CHIEF COMPLAINT: Wegeners granulomatosis

PRESENT ILLNESS: 34 y/o M with PMHx of DM I who was recently admitted
[**Date range (3) 89453**] for work-up of anemia of unclear etiology. He
was found to have a hematocrit of 18.9 at his PCP's office.
During his admission he was noted to have eosinophilia,
coagulopathy, infiltrates and an anterior mediastinal mass. He
was seen by [**Location (un) 2274**] Hematology/Oncology, and [**Hospital1 18**] pulmonary and
thoracic surgery. He received two units of PRBCs and Hct at
discharge was 24.6. Haptoglobin was high. Bone marrow biopsy
showed bone marrow suppression and iron deficiency. He was
discharged with iron supplementation.

MEDICAL HISTORY: DM

MEDICATION ON ADMISSION: 1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 96 109/60 70 19 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, mild pallor
Neck: supple, JVP not elevated, no LAD
Lungs:  Mild crackles at BL Bases, otherwise clear
CV: tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No family history of blood disorders. Lung cancer in his father

SOCIAL HISTORY: Occasional EtOH. No tobacco or illicit drug use. Not currently
sexually active. Has always used condoms in previous sexual
relationships. No recent travel
Wegener's granulomatosis,Acute kidney failure, unspecified,Other specified forms of effusion, except tuberculous,Hemorrhage complicating a procedure,Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled,Other specified diseases of thymus gland,Iron deficiency anemia secondary to blood loss (chronic),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
Wegener's granulomatosis,Acute kidney failure NOS,Effusion NEC exc tb,Hemorrhage complic proc,DMI wo cmp uncntrld,Diseases of thymus NEC,Chr blood loss anemia,Abn react-procedure NEC,Accid in resident instit
Admission Date:  [**2153-4-12**]              Discharge Date:   [**2153-4-19**]

Date of Birth:  [**2118-4-14**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Wegeners granulomatosis

Major Surgical or Invasive Procedure:
CT guided biopsy
Chest tube placement and removal
Kidney biopsy


History of Present Illness:
34 y/o M with PMHx of DM I who was recently admitted
[**Date range (3) 89453**] for work-up of anemia of unclear etiology. He
was found to have a hematocrit of 18.9 at his PCP's office.
During his admission he was noted to have eosinophilia,
coagulopathy, infiltrates and an anterior mediastinal mass. He
was seen by [**Location (un) 2274**] Hematology/Oncology, and [**Hospital1 18**] pulmonary and
thoracic surgery. He received two units of PRBCs and Hct at
discharge was 24.6. Haptoglobin was high. Bone marrow biopsy
showed bone marrow suppression and iron deficiency. He was
discharged with iron supplementation.

His mediastinal mass felt to most likely be a thymoma, and would
tie together all of his other findings including anemia,
atypical pneumonia and recurrent sinus infections with
eosinophilia and coagulopathy. Notably, germ cell marker HCG
neg, AFP normal. He had a bronchoscopy with BAL which was
negative for pathogens (some still pending) or eosinophilic
predominance. He had an MRI of the chest which showed Round
heterogeneous lesion in the anterior mediastinum measuring 5.4 x
3.9 x 4.7 cm without appreciable loss of signal intensity on
out-of-phase imaging with mild enhancement. Findings are NOT
consistent with thymic hyperplasia. Diagnostic considerations
include thymoma versus lymphoma. Thoracic surgery decided no
biopsy should be performed as risk of seeding the surrounding
tissue if this is malignant. He was to follow up with them next
week for further management.

Incidentally during his work up, P-ANCA was preliminarily
positive and thought to be paraneoplastic, but they were
awaiting confirmatory results from [**Hospital1 2025**]. On [**2153-4-10**] the attg was
notified from the [**Hospital1 2025**] lab that the patient was strongly positive
for PR3-ANCA - which has prompted the current admission.

Patient had labs drawn yesterday and notably his Hct was 20.1,
wbc: 12.0
On the floor, patient denies complaints.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
DM


Social History:
Occasional EtOH. No tobacco or illicit drug use. Not currently
sexually active. Has always used condoms in previous sexual
relationships. No recent travel

Family History:
No family history of blood disorders. Lung cancer in his father

Physical Exam:
Vitals: 96 109/60 70 19 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, mild pallor
Neck: supple, JVP not elevated, no LAD
Lungs:  Mild crackles at BL Bases, otherwise clear
CV: tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Admission labs:
[**2153-4-12**] 08:00PM BLOOD WBC-11.6* RBC-2.44* Hgb-6.6* Hct-19.8*
MCV-81* MCH-27.1 MCHC-33.4 RDW-14.2 Plt Ct-440
[**2153-4-12**] 08:00PM BLOOD Neuts-76.3* Bands-0 Lymphs-9.3* Monos-3.8
Eos-10.3* Baso-0.3
[**2153-4-12**] 08:00PM BLOOD Hypochr-3+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
[**2153-4-12**] 08:00PM BLOOD Ret Man-4.8*
[**2153-4-13**] 05:45AM BLOOD Glucose-176* UreaN-21* Creat-1.2 Na-137
K-4.9 Cl-102 HCO3-28 AnGap-12
[**2153-4-12**] 08:00PM BLOOD LD(LDH)-138 TotBili-0.4
[**2153-4-13**] 05:45AM BLOOD Calcium-8.7 Phos-4.5 Mg-2.2
[**2153-4-12**] 08:00PM BLOOD Hapto-365*

[**2153-4-13**] 05:45AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2153-4-13**] 05:45AM BLOOD HCV Ab-NEGATIVE

UA   Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH
Leuks
[**4-13**]  LG   NEG     TR 	     NEG    NEG     NEG    NEG 	 5.0
NEG

MICROSCOPIC URINE RBC 	WBC 	Bacteri Yeast 	Epi 	
[**2153-4-13**] 10:53  18* 	4 	FEW 	NONE 	0 	
	
URINE CHEMISTRY 	Hours 	Creat 	TotProt 	Prot/Cr
[**2153-4-13**] 10:53   	RANDOM 	63     	38             	0.6*

Discharge labs:
[**2153-4-19**] 05:56AM BLOOD WBC-14.4* RBC-2.94* Hgb-7.7* Hct-23.9*
MCV-81* MCH-26.3* MCHC-32.4 RDW-13.7 Plt Ct-409
[**2153-4-19**] 05:56AM BLOOD Glucose-149* UreaN-29* Creat-1.1 Na-137
K-4.8 Cl-100 HCO3-30 AnGap-12

Pathology:
[**2153-4-17**] Renal biopsy:
DIAGNOSIS: Necrotizing extracapillary glomerulonephritis
consistent with the ANCA-associated vasculitic syndrome (see
note).

NOTE: Sections reveal fragments of renal parenchyma containing
approximately 33 glomeruli, one or two of which, depending on
the level, are globally sclerotic.  Glomerular necrotizing
lesions are noted associated with mild extracapillary
proliferation (very small crescent formation).  Mild
interstitial fibrosis and tubular atrophy are noted accompanied
by chronic inflammation. Of interest is the medullary thick
ascending limbs which show apoptotic/degenerative changes.
Endocapillary proliferation is minimal.  The small
arteries/arterioles show mild fibrotic changes.  Larger arteries
show intimal fibroplasia..

Immunofluorescence studies reveal 4 to 8 glomeruli to be present
depending on the level.  There is no staining with IgG or IgM.
Mesangial IgA (minimal), kappa light chain (trace), lambda light
chain (minimal), and C1q (minimal) are seen.  Trace C3 is noted
in tubular basement membranes and vessels.  In the fibrin
preparations, there is considerable ([**1-14**]+) segmental staining.
Albumin stains are non-contributory.

Electron microscopy studies will be sent as an addendum.  PAS
and silver  methenamine stains were done to evaluate basement
membranes.  Masson trichrome preparations were done to study
fibrotic changes.

Findings are those of a glomerulonephritis of the type
associated with the ANCA vasculitic syndromes. The thick
ascending limb changes have been reported as a result of drug
toxicity (Am J Kidney Dis 31:[**2153**]).

[**2153-4-13**] mediastinal mass cytology:
IMPRESSION: Technically successful aspiration of a predominantly
cystic
anterior mediastinal mass.
FNA, Anterior mediastinal mass:
NON-DIAGNOSTIC
Specimen consists of scattered macrophages.
Note: Please also refer to flow cytometry report

Imaging:
[**2153-4-16**] CXR:
Comparison chest radiographs dating between [**2153-4-4**] to
[**2153-4-15**].
FINDINGS: Tiny left apical pneumothorax has decreased in size
since the priorradiograph. Cardiomediastinal contours are
unchanged. Bilateral patchy
infrahilar opacities have slightly improved. Subtle ground-glass
opacities
are present and shown to better detail on recent CT scan.
	  	

Brief Hospital Course:
Mr. [**Known lastname 89454**] is a 34 year-old male with Type I DM and recent
complicated history and hospitalizations for a mediastinal mass
now thought to be a thymic cyst, vasculitis with DAH on BAL
thought to be Wegeners granulomatosis (also with renal
involvement confirmed on biopsy) whose course has been
complicated by pneumothorax s/p chest tube placement and removal
s/p high dose methylprednisolone and first dose of rituxan.

Active issues:
# Wegeners Granulomatosis:  The patient has both pulmonary and
renal manifestations of Wegeners.  He was found to have a high
titer positive for C-ANCA after extensive workup of iron
deficiency anemia on prior hospitalization.  He was treated with
IV solumedrol 1gm X 3days then transitioned to prednisone 40 mg
po bid.  As he did have a mediastinal mass, the concern was that
this may be lymphoma and steroids would partially treat,
obscuring a diagnosis.  A CT guided biopsy of the mass was
performed on [**2153-4-13**] which revealed it was cystic in nature, not
consistent with lymphoma.  He will require prolonged steroid
treatment so omeprazole, vit d, calcium and bactrim were added
for ppx.  Hepatitis serologies were negative and a PPD was
negative on [**4-9**].

After renal biopsy confirmed acute changes consistent with
Wegner's in the kidney, the rheumatology and renal consult teams
conferred and decided to treat him with rituxan (instead of
cytoxan) due to rituxan's more favorable side effect profile.
He was given his first rituxan infusion on [**4-19**] without
complication and will receive 3 more infusions over the next
month.

# Hyperglycemia/Type I diabetes:  The patient had worsening
control of blood sugars with high dose steroids.  Despite
uptitration of his insulin he remained hyperglycemic and was
transferred to the ICU for one day for insulin gtt titration.
His blood sugars decreased on increased lantus dosing (now at 35
qam and 30 qpm) and an increased humalog sliding scale.  [**Last Name (un) **]
had been consulted and educated the patient how to down titrate
his lantus dose when his steroid dose changes.  He will follow
up with his endocrinologist.

#  Anterior mediastinal mass:  Visualized on previous imaging.
Appears to be thymic cyst based on fluid aspirated.  Cytology
was nondiagnostic showing only macrophages.  Per discussion with
heme/onc, we cannot definitively rule out lymphoma, but that
they felt it is very unlikely to be lymphoma.  He was treated
with high-dose steroids without change in clinical status which
makes it even more unlikely this is lymphoma.  Their
recommendation is to repeat an MRI of his chest in 3 months.  He
does not currently need heme/onc follow up as this is unlikely
to be malignancy.

# Anemia:  Thought to be secondary to blood loss from likely DAH
from Wegeners.  His Hct dropped as low as 21, but then rose on
its own and was 23 by discharge.  He received one unit of PRBCs
during this hospitalization and was maintained on iron and vit c
supplementation.  He should have a Hct check during follow up to
ensure his anemia continues to improve.

#  Hemopneumothorax:  Complication of mediastinal biopsy.  The
patient was found to be more hypoxic on [**2153-4-14**], tachycardic and
with chest pain on the left.  Exam was significant for
hyperresonance.  CXR revealed large hemopneumothorax with mild
tension.  Thoracic surgery was consulted and chest tube placed.
The pneumothorax resolved within 24 hours and the chest tube was
removed.  Follow up CXR on [**4-16**] showed continued resolution.

# Leukocytosis:   Thought to be secondary to steroids. No
clinical evidence of infection.

Transition of care:
- Patient needs repeat chest MRI in 3 months (early [**2153-7-13**])
for follow up of the mediastinal mass.
- Patient will need continued titration of insulin dosing as his
steroid dose changes.
- Hct check to monitor anemia.
- Follow up has been arranged with his PCP, [**Name10 (NameIs) 10368**],
nephrologist, pulmonologist, and endocrinologist.

Medications on Admission:
1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units

Subcutaneous twice a day.
3. ferrous sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Insulin Sliding Scale
Please use attached Flowsheet for regimen

Discharge Medications:
1. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
2. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
3. prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: 35 units in the morning and
30 units at bedtime lantus Subcutaneous .
7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
8. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
9. Humalog 100 unit/mL Solution Sig: sliding scale humalog
Subcutaneous four times a day: See attached sliding scale.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnoses:
Wegeners granulomatosis
Thymic cyst
Hemopneumothorax

Secondary diagnoses:
Diabetes Type I
Anemia


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


Discharge Instructions:
You were admitted to [**Hospital1 18**] for treatment of Wegeners
Granulomatosis.  You were started on high dose steroids and
ultimately placed on 40 mg of prednisone twice daily.  The
rheumatologists decided to treat you adjunctively with rituxan
as this [**Doctor Last Name 360**] has fewer sided effects then the mainline
treatment for your condition.  You will need 3 more doses of
rituxan which the rheumatologists will arrange.

You had a biopsy of the mass in your chest which was found to be
a cyst.  You suffered a complication of this procedure which was
a pneumothorax (collapse of part of the lung).  A chest tube was
placed and then removed.  Cytology from the biopsy was
nondiagnostic.  Hematology/oncology had evaluated you during
your stay and felt that it was very unlikely that the mass in
your chest was a lymphoma or other cancer, but this has not been
definately ruled out.  You will need a repeat chest imaging in 3
months to check for any change in the mass/cyst.  We will
communicate with your primary doctor so he is aware of the need
for this repeat imaging.

It is important that you avoid non-steroidal anti-inflammatory
medications in the future (alleve, ibuprofen, ect).  You can use
tylenol as need for pain control.  Otherwise discuss other pain
medications with your primary doctor before using.

MEDICATION CHANGES:
INCREASE lantus to 35 units every morning and 30 units every
evening
USE NEW humalog sliding scale
Glucose          Mealtime Insulin Dose   Bedtime Insulin Dose
71-79  mg/dL          0     Units               0    Units
80-119  mg/dL         12    Units               0    Units
120-159 mg/dL         14    Units               0    Units
160-199 mg/dL         17    Units               0    Units
200-239 mg/dL         20    Units               3    Units
240-279 mg/dL         24    Units               5    Units
280-319 mg/dL         28    Units               9    Units
320-359 mg/dL         32    Units               13   Units
360-400 mg/dL         36    Units               16   Units

START Prednisone 40 mg twice daily
START Calcium and Vit D
START Bactrim daily
START Omeprazole 20 mg daily

Otherwise continue your outpatient medications as prescribed.

An endocrinologist from [**Last Name (un) **] helped manage your blood sugars
and recommends decreasing your lantus by 2 units each dose every
time your prednisone dose decreases by 5 mg.  You should also
contact your endocrinologist when your prednisone dose changes.

Followup Instructions:
Multiple follow up appointments were made for you to follow up
with your outpatient providers.  It is important that you keep
these appointments.

Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **]
Location: [**Location (un) 2274**]-[**Location (un) 2277**] Rheumatology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Wednesday [**2153-4-25**] 3:50pm

Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**] Primary Care
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
Appointment: Friday [**2153-4-27**] 2:00pm

Name: [**Last Name (LF) 6810**],[**Name8 (MD) 6811**] MD
Location: [**Hospital1 641**] Endocrinology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday [**2153-5-3**] 8:00am

Name: [**Last Name (LF) 3112**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital1 641**] Nephrology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Wednesday [**2153-5-9**] 3:40pm

Name: [**Last Name (LF) 9303**], [**Name8 (MD) **] MD
Location: [**Hospital1 641**] Pulmonary
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: [**2153-7-4**] 8:40am
Dr. [**Last Name (STitle) 9303**] is out of the office and this was the first
appointment available.  You should be called with a sooner
appointment when he returns.  If you don't hear from their
office within a week, please call to check if your appointment
has been moved.



Completed by:[**2153-4-19**]
{"Wegener's granulomatosis,Acute kidney failure, unspecified,Other specified forms of effusion, except tuberculous,Hemorrhage complicating a procedure,Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled,Other specified diseases of thymus gland,Iron deficiency anemia secondary to blood loss (chronic),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution"}


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: Wegeners granulomatosis

PRESENT ILLNESS: 34 y/o M with PMHx of DM I who was recently admitted
[**Date range (3) 89453**] for work-up of anemia of unclear etiology. He
was found to have a hematocrit of 18.9 at his PCP's office.
During his admission he was noted to have eosinophilia,
coagulopathy, infiltrates and an anterior mediastinal mass. He
was seen by [**Location (un) 2274**] Hematology/Oncology, and [**Hospital1 18**] pulmonary and
thoracic surgery. He received two units of PRBCs and Hct at
discharge was 24.6. Haptoglobin was high. Bone marrow biopsy
showed bone marrow suppression and iron deficiency. He was
discharged with iron supplementation.

MEDICAL HISTORY: DM

MEDICATION ON ADMISSION: 1. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 96 109/60 70 19 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, mild pallor
Neck: supple, JVP not elevated, no LAD
Lungs:  Mild crackles at BL Bases, otherwise clear
CV: tachycardic regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No family history of blood disorders. Lung cancer in his father

SOCIAL HISTORY: Occasional EtOH. No tobacco or illicit drug use. Not currently
sexually active. Has always used condoms in previous sexual
relationships. No recent travel 

### Response:
{"Wegener's granulomatosis,Acute kidney failure, unspecified,Other specified forms of effusion, except tuberculous,Hemorrhage complicating a procedure,Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled,Other specified diseases of thymus gland,Iron deficiency anemia secondary to blood loss (chronic),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution"}
