CHIEF COMPLAINT: Confusion, rash and fever.

PRESENT ILLNESS: This is a 66 year old woman with recent diagnosis of HIV/AIDS
on HAART, last CD4 count 253 and, depression and mild dementia,
who presented from home with a vesicular rash, confusion and
fevers on the [**4-4**]. She was admitted to medicine.

MEDICAL HISTORY: 1. Diabetes mellitus - diet controlled.
2. History of cutaneous T-cell lymphoma - quiescent after UV
light treatment.
3. Hospitalized at [**Location (un) 511**] [**Hospital **] Hospital in [**2087**] for
psychotic depression.
4. Hospitalized at [**Hospital 1263**] Hospital in [**2098**] for depression (with
psychotic features) - in remission and controlled with
mirtazipine, aripiprazole.
5. Question of mild cognitive impairment prior to HIV diagnosis.
6. HIV - diagnosed after presenting with pneumocystic pneumonia
in [**2100-6-14**].  Last negative test [**2087**].  Possible occupational
exposure (unclear).  CD4 count at diagnosis 60, started on HAART
with good response (see below).

MEDICATION ON ADMISSION: Abilify 20 mg, 1 tablet, PO daily
Mirtazapine 15 mg, 1 tablet PO HS
Multivitamin, one capsule PO daily
Norvir 100 mg, one capsule PO daily
Reyataz 150 mg, 2 capsules PO daily
Trimethoprim-Sulfamethoxazole 400 mg- 80 mg, 1 tablet PO daily
Truvada 200 mg- 300 mg, 1 tablet PO daily
Zithromax, 2 tablets PO weekly

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Initial examination on arrival on the [**Hospital1 **]
Vitals: T: 99.5 BP: 154/85 P: 86 R: 18 O2: 100% on RA
General: Cachectic, somolent but arrousable, oriented x 3, no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.

FAMILY HISTORY: Adult onset DM in both parents. Father with possible depression.
Colon CA in brother who died of it at 67; heart disease in one
brother. [**Name (NI) **] breast cancer.

SOCIAL HISTORY: From [**State 9512**], college in [**State 33977**]. Separated from husband
[**Doctor Last Name **] [**Telephone/Fax (1) 100761**] cell). Has a daughter who lives in
[**State 9512**]. Worked in [**Hospital1 18**] micro lab as medical technician since
[**2066**].  Reports occupational exposures.  No h/o smoking,
excessive alcohol drinking or illicit drug use.
Herpes zoster with meningitis,Human immunodeficiency virus [HIV] disease,Hyposmolality and/or hyponatremia,Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Backache, unspecified,Swelling of limb,Other persistent mental disorders due to conditions classified elsewhere,Muscle weakness (generalized),Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of other lymphatic and hematopoietic neoplasms
Herpes zoster meningitis,Human immuno virus dis,Hyposmolality,Rec depr psych-psychotic,Hypertension NOS,DMII wo cmp nt st uncntr,Drug dermatitis NOS,Adv eff cephalosporin,Abnrml coagultion prfile,Adv eff anticoagulants,Backache NOS,Swelling of limb,Mental disor NEC oth dis,Muscle weakness-general,Anemia NOS,Osteoarthros NOS-unspec,Hx-lymphatic malign NEC
Admission Date:  [**2100-11-4**]              Discharge Date:   [**2100-11-23**]

Date of Birth:  [**2034-7-13**]             Sex:   F

Service: MEDICINE

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
Confusion, rash and fever.

Major Surgical or Invasive Procedure:
Lumbar puncture, twice.


History of Present Illness:
  This is a 66 year old woman with recent diagnosis of HIV/AIDS
on HAART, last CD4 count 253 and, depression and mild dementia,
who presented from home with a vesicular rash, confusion and
fevers on the [**4-4**]. She was admitted to medicine.

  Mrs. [**Known lastname 100760**] was in her usual state of health approximately one
week before admission. Her husband has noticed for the past [**3-17**]
days she has seemed more confused than normal. At the same time
she has developed a right sided vesicular rash, located over her
right breast. The rash was painful and mildly pruritic.  She had
had mild fevers at home to as high as 100.1 without chills. She
had not had headache, photophobia or neck stiffness. Nor had she
chest pain or difficulty breathing. No nausea, vomiting,
adominal pain, diarrhea, constipation, dysuria, hematuria, leg
pain or swelling. She did have decreased PO intake for the past
week. She did have one episode of urinary incontinence which is
unusual for her and no episodes of bowel incontinence. She was
seen by her VNA on the day of presentation who noted her to be
mildly confused with a temperature of 100.1. Her primary care
physician was [**Name (NI) 653**] who recommended transfer to the
emergency room.

  In the ED, initial vs were: T: 102 BP: 136/75 P: 85 R: 16 O2:
100% on RA. She had a CXR which showed a possible small left
lower lobe opacity. She had a head CT without acute changes. EKG
showed normal sinus rhythm, normal axis, normal intervals, small
q waves in III, avF, poor baseline tracing but no acute ST
segment changes, no change from prior dated [**2100-6-24**]. She had a
lumbar puncture which showed 18 WBC in tube 4 with 16 RBC, 61%
neutrophils. Protein was 62, glucose 66. She received
ceftriaxone 2 grams IV x 1 and azithromycin 500 mg PO x 1. She
weas admitted to the floor for further workup.

Past Medical History:
1. Diabetes mellitus - diet controlled.
2. History of cutaneous T-cell lymphoma - quiescent after UV
light treatment.
3. Hospitalized at [**Location (un) 511**] [**Hospital **] Hospital in [**2087**] for
psychotic depression.
4. Hospitalized at [**Hospital 1263**] Hospital in [**2098**] for depression (with
psychotic features) - in remission and controlled with
mirtazipine, aripiprazole.
5. Question of mild cognitive impairment prior to HIV diagnosis.
6. HIV - diagnosed after presenting with pneumocystic pneumonia
in [**2100-6-14**].  Last negative test [**2087**].  Possible occupational
exposure (unclear).  CD4 count at diagnosis 60, started on HAART
with good response (see below).

Social History:
From [**State 9512**], college in [**State 33977**]. Separated from husband
[**Doctor Last Name **] [**Telephone/Fax (1) 100761**] cell). Has a daughter who lives in
[**State 9512**]. Worked in [**Hospital1 18**] micro lab as medical technician since
[**2066**].  Reports occupational exposures.  No h/o smoking,
excessive alcohol drinking or illicit drug use.


Family History:
Adult onset DM in both parents. Father with possible depression.
Colon CA in brother who died of it at 67; heart disease in one
brother. [**Name (NI) **] breast cancer.


Physical Exam:
Initial examination on arrival on the [**Hospital1 **]
Vitals: T: 99.5 BP: 154/85 P: 86 R: 18 O2: 100% on RA
General: Cachectic, somolent but arrousable, oriented x 3, no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.

Exam on re-admission to floor (from ICU)
Vitals: T: 99.6  BP: 134/86  P: 79  R: 18  O2: 100% on RA
General: Cachectic, slightly withdrawn with little spontaneous
behavior, oriented x 3, no acute distress
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: Supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, systolic blowing
murmur loudest at upper left sternal edge, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.
Neurological: Mentation is slow and there is a poverty of speech
and movement.  Affect is flat.  Oriented to person, place and
time. Decreased 4/5 strength on left side in UMN pattern: paucy
of finger movement which is slow and clumsy; RUE WNL.  Tone
decreased in lower extremities and surprisingly depressed
reflexes in the lower extremities.  Tone lower in legs.  Unable
to walk at present and needs walker at baseline.

Exam on discharge:
VS: T 98.8  BP 126/73  HR 91  RR 18  O2 Sat 98% RA
Gen: cachectic-appearing, in NAD. MMM. No thrush.
Neck: supple, trachea midline, no LAD, no JVD
Lungs: CTAB, no evidence of accessory muscle use
COR: RRR, no n/g/r
Abd: soft, non-tender. No h/s/m.
BACK: no CVAT.
SKIN: faint erythematous macular rashes of various shape and
sizes on cheeks, trunk, and limbs. No vesicle or ulcer.
Musculoskeletal: Decreased range of motion in lower extremities.

Neuro: Mental status: alert, oriented to person and place.
Intermittently oriented to year. Knows president is [**Last Name (un) 2753**]. Says
that her colleague came to see her today (on the day of
discharge). "[**Doctor First Name **] had swine flu!" Took 3 trials to learn
objects. Recalled [**1-16**] objects without hint. Recalled 2nd object
with a hint. Did not recall 3rd object with hint. Could not
complete days of week backwards, though she occasionally is able
to. Able to name pen and pen-cap. Able to repeat "no ifs, ands,
or buts." Followed 2-step command. Answered questions
appropriately, with some delay, improved.  CN: PERRL, EOM
intact, visual fields intact, facial sensation intact, tongue
protrudes midline. I, VIII, visual acuity not evaluated
specifically. Sensation: intact to touch and temperature in both
upper and lower extremities.  Strength: Increased tone in upper
and lower extremities. Hip flexion [**4-18**], hip extension not
evaluated. Right leg extension [**3-18**]. Left leg extension [**4-18**]. Leg
flexion [**3-18**]. Plantar flexion [**4-18**]. Dorsiflexion [**3-18**]. Upper
extremity strength 4/5. Patient able to sit up from supine to 40
degrees without assistance. Able to prop herself up on her arms.
Able to sit up in chair without props. Finger-to-nose intact.
DTR exam deferred. Unable to walk at present.

Pertinent Results:
Laboratory data at admission
Blood studies:
[**2100-11-4**] 02:00PM BLOOD WBC-4.0 RBC-3.47* Hgb-9.3* Hct-27.9*
MCV-80* MCH-26.8* MCHC-33.3 RDW-15.0 Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD Neuts-65.7 Lymphs-25.9 Monos-7.1 Eos-0.4
Baso-0.9
[**2100-11-4**] 02:00PM BLOOD Plt Ct-207
[**2100-11-4**] 02:00PM BLOOD PT-12.5 PTT-26.6 INR(PT)-1.1
[**2100-11-4**] 02:00PM BLOOD Glucose-131* UreaN-14 Creat-1.1 Na-133
K-4.2 Cl-99 HCO3-25 AnGap-13
[**2100-11-5**] 08:05AM BLOOD ALT-22 AST-31 AlkPhos-76
[**2100-11-5**] 08:05AM BLOOD Albumin-4.0 Calcium-8.4 Phos-3.7 Mg-1.9
[**2100-11-5**] 08:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2100-11-4**] 02:10PM BLOOD Lactate-1.5
Crytococcal antigen - Negative
HIV-1 Viral Load/Ultrasensitive (Final [**2100-11-12**]): 177 copies/ml.


Urine studies:
[**2100-11-4**] 03:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.002
[**2100-11-4**] 03:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG

CSF studies:
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) WBC-18 RBC-16*
Polys-61 Lymphs-28 Monos-0 Eos-1 Atyps-1 Macroph-9
[**2100-11-4**] 07:24PM CEREBROSPINAL FLUID (CSF) TotProt-62*
Glucose-66
CYTOMEGALOVIRUS - Negative
PCR HERPES SIMPLEX VIRUS - Negative
PCR [**Male First Name (un) 2326**] VIRUS (JCV) - Negative
TOXOPLASMA GONDII BY PCR - Negative
VARICELLA DNA (PCR) VDRL - Positive
VDRL - Negative

Laboratory data at discharge:
[**2100-11-23**] 06:36AM BLOOD WBC-5.1 RBC-2.81* Hgb-7.6* Hct-22.4*
MCV-80* MCH-26.9* MCHC-33.7 RDW-16.1* Plt Ct-447*
[**2100-11-20**] 06:50AM BLOOD Neuts-78.9* Lymphs-14.0* Monos-2.3
Eos-4.7* Baso-0.2
[**2100-11-23**] 06:36AM BLOOD Plt Ct-447*
[**2100-11-23**] 06:36AM BLOOD PT-13.2 PTT-33.4 INR(PT)-1.1
[**2100-11-23**] 06:36AM BLOOD Glucose-112* UreaN-6 Creat-0.8 Na-141
K-4.1 Cl-103 HCO3-30 AnGap-12
[**2100-11-23**] 06:36AM BLOOD ALT-36 AST-39 LD(LDH)-342* AlkPhos-100
TotBili-1.3
[**2100-11-22**] 05:01AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0

Other studies (pertinent only):
MRI head (with and without contrast):
Mild brain atrophy and mild medial temporal atrophy and mild
changes of small vessel disease. These findings are unchanged
from previous MRI of [**2100-6-20**]. No enhancing brain lesions are
seen.

MRI spine (with and without contrast):
No abnormal signal is seen within the spinal cord or extrinsic
compression identified, nor there is evidence of abnormal
enhancement. No significant change is seen since [**2100-11-11**].
Degenerative changes.

EMG ([**2100-11-12**]):
Limited study. There is no electrophysiologic evidence for a
generalized polyneuropathy affecting large-diameter nerve
fibers. There is no evidence of ongoing denervation suggestive
of a neurogenic process. Poor muscle activation, likely
secondary to a central nervous system process, prevents accurate
diagnosis or exclusion of a myopathy or radiculopathy.

Portable chest x-ray ([**2100-11-17**]):
Left PICC line shows a normal course and terminates in the right
atrium, withdraw the catheter to 3 cm for standard positioning.
No complications related to the procedure.

EKG ([**2100-11-4**]):
Artifact is present. Sinus rhythm. There is a late transition
with Q waves in the anterior leads consistent with probable
prior anterior myocardial infarction. Low voltage in the
precordial leads. Compared to the previous tracing low voltage
is new.

Brief Hospital Course:
Summary
  Ms. [**Known lastname 100760**] presents with single dermatomal herpes zoster with
concurrent CNS herpes zoster infection, manifesting as a
meningoencephalitis (confirmed by pleocytosis and elevated
protein level in CSF, VZV PCR positive in CSF, and positive VZV
DFA from scrapings of vesicular rashes in the right T3
dermatome), in the context of HIV/AIDS.  Tests for other causes
including seizure, TB, fungi, HSV, HTLV, CMV, JCV, T. pallidum
were negative.  Varicella zoster virus infection was treated
with intravenous acyclovir resulting in the resolution of mental
status changes and a return to baseline over cognitive function
over the two weeks following admission.  She will now need some
intensive physical therapy to restore the function of her legs.
Acyclovir therapy will continue until she follows up with
Neurology, Dr. [**Last Name (STitle) 2340**], on the [**7-1**].  Dr. [**Last Name (STitle) 2340**]
will perform lumbar puncture at that time to repeat CSF VZV PCR.


Chronology
  Ms. [**Known lastname 100760**] was initially admitted to the floor, where she was
initially somnolent but alert and oriented, but became less
responsive over the course of the day. Repeat CSF on the floor
showed 133 with 69% PMNs, protein 114 and glucose 54, concerning
for evolving meningoencephalitis.  Brain MR w/wo contrast was
obtained, per Neurology recommendations, and showed no
abnormalities. The patient was transferred to the [**Hospital Unit Name 153**] for
further care.
  In the [**Hospital Unit Name 153**], antibiotic treatment continued that included
empiric treatment for bacterial or viral meningitis with
acyclovir, ceftriaxone, amoxicillin, and vancomycin. She was
noted to have hyperreflexia and spasticity on exam. Her mental
status improved over the course of her ICU stay.  She was alert,
responsive to voice commands, able to answer simple questions.
Upon becoming more stable she was returned to the floor.

Brief Hospital Course by Problem

Meningoencephalitis and Mental Status Changes
  Given fever, confusion and lumbar puncture findings, viral and
other non-bacterial meningoencephalitides were considered most
likely early in the stay.  Numerous other processes were
excluded as summarized above and these phenomena were attributed
to CNS VZV infection.  This was also considered most likely
given concomitant Shingles.  As can sometimes occur in the
context of HIV, Ms. [**Known lastname 100760**] suffered from a diffuse and
generalized encephalitis as a result of this infection.  This
has been successfully treated with high-dose intravenous
acyclovir.  Mental status appears to have returned to
pre-admission character with some residual lower extremity
weakness (as discussed below).
  Given her gradual deterioration prior to admission, we also
consider it likely that AIDS dementia complex may have been
present, that has possibly partially responded to HAART.

Herpes Zoster rash
 The patient had a vesicular rash over her right breast, classic
in appearance for zoster; her direct antigen test was positive
for VZV and negative for HSV.  Acyclovir was given throughout
the admission.  The rash resolved over about ten days. Analgesia
was given cautiously given her mental status and our concern for
masking fever.  Low doses of opioids were used.

HIV/AIDS
  Ms. [**Known lastname 100760**] was recently diagnosed with HIV/AIDS in [**6-/2100**] when
she presented with PCP pneumonia, most recent CD4 count 253.
She was continued on her antiretroviral therapy consisting of
Norvir, Reyataz and Truvada.  She was continued on Bactrim for
and azithromycin prophylaxis.

Depression with psychotic features
  Given the resolution of her mental status changes, we can now
see that it is unlikely that depression contributed to these
changes.  Nonetheless, psychiatry was consulted while she was an
inpatient.  Abilify was reduced from 20 to 10 mg at night
because of concern that this may have contributed to mental
status changes.

Elevated PTT - excessive response to heparin
  The patient was initially placed on subcutaneous heparin for
DVT prophylaxis. After a couple of days on the subcutaneous
heparin, her PTT was noted to be elevated at 150, and her PT and
INR were also elevated.  Recheck of her coags showed that they
were down-trending, and they had returned to [**Location 213**] levels by
the evening.
The patient was placed on pneumoboots for DVT prophylaxis.  It
appears that she does not have an allergy to heparin, but
responded in excess of expectation.  We advise caution with
further use (lower dose and monitor PTT).

Rash
  She developed an erythematous rash with confluent plaques on
the arms, legs, chest, and back, sparing the mucous membranes,
consistent with a drug reaction. This appeared two weeks after
admission.  Dermatology were consulted and thought the reaction
most consistent with cephalosporins rather than acyclovir.
Given this impression and the importance of acyclovir in
treatment, acyclovir was continued and the rash treated with
fexofenadine, famotidine, and triamcinolone ointment.  The rash
resolved while acyclovir was continued supporting the above
impression.

Lower Extremity Weakness
  Despite improvements in mental status, the patient continued
to have lower extremity weakness of unknown etiology.  An MRI
and EMG were performed to evaluate for cord compression, other
intrathecal process, radiculopathy or polyneuropathy without
identifying a cause.  Her lower extremity weakness is improving
with her mental status, suggesting that this was a result of
encephalitis.  She has developed some degree of contracture in
the lower extremities and intermittently complains of joint
aches.  Physical therapy has worked with her to help improve her
range of motion.

Nutrition
  Feeding has also recovered with the recovery of baseline
mental status.  Feeding had been an issue with poor PO intake.
The patient and her husband have declined replacement of a
Dobbhoff feeding tube, and she required 1:1 assistance with
meals of ground solids.  PO intake continues to improve, and
patient has started to feed herself.

Anemia
  Likely contributions include reduced nutritive intake for part
of the admission, the present illness and HIV.  No source of
blood loss, no evidence of hemolysis.

Joint Pain
  Likely due to osteoarthritis and immobility.

Diabetes Mellitus
  Stable with small doses (two units) of Humalog by sliding
scale on occasion.

Medications on Admission:
Abilify 20 mg, 1 tablet, PO daily
Mirtazapine 15 mg, 1 tablet PO HS
Multivitamin, one capsule PO daily
Norvir 100 mg, one capsule PO daily
Reyataz 150 mg, 2 capsules PO daily
Trimethoprim-Sulfamethoxazole 400 mg- 80 mg, 1 tablet PO daily
Truvada 200 mg- 300 mg, 1 tablet PO daily
Zithromax, 2 tablets PO weekly

Discharge Medications:
1. Acyclovir Sodium 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours).
2. Insulin sliding scale
Humalog 2 units has sometimes been required before lunch or
dinner.
3. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day.

4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Reyataz 300 mg Capsule Sig: One (1) Capsule PO once a day.
7. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
8. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(FR).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for Skin rash: Please continue
while rash is present.  Likely to only be required for another
few days after discharge. .
11. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**]

Discharge Diagnosis:
Primary diagnoses
Varicella zoster virus rash (shingles)
Varicella zoster virus meningoencephalitis.

Secondary diagnoses:
Dementia
Hypertension
HIV
Depression
Diabetes, type II
Drug reaction - rash
Osteoarthritis
Anemia
Drug rash


Discharge Condition:
mental status now at baseline; lower extremity weakness,
improving
Stable, mental status at baseline. Lower extremity weakness
improving.


Discharge Instructions:
You were seen at [**Hospital1 18**] for varicella zoster virus
meningoencephalitis (viral infection with inflammation of the
brain and membranes surrounding it) and shingles (varicella
zoster virus rash). We have been treating you with acyclovir, to
treat this infection, greatly impoving your mental status, lower
body weakness, and rash.

Please continue to take all of your prescribed medications, as
directed. Your medications have changed. Please note new
medications and/or old medications with NEW doses.

ACYCLOVIR- 500 mg IV every 8 hours
LISINOPRIL- 5 mg by mouth at bedtime
ABILIFY- NEW dose- 10 mg by mouth daily

We did not change your HIV medications. Please continue to take
NORVIR 100 mg by mouth daily, REYATAZ 2 capsules by mouth daily,
TRUVADA 200mg-300mg by mouth daily.

Please keep all of your follow-up appointments.

If you get a fever of 100.4, chills, nausea, vomiting, your
symptoms do not improve or if they worsen, please return to the
hospital for evaluation.

Followup Instructions:
Please follow-up with:
Provider: [**Name10 (NameIs) 2341**] [**Name11 (NameIs) **], Neurologist and HIV specialist. Your
appointment is on [**2100-12-1**] at 2:00 PM. MD Phone: ([**Telephone/Fax (1) 100762**]

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:([**Telephone/Fax (1) 6732**]
Date/Time:[**2100-12-3**] 11:30

Provider: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 26**] [**Name8 (MD) 30125**], MD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2100-12-14**] 2:20


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
{'Herpes zoster with meningitis,Human immunodeficiency virus [HIV] disease,Hyposmolality and/or hyponatremia,Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Backache, unspecified,Swelling of limb,Other persistent mental disorders due to conditions classified elsewhere,Muscle weakness (generalized),Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of other lymphatic and hematopoietic neoplasms'}


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: Confusion, rash and fever.

PRESENT ILLNESS: This is a 66 year old woman with recent diagnosis of HIV/AIDS
on HAART, last CD4 count 253 and, depression and mild dementia,
who presented from home with a vesicular rash, confusion and
fevers on the [**4-4**]. She was admitted to medicine.

MEDICAL HISTORY: 1. Diabetes mellitus - diet controlled.
2. History of cutaneous T-cell lymphoma - quiescent after UV
light treatment.
3. Hospitalized at [**Location (un) 511**] [**Hospital **] Hospital in [**2087**] for
psychotic depression.
4. Hospitalized at [**Hospital 1263**] Hospital in [**2098**] for depression (with
psychotic features) - in remission and controlled with
mirtazipine, aripiprazole.
5. Question of mild cognitive impairment prior to HIV diagnosis.
6. HIV - diagnosed after presenting with pneumocystic pneumonia
in [**2100-6-14**].  Last negative test [**2087**].  Possible occupational
exposure (unclear).  CD4 count at diagnosis 60, started on HAART
with good response (see below).

MEDICATION ON ADMISSION: Abilify 20 mg, 1 tablet, PO daily
Mirtazapine 15 mg, 1 tablet PO HS
Multivitamin, one capsule PO daily
Norvir 100 mg, one capsule PO daily
Reyataz 150 mg, 2 capsules PO daily
Trimethoprim-Sulfamethoxazole 400 mg- 80 mg, 1 tablet PO daily
Truvada 200 mg- 300 mg, 1 tablet PO daily
Zithromax, 2 tablets PO weekly

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Initial examination on arrival on the [**Hospital1 **]
Vitals: T: 99.5 BP: 154/85 P: 86 R: 18 O2: 100% on RA
General: Cachectic, somolent but arrousable, oriented x 3, no
acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, able to move neck [**Last Name (un) 96593**] in all directions, JVP not
elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Vessicular rash over right breast extending to the axilla
and slightly to the back.

FAMILY HISTORY: Adult onset DM in both parents. Father with possible depression.
Colon CA in brother who died of it at 67; heart disease in one
brother. [**Name (NI) **] breast cancer.

SOCIAL HISTORY: From [**State 9512**], college in [**State 33977**]. Separated from husband
[**Doctor Last Name **] [**Telephone/Fax (1) 100761**] cell). Has a daughter who lives in
[**State 9512**]. Worked in [**Hospital1 18**] micro lab as medical technician since
[**2066**].  Reports occupational exposures.  No h/o smoking,
excessive alcohol drinking or illicit drug use. 

### Response:
{'Herpes zoster with meningitis,Human immunodeficiency virus [HIV] disease,Hyposmolality and/or hyponatremia,Major depressive affective disorder, recurrent episode, severe, specified as with psychotic behavior,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Dermatitis due to drugs and medicines taken internally,Cephalosporin group causing adverse effects in therapeutic use,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Backache, unspecified,Swelling of limb,Other persistent mental disorders due to conditions classified elsewhere,Muscle weakness (generalized),Anemia, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Personal history of other lymphatic and hematopoietic neoplasms'}
