CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: 50 yo male with history of HIV ([**2-26**] - CD4 908, VL < 50 copies)
and previous episode of PCP was admitted with 2-3 days of
fevers, myalgias, and malaise.
.
Patient reports that 2-3 days ago, he developed sudden onset of
increased fatigue, malaise, and muscle aches in his legs
bilaterally. Additional ROS was notable for the following:
- vomiting after trying to drink water
- decreased PO intake
- sick contacts including multiple co-workers sick with fatigue,
fevers, and cough
- loose stools - 2 loose, watery stools per day
- fevers and chills to 104 at home
- bitemporal headache pain which is now slightly improved
- reported abdominal pain in the ED but denies upon arrival to
the floor
.
He otherwise denies productive cough, facial pain, postnasal
drip, nasal congestion, sore throat, abdominal pain, dysuria,
hematuria, melena, or shortness of breath at home. Denies any
recent travel or antibiotic use. Did not receive the flu shot.
Patient has only tried tylenol at home for relief.
.
Upon arrival to the ED, temp 100.6, HR 118 (98-130), BP 144/78
(119-144/59-79), RR 36, and O2 sat 93% on 4L. While in the ED,
his temperature peaked to 101.3, O2 requirement increased to 97%
on 100% NRB. CXR was notable for a right lower lobe infiltrate.
RUQ US and Head CT were unremarkable. He received motrin 800mg x
1, zosyn 4.5g x 1, levofloxacin 750mg x 1, combivent, and
tylenol 1g x 1. He received 3-4L NS in the ED.

MEDICAL HISTORY: 1. HIV/AIDS
2. h/o PCP [**Name Initial (PRE) 1064**]

MEDICATION ON ADMISSION: 1. Ritonavir 100mg PO daily
2. Atazanavir 300mg PO daily
3. Combir 150-300mg Tab [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.9 / HR 132 / BP 182/95 / RR 42 / 91% on NRB
Gen: resting in bed, uncomfortable appearing but no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: tachycardic but No murmurs, rubs or gallops
LUNGS: scattered wheezes throughout with crackles at LLB
ABD: obese, decreased BS, soft, NT, ND, no rebound
EXT: No edema. 2+ DP pulses BL. Onychomycoses on all toenails
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: N/C

SOCIAL HISTORY: Home: lives with mother in [**Location 1268**]
Occupation: Machinist
EtOH: Denies
Drugs: Denies
Tobacco: 25 PPY history
Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other specified septicemias,Septic shock,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Severe sepsis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Hyposmolality and/or hyponatremia,Pneumonia due to Legionnaires' disease,Other encephalopathy,Diarrhea,Chronic airway obstruction, not elsewhere classified,Other specified anemias,Encounter for palliative care
Human immuno virus dis,Acute respiratry failure,Septicemia NEC,Septic shock,Defibrination syndrome,Ac kidny fail, tubr necr,Acute pancreatitis,Severe sepsis,Ac DVT/embl low ext NOS,Hyposmolality,Legionnaires' disease,Encephalopathy NEC,Diarrhea,Chr airway obstruct NEC,Anemia NEC,Encountr palliative care
Admission Date:  [**2106-4-23**]              Discharge Date:   [**2106-5-24**]

Date of Birth:  [**2056-1-20**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
RIJ triple-lumen placement
Intubation
Arterial line placement

History of Present Illness:
50 yo male with history of HIV ([**2-26**] - CD4 908, VL < 50 copies)
and previous episode of PCP was admitted with 2-3 days of
fevers, myalgias, and malaise.
.
Patient reports that 2-3 days ago, he developed sudden onset of
increased fatigue, malaise, and muscle aches in his legs
bilaterally. Additional ROS was notable for the following:
- vomiting after trying to drink water
- decreased PO intake
- sick contacts including multiple co-workers sick with fatigue,
fevers, and cough
- loose stools - 2 loose, watery stools per day
- fevers and chills to 104 at home
- bitemporal headache pain which is now slightly improved
- reported abdominal pain in the ED but denies upon arrival to
the floor
.
He otherwise denies productive cough, facial pain, postnasal
drip, nasal congestion, sore throat, abdominal pain, dysuria,
hematuria, melena, or shortness of breath at home. Denies any
recent travel or antibiotic use. Did not receive the flu shot.
Patient has only tried tylenol at home for relief.
.
Upon arrival to the ED, temp 100.6, HR 118 (98-130), BP 144/78
(119-144/59-79), RR 36, and O2 sat 93% on 4L. While in the ED,
his temperature peaked to 101.3, O2 requirement increased to 97%
on 100% NRB. CXR was notable for a right lower lobe infiltrate.
RUQ US and Head CT were unremarkable. He received motrin 800mg x
1, zosyn 4.5g x 1, levofloxacin 750mg x 1, combivent, and
tylenol 1g x 1. He received 3-4L NS in the ED.


Past Medical History:
1. HIV/AIDS
2. h/o PCP [**Name Initial (PRE) 1064**]

Social History:
Home: lives with mother in [**Location 1268**]
Occupation: Machinist
EtOH: Denies
Drugs: Denies
Tobacco: 25 PPY history

Family History:
N/C

Physical Exam:
T 98.9 / HR 132 / BP 182/95 / RR 42 / 91% on NRB
Gen: resting in bed, uncomfortable appearing but no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: tachycardic but No murmurs, rubs or gallops
LUNGS: scattered wheezes throughout with crackles at LLB
ABD: obese, decreased BS, soft, NT, ND, no rebound
EXT: No edema. 2+ DP pulses BL. Onychomycoses on all toenails
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

Pertinent Results:
Admission labs:
Na 129 / K 3.5 / Cl 93 / CO2 20 / BUN 18 / Cr 1 / BG 128
Ca 9 / Mg 1.6 / Phos 1.4
ALT 34 / AST 62 / Alk Phos 55 / TB .5 / Amylase 15 / Lipase 19
LDH 320
WBC 17.5 / Hct 42.9 / Plt 212
N 91 / Bands 4 / L 5 / M 0 / E 0 / B0
INR 1.2
Lactate 1.7
UA large blood, neg nit, neg prot, neg glu, neg ket, 0 RBCs, [**3-24**]
WBCs, occasional bacteria, no yeast, 0-2 epis
.
[**2106-4-24**]
pH 7.39 / PCO2 32 / PO2 61
.
Baseline Hct 42-45
.
MICROBIOLOGY:
Urine legionella antigen presumptively positive
Blood cultures from [**5-15**] grew coagulase negative staphylococcus
Otherwise, several blood, urine, BAL, CSF and sputum cultures
were negative
CSF showed 2+ PMNs
.
ADMISSION STUDIES:
- ECG [**2106-4-23**] - Sinus tachycardia
- Portable CXR - [**2106-4-23**] -  New right hilar opacity and vague
opacity in the left lung which likely represent pneumonia.
Dedicated PA and lateral films may be helpful Suggest followup
to resolution.
- RUQ US - [**2106-4-23**] - No evidence of cholelithiasis, gallbladder
wall thickening, or edema.
- CT Head w/o contrast - [**2106-4-23**] - No acute hemorrhage or mass
effect.
.
CSF:
Cytology: negative
Protein 46/ Glucose 74/ 100 WBC's/ 213,500 RBC's/ with 92% polys
.
MRI [**5-17**]
FINDINGS: There is marked FLAIR hyperintensity within the
bilateral posterior parietal and occipital subcortical white
matter and milder FLAIR abnormality within the bilateral
cerebellar hemispheres, suggestive of posterior reversible
encephalopathy syndrome (PRES). No diffusion abnormality is seen
in these areas, also consistent with PRES. Tiny scattered
punctate areas of restricted diffusion are seen within the left
frontal and right parietal lobes, suggesting tiny embolic
infarcts. There is no evidence of hemorrhage or mass effect. The
ventricles are normal in size and configuration. Fluid is seen
in the mastoid air cells and nasopharynx, likely related to
prolonged intubation. On post-contrast images, there is a small
amount of enhancement within the right occipital cortex, also
likely related to PRES and breakdown of the blood -brain
barrier.
MRA OF THE HEAD AND NECK: The MRA is normal, with normal caliber
of the
carotid and vertebral arteries and their intracranial branches.
No evidence of stenosis or aneurysm.
IMPRESSION:
1. Marked edema within the posterior parietal, occipital, and
cerebellar
hemispheres without diffusion abnormality, suggestive of PRES
(posterior
reversible encephalopathy syndrome).
3. Small punctate foci of restricted diffusion within the left
frontal and
right parietal lobes, likely small embolic infarcts.
.
CT HEAD [**2106-5-20**]
Dramatically progressed subcortical hypodensities in bilateral
cerebral hemispheres with early left uncal herniation. The
differential in the context of HIV is broad and includes
vascular etiologies (posterior reversible encephalopathy
syndrome), infectious etiologies, PML, metabolic
encephalopathy, and less likely HIV encephalopathy.


Brief Hospital Course:
Hospital course by problem:
.
Respiratory failure: Legionella positive (matching clinical sx
of (1) diarrhea, (2) hyponatremia, (3) office coworkers ill en
masse).  Underlying contribution from COPD; question of PCP
given no outpatient ppx.  The patient was intubated shortly
after admission for hypoxia/respiratory failure.  He was
ventilated per ARDSnet protocol, though very difficult to
oxygenate.  He initially required proning to improve
oxygenation.  He continued to have difficulty with ventilation
eventually requiring paralysis with cisatracurium, and a
pentobarbital induced coma.  He was eventually taken off the
proning bed, and eventually was weaned off paralysis and was
maintained on pressure control.  He was switched to assist
control, and eventually as his oxygenation improved, he was
switched to pressure support.  He had a tracheostomy placed on
[**2106-5-14**] as well as a PEG tube.  He continued to improve from a
respiratory standpoint.  During his course, he was noted to have
a pleural effusion, which was difficult to perform a
thoracentesis because of his positioning and difficulty with
dysynchronus breathing.  He developed a pneumothorax which
required chest tube placement by thoracic surgery.  He was
eventually weaned off of respiratory support fully and his chest
tube was removed.
.
Sepsis:  Source likely legionella.  He was initially started on
vancomycin, levofloxacin, cefepime, and oseltamivir which was
stopped once when the influenza test was negative.  He was
maintained on the levofloxacin, cefepime, and vancomycin and
because of his poor respiratory status, azithromycin was added
for double coverage of legionella.  He continued to spike very
high temperatures (>103) despite antibiotics and despite
negative cultures.  Eventually, it was thought that he was
having a drug fever, so all of his antibiotics were stopped, but
he did complete a 14 day course of levofloxacin.  Despite being
off antibiotics, he continued to spike fevers.  His cultures
(sputum, blood, stool, urine) all remained negative.  He had
viral studies sent which were also negative.  He was never
hypotensive requiring pressors, though at one point during his
hospitalization, he was transiently hypotensive with MAPs in the
50s-60s which responded to IVFs.  He developed acute kidney
injury secondary to his sepsis, and he also developed DIC.  He
was given a 96 hr course of activated protein C when he
developed these multiple organ failures.  During the workup of
his ongoing temperatures, he was found to have a DVT in his
right leg, for which he had an IVC filter placed given his very
tenuous respiratory status and the inability to anticoagulate
while on activated protein C and in DIC. He was also noted to
have pancreatitis based on lab tests, but on CT abdomen, there
was no evidence of pancreatitis or hemorrhage.
.
Acute Kidney Injury: The patient developed acute kidney injury
likely in the setting of sepsis and hypovolemia.  He was given
IVFs with improvement in his renal function.  He then had to
undergo CT Torso with contrast to evaluate for source of fever,
which once again increased his creatinine.  Then, it slowly
began to trend towards baseline.  He did not require
hemodialysis.
Increasing Cr: Likely [**2-20**] dehydration.
.
DIC:  During the early part of his hospitalization, the patient
developed discoloration of his fingers and toes.  During the
workup, he was found to have DIC with elevated FDP, decreased
fibrinogen, and decreased platelets.  He never required blood
products for these derangements.  His digital cyanosis
continued, and vascular surgery was consulted who felt that he
would eventually need amputation of his digits, but that it did
not need to be done acutely.  He was treated with 96 hour of
APC, and his DIC labs improved.
.
Anemia: The patient's HCT was stable during most of his
hospitalization, but did begin to decline and at one point, was
<21 requriring 1 unit of pRBCs.  His HCT then continued to trend
upwards.  It was thought that this was likely secondary to his
acute illness, and phlebotomizing.  His B12/Folate were WNL.
His ferritin was elevated, but iron and TIBC were low, likely
from his acute illness.  He was started on PO iron
supplementation via his PEG tube.
.
HIV: Patient has a history of HIV and h/o PCP [**Name Initial (PRE) 1064**].  He was
adequately controlled on [**Name Initial (PRE) 2775**] therapy.  It was held during the
acute period, but after speaking with his HIV physician, [**Name10 (NameIs) **]
[**Name11 (NameIs) 2775**] therapy was restarted once he had a PEG tube placed.
.
Mental status: Since [**5-16**] mental status not back at baseline,
[**5-19**] patient nodding appropriately and would wiggle toes to
command. MRI brain showing ring enhancing lesions right
occipital [**Last Name (un) 14097**], suggestive PRES. LP performed [**5-19**] and sent
for flow cytometry, HIV VL, and various viral cultures/PCR.  LP
was largely unrevealing, except for a leftward shift.  He was
started on empiric antibiotics for this.  CT showed early uncal
herniation.  The decision was made by the family to make the
patient CMO

Medications on Admission:
1. Ritonavir 100mg PO daily
2. Atazanavir 300mg PO daily
3. Combir 150-300mg Tab [**Hospital1 **]

Discharge Medications:
1. Morphine Concentrate 10 mg/0.5 mL Solution Sig: 1.5-3.0 ml PO
Q2H as needed for pain: =30-60mg for breakthrough pain. .
Disp:*60 mL* Refills:*0*
2. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H
(every 6 hours) as needed for pain.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours): for pain.
Disp:*10 Patch 72 hr(s)* Refills:*2*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*12 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Old [**Hospital **] Hospice

Discharge Diagnosis:
Legionella pneumonia
Acute respiratory failure
Septic shock
Diseminated intravascular coagulopathy
PRES resulting in uncal herniation


Discharge Condition:
Comfortable on a fentanyl patch


Discharge Instructions:
Patient was admitted to the ICU for acute respiratory distress.
On admission he was intubated for airway support.  It was found
that he had a legionella pneumonia which was treated with
approrpiate antibiotics.  Patient's course was complicated by
sepsis, DIC, severe digital ischemia leading to necrosis of
fingers and toes, and PRES syndrome, unfortunately resulting in
uncal herniation.  He was made CMO and discharged home with
hospice.

Followup Instructions:
NA
{"Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other specified septicemias,Septic shock,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Severe sepsis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Hyposmolality and/or hyponatremia,Pneumonia due to Legionnaires' disease,Other encephalopathy,Diarrhea,Chronic airway obstruction, not elsewhere classified,Other specified anemias,Encounter for palliative care"}


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: Hypoxia

PRESENT ILLNESS: 50 yo male with history of HIV ([**2-26**] - CD4 908, VL < 50 copies)
and previous episode of PCP was admitted with 2-3 days of
fevers, myalgias, and malaise.
.
Patient reports that 2-3 days ago, he developed sudden onset of
increased fatigue, malaise, and muscle aches in his legs
bilaterally. Additional ROS was notable for the following:
- vomiting after trying to drink water
- decreased PO intake
- sick contacts including multiple co-workers sick with fatigue,
fevers, and cough
- loose stools - 2 loose, watery stools per day
- fevers and chills to 104 at home
- bitemporal headache pain which is now slightly improved
- reported abdominal pain in the ED but denies upon arrival to
the floor
.
He otherwise denies productive cough, facial pain, postnasal
drip, nasal congestion, sore throat, abdominal pain, dysuria,
hematuria, melena, or shortness of breath at home. Denies any
recent travel or antibiotic use. Did not receive the flu shot.
Patient has only tried tylenol at home for relief.
.
Upon arrival to the ED, temp 100.6, HR 118 (98-130), BP 144/78
(119-144/59-79), RR 36, and O2 sat 93% on 4L. While in the ED,
his temperature peaked to 101.3, O2 requirement increased to 97%
on 100% NRB. CXR was notable for a right lower lobe infiltrate.
RUQ US and Head CT were unremarkable. He received motrin 800mg x
1, zosyn 4.5g x 1, levofloxacin 750mg x 1, combivent, and
tylenol 1g x 1. He received 3-4L NS in the ED.

MEDICAL HISTORY: 1. HIV/AIDS
2. h/o PCP [**Name Initial (PRE) 1064**]

MEDICATION ON ADMISSION: 1. Ritonavir 100mg PO daily
2. Atazanavir 300mg PO daily
3. Combir 150-300mg Tab [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 98.9 / HR 132 / BP 182/95 / RR 42 / 91% on NRB
Gen: resting in bed, uncomfortable appearing but no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: tachycardic but No murmurs, rubs or gallops
LUNGS: scattered wheezes throughout with crackles at LLB
ABD: obese, decreased BS, soft, NT, ND, no rebound
EXT: No edema. 2+ DP pulses BL. Onychomycoses on all toenails
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: N/C

SOCIAL HISTORY: Home: lives with mother in [**Location 1268**]
Occupation: Machinist
EtOH: Denies
Drugs: Denies
Tobacco: 25 PPY history 

### Response:
{"Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other specified septicemias,Septic shock,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Acute pancreatitis,Severe sepsis,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Hyposmolality and/or hyponatremia,Pneumonia due to Legionnaires' disease,Other encephalopathy,Diarrhea,Chronic airway obstruction, not elsewhere classified,Other specified anemias,Encounter for palliative care"}
