shows some granular deposition with a vague
substruture, as well as electron dense material suggestive of
hyalin.

These findings support the diagnosis of Cryoglobulinemic
nephropathy. The amount of deposition is striking.





Electron microscopy added by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**]/is??????
Date: [**2101-4-15**]

Clinical: Sjogren's syndrome. ARF; SCr=3.1. Positive
cryoglobulin and RF factor. Low C3 and C4. Hepatitis B and C
negative. [**Doctor First Name **] positive; dsDNA negative.
Gross:

     Received are needle core(s) of light brown tissue.  The
specimen is viewed in the dissecting microscope, identified as
renal by Dr. [**First Name4 (NamePattern1) 3535**] [**Last Name (NamePattern1) **], and divided into material for light
(formalin) and electron microscopy and immunofluorescence
studies.



PAS and [**Doctor Last Name **] stains were done to evaluate basement membranes -
Masson's trichrome stains were done to evaluate interstitial
fibrosis.


Brief Hospital Course:
The patient was transferred from [**Location (un) **] [**Location (un) 1459**] for critical
hyponatremia and acute renal failure. She was initially accepted
on the floor, and was then transferred to the MICU, where she
was started on hypertonic saline with slow correction of her
hyponatremia. Due to hyperkalemia, she was also started on
hemodialysis. She received a renal biopsy consistent with
cryoglobulinemia, and was started on plasmapheresis and high
dose steroids. She had a good response to therapy, limiting her
to only two runs of dialysis, and a short course of
plasmapheresis. She was subsequently maintained on prednisone
with resolution of her acute renal failure. After a discussion
between nephrology and the patient, she was started on rituximab
for her cryoglobulinemia rather than cyclophosphamide given her
prior treatment for her index presentation of cryoglobulinemia
several years ago and the risk of cumulative toxicity. She
received her first dose during this hospitalization, and is
scheduled for three additional doses over the next three weeks
as an outpatient. She was discharged with normal serum
creatinine, normal urine output, on prednisone, and appropriate
opportunistic infection prophylaxis.

Medications on Admission:
doxycycline- stopped
multivitamins
melatonin

Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
Disp:*120 Troche(s)* Refills:*0*
2. Calcium Carbonate-Vitamin D2 500-200 mg-unit Tablet Sig: One
(1) Tablet PO twice a day: Take between meals.
Disp:*60 Tablet(s)* Refills:*0*
3. Pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday): Take while on
prednisone.
Disp:*12 Tablet(s)* Refills:*0*
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*45 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Take while on
prednisone.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. Outpatient Lab Work
[**2101-4-19**] Draw CBC with differential, basic metabolic panel,
phosphorus, calcium. Please have results faxed to Dr. [**First Name (STitle) 4102**]
[**Name (STitle) 4090**] Office ([**Telephone/Fax (1) 817**], Fax ([**Telephone/Fax (1) 77460**].


Discharge Disposition:
Home

Discharge Diagnosis:
Cryoglobulinemia
Acute renal failure, resolved
Sjogren's disease
Anemia
Hyponatremia, resolved


Discharge Condition:
stable


Discharge Instructions:
You were admitted with cryoglobulinemia that resulted in kidney
damage.  You will need careful follow up with nephrology upon
discharge (see below).  Please call your PCP or return to the ER
if you develop any numbness, weakness, or coolness of your
extremities.

Followup Instructions:
You will receive a call from the nephrology fellow for a follow
up appointment.
Provider: [**Name Initial (NameIs) 455**] 4-HEM ONC 7F HEMATOLOGY/ONCOLOGY-7F
Date/Time:[**2101-4-21**] 10:00
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2101-5-4**] 3:00
{'Other paraproteinemias,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Anemia, unspecified,Sicca syndrome'}


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: hyponatremia, n/v

PRESENT ILLNESS: 48 y/o F with h/o sjogrens, cryoglobulinemia, transferred from
[**Location (un) **] [**Location (un) **] with hyponatremia to 112. Felt poorly for
several weeks feeling weak, tired. Started vomiting (non-bloody,
non-bilious) on wednesday with decreased apetite, nausea. No
associated headache, abdominal pain, diarrhea, or fevers.
However, also did have a non-productive cough with episode of
bronchitis 5 weeks ago. She reports no similar prior episodes
like this. Of note ,symptoms worsened after starting a trial of
doxcycline on wednesday. She stopped after one day due to the
N/V. No associated rash.

MEDICAL HISTORY: sjogren's disease
h/o cryoglobulinemia

MEDICATION ON ADMISSION: doxycycline- stopped
multivitamins
melatonin

ALLERGIES: Codeine

PHYSICAL EXAM: 98.3, BP 134/70, HR 79, RR 16, 94% RA, 134 lb
gen- awake, alert, pleasant, NAD
heent- dry eyes, mouth. + swollen 2-3 cm, non-tender salivary
glands b/l at angle of jaw b/l.
neck- supple. no add'l swollen glands/lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND, NABS, no bruits auscultated
ext- no rash, no edema, warm, 2+ pulses
neuro- alert and oriented x 3. CNII-XII intact. motor strength
full. normal sensation
skin- no hyperpigmentation, no jaundice
affect- normal

FAMILY HISTORY: no fh of auto-immune disease. brother with gout

SOCIAL HISTORY: denies tobacco, occ ETOH. no IVDU. denies HIV risk factors. no
tattoos. Works at a private high school. Irish descent, lives in
[**Location 246**] now. 

### Response:
{'Other paraproteinemias,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney,Anemia, unspecified,Sicca syndrome'}
