CHIEF COMPLAINT: splenic marginal zone lymphoma

PRESENT ILLNESS: 81-year-old woman who has been evaluated originally for abnormal
blood smear.  She was further worked up with a bone marrow
biopsy and CAT scan and diagnosed with a low-grade lymphoma and
thought most consistent with a splenic marginal zone lymphoma.

MEDICAL HISTORY: PMH:
1.  Headaches.
2.  Thalassemia minor.
3.  Degenerative joint disease.
4.  Question of tuberculosis.

MEDICATION ON ADMISSION: prilosec 20', Ca-Vit D 600 mg-400'', MVI'

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: 97.0, 76, 126/52, 20, 96% RA
Gen: A&O, NAD
CV: RRR no m/r/g
Pulm: CTAB
Abd: soft, TTP over incision site, non-distended, incision c/d/i
with staples
Ext: warm, 2+dp/pt, 1+LE edema

FAMILY HISTORY: Family history is significant for her father having had kidney
cancer. Her children have thalassemia, brother had thyroid
cancer, another brother had [**Name2 (NI) 499**] and prostate cancer.

SOCIAL HISTORY: She is a former smoker but quit years ago.  She does not drink
or use drugs.  She is retired.  She lives with her husband,
daughter, and son.  She has eight grandchildren.
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites,Portal vein thrombosis,Drug-induced delirium,Splenomegaly,Laparoscopic surgical procedure converted to open procedure,Essential thrombocythemia,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Personal history of tobacco use,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Sickle-cell trait
Margnl zone lym xtrndl,Portal vein thrombosis,Drug-induced delirium,Splenomegaly,Lap surg convert to open,Essntial thrombocythemia,Thrombocytopenia NOS,Chr blood loss anemia,History of tobacco use,Adv eff sedat/hypnot NOS,Sickle-cell trait
Admission Date:  [**2168-8-30**]              Discharge Date:   [**2168-9-8**]

Date of Birth:  [**2086-9-30**]             Sex:   F

Service: SURGERY

Allergies:
Bactrim

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
splenic marginal zone lymphoma

Major Surgical or Invasive Procedure:
laparoscopic converted to open splenectomy


History of Present Illness:
81-year-old woman who has been evaluated originally for abnormal
blood smear.  She was further worked up with a bone marrow
biopsy and CAT scan and diagnosed with a low-grade lymphoma and
thought most consistent with a splenic marginal zone lymphoma.

In terms of symptoms, she has had right lower abdominal
"pressure pain" which is more prominent at night when just prior
to bed. Otherwise, she has had no symptoms, no nausea, vomiting,
no exacerbating or alleviating symptoms.


Past Medical History:
PMH:
1.  Headaches.
2.  Thalassemia minor.
3.  Degenerative joint disease.
4.  Question of tuberculosis.

PSH:
1.  Total abdominal hysterectomy and bilateral salpingo-
    oophorectomy for bleeding.
2.  Cataract surgery, left eye.
3.  Cesarean section x1.
4.  Bartholin cyst surgery.
5.  Thumb surgery.


Social History:
She is a former smoker but quit years ago.  She does not drink
or use drugs.  She is retired.  She lives with her husband,
daughter, and son.  She has eight grandchildren.


Family History:
Family history is significant for her father having had kidney
cancer. Her children have thalassemia, brother had thyroid
cancer, another brother had [**Name2 (NI) 499**] and prostate cancer.


Physical Exam:
VS: 97.0, 76, 126/52, 20, 96% RA
Gen: A&O, NAD
CV: RRR no m/r/g
Pulm: CTAB
Abd: soft, TTP over incision site, non-distended, incision c/d/i
with staples
Ext: warm, 2+dp/pt, 1+LE edema

Pertinent Results:
[**2168-9-8**] 11:50AM BLOOD WBC-12.9* RBC-3.71* Hgb-9.1* Hct-29.2*
MCV-79* MCH-24.6* MCHC-31.2 RDW-17.0* Plt Ct-840*
[**2168-9-8**] 11:50AM BLOOD PT-34.2* PTT-35.2* INR(PT)-3.4*
[**2168-9-8**] 11:50AM BLOOD Glucose-107* UreaN-10 Creat-0.5 Na-137
K-3.8 Cl-97 HCO3-32 AnGap-12
[**2168-9-6**] 07:20AM BLOOD ALT-34 AST-22 AlkPhos-74 TotBili-0.4
[**2168-9-8**] 11:50AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8

Brief Hospital Course:
Date of Admission: [**2168-8-30**]
Date of Discharge: [**2168-9-8**]

Procedures: laparoscopic converted to open splenectomy, Epidural
placement x2

Imaging:

  CXR ([**2168-9-1**]): No acute infiltrate. Bilateral lower lobe
atelectasis with small   left pleural effusion. No cardiomegaly.
No pulmonary edema.

  Abdominal U/S ([**2168-9-1**]):  1. Markedly abbreviated study due to
poor patient noncompliance.  2. Limited findings are concerning
for portal vein thrombus versus
undetectable flow, but cannot be further clarified with
ultrasound at the
present time. A contrast enhanced liver CT is advised to further
evaluate.

  CT Abd/Pelv ([**2168-9-1**]): occlusive PV thrombus in intrahepatic R
and L branches of the PV. Non-occlusive thrombus in the main PV.
Thrombus in splenic vein remnant. Colonic wall thickening,
likely due to underdistention, but could
represent colitis in the right clinical setting. Multiple
hepatic and renal cysts.
Bilateral pleural effusions, greater on the left than the right.


  CXR ([**2168-9-2**]): IJ is in proper position in the lower SVC.
Otherwise, bilateral
pancake atelectasis with small pleural effusions are unchanged.

  CXR ([**2168-9-7**]): Neg for PNA or effusions

Pending labs: spleen for pathology

Medication changes: none

The patient was admitted for observation after laparoscopic
splenectomy that was converted to open. An epidural was placed
by the Acute Pains Service (APS) post-operatively for pain
control which provided moderate pain relief. This was removed
and was briefly started on a dilaudid PCA. However, she
developed confusion and this was d/c'd and started on vicodin
with IV morphine for breakthrough. APS was re-contact[**Name (NI) **] and
another epidural was placed. POD#2 she developed low grade
temperature with leukocytosis of 15,000 with a HCT drop from
29.6 to 26.8 and worsening abdominal pain. There was concern for
possible venous thrombosis so an abdominal U/S was performed.
However, this was suboptimal study limited  views due to pain
but did demonstrate lack of flow through the portal vein. A
follow-up CT scan demonstrated an occlusive thrombus in the
portal vein and non-occlusive thrombus in the splenic vein
remnant. APS was paged and the epidural was removed and she was
transferred to the SICU for observation and was started on
Heparin drip. A right IJ CVL was placed for access. Her HCT
continued to drop to 22.4 and she was transfused 2 units PRBCs,
she responded appropriately with a HCT of 30. ID was consulted
who recommend checking blood cultures and UA which were
negative. She received pre-splenectomy vaccinations in [**Month (only) **].
Heme/Onc was consulted to assist with management and transfusion
requirements in patient post-splenectomy with history of
thalassemia minor. Their recommendations were to keep HCT
greater than 21 and to follow up as an outpatient with her
Oncologist and her scheduled f/u CT scan. POD#4 she was
transferred to the floor and was started on coumadin. She was
placed on regular diet and a morphine PCA for pain control.
POD#5 the foley was removed and she was voiding without
difficulty. She was transitioned to oxycodone and the PCA was
stopped. PT was consulted who recommend [**Hospital 3058**] rehab upon
discharge. POD#6 the heparin drip was stopped and she continued
on coumadin. POD#7 her INR returned as 6.6 and all
anticoagulation was held to allow her to drift back down. Her R
IJ was removed and sent for culture which was negative. She
continued to have mild O2 requirements via nasal cannula likely
due to decreased ambulation. IS was continued to be encouraged
and the O2 was then weaned. The oxycodone was stopped because
she was overly sedated and she was placed on scheduled Tylenol
and PRN tramadol of which she only needed 1 dose. POD#8 she did
have temperature of 101.0, CXR was negative for infiltrate and
UA was negative. She remained afebrile therafter, her WBC
continued to trend down and her INR trended down to 3.4, and she
developed post-splenectomy thrombocytosis with platelet count of
840 on discharge. She was ambulating, tolerating a regular diet,
voiding, and having BM's. She was discharged to rehab with
appropriate follow up appointments with Dr. [**Last Name (STitle) **] from
surgery and her oncologist. She is going to receive 1mg coumadin
tonight and should have her INR checked at rehab to titrate
coumadin.




Medications on Admission:
prilosec 20', Ca-Vit D 600 mg-400'', MVI'

Discharge Medications:
1. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
3. M-Vit 27-1 mg Tablet Oral
4. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
5. Coumadin. titrate to goal INR of [**3-3**].


Discharge Disposition:
Extended Care

Facility:
[**Male First Name (un) 4542**] Nursing Center - [**Hospital1 1562**]

Discharge Diagnosis:
splenic marginal zone lymphoma
portal vein thrombosis
splenic vein thrombosis


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


Discharge Instructions:
Call the surgery clinic ([**Telephone/Fax (1) 3201**]) or go to the Emergency
Department for the following: Temperature greater than 101.4;
increasing redness, pain, swelling, or discharge from the
incision sites; blood in your stool or black tarry stools;
inability to tolerate food or drink; worsening abdominal pain;
or any other concerns.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drink alcohol, drive or operate heavy machinery while
taking narcotic analgesic medications.  You may also take
acetaminophen (Tylenol) as directed, but do not exceed 4000 mg
in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 3201**]
Date/Time:[**2168-9-16**] 2:15

Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-10-10**] 11:00

Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2168-10-14**] 10:00



Completed by:[**2168-9-8**]
{'Marginal zone lymphoma, unspecified site, extranodal and solid organ sites,Portal vein thrombosis,Drug-induced delirium,Splenomegaly,Laparoscopic surgical procedure converted to open procedure,Essential thrombocythemia,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Personal history of tobacco use,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Sickle-cell trait'}


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: splenic marginal zone lymphoma

PRESENT ILLNESS: 81-year-old woman who has been evaluated originally for abnormal
blood smear.  She was further worked up with a bone marrow
biopsy and CAT scan and diagnosed with a low-grade lymphoma and
thought most consistent with a splenic marginal zone lymphoma.

MEDICAL HISTORY: PMH:
1.  Headaches.
2.  Thalassemia minor.
3.  Degenerative joint disease.
4.  Question of tuberculosis.

MEDICATION ON ADMISSION: prilosec 20', Ca-Vit D 600 mg-400'', MVI'

ALLERGIES: Bactrim

PHYSICAL EXAM: VS: 97.0, 76, 126/52, 20, 96% RA
Gen: A&O, NAD
CV: RRR no m/r/g
Pulm: CTAB
Abd: soft, TTP over incision site, non-distended, incision c/d/i
with staples
Ext: warm, 2+dp/pt, 1+LE edema

FAMILY HISTORY: Family history is significant for her father having had kidney
cancer. Her children have thalassemia, brother had thyroid
cancer, another brother had [**Name2 (NI) 499**] and prostate cancer.

SOCIAL HISTORY: She is a former smoker but quit years ago.  She does not drink
or use drugs.  She is retired.  She lives with her husband,
daughter, and son.  She has eight grandchildren. 

### Response:
{'Marginal zone lymphoma, unspecified site, extranodal and solid organ sites,Portal vein thrombosis,Drug-induced delirium,Splenomegaly,Laparoscopic surgical procedure converted to open procedure,Essential thrombocythemia,Thrombocytopenia, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Personal history of tobacco use,Unspecified sedatives and hypnotics causing adverse effects in therapeutic use,Sickle-cell trait'}
