Medical Text: Admission Date:  [**2108-4-6**]       Discharge Date:  [**2081-4-7**]

Date of Birth:   [**2059-5-7**]       Sex:  F

Service:  O MED

CHIEF COMPLAINT:  Dyspnea.

HISTORY OF PRESENT ILLNESS:  This is a 48 year old African
American female with a history of multiple myelomas being
admitted for respiratory distress.  The patient has been
recently discharged one week ago from outside hospital ([**Hospital3 7900**]) for respiratory distress.  Back at [**Hospital3 7362**],
she was given nebulizer, antibiotics and steroids.  She also
had elevated INR and was given medication to lower INR
although there was no evidence of bleeding.

Last night, she reports having increased difficulty with
breathing.  She has also had a cough.  She denies any fever
or chills.  The patient admitted to decreased p.o. intake but
has been recently sedimentary.  She denies any swelling of
the legs.  The patient had noted some wheezing but then took
her Albuterol inhaler without any effect.  She has been on a
Prednisone taper but reports that she has been coughing up
thick sputum.

She went to her primary care provider today but could not say
a sentence so was sent to the Emergency Department.  In the
Emergency Department, she was tachypneic and wheezing with
heart of 120 and blood pressure of 127/82.  She received
Solu-Medrol and continued with nebulizer treatment.  She
improved, but seemed to be tiring.  Her ABG was done and
showed pH of 7.41; PCO2, 40; PO2, 92.  She can speak in full
sentences but still just making wheezing.  She is requiring
continued nebulizer treatment but denies any chest pain,
nausea, vomiting, diarrhea or abdominal pain.  She feels weak
in general.

PAST MEDICAL HISTORY:
1.  Multiple myeloma diagnosed in [**2107-12-9**], with
increase protein in bone marrow biopsy.  She is to receive
Decadron 40 mg q d every other week.
2.  Pulmonary embolism, [**2108-1-2**].
3.  Asthma.  No PFTs .....................
4.  History of steroid psychosis.
5.  Pneumonia requiring intubation in [**2107-12-9**].

MEDICATIONS UPON ADMISSION:
1.  Coumadin 2.5 mg p.o. q d.
2.  Serevent two puffs q.i.d.
3.  Albuterol inhaler one to two puffs q 6 hours prn.
4.  Dexamethasone 10 mg p.o. q d.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  Socially, she lives with her children and
works at home as a home health aid.  She has twenty years of
two pack a day smoking history but quit in [**2107-12-9**].
She drinks an occasional alcohol.

FAMILY HISTORY:  Family history shows father died of an
myocardial infarction.  Sister with ovarian cancer.

PHYSICAL EXAMINATION UPON ADMISSION:  Temperature, 96.6;
heart rate, 122; blood pressure, 127/82; respiratory rate,
24; O2 saturation, 99%.  Head, eyes, ears, nose and throat,
pupils are equal, round, and reactive to light and
accommodation and extraocular movements intact.  No accessory
muscles are being used.  Neck is supple without
lymphadenopathy.  Pulmonary, diffuse wheezing with bibasilar
crackles with the left greater than right.  Cardiac, regular
rate and rhythm with normal S1 or S2.  No murmurs or thrills
noted.  Abdomen is soft, nontender, nondistended with normal
active bowel sounds.  Extremities, no edema, cyanosis or
clubbing noted.  Neurologically, the patient is somnolent but
oriented x 3.  No focal defects are noted.

LABORATORIES UPON ADMISSION:  White count, 9.6; neutrophils,
66%; lymphocytes, 5%; bandemia, 21%; monocytes, 1%.  Sodium,
131; potassium, 4.4; chloride, 92; bicarbonate, 24.  BUN, 14;
creatinine, 0.8.  Glucose, 131.  INR, 1.3.  PTT, 29.1.  ABG,
7.41; PCO2, 40; PO2, 92.

HOSPITAL COURSE:
1.  Pulmonary - Dyspnea secondary to chronic obstructive
pulmonary disease/emphysema under this hospital course.
Briefly, the patient received BIPAP, ....................,
intravenous Solu-Medrol, nebulizer treatment and inhaler
treatment while in the Intensive Care Unit.  She was able to
be weaned off of the oxygen back to room air, sating to about
93 or 94 percent.

Though her chest x-rays show hyperinflation and no signs of
infection, she was given five days worth of Zithromax.  An
echocardiogram was to rule out any cardiac wheezes which then
showed an ejection fraction of greater than 55%, mild right
ventricular dilation and mild pulmonary arterial pressure.
Pulmonary function tests were performed showing obstructive
pattern with FEC of 2.56 which is 93% of the predicted and
FEV1 of 0.9 which is 43% of the predicted in FEV1 to FEC
ratio of 46%.

When the patient was transferred to the Medical Floor, a CT
was performed showed no evidence of a pulmonary embolism but
did show signs of emphysema.  Sputum cultures were sent and
showed no growth of any organism.  Alpha antitrypsin was sent
out but is still pending.

2.  Pulmonary Embolism - The patient was continued on
Coumadin for an INR between 2 and 3.  Since she was
subtherapeutic, she was started on Lovenox until she became
therapeutic on the Coumadin.

3.  Psychiatry - Anxiety.  The patient was quite anxious
during the hospital course.  Psychiatry was called to consult
and recommended that she be on Risperidone at 0.25 mg q hs.
The patient did well on this medication.

4.  Oncology - Multiple myeloma.  A protein electrophoresis
was done showing a monoclonal IGG capa gammaglobulinopathy
(60% of the total protein in [**2108-1-8**], but now is 66%
of total protein on [**2108-4-9**], despite q weekly
Dexamethasone treatment.  Bone marrow biopsy was done
revealing 70 to 80 percent plasma cells.  Given these
findings, the patient was then transferred to the [**Hospital Ward Name 516**]
for start of chemotherapy with Vincristine,
................... and Decadron in preparation for bone
marrow transplant to be done.



                            [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D.  [**MD Number(1) 8285**]

Dictated By:[**First Name3 (LF) 30667**]
MEDQUIST36

D:  [**2108-4-17**]  15:47
T:  [**2108-4-17**]  15:46
JOB#:  [**Job Number 30668**]

ICD9 Codes: 486, 2761