history of present illness: the patient is a 76-year-old woman who was recently discharged from the , where she was evaluated for multiple medical problems listed separately in the past medical history, who was transferred from point because of increasing dyspnea, shortness of breath, and cough for one day. the patient has chronic fevers. she denied a battery of constitutional symptoms including headache, fever, chills, nausea, vomiting, diarrhea, dysuria. past medical history: 1. breast cancer metastatic to and spleen. 2. fever of unknown origin likely due to malignancy or adrenal insufficiency. 3. left lower lobe collapse. 4. congestive heart failure with diastolic dysfunction and preserved ejection fraction. 5. atrial fibrillation. 6. adrenal insufficiency status post bilateral adrenalectomy. 7. melanoma status post excisional biopsy. 8. meningioma status post resection. 9. thyroid nodules of unclear origin. 10. inappropriate antidiuretic hormone release previously. 11. external hemorrhoids. allergies: opiates of unclear reaction as well as to tape, where she develops a rash. medications on presentation: 1. mirtazapine 50 mg in the evening. 2. tranxene 7.5 mg daily. 3. lorazepam 0.25 mg daily. 4. colace 100 mg twice daily. 5. fludrocortisone 0.1 mg daily. 6. hydrocortisone 30 mg in the morning and 20 mg in the evening. 7. pantoprazole 40 mg daily. 8. arimidex 4 mg daily. 9. metoprolol 62.5 mg daily. physical examination on presentation: vital signs: temperature 98.4, heart rate 101 and irregular, blood pressure of 164/67, and oxygen saturation is 89% on room air, and 98% on 4 liters nasal cannula. general: this is a chronically ill appearing elderly-pale woman, who did not cooperate with the entire examination. heent: normocephalic. there is a well-healed scar from her meningeal resection, she has anicteric sclerae and pale conjunctivae. pupils are equal, round, and reactive to light. extraocular movements are intact without nystagmus. the throat was clear. neck: supple, thyroid not palpable, the jugular veins are flat. there is no carotid bruit. nodes: there is no cervical, supraclavicular, axillary, or inguinal adenopathy. lungs: she had poor effort, decreased excursion, and decreased breath sounds at the based. she had slight wheezing and crackles diffusely. heart: irregular, tachycardic, normal s1, s2, no extra sounds. abdomen: she had normal bowel sounds, soft, nontender, and nondistended. spleen tip was palpable. the liver was not palpable. extremities: the patient had +2 lower extremity edema to her mid calf. vascular: the radial, carotid, and dorsalis pedis pulses were +2 bilaterally. laboratory evaluation on presentation: white blood cell count 47.4, hematocrit 26.0, platelets 209. chemistry panel was normal. electrocardiogram revealed multifocal atrial tachycardia at 95 beats per minute, there was no interval change from a previous electrocardiograms. hospital course: 1. cardiac: over the course of the patient's long hospital stay, her dose of metoprolol was sequentially increased from 62.5 mg twice daily to ultimately 75 mg every eight hours for rate control. in consultation with the cardiology service, the patient was also given an ace inhibitor. she required periodic diuresis with furosemide, approximately every four days she received furosemide for volume overload. her heart rate and blood pressure were well controlled on this regimen. patient underwent repeat surface echocardiography which revealed increased pulmonary hypertension, unchanged ejection fraction. 2. endocrine: the patient's requirement for hydrocortisone replacement fluctuated during the course of the hospital stay in consultation with the endocrine service, an attempt was made to lower her hydrocortisone replacement, however, her white blood cell count climbed to over 70 when decreasing the dose of hydrocortisone to 25 mg every 12 hours. she ultimately required several stress doses up to 100 mg every eight hours. her fingersticks were always within the normal range despite several conventional serum glucose values below 40, this was attributed to pseudohypoglycemia caused by high white blood cell count. the patient underwent ultrasonography of the thyroid gland, which revealed nodules unchanged from previous evaluation. given the multiple comorbidities of this patient, the endocrine service did not recommend further evaluation at this time. 3. psychiatric: the patient had several episodes of confusion, paranoid delusions, and visual hallucinations. in consultation with the psychiatric service, she was given a trial of risperidone, however, the patient was overly sedated on this medication, and was eventually withdrawn. the patient underwent further computer tomography of the head revealing no new mass lesions during two or three episodes of unresponsiveness. 4. hematology: as reviewed in previous summary, the patient is now transfusion dependent. he received a transfusion of pack units approximately every 3-4 days while in the hospital to maintain a hematocrit of approximately 38%. she also required periodic diuresis with blood transfusions, no fevers or adverse reactions occurred during transfusion. 5. oncology: as reviewed in previous summaries, the patient underwent marrow biopsy on her last admission. her cytogenetic evaluation revealed possible early myelodysplastic syndrome or aml given that there were two cells bearing the lesion that .................... chromosome. the oncology service was consulted, and they deemed that the patient does not have either myelodysplastic syndrome or aml. the patient underwent splenic biopsy in the interventional radiology suite twice. the first time the pathology specimen revealed collection of megakaryocytes, though was not diagnostic. the second time, a large amount of necrotic debris, macrophages was recovered as well as neutrophils. this was deemed to be consistent with infection. 6. infectious disease: patient's fevers over the first half of her hospital course abated, however, she did have persistent white blood cell elevation attributed to malignancy and adrenal insufficiency. her large left pleural effusion as well as her cerebrospinal fluids were sampled, neither which shown to have an infection. however, on , the patient became hypotensive. urinalysis revealed enterococcal urinary tract infection. she was transferred to the intensive care unit for sepsis. she was placed on vancomycin intravenously. after two days, her blood pressure stabilized, and she was returned to the general medical floor. the remainder of this hospital summary will be dictated separately. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Spinal tap Incision of lung Thoracentesis Closed [aspiration] [percutaneous] biopsy of spleen Diagnoses: Unspecified pleural effusion Urinary tract infection, site not specified Atrial fibrillation Secondary malignant neoplasm of brain and spinal cord Other specified septicemias Diastolic heart failure, unspecified Secondary malignant neoplasm of bone and bone marrow Secondary malignant neoplasm of other digestive organs and spleen