CHIEF COMPLAINT: acute leukemia

PRESENT ILLNESS: 54 yo F with h/o anxiety presents with new onset leukemia.  For
the past 4-6 weeks, she has been experiencing SOB and increasing
bruising and went to her PCP who referred her to the emergency
department for anemia with Hgb of 7.0, Hct 19, platelets of 6,
WBC 10.7.  In the ER, smear showed blasts and sample was sent
for flow cytometry.  She was admitted to BMT floor for diagnosis
and treatment of new onset leukemia.

MEDICAL HISTORY: Anxiety
Depression

MEDICATION ON ADMISSION: ativan 1 mg [**Hospital1 **]
paroxetine 30 mg [**Hospital1 **]

ALLERGIES: Ceftin

PHYSICAL EXAM: VS 99.5 102/60 110 24 95% RA
Gen: NAD
HEENT: CN II-XII grossly intact, NCAT, mmm, no lesions
Neck: no lymphadenopathy
Cardiac: RRR, nl s1s2, no m/r/g
Lungs: CTAB
Abd: soft, NT, ND, + bs, no hsm
ext: no c/c/e
Skin: bruising on extremities
.
Physical Exam on day of Discharge:
VS: Tm 98.7 Tc 97.3 BP: 90/62 (82-100/50-66) HR:80 (80-96) RR:
18 O2 Sat:97-100% RA wgt:143
shift I= sips +468/O=1500
24hr I=2225/O=4075
GEN: [x]NAD []Cacjectic
SKIN: [x]WNL, line looks ok
HEENT: [x]Anicteric [x]MMM [x]OP Clear [x]No LAD
CV: [x]RRR [x]NML S1 S2 [x]no g/m/r [x]no JVD
RESP: [x]CTAB [x]no wheezes/rhonchi/rales
ABD: [x]S/NT/ND [x]+BS [x]No HSM
EXT: [x]No CCE [x] +2 DP B/L
NEURO: [x]A&Ox3 [x]CN2-12 intact [x] motor [x] sensory [x]coord
[x]language normal

FAMILY HISTORY: grandmother with lymphoma; no family history of leukemia.
diabetes in several family members

SOCIAL HISTORY: smokes 3/4-1 ppd, marijuana nightly, no h/o IVDU, no alcohol
use, no prior transfusions.
Acute lymphoid leukemia, without mention of having achieved remission,Cardiac tamponade,Unspecified pleural effusion,Hypotension, unspecified,Mechanical complication of other vascular device, implant, and graft,Neutropenia, unspecified,Stomatitis and mucositis, unspecified,Pulmonary collapse,Dysthymic disorder,Other abnormal blood chemistry,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,Nausea with vomiting,Fever presenting with conditions classified elsewhere,Prickly heat,Constipation, unspecified
Ac lym leuk wo achv rmsn,Cardiac tamponade,Pleural effusion NOS,Hypotension NOS,Malfunc vasc device/graf,Neutropenia NOS,Stomatitis/mucositis NOS,Pulmonary collapse,Dysthymic disorder,Abn blood chemistry NEC,Abn react-procedure NEC,Accid in resident instit,Nausea with vomiting,Fever in other diseases,Prickly heat,Constipation NOS
Admission Date:  [**2191-11-24**]              Discharge Date:   [**2192-1-13**]

Date of Birth:  [**2135-5-24**]             Sex:   F

Service: MEDICINE

Allergies:
Ceftin

Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
acute leukemia

Major Surgical or Invasive Procedure:
Liver was biopsied via IR transjugular approach on [**11-28**]. Biopsy
procedure was complicated with catheter dislodged in right
atrium extending across tricuspid valve into right ventricle.
Pericardial effusion causing cardiac tamponade requiring
drainage
Chemotherapy (systemic and intrathecal, requiring multiple LPs)
Echocardiogram
placement and removal of CVL
placement of PICC
transjugular hepatic biopsy, with catheter fragment lodged in
right atrium and right ventricle
Cardiac cath for removal of catheter fragment


History of Present Illness:
54 yo F with h/o anxiety presents with new onset leukemia.  For
the past 4-6 weeks, she has been experiencing SOB and increasing
bruising and went to her PCP who referred her to the emergency
department for anemia with Hgb of 7.0, Hct 19, platelets of 6,
WBC 10.7.  In the ER, smear showed blasts and sample was sent
for flow cytometry.  She was admitted to BMT floor for diagnosis
and treatment of new onset leukemia.

On the floor, she complains of being SOB even at rest, but
otherwise no complaints.  no bleeding, nausea, vomiting,
diarrhea, constipation, fever, chills, night sweats recently.


Past Medical History:
Anxiety
Depression


Social History:
smokes 3/4-1 ppd, marijuana nightly, no h/o IVDU, no alcohol
use, no prior transfusions.


Family History:
grandmother with lymphoma; no family history of leukemia.
diabetes in several family members


Physical Exam:
VS 99.5 102/60 110 24 95% RA
Gen: NAD
HEENT: CN II-XII grossly intact, NCAT, mmm, no lesions
Neck: no lymphadenopathy
Cardiac: RRR, nl s1s2, no m/r/g
Lungs: CTAB
Abd: soft, NT, ND, + bs, no hsm
ext: no c/c/e
Skin: bruising on extremities
.
Physical Exam on day of Discharge:
VS: Tm 98.7 Tc 97.3 BP: 90/62 (82-100/50-66) HR:80 (80-96) RR:
18 O2 Sat:97-100% RA wgt:143
shift I= sips +468/O=1500
24hr I=2225/O=4075
GEN: [x]NAD []Cacjectic
SKIN: [x]WNL, line looks ok
HEENT: [x]Anicteric [x]MMM [x]OP Clear [x]No LAD
CV: [x]RRR [x]NML S1 S2 [x]no g/m/r [x]no JVD
RESP: [x]CTAB [x]no wheezes/rhonchi/rales
ABD: [x]S/NT/ND [x]+BS [x]No HSM
EXT: [x]No CCE [x] +2 DP B/L
NEURO: [x]A&Ox3 [x]CN2-12 intact [x] motor [x] sensory [x]coord
[x]language normal


Pertinent Results:
[**2191-11-24**] 09:54PM   GLUCOSE-136* UREA N-18 CREAT-1.2* SODIUM-140
POTASSIUM-3.1* CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
[**2191-11-24**] 09:54PM   LD(LDH)-870*
[**2191-11-24**] 09:54PM   CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.1 URIC
ACID-4.5
[**2191-11-24**] 09:54PM   PLT COUNT-95*#
[**2191-11-24**] 09:00PM BONE MARROW  [**Doctor Last Name **]-G-DONE
[**2191-11-24**] 03:40PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2191-11-24**] 03:40PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-9.0* LEUK-NEG
[**2191-11-24**] 03:40PM URINE  RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-[**4-15**]
[**2191-11-24**] 01:30PM   GLUCOSE-109* UREA N-15 CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17
[**2191-11-24**] 01:30PM   ALT(SGPT)-73* AST(SGOT)-69* LD(LDH)-1141* ALK
PHOS-176* TOT BILI-0.7
[**2191-11-24**] 01:30PM   cTropnT-<0.01
[**2191-11-24**] 01:30PM   ALBUMIN-4.3 CALCIUM-9.3 PHOSPHATE-2.3*
MAGNESIUM-2.1 URIC ACID-6.2*
[**2191-11-24**] 01:30PM   HAPTOGLOB-11*
[**2191-11-24**] 01:30PM   WBC-10.7 RBC-2.09* HGB-7.0* HCT-19.2* MCV-92
MCH-33.4* MCHC-36.4* RDW-19.2*
[**2191-11-24**] 01:30PM   NEUTS-11* BANDS-2 LYMPHS-13* MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-73*
[**2191-11-24**] 01:30PM   FIBRINOGE-355

[**2191-11-24**] flow cytometry
Immunophenotypic findings consistent with involvement by
precursor B-acute lymphoblastic leukemia.
Cell marker analysis demonstrates that the majority of the cells
isolated from this peripheral blood express immature antigens
CD34, HLA-DR, myeloid associated antigens CD33, lymphoid
associated antigens CD10, CD20, nTdT.

[**2191-11-24**] bone marrow biopsy
Precursor B- Acute lymphoblastic leukemia.

[**2191-11-25**] chromosome analysis
positive for t(9,22), BCR-ABL

[**2191-11-25**] ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.

[**2191-11-25**] RUQ U/S
1. In the absence of localized symptoms or clinical suspicion
for
cholecystitis, asymmetric gallbladder wall edema at the liver
edge likely
represents a component of liver disease which may include acute
hepatitis or
hypoalbuminemia.

2. Borderline enlarged spleen.

[**2191-11-28**] liver biopsy
Sections are of liver parenchyma with a patchy dense lymphoid
infiltrate composed of medium-sized lymphocytes with scant
cytoplasm, round-to-irregular nuclei, pale chromatin and
occasional small nucleoli.  By immunohistochemistry, the
infiltrate is diffusely immunoreactive for pan B-marker CD20,
along with TdT, CD34, and CD10.  CD3 and CD5 highlight fewer
admixed small T-lymphocytes.  BCL-1 is predominantly negative
with rare cells staining.  Myeloperoxidase is not expressed in
the infiltrate.  By MIB-1 staining, the proliferation fraction
is 60%.
Overall, the morphologic and immunophenotypic findings are of
involvement by patient's known precursor B-lymphoblastic
leukemia.

[**2191-11-28**] CT chest
Fragment of the intervention device, presumably a part of the
access kit, misplaced in the right atrium and right ventricle.
The fragment is approximately 8 cm in length. The fragment has
no connection with the subclavian line whose tip projects over
the proximal parts of the right atrium.

[**2191-11-30**] ECHO
small tricuspid valve/chordal mass vs focal
thickening/redundancy of the valve; vegetation cannot be
excluded; consider transesophageal echocardiography for
(possibly) better visualization

[**2191-12-2**] ECHO
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is no aortic valve stenosis. No mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is probably a small vegetation/mass on the tricuspid
valve/tricuspid chordae on the RV side (septal leaflet). There
is a small pericardial effusion. There are no echocardiographic
signs of tamponade.
Compared with the prior study (images reviewed) of [**2191-11-30**],
the tricuspid valve vegetation (versus mass/thrombus) appears
smaller. A small pericardial effusion is now present. If
indicated, a TEE may better assess the tricupsid valve
vegetation/mass.
.
TTE (Focused views) Done [**2191-12-12**] at 2:20:06 PM      FINAL
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a very small residual pericardial effusion. There are
no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2191-12-8**],
no change.
.
Portable TTE (Focused views) Done [**2191-12-22**] at 2:36:59 PM
FINAL
Conclusions
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The mitral valve
leaflets are structurally normal. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: Trival pericardial effusion. No echocardgiographic
evidence of tamponade.
Compared with the prior study (images reviewed) of [**2191-12-12**],
the pericardial effusion has essentially resolved.
.
TTE (Complete) Done [**2192-1-3**] at 3:17:56 PM      FINAL
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
.
CT HEAD W/O CONTRAST Study Date of [**2191-12-17**] 2:40 PM
IMPRESSION:
1. No acute intracranial process.
2. Focal area of hypodensity in the territory of right PCA
likely related to old ischemic event.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2191-12-21**]
9:05 PM
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Two right pulmonary nodules measuring 2 and 4 mm
respectively, in light of the history of smoking, a 12-month
followup CT is suggested to assess for stability.
.
UNILAT UP EXT VEINS US RIGHT Study Date of [**2191-12-30**] 11:22 AM
IMPRESSION:
Deep vein thrombosis extending from the right subclavian vein to
the right
brachial vein, surrounding the right PICC line.
.
ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2192-1-4**] 4:10 PM
IMPRESSION:
1. Normal arterial and venous waveforms.
2. Apparent gallbladder wall thickening which is most likely
secondary to
underdistension.
.
UNILAT UP EXT VEINS US Study Date of [**2192-1-12**] 2:42 PM
IMPRESSION:
1. Deep vein thrombosis in the right subclavian vein which
extends to the
right axillary vein and more superficial right brachial vein,
without
significant change from prior study.
2. Interval increase in small thrombus involving the basilic
vein, when
compared to prior study ([**2191-12-30**]).
.

Brief Hospital Course:
56 yo F new diagnosis Pre B cell ALL HyperCVAD Part A and B
administered . Started Part A on [**12-1**] and Part B [**12-26**].
Intrathecal methotrexate and cytarabine alternating weekly.
Presented with 4-6 weeks fatigue and bruising and initial WBC 14
with 73% lymphoblasts and plt 6), s/p removal of IR apparatus
from R atrium/ventricle [**11-28**] following transjugular liver bx
and echo showed some clot after this. Had worsening chest
tightness and shortness of breath and increasing pulsus
paradoxus in context of low ECG voltage and large heart on CXR.
Had emergent echo showing pericardial tamponade and went for
drainage and to CCU post drainage of  400ml blood (Hct 25) .
Back to BMT unit and doing well but still had large L>>R pleural
effusions which resolved as patient was auto-diuresing. Imatinib
stopped [**12-6**] due to concerns for effusions. High risk of CNS
involvement as 2 WBCs after LP were suspicious for ALL cells.
Unexplained tachyardia on telemetry with episodes of vasovagal
syncopal episodes resulting in several collapses - PE/recurrent
pericardial effusion and other serious causes ruled out and
cardiology reviewed. RUE DVT found on doppler U/S [**12-30**] and
anticoagulation with treatment dose LMWH started [**12-31**] post LP
with a plan to hold LMWH if Plt <50. Brother was found to be a
donor match and the plan will be for allo SCT once she is in
remisson. Imatinib restarted [**12-30**] but held on [**1-4**] b/c of
rising LFTs. Recurrent vasovagals and tachycardia and seen by
neurology who suggested compression stockings / trial of
midodrine. Bactrim was also held on [**1-4**] b/c of LFTs and pt was
placed on inhaled pentamidine for PCP [**Name Initial (PRE) 1102**].
.
.
# ALL: Pre B cell ALL Ph C +ve: C1 HyperCVAD started [**12-1**]. Part
B started [**12-26**]. She Initially presented as a referral from PCP
to emergency department for anemia with Hgb of 7.0, Hct 19,
platelets of 6, WBC 10.7. In the ER, smear showed blasts and
sample was sent for flow cytometry.  Results c/w PHL+ pre-B cell
ALL, also had elevated AST and ALT, which was evaluated by
livery biopsy that showed hepatic involvement with leukemia (c/b
dislodged IR catheter, see below for details).  Imatinib was
started for treatment of PHL+ leukemia, and cycle 1 of hyperCVAD
was started on [**12-1**].  Tumor lysis labs were followed and she
was on allopurinol. She had a complicated course as detailed
below. There was concern for CNS involvement as 2 WBCs in CSF
were suspicious for leukemic cells.  She had IT cytarabine [**12-9**]
and [**12-30**] and IT methotrexate [**12-16**] and [**12-23**].. She had a
profound neutropenia and thrombocytopenia which resolved. At the
time of further IT chemo [**12-16**], further samples sent for cytology
and flow cytometry with no evidence eof leukemic cells. Started
GCSF [**12-19**] for persistently low counts and stopped [**12-22**].
Cefepime, vanc and allopurinol stopped [**12-22**] when counts
improved . Added po fluconazole and trim/sulfa for prophylaxis
[**12-19**]. Allopurinol stopped [**12-22**].  Rpt BMBx [**12-23**] - no disease.
Brother is a SCT match. Plan will be for allo SCT once in
remisson. Transfusion goals were for HCt >24 Plt >20. Imatinib
was stopped on [**1-4**] b/c of rising LFTs.
.
# Elevated LFTs: followed by hepatology during admission, on
liver biopsy [**12-29**] was secondary to leukemic infiltration (see
CCU course for liver bx complications).  Improved with treatment
of leukemia.  Iron studies were elevated and per liver team this
was felt likely [**3-15**] inflammation, and smooth muscle antibodies
returned positive, which was a nonspecific finding. Her liver
biopsy was complicated as detailed below and required IR
intervention and subsequent CCU admission. In the next weeks
there was evidence of slow deterioration and a possible drug
cause was postulated. Stopped fluconazole [**12-27**] and trended
LFTs. On [**1-4**] imatinib and bactrim were also stopped as LFTs
had remained elevated. LFTs improved after these medications
were stopped.
.
# Liver biopsy with complication requiring IR intervention:
During her liver biopsy, IR dislodged a 7cm catheter in her
right atrium and were unable to retrieve it. CT showed catheter
extending across tricuspid valve to the RV.  On arrival to the
CCU floor, the patient was complaining of severe back pain, no
chest pain. Pain was controlled with morphine, ativan, lidocaine
patch. The patient had no ectopy or arrhtymia overnight and HCT
remained stable. Patient went to catheterization in the am [**11-29**]
and catheter was successfully removed, patient was then
transferred back to BMT floor for futher managment of leukemia.
.
#Pericardial effusion post drain: ECG after [**11-29**] showed low
voltages and she became symptomatic on [**12-5**]. At this point her
ECG showed even lower voltages (when compared with previous
ECGs) and had a large heart on CXR. On [**12-6**] the patient was
found to have a pericardial effusion with cardiac tamponade
physiology in setting of chest pain, SOB, decreased voltage on
ECG, and a pulsus paradoxus of 15mmHg. She was rushed urgently
to cath lab for drainage which drained 300ml serosanguinous
fluid. Symptoms improved and pt remained hemodynamically stable
with no chest pain after procedure. Pt was transfered back to
the CCU post procedure. Pericardial effusion was felt likely
iatrogenic following catheter penetration of ventricle from
prior liver bx accident. Cytology returned suggestive of frank
blood (HCt 25). Flow cytometry of sample negative for malignant
cells.  She was transfered back to BMT service. Post procedure
there was trivial residual effusion on removing drain. Following
transfer back to the BMT unit, she remained stable in regard to
her pericrdial effusion and pulsus between 6 and 8mmHg
throughout. CXR on[**12-10**] showed her heart size unchanged. She was
auto-diuresing and echo on [**12-12**] showed no change. Imatinib was
initially held due to concerns for precipitating effusions and
was only restarted after MTX (as Part B) was cleared and
re-comenced [**12-31**]. Repeat ECHOs on [**12-22**] and [**1-3**] showed no
significant effusion remaining.
.
# Unexplained tachycardia: Initially considered PE although low
prob, PE ruled out by CT-PA. Further syncope on [**12-21**] in setting
of tachycardia up to 143 on minimal exertion. SR on tele. S/B
cardiology. CXR showed resolved effusions. Pulsus was 6-8mmHg
and cardiology agreed clinically unlikely. Echo [**12-22**] showed a
trival pericardial effusion with no echocardgiographic evidence
of tamponade and compared with the prior echo, the pericardial
effusion had essentially resolved. Has improved since. Likely
multi-factorial. Pt was encouraged to drink plenty of fluids and
was given IV boluses of fluids. Gradually improved.
.
# Syncopal episodes: Syncope while in shower [**12-17**]. This was felt
to be a vasovagal episode perhaps exacerbated by dehydration -
given IV fluids and decreased lorazepam to 0.5mg [**Hospital1 **]. Initially
low BP with systolic 70mmHg and improved with fluids. CT-head no
ICH/SDH. Final CT report - hypodensity R PCA territory ?? old
infarct but no RFs and would be unlikely - MRI not clinically
indicated at present. Triggered [**1-1**] for further syncope,
likely vagal episode, BP 79 systolic.  Resolved with 1L NS
bolus, gave 2nd liter. Cortisol normal.  Repeat labs were
stable. Pt triggered again on [**1-6**] for SBP in 80s but pt was
asymptomatic (no dizziness). Pt received several boluses of IVF
w/good response. Pt was then placed on maintence fluids and
encouraged to increase her PO intake with improvement.
.
# Bilateral pleural effusions: Now resolved. Initially large L
and small R. If becomes acutely SOB may have to be tapped and
for urgent CXR or if spikes fever. Improving on CXR of [**12-10**]
Auto-diuresing and now resolved as per CXR [**12-21**]. Furosemide
20mg po [**12-24**] to diurese remaining pleural fluid prior to
Methotrexate.Rpt CXR [**12-25**] to show resolution of effusions prior
to starting Part B [**12-25**].
.
#Rash: Maculopapular rash was noted only on her back on [**12-12**].
Dermatology consulted [**12-13**] who felt that this was miliaria rubra
and not concerning and not drug rash and required no treatment.
Resolved.
.
# Anxiety/depression:  Home medications were paroxetine 30 mg
[**Hospital1 **] and 1 mg ativan [**Hospital1 **].  Paroxetine was tapered and
discontinued for concern for effects on platelet function in an
already thrombocytopenic patient. Because of hypotension ativan
decreased to 0.5mg [**Hospital1 **].
.
# Low grade fever (max 100.3 - 100.1 on [**12-10**]) in context of
neutropenia: IV cefepime and vanc started on [**12-6**]. She had no
true fevers and counts improved by [**12-22**] at which point
antibiotics were discontinued.
.
# RUE DVT: Unilateral swollen R arm with PICC - went on to U/S
and showed clot extending from subclavian to brachial vein - for
anticoagulation with enoxaparin post LP on [**12-31**] and to hold
LMWH if Plt <50. Decision was made to stop lovenox onf [**1-4**] b/c
plts <50. Repeat US on [**2192-1-12**] showed remaining clot but was
non-occlusive; per att recs, pt was not restarted on lovenox.
.
# Incidental finding: CT-PA [**12-21**] showed two right pulmonary
nodules measuring 2 and 4 mm respectively, in light of the
history of smoking, a 12-month followup CT is suggested to
assess for stability.
.
Pt was able to be discharged home to continue recovery of counts
before starting next cycle.

Medications on Admission:
ativan 1 mg [**Hospital1 **]
paroxetine 30 mg [**Hospital1 **]


Discharge Medications:
1. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
4. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
Disp:*14 Tablet(s)* Refills:*0*
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-12**] Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
ALL, with CNS involvement; treated with HyperCVAD and
intrathecal chemotherapy
.
Secondary:
Pericardial effusion with cardiac tamponade requiring drainage
Hypotension
Syncope
Upper extremity DVT, non-occlusive, catheter-associated

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

Discharge Instructions:
You were admitted to the hosptial for treatment of your ALL
(leukemia) to receive chemotherapy. Your course of treatment was
 complicated by elevated levels of liver enzymes. It was was
found that there was some leukemic infiltration of the liver;
your liver enzymes also were elevated because of drugs that were
needed to treat your cancer as well. Some of these drugs were
stopped and your liver function improved. You also had a
procedural complication requiring interventional radiology to
remove a dislodged catheter. You had a pericardial effusion
causing tamponade (or fluid or blood in the sac surround the
heart) resulted in decreased ability of the heart to pump blood
forward to the rest of your body. This required emergent
drainage to allow the heart to return to normal functioning. The
effusion resolved and repeat echocardiogram demonstrated that
there was no more effusion. You also experienced episodes of
faintness and low blood pressure. You feeling of faintness
resolved but you continued to have low blood pressures. You were
seen by neurology and cardiology and no acute cause could be
identified. You responded well to additional fluids and,
although your blood pressure is at times low, you have not had
anymore episodes of fainting or dizziness for over a week. You
had a DVT in your arm from a catheter. The catheter was removed
and a repeat U/S on [**2192-1-12**] showed that the DVT is still there,
but it is non-occlusive so anticoagulation was not started.
Given your improvement in blood counts and symptoms, it was felt
that you could safely go home for several days after your
intrathecal chemo today ([**1-13**]) to await the next round of
treatment early next week. You will be readmitted on Wednesday
[**1-18**] for the next stage of treatment.
.
The following changes were made you your medications:
- Please decrease your dose of lorazepam to 0.5mg [**Hospital1 **]; this was
reduced because of your low blood pressures.
- Please decrease your dose of paroxetine to 30mg daily (rather
than twice daily)
- Please use olanzapine 5 mg twice daily as needed for anxiety
- Please START taking omeprazole 40mg daily.
- Please START using nystatin four times a day.
- If you have nausea, you can take 4-8mg of ondansetron every 8
hours as needed.
- Please use colace and senna if you experience constipation.
- Please continue to take all of your other home medications as
prescribed.
.
Please be sure to keep all follow-up appointments with your PCP,
[**Name10 (NameIs) 86159**] and other healthcare providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.


Followup Instructions:
Please return to 7F outpatient area at 2pm on Monday, [**2192-1-16**].
You will need to have blood tests at that time.
.
You will be readmitted for your next cycle of chemotherapy on
Wednesday, [**2192-1-18**].
.


Completed by:[**2192-2-10**]
{'Acute lymphoid leukemia, without mention of having achieved remission,Cardiac tamponade,Unspecified pleural effusion,Hypotension, unspecified,Mechanical complication of other vascular device, implant, and graft,Neutropenia, unspecified,Stomatitis and mucositis, unspecified,Pulmonary collapse,Dysthymic disorder,Other abnormal blood chemistry,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,Nausea with vomiting,Fever presenting with conditions classified elsewhere,Prickly heat,Constipation, 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 leukemia

PRESENT ILLNESS: 54 yo F with h/o anxiety presents with new onset leukemia.  For
the past 4-6 weeks, she has been experiencing SOB and increasing
bruising and went to her PCP who referred her to the emergency
department for anemia with Hgb of 7.0, Hct 19, platelets of 6,
WBC 10.7.  In the ER, smear showed blasts and sample was sent
for flow cytometry.  She was admitted to BMT floor for diagnosis
and treatment of new onset leukemia.

MEDICAL HISTORY: Anxiety
Depression

MEDICATION ON ADMISSION: ativan 1 mg [**Hospital1 **]
paroxetine 30 mg [**Hospital1 **]

ALLERGIES: Ceftin

PHYSICAL EXAM: VS 99.5 102/60 110 24 95% RA
Gen: NAD
HEENT: CN II-XII grossly intact, NCAT, mmm, no lesions
Neck: no lymphadenopathy
Cardiac: RRR, nl s1s2, no m/r/g
Lungs: CTAB
Abd: soft, NT, ND, + bs, no hsm
ext: no c/c/e
Skin: bruising on extremities
.
Physical Exam on day of Discharge:
VS: Tm 98.7 Tc 97.3 BP: 90/62 (82-100/50-66) HR:80 (80-96) RR:
18 O2 Sat:97-100% RA wgt:143
shift I= sips +468/O=1500
24hr I=2225/O=4075
GEN: [x]NAD []Cacjectic
SKIN: [x]WNL, line looks ok
HEENT: [x]Anicteric [x]MMM [x]OP Clear [x]No LAD
CV: [x]RRR [x]NML S1 S2 [x]no g/m/r [x]no JVD
RESP: [x]CTAB [x]no wheezes/rhonchi/rales
ABD: [x]S/NT/ND [x]+BS [x]No HSM
EXT: [x]No CCE [x] +2 DP B/L
NEURO: [x]A&Ox3 [x]CN2-12 intact [x] motor [x] sensory [x]coord
[x]language normal

FAMILY HISTORY: grandmother with lymphoma; no family history of leukemia.
diabetes in several family members

SOCIAL HISTORY: smokes 3/4-1 ppd, marijuana nightly, no h/o IVDU, no alcohol
use, no prior transfusions. 

### Response:
{'Acute lymphoid leukemia, without mention of having achieved remission,Cardiac tamponade,Unspecified pleural effusion,Hypotension, unspecified,Mechanical complication of other vascular device, implant, and graft,Neutropenia, unspecified,Stomatitis and mucositis, unspecified,Pulmonary collapse,Dysthymic disorder,Other abnormal blood chemistry,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,Nausea with vomiting,Fever presenting with conditions classified elsewhere,Prickly heat,Constipation, unspecified'}
