CHIEF COMPLAINT: Admitted for migraine, fever, back pain, and left sided chest
pain

PRESENT ILLNESS: The patient is a 34yo woman with history of complicated
migraines, [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease, DM, hypercholesterolemia,
asthma, and stroke in [**12-20**] who came to the ED on [**2110-9-2**] for
evaluation of headache, and left sided chest pain.   She was a
questionable historian and much of the following history was
obtained from prior records.
.
During late [**Month (only) 205**] she experienced heat exhaustion and was
admitted to [**Hospital **] [**Hospital 68352**] Hospital in [**Doctor First Name 26692**].  At
discharge she developed pain, erythema, and swelling on the
dorsum of her right wrist (the site of her IV).  She was
prescribed po keflex as an outpatient.  Her symptoms persisted
and she was admitted to [**Location (un) 60883**]Hospital on [**2110-7-18**] for thrombophelbitis/cellulitis. She complained of nausea,
vomiting, and abdomimal pain. She experienced no fevers, chills,
headache, SOB, or cough.  She was started on IV Vancomycin and
IV clindamycin.  Her symptoms improved though did not completely
resolve.  She was switched to PO Augmentin (7 day course 875 po
BID) and discharged on [**7-20**].  During her hospitalization
she was also found to be anemic, with no evidence of a "gross
bleed."  Her anemia work-up was deferred to her PCP.
.
She went back to the hospital at the beginning of [**Month (only) **]
because her wrist symptoms had not completely resolved.  She was
given IV vancomycin and prescribed Linezolid.  She [**Month (only) 20227**]'t
afford the medication and was switched to an unknown dose/course
of levaquin.
.
Despite numerous antibiotics, she notes the persistence of mild
erythema, pain, and swelling of her left wrist.  She lives in
CT, and denies any recent outdoor hikes, camping, or tick bites.
  She came to [**Location (un) 86**] to visit her sister whose husband was
recently injured in [**Country 2451**].  On Saturday she experienced an aura
of flashing lights and developed an intense migraine.  She tried
taking an extra dose of neurontin but it didn't help.  She was
able to sleep,but notes ongoing nausea, vomiting, and
photophobia.  The migraine pain has been localized mainly on the
right side, throbbing, and currently feels as if her eye is
"going to [**Doctor Last Name **] out."  According to the neurology note she
developed R-arm heaviness a few hours after the onset of her
headache. Ms. [**Known lastname **] [**Last Name (Titles) 36665**]'t comment when asked about this.
Her symptoms persisted and on Monday she developed left upper
chest and upper back pain.  She [**Last Name (Titles) 20227**]'t describe the pain
further. She denied any sensory changes, motor changes, numbness
or tingling.  She has no neck pain, facial droop, or slurred
speech.
.
She came to the ED on Tuesday ([**2110-9-2**]) after her sympoms didn't
improve.  She has had minor migraine relief with dilaudid and
phenergan. During her time in the ED, she noted ongoing constant
left sided chest pain, which is not affected by breathing.  At
6:00 am on [**2110-9-3**] she developed fever (103), tachycardia (141),
and shaking chills. An EKG was done and showed no ST changes and
one set of cardiac enzymes was negative. She was given 1 gram IV
Vanco, had an LP that was unimpressive.  A PICC was placed due
to difficulty establishing access.  She was given 2 liters of NS
and was transferred to medicine.
.
Upon arrival to the floor, she was tachycardic (108), afebrile,
and 96% on room air.  She was lying in the dark, looking mildly
uncomfortable in bed.  She was a poor historian and somnolent
througout the interview. She required frequent reminders to stay
on subject and often responded inappropriately to questions.
Her major complaints were right sided migraine and left upper
chest and back pain.  She also states that her left wrist
continues to be mildly painful.  Shortly after the interview,
she developed shaking chills, tachycardia (130), and fever to
103. Blood cx and ABG were drawn, tylenol was given, and ice was
applied.  She was given on 1 L normal saline.
.
ROS:
She denies weight loss, infectious contacts, IVDU, recent tampon
use,no tick bites (though she lives in CT and has a dog),
trauma, heavy lifting, SOB, DOE, PND, chest pressure,
hemoptysis, jaundice, abdominal pain, bowel-bladder changes,
vaginal pain/problems, dysuria, hematuria, or bright red blood
per rectum.

MEDICAL HISTORY: - Migraine: These began in her late teens and she usually gets
at least once a month.   She often has auras of flashing lights.
 Her  associated symptoms include N/V, photo-and phonophobia.
Prior to this migraine, her longest migraine lasted 2-3 days.
- [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease: diagnosed at age 17 during
tonsillectomy pre-op workup.  Multiple bleeding complications
through life (bloody noses, heavy periods bleeding from gums,
bleeding post-op).  She has 3 children, delivered vaginally, and
had significant bleeding during and following the deliveries.
She ultimately had a hysterectomy due to heavy menstrual
bleeding.  ASA is contra-indicated.  She has been treated in the
past with whole blood transfusions, DDAVP and Humate (factor
VIII).
- Stroke: [**12-20**], had R-facial droop and was not talking
properly-resolved over time. Had a headache prior to her
symptoms.
- ARDS in [**2108**], required intubation.  Woke up on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**]
[**2108**] and [**Year (4 digits) 20227**]'t breathe.  She was told she had respiratory
failure, ARDS, Pneumonia, EColi sepsis.
- asthma-developed after her ARDS in [**2108**] and has been poorly
controlled and required numerous hospital visits.
- HTN-diagnosed via routine blood work
- DM type 2: diagnosed via routine blood work 3-4 years ago.
Controlled with Glucophage.  She has no associated eye, kidney,
or sensory problems.  She doesn't get -asthma-developed after
her ARDS in [**2108**] and has been poorly controlled and required
numerous hospital visits.
- hypercholesterolemia-diagnosed via routine blood work
- obesity
.
Surgeries:
- tonsillectomy age 17 significant for early and delayed
bleeding.
- one ovary removed in [**2100**] with bleeding complications
- cholecystectomy and hysterectomy in [**2101**] with late bleeding
- Back surgergy (L5,S1--herniated discs) [**2103**] and [**2106**], bleeding
complications

MEDICATION ON ADMISSION: Atenolol 50mg [**Hospital1 **] PO
HCTZ 25mg PO BID
Glucophage 500mg PO daily
zocor 40mg PO daily
advair 50/500 [**Hospital1 **]
combivent
neurontin 900mg PO 4 times daily (for migraine proph)
ativan 1mg PO qHS PRN

ALLERGIES: Demerol / Topamax / Codeine / Compazine / Aspirin / Nsaids /
Toradol / Reglan

PHYSICAL EXAM: VITALS: T 100.1 HR 108 BP 118/70 RR 18 O2sat96%ra FSBS not
recorded
GEN: obese, lying in bed
HEAD: NC/AT,
EYES: PERRLA, sluggish extraocular movements, patient would not
open right eye, no scleral icterus, no conjunctival injections
EARS: canals not visualized
NOSE: septum midline, no exudate, epistaxis
MOUTH: MMM, symmetrical palatal elevation
NECK: no carotid bruits;no JVD appreciated due to thick neck,
neck supple, able to touch chin to chest
NODES: no occipital, pre-auricular, cervical, submandibular,
axillary, epitrochlear, or inguinal adenopathy
LUNGS: Clear to auscultation bilaterally, breathing rapidly.
Pressure applied to anterior left chest was mildly tender.
Pressure applied to upper left paravertebral region was not
tender to palpation.
HEART: Heart sounds muffled by increased breath sounds.  Regular
rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: obese, bowel sounds present, soft, nontender,
nondistended, no rebound tenderness.  Large midline scar and
central ecchmoses.
EXTREMITIES: erythema L-hand (still swollen, erythematous and
warm-No cords detected, tender to palpation), no clubbing,
cyanosis, no splinter hemorrhages, [**Doctor Last Name **] spots, [**Last Name (un) **] lesions.
Raising either leg elicited extreme pain (localizing to her left
upper back) and nausea.
.
Neuro exam deferred by patient.

FAMILY HISTORY: DM, HTN, CAD, Migraines, Cancer(unsure of types), no other hx of
bleeding
Two grandparents had strokes.  Her mother and father are in
their 60's and have both had MI's.  Her mother and sister both
have migraines.  She has 3 brothers and [**Name2 (NI) 20227**]'t comment on
their health.   She has 3 daughters and had one miscarriage.

SOCIAL HISTORY: On admission, her social history was as follows: Lives in CT
with her fiance [**Doctor First Name 892**], 3 daughters ([**Name (NI) 2331**], [**First Name3 (LF) **], and [**Name (NI) 636**]),
and their (indoor) dog Copper.  She works as an Alcohol/drug
counselor.  She divorced the father of her 3 children after
experiencing several years of physical abuse (she left her
husband in [**2096**] and the divorce was finalized two weeks ago).
Her eldest brother was an addict, and he abused her as a child.
 She currently feels safe and secure in her home environment and
states that her fiance is a "good man."  She is not sexually
active.
.
Habits:
Cigaretts: none
Ethanol: none
Drugs: none
.
Exposures:  She is not aware of any toxin exposure.
.
Trips: She visit [**Doctor First Name 5256**] over the summer and went on a
fishing trip.  She lives in CT.  She is not aware of any tick,
mosquito, spider bites.
.
Health Maintanence: She has not received regular medical care.
She has seen a physician for her [**Name9 (PRE) 68353**]. [**First Name (STitle) **] [**Name (STitle) 68354**].  She
has no PCP.  [**Name10 (NameIs) **] saw an OB/GYN Dr. [**Last Name (STitle) 1182**] in [**Location (un) **] for her
deliveries and hysterectomy.  She recieved her primary care from
a staff of rotating Doctors at the [**Name5 (PTitle) 68352**] Hospital for the past
several years, but due to the recent finalization of her
divorce, she has lost her benefits. She plans to start care at
the Women's Medical Center near her home, if they accept her
insurance.
Streptococcal septicemia,Von Willebrand's disease,Chronic factitious illness with physical symptoms,Phlebitis and thrombophlebitis of upper extremities, unspecified,Cellulitis and abscess of hand, except fingers and thumb,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Anemia, unspecified
Streptococcal septicemia,Von willebrand's disease,Chr factitious illness,Phlbts vn NOS up extrm,Cellulitis of hand,Migrne unsp wo ntrc mgrn,DMII wo cmp nt st uncntr,Asthma NOS,Anemia NOS
Admission Date:  [**2110-9-3**]              Discharge Date:   [**2110-9-20**]

Date of Birth:  [**2076-2-3**]             Sex:   F

Service: MEDICINE

Allergies:
Demerol / Topamax / Codeine / Compazine / Aspirin / Nsaids /
Toradol / Reglan

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Admitted for migraine, fever, back pain, and left sided chest
pain

Major Surgical or Invasive Procedure:
PICC placement x 2
TEE


History of Present Illness:
The patient is a 34yo woman with history of complicated
migraines, [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease, DM, hypercholesterolemia,
asthma, and stroke in [**12-20**] who came to the ED on [**2110-9-2**] for
evaluation of headache, and left sided chest pain.   She was a
questionable historian and much of the following history was
obtained from prior records.
.
During late [**Month (only) 205**] she experienced heat exhaustion and was
admitted to [**Hospital **] [**Hospital 68352**] Hospital in [**Doctor First Name 26692**].  At
discharge she developed pain, erythema, and swelling on the
dorsum of her right wrist (the site of her IV).  She was
prescribed po keflex as an outpatient.  Her symptoms persisted
and she was admitted to [**Location (un) 60883**]Hospital on [**2110-7-18**] for thrombophelbitis/cellulitis. She complained of nausea,
vomiting, and abdomimal pain. She experienced no fevers, chills,
headache, SOB, or cough.  She was started on IV Vancomycin and
IV clindamycin.  Her symptoms improved though did not completely
resolve.  She was switched to PO Augmentin (7 day course 875 po
BID) and discharged on [**7-20**].  During her hospitalization
she was also found to be anemic, with no evidence of a "gross
bleed."  Her anemia work-up was deferred to her PCP.
.
She went back to the hospital at the beginning of [**Month (only) **]
because her wrist symptoms had not completely resolved.  She was
given IV vancomycin and prescribed Linezolid.  She [**Month (only) 20227**]'t
afford the medication and was switched to an unknown dose/course
of levaquin.
.
Despite numerous antibiotics, she notes the persistence of mild
erythema, pain, and swelling of her left wrist.  She lives in
CT, and denies any recent outdoor hikes, camping, or tick bites.
  She came to [**Location (un) 86**] to visit her sister whose husband was
recently injured in [**Country 2451**].  On Saturday she experienced an aura
of flashing lights and developed an intense migraine.  She tried
taking an extra dose of neurontin but it didn't help.  She was
able to sleep,but notes ongoing nausea, vomiting, and
photophobia.  The migraine pain has been localized mainly on the
right side, throbbing, and currently feels as if her eye is
"going to [**Doctor Last Name **] out."  According to the neurology note she
developed R-arm heaviness a few hours after the onset of her
headache. Ms. [**Known lastname **] [**Last Name (Titles) 36665**]'t comment when asked about this.
Her symptoms persisted and on Monday she developed left upper
chest and upper back pain.  She [**Last Name (Titles) 20227**]'t describe the pain
further. She denied any sensory changes, motor changes, numbness
or tingling.  She has no neck pain, facial droop, or slurred
speech.
.
She came to the ED on Tuesday ([**2110-9-2**]) after her sympoms didn't
improve.  She has had minor migraine relief with dilaudid and
phenergan. During her time in the ED, she noted ongoing constant
left sided chest pain, which is not affected by breathing.  At
6:00 am on [**2110-9-3**] she developed fever (103), tachycardia (141),
and shaking chills. An EKG was done and showed no ST changes and
one set of cardiac enzymes was negative. She was given 1 gram IV
Vanco, had an LP that was unimpressive.  A PICC was placed due
to difficulty establishing access.  She was given 2 liters of NS
and was transferred to medicine.
.
Upon arrival to the floor, she was tachycardic (108), afebrile,
and 96% on room air.  She was lying in the dark, looking mildly
uncomfortable in bed.  She was a poor historian and somnolent
througout the interview. She required frequent reminders to stay
on subject and often responded inappropriately to questions.
Her major complaints were right sided migraine and left upper
chest and back pain.  She also states that her left wrist
continues to be mildly painful.  Shortly after the interview,
she developed shaking chills, tachycardia (130), and fever to
103. Blood cx and ABG were drawn, tylenol was given, and ice was
applied.  She was given on 1 L normal saline.
.
ROS:
She denies weight loss, infectious contacts, IVDU, recent tampon
use,no tick bites (though she lives in CT and has a dog),
trauma, heavy lifting, SOB, DOE, PND, chest pressure,
hemoptysis, jaundice, abdominal pain, bowel-bladder changes,
vaginal pain/problems, dysuria, hematuria, or bright red blood
per rectum.


Past Medical History:
- Migraine: These began in her late teens and she usually gets
at least once a month.   She often has auras of flashing lights.
 Her  associated symptoms include N/V, photo-and phonophobia.
Prior to this migraine, her longest migraine lasted 2-3 days.
- [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease: diagnosed at age 17 during
tonsillectomy pre-op workup.  Multiple bleeding complications
through life (bloody noses, heavy periods bleeding from gums,
bleeding post-op).  She has 3 children, delivered vaginally, and
had significant bleeding during and following the deliveries.
She ultimately had a hysterectomy due to heavy menstrual
bleeding.  ASA is contra-indicated.  She has been treated in the
past with whole blood transfusions, DDAVP and Humate (factor
VIII).
- Stroke: [**12-20**], had R-facial droop and was not talking
properly-resolved over time. Had a headache prior to her
symptoms.
- ARDS in [**2108**], required intubation.  Woke up on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**]
[**2108**] and [**Year (4 digits) 20227**]'t breathe.  She was told she had respiratory
failure, ARDS, Pneumonia, EColi sepsis.
- asthma-developed after her ARDS in [**2108**] and has been poorly
controlled and required numerous hospital visits.
- HTN-diagnosed via routine blood work
- DM type 2: diagnosed via routine blood work 3-4 years ago.
Controlled with Glucophage.  She has no associated eye, kidney,
or sensory problems.  She doesn't get -asthma-developed after
her ARDS in [**2108**] and has been poorly controlled and required
numerous hospital visits.
- hypercholesterolemia-diagnosed via routine blood work
- obesity
.
Surgeries:
- tonsillectomy age 17 significant for early and delayed
bleeding.
- one ovary removed in [**2100**] with bleeding complications
- cholecystectomy and hysterectomy in [**2101**] with late bleeding
- Back surgergy (L5,S1--herniated discs) [**2103**] and [**2106**], bleeding
complications

Social History:
On admission, her social history was as follows: Lives in CT
with her fiance [**Doctor First Name 892**], 3 daughters ([**Name (NI) 2331**], [**First Name3 (LF) **], and [**Name (NI) 636**]),
and their (indoor) dog Copper.  She works as an Alcohol/drug
counselor.  She divorced the father of her 3 children after
experiencing several years of physical abuse (she left her
husband in [**2096**] and the divorce was finalized two weeks ago).
Her eldest brother was an addict, and he abused her as a child.
 She currently feels safe and secure in her home environment and
states that her fiance is a "good man."  She is not sexually
active.
.
Habits:
Cigaretts: none
Ethanol: none
Drugs: none
.
Exposures:  She is not aware of any toxin exposure.
.
Trips: She visit [**Doctor First Name 5256**] over the summer and went on a
fishing trip.  She lives in CT.  She is not aware of any tick,
mosquito, spider bites.
.
Health Maintanence: She has not received regular medical care.
She has seen a physician for her [**Name9 (PRE) 68353**]. [**First Name (STitle) **] [**Name (STitle) 68354**].  She
has no PCP.  [**Name10 (NameIs) **] saw an OB/GYN Dr. [**Last Name (STitle) 1182**] in [**Location (un) **] for her
deliveries and hysterectomy.  She recieved her primary care from
a staff of rotating Doctors at the [**Name5 (PTitle) 68352**] Hospital for the past
several years, but due to the recent finalization of her
divorce, she has lost her benefits. She plans to start care at
the Women's Medical Center near her home, if they accept her
insurance.


Family History:
DM, HTN, CAD, Migraines, Cancer(unsure of types), no other hx of
bleeding
Two grandparents had strokes.  Her mother and father are in
their 60's and have both had MI's.  Her mother and sister both
have migraines.  She has 3 brothers and [**Name2 (NI) 20227**]'t comment on
their health.   She has 3 daughters and had one miscarriage.

Physical Exam:
VITALS: T 100.1 HR 108 BP 118/70 RR 18 O2sat96%ra FSBS not
recorded
GEN: obese, lying in bed
HEAD: NC/AT,
EYES: PERRLA, sluggish extraocular movements, patient would not
open right eye, no scleral icterus, no conjunctival injections
EARS: canals not visualized
NOSE: septum midline, no exudate, epistaxis
MOUTH: MMM, symmetrical palatal elevation
NECK: no carotid bruits;no JVD appreciated due to thick neck,
neck supple, able to touch chin to chest
NODES: no occipital, pre-auricular, cervical, submandibular,
axillary, epitrochlear, or inguinal adenopathy
LUNGS: Clear to auscultation bilaterally, breathing rapidly.
Pressure applied to anterior left chest was mildly tender.
Pressure applied to upper left paravertebral region was not
tender to palpation.
HEART: Heart sounds muffled by increased breath sounds.  Regular
rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: obese, bowel sounds present, soft, nontender,
nondistended, no rebound tenderness.  Large midline scar and
central ecchmoses.
EXTREMITIES: erythema L-hand (still swollen, erythematous and
warm-No cords detected, tender to palpation), no clubbing,
cyanosis, no splinter hemorrhages, [**Doctor Last Name **] spots, [**Last Name (un) **] lesions.
Raising either leg elicited extreme pain (localizing to her left
upper back) and nausea.
.
Neuro exam deferred by patient.

Pertinent Results:
[**2110-9-3**] 09:46PM   TYPE-ART PO2-110* PCO2-35 PH-7.45 TOTAL
CO2-25 BASE XS-0 INTUBATED-NOT INTUBA
[**2110-9-3**] 09:46PM   LACTATE-2.3*
[**2110-9-3**] 05:59PM   GLUCOSE-93 UREA N-8 CREAT-0.9 SODIUM-137
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-25 ANION GAP-14
[**2110-9-3**] 05:59PM   CALCIUM-9.0 PHOSPHATE-2.8# MAGNESIUM-2.1
[**2110-9-3**] 05:59PM   WBC-7.7 RBC-3.44* HGB-9.7* HCT-27.4* MCV-80*
MCH-28.3 MCHC-35.5* RDW-17.8*
[**2110-9-3**] 05:59PM   NEUTS-81.7* LYMPHS-13.6* MONOS-3.7 EOS-0.8
BASOS-0.1
[**2110-9-3**] 05:59PM   ANISOCYT-1+ MICROCYT-2+
[**2110-9-3**] 05:59PM   PLT COUNT-283
[**2110-9-3**] 05:59PM   PT-14.8* PTT-38.6* INR(PT)-1.3*
[**2110-9-3**] 03:30PM CEREBROSPINAL FLUID (CSF)  PROTEIN-34
GLUCOSE-68
[**2110-9-3**] 03:30PM CEREBROSPINAL FLUID (CSF)  WBC-2 RBC-1* POLYS-8
LYMPHS-80 MONOS-12
[**2110-9-2**] 10:45PM   PT-12.6 PTT-34.9 INR(PT)-1.1
[**2110-9-2**] 10:45PM   D-DIMER-1258*
[**2110-9-2**] 10:44PM   COMMENTS-GREEN TOP
[**2110-9-2**] 10:44PM   LACTATE-2.9*
[**2110-9-2**] 09:39PM   GLUCOSE-118* UREA N-13 CREAT-1.1 SODIUM-137
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20
[**2110-9-2**] 09:39PM   ALT(SGPT)-22 AST(SGOT)-32 CK(CPK)-59 ALK
PHOS-88 AMYLASE-30 TOT BILI-0.4
[**2110-9-2**] 09:39PM   CK-MB-NotDone cTropnT-<0.01
[**2110-9-2**] 09:39PM   CALCIUM-9.7 PHOSPHATE-4.8* MAGNESIUM-2.4
[**2110-9-2**] 09:39PM   HCG-<5
[**2110-9-2**] 09:39PM   ASA-NEG ETHANOL-NEG ACETMNPHN-6.3
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-9-2**] 09:39PM   WBC-10.1 RBC-4.01* HGB-11.1* HCT-31.8*
MCV-79* MCH-27.7 MCHC-34.9 RDW-17.6*
[**2110-9-2**] 09:39PM   NEUTS-67.8 LYMPHS-25.3 MONOS-4.8 EOS-1.9
BASOS-0.1
[**2110-9-2**] 09:39PM   ANISOCYT-1+ MICROCYT-2+
[**2110-9-2**] 09:39PM   PLT COUNT-425
.
CXR [**2110-9-2**]: No acute pulmonary process.
.
ECG [**2110-9-2**]: Sinus tachycardia. No previous tracing available
for comparison.
.
CT /CTA [**2110-9-3**]: normal, no hemorrhage; cannot see an old stroke
or
lacune, No pulmonary embolism.
.
MRI/MRA [**2110-9-3**]: Normal circle of [**Location (un) 431**].  No acute intracranial
abnormality.
.
ECG [**2110-9-3**]: Probable sinus tachycardia with poor baseline. No
change compared to the previous tracing of [**2110-9-2**].
.
CXR [**2110-9-7**]: Interval placement of PICC line with position as
above.
.
CXR [**2110-9-8**]: IMPRESSION: Linear opacity in the right lower lung
zone could represent atelectasis. However, early pneumonia
cannot be excluded.
.
CXR [**2110-9-9**]: No convincing radiographic evidence of acute
cardiopulmonary disease.
.
Echo [**2110-9-9**]: The left atrium is normal in size. Left
ventricular wall thicknesses and cavity size are normal. Overall
left ventricular systolic function is normal (LVEF 60-70%). The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No masses or vegetations are seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. The absence of a vegetation by 2D
echocardiography does not exclude endocarditis if clinically
suggested.
.
RUE U/S [**9-11**]: 1) No deep venous thrombosis. 2) Occlusive
thrombus in the distal, superficial cephalic vein in the right
lateral wrist.
.
Panorex [**2110-9-11**]: TEETH PANOREX VIEW: Multiple missing teeth.
Dental caries is seen in multiple teeth. There is no obvious
abscess visualized. A lucency along the lateral lower incisors
does not appear to represent an abscess. No fractures are
visualized. The teeth have well defined sclerotic borders.
.
Wrist, 3 views [**2110-9-11**]: A true AP view of the wrist was not
obtained. No fracture is identified. The joint spaces are
preserved. There is prominence of the soft tissues, without a
radiopaque foreign body visualized.
.
TEE [**2110-9-12**]: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic, mitral, tricuspid or pulmonic valves. No aortic valve
abscess is seen. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is
no pericardial effusion. IMPRESSION: No valvular endocarditis or
aortic root abscess identified. Preserved biventricular systolic
function.
.
CT Abd/Pelvis [**2110-9-12**]: IMPRESSION: No intra-abdominal fluid
collections or source of infection is identified.


Brief Hospital Course:
Ms. [**Known lastname **] is a 34yF with history of complicated migraines, [**First Name5 (NamePattern1) **]
[**Last Name (Prefixes) 4516**] disease, DM, hypercholesterolemia, asthma, and
?stroke in [**12-20**] who came to the ED on [**2110-9-2**] for evaluation of
headache and left sided chest pain and developed fevers and
positive blood cultures, the most likely etiology of which is
contamination of PICC with oral flora. Her hospital course, by
problem:
.
#) Fever/tachycardia: She was admitted with fever and back pain,
which prompted a lumbar puncture (results were negative). These
fevers initially resolved during the first few days of her
hospital course, and restarted overnight on [**9-7**].  On [**9-7**] she
also developed a new leukocytosis and was started on Vancomycin
on [**9-7**] for this to cover for possible skin infection
(cellulitis) causing fever.  She had a CK that remained
elevated, and that we attributed to her rigors on admission.  An
ABG on [**2110-9-3**] displayed a slight respiratory alkalosis
consistent with hyperventilation.  She was given scheduled
tylenol for her persistent fevers.  Throughout the admission,
blood cultures grew Strep viridans, micrococcus, stomatococcus,
veillonella, [**Female First Name (un) 564**] albicans, and lactobacillus. HIV negative.
TTE/TEE have been negative for endocarditis, ophthalmology exam
negative for endophthalmitis, no evidence of dental pathology on
dental exam and panorex, no evidence of foreign bodies. CT
abd/pelvis unrevealing. Etiology of positive blood cultures with
these organisms points to contamination of PICC with oral flora.
The PICC was pulled out on [**2110-9-16**]. Patient has been afebrile x
72+ hours. She was put on vancomycin and Zosyn IV and oral
fluconazole and transitioned to oral antibiotics (Augmentin
875mg PO TID, clindamycin 450mg PO QID, fluconazole 400mg PO
DAILY) for discharge; total course to be 14 days (last day of
antibiotics [**2110-9-30**]). At the time of discharge, she had been
afebrile for >96 hours. From an infectious disease perspective,
she is stable for discharge to psychiatric inpatient unit.
.
#) Respiratory distress. Patient's O2 saturation decreased to
76% on room air during episode of rigors with fevers on [**9-8**].
ABG showed hypoxemia. CXR unrevealing.  She required overnight
observation in the medical ICU, during which her oxygen
saturations were stable on 2L nasal cannula. After one night,
she was transferred back to the floor ([**2110-9-9**]), and she
continued to sat well on room air without event.
.
#) Psych. Patient's belongings were searched on [**9-8**] due to
suspicion of illicit drug use and injecting into the PICC.
Several syringes and syringe adapters were confiscated, as were
a Dilaudid prescription bottle and Neurontin tablets. Tox screen
was positive for opiates (known; patient getting dilaudid).
Phone conversation with patient's mother elucidated substantial
psych and substance abuse history. High suspicion that patient
has been tampering with PICC. The patient had a 1:1 sitter 24
hours per day, including in the bathroom and shower. It was
determined that the patient could not leave the hospital without
first being seen by psychiatry.
.
#) Atypical chest pain. Resolved with hospitalization.  A PE was
ruled out in the ED via negative CTA, nothing focal was noted on
the scan. Unlikely MI/Ischemia as no anginal symptoms (though
she is female and a diabetic so symptoms may be atypical). She
had two negative sets of enzymes.
.
#) Migraines: her admission migraine headache was consistent
with prior migraines however lasting longer than usual. An MRI
of the head showed no evidence of previous stroke. It has been
mildly responsive to phenergen and dilaudid. Had c/o right eye
pain, no pathology detected on MRI/MRA, cont to have difficulty
opening eye. [**Doctor First Name **] [**Doctor First Name 68354**] (her VWD hemotologist) hasn't seen
her since [**2108**] and could provide no further information about
her stroke or migraines.  She was continued on PO phenergan,
Dilaudid 4mg q4h PRN, and standing Tylenol. In addition, her
Neurontin was continued.
.
#) Left wrist pain: cellulitis/thrombophlebitis. Improved with
warm compresses and antibiotics (vancomycin). No evidence of
foreign body in left wrist per X-ray.
.
#) Right hand/finger pain: cellulitis due to recent IV access.
No streaking up arm. Thrombophlebitis on RUE ultrasound.
Improved with warm compresses and antibiotics (vancomycin).
.
#) Lower back pain. Patient complained of exquisite pain on
palpation of LP site, resolved with rest and pain medications as
noted above.
.
#) Anemia. Her anemia has been previously documented with
unknown cause. Her HCT has dropped from 31.8 at admission but
stabilized around 26. Possibly dilutional component, occult
losses due to VWD, and iron deficiency. Her stools were guaiac
negative in the hospital. She should have her anemia worked up
as an outpatient.
.
#) VWD, followed by Dr. [**First Name (STitle) **] [**Name (STitle) 68354**] (hematologist). It is
unclear why her INR and PT are elevated, as they should not be
affected by pure VWD. She may be Vit K deficient or has a mixed
coagulopathy that involves the vitamin K factors as well. No
active issues during this inpatient stay.
.
#) Diabetes. During this hospitalization, she had 8 straight
days of normal blood sugars. Her finger sticks and sliding scale
were discontinued. She should continue on her home dose of
metformin.
.
#) HTN. Will continue to monitor blood pressure.  Atenolol and
HCTZ were continued.
.
#) Asthma: advair and combivent were continued.

Medications on Admission:
Atenolol 50mg [**Hospital1 **] PO
HCTZ 25mg PO BID
Glucophage 500mg PO daily
zocor 40mg PO daily
advair 50/500 [**Hospital1 **]
combivent
neurontin 900mg PO 4 times daily (for migraine proph)
ativan 1mg PO qHS PRN


Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO QID (4
times a day).
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain/fever.
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
12. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
Disp:*12 Tablet(s)* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*15 Tablet(s)* Refills:*0*
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
15. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 11 days.
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
17. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 11 days.
18. Clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 11 days.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] 4

Discharge Diagnosis:
Bacteremia, Fungemia
Munchausen's Syndrome
Thrombophlebitis
Cellulitis
Migraine Headache
Hypertension
Hyperlipidemia
Diabetes
Asthma


Discharge Condition:
Stable from a medical perspective. Afebrile with stable vital
signs.


Discharge Instructions:
Please take your medications as prescribed, especially your
antibiotics. If you experience worsening pain, headache, fevers,
nausea, vomiting, or other concerning symptoms, please seek
medical attention immediately.

Followup Instructions:
Please follow up with your primary care provider within one week
after discharge from the hospital. Please follow up with your
hematologist Dr. [**Last Name (STitle) 68355**] in the next few weeks.  It is important
that you select a PCP as soon as possible so that you can be
followed for your ongoing health issues (Diabetes, Anemia, High
blood pressure, and high cholesterol).


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{"Streptococcal septicemia,Von Willebrand's disease,Chronic factitious illness with physical symptoms,Phlebitis and thrombophlebitis of upper extremities, unspecified,Cellulitis and abscess of hand, except fingers and thumb,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,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: Admitted for migraine, fever, back pain, and left sided chest
pain

PRESENT ILLNESS: The patient is a 34yo woman with history of complicated
migraines, [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease, DM, hypercholesterolemia,
asthma, and stroke in [**12-20**] who came to the ED on [**2110-9-2**] for
evaluation of headache, and left sided chest pain.   She was a
questionable historian and much of the following history was
obtained from prior records.
.
During late [**Month (only) 205**] she experienced heat exhaustion and was
admitted to [**Hospital **] [**Hospital 68352**] Hospital in [**Doctor First Name 26692**].  At
discharge she developed pain, erythema, and swelling on the
dorsum of her right wrist (the site of her IV).  She was
prescribed po keflex as an outpatient.  Her symptoms persisted
and she was admitted to [**Location (un) 60883**]Hospital on [**2110-7-18**] for thrombophelbitis/cellulitis. She complained of nausea,
vomiting, and abdomimal pain. She experienced no fevers, chills,
headache, SOB, or cough.  She was started on IV Vancomycin and
IV clindamycin.  Her symptoms improved though did not completely
resolve.  She was switched to PO Augmentin (7 day course 875 po
BID) and discharged on [**7-20**].  During her hospitalization
she was also found to be anemic, with no evidence of a "gross
bleed."  Her anemia work-up was deferred to her PCP.
.
She went back to the hospital at the beginning of [**Month (only) **]
because her wrist symptoms had not completely resolved.  She was
given IV vancomycin and prescribed Linezolid.  She [**Month (only) 20227**]'t
afford the medication and was switched to an unknown dose/course
of levaquin.
.
Despite numerous antibiotics, she notes the persistence of mild
erythema, pain, and swelling of her left wrist.  She lives in
CT, and denies any recent outdoor hikes, camping, or tick bites.
  She came to [**Location (un) 86**] to visit her sister whose husband was
recently injured in [**Country 2451**].  On Saturday she experienced an aura
of flashing lights and developed an intense migraine.  She tried
taking an extra dose of neurontin but it didn't help.  She was
able to sleep,but notes ongoing nausea, vomiting, and
photophobia.  The migraine pain has been localized mainly on the
right side, throbbing, and currently feels as if her eye is
"going to [**Doctor Last Name **] out."  According to the neurology note she
developed R-arm heaviness a few hours after the onset of her
headache. Ms. [**Known lastname **] [**Last Name (Titles) 36665**]'t comment when asked about this.
Her symptoms persisted and on Monday she developed left upper
chest and upper back pain.  She [**Last Name (Titles) 20227**]'t describe the pain
further. She denied any sensory changes, motor changes, numbness
or tingling.  She has no neck pain, facial droop, or slurred
speech.
.
She came to the ED on Tuesday ([**2110-9-2**]) after her sympoms didn't
improve.  She has had minor migraine relief with dilaudid and
phenergan. During her time in the ED, she noted ongoing constant
left sided chest pain, which is not affected by breathing.  At
6:00 am on [**2110-9-3**] she developed fever (103), tachycardia (141),
and shaking chills. An EKG was done and showed no ST changes and
one set of cardiac enzymes was negative. She was given 1 gram IV
Vanco, had an LP that was unimpressive.  A PICC was placed due
to difficulty establishing access.  She was given 2 liters of NS
and was transferred to medicine.
.
Upon arrival to the floor, she was tachycardic (108), afebrile,
and 96% on room air.  She was lying in the dark, looking mildly
uncomfortable in bed.  She was a poor historian and somnolent
througout the interview. She required frequent reminders to stay
on subject and often responded inappropriately to questions.
Her major complaints were right sided migraine and left upper
chest and back pain.  She also states that her left wrist
continues to be mildly painful.  Shortly after the interview,
she developed shaking chills, tachycardia (130), and fever to
103. Blood cx and ABG were drawn, tylenol was given, and ice was
applied.  She was given on 1 L normal saline.
.
ROS:
She denies weight loss, infectious contacts, IVDU, recent tampon
use,no tick bites (though she lives in CT and has a dog),
trauma, heavy lifting, SOB, DOE, PND, chest pressure,
hemoptysis, jaundice, abdominal pain, bowel-bladder changes,
vaginal pain/problems, dysuria, hematuria, or bright red blood
per rectum.

MEDICAL HISTORY: - Migraine: These began in her late teens and she usually gets
at least once a month.   She often has auras of flashing lights.
 Her  associated symptoms include N/V, photo-and phonophobia.
Prior to this migraine, her longest migraine lasted 2-3 days.
- [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease: diagnosed at age 17 during
tonsillectomy pre-op workup.  Multiple bleeding complications
through life (bloody noses, heavy periods bleeding from gums,
bleeding post-op).  She has 3 children, delivered vaginally, and
had significant bleeding during and following the deliveries.
She ultimately had a hysterectomy due to heavy menstrual
bleeding.  ASA is contra-indicated.  She has been treated in the
past with whole blood transfusions, DDAVP and Humate (factor
VIII).
- Stroke: [**12-20**], had R-facial droop and was not talking
properly-resolved over time. Had a headache prior to her
symptoms.
- ARDS in [**2108**], required intubation.  Woke up on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**]
[**2108**] and [**Year (4 digits) 20227**]'t breathe.  She was told she had respiratory
failure, ARDS, Pneumonia, EColi sepsis.
- asthma-developed after her ARDS in [**2108**] and has been poorly
controlled and required numerous hospital visits.
- HTN-diagnosed via routine blood work
- DM type 2: diagnosed via routine blood work 3-4 years ago.
Controlled with Glucophage.  She has no associated eye, kidney,
or sensory problems.  She doesn't get -asthma-developed after
her ARDS in [**2108**] and has been poorly controlled and required
numerous hospital visits.
- hypercholesterolemia-diagnosed via routine blood work
- obesity
.
Surgeries:
- tonsillectomy age 17 significant for early and delayed
bleeding.
- one ovary removed in [**2100**] with bleeding complications
- cholecystectomy and hysterectomy in [**2101**] with late bleeding
- Back surgergy (L5,S1--herniated discs) [**2103**] and [**2106**], bleeding
complications

MEDICATION ON ADMISSION: Atenolol 50mg [**Hospital1 **] PO
HCTZ 25mg PO BID
Glucophage 500mg PO daily
zocor 40mg PO daily
advair 50/500 [**Hospital1 **]
combivent
neurontin 900mg PO 4 times daily (for migraine proph)
ativan 1mg PO qHS PRN

ALLERGIES: Demerol / Topamax / Codeine / Compazine / Aspirin / Nsaids /
Toradol / Reglan

PHYSICAL EXAM: VITALS: T 100.1 HR 108 BP 118/70 RR 18 O2sat96%ra FSBS not
recorded
GEN: obese, lying in bed
HEAD: NC/AT,
EYES: PERRLA, sluggish extraocular movements, patient would not
open right eye, no scleral icterus, no conjunctival injections
EARS: canals not visualized
NOSE: septum midline, no exudate, epistaxis
MOUTH: MMM, symmetrical palatal elevation
NECK: no carotid bruits;no JVD appreciated due to thick neck,
neck supple, able to touch chin to chest
NODES: no occipital, pre-auricular, cervical, submandibular,
axillary, epitrochlear, or inguinal adenopathy
LUNGS: Clear to auscultation bilaterally, breathing rapidly.
Pressure applied to anterior left chest was mildly tender.
Pressure applied to upper left paravertebral region was not
tender to palpation.
HEART: Heart sounds muffled by increased breath sounds.  Regular
rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: obese, bowel sounds present, soft, nontender,
nondistended, no rebound tenderness.  Large midline scar and
central ecchmoses.
EXTREMITIES: erythema L-hand (still swollen, erythematous and
warm-No cords detected, tender to palpation), no clubbing,
cyanosis, no splinter hemorrhages, [**Doctor Last Name **] spots, [**Last Name (un) **] lesions.
Raising either leg elicited extreme pain (localizing to her left
upper back) and nausea.
.
Neuro exam deferred by patient.

FAMILY HISTORY: DM, HTN, CAD, Migraines, Cancer(unsure of types), no other hx of
bleeding
Two grandparents had strokes.  Her mother and father are in
their 60's and have both had MI's.  Her mother and sister both
have migraines.  She has 3 brothers and [**Name2 (NI) 20227**]'t comment on
their health.   She has 3 daughters and had one miscarriage.

SOCIAL HISTORY: On admission, her social history was as follows: Lives in CT
with her fiance [**Doctor First Name 892**], 3 daughters ([**Name (NI) 2331**], [**First Name3 (LF) **], and [**Name (NI) 636**]),
and their (indoor) dog Copper.  She works as an Alcohol/drug
counselor.  She divorced the father of her 3 children after
experiencing several years of physical abuse (she left her
husband in [**2096**] and the divorce was finalized two weeks ago).
Her eldest brother was an addict, and he abused her as a child.
 She currently feels safe and secure in her home environment and
states that her fiance is a "good man."  She is not sexually
active.
.
Habits:
Cigaretts: none
Ethanol: none
Drugs: none
.
Exposures:  She is not aware of any toxin exposure.
.
Trips: She visit [**Doctor First Name 5256**] over the summer and went on a
fishing trip.  She lives in CT.  She is not aware of any tick,
mosquito, spider bites.
.
Health Maintanence: She has not received regular medical care.
She has seen a physician for her [**Name9 (PRE) 68353**]. [**First Name (STitle) **] [**Name (STitle) 68354**].  She
has no PCP.  [**Name10 (NameIs) **] saw an OB/GYN Dr. [**Last Name (STitle) 1182**] in [**Location (un) **] for her
deliveries and hysterectomy.  She recieved her primary care from
a staff of rotating Doctors at the [**Name5 (PTitle) 68352**] Hospital for the past
several years, but due to the recent finalization of her
divorce, she has lost her benefits. She plans to start care at
the Women's Medical Center near her home, if they accept her
insurance. 

### Response:
{"Streptococcal septicemia,Von Willebrand's disease,Chronic factitious illness with physical symptoms,Phlebitis and thrombophlebitis of upper extremities, unspecified,Cellulitis and abscess of hand, except fingers and thumb,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Anemia, unspecified"}
