CHIEF COMPLAINT: Rash

PRESENT ILLNESS: HISTORY OF PRESENT ILLNESS: 44F w maculopapular rash total body
since 5 days ago, starting on chest. This rash has worsened and
she presented to OSH today. She was recently hospitalized for
ETOH hepatitis. Denies any drinking since before [**Holiday 1451**].
.
Also noted increased shortness of breath over past several days,
fever to 102 at PCP [**Name Initial (PRE) 3011**]. Presented to OSH and found to have
PNA --> treated w/ vanc/zosyn; also given benadryl or pruritis.
Transferered to our ED for further care, vitals upon arrival
98.4 92 112/78 18 97%. Also given acyclovir for concern of
herpetic rash and azithromycin.
.
Vitals upon transfer 97.5, 93, 20, 140/73, 98%RA.
.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea,burning in vagina, nose, eyes, or anal mucosa.

MEDICAL HISTORY: Alcohol abuse

MEDICATION ON ADMISSION: 1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Zosyn / meropenem / azithromycin / vancomycin

PHYSICAL EXAM: ON ADMISSION:
VS - Temp 97.5 F, BP 112/68, HR 94, R 18, O2-sat % 100 RA
GENERAL - Slightly uncomfortable in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae slightly icteric. MMM with
torus on roof of mouth. Lips with resolving cold sore.
NECK - supple,
LUNGS - Crackles at left base. No r/rh/wh, good air movement,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

SOCIAL HISTORY: - She has 1 son who is not living with her.
- She was employed until her hospitalization in [**Month (only) 531**] and is
out on FMLA.
- Had her last drink in early [**2103-10-9**].
- She and her sister report no history of polysubstance abuse.
Dermatitis due to drugs and medicines taken internally,Acute respiratory failure,Hepatic encephalopathy,Cryptogenic organizing pneumonia,Acute kidney failure, unspecified,Candidiasis of mouth,Acidosis,Penicillins causing adverse effects in therapeutic use,Other, mixed, or unspecified drug abuse, in remission,Personal history of tobacco use,Chronic kidney disease, unspecified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, in remission,Anemia in chronic kidney disease
Drug dermatitis NOS,Acute respiratry failure,Hepatic encephalopathy,Cryptogenic organiz pneu,Acute kidney failure NOS,Thrush,Acidosis,Adv eff penicillins,Drug abuse NEC-in remiss,History of tobacco use,Chronic kidney dis NOS,Ac alcoholic hepatitis,Alcoh dep NEC/NOS-remiss,Anemia in chr kidney dis
Name:  [**Known lastname 14466**],[**Known firstname 7401**] M                Unit No:   [**Numeric Identifier 14467**]

Admission Date:  [**2103-12-6**]              Discharge Date:   [**2103-12-21**]

Date of Birth:  [**2059-4-15**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / meropenem / azithromycin / vancomycin

Attending:[**First Name3 (LF) 4091**]
Addendum:
Correction to Social History:
- She has 1 son who is not living with her.
- She was employed until her hospitalization in [**Month (only) 531**] and is
out on FMLA.
- Had her last drink in early [**2103-10-9**].
- She and her sister report no history of polysubstance abuse.


Social History:
Correction to Social History:
- She has 1 son who is not living with her.
- She was employed until her hospitalization in [**Month (only) 531**] and is
out on FMLA.
- Had her last drink in early [**2103-10-9**].
- She and her sister report no history of polysubstance abuse.


Discharge Disposition:
Home With Service

Facility:
VNA of [**Hospital3 709**]

                             [**First Name8 (NamePattern2) 1558**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2301**]

Completed by:[**2104-3-8**]

Admission Date:  [**2103-12-6**]              Discharge Date:   [**2103-12-21**]

Date of Birth:  [**2059-4-15**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / meropenem / azithromycin / vancomycin

Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Rash

Major Surgical or Invasive Procedure:
-Endotracheal intubation
-Mechanical Ventilation
-Bronchoscopy
-Dermal Biopsy
-VATS procedure
-Lung biopsy


History of Present Illness:
HISTORY OF PRESENT ILLNESS: 44F w maculopapular rash total body
since 5 days ago, starting on chest. This rash has worsened and
she presented to OSH today. She was recently hospitalized for
ETOH hepatitis. Denies any drinking since before [**Holiday 1451**].
.
Also noted increased shortness of breath over past several days,
fever to 102 at PCP [**Name Initial (PRE) 3011**]. Presented to OSH and found to have
PNA --> treated w/ vanc/zosyn; also given benadryl or pruritis.
Transferered to our ED for further care, vitals upon arrival
98.4 92 112/78 18 97%. Also given acyclovir for concern of
herpetic rash and azithromycin.
.
Vitals upon transfer 97.5, 93, 20, 140/73, 98%RA.
.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea,burning in vagina, nose, eyes, or anal mucosa.


Past Medical History:
Alcohol abuse

Social History:
Lives with his eldest of 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- Smoking: quit > 16 yrs ago, 25 pack year history
- EtOH: history of abuse, denies any alcohol use since last
admission
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. None for 20
years.


Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

Physical Exam:
ON ADMISSION:
VS - Temp 97.5 F, BP 112/68, HR 94, R 18, O2-sat % 100 RA
GENERAL - Slightly uncomfortable in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae slightly icteric. MMM with
torus on roof of mouth. Lips with resolving cold sore.
NECK - supple,
LUNGS - Crackles at left base. No r/rh/wh, good air movement,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - Patient with diffuse erythematous macules coalesing into
patches and plaques most notably on face, chest, back, and
thighs bilaterally. No evidence of nose, mouth, conjunctival, or
anal mucossa involvement. Some secondary excoriations; some of
the lesions may have tiny pustular component.
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
DISCHARGE EXAM:
VS 98.3, 129/72, 69, 18, 97 RA
GENERAL - well-appearing, NAD, comfortable
HEENT - PERRL, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS -  good air movement, no other focal findings, no
accessory musc use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Obese, nontender, no rebound/guarding
EXTREMITIES - significant pitting edema in the lower extremities
bilaterally
SKIN - diffuse errythema without macules or pustules and dry
scaling across all of her skin.
NEURO - awake, A&Ox3, moving all extremities, CNs II-XII grossly
intact

Pertinent Results:
ADMISSION LABS:
[**2103-12-6**] 07:20PM BLOOD WBC-31.2* RBC-2.85* Hgb-8.7* Hct-30.1*
MCV-106* MCH-30.5 MCHC-28.9* RDW-17.7* Plt Ct-537*
[**2103-12-6**] 07:20PM BLOOD Neuts-92.4* Bands-0 Lymphs-4.4*
Monos-0.7* Eos-1.9 Baso-0.6
[**2103-12-6**] 08:45PM BLOOD PT-25.1* PTT-43.8* INR(PT)-2.4*
[**2103-12-6**] 07:20PM BLOOD Glucose-136* UreaN-56* Creat-1.9* Na-136
K-4.7 Cl-106 HCO3-17* AnGap-18
[**2103-12-6**] 07:20PM BLOOD ALT-47* AST-154* LD(LDH)-388*
AlkPhos-314* TotBili-3.1*
[**2103-12-6**] 07:20PM BLOOD Albumin-2.5* Calcium-8.2* Phos-5.4*
Mg-1.9
[**2103-12-6**] 08:59PM BLOOD Lactate-1.5
[**2103-12-6**] 09:30PM URINE RBC-2 WBC-28* Bacteri-NONE Yeast-NONE
Epi-5
[**2103-12-6**] 09:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
.
DISCHARGE LABS:
[**2103-12-21**] 05:12AM BLOOD WBC-31.0* RBC-2.37* Hgb-7.0* Hct-23.2*
MCV-98 MCH-29.5 MCHC-30.2* RDW-19.6* Plt Ct-261
[**2103-12-18**] 04:18AM BLOOD Neuts-94.2* Lymphs-3.1* Monos-2.2 Eos-0.3
Baso-0.3
[**2103-12-19**] 05:03AM BLOOD PT-17.5* PTT-30.6 INR(PT)-1.6*
[**2103-12-21**] 05:12AM BLOOD Glucose-103* UreaN-39* Creat-0.7 Na-140
K-3.5 Cl-106 HCO3-25 AnGap-13
[**2103-12-20**] 05:53AM BLOOD ALT-141* AST-165* AlkPhos-234*
TotBili-2.0*
[**2103-12-19**] 05:03AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.1
.
MICROBIOLOGY:
---------------
#From Lung Biopsy:
   GRAM STAIN (Final [**2103-12-17**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2103-12-20**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

   ACID FAST SMEAR (Final [**2103-12-18**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2103-12-18**]):
      NO FUNGAL ELEMENTS SEEN.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2103-12-18**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

#PLEURAL FLUID      RIGHT PLEURAL FLUID.

   GRAM STAIN (Final [**2103-12-17**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2103-12-20**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

   ACID FAST SMEAR (Final [**2103-12-18**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2103-12-18**]):
      NO FUNGAL ELEMENTS SEEN.

# VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.
   Respiratory Viral Culture (Final [**2103-12-15**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus
# VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
      No Cytomegalovirus (CMV) isolated.

# CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2103-12-16**]):
      Negative for Cytomegalovirus early antigen by
immunofluorescence.
      Refer to culture results for further information.

# BRONCHOALVEOLAR LAVAGE

   GRAM STAIN (Final [**2103-12-12**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2103-12-14**]):
      ~[**2091**]/ML Commensal Respiratory Flora.
      YEAST.    ~[**2091**]/ML.

   LEGIONELLA CULTURE (Final [**2103-12-19**]):    NO LEGIONELLA
ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2103-12-12**]):
      Test cancelled by laboratory.
      PATIENT CREDITED.
      This is a low yield procedure based on our in-house
studies.
      if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
      Aspergillosis or Mucormycosis is strongly suspected,
contact the
      Microbiology Laboratory (7-2306).

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2103-12-13**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Preliminary):
      YEAST.

   ACID FAST SMEAR (Final [**2103-12-13**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


# Legionella Urinary Antigen  (Final [**2103-12-11**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.

#  VARICELLA-ZOSTER IgG SEROLOGY (Final [**2103-12-11**]):
      POSITIVE BY EIA.
      A positive IgG result generally indicates past exposure
and/or
      immunity.

# CMV IgG ANTIBODY (Final [**2103-12-14**]):
      POSITIVE FOR CMV IgG ANTIBODY BY EIA.
      108 AU/ML.
      Reference Range:  Negative < 4 AU/ml, Positive >= 6 AU/ml.


# CMV IgM ANTIBODY (Final [**2103-12-14**]):
      POSITIVE FOR CMV IgM ANTIBODY BY EIA.
      Interpret IgM result with caution; liver disease,
autoimmune and
      lymphoproliferative diseases may cause false positive
results.
      A positive IgG result generally indicates past exposure.
      Infection with CMV once contracted remains latent and may
reactivate
      when immunity is compromised.
      IgM antibody may persist for 6 months or longer after
primary
      infection and may reappear during reactivation.
      Greatly elevated serum protein with IgG levels >[**2091**] mg/dl
may cause
      interference with CMV IgM results.
      Submit follow-up serum in [**1-11**] weeks.

# Blood Culture, Routine (Final [**2103-12-12**]):    NO GROWTH.
# URINE CULTURE (Final [**2103-12-10**]):    <10,000 organisms/ml.
# RAPID PLASMA REAGIN TEST (Final [**2103-12-11**]):  NONREACTIVE.
# HEPATITIS HBsAg    NEGATIVE
# HIV SEROLOGY HIV Ab:  NEGATIVE
# B-GLUCAN (negative)
# HISTOPLASMA ANTIBODY  1:1 (negative)
# COCCIDIOIDES ANTIBODY   1:16 (negative)
# VZV AB IGM, EIA    3.76  H  (positive)
# HSV 1 IGG TYPE SPECIFIC AB    >5.00  (positive)
# HSV 2 IGG TYPE SPECIFIC AB    3.99   (positive)
# HSV 1 IgM, IFA             <1:20 (negative)
          # HSV 2 IgM, IFA             <1:20 (negative)
# ASPERGILLUS ANTIGEN           0.1 (negative)

IMMUNOLOGY:
-------------
# AUTOANTIBODIES Smooth ANCA  NEGATIVE B1
# IMMUNOLOGY [**Doctor First Name **]: NEGATIVE
# GASTROINTESTINAL tTG-IgA 101
# GLOMERULAR BASEMENT MEMBRANE  <1.0  (negative)
# SOLUBLE LIVER ANTIGEN  (SLA)  <20.1 (negative)

IMAGING:
----------
# CXR [**2103-12-7**]:  Bilateral multifocal pneumonias are in a
similar distribution and extent as compared to prior radiograph
from [**2103-12-6**]. However, some of these cavitations are
showing central lucencies which is concerning for cavitation.
Bilateral small pleural effusions are present, which are
unchanged. Top normal heart size, mediastinal and hilar contours
are stable.

# Abdominal US [**2103-12-7**]:
1. Patent hepatic vasculature.
2. Cholelithiasis without cholecystitis or intra-/extra-hepatic
biliary
dilatation.
3. Echogenic liver, compatible with fatty infiltration, although
other forms
of cirrhosis/fibrosis cannot be excluded.
4. Trace ascites and splenomegaly.

# Chest CT [**2103-12-8**]:
1. Diffuse ground-glass opacities in both lungs some of which
are nodular,
but not cavitated, most likely representing multifocal
pneumonia.
2. The moderate right pleural effusion and scattered
mediastinal, hilar,
axillary lymph nodes are likely reactive.

# Chest CT [**2103-12-11**]:
1. Extensive largely interstitial infiltration and
nonconsolidated alveolitis worsened throughout both lungs.
Pulmonary hemorrhage and viral pneumonia would be leading
possibilities. Smaller regions of consolidation are less
prominent today than five days ago, suggesting some improvement
in what might have been smaller foci of severe hemorrhage or
pneumonia due to another pathogen. Since there has been an
increase in a moderate nonhemorrhagic pleural effusion,
pulmonary edema is an alternative third explanation for the
widespread pulmonary abnormality.

#  ECHO [**2103-12-13**]:
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is 5-10 mmHg. 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 diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild-moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.

IMPRESSION: No endocarditis or abscess seen. Normal regional and
global biventricular systolic function. Mild-moderate pulmonary
artery systolic hypertension.

# CXR [**2103-12-19**]:
In comparison with the study of [**12-18**], the endotracheal tube and

nasogastric tubes have been removed. Following chest tube
removal, there is no definite evidence of pneumothorax. Diffuse
bilateral pulmonary
opacifications persist, though they may be somewhat decreased
since the
previous study. The appearance probably reflects a combination
of pulmonary edema and multifocal pneumonia.

# CXR [**2103-12-21**]:

PATHOLOGY:
----------
# RUE Biopsy:
Skin, right upper arm, punch biopsy (A):

Focal intraepidermal pustule, mild spongiosis, dyskeratosis, and
superficial perivascular infiltrate with focal neutrophils and
rare eosinophils.

Note: The pustule appears in deeper sections.  The combined
findings of an intraepidermal pustule, dyskeratosis, and dermal
eosinophils favors a pustular drug eruption or acute generalized
exanthematous pustulosis (AGEP).  AGEP is usually due to a drug,
however, rarely cases may be associated with a bacterial or
viral infection.  Gram stain is negative for bacteria.
Preliminary findings discussed with Dr. [**Last Name (STitle) **], Dermatology on
[**2103-12-15**].

# LUNG BIOPSY:
I.  Lung, lower lobe superior segment, wedge biopsy (A-E):
Acute and organizing pneumonia with hemorrhage, see note.

II.  Lung, right upper lobe, wedge biopsy (F-K):
Acute and organizing pneumonia with hemorrhage, see note.

III.  Lung, right middle lobe, wedge biopsy (L-M):
Acute and organizing pneumonia with hemorrhage, see note.

Note: Likely causes include viral and bacterial etiologies.
Special stains for bacterial organisms, fungi, and PCP will be
issued in an addendum.

PULMONARY FUNCTION TESTS:
SPIROMETRY 10:05 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred %chg
FVC   1.54 3.68 42
FEV1   1.32 2.84 47
MMF   1.72 3.19 54
FEV1/FVC   86 77 112

LUNG VOLUMES 10:05 AM Pre drug Post drug
    Actual Pred %Pred Actual %Pred
TLC   2.51 5.54 45
FRC   1.30 3.01 43
RV   0.98 1.86 53
VC   1.56 3.68 42
IC   1.21 2.53 48
ERV   0.31 1.15 27
RV/TLC   39 34 117
He Mix Time   2.25

DLCO 10:05 AM
    Actual Pred %Pred
DSB   9.21 21.31 43
VA(sb)   2.03 5.54 37
HB   7.50
DSB(HB)   12.20 21.31 57
DL/VA   6.01 3.84 156


Brief Hospital Course:
ASSESSMENT AND PLAN: 44F with recent alcoholic hepatitis who
presented with shortness of breath, leukocytosis, fever, rash.
She was treated with vanc and zosyn at an outside hosptial for
possible hospital acquired pneumonia based on CXR.  Her rash was
felt to be related to a drug reaction and despite removing the
most likely offending [**Doctor Last Name 360**] (zosyn) her respiratory status
worsened and she was treated with IV steroids.  Her rash evolved
in this setting and initial concern for dismemiated zoster was
raised, this ultimately was not felt to be the cause of her skin
or lung pathology.  As patient had worsening hypoxia and
increase in interstitial process seen on interval Chest CTs
despite antibacterial and antiviral therapy a bronchoscopy was
preformed which did not show evidence of bacterial infection.
The patient was started again on IV steroids and a lung biopsy
by VATS preformed for evaluation of her lung process.  Pathology
demonstrated both a chronic cryptogenic organizing pneumonia as
well as a more acute process with evidence of alveolar
hemorrhage.  The patient improved with steroids after a total of
three trips to the ICU for respiratory distress.  She was
transitioned to PO steroids and had marked improvement in her
oxygenation and rash.  She was discharged to follow up with her
PCP, [**Name10 (NameIs) **] hepatologist and pulmonologist with a plan for drug
allergy testing at a later date.
.
# AGEP:  The patient presented from an outside hospital after
developing a diffuse errythematous, puritic and pustulitic drug
rash over her limbs, trunk and face.  This occured approx 10
days after completing a course of vanc/zosyn for a hospital
acquirred pneumonia during a previous admission.  Drematology
saw the patient on presentation and felt it was likely a simple
drug rash that would improve with cesation of the causitive
[**Doctor Last Name 360**], most likely felt to be zosyn.  Patient did recieve this
medication prior to transfer from the OSH complicating the
evolution of her drug rash.  The rash worsened over the next
several days despite conservative managment developing diffuse
pustules initially concerning for diseminated zoster.  IgG was
positive and IgM for viracella was positive as well, patient
recieved a 7 day course of acyclovir while her pulmonary process
was evaluated out of convern for a zoster pneumonitis.  A skin
biopsy was preformed which showed acute generalized
errythematous pustulosis, a rare neutrophil mediated drug
reaction.  The patient ultimately recieved 5 days of IV
solumedrol prior to being converted to 60 mg prednisone with
marked improvement in her rash.
.
# Acute on Chronic Cryptogenic Organizing Pneumonia:  prior to
discharge from [**Hospital1 18**] in mid [**2103-11-8**] the patient developed
respiratory distress and found to have a presumed multifocal
pneumonia and was treated with vanc/zosyn for likely healthcare
associated pneumonia.  10 days after her exposure to these drugs
she developed the drug rash outlined above.  She also reports an
indolent history of SOB and DOE prior to her [**Month (only) 1096**] admission.
 Upon presentation to the OSH as CXR showed multifocal pneumonia
for which she recieved vanc/zosyn, on arrival to [**Hospital1 18**] this was
changed to Vanc/meropenem out of concern for drug rash.  As her
skin improved her respiratory status worsened despite
antibiotics, Chest CT was preformed which showed diffuse ground
glass opacities concerning for pneumoina.  Her respiratory
status continued to deteriorate and a pulmonary consult
preformed a bronchoscopy which was not reveiling.  Prior to this
procedure, which was preformed in the ICU, the patient developed
stridor and was started on solumedrol.  ENT evaluated the
patient and did not find evidence of layrngeal inflammation.  As
her interval chest imgaging continued to show worsening of her
inflammatory process with steroids a VATS procedure for biopsy
was preformed.  Pathology demonstrated both a chronic
cryptogenic organizing pneumonia as well as a more acute process
with evidence of alveolar hemorrhage.   The decision was made to
continue steroids as infectious processes for her lung pathology
were excluded by multiple cultures and serologies.  She improved
dramatically with this treatment and was no longer hypoxic.  She
had PFTs which showed a restrictive pattern and the patient was
discharged on 60 mg prednisone daily, bactrim ppx, vitamin D and
Calcium for a steroid course to be determined by outpatient
pulmonology.
.
# Elevated LFTs:  The patient was noted to have elevated AST and
ALT as well as T bili from the time of discharge 2 weeks prior.
This was initially felt to be possibly related to a DRESS
phenomenon, though ultimately acute illness was the likely
cause.  Abdominal Ultrasound did not show acute liver process.
Her LFTs continued to fluctate over the course of her stay, but
she did not have signs of hepatic compromise.  She will follow
up with her primary hepatologist after discharge.
.
# Acute on chronic renal failure:  patient had rise in her
creatinine to 1.8 over the course of her stay, renal ultrasound
was normal and patient responded to albumin challenge.  She had
urine eosinophils suggesting that the actue drug reaction may
have caused a transient nephritis at the time of discharge her
creatinine was 0.8.
.
# Leukocytosis:  Patient was noted to have a leukocytosis of
30-40 over the course of her hospitalization.  This was felt to
be secondary to her alcoholic hepatitis and not an infectious
process.  She was discharged with a leukocytosis in the 30s that
was normal for her.
.
# Hypercarbic failure:  Post VATS procedure and extubation the
patient was noted to be hypercarbic with a pH of 7.19.  This was
felt to be secondary to poor clearance of her anastehtic agents
due to hepatic insufficency and the patient was reintubated and
sent to the ICU.  She was extubated 24 hours later without
incident.
.
# Oral Candidiasis:  Patient was noted to have non-painful
candidial placques on her mouth and tounge in the setting of
high dose steroids.  She was given nystatin oral rinse without
response adn was therefore treated with a 7 day course of oral
fluconazole to be completed as an outpatient.
.
# Leg Swelling:  felt to be secondary to hepatic chirrosis and
vascular congestion, but patient was having improvement with
diuresis with lasix.  Was discharged on 80 mg lasix and 25 mg
spirinolactone daily.
.
TRANSITIONAL ISSUES:
-Patient is a full code confirmed on this admission
-Patient will need to undergo allergy testing 1-2 months after
resolution of her acute illness as the specific [**Doctor Last Name 360**] has yet to
be identified and carrying unconfirmed allergies to such broad
spectrum antibiotics would severely limit future antibiotic
regimens.


Medications on Admission:
1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

Disp:*30 Tablet(s)* Refills:*0*
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a

day).
Disp:*60 Tablet(s)* Refills:*0*
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed) as needed for rectal irritation.
Disp:*1 tube* Refills:*0*
6. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO twice a

day.
Disp:*1800 ML(s)* Refills:*1*
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
9. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,

Rapid Dissolve PO every twelve (12) hours as needed for nausea.



Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing/SOB.
Disp:*1 inhaler* Refills:*2*
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
Disp:*1 tube* Refills:*10*
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
5. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*0*
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
10. calcium carbonate-vitamin D3 500mg (1,250mg) -600 unit
Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA of [**Hospital3 **]

Discharge Diagnosis:
PRIMARY:
-Cryptogenic organizing pneumomina
-acute pulmonary inflammation
-acute generalized errythematous pustulosis (drug reaction)
-alcholic hepatitis
-acute renal failure
-hypercarbic respiratory failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital.  You were admitted for evaluation and treatment of
your rash, which was felt to be an allergic reaction to
antibiotics.  We are not sure which antibiotic caused this as
you were exposed to several including:  Vancomycin, zosyn,
meropenem and azithromycin.  The most likely cause was zosyn
however.  You will need to have allergy testing in the next few
months to determine which antibiotics are safe for you to take.
Your skin was biopsied and confirmed a drug reaction called
acute generalized errythematous pustulosis or AGEP.  This rash
improved with topical creams and systemic steroids.
.
You were also transfered to the [**Hospital1 18**] with concern for a
pneumonia.  You recieved antibiotics at the outside hospital
that may have contributed to the worsening of your rash and upon
arrival to [**Hospital1 18**] these were changed and you continued to be
treated for a bacterial pneumonia.  Despite antibiotics your
breathing and oxygenation actually got worse and you were seen
by our pulmonologists who felt that your rash and breathing
could have been caused by a severe case of chicken pox, you were
treated for this but ultimately this was not felt to be the
cause of your sypmtoms.  A CT scan of your chest showed a large
amount of inflammation in your lungs that despite steroids and
antibiotics got worse on a repeat scan two days later.  You were
brought to the ICU for a procedure called a bronchoscopy and
cultures were sent from this material which were negative.  As
it was not clear to any of the doctors [**Name5 (PTitle) 40087**] for [**Name5 (PTitle) **] whether
you had an infection or an allergic reaction in your lungs a
lung biopsy was preformed.  You tolerated the procedure well,
but were slow to wake up so you were sent to the ICU for
monitoring overnight.  The biopsy results were unexpected.  It
appears that part of your lung was affected by a chronic
condition called cryptogenic organizing pneumonia while other
parts of your lung were affected by more acute inflammation.
You likely developed the chronic condition prior to your
hospitalization in early [**Month (only) 1096**] and during this most reccent
hospitalization had acute inflammation from a viral infection.
Both of these processes are treated with steroids and you
improved greatly with steroids while in the hospital.  You were
discharged on steroids and will follow up with our
pulmonologists in a few weeks to determine the course of
treatment.  You should continue to quit smoking and avoid any
contact with smokers while your lungs heal.

Your liver enzymes were also noticed to be elevated which was
felt to be from an acute stress on your liver from your acute
illness.  You do still have signs of the alcoholic hepatitis
that you were admitted for in [**Month (only) **].  You will need to follow
up with your liver doctor Dr. [**First Name (STitle) 679**] in a few weeks.  We recommend
that you continue to abstain from drinking and attend AA
meetings as you have expressed interest in.  Continuing to drink
will have severe consequences to your health and may very well
kill you.

You will be discharged home on prednisone which is a steroid.
As you will be on this medication for several weeks you will
need to take a medication called bactrim daily to prevent
infections, vitamin D and calcium to prevent osteoperosis.  You
have a fungal infeciton in your mouth from these steroids that
you will treat with a medication called fluconazole for the next
7 days.

The following changes were made to your medications:
-START Fluconazole 200 mg daily for 6 more days
-START Prednisone 60 mg daily
-START Vitamin D/Calcium supplement daily
-START Bactrim SS 1 tablet daily
-START Lasix 80 mg daily
-START Spironolactone 25 mg daily
-START Albuterol 2 puffs every 6 hours as needed for wheezing
-START Moisturizing lotion daily

-CONTINUE Lactulose 30 ml twice daily
-CONTINUE Rifaximin 550 mg twice daily
-CONTINUE Pantoprazole 50 mg daily

-CONTINUE

Followup Instructions:
Name: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Address: 99 [**Location (un) **] STRAITS, [**Hospital1 **],[**Numeric Identifier 19665**]
Phone: [**Telephone/Fax (1) 72602**]
*It is recommended that you see your primary care doctor within
one week. Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 91911**] office to schedule an
appointment.

Name: [**Last Name (LF) **],[**First Name3 (LF) **]/GASTROENTEROLOGY
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 682**]
When: [**Last Name (LF) 766**], [**12-31**], 2:15 PM

Department: PULMONARY FUNCTION LAB
When: [**First Name3 (LF) **] [**2104-1-21**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES/PULMONARY
When: [**Hospital Ward Name **] [**2104-1-21**] at 11:00 AM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: DIV OF ALLERGY
When: THURSDAY [**2104-2-7**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS     Best Parking: Parking on Site
{'Dermatitis due to drugs and medicines taken internally,Acute respiratory failure,Hepatic encephalopathy,Cryptogenic organizing pneumonia,Acute kidney failure, unspecified,Candidiasis of mouth,Acidosis,Penicillins causing adverse effects in therapeutic use,Other, mixed, or unspecified drug abuse, in remission,Personal history of tobacco use,Chronic kidney disease, unspecified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, in remission,Anemia in chronic kidney disease'}


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: Rash

PRESENT ILLNESS: HISTORY OF PRESENT ILLNESS: 44F w maculopapular rash total body
since 5 days ago, starting on chest. This rash has worsened and
she presented to OSH today. She was recently hospitalized for
ETOH hepatitis. Denies any drinking since before [**Holiday 1451**].
.
Also noted increased shortness of breath over past several days,
fever to 102 at PCP [**Name Initial (PRE) 3011**]. Presented to OSH and found to have
PNA --> treated w/ vanc/zosyn; also given benadryl or pruritis.
Transferered to our ED for further care, vitals upon arrival
98.4 92 112/78 18 97%. Also given acyclovir for concern of
herpetic rash and azithromycin.
.
Vitals upon transfer 97.5, 93, 20, 140/73, 98%RA.
.
REVIEW OF SYSTEMS:
Denies chills, night sweats, headache, vision changes,
rhinorrhea,burning in vagina, nose, eyes, or anal mucosa.

MEDICAL HISTORY: Alcohol abuse

MEDICATION ON ADMISSION: 1. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Zosyn / meropenem / azithromycin / vancomycin

PHYSICAL EXAM: ON ADMISSION:
VS - Temp 97.5 F, BP 112/68, HR 94, R 18, O2-sat % 100 RA
GENERAL - Slightly uncomfortable in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae slightly icteric. MMM with
torus on roof of mouth. Lips with resolving cold sore.
NECK - supple,
LUNGS - Crackles at left base. No r/rh/wh, good air movement,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. (Has identical twin brother
without above conditions). Grandfather with diabetes.

SOCIAL HISTORY: - She has 1 son who is not living with her.
- She was employed until her hospitalization in [**Month (only) 531**] and is
out on FMLA.
- Had her last drink in early [**2103-10-9**].
- She and her sister report no history of polysubstance abuse. 

### Response:
{'Dermatitis due to drugs and medicines taken internally,Acute respiratory failure,Hepatic encephalopathy,Cryptogenic organizing pneumonia,Acute kidney failure, unspecified,Candidiasis of mouth,Acidosis,Penicillins causing adverse effects in therapeutic use,Other, mixed, or unspecified drug abuse, in remission,Personal history of tobacco use,Chronic kidney disease, unspecified,Acute alcoholic hepatitis,Other and unspecified alcohol dependence, in remission,Anemia in chronic kidney disease'}
