CHIEF COMPLAINT: Acute mastocytosis flare

PRESENT ILLNESS: The patient is a 28 yo WF with known history of systemic
mastocytosis with intermittent flares in the past who presented
to ED with an acute episode of flushing, tachycardia, nausea,
and vomiting.  The patient has had  several prior
hospitalizations, most recently [**10-6**], for mastocytosis. The
patient stated that 3 days ago she began to notice increasing
flushing with palpitations and generalized pruritus. She took
P.O. Prednisone at home with some improvement in her symptoms
the following day. A day later, however, these aforementioned
symptoms returned along with nausea and she decided to go to ED.
 No recent clear precipitants. She denies fevers, sick contacts
but has been traveling more recently.

MEDICAL HISTORY: Systemic mastocytosis
Anemia
Thumb surgery
Tonsillectomy

MEDICATION ON ADMISSION: Cetirizine 10mg PO BID
Cromolyn 20mg/mL solution, 10mL PO QID
Doxepin 50mg PO QAM and 100mg PO QPM
EpiPen prn
NuvaRing
Hydroxyzine 30mg PO TID
Ativan 0.5mg PO PRN anxiety
Singulair 10mg PO Qdaily
Prednisone 50mg Qdaily X7 days PRN mastocytosis flare
Ranitidine 150mg PO BID
Ferrous sulfate 325mg PO BID

ALLERGIES: Aspirin / Iodine / Nsaids / Opioid Analgesics

PHYSICAL EXAM: Gen: patient's skin diffusely flushed, visibly distressed with
wretching, nausea and vomiting
HEENT: conjunctiva well perfused, PERRL, EOMI, dry MM, OP clear,
no signs of angioedema
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: tachycardic. S1/S2 regular, no murmurs, rubs or gallops
noted
LUNGS: CTA B/L, no inspiratory or expiratory stridor or
accessory muscle use
ABD: NT/ND, normoactive BS throughout
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse body flushing, more erythematous patches over R
side of face
NEURO: AAOx3, slightly somnolent but able to follow commands and
respond to questions appropriately
.

FAMILY HISTORY: Father alive and in good health, mother has MS. [**Name13 (STitle) **] family h/o
allergic, rheumatologic, or autoimmune diseases. Grandfather
with CAD, colon CA and grandmother with skin CA.

SOCIAL HISTORY: Patient employed as a librarian. Honorably discharged from air
force in [**2139**] due to her recurrent mastocytosis flares and
hospitalizations.
Married, no children. Does not smoke or use drugs, social
drinker.
Malignant mast cell tumors, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Hypotension, unspecified,Hypoxemia,Anemia, unspecified
Mlg mast unsp xtrndl org,Gastrointest hemorr NOS,Hypotension NOS,Hypoxemia,Anemia NOS
Admission Date:  [**2142-7-25**]              Discharge Date:   [**2142-7-29**]

Date of Birth:  [**2114-5-11**]             Sex:   F

Service: MEDICINE

Allergies:
Aspirin / Iodine / Nsaids / Opioid Analgesics

Attending:[**First Name3 (LF) 5806**]
Chief Complaint:
Acute mastocytosis flare

Major Surgical or Invasive Procedure:
Right femoral line and peripheral IVs placed, NGT placement
attempted

History of Present Illness:
The patient is a 28 yo WF with known history of systemic
mastocytosis with intermittent flares in the past who presented
to ED with an acute episode of flushing, tachycardia, nausea,
and vomiting.  The patient has had  several prior
hospitalizations, most recently [**10-6**], for mastocytosis. The
patient stated that 3 days ago she began to notice increasing
flushing with palpitations and generalized pruritus. She took
P.O. Prednisone at home with some improvement in her symptoms
the following day. A day later, however, these aforementioned
symptoms returned along with nausea and she decided to go to ED.
 No recent clear precipitants. She denies fevers, sick contacts
but has been traveling more recently.

In the ED, the patient was afebrile, HR in 150s with EKG showing
sinus tachycardia. She was given IV Solumedrol 125 mg, Phenergan
25 mg IV X 2, and Ativan 1 mg IV X 3, Zofran 4 mg IV X 2,
Benadryl 50 mg IV X 2, Tylenol 650 mg po X 1, and 3L IVFs before
admission.

Upon arrival to the medical inpatient floor, the patient's
status declined and she developed HR 160-170s, SBP 80s, and
worsening nausea and vomiting. Pt had poor access.  Patient was
then transferred to the MICU. n MICU, attempted multiple times
to obtain U/S guided PIV, then placed R femoral TLC as patient
unable to reliably lie flat for IJ or SCV line due to wretching,
nausea and vomiting. Patient had multiple episodes of coffee
ground emesis. NGT placement was attempted several times without
success. Aggressive IVF resusitation continued. Two hours later,
the patient desaturated down to upper 60s despite 100% face
tent. Clinically, however, the patient was not cyanotic or
experiencing labored breaths. Corresponding ABG of
7.51/32/143/26 confirmed a healthy PaO2 level. CXR was
unremakable for any acute cardiopulmonary pathology. Given PaO2
and clinical picture of patent airway without wheezes or clear
distress the team decided not to intubate patient. It was felt
that the patient was protected her airway appropriately despite
aspiration risks given multiple episodes of vomiting. GI
consulted for coffee ground emesis. Most likely etiology for
emesis was persistent wretching on the day of admission.  Given
that the pt's HCT stabilized and no further episodes of emesis
occurred it was felt that GI f/u could be obtained as an
outpatient.

Pt was transferred to the floor from the MICU after being seen
by her allergist Dr. [**Last Name (STitle) 2603**].


Past Medical History:
Systemic mastocytosis
Anemia
Thumb surgery
Tonsillectomy


Social History:
Patient employed as a librarian. Honorably discharged from air
force in [**2139**] due to her recurrent mastocytosis flares and
hospitalizations.
Married, no children. Does not smoke or use drugs, social
drinker.

Family History:
Father alive and in good health, mother has MS. [**Name13 (STitle) **] family h/o
allergic, rheumatologic, or autoimmune diseases. Grandfather
with CAD, colon CA and grandmother with skin CA.

Physical Exam:
Gen: patient's skin diffusely flushed, visibly distressed with
wretching, nausea and vomiting
HEENT: conjunctiva well perfused, PERRL, EOMI, dry MM, OP clear,
no signs of angioedema
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: tachycardic. S1/S2 regular, no murmurs, rubs or gallops
noted
LUNGS: CTA B/L, no inspiratory or expiratory stridor or
accessory muscle use
ABD: NT/ND, normoactive BS throughout
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse body flushing, more erythematous patches over R
side of face
NEURO: AAOx3, slightly somnolent but able to follow commands and
respond to questions appropriately
.

Pertinent Results:
Admission Labs on [**2142-7-25**] included :

ABG of 7.51/32/143/26

CHEM 10: GLUCOSE-161* BUN 15, Cr 1.1, NA-149* POTASSIUM-3.2*
CHLORIDE-108, CALCIUM-9.3 PHOSPHATE-3.0 MAGNESIUM-1.7
TOTAL CO2-24
ANION GAP: 20
LACTATE: 5.3*
UA: -negative
CBC: WBC-29.8*# RBC-3.87* HGB-11.0* HCT-30.8* MCV-80* MCH-28.4
MCHC-35.7*,  PLT COUNT-430, RDW-14.3
Coag values:  PT-13.7* PTT-25.4 INR(PT)-1.2*
ASt/ALT/AP were 16/9/85 respectively


[**2142-7-27**] Labs

WBC 13.4, RBC 3.32*, Hgb 9.7*, Hct 28.0*,  MCV 84, MCH 29.3,MCHC
34.8,
RDW 14.2, and Plt 281

Differential for WBCs 	89.9*N/	9.1*L/0.8*M
Glucose	127, BUN 19, Cr	1.0, Na 141, K 4.3, Cl 107, Bicarb 26
Anion Gap =12

[**2142-7-28**] 07:22AM BLOOD WBC-12.6* RBC-3.57* Hgb-10.3* Hct-30.1*
MCV-84 MCH-28.8 MCHC-34.1 RDW-14.4 Plt Ct-308
[**2142-7-28**] 07:22AM BLOOD Plt Ct-308
[**2142-7-28**] 07:22AM BLOOD Glucose-87 UreaN-20 Creat-0.9 Na-142
K-4.0 Cl-107 HCO3-27 AnGap-12
[**2142-7-28**] 07:22AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.4

[**2142-7-29**] 06:39AM BLOOD WBC-10.5 RBC-3.72* Hgb-10.7* Hct-31.3*
MCV-84 MCH-28.8 MCHC-34.2 RDW-14.3 Plt Ct-294
[**2142-7-29**] 06:39AM BLOOD Plt Ct-294
[**2142-7-29**] 06:39AM BLOOD Glucose-88 UreaN-19 Creat-0.9 Na-140
K-3.6 Cl-105 HCO3-26 AnGap-13

Brief Hospital Course:
The patient initially presented with acute hypotension,
tachycardia and severe flushing, nausea/vomiting related to a
systemic mastocytosis attack.

Hypotension: Patient's initial ED SBP of 80s-90s resolved s/p
aggressive IVFs and lactate levels decreased. By hospital day 2
the patient's blood pressures ranged between 110-130/60-80s and
IVFs were discontinued and PO diet was initiated. Patient
advised to maintain appropriate hydration.

Systemic mastocytosis: The patient's acute episode was
stabilized with the help of the allergy team's recommendations
which included IV Solumedrol, Cromolyn and IV Benadryl. A
tryptase level was also ordered to assess severity of flare.
Once patient stabilized IV Solumedrol 125 mg IV q12h was
discontinued and prior home regimen of oral Prednisone 50mg was
started. Daily Benadryl and Cromolyn were continued and patient
supplemented with additional hydralazine prn.  She was monitored
for any swelling of the airway and EKG changes.
The patient will restart home meds of Singulair, Zyrtec,
Gastrocrom, and Doxepin on discharge home. Although patient
denies any illness, blood and urine cultures were sent to rule
out any underlying triggers for mastocytosis exacerbation.

Hypoxia: During acute phase of mastocytosis exacerbation
desaturated to 60s on high flow face tent but PaO2 on ABG much
more reassuring with levels >100. Furthermore, patient was
without any signs of acute respiratory distress;no lung
crackles/wheezes, no SOB, non-elevated JVD on PE. After acute
attack controlled the patient was consistently >95% on low flow
O2 via NC and then RA.

Hallucinations and Agitation: After 2 days in hospital on high
dose Solumedrol the patient experienced hallucinations and overt
agitation most likely [**3-3**] high Solumedrol levels and perhaps
complicated further by high Diphenhydramine amounts as well. She
was given Ativan PRN orders and Solumedrol switched to lower
Prednisone 50mg dose. Patient's mood/emotionality seemed to
stabilize after these changes.

GI bleed: Initially had multiple episodes of coffee ground
emesis which abated by day 2. Patient appears well-perfused and
hemodynamically stable despite her anemia history and dilutional
drop in Hgb/Hct values s/p aggressive IVF resuscitation.
Followed Hcts/CBCs and agreed on transfusion cutoff for Hct < 21
but patient's values improved. Continued IV PPI q12h.  GI was
consulted due to episodes of bloody, "coffee ground" emesis on
admission and agreed to follow patient with urgent EGD if she
showed signs of active bleeding but otherwise felt elective EGD
once she is out of the ICU would be a reasonable approach to
explore etiology once patient more stable. Initially the patient
was double covered with H2B and PPIs due to aspiration risks as
per GI advice but was later switched to [**Hospital1 **] PPIs alongside
Phenergen and Zofran antiemetics.

Femoral/Groin pain- patient had a right femoral line placed for
emergent access during acute episode as she was writhing and
unable to be safely positioned for a central line. After femoral
line was removed on day 2 patient c/o pain at removal site of
Right Femoral line and was given PO Tylenol for pain. No active
bleeding noted after pressure held for >20mins. On PE, femoral,
popliteal and pedal pulses all in tact. Hematoma noted at site
and dressed and monitored daily for any changes.
.
Leukocytosis: Rise in WBC likely due to demargination after
recent solumedrol loads as well as underlying mastocytosis
insult. Patient remained afebrile throughout her stay and blood
and urine cultures were sent.
.
FEN: Advanced to PO diet and tolerated well by day 2. No current
signs of active nausea, vomiting or UGI/LGI bleeding. Team
repleted electrolytes as needed and  Zofran and Phenergan given
for N/V.

PPx: Pneumoboots given for DVT prophylaxis and heparin SC held
given GI bleed setting, PPIs given for GI PPx

Access: patient had right femoral line in place with PIV during
her stay

Code: Full Code status


Medications on Admission:
Cetirizine 10mg PO BID
Cromolyn 20mg/mL solution, 10mL PO QID
Doxepin 50mg PO QAM and 100mg PO QPM
EpiPen prn
NuvaRing
Hydroxyzine 30mg PO TID
Ativan 0.5mg PO PRN anxiety
Singulair 10mg PO Qdaily
Prednisone 50mg Qdaily X7 days PRN mastocytosis flare
Ranitidine 150mg PO BID
Ferrous sulfate 325mg PO BID

Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for anxiety.
2. Cetirizine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Cromolyn 100 mg/5 mL Solution Sig: Ten (10) ML PO QID (4
times a day).
4. Doxepin 25 mg Capsule Sig: Two (2) Capsule PO QAM (once a day
(in the morning)).
5. Doxepin 25 mg Capsule Sig: Four (4) Capsule PO QPM (once a
day (in the evening)).
6. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) injection
Intramuscular once as needed for acute mastocytosis flare.
7. Hydroxyzine HCl 10 mg Tablet Sig: Three (3) Tablet PO three
times a day as needed.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
11. Prednisone 10 mg Tablet Sig: see instructions Tablet PO see
instructions for 12 days: Please see instructions on attached
sheet.
Disp:*41 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Acute flare of systemic mastocytosis
Hypotension
Gastrointestinal bleed
Hypoxia
Delirium

Discharge Condition:
Stable.


Discharge Instructions:
You were treated for an acute flare of your systemic
mastocytosis.  When you first arrived you needed to be treated
in the intensive care unit because your blood pressure was too
low.  You were treated with steroids and other anti-inflammatory
medications that your allergist recommended.  You also had a
minor GI bleed while in the intensive care unit.  It was
determined that you could follow-up as an outpatient with GI.

Your medications from home were not changed, however you will
need to take the steroid taper which you were prescribed.
Appropriate instructions are written below:
Take 5 tablets (50mg) once a day until [**8-2**].

On [**8-2**] start taking 4 tablets (40mg) once a day until [**8-5**].

On [**8-5**] take 2 tablets (20mg) once a day until [**8-8**].

On [**8-8**] take one tablet (10mg) once a day for a total of
three days.

You should call your doctor or return to the ED if your symptoms
worsen or you experience chest pain, shortness of breath,
lightheadedness or any other concerning symptoms.

You should follow-up with Dr. [**Last Name (STitle) 2603**] in [**1-31**] weeks.
You should follow-up with your PCP [**Last Name (NamePattern4) **] [**1-31**] weeks.
You should follow-up with GI in [**1-31**] weeks.

Followup Instructions:
Please follow-up with your PCP in [**Name Initial (PRE) **] couple of weeks.  You will
need to call to schedule an appointment. ([**Telephone/Fax (1) 59411**]

Please follow-up with your allergist Dr. [**Last Name (STitle) 2603**] in [**1-31**] weeks.
You will need to call to schedule an appointment. ([**Telephone/Fax (1) 44274**]

Please follow-up with the [**Hospital **] clinic in [**1-31**] weeks.  You will need
to call to schedule an appointment ([**Telephone/Fax (1) 2744**]



Completed by:[**2142-7-29**]
{'Malignant mast cell tumors, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Hypotension, unspecified,Hypoxemia,Anemia, 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: Acute mastocytosis flare

PRESENT ILLNESS: The patient is a 28 yo WF with known history of systemic
mastocytosis with intermittent flares in the past who presented
to ED with an acute episode of flushing, tachycardia, nausea,
and vomiting.  The patient has had  several prior
hospitalizations, most recently [**10-6**], for mastocytosis. The
patient stated that 3 days ago she began to notice increasing
flushing with palpitations and generalized pruritus. She took
P.O. Prednisone at home with some improvement in her symptoms
the following day. A day later, however, these aforementioned
symptoms returned along with nausea and she decided to go to ED.
 No recent clear precipitants. She denies fevers, sick contacts
but has been traveling more recently.

MEDICAL HISTORY: Systemic mastocytosis
Anemia
Thumb surgery
Tonsillectomy

MEDICATION ON ADMISSION: Cetirizine 10mg PO BID
Cromolyn 20mg/mL solution, 10mL PO QID
Doxepin 50mg PO QAM and 100mg PO QPM
EpiPen prn
NuvaRing
Hydroxyzine 30mg PO TID
Ativan 0.5mg PO PRN anxiety
Singulair 10mg PO Qdaily
Prednisone 50mg Qdaily X7 days PRN mastocytosis flare
Ranitidine 150mg PO BID
Ferrous sulfate 325mg PO BID

ALLERGIES: Aspirin / Iodine / Nsaids / Opioid Analgesics

PHYSICAL EXAM: Gen: patient's skin diffusely flushed, visibly distressed with
wretching, nausea and vomiting
HEENT: conjunctiva well perfused, PERRL, EOMI, dry MM, OP clear,
no signs of angioedema
NECK: Supple, No LAD, No JVD. No thyromegaly.
CV: tachycardic. S1/S2 regular, no murmurs, rubs or gallops
noted
LUNGS: CTA B/L, no inspiratory or expiratory stridor or
accessory muscle use
ABD: NT/ND, normoactive BS throughout
EXT: WWP, NO CCE. 2+ DP pulses BL
SKIN: diffuse body flushing, more erythematous patches over R
side of face
NEURO: AAOx3, slightly somnolent but able to follow commands and
respond to questions appropriately
.

FAMILY HISTORY: Father alive and in good health, mother has MS. [**Name13 (STitle) **] family h/o
allergic, rheumatologic, or autoimmune diseases. Grandfather
with CAD, colon CA and grandmother with skin CA.

SOCIAL HISTORY: Patient employed as a librarian. Honorably discharged from air
force in [**2139**] due to her recurrent mastocytosis flares and
hospitalizations.
Married, no children. Does not smoke or use drugs, social
drinker. 

### Response:
{'Malignant mast cell tumors, unspecified site, extranodal and solid organ sites,Hemorrhage of gastrointestinal tract, unspecified,Hypotension, unspecified,Hypoxemia,Anemia, unspecified'}
