CHIEF COMPLAINT: Shortness of breath.

PRESENT ILLNESS: Ms. [**Known lastname 19960**] is a 52 yo woman h/o COPD, breast cancer who
presented to an OSH for evaluation of shortness of breath.  She
notes she has not been feeling well for several weeks when she
noted pain in her back. Initially she was diagnosed with a
muscle spasm and given pain mediation. When the pain did not
subside she returned for further care and it was noted that she
had a rash that appeared to be consistant with shingles. She
describes the pain as a band from her abdomen to her back. She
was treated with a course of valtrex which she completed and the
rash resolved. Her pain persisted, despite treatment with
oxycodone and vicodin. Over the last several days, the patient
noted a sore throat and increasing oxygen requirement (she
typically is on 2L O2 NC at home). She also noted fevers to 102
at home and decreasing O2 sats from 90s to 79% with ambulation.
This past weekend (during storm) the patient was exceedingly
anxious after the electricity went out. She was trying to find
her oxygen tank and felt herself coughing so hard she could
barely catch her breath.
She denies having any chest pains or dizziness, N/V. She went to
an OSH for shortness of breath and back pain. On CXR she found
to have multifocal PNA, also notable on labs were a leukocytosis
to 24, d-dimer 1.2 (elevated). A CTA was performed however there
was dye leak into the left hand and the test was aborted. She
was given ceftriaxone and transfered to [**Hospital1 18**].
.
On arrival, she was noted to be afebrile with BPs in 120/60s, HR
105, breathing in 20s, O2 sats 80s on 2L. With albuterol and
ipratropium nebs and morphine her O2 sat was 90s on 4L and much
more comfortable. Noted on exam were a tense compartment in L
hand. Plastics was called to evaluate and recommended elevation
and frequent pulse checks. CT from the outside hospital shows
multifocal PNA, however given lack of contrast cannot evaluate
for PE. Notable on her labs in the ED were a leukocytosis with
left shift, elevated bicarb. She was started on 750mg
levofloxacin IV and 1L IVF was started prior to transfer to the
MICU. On admission to ICU, she was afebrile with BP 130/70s, HR
103, 95% 4L O2.
.
ROS: pertinent positives include headaches (several months),
poor appetite, constipation.  Denies any visual changes, chest
pains, N/V, URI, trouble swallowing, blood in stool or urine,
numbness/tingling, trouble walking.
She has not received the flu vaccine this year. Denies any
trauma.

MEDICAL HISTORY: COPD, 2L O2 at home (at [**Hospital 81747**] Rehab 1 [**12-4**] yr ago for
respiratory rehab)
asthma
hypothyroid
?arrhythmia
?rib fracture on CXR
herpez zoster (treated w/valtrex)
Breast ca to both breast ([**2130**], [**2132**], treated w/ lumpectomy and
radiation, L axillary lymph node dissection)
insomnia
anxiety
miscarriage
hysterectomy

MEDICATION ON ADMISSION: theophylline 200mg po q12h
levothyroxine 137mcg qd
prednisone 5mg 1 1/2 tabs po qd
zoloft 100mg 2 tabs qd
femara? 2.5mg po qd
xopenex 0.63mg qid prn
ativan 1mg q8h ([**12-4**] q4 prn)
prilosec 20mg po
oscal 500mg po
combivent
advair 500mg
super B complex
vitamin C&E
flax seed oil
[**Last Name (un) 2432**] vitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 97.6 HR 109 BP 135/57 RR 20 94% 4L O2
Gen: Alert and oriented, but appears lethargic, appropirate
HEENT: NCAT, dry mucus membranes, pink conjunctiva, anicteric,
OP clear, plaque on tongue, poor dentition
Lymph: no cervical or axillary lymphadenopathy. Noted on exam is
swelling (?fluid collection) over left supraclavicular space. no
erythema, nontender.
Heart: S1S2 regular rhythm, tachycardic, no MRG appreciated, no
JVD
Lungs: decreased breath sounds in bilateral bases with
expiratory wheezes heard in mid-lung fields
Chest: Large, tender mass over right posterior thorax, fixed, no
erythema, non-fluctuant. Also scabbed lesion on right chest,
mid-axillary region, no vescicles.
Abdomen: BS present, soft, NTND, ? hepatosplenomegaly.
Ext: WWP, no edema, no cyanosis
Neuro: Somnolent but oriented, following commands, CN II-XII
grossly intact, sensation intact, strength 5/5 b/l in LE

FAMILY HISTORY: Mother and aunt with breast cancer.

SOCIAL HISTORY: Lives at home with husband and daughter (17yo). She is retired
on disability. A long time smoker, she smokes [**12-4**] ppd for 35yrs.
She drinks alcohol occasionally. Denies any drug use.
Unspecified septicemia,Pneumonia, organism unspecified,Extravasation of other vesicant agent,Obstructive chronic bronchitis with acute bronchitis,Hyperosmolality and/or hypernatremia,Tietze's disease,Unspecified acquired hypothyroidism,Tobacco use disorder,Personal history of malignant neoplasm of breast,Sepsis,Herpes zoster without mention of complication
Septicemia NOS,Pneumonia, organism NOS,Extravasn vesicant NEC,Obs chr bronc w ac bronc,Hyperosmolality,Tietze's disease,Hypothyroidism NOS,Tobacco use disorder,Hx of breast malignancy,Sepsis,Herpes zoster NOS
Admission Date:  [**2138-11-16**]              Discharge Date:   [**2138-11-21**]

Date of Birth:  [**2086-1-19**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
Shortness of breath.

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
Ms. [**Known lastname 19960**] is a 52 yo woman h/o COPD, breast cancer who
presented to an OSH for evaluation of shortness of breath.  She
notes she has not been feeling well for several weeks when she
noted pain in her back. Initially she was diagnosed with a
muscle spasm and given pain mediation. When the pain did not
subside she returned for further care and it was noted that she
had a rash that appeared to be consistant with shingles. She
describes the pain as a band from her abdomen to her back. She
was treated with a course of valtrex which she completed and the
rash resolved. Her pain persisted, despite treatment with
oxycodone and vicodin. Over the last several days, the patient
noted a sore throat and increasing oxygen requirement (she
typically is on 2L O2 NC at home). She also noted fevers to 102
at home and decreasing O2 sats from 90s to 79% with ambulation.
This past weekend (during storm) the patient was exceedingly
anxious after the electricity went out. She was trying to find
her oxygen tank and felt herself coughing so hard she could
barely catch her breath.
She denies having any chest pains or dizziness, N/V. She went to
an OSH for shortness of breath and back pain. On CXR she found
to have multifocal PNA, also notable on labs were a leukocytosis
to 24, d-dimer 1.2 (elevated). A CTA was performed however there
was dye leak into the left hand and the test was aborted. She
was given ceftriaxone and transfered to [**Hospital1 18**].
.
On arrival, she was noted to be afebrile with BPs in 120/60s, HR
105, breathing in 20s, O2 sats 80s on 2L. With albuterol and
ipratropium nebs and morphine her O2 sat was 90s on 4L and much
more comfortable. Noted on exam were a tense compartment in L
hand. Plastics was called to evaluate and recommended elevation
and frequent pulse checks. CT from the outside hospital shows
multifocal PNA, however given lack of contrast cannot evaluate
for PE. Notable on her labs in the ED were a leukocytosis with
left shift, elevated bicarb. She was started on 750mg
levofloxacin IV and 1L IVF was started prior to transfer to the
MICU. On admission to ICU, she was afebrile with BP 130/70s, HR
103, 95% 4L O2.
.
ROS: pertinent positives include headaches (several months),
poor appetite, constipation.  Denies any visual changes, chest
pains, N/V, URI, trouble swallowing, blood in stool or urine,
numbness/tingling, trouble walking.
She has not received the flu vaccine this year. Denies any
trauma.

Past Medical History:
COPD, 2L O2 at home (at [**Hospital 81747**] Rehab 1 [**12-4**] yr ago for
respiratory rehab)
asthma
hypothyroid
?arrhythmia
?rib fracture on CXR
herpez zoster (treated w/valtrex)
Breast ca to both breast ([**2130**], [**2132**], treated w/ lumpectomy and
radiation, L axillary lymph node dissection)
insomnia
anxiety
miscarriage
hysterectomy

Social History:
Lives at home with husband and daughter (17yo). She is retired
on disability. A long time smoker, she smokes [**12-4**] ppd for 35yrs.
She drinks alcohol occasionally. Denies any drug use.

Family History:
Mother and aunt with breast cancer.

Physical Exam:
Vitals: T 97.6 HR 109 BP 135/57 RR 20 94% 4L O2
Gen: Alert and oriented, but appears lethargic, appropirate
HEENT: NCAT, dry mucus membranes, pink conjunctiva, anicteric,
OP clear, plaque on tongue, poor dentition
Lymph: no cervical or axillary lymphadenopathy. Noted on exam is
swelling (?fluid collection) over left supraclavicular space. no
erythema, nontender.
Heart: S1S2 regular rhythm, tachycardic, no MRG appreciated, no
JVD
Lungs: decreased breath sounds in bilateral bases with
expiratory wheezes heard in mid-lung fields
Chest: Large, tender mass over right posterior thorax, fixed, no
erythema, non-fluctuant. Also scabbed lesion on right chest,
mid-axillary region, no vescicles.
Abdomen: BS present, soft, NTND, ? hepatosplenomegaly.
Ext: WWP, no edema, no cyanosis
Neuro: Somnolent but oriented, following commands, CN II-XII
grossly intact, sensation intact, strength 5/5 b/l in LE


Pertinent Results:
Labs at Admission:
[**2138-11-16**] 06:30PM BLOOD WBC-24.7* RBC-3.64* Hgb-11.8* Hct-35.0*
MCV-96 MCH-32.4* MCHC-33.7 RDW-13.8 Plt Ct-436
[**2138-11-16**] 06:30PM BLOOD PT-13.4 PTT-27.9 INR(PT)-1.1
[**2138-11-16**] 06:30PM BLOOD Glucose-133* UreaN-9 Creat-0.5 Na-138
K-4.7 Cl-90* HCO3-40* AnGap-13
[**2138-11-17**] 03:22AM BLOOD ALT-17 AST-17 LD(LDH)-170 CK(CPK)-114
AlkPhos-70 TotBili-0.2
[**2138-11-17**] 03:22AM BLOOD CK-MB-4 cTropnT-<0.01
[**2138-11-17**] 09:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2138-11-17**] 03:22AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.3 Mg-2.1
Iron-29*
[**2138-11-17**] 03:22AM BLOOD calTIBC-257* Ferritn-167* TRF-198*
[**2138-11-17**] 03:22AM BLOOD TSH-0.29
[**2138-11-17**] 07:38AM BLOOD Type-ART pO2-43* pCO2-72* pH-7.37
calTCO2-43* Base XS-12
[**2138-11-17**] 11:06AM BLOOD Lactate-0.7
.
Labs at Discharge:
[**2138-11-21**] 05:40AM BLOOD WBC-9.8 RBC-3.15* Hgb-10.1* Hct-30.6*
MCV-97 MCH-32.2* MCHC-33.2 RDW-13.7 Plt Ct-432
[**2138-11-21**] 05:40AM BLOOD Glucose-85 UreaN-8 Creat-0.4 Na-145 K-3.8
Cl-99 HCO3-42* AnGap-8
[**2138-11-21**] 05:40AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
.
Microbiology:
Blood cultures ([**2138-11-16**]):  negative x2.
Urine legionella ([**2138-11-17**]):  negative.
Nasopharyngeal aspirate DFA for influenza A/B:  negative.
.
Imaging:
.
CXR AP Port ([**2138-11-17**]):
Severe scoliosis with subsequent asymmetric ribcage. Linear
opacities in left lower lobe, most suggestive of atelectasis. No
consolidation or areas suggestive of pneumonia.
Cardiomediastinal silhouette is unremarkable. No pleural
effusion.
.
AP Wrist ([**2138-11-17**]):
Overlying bandage or cast greatly obscures bony detail. No
definite fracture is seen. There is a lucency crossing the
navicular, though this could merely be due to the texture of the
overlying cast.
.
Dedicated rib films ([**2138-11-19**]):
No previous bone studies are available. Scoliosis of the
thoracic
spine, convex to the right and centered in the mid thoracic
region. No
definite acute fracture is appreciated. No evidence of
pneumothorax.
.
Right upper quadrant ultrasound ([**2138-10-21**]):
FINDINGS: There are no gallstones. The gallbladder is
unremarkable in appearance. The liver is within normal limits in
echotexture throughout. Main portal vein is patent.
IMPRESSION: Unremarkable right upper quadrant ultrasound.
Specifically, no
evidence of gallstones.

Brief Hospital Course:
A 52 year-old woman with history of COPD, breast cancer, herpes
zoster presenting with shortness of breath, increasing oxygen
requirements and subacute back pain.
.
1. Dyspnea/hypoxia.
Differential diagnosis included pneumonia, COPD exacerbation,
ACS, and PE. Given the acute on chronic presentation of
shortness of breath, including fever and leukocytosis, the most
likely cause for her symptoms was infectious. Clinically it was
apparent that her pain (recent zoster and ?rib fractures on OSH
CXR) was limiting her ability to take full, deep breaths.  Her
tachycardia and dyspnea also were also concerning for PE
(history of malignancy is risk factor). In terms of cardiac
etiology, ACS was a consideration but less likely given the
radiographic findings of pulmonary infiltrate at OSH, fever, and
white count.  Lastly, her dyspnea also had a component of
restrictive physiology, given her back pain which is worse with
inspiration.
.
She was started on prednisone 60 mg po for a slow taper, started
on levofloxacin for a five day course, her home nebs were
continued, and her oxygen was weaned off as tolerated.  Cardiac
enzymes were negative x2.  She underwent dedicated rib films to
look for fracture; these were negative.  Due to her clinical
improvement, PE was felt to be less likely and CTA was not
pursued.  Pain was controlled initially with morphine and
oxycodone, and switched to non-narcotic analgesics as below.
This allowed her to take [**Hospital1 2824**] breaths, prior to which she was
splinting.
.
Gradually, with nebs, steroids, and antibiotics, her hypoxia
improved.  Probably as important as any intervention was the
fact that she was not allowed to smoke during this admission.
(Withdrawal symptoms were treated with nicotine replacement.)
At time of discharge, her ambulatory oxygen sats were in the low
nineties on 2L oxygen.  Her home meds were restarted and she
will finish a slow 15 day taper of prednisone.
.
2. Pain.
Her right upper back pain was a large reason why she was
tachypneic, tachycardic and possibly hypercarbic.  We treated
with morphine IV and switched to oxycodone prn when her pain was
better controlled.  Dedicated rib films showed no fracture.  RUQ
ultrasound was negative for gallstone disease.  Physical exam
showed what appeared to be a healed and scabbed-over rash versus
scabbing over from excessive use of heat pack; however, there
was no vesicular inflammation to suggest active zoster.
.
We treated the pain with narcotics initially; however, after
transfer out of the ICU, the narcotics were quickly weaned and
switched over to standing ibuprofen and lidocaine patch.  She
had a steady improvement in symptoms, which suggests that the
pain may be inflammatory in nature (?costochondritis), possibly
due to her cough and pneumonia-type symptoms.
.
3. Pneumonia.
On report from OSH her CXR and CT chest were read as multifocal
PNA. On review here, radiology felt that she may have a small
LUL pneumonia and underlying emphysema. She was started on
ceftriaxone initially then switched to levofloxacin. She was
treated with a five-day course of levofloxacin.  Infectious
work-up, including blood and urine cultures, influenza DFA, and
urinary legionella, were all negative.
.
4. Left hand contrast infiltration
She was transferred from [**Hospital6 **] where during the
administration of contrast dye for CTA there was extravasation
and infiltration into the soft tissue over the dorsum of her
left hand.  Afterwards there was significant blistering and
inflammation at the site.  Upon transfer to [**Hospital1 18**], she was seen
by the plastic surgery service.  Recommendations included
elevation and frequent pulse checks acutely.  Her blisters
opened and were treated with Xeroform, guaze, and Kurlex
dressing.  At time of discharge the wound was healing well;
there was no evidence of superinfection.  She will follow-up in
plastics clinic in two weeks.
.
5. Chronic obstructive pulmonary disease.
Her wheezes and decreased air movement on physical exam were
consistent with a COPD exacerbation and thus she was treated
with high-dose prednisone. Her home inhalers were continued and
standing nebulizer treatment was added.  At home she is on 2L of
oxygen.  She will complete a slow prednisone taper, resume her
home O2, and follow-up with her primary provider to discuss need
for continued low dose steroid treatment.
.
6. Smoking.
She did not smoke at all during the admission.  We provided
nicotine replacement with a patch.  She wanted to try nicotine
lozenges and inhaler at discharge, so prescriptions were
provided.  She was encouraged multiple times to stop smoking, as
this will only worsen her pulmonary disease.  She is trying to
cut down.
.
7. Hypothyroidism.
We continued her home dose of levothyroxine.  TSH was normal.
.
She was kept on a regular diet.  Subcutaneous heparin was used
for prophylaxis.  Her code status is full code.

Medications on Admission:
theophylline 200mg po q12h
levothyroxine 137mcg qd
prednisone 5mg 1 1/2 tabs po qd
zoloft 100mg 2 tabs qd
femara? 2.5mg po qd
xopenex 0.63mg qid prn
ativan 1mg q8h ([**12-4**] q4 prn)
prilosec 20mg po
oscal 500mg po
combivent
advair 500mg
super B complex
vitamin C&E
flax seed oil
[**Last Name (un) 2432**] vitamin

Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Sertraline 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8
hours) as needed: Please do not drive after taking this
medication.  It will impair your concentration.
Disp:*20 Tablet(s)* Refills:*0*
7. Theophylline 200 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO twice a day.
8. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation four times a day.
9. Os-Cal 500 + D 500 (1,250)-400 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
10. Super B Complex     Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
11. Vitamin C-Vitamin E     Capsule Sig: One (1) Capsule PO once
a day.
12. Flaxseed Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
13. [**Last Name (un) **] Multivitamin     Tablet Sig: One (1) Tablet PO once a
day.
14. Combivent 18-103 mcg/Actuation Aerosol Inhalation
15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: Please do not drive after taking this
medication.  It will impair your concentration.
Disp:*10 Tablet(s)* Refills:*0*
16. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
18. Nicotine (Polacrilex) 2 mg Lozenge Sig: One (1)  Mucous
membrane three times a day as needed for nicotine withdrawal
symptoms.
Disp:*30 qs* Refills:*2*
19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Take 6 tablets per day for 2 days, then take 5 tablets per day
for 2 days, then take 4 tablets per day for 2 days, then take 3
tablets per day for 2 days, then take 2 tablets per day for 3
days, then take 1 tablet per day for 3 days.  Then follow-up
with your primary care physician about how much prednisone to
continue taking.
Disp:*45 Tablet(s)* Refills:*0*
20. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
21. Nicotine 10 mg Cartridge Sig: One (1)  Inhalation once a day
as needed for nicotine withdrawal symptoms.
Disp:*1 qs* Refills:*0*

Discharge Disposition:
Home With Service

Facility:
[**Location (un) 8300**] VNA

Discharge Diagnosis:
Primary Diagnoses
Exacerbation of chronic obstructive pulmonary disease
Costochondritis
Left hand contrast infiltration
.
Secondary Diagnoses
Hypothyroid
Anxiety
Herpes zoster
Cigarette smoking


Discharge Condition:
Vital signs stable.  Satting mid to high 90s on 2L.  Ambulatory
sats in low 90s.


Discharge Instructions:
You were hospitalized for treatment of chronic obstructive
pulmonary disease exacerbation.  We think that you may have had
a pneumonia, although the x-rays were not able to confirm this.
The x-rays from this hospital did not show any rib fractures.
.
We have treated your symptoms with steroids, inhaled
bronchodilators, and a brief course of antibiotics.  The changes
to your medicines are as follows:
1. We have started you on a slow prednisone taper that will last
approximately 15 days.  At the end of this taper, you should
follow-up with your primary provider regarding how much
prednisone to continue taking.
2. We have started you on nicotine replacement with lozenges.
3. We have given you lidocaine patches for pain.  Apply to
affected area once per day.  Please do not use more than one
patch at a time.
4. We have started you on ibuprofen.  Please take 800 mg with
meals as needed for pain.
5. We have given you a small amount of oxycodone for pain.
Please only use as needed, and only after you have tried the
tylenol, ibuprofen, and lidocaine patch.
6. We have given you a small amount of ativan for symptoms of
anxiety.  You should follow-up with your primary provider if you
need more of this medicine for your anxiety symptoms.
.
We have spoken to you about the importance of smoking cessation.
 Continuing to smoke will worsen your lung disease.  As above,
we will prescribe nicotine lozenges to help treat withdrawal
symptoms.
.
Please follow-up with your primary care physician.  [**Name10 (NameIs) **] note
your follow-up in plastics clinic below (to look at your left
hand).
.
Please call your doctor or return to the emergency room if you
experience any worsening of shortness of breath, cough, fever,
or any other symptoms that are concerning to you.

Followup Instructions:
1. Please follow-up in plastics clinic on [**2138-12-12**].
The appointment is with Dr. [**First Name (STitle) 3228**] at 2:00 PM at [**Hospital Ward Name 23**]
Building, [**Location (un) 470**], surgical specialities.
.
2. Please follow-up with Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 81748**].


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]

Completed by:[**2138-11-21**]
{"Unspecified septicemia,Pneumonia, organism unspecified,Extravasation of other vesicant agent,Obstructive chronic bronchitis with acute bronchitis,Hyperosmolality and/or hypernatremia,Tietze's disease,Unspecified acquired hypothyroidism,Tobacco use disorder,Personal history of malignant neoplasm of breast,Sepsis,Herpes zoster without mention of complication"}


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: Shortness of breath.

PRESENT ILLNESS: Ms. [**Known lastname 19960**] is a 52 yo woman h/o COPD, breast cancer who
presented to an OSH for evaluation of shortness of breath.  She
notes she has not been feeling well for several weeks when she
noted pain in her back. Initially she was diagnosed with a
muscle spasm and given pain mediation. When the pain did not
subside she returned for further care and it was noted that she
had a rash that appeared to be consistant with shingles. She
describes the pain as a band from her abdomen to her back. She
was treated with a course of valtrex which she completed and the
rash resolved. Her pain persisted, despite treatment with
oxycodone and vicodin. Over the last several days, the patient
noted a sore throat and increasing oxygen requirement (she
typically is on 2L O2 NC at home). She also noted fevers to 102
at home and decreasing O2 sats from 90s to 79% with ambulation.
This past weekend (during storm) the patient was exceedingly
anxious after the electricity went out. She was trying to find
her oxygen tank and felt herself coughing so hard she could
barely catch her breath.
She denies having any chest pains or dizziness, N/V. She went to
an OSH for shortness of breath and back pain. On CXR she found
to have multifocal PNA, also notable on labs were a leukocytosis
to 24, d-dimer 1.2 (elevated). A CTA was performed however there
was dye leak into the left hand and the test was aborted. She
was given ceftriaxone and transfered to [**Hospital1 18**].
.
On arrival, she was noted to be afebrile with BPs in 120/60s, HR
105, breathing in 20s, O2 sats 80s on 2L. With albuterol and
ipratropium nebs and morphine her O2 sat was 90s on 4L and much
more comfortable. Noted on exam were a tense compartment in L
hand. Plastics was called to evaluate and recommended elevation
and frequent pulse checks. CT from the outside hospital shows
multifocal PNA, however given lack of contrast cannot evaluate
for PE. Notable on her labs in the ED were a leukocytosis with
left shift, elevated bicarb. She was started on 750mg
levofloxacin IV and 1L IVF was started prior to transfer to the
MICU. On admission to ICU, she was afebrile with BP 130/70s, HR
103, 95% 4L O2.
.
ROS: pertinent positives include headaches (several months),
poor appetite, constipation.  Denies any visual changes, chest
pains, N/V, URI, trouble swallowing, blood in stool or urine,
numbness/tingling, trouble walking.
She has not received the flu vaccine this year. Denies any
trauma.

MEDICAL HISTORY: COPD, 2L O2 at home (at [**Hospital 81747**] Rehab 1 [**12-4**] yr ago for
respiratory rehab)
asthma
hypothyroid
?arrhythmia
?rib fracture on CXR
herpez zoster (treated w/valtrex)
Breast ca to both breast ([**2130**], [**2132**], treated w/ lumpectomy and
radiation, L axillary lymph node dissection)
insomnia
anxiety
miscarriage
hysterectomy

MEDICATION ON ADMISSION: theophylline 200mg po q12h
levothyroxine 137mcg qd
prednisone 5mg 1 1/2 tabs po qd
zoloft 100mg 2 tabs qd
femara? 2.5mg po qd
xopenex 0.63mg qid prn
ativan 1mg q8h ([**12-4**] q4 prn)
prilosec 20mg po
oscal 500mg po
combivent
advair 500mg
super B complex
vitamin C&E
flax seed oil
[**Last Name (un) 2432**] vitamin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 97.6 HR 109 BP 135/57 RR 20 94% 4L O2
Gen: Alert and oriented, but appears lethargic, appropirate
HEENT: NCAT, dry mucus membranes, pink conjunctiva, anicteric,
OP clear, plaque on tongue, poor dentition
Lymph: no cervical or axillary lymphadenopathy. Noted on exam is
swelling (?fluid collection) over left supraclavicular space. no
erythema, nontender.
Heart: S1S2 regular rhythm, tachycardic, no MRG appreciated, no
JVD
Lungs: decreased breath sounds in bilateral bases with
expiratory wheezes heard in mid-lung fields
Chest: Large, tender mass over right posterior thorax, fixed, no
erythema, non-fluctuant. Also scabbed lesion on right chest,
mid-axillary region, no vescicles.
Abdomen: BS present, soft, NTND, ? hepatosplenomegaly.
Ext: WWP, no edema, no cyanosis
Neuro: Somnolent but oriented, following commands, CN II-XII
grossly intact, sensation intact, strength 5/5 b/l in LE

FAMILY HISTORY: Mother and aunt with breast cancer.

SOCIAL HISTORY: Lives at home with husband and daughter (17yo). She is retired
on disability. A long time smoker, she smokes [**12-4**] ppd for 35yrs.
She drinks alcohol occasionally. Denies any drug use. 

### Response:
{"Unspecified septicemia,Pneumonia, organism unspecified,Extravasation of other vesicant agent,Obstructive chronic bronchitis with acute bronchitis,Hyperosmolality and/or hypernatremia,Tietze's disease,Unspecified acquired hypothyroidism,Tobacco use disorder,Personal history of malignant neoplasm of breast,Sepsis,Herpes zoster without mention of complication"}
