CHIEF COMPLAINT: Rash, bleeding

PRESENT ILLNESS: History obtained from records. The pt is a 45 yo woman with
eczema, rheumatoid arthritis, hypertension, h/o nephrolithiasis
recently started on cefazolin for two days followed by
levofloxacin for a superinfection of her eczema who intially
presented to [**Hospital3 **] Hospital complaining of hemoptysis x 3
days. Initial labs were concerning for pancytopenia with a WBC
less than 0.2, Hct of 26 and platelets of 7. She was intubated
in the field for airway protection and med-flighted to [**Hospital1 18**] for
further evaluation.
.
In the ED, her VSs were 100, 116, 93/53, 18, 100% vented. She
received a 4-pack of platelets, lorazepam 2 IV, acetaminophen
650 and midazolam 2 IV. A CXR revealed ? RUL atelectasis, and a
head CT revealed no acute intracranial hemorrhage.

MEDICAL HISTORY: Eczema
hypertension
nephrolithiasis
Rheumatoid arthritis
Uterine fibroids

MEDICATION ON ADMISSION: Omeprazole 20 daily
Lisinopril 20 daily
Metoprolol 50 [**Hospital1 **]
Ciprofloxacin
Diflunisal 500 [**Hospital1 **]
Prednisone 40mg x3 days ([**2169-6-26**]), then taper
Embrel

ALLERGIES: Keflex / Levofloxacin / Methotrexate

PHYSICAL EXAM: Vitals: T: 97.9 BP: 88/60 P: 109 R: 29 SaO2: 100%
General: sedated, intubated
Skin: multiple excoriated, erythematous ezcematous lesions all
over her skin, no bullous lesions noted
HEENT: anicteric, bleeding from conjunctiva, nares and
oropharynx
Neck: no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no splenomegaly

FAMILY HISTORY: adopted

SOCIAL HISTORY: smokes 4 packs/wk. drinks 2 beers/day
Acute respiratory failure,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure with lesion of tubular necrosis,Acidosis,Retention of urine, unspecified,Malnutrition of mild degree,Neutropenia, unspecified,Other psoriasis,Hypercalcemia,Dysthymic disorder,Unspecified essential hypertension,Rheumatoid arthritis
Acute respiratry failure,Crbl art ocl NOS w infrc,Ac kidny fail, tubr necr,Acidosis,Retention urine NOS,Malnutrition mild degree,Neutropenia NOS,Other psoriasis,Hypercalcemia,Dysthymic disorder,Hypertension NOS,Rheumatoid arthritis
Admission Date:  [**2169-7-1**]              Discharge Date:   [**2169-8-11**]

Date of Birth:  [**2123-11-9**]             Sex:   F

Service: MEDICINE

Allergies:
Keflex / Levofloxacin / Methotrexate

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Rash, bleeding

Major Surgical or Invasive Procedure:
Right IJ
Left IJ
Lumbar puncture
Tracheostomy & PEG
Bronchoscopy x 2
Bone marrow biopsy


History of Present Illness:
History obtained from records. The pt is a 45 yo woman with
eczema, rheumatoid arthritis, hypertension, h/o nephrolithiasis
recently started on cefazolin for two days followed by
levofloxacin for a superinfection of her eczema who intially
presented to [**Hospital3 **] Hospital complaining of hemoptysis x 3
days. Initial labs were concerning for pancytopenia with a WBC
less than 0.2, Hct of 26 and platelets of 7. She was intubated
in the field for airway protection and med-flighted to [**Hospital1 18**] for
further evaluation.
.
In the ED, her VSs were 100, 116, 93/53, 18, 100% vented. She
received a 4-pack of platelets, lorazepam 2 IV, acetaminophen
650 and midazolam 2 IV. A CXR revealed ? RUL atelectasis, and a
head CT revealed no acute intracranial hemorrhage.


Past Medical History:
Eczema
hypertension
nephrolithiasis
Rheumatoid arthritis
Uterine fibroids


Social History:
smokes 4 packs/wk. drinks 2 beers/day

Family History:
adopted

Physical Exam:
Vitals: T: 97.9 BP: 88/60 P: 109 R: 29 SaO2: 100%
General: sedated, intubated
Skin: multiple excoriated, erythematous ezcematous lesions all
over her skin, no bullous lesions noted
HEENT: anicteric, bleeding from conjunctiva, nares and
oropharynx
Neck: no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no splenomegaly

Extremities: No edema, 2+ radial, DP pulses b/l
Neurologic: sedated, intubated


Pertinent Results:
[**2169-6-30**]
WBC-0.2* RBC-2.19* Hgb-8.3* Hct-23.9* MCV-109* MCH-37.8*
MCHC-34.7 RDW-19.4* Plt Ct-5*
Neuts-0* Bands-0 Lymphs-92* Monos-0 Eos-8* Baso-0 Atyps-0
Metas-0 Myelos-0
Hypochr-2+ Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-OCCASIONAL
Polychr-Spheroc-1+ Ovalocy-OCCASIONAL Target-NORMAL
Schisto-OCCASIONAL Burr-1+ Tear Dr[**Last Name (STitle) **]1+ Acantho-1+
PT-12.0 PTT-27.3 INR(PT)-1.0
Fibrino-1332*
Ret Man-.2*
Glucose-100 UreaN-138* Creat-3.7* Na-141 K-4.3 Cl-107 HCO3-12*
AnGap-26*
ALT-24 AST-50* AlkPhos-63 Amylase-119* TotBili-2.1*
Albumin-2.2* | Hapto-337* | Lactate-1.4
Type-ART Temp-37.7 pO2-459* pCO2-23* pH-7.31* calTCO2-12* Base
XS--12
.
[**2169-8-11**]:
WBC 12.3 Hgb 10.6 Hct 31.7 MCV 101 Plt Ct 526
Glu 90 BUN 12 Cr 0.5 NA 138 K 4.6 Cl 104 HCO3 23
Ca-9.9 P-5.1* Mg-2.0
.
CHEST X-RAY ([**2169-6-30**])
IMPRESSION:
1. Band of opacity projecting over the right upper chest likely
representing atelectasis. However, other underlying processes,
including neoplasm or infection can't be excluded. Follow-up
radiograph to evaluate clearance or CT chest is recommeded.
2. Likely mild CHF.
.
BIOPSY ([**2169-6-30**])
#1. Skin, left medial thigh, punch biopsy (A):
a. Ulcer with yeasts within ulcer bed, subjacent upper dermis,
and focally within superficial dermal small vessel, and abundant
surface gram positive cocci (see note).
b. Background psoriasiform dermatitis with paucicellular
superficial dermal perivascular lymphocytic infiltrate and rare
eosinophils (see note).
#2.  Skin, left medial thigh, direct immunofluorescence:
a. No IgG, IgA, IgM, C3 deposits found between keratinocytes of
the epidermis or along the basement membrane zone.
b. C3 is noted within the scale (? near ulcer) consistent with
psoriasiform dermatitis or non-specific if near ulcer.
c. Non-specific fibrinogen deposits present in the dermis.
#3. Skin, left leg, punch biopsy (B):
a. Psoriasiform dermatitis with parakeratotic scale containing
neutrophil aggregates.
b. No fungi or bacteria seen in PAS, GMS, and Gram stained
sections.
.
Note:  No acantholysis or bulla are seen (multiple levels
examined). Abundant yeasts are present within the ulcer bed,
upper reticular dermis, and one small superficial blood vessel.
While this may represent surface colonization, in the setting of
pancytopenia, this raises concern for a disseminated yeast
infection. Blood cultures may be further illustrative.
.
The background skin shows a psoriasiform dermatitis, the
differential of which includes psoriasis, and as there are rare
eosinophils, a psoriasiform drug reaction, and possibly
impetiginized atopic dermatitis.
.
*******************
BONE MARROW BIOPSY  ([**2169-7-1**])
*******************
SPECIMEN:  BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS: Markedly hypocellular marrow in keeping with a
hypoplastic / aplastic process, see note.
Note: The aplasia may be primary or secondary from a marrow
insult from drugs, infection, immune, or toxic/metabolic causes.
 Clinical correlation recommended.
.
*******************
CT TORSO   ([**2169-7-8**])
*******************
IMPRESSION:
Right upper lobe pneumonia. Bilateral pleural effusions
associated with atelectasis of the lower lobes.
Splenic and left kidney infarcts.
Mild fluid overload.
Right rib fractures.
Mediastinal, axillary and mesenteric lymphadenopathy is likely
reactive.
.
TRANS-THORACIC ECHO ([**2169-7-10**])
IMPRESSION: Normal study. No 2D echocardiographic evidence for
endocarditis or pathologic flow identified.
Compared with the prior study (images reviewed) of [**2169-7-3**], the
findings are similar (heart rate is slower).
.
MRI HEAD ([**2169-7-14**])
IMPRESSION: Multiple infarcts are identified involving the right
frontal and parietal lobe, left frontal lobe and left cerebellar
hemisphere. Infarcts in the right frontal lobe in the MCA
territory demonstrate enhancement. The findings are indicative
of acute/subacute infarcts. The enhancement in the right MCA
territory infarct may indicate more subacute nature. Although
there are no MRI signs of septic emboli such as abscess, given
patient's clinical history, clinical correlation is recommended.
Findings were discussed with Dr. [**First Name (STitle) 805**] at the time of
interpretation of this study on [**2169-7-13**].
.
CT CHEST W/O CONTRAST  [**2169-8-3**]
IMPRESSION:
1. Improving right upper lobe consolidation with residual
opacity likely due to slowly resolving pneumonia.
2. Several bilateral noncalcified lung nodules measuring up to 8
mm. As these were largely obscured by preexisting areas of
consolidation atelectasis on the previous study, their time
course is uncertain. Differential diagnosis includes previous
and active infection (e.g. granulomatous infection) versus
metastatic foci.
Consider a followup CT scan in four to six weeks to document
anticipated complete resolution of the right upper lobe
abnormality and to re-assess the lung nodules.


Brief Hospital Course:
The patient is a 45 yo woman originally admitted on [**7-1**] from an
[**Hospital **] transferred from the MICU to the floor on [**7-25**], admitted for
pancytopenia with hemoptysis, intubated for airway protection.
Her pancytopenia has now resolved, likely due to Mycoplasma
infection versus medication-induced aplasia. She had a prolonged
and difficult wean from the ventilator, s/p tracheostomy and
PEG, now doing well s/p trach decannulation.  She has a
persistent rash c/w psoriasis, improving on topical steroids.
She has hypercalcemia and hyperphosphatemia of unclear etiology,
improving on [**Name (NI) **].
.
Respiratory failure. The patient presented to OSH on [**2169-6-30**]
with hemoptysis which was [**1-20**] new pancytopenia.  She was
intubated for airway protection before transport here.  On
bronchoscopy, she initially had  bleeding from the RUL.  On CXRs
and CT, she had had some intermittent right upper lobe collapse
vs PNA, and bibasilar atelectasis.  During her ICU course at
[**Hospital1 18**], she was difficult to wean off the vent due to volume
overload,  possible mycoplasma infection, and ICU myopathy, with
EMG/NCVs showing myopathy with ongoing denervation. She got PEG
and tracheostomy on [**2169-7-18**], on [**7-19**] was weaned to trach mask,
cleared for PMV on [**7-20**].   Repeat chest CT on [**8-3**] showed
resolving RUL consoldiation, also several bilateral noncalcified
lung nodules, possibly c/w granulomatous disease.  Pulmonary was
consulted, and deferred further work-up at this time, and will
follow-up with repeat chest CT in 3 months.  Her tracheostomy
was decannulated on [**8-10**], and she has been saturating in the
high 90s at rest and while ambulating with PT.
.
Pancytopenia: The patient was seen by hematology, and had a bone
marrow biopsy, consistent with primary or secondary hypocellular
aplasia. She was given supportive transfusions, and treated with
leucovorin and filgrastim for her pancytopenia.  The likely
diagnosis is secondary marrow aplasia, due either to Mycoplasma
or drug-induced (levofloxacin vs. Keflex vs. diflunisol vs.
Embrel).  Her condition improved, and by transfer to the floor
her pancytopenia had resolved with normal WBC, and platelets,
Hct of 30.   On discharge, she had a persistent mild
leukocytosis to 12,000, Hct 31, Plt 536.  She was discharged on
B12 and folate, to follow-up with hematology.  If she is to see
rheumatology or dermatology for her RA or psoriasis in the
future, careful consideration should be made about the use of
any immunosuppressive agents given these may have caused her
pancytopenia.
.
Fevers: She had persisent fevers to 101 while in the MICU, which
was originally thought to be [**1-20**] febrile neutropenia.  She was
started on IV vancomycin and ceftazidime for febrile neutropenia
on admission, and completed a two-week course.  She was also
briefly on doxycycline [**Date range (1) 27564**] until serologies for
tick-[**Location (un) **] diseases from the OSH came back negative.  She was
also started on fluconazole for concern for invasive fungal
infection (see below).  However, after discontinuation of all
antibiotics after [**7-12**], she was persistently febrile with no
source.  Rheumatology was also consulted, and did not believe
her presentation was consistent with vasculitis.  On review of
her fever curve, ID consult noted she had defervesced while on
doxycycline.  Her Mycoplasma IgM was positive and IgG was weakly
negative (670, postive is 770), though it was possible could not
mount a proper response due to her recent pancytopenia.   She
was restarted on doxycycline on [**7-16**] for a two-week course for
presumed disseminated Mycoplasma infection, and has since
defervesced.
.
Psoriasis:   When she presented to OSH, she had a dramatic
desquamating rash that affected her trunk as well as her
extremities.  She was seen by dermatology, with skin biopsy
showing psoriasiform background in the dermis, and an
infiltration of fungal organisms, including around dermal
vessels. Cultures from her wound biopsy and urine proceeded to
grow [**Female First Name (un) **] albicans, sputum showed budding yeast.   The
patient was therefore treated with fluconazole for 10 days from
[**Date range (1) 74297**].   Dermatology was re-consulted on the floor, and
recommended topical steroids for psoriasis, and suggested
phototherapy on discharge.
.
Hypercalcemia/Hyperphosphatemia:  The patient was noted to have
slowly increasing phosphorus levels after transferred to the
floor.  Her calcium also began to rise.  She was placed on a low
phosphorus diet, without resolution of these abnormalities.
Renal and endocrine were consulted.  She has an appropriate
renal clearance of calcium and phosphorus, and an appropriately
low PTH.  Chest CT was concerning for possible granulomatous
disease but vitamin D (25, and [**1-12**]) were both low normal.  At
discharge, there is no clear etiology for her
hypercalcemia/phosphatemia.  Both these levels have come down
and are stable on [**Month/Year (2) **].  PTH-rp and FGF23 mutation analysis
are still pending at discharge.  Her electrolytes will be
monitored by her VNA and PCP, [**Name10 (NameIs) **] she will follow-up with
endocrine.
.
Strokes/Question of Hypercoagulability:  Neurology was consulted
for difficulty weaning of the ventilator.  As stated above, they
postulated that possible contributions could include steroid
myopathy, and prolonged encephalopathy.  Head MRI on [**7-13**]
revealed multiple bilateral acute and subacute infarcts.  She
also was found to have wedge shaped infarcts in her kidyney and
spleen on abdominal CT.  Several echos showed no intracardiac
embolic source.  Rheumatology was consulted, and  did not think
this was consistent with vasculitis. Heme-onc was consulted and
a hypercoagulabity workup was done. Anticardiolipin IgG and IgM
were weakly positive, but Heme did not think this was consistent
with antiphospholipid antibody syndrome as this can be seen with
infection and acute illness.  She will follow-up with Heme for
further outpatient work-up.  She appears to have no residual
neurological deficits.
.
Acute Renal Failure:  The patient was found to be in ARF on
admission.  Urine eosinophils were negative, making AIN
unlikely.  Her presumed diagnosis was ATN, and her creatinine
slowly normalized with hydration, with normal renal function at
discharge.
.
Anxiety/Depression:  The patient had significant
anxiety/depression during her long MICU stay, which possibly
contributed to her long wean from the ventilator.  On [**7-25**], She
was started on an SSRI, with significant improvement in affect
and mood on the floor.
.
FEN:  The patient is s/p PEG on [**7-18**].  By transfer to the floor
on [**7-25**], she was cleared for a normal diet, and was taking
adequate Pos by discharge.  She will follow-up with Thoracics
for PEG pull on [**8-29**].


Medications on Admission:
Omeprazole 20 daily
Lisinopril 20 daily
Metoprolol 50 [**Hospital1 **]
Ciprofloxacin
Diflunisal 500 [**Hospital1 **]
Prednisone 40mg x3 days ([**2169-6-26**]), then taper
Embrel

Discharge Medications:
1. AFO
Please provide AFO to patient [**Known firstname **] [**Known lastname 37080**], patient of Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for right-sided foot drop. Patient has a size 7.5
inch foot.
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)) as needed for pruritis.
Disp:*30 Tablet(s)* Refills:*2*
6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
Disp:*1 tube* Refills:*2*
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for rash.
Disp:*1 tube* Refills:*0*
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 tube* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA Assoc. of [**Hospital3 **]

Discharge Diagnosis:
1) Pancytopenia
2) Respiratory failure s/p tracheostomy and PEG
3) Psoriasis
4) Acute/Subacute Strokes
5) Hyperphospatemia/Hypercalcemia


Discharge Condition:
The patient's pancytopenia is largely resolved, with a mild
persistent anemia, Hct stable at 31.  Her tracheostomy was
decannulated the day prior to discharge, and she is saturating
in the high 90s and able to ambulate well with physical therapy.
 She is able to eat a regular adult diet, and PEG will be
removed [**8-29**].  She continues to have hyperphosphatemia and
hypercalcemia, improved since starting [**Month/Year (2) **].


Discharge Instructions:
You were admitted because of low blood counts that caused you to
bleed from your lungs.  You had a bone marrow biopsy to help
determine the cause of your low blood counts, which may have
been either a medication you were taking (Keflex, Levofloxacin,
Embrel, or Diflunisil) or an infection (Mycoplasma).  You were
given antibiotics for this infection.  You were put on a
ventilator and got a tracheostomy tube in your neck to help you
breathe, which was taken out yesterday.  You got a feeding tube
in your stomach to help you eat.  You had a skin biopsy, which
showed that your rash is psoriasis, and you were started on
topical steroids.  Your labs showed you have high levels of
phosphorus and calcium, and you were started on a medication
([**Month/Year (2) **]) to lower these levels.
.
Please take all new medications as prescribed.  Please make sure
to attend all follow-up appointments below.  The visiting nurses
will be drawing labs that your primary care doctor will be
monitoring, and he may call you to adjust the dose of [**Month/Year (2) **].
.
Please contact your doctor or go to the emergency room if you
have fever>101, chills, chest pain, abdominal pain, shortness of
breath, bleeding, or any other concerns.


Followup Instructions:
You have an appointment with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 36086**], at [**Hospital **] Health Center, on [**2169-8-16**] at 3:10pm.
His number is [**Telephone/Fax (1) 31979**].
.
You have an appointment with Dr. [**Last Name (STitle) 11482**] [**Name (STitle) **], with
Thoracic Surgery, for removal of your feeding tube, on [**2169-8-29**]
at 11:00am.  You should go to [**Hospital Ward Name 23**] [**Location (un) **] for a chest
x-ray at 10:30am prior to this appointment.  His number is
[**0-0-**].
.
You have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Dermatology
on [**2169-9-7**] at 11:00 am at [**Hospital1 18**] [**Location (un) 55**] at [**Street Address(2) 74298**].
[**Location (un) 55**], MA.  His number is ([**Telephone/Fax (1) 31239**].  His office
will call you if appointments become available on [**2169-8-29**].
.
You have an appointment with Dr. [**First Name4 (NamePattern1) 1726**] [**Last Name (NamePattern1) 7711**] with
Endocrinology at 8:30am on [**2169-9-11**].  His office is located at
[**Hospital1 18**] [**Last Name (un) 469**] [**Location (un) 436**].  His number is ([**Telephone/Fax (1) 74299**].
.
You have an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] with Hematology
on 10:30 am on [**2169-9-22**].  His office is located at [**Hospital1 18**] on
[**Hospital Ward Name 23**] [**Location (un) **].  His number is ([**Telephone/Fax (1) 74300**].
.
You have an appointment to get a repeat chest CT scan on
[**2169-11-2**] at 1:00pm at [**Hospital1 18**] on [**Last Name (un) 469**] [**Location (un) **].  You should
not eat for 3 hours before.  You then have an appointment with
Dr. [**First Name8 (NamePattern2) 4944**] [**Last Name (NamePattern1) **], with Pulmonology on [**2169-11-6**] at 1:00pm.  Her
number is ([**Telephone/Fax (1) 513**].


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

Completed by:[**2169-8-11**]
{'Acute respiratory failure,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure with lesion of tubular necrosis,Acidosis,Retention of urine, unspecified,Malnutrition of mild degree,Neutropenia, unspecified,Other psoriasis,Hypercalcemia,Dysthymic disorder,Unspecified essential hypertension,Rheumatoid arthritis'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Rash, bleeding

PRESENT ILLNESS: History obtained from records. The pt is a 45 yo woman with
eczema, rheumatoid arthritis, hypertension, h/o nephrolithiasis
recently started on cefazolin for two days followed by
levofloxacin for a superinfection of her eczema who intially
presented to [**Hospital3 **] Hospital complaining of hemoptysis x 3
days. Initial labs were concerning for pancytopenia with a WBC
less than 0.2, Hct of 26 and platelets of 7. She was intubated
in the field for airway protection and med-flighted to [**Hospital1 18**] for
further evaluation.
.
In the ED, her VSs were 100, 116, 93/53, 18, 100% vented. She
received a 4-pack of platelets, lorazepam 2 IV, acetaminophen
650 and midazolam 2 IV. A CXR revealed ? RUL atelectasis, and a
head CT revealed no acute intracranial hemorrhage.

MEDICAL HISTORY: Eczema
hypertension
nephrolithiasis
Rheumatoid arthritis
Uterine fibroids

MEDICATION ON ADMISSION: Omeprazole 20 daily
Lisinopril 20 daily
Metoprolol 50 [**Hospital1 **]
Ciprofloxacin
Diflunisal 500 [**Hospital1 **]
Prednisone 40mg x3 days ([**2169-6-26**]), then taper
Embrel

ALLERGIES: Keflex / Levofloxacin / Methotrexate

PHYSICAL EXAM: Vitals: T: 97.9 BP: 88/60 P: 109 R: 29 SaO2: 100%
General: sedated, intubated
Skin: multiple excoriated, erythematous ezcematous lesions all
over her skin, no bullous lesions noted
HEENT: anicteric, bleeding from conjunctiva, nares and
oropharynx
Neck: no significant JVD
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: tachycardic, nl S1 S2, no murmurs, rubs or gallops
appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no splenomegaly

FAMILY HISTORY: adopted

SOCIAL HISTORY: smokes 4 packs/wk. drinks 2 beers/day 

### Response:
{'Acute respiratory failure,Cerebral artery occlusion, unspecified with cerebral infarction,Acute kidney failure with lesion of tubular necrosis,Acidosis,Retention of urine, unspecified,Malnutrition of mild degree,Neutropenia, unspecified,Other psoriasis,Hypercalcemia,Dysthymic disorder,Unspecified essential hypertension,Rheumatoid arthritis'}
