CHIEF COMPLAINT: fever, chills

PRESENT ILLNESS: 57m with HIV (last CD4 525 with VL undetectable ~2 months ago)
presents with acute onset of fever, chills, and extreme weakness
several hours prior to presentation. He was at his office
working feeling in his usual state of health until about 9pm
last night. At that time, he developed abrupt onset of fever,
chills, hot flashes. +Nausea. No vomiting. No cough, SOB, chest
pain. No urinary symptoms. No sick contacts. [**Name (NI) 4084**] had episode
like this before. No recent travel.
.
In the [**Hospital1 18**] ED, initial vitals were T 102.5, BP 118/65, HR 116,
RR 20, 94% RA. His BP dropped to 70/30s at one point but
improved with IVF. BP then dropped again. R IJ was placed.
Levophed was started. He remained persistently tachy to
120-130s. Labs notable for lactate of 2.5, no leukocytosis, hct
49. UA neg. CXR unremarkable. Admitted to MICU for closer
monitoring.
.
On arrival to the MICU, the patient's main complaint is feeling
very thirsty. He also has severe back and knee discomfort [**3-18**]
chronic arthritis pain and lying flat on his back. SBP dropped
again to as low as 60s. Vasopressin and neosynephrine were added
to bring up BP.
.
ROS: As above. Otherwise negative in detail.

MEDICAL HISTORY: HIV
Hep B, never been treated
Obesity
Hypercholesterolemia
Asthma
R medial meniscal tear
DM type 2
Hx splenic abscess s/p splenectomy in [**2135**]

MEDICATION ON ADMISSION: Metformin 500mg PO BID
Atripla 1 tab PO daily
Lisinopril 5mg PO daily
Lipitor 10mg PO daily

ALLERGIES: Erythromycin Base / Biaxin / Ciprofloxacin

PHYSICAL EXAM: VS - T 100.9; BP 90/44; HR 120; RR 12; O2sat 92% on 4L
Gen: anxious appearing, obese male, diaphoretic, alert and
interacting appropriately
HEENT: PERRL, EOMI, dry MM, OP clear
CV: distant HS,
Chest: face tent, CTAB, no w/r/r
Abd: obese, soft, nondistended, mild tenderness at
RUQ/mid-epigastrium
Ext: no LE edema
Skin: no rash
Neuro: A+O x 3

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: In long term relationship w/ partner. [**Name (NI) **] smoking. No alcohol. No
drugs.
Human immunodeficiency virus [HIV] disease,Severe sepsis,Pneumonia due to other Streptococcus,Acute kidney failure, unspecified,Septic shock,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute respiratory failure,Acute pancreatitis,Streptococcal septicemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Asthma, unspecified type, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Thrombocytopenia, unspecified
Human immuno virus dis,Severe sepsis,Pneumonia oth strep,Acute kidney failure NOS,Septic shock,Hpt B acte wo cm wo dlta,Acute respiratry failure,Acute pancreatitis,Streptococcal septicemia,DMII wo cmp nt st uncntr,Obesity NOS,Asthma NOS,Elev transaminase/ldh,Thrombocytopenia NOS
Admission Date:  [**2148-6-12**]              Discharge Date:   [**2148-7-5**]

Date of Birth:  [**2091-2-25**]             Sex:   M

Service: MEDICINE

Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
fever, chills

Major Surgical or Invasive Procedure:
Mechanical Ventilation
Arterial Line Placement
Hemodialysis Line Placement
Internal Jugular Central Line Placement


History of Present Illness:
57m with HIV (last CD4 525 with VL undetectable ~2 months ago)
presents with acute onset of fever, chills, and extreme weakness
several hours prior to presentation. He was at his office
working feeling in his usual state of health until about 9pm
last night. At that time, he developed abrupt onset of fever,
chills, hot flashes. +Nausea. No vomiting. No cough, SOB, chest
pain. No urinary symptoms. No sick contacts. [**Name (NI) 4084**] had episode
like this before. No recent travel.
.
In the [**Hospital1 18**] ED, initial vitals were T 102.5, BP 118/65, HR 116,
RR 20, 94% RA. His BP dropped to 70/30s at one point but
improved with IVF. BP then dropped again. R IJ was placed.
Levophed was started. He remained persistently tachy to
120-130s. Labs notable for lactate of 2.5, no leukocytosis, hct
49. UA neg. CXR unremarkable. Admitted to MICU for closer
monitoring.
.
On arrival to the MICU, the patient's main complaint is feeling
very thirsty. He also has severe back and knee discomfort [**3-18**]
chronic arthritis pain and lying flat on his back. SBP dropped
again to as low as 60s. Vasopressin and neosynephrine were added
to bring up BP.
.
ROS: As above. Otherwise negative in detail.


Past Medical History:
HIV
Hep B, never been treated
Obesity
Hypercholesterolemia
Asthma
R medial meniscal tear
DM type 2
Hx splenic abscess s/p splenectomy in [**2135**]


Social History:
In long term relationship w/ partner. [**Name (NI) **] smoking. No alcohol. No
drugs.


Family History:
Noncontributory

Physical Exam:
VS - T 100.9; BP 90/44; HR 120; RR 12; O2sat 92% on 4L
Gen: anxious appearing, obese male, diaphoretic, alert and
interacting appropriately
HEENT: PERRL, EOMI, dry MM, OP clear
CV: distant HS,
Chest: face tent, CTAB, no w/r/r
Abd: obese, soft, nondistended, mild tenderness at
RUQ/mid-epigastrium
Ext: no LE edema
Skin: no rash
Neuro: A+O x 3


Pertinent Results:
[**2148-6-11**] 10:30PM BLOOD WBC-9.4 RBC-5.26# Hgb-16.2# Hct-49.1
MCV-93# MCH-30.8# MCHC-33.0 RDW-14.3 Plt Ct-432
[**2148-6-12**] 03:42PM BLOOD WBC-24.9* RBC-4.68 Hgb-14.3 Hct-43.9
MCV-94 MCH-30.5 MCHC-32.6 RDW-14.6 Plt Ct-247
[**2148-6-14**] 04:03AM BLOOD WBC-48.3* RBC-4.06* Hgb-12.4* Hct-37.1*
MCV-91 MCH-30.7 MCHC-33.5 RDW-15.1 Plt Ct-23*
[**2148-6-18**] 03:53PM BLOOD WBC-45.6* RBC-3.29* Hgb-10.4* Hct-30.0*
MCV-91 MCH-31.6 MCHC-34.6 RDW-16.4* Plt Ct-72*
[**2148-6-23**] 04:10AM BLOOD WBC-17.4* RBC-2.59* Hgb-8.2* Hct-24.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-17.1* Plt Ct-355#
[**2148-7-2**] 06:30AM BLOOD WBC-8.2 RBC-2.53* Hgb-8.0* Hct-26.0*
MCV-103* MCH-31.6 MCHC-30.8* RDW-19.2* Plt Ct-811*
[**2148-7-5**] 06:00AM BLOOD WBC-9.5 RBC-3.04* Hgb-9.6* Hct-29.7*
MCV-98 MCH-31.5 MCHC-32.3 RDW-19.5* Plt Ct-738*
[**2148-7-2**] 06:30AM BLOOD  WBC-8.2 Lymph-20 Abs [**Last Name (un) **]-1640 CD3%-81
Abs CD3-1333 CD4%-23 Abs CD4-373 CD8%-58 Abs CD8-953*
CD4/CD8-0.4*
[**2148-6-11**] 10:30PM BLOOD Glucose-133* UreaN-27* Creat-1.0 Na-137
K-4.4 Cl-99 HCO3-25 AnGap-17
[**2148-6-28**] 03:00AM BLOOD Glucose-79 UreaN-80* Creat-6.6* Na-147*
K-5.1 Cl-109* HCO3-19* AnGap-24*
[**2148-6-29**] 03:12AM BLOOD Glucose-89 UreaN-73* Creat-6.1* Na-150*
K-4.7 Cl-110* HCO3-18* AnGap-27*
[**2148-7-4**] 06:40AM BLOOD Glucose-86 UreaN-39* Creat-3.1* Na-145
K-4.1 Cl-107 HCO3-24 AnGap-18
[**2148-6-11**] 10:45PM BLOOD Lactate-2.5*
[**2148-6-12**] 12:17PM BLOOD Lactate-6.1*
[**2148-6-15**] 10:21AM BLOOD Lactate-2.0
[**2148-6-29**] 03:53PM BLOOD Lactate-0.8

ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2148-6-12**] 8:29 AM
IMPRESSION:
1. Limited examination shows no gross intrahepatic biliary
dilatation.
2. Markedly edematous gallbladder, without stones or distension.
The
appearance of the wall can be seen in patients with underlying
liver disease
or hypoproteinemia.
3. Fluid within the left upper quadrant, of uncertain etiology
or location.
Differential considerations include a fluid-filled, distended
stomach, vs.
post- operative fluid within the splenectomy bed.
4. Small amount of ascites.

Portable TTE (Complete) Done [**2148-6-14**] at 11:43:53 AM:
Left Ventricle - Ejection Fraction:  >= 55%
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality.
Trace aortic regurgitation is seen. No masses or vegetations are
seen on the mitral valve, but cannot be fully excluded due to
suboptimal image quality. There is no pericardial effusion.

IMPRESSION: No vegetations seen (suboptimal-quality study).
Normal global and regional biventricular systolic function. In
presence of high clinical suspicion, absence of vegetations on
transthoracic echocardiogram does not exclude endocarditis.

Brief Hospital Course:
Mr [**Known lastname **] is a 57 year old man with history of HIV,
splenectomy, presented with acute onset of fever, chills and
nausea. Patient was evaluated in the ED where he spiked fever to
102.5 and developed acute hypotension requiring rapid escalation
of care with 3 pressors and large volume resusitation for septic
shock.
.
Patient was in MICU from [**6-12**] where his course included Xigris
administration, CVVH for massive volume overload and treated
with broad spectrum antibiotics. Eventually the patient was
weaned off of pressors, received one dose of IVIG, and
subsequently placed on PCN G for strep viridans culture but had
one episode of hypotension and fever during which time 1 time
doses of vanc/zosyn were given. Today is day 18/28 as per ID of
PCN G course. In addition, the patient had unexplained
transaminitis during his stay, history of HBV infection and HBV
core antigen positive, negative HCV Ab. Transaminitis resolved
as patient was weaned from ventilation and pressures stabilized
-- on transfer AST/ALT have normalized and Alk Phos trending
down. Amylase and Lipase elevated on [**6-18**], continues to be
elevated -- there was an initial concern for pancreatitis and
abd. CT done showing mild pancreatitis; however lipase now
trending down and no signs of infection (fever, leukocytosis) is
present at transfer. Pt. also suffering from ARF likely ATN from
septic shock, received several rounds of CVVH after massive
fluid resuscitation, now auto-diuresing with up to 3L UOP/day,
though Cr still above 5 on transfer. In addition, pt. had a
transient drop in plt's to a nadir of 10 requiring plt
transfusion -- heme/onc consulted, reviewed smear, and believed
pathogenesis to be bone marrow suppression in light of
overwhelming sepsis, and not DIC. Plt levels have since returned
to normal.
.
On transfer to the floor, pt. was alert and talkative.  Was seen
by physical therapy and was able to transfer from bed to chair
and back with assistance.  Continued to have good urine output,
so renal concluded no need to place HD line.  Cr trended
downward to 3.1 the day prior to discharge, and patient was
tolerating adequate PO's.  Will be discharged on day 23 of 28 of
his PCN G as per ID.  In addition, was having diarrhea, C.diff
negative x 2.
.
Follow Up:
---------
- Please follow up MICROSPORIDIA STAIN, CYCLOSPORA STAIN, and
Cryptosporidium/Giardia DFA stool samples
- When Cr is under 1.5, please resume original HAART medications

MICU COURSE
===============
Events [**6-12**]:
- BCx [**3-18**] GPCs in pairs
- Zosyn changed to ceftriaxone and clindamycin
- Given IVIG
- RUQ u/s showed edematous gallbladder
[**6-13**]
-Climbing WBC
-Renal put in HD cath
-f/u CXR shows decreased pulm edema, effusions, but ?aspiration,
L retrocardiac opacity
-standing tylenol
-started IV hydrocortisone
- 25g albumin x2
- IVFs w/ bicarb
[**6-14**]
-Platelets to 10K, 1 bag of platelets given, increased to 39
-D/C'ed ceftriaxone per ID given interaction with calcium
gluconate on CVVH
-DIC labs
-Heme/Onc does not believe plt drop is DIC, believes it is
suppression of marrow due to sepsis
-Dopamine weaned off, on CVVH
.
[**6-15**] Events:
-PEEP decreased to 16
-cultures growing strep viridans
[**6-16**] events:
d/c-ed vanc, clinda. Started PCN with one dose of [**Last Name (LF) **], [**First Name3 (LF) **] ID
recs
-weaned off levophed and vasopressin!
-please bring up with nephrology whether patient can get
dialysis now that pressures are stable.
[**6-17**] Events
-Patient with labored breathing, PEEP was increased to 20, pt.
placed back on midazolam sedation.
-IP, saw free flowing fluid with no loculations, performed
diagnostic thoracentesis, transudative pleural fluid
-TEE to be done tomorrow, tube feeds restarted, NPO past
midnight
-RUQ ultrasound being done- prelim read -> interval decrease in
gb wall edema, gb not distended, no gstones, no cholecystitis,
small amount of free fluid adj to liver
-[**Month/Day (4) **] level 0.7, given [**Month/Day (4) **] per ID recs
-HIT Ab negative
-Bronch done, demonstrated esophageal balloon in lung, extracted

-PLT increasing
.
[**6-18**] Events:
-TEE showed no vegetations
-labs show pancreatitis, plan to obtain CT abd after off CVVH
-hypotensive to 70s with 500 ccs negative per hour, given 1000
cc bolus, changed CVVH to run at even, held versed
-hepatitis panel sent
-amylase level of pleural fluid added on
-started acyclovir
-need to ask ID in am about IV vs topical acyclovir, need for
[**Month/Day (1) **], and when to restart HAART
[**6-19**] events:
d/c-ed [**Month/Day (4) **] per ID recs
-wanted to continue po acyclovir for now
-considering starting HAART soon, not quite yet
-they did not comment on whether or not to start broader abx
coverage for pna. So we started Levofloxacin for pna.
I/Os: -4.2L
[**6-20**] events:
-two episodes of hypotension with SBP below 100, given two 500cc
boluses of fluid
-temp to 101, pan cultured, given 1x dose of zosyn and
vancomycin
-PEEP @ 12
-HCV and HBV negative
-Increased Cr to 2.1
-EBV IgG positive
.
[**6-21**] events:
-HD
-HD line removed, tip for culture
-ABx d/c'd
-CT abd completed- no abscess or fluid collection, mild
pancreatitis, b/l pleural effusions c/ atelectasis, L opacity
.
[**6-22**] events:
patient more arousable
+2L
.
[**6-23**] Events
- Renal recs to make patient NPO for tomorrow for possible
tunneled cath HD line placement; however, if patient's urine
output is picking up (last UOP decidedly more than prev. at
100-110 every 2 hours)
- Holding heparin
- Patient sitting up, responsive to questions
- ABG pristine on PS ventilation (7.42/40/90)
===================================


Medications on Admission:
Metformin 500mg PO BID
Atripla 1 tab PO daily
Lisinopril 5mg PO daily
Lipitor 10mg PO daily


Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Month/Year (2) **]: One
(1) Appl Ophthalmic PRN (as needed).
2. Senna 8.6 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical PRN
(as needed) as needed for pannus fungal infection.
4. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Year (2) **]: Six (6)
Puff Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Olanzapine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for aggitation.
8. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing,
SOB.
11. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
[**Last Name (STitle) **]: 3,000,000 units Intravenous Q4H (every 4 hours) for 6 days:
Please stop on [**2148-7-10**].
12. Insulin Glargine 100 unit/mL Solution [**Date Range **]: Eight (8) units
Subcutaneous QAM.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary:
Septic Shock
Acute Renal Failure

Secondary:
HIV on therapy
Hepatitis B, untreated
Obesity
Hypercholesterolemia
Asthma
Diabetes Mellitus Type 2
History of splenic abscess status post splenectomy in [**2135**]


Discharge Condition:
Stable, eating, drinking, voiding, and having bowel movements,
conversant, can get from chair to bed with assistance.


Discharge Instructions:
You were admitted initially for a severe infection and severe
inflammation.  Upon arrival you were promptly taken to the
intensive care unit where you were given antibiotics and
resucitated with fluids.  After you stabilized in the ICU, you
were transferred to the floor where you were recovering very
well.  You are being sent to a rehabilitation facility where you
will work with physical therapy to recover your strength.  You
will also complete your course of antibiotics there.  Upon
discharge from the rehab facility, please set up an appointment
with your primary care physician [**Name Initial (PRE) 176**] 1 to 2 weeks of
discharge.

Please take all medications as prescribed.  The most notable
medication that we are continuing you on is your penicillin, for
which you have 1 more week to complete.

If you experience any sudden chest pain, shortness of breath,
nausea, vomiting, diarrhea, constipation, lightheadedness, or
loss of consciousness, please contact your primary care provider
[**Name Initial (PRE) 2227**].

Followup Instructions:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-11-13**]
1:00



Completed by:[**2148-7-5**]
{'Human immunodeficiency virus [HIV] disease,Severe sepsis,Pneumonia due to other Streptococcus,Acute kidney failure, unspecified,Septic shock,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute respiratory failure,Acute pancreatitis,Streptococcal septicemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Asthma, unspecified type, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Thrombocytopenia, unspecified'}


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: fever, chills

PRESENT ILLNESS: 57m with HIV (last CD4 525 with VL undetectable ~2 months ago)
presents with acute onset of fever, chills, and extreme weakness
several hours prior to presentation. He was at his office
working feeling in his usual state of health until about 9pm
last night. At that time, he developed abrupt onset of fever,
chills, hot flashes. +Nausea. No vomiting. No cough, SOB, chest
pain. No urinary symptoms. No sick contacts. [**Name (NI) 4084**] had episode
like this before. No recent travel.
.
In the [**Hospital1 18**] ED, initial vitals were T 102.5, BP 118/65, HR 116,
RR 20, 94% RA. His BP dropped to 70/30s at one point but
improved with IVF. BP then dropped again. R IJ was placed.
Levophed was started. He remained persistently tachy to
120-130s. Labs notable for lactate of 2.5, no leukocytosis, hct
49. UA neg. CXR unremarkable. Admitted to MICU for closer
monitoring.
.
On arrival to the MICU, the patient's main complaint is feeling
very thirsty. He also has severe back and knee discomfort [**3-18**]
chronic arthritis pain and lying flat on his back. SBP dropped
again to as low as 60s. Vasopressin and neosynephrine were added
to bring up BP.
.
ROS: As above. Otherwise negative in detail.

MEDICAL HISTORY: HIV
Hep B, never been treated
Obesity
Hypercholesterolemia
Asthma
R medial meniscal tear
DM type 2
Hx splenic abscess s/p splenectomy in [**2135**]

MEDICATION ON ADMISSION: Metformin 500mg PO BID
Atripla 1 tab PO daily
Lisinopril 5mg PO daily
Lipitor 10mg PO daily

ALLERGIES: Erythromycin Base / Biaxin / Ciprofloxacin

PHYSICAL EXAM: VS - T 100.9; BP 90/44; HR 120; RR 12; O2sat 92% on 4L
Gen: anxious appearing, obese male, diaphoretic, alert and
interacting appropriately
HEENT: PERRL, EOMI, dry MM, OP clear
CV: distant HS,
Chest: face tent, CTAB, no w/r/r
Abd: obese, soft, nondistended, mild tenderness at
RUQ/mid-epigastrium
Ext: no LE edema
Skin: no rash
Neuro: A+O x 3

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: In long term relationship w/ partner. [**Name (NI) **] smoking. No alcohol. No
drugs. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Severe sepsis,Pneumonia due to other Streptococcus,Acute kidney failure, unspecified,Septic shock,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Acute respiratory failure,Acute pancreatitis,Streptococcal septicemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Asthma, unspecified type, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Thrombocytopenia, unspecified'}
