CHIEF COMPLAINT: New leukemia

PRESENT ILLNESS: This is a 66 year old woman with minimal past medical history
who is presenting to the ED for a WBC count of 600 on outpatient
labs. Symptoms began intermittently over the last year as she
has noticed a worsening sensation of fullness in abdomen along
with bloating and gas. Approximately three weeks ago she started
having a red spot in her right eye. She went to see an
outpatient opthalmologist who suggested a basic outpatient
workup. Labs drawn the week prior to admission revealed a WBC of
600 and sent her for an outpatient hematology consult who upon
seeing her WBC count sent her to the ED (didn't actually see her
yet). Of note, the red spot she was seeing has resolved and now
she just has what she thinks is blury vision in both eyes.

MEDICAL HISTORY: hypertension
hyperglycemia, hgbA1c 7.1 - no prior h/ DM
s/p finger surgery
s/p skin biopsy

MEDICATION ON ADMISSION: HCTZ 12.5mg
enalapril 5mg or 10mg (she is unsure)
calcium

ALLERGIES: Tetracycline

PHYSICAL EXAM: Admission Physical Exam:
VS: 144/80 85 RR 18 95%/ra
General: well, NAD
HEENT: MMM, PERRLA, EOMI, no jaundice, sclera normal
Neck: supple
Heart: RRR no R/G/M
Lungs: clear
Abdomen: soft, nontender, +bs, splenomegaly extending down to
umbilicus
Extremities: no edema, 2+ distal pulses
Neuro: CN2-12 intact, strength and sensation intact across upper
and lower extremities

FAMILY HISTORY: no known leukemia, lymphoma or cancer; father with CVA, [**1-22**]
sister with DM; does not know maternal history; 2 healthy sons
and one healthy gransdson

SOCIAL HISTORY: Lives with her son. [**Name (NI) 1403**] with adults with disabilities. Two
sons both in the area.
Chronic lymphoid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Background retinopathy, unspecified,Unspecified essential hypertension
Ch lym leuk wo achv rmsn,Thrombocytopenia NOS,Anemia in neoplastic dis,DMII wo cmp nt st uncntr,Backgrnd retinopathy NOS,Hypertension NOS
Admission Date:  [**2170-5-15**]              Discharge Date:   [**2170-5-20**]

Date of Birth:  [**2103-12-21**]             Sex:   F

Service: MEDICINE

Allergies:
Tetracycline

Attending:[**First Name3 (LF) 3233**]
Chief Complaint:
New leukemia


Major Surgical or Invasive Procedure:
Bone marrow biopsy - [**2170-5-16**]

History of Present Illness:
This is a 66 year old woman with minimal past medical history
who is presenting to the ED for a WBC count of 600 on outpatient
labs. Symptoms began intermittently over the last year as she
has noticed a worsening sensation of fullness in abdomen along
with bloating and gas. Approximately three weeks ago she started
having a red spot in her right eye. She went to see an
outpatient opthalmologist who suggested a basic outpatient
workup. Labs drawn the week prior to admission revealed a WBC of
600 and sent her for an outpatient hematology consult who upon
seeing her WBC count sent her to the ED (didn't actually see her
yet). Of note, the red spot she was seeing has resolved and now
she just has what she thinks is blury vision in both eyes.

On arrival to the ED initial VS were 98.4 87 157/69 18 99/ra.
She was initially denying any complaints, but then reported some
abdominal pain with turning to side. Noncon head CT was
negative. Smear suggestive of CLL vs CML vs blast crisis or
acute leukemia. Admitted to [**Hospital Unit Name 153**] for initiation of pheresis and
hydrea. Per discussion with pheresis attending and pheresis
nurse OK to pherese via periphals.

Of note she reports three episodes of pneumonia over the last
few months. No current cough, fevers or SOB.

ROS:
Positive per HPI
No fever, chills, night sweats. No unintentional weight loss
however has intentionally lost 10 pounds per year for each of
the last 3 years. No specific abdominal pain, nausea, vomiting,
diarrhea. Denies current floaters, scotoma, other visual changes

Past Medical History:
hypertension
hyperglycemia, hgbA1c 7.1 - no prior h/ DM
s/p finger surgery
s/p skin biopsy


Social History:
Lives with her son. [**Name (NI) 1403**] with adults with disabilities. Two
sons both in the area.

Family History:
no known leukemia, lymphoma or cancer; father with CVA, [**1-22**]
sister with DM; does not know maternal history; 2 healthy sons
and one healthy gransdson

Physical Exam:
Admission Physical Exam:
VS: 144/80 85 RR 18 95%/ra
General: well, NAD
HEENT: MMM, PERRLA, EOMI, no jaundice, sclera normal
Neck: supple
Heart: RRR no R/G/M
Lungs: clear
Abdomen: soft, nontender, +bs, splenomegaly extending down to
umbilicus
Extremities: no edema, 2+ distal pulses
Neuro: CN2-12 intact, strength and sensation intact across upper
and lower extremities

Discharge Physical Exam:
No significant change

Pertinent Results:
Admission Labs [**2170-5-15**] 08:40PM:
WBC-385.9* RBC-3.47* Hgb-9.0* Hct-27.0* MCV-84 MCH-25.7*
MCHC-30.7* RDW-16.1* Plt Ct-125*
Neuts-2* Bands-0 Lymphs-87* Monos-1* Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0 Blasts-0 Other-10*
PT-12.3 PTT-30.7 INR(PT)-1.1
Glucose-162* UreaN-17 Creat-0.7 Na-140 K-3.9 Cl-104 HCO3-27
AnGap-13
ALT-16 AST-45* LD(LDH)-503* AlkPhos-175* TotBili-0.4
Albumin-4.7 Calcium-9.0 Phos-4.0 Mg-2.3 UricAcd-6.7* Iron-52
calTIBC-391 Ferritn-88 TRF-301
IgG-934 IgA-49* IgM-83

CT head without contrast [**2170-5-15**]:  No evidence of acute
intracranial process. Prominent lymph nodes, partially imaged,
for which clinical correlation is recommended.

CXR AP [**2170-5-15**]:  Minimal linear opacity in the left lower lung
is likely
atelectasis. No other opacities worrisome for pneumonia.

CXR PA/Lateral [**2170-5-16**]:  The heart size is stable. No new
opacities are seen. Bibasilar atelectasis as well as additional
streaks of linear atelectasis in the left mid lung are
unchanged. No pleural effusion or pneumothorax. The study and
the report were reviewed by the staff radiologist.

CT CHEST W/O CONTRAST; CT ABD & PELVIS W/O CONTRAST
1. Axillary, mesenteric, retroperitoneal, and pelvic
lymphadenopathy.
2. Splenomegaly to 26 cm.

CT NECK W/O CONTRAST (EG: PAROTIDS) [**2170-5-17**] 4:17 PM
Diffuse cervical lymphadenopathy involving all stations and
bilateral axillary lymphadenopathy is consistent with lymphoma.

DISCHARGE LABS:
[**2170-5-20**] 12:00AM BLOOD WBC-378* RBC-2.91* Hgb-7.3* Hct-25.5*
MCV-88 MCH-25.1* MCHC-28.6* RDW-16.8* Plt Ct-97*
[**2170-5-20**] 12:00AM BLOOD Neuts-10* Bands-0 Lymphs-90* Monos-0*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2170-5-20**] 12:00AM BLOOD PT-12.0 PTT-27.0 INR(PT)-1.1
[**2170-5-20**] 12:00AM BLOOD Fibrino-171*
[**2170-5-20**] 12:00AM BLOOD Glucose-277* UreaN-17 Creat-0.7 Na-141
K-4.3 Cl-106 HCO3-27 AnGap-12
[**2170-5-20**] 12:00AM BLOOD ALT-15 AST-18 LD(LDH)-266* AlkPhos-146*
TotBili-0.5
[**2170-5-20**] 12:00AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.4 UricAcd-3.7
[**2170-5-17**] 05:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2170-5-17**] 05:10PM BLOOD HIV Ab-NEGATIVE
[**2170-5-17**] 05:10PM BLOOD HCV Ab-NEGATIVE

Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION
This is a 66 year old woman with newly diagnosed CLL; admission
complicated by leukostasis with vision changes.

ACTIVE PROBLEMS
# Leukemia with Leukostasis: The patient was sent to the
emergency department for vision changes associated with a WBC of
600k.  On admission, she was found to have blurry vision, and
was transferred to the ICU for leukophoresis for presumed
leukostasis retinopathy (later confirmed by ophthalmology - see
below).  She underwent bone marrow biopsy that showed CLL
(CD5+,CD19+,CD20+DIM,CD10-,CD38+).  While awaiting results of
the bone marrow biopsy, the patient was started on hydoxyurea.
She was also started on allopurinol for prophylaxis. She
underwent her first cycle of IV bendamustine while in house
without signficant side effects. Tumor lysis labs remained
stable.

# Visual Changes: Red spot in right eye 3 weeks prior to
admission suggestive of a retinal hemorrhage which has now
resolved. On admission, she reported ongoing blurry vision
bilaterally which she thinks is improving. She underwent
leukophoresis for presumed leukostasis retinopathy, as above.
She was seen by ophthalmology of following leukophoresis, and
was noted to have continued evidence of leukostasis retinopathy.
 She was treated with hydroxyurea and prednisone before
ultimately starting her first cycle of bendamustine.

# Anemia and thrombocytopenia: Likely related to CLL. HCT
remained between 24 and 30 during admission, with overall slight
down trend. In preparation for discharge, patient received 1
unit pRBC day of discharge. She should continue to have frequent
monitoring of blood counts as an outpatient.

# HTN: On HCTZ and ACEi at home. Antihypertensives were held
while in house. She SBP's noted to run in 140's while off
medications. She was restarted on home regimen on discharge.

# DMII: Per patient was being worked up for diabetes, per record
appears last A1c was 7.1. Not on outpatient meds.  The patient
was started on QAHCS with HISS.  With initiation of prednisone
for leukostasis retinopathy, she began to require insulin
sliding scale. She was not discharged on diabetic medication,
and this should be followed up as an outpatient.

TRANSITIONAL ISSUES
- Monitor blood sugar and consider initation of blood sugar
lowering agents
- Continue to monitor blood counts as outpatient
- Complete treatment course of rituxan/bendamustine as per
outpatient recommendations

Medications on Admission:
HCTZ 12.5mg
enalapril 5mg or 10mg (she is unsure)
calcium

Discharge Medications:
1. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
2. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO once a
day.


Discharge Disposition:
Home

Discharge Diagnosis:
Dear Ms [**Known lastname 110448**],
during this admission you have been diagnosed with a condition
called Chronic Lymphocytic Leukemia (CLL), you have received
treatment with a chemotherapy called bendamustine on day [**5-18**]
and [**5-19**].


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


Discharge Instructions:
You can resume your home medications (hydrochlorthiazide and
enalapril at the previous dose).
.
You will need to see your hematologist Dr [**Last Name (STitle) 110449**] [**Name (STitle) **] on
Tuesday [**5-22**], we could not schedule an appointment today. Please
call [**Telephone/Fax (1) 8809**] on Monday [**5-21**] to schedule the follow up
appointment.

Followup Instructions:
You will need to see your hematologist Dr [**Last Name (STitle) 110449**] [**Name (STitle) **] on
Tuesday [**5-22**], we could not schedule your appointment today.
Please call [**Telephone/Fax (1) 8809**] on Monday [**5-21**] to schedule the follow
up appointment.
{'Chronic lymphoid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Background retinopathy, unspecified,Unspecified essential hypertension'}


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: New leukemia

PRESENT ILLNESS: This is a 66 year old woman with minimal past medical history
who is presenting to the ED for a WBC count of 600 on outpatient
labs. Symptoms began intermittently over the last year as she
has noticed a worsening sensation of fullness in abdomen along
with bloating and gas. Approximately three weeks ago she started
having a red spot in her right eye. She went to see an
outpatient opthalmologist who suggested a basic outpatient
workup. Labs drawn the week prior to admission revealed a WBC of
600 and sent her for an outpatient hematology consult who upon
seeing her WBC count sent her to the ED (didn't actually see her
yet). Of note, the red spot she was seeing has resolved and now
she just has what she thinks is blury vision in both eyes.

MEDICAL HISTORY: hypertension
hyperglycemia, hgbA1c 7.1 - no prior h/ DM
s/p finger surgery
s/p skin biopsy

MEDICATION ON ADMISSION: HCTZ 12.5mg
enalapril 5mg or 10mg (she is unsure)
calcium

ALLERGIES: Tetracycline

PHYSICAL EXAM: Admission Physical Exam:
VS: 144/80 85 RR 18 95%/ra
General: well, NAD
HEENT: MMM, PERRLA, EOMI, no jaundice, sclera normal
Neck: supple
Heart: RRR no R/G/M
Lungs: clear
Abdomen: soft, nontender, +bs, splenomegaly extending down to
umbilicus
Extremities: no edema, 2+ distal pulses
Neuro: CN2-12 intact, strength and sensation intact across upper
and lower extremities

FAMILY HISTORY: no known leukemia, lymphoma or cancer; father with CVA, [**1-22**]
sister with DM; does not know maternal history; 2 healthy sons
and one healthy gransdson

SOCIAL HISTORY: Lives with her son. [**Name (NI) 1403**] with adults with disabilities. Two
sons both in the area. 

### Response:
{'Chronic lymphoid leukemia, without mention of having achieved remission,Thrombocytopenia, unspecified,Anemia in neoplastic disease,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Background retinopathy, unspecified,Unspecified essential hypertension'}
