CHIEF COMPLAINT: Abdominal pain, hypothermia

PRESENT ILLNESS: Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hepatitis B/C, ESRD
on peritoneal dialysis who presented to the ED with abdominal
pain, constipation and also feeling dizzy with lightheadedness.
Called the ambulance for these symptoms.  Initial VS 91.1F
orally, HR 72, BP initially unmeasurable, RR 20 and 100% oxygen
saturation on room air.  Exam with clear lungs, RRR, distended
abdomen which was soft and full.  He refused a rectal exam.  CT
was obtained given abdominal pain and preliminary read was
negative for any acute intrabdominal processes.  Right femoral
line was placed with some difficulty due to scar tissue.  BP
remained difficult to assess given severe vascular disease.
Repeat VS soon after presentation revealed temperature 96.1F,
75HR, BPs of 59/25-105/47, RR 12, and oxygen saturation was 100%
room air.  Fingerstick glucose was 123.  Patient had potassium
repleted with 40 mEq K in 1L NS, with 3 additional L NS.  His
peritoneal dialysate was sampled and did not reveal evidence of
infection.  Denies ever having abdominal pain, but more a sense
of constipation and "fullness".  Systolic blood pressures in ED
ranged 74--> 68 --> 90 --> 105.  By time of transfer from ED to
inpatient setting he was saturating well on RA, eating and
requesting more food. Given patient's initial presentation of
appearing very unwell, was sent to the ICU for closer
monitoring.

MEDICAL HISTORY: HIV
Hepatitis B
Venous capillary sepsis
Venous thromboembolism
Depressive disorder & nervousness
CMV infection
History of tuberculosis
ESRD [**1-12**] HIV - on peritoneal dialysis, followed at [**Last Name (un) 4029**] in
[**Location (un) **] on [**State **] St.
Chronic constipation - on senna PRN
h/o XRT at MEEI for SCC in his left ear
Hypertension
Syphilis in [**Month (only) **] l993.  CSF showed lymphocytosis.  The
patient was treated with intravenous penicillin for ten days.
Hepatitis C antibody positive

MEDICATION ON ADMISSION: (per CMA service 1-[**Telephone/Fax (1) 4031**])
Bactrim DS 1 tab MWF
Epivir 25mg daily
Phoslo 667mg 3 tabs TID with meals
Tenofovir 300mg (qWeek per CMA service)
Zerit 15mg daily
Zyprexa 5mg QHS
Epogen 10000u SC Qweek
Omeprazole 20mg Qday
Calcitriol 0.25mcg daily
Sensipar 90mg daily
Senna 2 tabs QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: unable to obtain initially, BP: 89/64, PR: 67, RR: 13,  O2:
100/RA
General: Alert, oriented, no acute distress; able to relay
history in a coherent fashion
HEENT: Sclera anicteric, MM mildly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds but no
appreciable murmurs, rubs, gallops
Abdomen:  soft, non-tender,  mildly distended, bowel sounds
present, no rebound tenderness or guarding; bandaged PD wound in
LLQ
Ext: Warm, nonpalpable distal pulses, no edema; R femoral groin
wound noted
Neuro: CN II-XII grossly intact; A&O x 3
Skin: Multiple excoriated lesions over entire body, slight
crusting; including arms, back

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Tobacco [**12-12**] PPDx 20 years, no ETOH, unemployed and lives alone
in an apartment and he has CMA nursing help at home.
Human immunodeficiency virus [HIV] disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other venous embolism and thrombosis of unspecified site,Constipation, unspecified,Leukocytopenia, unspecified,Hypothermia not associated with low environmental temperature,Cirrhosis of liver without mention of alcohol,Hypotension, unspecified,Hypopotassemia,Thrombocytopenia, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of tuberculosis,Cyst of kidney, acquired
Human immuno virus dis,Hyp kid NOS w cr kid V,End stage renal disease,Hpt B acte wo cm wo dlta,Venous thrombosis NOS,Constipation NOS,Leukocytopenia NOS,Hypothrm-wo low env tmp,Cirrhosis of liver NOS,Hypotension NOS,Hypopotassemia,Thrombocytopenia NOS,Hx of past noncompliance,Prsnl hst tuberculosis,Cyst of kidney, acquired
Admission Date:  [**2195-3-7**]              Discharge Date:   [**2195-3-11**]

Date of Birth:  [**2148-5-10**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4028**]
Chief Complaint:
Abdominal pain, hypothermia

Major Surgical or Invasive Procedure:
1) Arterial line
2) Central venous line /femoral line
3) Patient continued his usual peritoneal dialysis sessions


History of Present Illness:
Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hepatitis B/C, ESRD
on peritoneal dialysis who presented to the ED with abdominal
pain, constipation and also feeling dizzy with lightheadedness.
Called the ambulance for these symptoms.  Initial VS 91.1F
orally, HR 72, BP initially unmeasurable, RR 20 and 100% oxygen
saturation on room air.  Exam with clear lungs, RRR, distended
abdomen which was soft and full.  He refused a rectal exam.  CT
was obtained given abdominal pain and preliminary read was
negative for any acute intrabdominal processes.  Right femoral
line was placed with some difficulty due to scar tissue.  BP
remained difficult to assess given severe vascular disease.
Repeat VS soon after presentation revealed temperature 96.1F,
75HR, BPs of 59/25-105/47, RR 12, and oxygen saturation was 100%
room air.  Fingerstick glucose was 123.  Patient had potassium
repleted with 40 mEq K in 1L NS, with 3 additional L NS.  His
peritoneal dialysate was sampled and did not reveal evidence of
infection.  Denies ever having abdominal pain, but more a sense
of constipation and "fullness".  Systolic blood pressures in ED
ranged 74--> 68 --> 90 --> 105.  By time of transfer from ED to
inpatient setting he was saturating well on RA, eating and
requesting more food. Given patient's initial presentation of
appearing very unwell, was sent to the ICU for closer
monitoring.

Upon arrival in the ICU, denied any complaints except a sense of
constipation in his abdomen. Upon ROS, patient denied associated
nausea, vomiting, fevers, chills, dizziness,dysuria, rash,
dyspnea. Confirms he had decreased oral intake for 4 days in the
setting of his constipation and has taken an unknown medication
for his constipation in the past.  Also with partial blindness
which is his baseline.  States he had one episode of chest pain
on day before admission but this improved with sugar as provided
in the ED.  Denies any exertional component or pain radiation.


Past Medical History:
HIV
Hepatitis B
Venous capillary sepsis
Venous thromboembolism
Depressive disorder & nervousness
CMV infection
History of tuberculosis
ESRD [**1-12**] HIV - on peritoneal dialysis, followed at [**Last Name (un) 4029**] in
[**Location (un) **] on [**State **] St.
Chronic constipation - on senna PRN
h/o XRT at MEEI for SCC in his left ear
Hypertension
Syphilis in [**Month (only) **] l993.  CSF showed lymphocytosis.  The
patient was treated with intravenous penicillin for ten days.
Hepatitis C antibody positive

SURGICAL HISTORY:
PD catheter placement [**2190**], numerous HD catheters and AV
fistulas; all failed

Social History:
Tobacco [**12-12**] PPDx 20 years, no ETOH, unemployed and lives alone
in an apartment and he has CMA nursing help at home.

Family History:
Noncontributory


Physical Exam:
T: unable to obtain initially, BP: 89/64, PR: 67, RR: 13,  O2:
100/RA
General: Alert, oriented, no acute distress; able to relay
history in a coherent fashion
HEENT: Sclera anicteric, MM mildly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds but no
appreciable murmurs, rubs, gallops
Abdomen:  soft, non-tender,  mildly distended, bowel sounds
present, no rebound tenderness or guarding; bandaged PD wound in
LLQ
Ext: Warm, nonpalpable distal pulses, no edema; R femoral groin
wound noted
Neuro: CN II-XII grossly intact; A&O x 3
Skin: Multiple excoriated lesions over entire body, slight
crusting; including arms, back


Pertinent Results:
ADMISSION LABS
[**2195-3-7**] 07:15PM   LACTATE-0.9 K+-3.0*
[**2195-3-7**] 03:45PM ASCITES  WBC-2* RBC-0 POLYS-8* LYMPHS-17*
MONOS-72* MESOTHELI-4*
[**2195-3-7**] 01:42PM   LACTATE-3.0* K+-2.4*
[**2195-3-7**] 01:30PM   GLUCOSE-93 UREA N-28* CREAT-10.0* SODIUM-137
POTASSIUM-2.3* CHLORIDE-94* TOTAL CO2-27 ANION GAP-18
[**2195-3-7**] 01:30PM   estGFR-Using this
[**2195-3-7**] 01:30PM   CALCIUM-9.2 PHOSPHATE-2.9 MAGNESIUM-1.9
[**2195-3-7**] 01:30PM   WBC-2.3* RBC-4.44* HGB-13.3* HCT-40.0 MCV-90
MCH-30.1 MCHC-33.3 RDW-17.8*
[**2195-3-7**] 01:30PM   NEUTS-65 BANDS-0 LYMPHS-29 MONOS-3 EOS-2
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2195-3-7**] 01:30PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2195-3-7**] 01:30PM   PLT SMR-LOW PLT COUNT-92*
[**2195-3-7**] 01:30PM   PT-13.2 PTT-31.1 INR(PT)-1.1

[**2195-3-9**] BLOOD LABS /HIV CD COUNTS:
-WBC: 3.0
Lymph: 26
Abs-[**Last Name (un) **]: 780
CD3%: 78
Abs-CD3: 612
CD4%: 35
Abs-CD4: 273
CD8%: 42
Abs-CD8: 328
CD4/CD8: 0.8

ENDOCRINE STUDIES:
[**2195-3-8**] 06:04PM BLOOD Free T4-1.3
[**2195-3-9**] 04:32AM BLOOD TSH-3.6
[**2195-3-8**] 06:04PM BLOOD Cortsol-19.2
[**2195-3-11**] 05:29AM BLOOD Cortsol-17.5
.
IMAGING:

[**3-8**] CXR: IMPRESSION: AP chest reviewed in the absence of prior
chest radiographs: The patient has had resection of the medial
left clavicle, and a vascular graft follows the course of the
left subclavian and brachiocephalic veins to the SVC.
Mediastinal widening extends to the apices of the chest with
thickening of the pleura and may represent treated adenopathy.
Heart is mildly enlarged. Lower lungs clear. No pleural
effusion.
.
CT ABDOMEN /PELVIS:
IMPRESSION:
1. Cirrhosis with ascites.
2. Atrophic native kidneys wuth hyperdense cystic lesions in the
left kidney which do not qualify as simple cysts. These lesions
should be watched closly on follow-up exams.
3. PD catheter in place.
4. Probable emphysema at the lung bases.

[**3-11**] -CT HEAD WITHOUT CONTRAST:
1. No definite acute intracranial process.
2. Relatively symmetric, confluent low-attenuation in
bihemispheric
periventricular white matter, most likely representing chronic
microvascular
infarction, in a patient with these predisposing conditions;
there is no
evidence of acute vascular territorial infarction.
3. Extensive fluid-opacification involving the left mastoid air
cells, of
uncertain duration and clinical significance; this should be
closely
correlated clinically.
4. Prosthetic right globe with abnormal appearance to the left
globe, as
detailed above.

EKG: Sinus rhythm. P-R interval prolongation. Lateral ST-T wave
changes.  Modest QTc interval prolongation.

MICROBIOLOGY:
Blood Cultures 3/28, [**3-8**] and [**3-9**], [**3-10**] all negative to date at
time of discharge

Peritoneal Fluid:
[**2195-3-7**] 3:45 pm PERITONEAL FLUID      PERITONEAL FLUID.

   GRAM STAIN (Final [**2195-3-7**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2195-3-10**]):    NO GROWTH.

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.

.
DISCHARGE LABS:

[**2195-3-11**] 05:29AM BLOOD WBC-3.5* RBC-3.17* Hgb-9.7* Hct-28.9*
MCV-91 MCH-30.6 MCHC-33.6 RDW-18.8* Plt Ct-85*
[**2195-3-11**] 05:29AM BLOOD Neuts-68.3 Bands-0 Lymphs-25.6 Monos-3.6
Eos-2.2 Baso-0.4
[**2195-3-11**] 05:29AM BLOOD Plt Ct-85*
[**2195-3-11**] 05:29AM BLOOD Glucose-65* UreaN-29* Creat-9.5* Na-142
K-3.0* Cl-104 HCO3-28 AnGap-13
[**2195-3-11**] 05:29AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.8


Brief Hospital Course:
Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hep B/C, ESRD on
peritoneal dialysis who presented with abdominal pain x 1 day,
hypothermia, and hypotension which resolved status-post IVFs.

Brief MICU Course:

The patient was admitted to the MICU for close observation,
although his symptoms of abdominal pain had resolved. His blood
pressure did drop to as low as 60s systolic, and he received 2 L
NS, and was started on Levophed. He was cultured and covered
empirically with Vanco/Zosyn given the hypotension and this was
later narrowed to Zosyn alone. He was hypothermic to 92 degrees
rectally, and a Bair Hugger was applied. Peritoneal Dialysis was
attempted but terminated early given the hypotension. Blood
pressure readings were inconsistent so an a-line was placed.
Over the course of hospital day 1, the patient's hemodynamics
improved and the Levophed was weaned off. TSH and cortisol
levels were normal. Throughout this, the patient mentated well
and was A&Ox3. On Hospital Day 2 he was called out to the
regular medical floor from the ICU for ongoing monitoring.
Please see below for problem based summary after transfer to
general medical wards.

Continued course after transfer out of ICU to medical floor:

# Abdominal Discomfort: Continued to deny any active abdominal
pain after hospital day 2. Bloated from constipation on
admission but he had multiple bowel movements with relief of his
sense of "fullness" soon after admission. Oral intake improved
daily. Exam revealed a soft, NT abdomen. No noted organisms in
peritoneal culture; all cultures NTD thus far, finals pending.
Initially had elevated lactate, but this resolved. CT abdomen
essentially clear with exception of cirrhosis and ascites and
some kidney findings as [**Known lastname 4030**] below. Probably dehydration
from admitted poor PO intake promoted constipation. He was
monitored with serial abdominal exams. Aggressive bowel regimen
with Senna and lactulose given for regularity of bowel
movements.
.
# Hypothermia / Hypotension: Low blood pressures have
stabilized. Still unclear etiology, although likely from his
poor PO intake and some mild dehydration.  Changes in body
temperature unlikely endocrinologic in nature as initial
cortisol and TSH were within normal limits, repeat a.m. cortisol
added on [**3-11**] and was also WNL. Some of his borderline low blood
pressure shifts may be due to small amount of volume changes
with dialysis treatments as well (although PD not HD). Initial
infectious workup labs/studies for concerns over looming
SIRS/sepsis picture have all been unremarkable to date. History
of HIV, HepC, HepB. Latest CD-4 count=273. Leukopenias initially
concerning for an acute infection but as he appeared markedly
more stable after IVFs and all culture data was unrevealing it
was felt hat his low blood cell counts were more likely due to
his HIV. Anuric so no urine studies collected. Trended
temperatures, improved after he was transferred to the medical
floor from the ICU. However, he is still having some more
intermittent low temperatures in the 93F range with oral
measures. He had a CT head without contrast on the morning of
[**3-11**] to rule out of any hypothamalmic masses/CVAs that may have
impacted his ability to self regulate body temperature. Head CT
showed no definite acute intracranial process, and relatively
symmetric, confluent low-attenuation in bihemispheric
periventricular white matter, most likely representing chronic
microvascular infarction. Otherwise, it is quite possible that
his body temperature is having fluctuations in the setting of
his 2L exchanges during peritoneal dialysis with resultant
cooling of underlying mesenteric venous bed. Patient's rectal
temperature taken on [**2195-3-11**] but was too low to register on
rectal thermometer which had a cut-off of 96F. Vitals today at
time of discharge included BPs 98-110/60-80s range, HR 70-100,
RR 18 and oxygen saturations at 100% room air.  CXR unremarkable
for any acute new infiltrates or PNAs although some subtle
perihilar area changes should be followed up on a repeat CT/CXR
over the next 1-2 weeks time. At time of discharge several
cultures were also pending, will plan to follow-up final reports
and notify [**Hospital1 **] staff of any organisms/infections
identified.
.
# Leukopenia: Likely from his HIV history, appears to be a
chronic issue. Initial WBC with slight drop from baseline
however to 2.3; PMN 65%, now WBCs up to 3 range.  Not
neutropenic currently. CD4 is 273.  Trended daily CBC with
differential/ANC levels, remained stable. Continue Zosyn for
now; will complete 7 day course on [**2195-3-14**].

# ESRD: Continued peritoneal dialysate regimen with daily
exchanges. Euvolemic on exam now. Renal team followed while
inpatient. Anuric with his ESRD. Continued on Calcitriol 0.25mcg
daily, Sensipar 90mg daily, PhosLo TID, and Epogen. He will
resume his ongoing PD sessions on transfer. Last BUN/Cr was
29/9.5 respectively at time of discharge.
.
#Labile affect: Please note that Mr. [**Known lastname 122**] was refusing
multiple medications during his stay and missed a few doses of
his antibiotics and a few of his usual daily medications on
[**3-10**]. Also refused a P.M. peritoneal dialysis session on night
of [**3-10**] as well. Patient is alert and oriented x3 and seems to
have capacity so team felt he had right to refuse treatment but
made repeated efforts to discourage this behavior by reviewing
risks/benefits. Team was considering a psychiatry consult near
time of discharge as patient's refusal to collect vitals and
accept medications was counter to his effective management. He
has a noted PMH of depression and anxiety per records. He seemed
to perseverate on going back to [**Hospital1 **] and expressed that he
feels less anxious at [**Hospital1 **] as he has been cared for there in
past. He may benefit from formal psychiatric evaluation upon
return to [**Hospital1 **] if this behavior continues.
.
# Kidney cysts/masses: Please note that routine CT abdomen for
workup of abdominal pain showed atrophic native kidneys wuth
hyperdense cystic lesions in the left kidney which do not
qualify as simple cysts. These lesions should be watched closly
on follow-up exams and repeat CT recommended in 2 months.
.
# HIV: CD4 in [**2192-3-10**] was 27, now current CD4 count is up to
273. He was continued on outpatient Tenofovir 300mg once weekly.
Bactrim DS 1 tab MWF continued. As above, no new acute
infections identified. Will plan to follow-up on outstanding
final blood culture reports.
.
# Fluids, Electrolytes & Nutrition: Continued on his peritoneal
dialysis; hypokalemia trend noted so he was repleted as needed.
Given some magnesium repletion as well prior to discharge. Renal
diet provided, good appetite.

#Access: Femoral line was placed. Patient with very difficult
upper extremity access so team left access with femoral line in
place so that he could complete the additional 3 days of his
antibiotics. Line appears clean /dry/ intact. Also has left
abdominal catheter/peritoneal port for his ongoing peritoneal
dialysis sessions.

#Prophylaxis: He was continued on a PPI / Pneumoboots / bowel
regimen PRN
.
#Code Status: DNR/DNI confirmed on admission with patient.
.

.


Medications on Admission:
(per CMA service 1-[**Telephone/Fax (1) 4031**])
Bactrim DS 1 tab MWF
Epivir 25mg daily
Phoslo 667mg 3 tabs TID with meals
Tenofovir 300mg (qWeek per CMA service)
Zerit 15mg daily
Zyprexa 5mg QHS
Epogen 10000u SC Qweek
Omeprazole 20mg Qday
Calcitriol 0.25mcg daily
Sensipar 90mg daily
Senna 2 tabs QHS


Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
2. Lamivudine 100 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
3. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 3 days: please
complete on [**2195-3-14**] .
5. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 1X/WEEK ([**Doctor First Name **]).
6. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. Cinacalcet 30 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

11. Epogen 10,000 unit/mL Solution Sig: One (1)  Injection once
a week.
12. Stavudine 15 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
13. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day: with meals.
14. peritoneal dialysis instructions
Peritoneal Dialysis Orders:

4 exchanges/24hrs; 2.5% solution; 2L volume; 4 hr dwell time.
Please record daily weights, I/Os, effluent appearance daily.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 2222**] - [**Location (un) 538**]

Discharge Diagnosis:
Primary:
Hypotension
Hypothermia
Constipation
.
Secondary:
HIV
Hepatitis B/C
End Stage Renal Disease


Discharge Condition:
Good. At time of discharge the patient had stable blood
pressures, and he had no residual complaints of abdominal pain.
Constipation had resolved and he was having regular bowel
movements.


Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted with complaints of
lightheadedness, low blood pressures, low body temperatures
(hypothermia)and abdominal pains. A CT scan imaging study of
your abdomen showed no acute new abdominal issues to explain
this abdominal pain and your symptoms were likely due to your
constipation as you had not had a bowel movement in several
days. Once you had medication to help you have a bowel movement
you felt better. Multiple lab studies were done and there were
no infections found to explain your symptoms. The renal team was
called and helped to continue your usual peritoneal dialysis
sessions while you were here in the hospital.
.
Please follow-up with your primary doctor [**First Name (Titles) 3**] [**Last Name (Titles) 4030**] below.
If you have any additional abdominal pains, fevers, low blood
pressures, feelings of dizziness, diarrhea, more constipation,
or any additional health concerns please call your primary
doctor or notify your covering medical staff at the [**Hospital **]
Hospital.
.
Medication Instructions:
Antibiotics for broad coverage were added to your daily regimen
for a planned 7 days of therapy. Please continue daily Zosyn as
prescribed up until [**2195-3-14**].
-Otherwise you can continue taking all of your usual medications
as previously prescribed.
-
Additional Notes/Instructions:
Please follow-up with your doctor for a repeat CT abdomen in 2
months to assess a left sided kidney cystic region that was
found on CT. This should be evaluated for any increase in size
or signs or concerning features with repeat imaging.


Followup Instructions:
Please call the infectious disease clinic and your primary care
doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 4032**] to make a follow-up
appointment over the next 1-2 weeks time.



Completed by:[**2195-3-11**]
{'Human immunodeficiency virus [HIV] disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other venous embolism and thrombosis of unspecified site,Constipation, unspecified,Leukocytopenia, unspecified,Hypothermia not associated with low environmental temperature,Cirrhosis of liver without mention of alcohol,Hypotension, unspecified,Hypopotassemia,Thrombocytopenia, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of tuberculosis,Cyst of kidney, acquired'}


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: Abdominal pain, hypothermia

PRESENT ILLNESS: Mr. [**Known lastname 122**] is a 46 year-old male with HIV, Hepatitis B/C, ESRD
on peritoneal dialysis who presented to the ED with abdominal
pain, constipation and also feeling dizzy with lightheadedness.
Called the ambulance for these symptoms.  Initial VS 91.1F
orally, HR 72, BP initially unmeasurable, RR 20 and 100% oxygen
saturation on room air.  Exam with clear lungs, RRR, distended
abdomen which was soft and full.  He refused a rectal exam.  CT
was obtained given abdominal pain and preliminary read was
negative for any acute intrabdominal processes.  Right femoral
line was placed with some difficulty due to scar tissue.  BP
remained difficult to assess given severe vascular disease.
Repeat VS soon after presentation revealed temperature 96.1F,
75HR, BPs of 59/25-105/47, RR 12, and oxygen saturation was 100%
room air.  Fingerstick glucose was 123.  Patient had potassium
repleted with 40 mEq K in 1L NS, with 3 additional L NS.  His
peritoneal dialysate was sampled and did not reveal evidence of
infection.  Denies ever having abdominal pain, but more a sense
of constipation and "fullness".  Systolic blood pressures in ED
ranged 74--> 68 --> 90 --> 105.  By time of transfer from ED to
inpatient setting he was saturating well on RA, eating and
requesting more food. Given patient's initial presentation of
appearing very unwell, was sent to the ICU for closer
monitoring.

MEDICAL HISTORY: HIV
Hepatitis B
Venous capillary sepsis
Venous thromboembolism
Depressive disorder & nervousness
CMV infection
History of tuberculosis
ESRD [**1-12**] HIV - on peritoneal dialysis, followed at [**Last Name (un) 4029**] in
[**Location (un) **] on [**State **] St.
Chronic constipation - on senna PRN
h/o XRT at MEEI for SCC in his left ear
Hypertension
Syphilis in [**Month (only) **] l993.  CSF showed lymphocytosis.  The
patient was treated with intravenous penicillin for ten days.
Hepatitis C antibody positive

MEDICATION ON ADMISSION: (per CMA service 1-[**Telephone/Fax (1) 4031**])
Bactrim DS 1 tab MWF
Epivir 25mg daily
Phoslo 667mg 3 tabs TID with meals
Tenofovir 300mg (qWeek per CMA service)
Zerit 15mg daily
Zyprexa 5mg QHS
Epogen 10000u SC Qweek
Omeprazole 20mg Qday
Calcitriol 0.25mcg daily
Sensipar 90mg daily
Senna 2 tabs QHS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: unable to obtain initially, BP: 89/64, PR: 67, RR: 13,  O2:
100/RA
General: Alert, oriented, no acute distress; able to relay
history in a coherent fashion
HEENT: Sclera anicteric, MM mildly dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds but no
appreciable murmurs, rubs, gallops
Abdomen:  soft, non-tender,  mildly distended, bowel sounds
present, no rebound tenderness or guarding; bandaged PD wound in
LLQ
Ext: Warm, nonpalpable distal pulses, no edema; R femoral groin
wound noted
Neuro: CN II-XII grossly intact; A&O x 3
Skin: Multiple excoriated lesions over entire body, slight
crusting; including arms, back

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Tobacco [**12-12**] PPDx 20 years, no ETOH, unemployed and lives alone
in an apartment and he has CMA nursing help at home. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other venous embolism and thrombosis of unspecified site,Constipation, unspecified,Leukocytopenia, unspecified,Hypothermia not associated with low environmental temperature,Cirrhosis of liver without mention of alcohol,Hypotension, unspecified,Hypopotassemia,Thrombocytopenia, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Personal history of tuberculosis,Cyst of kidney, acquired'}
