CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 75 yo W with recurrent/refractory multiple myeloma presenting
with several days of increased shortness of breath and
cough/chest congestion, transferred to the [**Hospital Unit Name 153**] for management
of hypoxia.
.
She was recently admitted to the BMT service from [**Date range (1) 20565**]
where she received a number of antimicrobials to treat fever,
cough, and URI symptoms ultimately attributed to parainflenza
virus III. The patient initially tested positive for
parainfluenza on [**3-16**] and failed outpatient treatment with a
Z-pack. During this last admission she also received IVIG and a
video swallow study to evaluate chronic aspiration attributed to
hiatal hernia. On [**2191-4-4**] she started Cytoxan/Velcade/Decadron
with D8 of Velcade on [**2191-4-11**].
.
According to the patient, she has not experienced any fevers,
chills, or night sweats since discharge. She felt her symptoms
had improved dramatically, but not entirely resolved. After
receiving chemo her symptoms returned and are now worse than
before. She endorses worsening sputum production, now pink and
occasional episodes of frank blood. No sick contacts or
significant outdoor exposures. Her dyspnea worsens with laying
flat and is associated with L-sided pleuritic chest pain. She
denies PND or LE swelling, hx of blood clots, hematuria, or
rash.
.
She contact[**Name (NI) **] her Oncologist and was sent to the ED for
evaluation of potential post-viral PNA. Her initial VS on
presentation were: 98.8, 76, 136/86, 20, 88% on RA. She was
placed on a NRB and her O2 sats rose to 98%. CXR revealed b/l
pleural effusions and opacification of the bases. She received
Vancomycin and Cefepime. They attempted to wean her supplemental
O2 to 40% FiO2 on Venturi mask; however, her oxygen saturations
again dropped to the 80s. Vitals prior to transfer were 141/94,
20, 99% NRB.
.
On admission to the [**Hospital Unit Name 153**], she appeared uncomfortable and
tachypneic. She was tired, but willing to converse. She answered
appropriately and expressed a need for pain medication to
control her "rib pain."
.
.
Review of sytems:
(+) Per HPI, + N/V/D attributed to recent chemotherapy
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness. Denied chest pain or palpitations. Denied
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias or rash.

MEDICAL HISTORY: Past Medical History:
- Vitiligo starting in [**2186**]
- Diverticulosis- found in colonoscopy [**2186**]. Last had
colonoscopy 6 months ago in [**Location (un) 47**].
- Atrial fibrillation
- History of thyroidectomy - for benign cyst
- History of radiation to her tonsils
- History of radiation to a left clavicle plasmacytoma after a
pathological fracture.
- History of mitral valve prolapse
- Allergies - since stem cell transplant
- Chronic back pain - s/p 9 compression fractures related to
multiple myeloma
- Restless leg syndrome - 30 yrs
- Auto. stem cell bone marrow transplant
- Multiple myeloma diagnosed in [**2184**].
.
Past Oncologic History:
"She is most recently status post five cycles of bendamustine
with her fifth cycle on [**2191-1-28**]. She was noted for increasing
lower back and right hip pain and underwent an MRI of the
thoracic and lumbar spine on [**2191-1-29**], which showed unchanged
extensive myelomatous involvement of the thoracic vertebrae with
no evidence of an epidural soft tissue mass. There were chronic
deformities of T7 through T12 and myelomatous involvement of the
lumbar spine, particularly the left anterior aspect of L4. Ms.
[**Known lastname **] developed increasing numbness of her right lower leg from
the anterior ankle and up the shin with some disruption of her
balance and gait due to this numbness. She had no changes in
bowel or bladder functioning.
She was initiated on Decadron 4 mg four times per day on
[**2191-2-4**], and began radiation therapy on [**2191-2-23**] to the
lower back in hopes of improving her symptoms. Her Decadron has
been decreased to 4 mg three times per day on [**2191-2-8**], 4 mg
twice per day as of [**2191-2-16**], 4 mg once per day on [**2191-2-25**],
and 2 mg daily as of [**2191-3-25**]. Radiation therapy completed on
[**2191-3-19**]. She also received weekly Velcade while she was
undergoing radiation therapy in order to continue to give her
some systemic therapy during her treatment. She received a dose
on [**2191-2-16**], [**2191-3-2**] and [**2191-3-9**]. She required periodic
platelet transfusions during this time.

MEDICATION ON ADMISSION: -Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-EMLA 2.5 %-2.5 % Topical Cream Apply to POC site prior to blood
draw
-Caltrate 600+D Plus Minerals 600 mg-400 unit Tab 1 Tablet(s) by
mouth once a day
-Nystatin 100,000 unit/mL Oral Susp 5 cc(s) by mouth four times
a day swish and spit as needed
-Vitamin C 500 mg Tab
1 Tablet(s) by mouth once a day will hold during radiation
treatment
-Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected
area twice per day Do not use on face.
-Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth once a day
-Acetaminophen 325 mg Tab 1 to 2 Tablet(s) by mouth every [**4-6**]
hours as needed
-Ativan 0.5 mg Tab [**1-2**] Tablet(s) by mouth q4-6 as needed for
nausea, insomnia
-Milk of Magnesia 400 mg/5 mL Oral Susp Suspension(s) by mouth
as needed for constipation
-Furosemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day in the morning. presently on hold per patient
-Alprazolam 0.5 mg Tab 2 Tablet(s) by mouth one hour before
procedure. [**Month (only) 116**] take additional 0.5 mg tablet if needed.
-Dexamethasone 4 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day ICD-9 code: 203.00
-Prochlorperazine Maleate 5 mg Tab [**1-2**] Tablet(s) by mouth every
eight (8) hours as needed for nausea
-Promethazine 12.5 mg Tab [**1-2**] Tablet(s) by mouth q 8 hours as
needed for nausuea
-Anti-Itch 0.5 %-0.5 % Lotion apply to affected areas three
times a day as needed for itching
-Colace 100 mg Cap 1 Capsule(s)(s) by mouth twice a day as
needed for constipation
Levothyroxine 112 mcg Tab 1 Tablet(s) by mouth once a day
-Nebupent 300 mg Solution for Inhalation 300 mg(s) inhaled every
month for 6 months Diluted in 6 ml sterile water administered
via aerosol. Please administer 2 puffs of albuterol prior to
treatment as needed.
-OxyContin 10 mg 12 hr Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours
-oxycodone 5 mg Cap 1 - 2 Capsule(s) by mouth every four (4)
hours as needed for breakthrough pain
-B Complex Cap one Capsule(s) by mouth daily
-Acyclovir 400 mg Tab 1 Tablet(s) by mouth two times a day
-Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day
-ranitidine 25 mg Effervescent Tab
-Ondansetron HCl 4 mg Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours as needed for nausea ICD-9 code: 203.00
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Epinephrine / Levofloxacin /
Penicillins / Benadryl

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 98.2, 114, 151/96, 16, 95% on 4L NC and high flow mask
General: Alert, oriented, tachypneic, in no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi bilaterally
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No known family history of myeloma or other blood disorders.
Grandmother: breast cancer.  Father: MI.

SOCIAL HISTORY: Retired former administrator for GTE.  Lives in [**Location 932**].  4
children who live in the [**Location (un) 86**] area. She is a widow, now has
male partner [**Name (NI) **] [**Name (NI) **], with whom she does not live. No tobacco
history. Occasional social drinking.
Bacterial pneumonia, unspecified,Acute respiratory failure,Acute systolic heart failure,Metabolic encephalopathy,Disseminated due to other mycobacteria,Acute kidney failure, unspecified,Primary pulmonary hypertension,Secondary cardiomyopathy, unspecified,Candidiasis of mouth,Peripheral stem cells replaced by transplant,Chronic kidney disease, unspecified,Abnormal coagulation profile,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Drug induced neutropenia,Atrial fibrillation,Mitral valve disorders,Backache, unspecified,Other chronic pain,Unspecified acquired hypothyroidism,Diaphragmatic hernia without mention of obstruction or gangrene
Bacterial pneumonia NOS,Acute respiratry failure,Ac systolic hrt failure,Metabolic encephalopathy,DMAC bacteremia,Acute kidney failure NOS,Prim pulm hypertension,Second cardiomyopath NOS,Thrush,Trspl sts-perip stm cell,Chronic kidney dis NOS,Abnrml coagultion prfile,Sec thrombocytpenia NEC,Adv eff antineoplastic,Drug induced neutropenia,Atrial fibrillation,Mitral valve disorder,Backache NOS,Chronic pain NEC,Hypothyroidism NOS,Diaphragmatic hernia
Admission Date:  [**2191-4-12**]              Discharge Date:   [**2191-4-30**]

Date of Birth:  [**2115-8-27**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Epinephrine / Levofloxacin /
Penicillins / Benadryl

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
Bronchoscopy


History of Present Illness:
75 yo W with recurrent/refractory multiple myeloma presenting
with several days of increased shortness of breath and
cough/chest congestion, transferred to the [**Hospital Unit Name 153**] for management
of hypoxia.
.
She was recently admitted to the BMT service from [**Date range (1) 20565**]
where she received a number of antimicrobials to treat fever,
cough, and URI symptoms ultimately attributed to parainflenza
virus III. The patient initially tested positive for
parainfluenza on [**3-16**] and failed outpatient treatment with a
Z-pack. During this last admission she also received IVIG and a
video swallow study to evaluate chronic aspiration attributed to
hiatal hernia. On [**2191-4-4**] she started Cytoxan/Velcade/Decadron
with D8 of Velcade on [**2191-4-11**].
.
According to the patient, she has not experienced any fevers,
chills, or night sweats since discharge. She felt her symptoms
had improved dramatically, but not entirely resolved. After
receiving chemo her symptoms returned and are now worse than
before. She endorses worsening sputum production, now pink and
occasional episodes of frank blood. No sick contacts or
significant outdoor exposures. Her dyspnea worsens with laying
flat and is associated with L-sided pleuritic chest pain. She
denies PND or LE swelling, hx of blood clots, hematuria, or
rash.
.
She contact[**Name (NI) **] her Oncologist and was sent to the ED for
evaluation of potential post-viral PNA. Her initial VS on
presentation were: 98.8, 76, 136/86, 20, 88% on RA. She was
placed on a NRB and her O2 sats rose to 98%. CXR revealed b/l
pleural effusions and opacification of the bases. She received
Vancomycin and Cefepime. They attempted to wean her supplemental
O2 to 40% FiO2 on Venturi mask; however, her oxygen saturations
again dropped to the 80s. Vitals prior to transfer were 141/94,
20, 99% NRB.
.
On admission to the [**Hospital Unit Name 153**], she appeared uncomfortable and
tachypneic. She was tired, but willing to converse. She answered
appropriately and expressed a need for pain medication to
control her "rib pain."
.
.
Review of sytems:
(+) Per HPI, + N/V/D attributed to recent chemotherapy
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness. Denied chest pain or palpitations. Denied
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias or rash.

Past Medical History:
Past Medical History:
- Vitiligo starting in [**2186**]
- Diverticulosis- found in colonoscopy [**2186**]. Last had
colonoscopy 6 months ago in [**Location (un) 47**].
- Atrial fibrillation
- History of thyroidectomy - for benign cyst
- History of radiation to her tonsils
- History of radiation to a left clavicle plasmacytoma after a
pathological fracture.
- History of mitral valve prolapse
- Allergies - since stem cell transplant
- Chronic back pain - s/p 9 compression fractures related to
multiple myeloma
- Restless leg syndrome - 30 yrs
- Auto. stem cell bone marrow transplant
- Multiple myeloma diagnosed in [**2184**].
.
Past Oncologic History:
"She is most recently status post five cycles of bendamustine
with her fifth cycle on [**2191-1-28**]. She was noted for increasing
lower back and right hip pain and underwent an MRI of the
thoracic and lumbar spine on [**2191-1-29**], which showed unchanged
extensive myelomatous involvement of the thoracic vertebrae with
no evidence of an epidural soft tissue mass. There were chronic
deformities of T7 through T12 and myelomatous involvement of the
lumbar spine, particularly the left anterior aspect of L4. Ms.
[**Known lastname **] developed increasing numbness of her right lower leg from
the anterior ankle and up the shin with some disruption of her
balance and gait due to this numbness. She had no changes in
bowel or bladder functioning.
She was initiated on Decadron 4 mg four times per day on
[**2191-2-4**], and began radiation therapy on [**2191-2-23**] to the
lower back in hopes of improving her symptoms. Her Decadron has
been decreased to 4 mg three times per day on [**2191-2-8**], 4 mg
twice per day as of [**2191-2-16**], 4 mg once per day on [**2191-2-25**],
and 2 mg daily as of [**2191-3-25**]. Radiation therapy completed on
[**2191-3-19**]. She also received weekly Velcade while she was
undergoing radiation therapy in order to continue to give her
some systemic therapy during her treatment. She received a dose
on [**2191-2-16**], [**2191-3-2**] and [**2191-3-9**]. She required periodic
platelet transfusions during this time.

Social History:
Retired former administrator for GTE.  Lives in [**Location 932**].  4
children who live in the [**Location (un) 86**] area. She is a widow, now has
male partner [**Name (NI) **] [**Name (NI) **], with whom she does not live. No tobacco
history. Occasional social drinking.


Family History:
No known family history of myeloma or other blood disorders.
Grandmother: breast cancer.  Father: MI.


Physical Exam:
Admission Physical Exam:
Vitals: 98.2, 114, 151/96, 16, 95% on 4L NC and high flow mask
General: Alert, oriented, tachypneic, in no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi bilaterally
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Discharge physical exam:
AFVSS
Gen: Well appearing, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, plasmacytoma
noted on scalp
Lungs: CTAB except for decreased BS in LLLF
Heart: Regular, no m/r, +S3
Abd: soft, NT, ND, with BS, no HSM
Ext: no c/c/e, WWP

Pertinent Results:
ADMISSION LABS
[**2191-4-11**]
-WBC-4.2 RBC-2.84* Hgb-9.1* Hct-27.8* MCV-98 MCH-32.1* MCHC-32.9
RDW-16.3* Plt Ct-24*# Neuts-92.8* Lymphs-2.5* Monos-3.7 Eos-0.2
Baso-0.8
[**2191-4-12**]
-WBC-1.6*# RBC-2.50* Hgb-8.4* Hct-23.6* MCV-94 MCH-33.8*
MCHC-35.8* RDW-17.0* Plt Ct-39* Neuts-91.1* Lymphs-5.6*
Monos-2.9 Eos-0.3 Baso-0.1
[**2191-4-13**]
-WBC-0.8* RBC-2.71* Hgb-8.9* Hct-26.1* MCV-96 MCH-32.8*
MCHC-34.1 RDW-16.7* Plt Ct-36* Neuts-88* Bands-1 Lymphs-7*
Monos-3 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
.
[**2191-4-12**]
-PT-13.5* PTT-24.8 INR(PT)-1.2*
-Glucose-146* UreaN-25* Creat-1.4* Na-141 K-3.7 Cl-105 HCO3-24
AnGap-16
-ALT-19 AST-33 LD(LDH)-357* CK(CPK)-31 AlkPhos-112* TotBili-0.3
.
[**2191-4-13**]
-Glucose-186* UreaN-27* Creat-1.5* Na-141 K-4.2 Cl-104 HCO3-24
AnGap-17
-Glucose-153* UreaN-29* Creat-1.6* Na-140 K-4.0 Cl-102 HCO3-28
AnGap-14
.
[**2191-4-12**] CK-MB-4 cTropnT-0.09*
[**2191-4-13**] CK-MB-5 cTropnT-0.27* proBNP-[**Numeric Identifier 20566**]*
[**2191-4-12**] IgG-632*

IMAGING
[**4-13**] Final CT Chest
1. Multifocal consolidations throughout all lung lobes. While
consolidations in the right and left lower lobes are more
consistent with bacterial pneumonia, the other consolidations
are concerning for fungal infection, specifically invasive
aspergillosis.
2. Small bilateral pleural effusions, increased since CT of
[**2191-3-21**].
3. Prominent main pulmonary artery which may be seen with
pulmonary
hypertension.
4. Large hiatal hernia.

CXR [**4-15**]
IMPRESSION: AP chest compared to [**3-24**] and [**2191-4-12**]:
Pulmonary vascular congestion and mild pulmonary edema have
improved since
[**4-12**]. Large area of consolidation at the right lung base and
a smaller
one at the left lateral to the large hiatus hernia have
worsened, consistent with progressive pneumonia.
Moderate-to-severe cardiomegaly is longstanding. Small bilateral
pleural effusions are presumed. No pneumothorax. Right
subclavian infusion port ends in the SVC.

[**2191-4-16**]
MR head
IMPRESSION:
No acute infarcts. Small vessel disease. Bony abnormalities in
the skull and cervical vertebrae as well as the clivus
indicative of multiple myeloma. No significant epidural disease
is seen, although evaluation is limited without gadolinium
administration.

[**2191-4-19**] CT chest
IMPRESSION: Improving bilateral bronchocentric ground-glass
opacities, right pulmonary consolidation and bilateral pleural
effusions, consistent with a responding multifocal
consolidation, angioinvasive aspergillosis is considered a
probable explanation for the appearance on the prior CT.

[**4-20**] Cardiac MR
Impression:
1. Moderately dilated left ventricle with global left
ventricular systolic
dysfunction. The LVEF was mildly depressed at 45%. The effective
forward LVEF was moderately depressed at 35%. No CMR evidence of
myocardial edema.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 57%.
3. Moderate mitral regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Mild right atrial enlargement.
6. A note is made of bilateral pleural effusions and a hiatal
hernia.

MICROBIOLOGY
RESPIRATORY VIRUS SCREEN [**4-28**]
[**2191-4-28**] 4:00 pm Rapid Respiratory Viral Screen & Culture
      Source: Nasopharyngeal swab.

   Respiratory Viral Culture (Pending):

   Respiratory Viral Antigen Screen (Final [**2191-4-29**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.

MYCOLYTIC BLOOD CX
[**2191-4-26**] 7:06 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
      Source: Line-poc.

   BLOOD/FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   BLOOD/AFB CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.


BAL [**4-15**]
[**2191-4-15**] 10:15 am BRONCHOALVEOLAR LAVAGE      BRONCHIAL LAVAGE.
      VIC WILL ALSO R/O CMV.
      Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20567**] [**2191-4-15**] AT
1320.

   GRAM STAIN (Final [**2191-4-15**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2191-4-17**]):
      ~[**2180**]/ML Commensal Respiratory Flora.

   LEGIONELLA CULTURE (Final [**2191-4-22**]):    NO LEGIONELLA
ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2191-4-15**]):
      NO FUNGAL ELEMENTS SEEN.
      This is a low yield procedure based on our in-house
studies.
      KOH PERFORMED PER [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6401**] [**2191-4-15**].

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2191-4-15**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2191-4-29**]):
      YEAST.

   ACID FAST SMEAR (Final [**2191-4-18**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):
      AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.

   VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2191-4-15**]):
      TEST CANCELLED, PATIENT CREDITED.
      PLEASE REFER TO VIRAL CULTURE FOR RESULT.

   VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.

SPUTUM CX [**4-13**]
[**2191-4-13**] 12:25 pm SPUTUM      Source: Induced.

   GRAM STAIN (Final [**2191-4-13**]):
      [**10-25**] PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   RESPIRATORY CULTURE (Final [**2191-4-15**]):
      SPARSE GROWTH Commensal Respiratory Flora.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2191-4-13**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2191-4-29**]):
      YEAST.

   ACID FAST SMEAR (Final [**2191-4-14**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):
      Reported to and read back by DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] AND
[**Last Name (LF) 20568**],[**First Name3 (LF) 20569**] @
      15:30, [**2191-4-22**].
      AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
         SENT TO STATE LAB FOR FURTHER IDENTIFICATION
[**2191-4-24**].
   - per verbal report from state lab, probe of plated organism
+[**Doctor First Name **]

[**4-13**] Legionella negative

[**4-13**]
                            **FINAL REPORT [**2191-4-15**]**

   CMV IgG ANTIBODY (Final [**2191-4-15**]):
      POSITIVE FOR CMV IgG ANTIBODY BY EIA.
      35 AU/ML.
      Reference Range:  Negative < 4 AU/ml, Positive >= 6 AU/ml.


   CMV IgM ANTIBODY (Final [**2191-4-15**]):
      NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
      INTERPRETATION:  INFECTION AT UNDETERMINED TIME.
      A positive IgG result generally indicates past exposure.
      Infection with CMV once contracted remains latent and may
reactivate
      when immunity is compromised.
      If current infection is suspected, submit follow-up serum
in [**2-3**]
      weeks.
      Greatly elevated serum protein with IgG levels >[**2180**] mg/dl
may cause
      interference with CMV IgM results.

All Blood Cxs no growth/pending.

DISCHARGE LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2191-4-30**] 05:26    5.0 2.84* 9.2* 27.3* 96 32.3* 33.6 17.9* 23*

DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2191-4-30**] 05:26    85* 0 4* 11 0 0 0 0 0
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2191-4-30**] 05:26    901 29* 1.7* 141 4.2 107 23 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2191-4-30**] 05:26    24 23 243   142*   0.5

Free kappa/lambda light chains pending


Brief Hospital Course:
75 yo W with recurrent/refractory multiple myeloma, recent
parainfluenza virus infection, presenting with increased
dyspnea, transferred to [**Hospital Unit Name 153**] for management of hypoxia
.
# Dyspnea/Hypoxia: Likely multifactorial in etiology. Patient
has an element of volume overload from acute congestive heart
failure, supported by BNP of 33k, bilateral pleural effusions,
and improvement with initial BiPAP and IV Lasix boluses. She
also demonstrated multifocal opacities on CT chest, concerning
for bacterial PNA (and potentially invasive Aspergillus). Given
her immunocompromised state she was immediately started on broad
antimicrobials (Vancomycin, Cefepime, and Azithromycin) and
extensive studies for bacterial, viral, and fungal pathogens
were sent. Respiratory culture was positive for Parainfluenza
III. Sputum grew gram positive cocci from one induced culture
that were further speciated to respiratory flora. A bronchoscopy
was performed and revealed alveolar hemorrhage. Per infection
control, pt needs to stay on droplet precautions until
parainfluenza negative.
.
After stabilization, she was called out to the BMT floor.  she
received IVIG x1 for the paraflu, and we continued her abx for a
14 day course.  She did well and her oxygenation improved to the
point that her ambulatory saturation did not dip below 91.  The
patient then started to have AFB + cultures (x 3), and ID was
consulted.  She was empirically started on a brief course of
linezolid, imipenem, and clarithromycin as she will likely
require chemotherapy soon for her myeloma.  However, the state
lab probed her cx which was + for [**Doctor First Name **], and her regimen was
changed to rifabutin, ethambutol, and clarithromycin.  She will
require a baseline eye exam as an outpatient, and she has close
f/u with oncology and infectious disease.
.
# Acute Congestive Heart Failure: Patient presented with dyspnea
and hypoxia (as above). CXR revealed b/l pleural effusions. BNP
was elevated at 33k. Echocardiogram revealed EF of 30% with
severe hypokinesis of the inferior wall and basal 2/3rds of the
septum and anterior wall, which was new from her prior echo in
[**6-10**]. Cardiac biomarkers did not support acute coronary
syndrome. Cardiology was consulted and recommended starting low
dose beta-blocker and uptitrating as needed to provide rate
control and augment cardiac output. Initiation of ace-inhibitor
was deferred until hemodynamic stability was assured. The
etiology of her cardiomyopathy is unclear. Amyloid was
considered (SPEP negative, UPEP was +), as well as [**2-2**]
Parainfluenza virus, Velcade (very rare), or a missed ischemic
cardiac event.
.
Out of concern that the echo showed coronary distribution
hypokinesis, a cardiac MR was done which was c/w chemo induced
cardiomyopathy, not a coronary issue.  The repeat study showed
an EF of ~ 45%.  The CMR also did not show any signs of amyloid
involvement.  A cardiology c/s was recalled to assist with CM
management, and metop was uptitrated to 37.5 POTID, and
lisinopril was started and titrated to 5 mg PO daily, which she
tolerated well.  On discharge, her Metop was changed to long
acting Toprol XL 100 mg PO daily.
.
# Multiple Myeloma: Diagnosed in [**2184**] and s/p Auto SCT in [**2184**].
Currently on C1D1 of Cytoxan/Velcade/Decadron on [**2191-4-4**]. Had
increase of lytic lesions while on prior Bendamustine. ANC on
admission was approaching neutropenia, so the patient was placed
on neutropenic precautions. Hematolog/Oncology followed closely
and provided daily recommendations. We transfused to maintain
platlets >20 and Hct >25. She was continued on her prophylactic
Acyclovir, inhaled Pentamidine (last dose 3/17), and current
Dexamethasone. Per onc recs, her pentamidine was held. Her pain
and other symptoms were controlled.  Given the need for
chemotherapy soon, she was placed on tx for MAC (see above).
She has close f/u with oncology scheduled.
.
# Word finding difficulty: Pt endorsed word finding difficulty a
few hours after bronchoscopy. Given concern for possible
pulmonary/systemic fungal infection, aspergillosis or even
mucor, vs acute embolic event, she was sent for MRI wo contrast.
Neurological exam was negative for any focal findings.
Preliminary read on MRI was negative for acute infarct, notable
for chronic small vessel disease, mild atrophy, and skull
deformities in L frontal/parietal/clivus/cervical vertebrae c/w
known multiple myeloma.  A neuro c/s was called, and as the
patient improved, the thought was that this was [**2-2**]
toxic/metabolic causes from acute infection.  The word finding
difficulty resolved over time, and she was set up for outpatient
f/u appointment in Neurology.
.
# Chronic kidney injury: Related to multiple myeloma. Cr
currently uptrending in the setting of diuresis. Baseline
1.4-1.8.  Trended and was stble throughout stay.  All
medications were renally dosed.
.
# Prolonged PT: Likely secondary to nutritional deficiency
and/or recent antibiotic use. She was given 1 dose of PO vitamin
K 5 mg for repletion and INR improved.
.
# Paroxysmal Atrial Fibrillation: Held ASA 81 daily given low
plts and monitored on telemetry. Pt was tachycardic and not on
nodal blocking [**Doctor Last Name 360**] as outpatient. Last EKG shows ST with
frequent PACs. Troponins peaked (othwer biomarkers flat), likely
[**2-2**] heart failure/demand in setting of CKI. Per Cards, started
low dose BB.
Metoprolol 12.5 TID was started with subsequent improvement in
rate and uptitrated to 25mg TID per cards rec. They attribute
cardiomyopathy to chemotherapy and anticipate improvement w
time. As above, these medications were continued to be titrated
to metop succinate 100 po daily as well as lisinopril 5 mg for
afterload reduction
.
# Hypothyroidism: Continued outpatient Levothyroxine 112mcg
daily.
.
# Hiatal Hernia: Continued Ranitidine 150 mg daily (home dosage
unknown), to restart home dose at discharge (25 mg effervescent
tab).

Medications on Admission:
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-EMLA 2.5 %-2.5 % Topical Cream Apply to POC site prior to blood
draw
-Caltrate 600+D Plus Minerals 600 mg-400 unit Tab 1 Tablet(s) by
mouth once a day
-Nystatin 100,000 unit/mL Oral Susp 5 cc(s) by mouth four times
a day swish and spit as needed
-Vitamin C 500 mg Tab
1 Tablet(s) by mouth once a day will hold during radiation
treatment
-Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected
area twice per day Do not use on face.
-Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth once a day
-Acetaminophen 325 mg Tab 1 to 2 Tablet(s) by mouth every [**4-6**]
hours as needed
-Ativan 0.5 mg Tab [**1-2**] Tablet(s) by mouth q4-6 as needed for
nausea, insomnia
-Milk of Magnesia 400 mg/5 mL Oral Susp Suspension(s) by mouth
as needed for constipation
-Furosemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day in the morning. presently on hold per patient
-Alprazolam 0.5 mg Tab 2 Tablet(s) by mouth one hour before
procedure. [**Month (only) 116**] take additional 0.5 mg tablet if needed.
-Dexamethasone 4 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day ICD-9 code: 203.00
-Prochlorperazine Maleate 5 mg Tab [**1-2**] Tablet(s) by mouth every
eight (8) hours as needed for nausea
-Promethazine 12.5 mg Tab [**1-2**] Tablet(s) by mouth q 8 hours as
needed for nausuea
-Anti-Itch 0.5 %-0.5 % Lotion apply to affected areas three
times a day as needed for itching
-Colace 100 mg Cap 1 Capsule(s)(s) by mouth twice a day as
needed for constipation
Levothyroxine 112 mcg Tab 1 Tablet(s) by mouth once a day
-Nebupent 300 mg Solution for Inhalation 300 mg(s) inhaled every
month for 6 months Diluted in 6 ml sterile water administered
via aerosol. Please administer 2 puffs of albuterol prior to
treatment as needed.
-OxyContin 10 mg 12 hr Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours
-oxycodone 5 mg Cap 1 - 2 Capsule(s) by mouth every four (4)
hours as needed for breakthrough pain
-B Complex Cap one Capsule(s) by mouth daily
-Acyclovir 400 mg Tab 1 Tablet(s) by mouth two times a day
-Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day
-ranitidine 25 mg Effervescent Tab
-Ondansetron HCl 4 mg Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours as needed for nausea ICD-9 code: 203.00
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day

Discharge Medications:
1. rifabutin 150 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
2. ethambutol 400 mg Tablet Sig: Two (2) Tablet PO DAYS
(MO,WE,FR).
Disp:*24 Tablet(s)* Refills:*2*
3. clarithromycin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. Caltrate 600 + D  Oral
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) cc PO four
times a day as needed for thrush.
8. Vitamin C  Oral
9. triamcinolone acetonide 0.1 % Cream Sig: One (1) appl Topical
twice a day as needed for rash.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for nausea or anxiety.
12. Milk of Magnesia 400 mg/5 mL Suspension Oral
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. EMLA  Topical
15. alprazolam 0.5 mg Tablet Sig: Two (2) Tablet PO asdir as
needed for before procedure: take 1 hr before procedure.
16. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for nausea.
17. promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea.
18. Sarna Anti-Itch  Topical
19. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
20. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. Nebupent 300 mg Recon Soln Inhalation
22. oxycodone 10 mg Tablet Extended Release 12 hr Sig: [**1-2**]
Tablet Extended Release 12 hrs PO every eight (8) hours.
23. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
24. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
25. acyclovir 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

27. ranitidine HCl 25 mg Tablet, Effervescent Sig: One (1)
Tablet, Effervescent PO once a day.
28. Zofran 4 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours
as needed for nausea.
29. cetirizine 10 mg Capsule Sig: One (1) Capsule PO once a day.



Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis
Pneumonia

Secondary Diagnoses
Mycobacterium Avium Intracellulare
Multiple Myeloma
Parainfluenza


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


Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization.  You were admitted to [**Hospital1 18**] with shortness of
breath and were in the ICU because you needed to have assistance
with your breathing.  You were treated with antibiotics for 14
days for a bacterial pneumonia, and you were given IVIG because
you were para-influenza positive.  Finally, we found acid-fast
bacilli in your sputum multiple times which required you to stay
on precautions while here.  Infectious Disease saw you while you
were here and they felt you could be discharged with three drugs
to treat MAC before your next round of chemo.  We also had our
cardiologists see you who added on medicine to keep your heart
healthy.  We also had our neurologists see you because of some
word-finding difficulty, and they would like to see you in
clinic.

PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP TAKING LASIX
- STOP taking ASPIRIN
- DECREASE your ACYCLOVIR to 400 mg by mouth daily
- START taking RIFABUTIN 150 mg by mouth daily
- START taking ETHAMBUTOL 800 mg by mouth every MON, WED, FRI
- START taking CLARITHROMYCIN 250 mg by mouth daily
- START taking METOPROLOL SUCCINATE (TOPROL XL) 100 mg by mouth
daily
- START taking LISINOPRIL 5 mg by mouth daily

Please follow up with you physicians as indicated below

Followup Instructions:
You will be contact[**Name (NI) **] by the [**Name (NI) **]/BMT department regarding
an appointment on Monday with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].

**You should also schedule an eye exam in the next week since
you are on ETHAMBUTOL **

Otherwise, these are the appointments for your follow up:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2191-5-4**] at 1:45 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20564**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/BMT
When: THURSDAY [**2191-5-5**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY
When: TUESDAY [**2191-5-17**] at 1:30 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 20570**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2191-4-30**]
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Acute systolic heart failure,Metabolic encephalopathy,Disseminated due to other mycobacteria,Acute kidney failure, unspecified,Primary pulmonary hypertension,Secondary cardiomyopathy, unspecified,Candidiasis of mouth,Peripheral stem cells replaced by transplant,Chronic kidney disease, unspecified,Abnormal coagulation profile,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Drug induced neutropenia,Atrial fibrillation,Mitral valve disorders,Backache, unspecified,Other chronic pain,Unspecified acquired hypothyroidism,Diaphragmatic hernia without mention of obstruction or gangrene'}


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: 75 yo W with recurrent/refractory multiple myeloma presenting
with several days of increased shortness of breath and
cough/chest congestion, transferred to the [**Hospital Unit Name 153**] for management
of hypoxia.
.
She was recently admitted to the BMT service from [**Date range (1) 20565**]
where she received a number of antimicrobials to treat fever,
cough, and URI symptoms ultimately attributed to parainflenza
virus III. The patient initially tested positive for
parainfluenza on [**3-16**] and failed outpatient treatment with a
Z-pack. During this last admission she also received IVIG and a
video swallow study to evaluate chronic aspiration attributed to
hiatal hernia. On [**2191-4-4**] she started Cytoxan/Velcade/Decadron
with D8 of Velcade on [**2191-4-11**].
.
According to the patient, she has not experienced any fevers,
chills, or night sweats since discharge. She felt her symptoms
had improved dramatically, but not entirely resolved. After
receiving chemo her symptoms returned and are now worse than
before. She endorses worsening sputum production, now pink and
occasional episodes of frank blood. No sick contacts or
significant outdoor exposures. Her dyspnea worsens with laying
flat and is associated with L-sided pleuritic chest pain. She
denies PND or LE swelling, hx of blood clots, hematuria, or
rash.
.
She contact[**Name (NI) **] her Oncologist and was sent to the ED for
evaluation of potential post-viral PNA. Her initial VS on
presentation were: 98.8, 76, 136/86, 20, 88% on RA. She was
placed on a NRB and her O2 sats rose to 98%. CXR revealed b/l
pleural effusions and opacification of the bases. She received
Vancomycin and Cefepime. They attempted to wean her supplemental
O2 to 40% FiO2 on Venturi mask; however, her oxygen saturations
again dropped to the 80s. Vitals prior to transfer were 141/94,
20, 99% NRB.
.
On admission to the [**Hospital Unit Name 153**], she appeared uncomfortable and
tachypneic. She was tired, but willing to converse. She answered
appropriately and expressed a need for pain medication to
control her "rib pain."
.
.
Review of sytems:
(+) Per HPI, + N/V/D attributed to recent chemotherapy
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness. Denied chest pain or palpitations. Denied
constipation or abdominal pain. No dysuria. Denied arthralgias
or myalgias or rash.

MEDICAL HISTORY: Past Medical History:
- Vitiligo starting in [**2186**]
- Diverticulosis- found in colonoscopy [**2186**]. Last had
colonoscopy 6 months ago in [**Location (un) 47**].
- Atrial fibrillation
- History of thyroidectomy - for benign cyst
- History of radiation to her tonsils
- History of radiation to a left clavicle plasmacytoma after a
pathological fracture.
- History of mitral valve prolapse
- Allergies - since stem cell transplant
- Chronic back pain - s/p 9 compression fractures related to
multiple myeloma
- Restless leg syndrome - 30 yrs
- Auto. stem cell bone marrow transplant
- Multiple myeloma diagnosed in [**2184**].
.
Past Oncologic History:
"She is most recently status post five cycles of bendamustine
with her fifth cycle on [**2191-1-28**]. She was noted for increasing
lower back and right hip pain and underwent an MRI of the
thoracic and lumbar spine on [**2191-1-29**], which showed unchanged
extensive myelomatous involvement of the thoracic vertebrae with
no evidence of an epidural soft tissue mass. There were chronic
deformities of T7 through T12 and myelomatous involvement of the
lumbar spine, particularly the left anterior aspect of L4. Ms.
[**Known lastname **] developed increasing numbness of her right lower leg from
the anterior ankle and up the shin with some disruption of her
balance and gait due to this numbness. She had no changes in
bowel or bladder functioning.
She was initiated on Decadron 4 mg four times per day on
[**2191-2-4**], and began radiation therapy on [**2191-2-23**] to the
lower back in hopes of improving her symptoms. Her Decadron has
been decreased to 4 mg three times per day on [**2191-2-8**], 4 mg
twice per day as of [**2191-2-16**], 4 mg once per day on [**2191-2-25**],
and 2 mg daily as of [**2191-3-25**]. Radiation therapy completed on
[**2191-3-19**]. She also received weekly Velcade while she was
undergoing radiation therapy in order to continue to give her
some systemic therapy during her treatment. She received a dose
on [**2191-2-16**], [**2191-3-2**] and [**2191-3-9**]. She required periodic
platelet transfusions during this time.

MEDICATION ON ADMISSION: -Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-EMLA 2.5 %-2.5 % Topical Cream Apply to POC site prior to blood
draw
-Caltrate 600+D Plus Minerals 600 mg-400 unit Tab 1 Tablet(s) by
mouth once a day
-Nystatin 100,000 unit/mL Oral Susp 5 cc(s) by mouth four times
a day swish and spit as needed
-Vitamin C 500 mg Tab
1 Tablet(s) by mouth once a day will hold during radiation
treatment
-Triamcinolone Acetonide 0.1 % Topical Cream Apply to affected
area twice per day Do not use on face.
-Aspirin 81 mg Chewable Tab 1 Tablet(s) by mouth once a day
-Acetaminophen 325 mg Tab 1 to 2 Tablet(s) by mouth every [**4-6**]
hours as needed
-Ativan 0.5 mg Tab [**1-2**] Tablet(s) by mouth q4-6 as needed for
nausea, insomnia
-Milk of Magnesia 400 mg/5 mL Oral Susp Suspension(s) by mouth
as needed for constipation
-Furosemide 20 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day in the morning. presently on hold per patient
-Alprazolam 0.5 mg Tab 2 Tablet(s) by mouth one hour before
procedure. [**Month (only) 116**] take additional 0.5 mg tablet if needed.
-Dexamethasone 4 mg Tab 0.5 (One half) Tablet(s) by mouth once a
day ICD-9 code: 203.00
-Prochlorperazine Maleate 5 mg Tab [**1-2**] Tablet(s) by mouth every
eight (8) hours as needed for nausea
-Promethazine 12.5 mg Tab [**1-2**] Tablet(s) by mouth q 8 hours as
needed for nausuea
-Anti-Itch 0.5 %-0.5 % Lotion apply to affected areas three
times a day as needed for itching
-Colace 100 mg Cap 1 Capsule(s)(s) by mouth twice a day as
needed for constipation
Levothyroxine 112 mcg Tab 1 Tablet(s) by mouth once a day
-Nebupent 300 mg Solution for Inhalation 300 mg(s) inhaled every
month for 6 months Diluted in 6 ml sterile water administered
via aerosol. Please administer 2 puffs of albuterol prior to
treatment as needed.
-OxyContin 10 mg 12 hr Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours
-oxycodone 5 mg Cap 1 - 2 Capsule(s) by mouth every four (4)
hours as needed for breakthrough pain
-B Complex Cap one Capsule(s) by mouth daily
-Acyclovir 400 mg Tab 1 Tablet(s) by mouth two times a day
-Folic Acid 1 mg Tab 1 Tablet(s) by mouth once a day
-ranitidine 25 mg Effervescent Tab
-Ondansetron HCl 4 mg Tab 1 to 2 Tablet(s) by mouth every eight
(8) hours as needed for nausea ICD-9 code: 203.00
-Cetirizine 10 mg Tab 1 (One) Tablet(s) by mouth once a day

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Epinephrine / Levofloxacin /
Penicillins / Benadryl

PHYSICAL EXAM: Admission Physical Exam:
Vitals: 98.2, 114, 151/96, 16, 95% on 4L NC and high flow mask
General: Alert, oriented, tachypneic, in no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi bilaterally
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
appreciated
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: No known family history of myeloma or other blood disorders.
Grandmother: breast cancer.  Father: MI.

SOCIAL HISTORY: Retired former administrator for GTE.  Lives in [**Location 932**].  4
children who live in the [**Location (un) 86**] area. She is a widow, now has
male partner [**Name (NI) **] [**Name (NI) **], with whom she does not live. No tobacco
history. Occasional social drinking. 

### Response:
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Acute systolic heart failure,Metabolic encephalopathy,Disseminated due to other mycobacteria,Acute kidney failure, unspecified,Primary pulmonary hypertension,Secondary cardiomyopathy, unspecified,Candidiasis of mouth,Peripheral stem cells replaced by transplant,Chronic kidney disease, unspecified,Abnormal coagulation profile,Other secondary thrombocytopenia,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Drug induced neutropenia,Atrial fibrillation,Mitral valve disorders,Backache, unspecified,Other chronic pain,Unspecified acquired hypothyroidism,Diaphragmatic hernia without mention of obstruction or gangrene'}
