CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers, and asthma who presented to
[**Hospital1 **] [**Location (un) 620**] on [**10-7**] with the course described below:

MEDICAL HISTORY: - LGL on low dose methotrexate, last dose in [**2103-7-30**] at [**Hospital1 112**]
- Anemia.
- Asthma.
- Multiple bilateral leg ulcerations due to reported VZV
- hyperglandular autoimmune syndrome(hypoparathyroidism and
adrenal insufficiency
- h/o cervical dysplasia
- HTN
- h/o seizure
- CKD, stage 1
- Osteopenia

MEDICATION ON ADMISSION: Oxycodone 10 mg Oral Tablet 1 tab q6h prn for pain
  Valacyclovir 1 g Oral Tablet 1 tab po bid for 28 days (THROUGH
[**10-5**])
  Prednisone 5 mg Oral Tablet 1 po qd
 Lorazepam 1 mg Oral Tablet 1 tablet at bedtime as needed
 Mirtazapine (REMERON) 30 mg Oral Tablet 1 QHS PRN
 Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) taking 2
capsules a day
  Methotrexate Sodium 2.5 mg Oral Tablet 8 TABLETS EVERY
SATURDAY
  MAGNESIUM CHLORIDE ORAL 3 400MG TABS DAILY
  Cyclobenzaprine 10 mg Oral Tablet Take 1 tablet at bedtime as
needed for muscle spasm
 Cyanocobalamin, Vitamin B-12, 1,000 mcg/mL Injection Solution
1000mcg IM monthly
 Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
 Betamethasone Dipropionate 0.05 % Topical Cream apply po bid
topically
 Calcitriol 0.25 mcg Oral Capsule Take 2 cap(s) orally twice a
day or uad
 Potassium Chloride (K-DUR) 20 mEq Oral TbTQ mo,we,fr 20meq
  MEGACE ES ORAL as needed
 FLORINEF 0.1 MG TAB (FLUDROCORTISONE ACETATE) 2 tabs daily
 NYSTATIN 100,000 UNIT/ML ORAL SUSP

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission to ICU:
Vitals: 98.7  93/68  114  26  97% 50%bipap
General: Alert, oriented (though initially says at [**Hospital1 112**]), no
acute distress

FAMILY HISTORY: NC

SOCIAL HISTORY: She lives at home with her children age 23 and 28.  She is
independent. She denies tobacco, alcohol, or illicit drug use.
Other pulmonary embolism and infarction,Pneumonia due to Pseudomonas,Acute respiratory failure,Unspecified pleural effusion,Malnutrition of moderate degree,Glucocorticoid deficiency,Chickenpox with other specified complications,Ulcer of other part of lower limb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Autoimmune lymphoproliferative syndrome,Asthma, unspecified type, unspecified,Hypoparathyroidism,Chronic kidney disease, Stage I,Anemia, unspecified
Pulm embol/infarct NEC,Pseudomonal pneumonia,Acute respiratry failure,Pleural effusion NOS,Malnutrition mod degree,Glucocorticoid deficient,Varicella complicat NEC,Ulcer oth part low limb,Hy kid NOS w cr kid I-IV,Autoimmun lymphprof synd,Asthma NOS,Hypoparathyroidism,Chro kidney dis stage I,Anemia NOS
Admission Date:  [**2103-10-14**]              Discharge Date:   [**2103-10-23**]

Date of Birth:  [**2054-8-15**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
dyspnea


Major Surgical or Invasive Procedure:
central line placed at [**Hospital1 **] [**Location (un) 620**], replaced at [**Hospital1 18**] ICU and
removed prior to discharge

History of Present Illness:
49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers, and asthma who presented to
[**Hospital1 **] [**Location (un) 620**] on [**10-7**] with the course described below:

She was initially thought to have sepsis either from leg ulcer
infection, urinary or pulmonary source, and was initially
treated with Ceftriaxone and vancomycin, which was then changed
to unasyn, then evenutally to zosyn. She had initially been on
levophed and hydorcortisone as well, which were then weaned off.
She has been off pressors for 4 days. Urine culture grew Beta
hemolytic strep. Her wound culture grew Staphylococcus which
were sensitive to cephalosporins. She is transferred to us on
zosyn alone.
.
Also in the differential for her hypotension (and accompanying
tachycardia) was PE, and a VQ scan was done on [**10-7**] which was
low probability, so HR's in the 110-140's attributed to
deconditioning and anxiety. She had initially been on heparin
gtt, which was d/c'ed when VQ scan was low prob; she had been
maintained on lovenox SQ for DVT ppx per report. Also of note,
she was noted to be volume overloaded and received lasix during
her hospitalization eventually requiring intermittent BiPAP as
well.
.
Non-contrast CT Chest (b/c of renal failure) was then done on
[**10-13**] which showed large pleural effusions and also bilateral
subsegmental PE.  The patient was seen by cardiology and
pulmonology, and she diuresed adequately, about 7 liters. The
CVP initially was 18 and then improved to 4 this morning.
Despite the significant diuresis, her hypoxia has not improved
much.  She is still on BiPAP and requires 100% F1O2 (down to 50%
at time of transfer). Currently, she is on  Lovenox,
weight-based, twice a day and Coumadin was started for treatment
of her PE.
.
Her CT Chest also showed that she also has somewhat worsening of
air space disease with pneumonia and significant pleural
effusion and signs of congestive heart failure. During her
course, zosyn was added for pneumonia coverage and vancomycin
has been stopped. Again she remains on zosyn alone for
antibiotics upon transfer.
.
On transfer, she has no complaints. She reports her breathing is
"okay," and she is hungry. 30 minutes after arrival, she was
somnolent and ABG showed 7.45/70/94/50 on nasal cannula,
however, she was back to being interactive and asking for food
an hour later with no intervention.
.
(+) Per HPI. + ulcers (started as bumps last month, now
progressed to disseminated VZV per [**Hospital1 112**] providers)
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency.


Past Medical History:
- LGL on low dose methotrexate, last dose in [**2103-7-30**] at [**Hospital1 112**]
- Anemia.
- Asthma.
- Multiple bilateral leg ulcerations due to reported VZV
- hyperglandular autoimmune syndrome(hypoparathyroidism and
adrenal insufficiency
- h/o cervical dysplasia
- HTN
- h/o seizure
- CKD, stage 1
- Osteopenia


Social History:
She lives at home with her children age 23 and 28.  She is
independent. She denies tobacco, alcohol, or illicit drug use.


Family History:
NC


Physical Exam:
On admission to ICU:
Vitals: 98.7  93/68  114  26  97% 50%bipap
General: Alert, oriented (though initially says at [**Hospital1 112**]), no
acute distress

HEENT: Sclera anicteric, MM dry, oropharynx clear with no e/o
thrush

Neck: supple, no LAD

Lungs: b/l bronchial breath sounds, dullness to percussion to
mid lung fields

CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops

Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding

Ext: warm, well perfused, 2+ pulses, bilateral multiple 2mm
ulcerating lesions on LE, with violaceous borders. RLE ulcer to
tendon. Bilateral upper extremity ulcers as well.


Pertinent Results:
On admission:

[**2103-10-14**] 03:00PM BLOOD WBC-10.5 RBC-2.86* Hgb-10.3* Hct-31.5*
MCV-110* MCH-36.2* MCHC-32.9 RDW-21.6* Plt Ct-346
[**2103-10-14**] 03:00PM BLOOD PT-12.8 PTT-37.1* INR(PT)-1.1
[**2103-10-14**] 03:00PM BLOOD Glucose-81 UreaN-13 Creat-1.0 Na-145
K-4.0 Cl-92* HCO3-46* AnGap-11
[**2103-10-14**] 03:00PM BLOOD ALT-15 AST-19 LD(LDH)-295* AlkPhos-49
TotBili-0.3
[**2103-10-14**] 03:00PM BLOOD Albumin-2.9* Calcium-7.2* Phos-4.9*
Mg-2.4 Iron-36
[**2103-10-14**] 03:00PM BLOOD calTIBC-195 VitB12-1407* Folate-GREATER
TH Ferritn-453* TRF-150*
[**2103-10-14**] 02:50PM BLOOD Type-ART pO2-94 pCO2-70* pH-7.45
calTCO2-50* Base XS-19 Intubat-NOT INTUBA
[**2103-10-15**] 04:03AM BLOOD freeCa-0.88*

Micro:
OSH blood cx [**10-7**]: NGTD x 2 sets
OSH blood cx [**10-13**]: NGTD x 2 sets
Urine cx [**10-7**]: 50,000-100,000 Group B strep
Urine cx [**10-13**]: prelim no growth
Ulcer Skin swab [**10-8**]:
POLYS /LOW POWER FIELD: >25 POLYS SEEN
GRAM POS COCCI,CLUSTERS: FEW
GRAM POS COCCI, PAIRS: MODERATE
GRAM NEG BACILLI: FEW
GRAM POS BACILLI, SMALL: FEW
> Skin Lesion/Superficial Cult Final 10/13/11-1005
Light growth Normal skin flora
Organism 1 STAPHYLOCOCCUS AUREUS
GROWTH: MODERATE GROWTH
Organism 2 BETA HEMOLYTIC STREP GROUP G
GROWTH: MODERATE GROWTH
1. STAPHYLOCOCCUS AUREUS
Target Route Dose RX AB Cost M.I.C. IQ
------ ----- ------------------ ------ -- ------ ---------
------
CEFAZOLIN S
CIPROFLOXACIN S <=0.5
CLINDAMYCIN S <=0.25
ERYTHROMYCIN S <=0.25
GENTAMICIN S <=0.5
INDUCIBLE CLIND - NEG
LEVOFLOXACIN S 0.25
LINEZOLID S 2
BENZYLPENICILLI R 0.12
OXACILLIN S <=0.25
TETRACYCLINE S <=1
TRIM/SULFA S <=10
VANCOMYCIN S <=0.5
.
Images:
[**10-13**]: Chest CT
Filling defects are seen in the right upper lobe pulmonary
artery, right middle lobe pulmonary artery and subsegmental
branches of the left lower lobe. Moderate-to-large bilateral
pleural effusions noted. There are air space consolidations
especially in the upper lobes. Similar changes with associated
volume loss noted in the lower lobes along with compressive
atelectasis secondary to the pleural effusions. No definite
adenopathy is seen. Bone windows do not show any suspicious
findings.
.
CONCLUSION: PULMONARY EMBOLI. BILATERAL UPPER LOBE AIR SPACE
CONSOLIDATIONS. CONSOLIDATIONS WITH VOLUME LOSS/ATELECTASIS AT
THE LOWER LOBES BILATERALLY AS WELL AS BILATERAL PLEURAL
EFFUSIONS.
.
Abdominal U/S [**10-13**]
CLINICAL HISTORY: Rule out gallstones/pancreatitis.
FINDINGS: There is a small right pleural effusion. Visualized
image appears normal. Normal gallbladder. No gallstones. No
obvious dilated bile ducts. The pancreatic is slightly
heterogeneous in echotexture but no definite calculi or evidence
for pancreatitis was seen in the visualized portions of the
pancreas. No peripancreatic fluid or pseudocyst identified.
.
CONCLUSION:
EXTREMITY LIMITED EXAMINATION. NORMAL GALLBLADDER. NO
SIGNIFICANT ABNORMALITIES ARE IDENTIFIED IN THE PANCREAS BUT THE
ASSESSMENT OF THE PANCREAS IS INCOMPLETELY. IF CLINICAL
SUSPICION FOR PANCREATITIS IS HIGH, CT SCAN IS RECOMMENDED.
.
CXR [**10-13**]
IMPRESSION:
CONGESTIVE FAILURE, NEW AIR SPACE OPACITIES, COULD REPRESENT
ASPIRATION VERSUS PNEUMONIA, BILATERAL PLEURAL EFFUSIONS MILDLY
INCREASED SINCE PRIOR STUDY. elevated R hemidiaphragm.
.
VQ scan [**10-7**]
LOW PROBABILITY OF PULMONARY EMBOLISM. MINOR IRREGULARITIES OF
VENTILATION PERFUSION PRIMARILY AT THE BASES.
.


Brief Hospital Course:
49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers due to biopsy proven
varicella, and asthma who initially presented to [**Hospital1 **] [**Location (un) 620**] on
[**10-7**] with hypotension and tachycardia which was thought to be
sepsis from leg ulcer infection vs urinary tract infection.
Patient initially required levophed gtt plus hydrocortisone -
both of which weaned off for 4 days prior to transfer.  Patient
was initially treated with ceftriaxone and vancomycin then
changed to amp/sulbactam and eventually switched to pip/tazo (?
pneumonia).  Her urine culture grew beta hemolytic strep and leg
wound cultre grew MSSA.  On [**2103-10-13**] patient was found to have
bilateral subsegmental PE's and large pleural effusions on
non-contrast chest CT (no contrast due to renal failure).
Patient was started on lovenox and diuresed approximately 7
liters.  Per report her CVP (via L. subclavian) improved from 18
to 4 after diuresis.  Despite diuresis patient still had high
oxygen requirements (50% FiO2) therefore transferred to [**Hospital1 18**]
ICU for further management.
.
On transfer patient was reportedly AAO x 3 with sbp in 80s-90s
(reported baseline) and satting well on 50% FiO2.  Of note,
thirty minutes after arrival patient was somnolent (abg
7.45/70/94/50) which resolved without any intervention.  Patient
was transitioned from lovenox to heparin gtt.  She was given 20
iv lasix with net 1.6L out and oxygen weaned down to 35% face
tent (does not tolerate nasal canula due to nose bleeds).  ICU
team contact[**Name (NI) **] Dr. [**Last Name (STitle) 67458**] (patient's oncologist at [**Hospital1 112**]) who
verified that her LE ulcers have recently been biopsied and are
varicella.  Patient was not continued on antibiotics as had
alread received 7 days of gram negative coverage for possible
pneumonia without fever or cough.  Also had received a complete
course of antibiotics for UTI.  Low suspicion for secondary
infection of varicella ulcers.
.

ACTIVE ISSUES:

## Hypoxic and hypercarbic respiratory failure: Initially
presented on BiPAP 50% mask, weaned off to nasal cannula.
Hypoxemia was thought to be due to known pulmonary embolism and
concomitant volume overload. She was given 20mg iv lasix x 2
doses during ICU course with good urine output.  She was
continued on heparin gtt for subsegmental bilateral PEs with
improvement in oxygenation.

## Hypotension: Maintained on home dose of prednisone and
florinef for known adrenal insfufficiency.  Pressor was only
required at [**Hospital1 **]: multifactorial due to PE and possible
pneumonia.

## Pulmonary Embolism: CTA of chest at [**Hospital1 **] [**Location (un) 620**] done on [**10-13**]
showed filling defects right upper lobe pulmonary artery, right
middle lobe pulmonary artery, and subsegmental branches of the
left lower lobe.  She was initially placed on Heparin. She
underwent TTE on [**2103-10-16**] that showed an EF>55% and normal RV
function with systolic flattening and possible RV pressure
overload but no overt RV strain.
Coumadin dosing thus far
[**10-16**] INR 1.2, coumadin 5mg started
[**10-17**] INR 1.4, coumadin 5mg
[**10-18**] INR 5.9, no coumadin given
[**10-19**] INR 13, Vit K 5mg po given (epistaxis)
[**10-20**] INR 1.6, coumadin 2mg
[**10-21**] INR 2, coumadin 2mg
[**10-22**] INR 4, coumadin 1mg
[**10-23**] INR 5, discharged, instructed not to take coumadin this
afternoon, with plans for daily INR checks until dosing has been
established.

## Disseminated Varicella: Biopsies of lower extremity ulcers
showed Varicella. She was treated with Valacyclovir and local
wound care with good effect. General surgery evaluated wond on
[**10-19**] and felt that they are not infected and do not need
further debridement. She can follow-up with Dr. [**First Name (STitle) 44989**] [**Name (STitle) 108877**]
(Dermatology at [**Hospital1 **], [**Numeric Identifier **])

## Sinus tachycardia: This could have been multi-factorial in
setting of PE and possible volume depletion after aggressive
diuresis in the ICU. She was monitored on Telemetry and had no
events. Her rhythm remained in sinus. She was scheduled for an
outpatient cardiology evaluation given her year-long history of
tachycardia.

## Clonal NK cell lymphopriliferative disorder: followed at [**Company 2860**]
by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. She was previously on methotrexate which
has been held given her varicella skin infection. Further
management will take place as outpatient.

## Adrenal insufficiency:  She was continued on home dose of
Prednisone and Florinef.

Medications on Admission:
Oxycodone 10 mg Oral Tablet 1 tab q6h prn for pain
  Valacyclovir 1 g Oral Tablet 1 tab po bid for 28 days (THROUGH
[**10-5**])
  Prednisone 5 mg Oral Tablet 1 po qd
 Lorazepam 1 mg Oral Tablet 1 tablet at bedtime as needed
 Mirtazapine (REMERON) 30 mg Oral Tablet 1 QHS PRN
 Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) taking 2
capsules a day
  Methotrexate Sodium 2.5 mg Oral Tablet 8 TABLETS EVERY
SATURDAY
  MAGNESIUM CHLORIDE ORAL 3 400MG TABS DAILY
  Cyclobenzaprine 10 mg Oral Tablet Take 1 tablet at bedtime as
needed for muscle spasm
 Cyanocobalamin, Vitamin B-12, 1,000 mcg/mL Injection Solution
1000mcg IM monthly
 Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
 Betamethasone Dipropionate 0.05 % Topical Cream apply po bid
topically
 Calcitriol 0.25 mcg Oral Capsule Take 2 cap(s) orally twice a
day or uad
 Potassium Chloride (K-DUR) 20 mEq Oral TbTQ mo,we,fr 20meq
  MEGACE ES ORAL as needed
 FLORINEF 0.1 MG TAB (FLUDROCORTISONE ACETATE) 2 tabs daily
 NYSTATIN 100,000 UNIT/ML ORAL SUSP


Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): Please complete the valacyclovir that you have
remaining at home.
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety.
8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. magnesium chloride  Oral
14. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
15. Megace Oral 625 mg/5 mL Suspension Oral
16. nystatin 100,000 unit/mL Suspension Sig: One (1)  PO three
times a day as needed for thrush.
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO qmwf.
18. betamethasone dipropionate  Topical
19. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1)  Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
20. warfarin 1 mg Tablet Sig: 0.5 Tablet PO once a day: Only
take as directed by coumadin clinic. Only take at 4pm .
Disp:*15 Tablet(s)* Refills:*2*
21. Cut N Crush     Misc Sig: One (1)  Miscellaneous once:
patient will need pill cutter to cut coumadin tabs.
Disp:*1 1* Refills:*2*
22. Outpatient Lab Work
Daily INR check ([**10-24**], [**10-25**], [**10-26**], [**10-27**]) by VNA to be faxed
to:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Fax: [**Telephone/Fax (1) 19406**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Pulmonary embolism
Lymphoproliferative disorder
Disseminated varicella with extremity ulcers/wounds
Pneumonia/sepsis
Adrenal insufficiency

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

Discharge Instructions:
You were hospitalized for a pulmonary embolisim.  You are now
started on a blood thinner called coumadin.  You will need to
have daily blood tests to monitor a test called the INR.  The
goal is that the INR is between [**2-1**].  Your PCP will be the
pyhsician to monitor this blood test and advise you what changes
to make in your dose of coumadin.  If you develop bleeding,
increased bruising or swelling of either leg or shortness of
breath you should contact your doctor.

Medication changes:
STARTED on Coumadin. However, do not take this medication until
your PCP's coumadin clinic advises you to.


Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: MONDAY [**10-29**] AT 10:15AM
**A nurse from your PCPs office will call you at home to set up
your time for an INR check.**

Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital3 **]
Address: [**Location (un) 108878**], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 108879**]
Appointment: MONDAY [**11-5**] AT 8:45AM
**Please arrive at 7:40AM for your blood draw on the 2nd Fl**

Name: [**Last Name (LF) **], [**First Name3 (LF) **]
[**First Name3 (LF) 4094**]: CARDIOLOGY
Location: [**Hospital **] MEDICAL ASSOCIATES OF [**Location (un) **]
Address: 325 RIVER RIDGE DR, [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 8506**]
Appointment: THURSDAY [**11-15**] AT 2PM
{'Other pulmonary embolism and infarction,Pneumonia due to Pseudomonas,Acute respiratory failure,Unspecified pleural effusion,Malnutrition of moderate degree,Glucocorticoid deficiency,Chickenpox with other specified complications,Ulcer of other part of lower limb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Autoimmune lymphoproliferative syndrome,Asthma, unspecified type, unspecified,Hypoparathyroidism,Chronic kidney disease, Stage I,Anemia, 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: dyspnea

PRESENT ILLNESS: 49-year-old female with a lymphoproliferative disorder (LGL,
treated at [**Hospital1 112**]; last dose of methotrexate [**2103-7-30**]),
hyperglandular autoimmune syndrome (hypoparathyroidism and
adrenal insufficiency), leg ulcers, and asthma who presented to
[**Hospital1 **] [**Location (un) 620**] on [**10-7**] with the course described below:

MEDICAL HISTORY: - LGL on low dose methotrexate, last dose in [**2103-7-30**] at [**Hospital1 112**]
- Anemia.
- Asthma.
- Multiple bilateral leg ulcerations due to reported VZV
- hyperglandular autoimmune syndrome(hypoparathyroidism and
adrenal insufficiency
- h/o cervical dysplasia
- HTN
- h/o seizure
- CKD, stage 1
- Osteopenia

MEDICATION ON ADMISSION: Oxycodone 10 mg Oral Tablet 1 tab q6h prn for pain
  Valacyclovir 1 g Oral Tablet 1 tab po bid for 28 days (THROUGH
[**10-5**])
  Prednisone 5 mg Oral Tablet 1 po qd
 Lorazepam 1 mg Oral Tablet 1 tablet at bedtime as needed
 Mirtazapine (REMERON) 30 mg Oral Tablet 1 QHS PRN
 Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) taking 2
capsules a day
  Methotrexate Sodium 2.5 mg Oral Tablet 8 TABLETS EVERY
SATURDAY
  MAGNESIUM CHLORIDE ORAL 3 400MG TABS DAILY
  Cyclobenzaprine 10 mg Oral Tablet Take 1 tablet at bedtime as
needed for muscle spasm
 Cyanocobalamin, Vitamin B-12, 1,000 mcg/mL Injection Solution
1000mcg IM monthly
 Albuterol Sulfate (VENTOLIN HFA) 90 mcg/Actuation Inhalation
HFA Aerosol Inhaler Take 1 to 2 inhalations every 4 to 6 hours
as needed; rinse mouthpiece at least once a week
 Betamethasone Dipropionate 0.05 % Topical Cream apply po bid
topically
 Calcitriol 0.25 mcg Oral Capsule Take 2 cap(s) orally twice a
day or uad
 Potassium Chloride (K-DUR) 20 mEq Oral TbTQ mo,we,fr 20meq
  MEGACE ES ORAL as needed
 FLORINEF 0.1 MG TAB (FLUDROCORTISONE ACETATE) 2 tabs daily
 NYSTATIN 100,000 UNIT/ML ORAL SUSP

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission to ICU:
Vitals: 98.7  93/68  114  26  97% 50%bipap
General: Alert, oriented (though initially says at [**Hospital1 112**]), no
acute distress

FAMILY HISTORY: NC

SOCIAL HISTORY: She lives at home with her children age 23 and 28.  She is
independent. She denies tobacco, alcohol, or illicit drug use. 

### Response:
{'Other pulmonary embolism and infarction,Pneumonia due to Pseudomonas,Acute respiratory failure,Unspecified pleural effusion,Malnutrition of moderate degree,Glucocorticoid deficiency,Chickenpox with other specified complications,Ulcer of other part of lower limb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Autoimmune lymphoproliferative syndrome,Asthma, unspecified type, unspecified,Hypoparathyroidism,Chronic kidney disease, Stage I,Anemia, unspecified'}
