CHIEF COMPLAINT: Fever and rash.

PRESENT ILLNESS: This is a 54 year old woman with
a history of hepatitis C status post interferon ribavirin
treatment.  Patient had been diagnosed with hepatitis C
screen for her new job as a medical office worker.  It is
believed that she had acquired hepatitis C due to
transfusions in the past.  Patient had been treated with
pegylated interferon 120 mcg per week and ribavirin 1000 mg a
week starting in [**2122-9-24**].  In [**2121-8-24**] patient also
received hepatitis A and B vaccines.  Her initial evaluation
was by Dr. [**Last Name (STitle) 35720**] [**Name (STitle) 15844**] and at that time patient was
upper quadrant pain, no nausea, vomiting, fever, chills or
fatigue, hepatosplenomegaly, jaundice or encephalopathy.
However, her viral load at that time was greater than one
million particles.  ALT was 38.  Hepatitis C was genotyped
1B.  Liver biopsy at that time obtained on [**2122-8-13**], showed mild inflammation grade 2 and moderate hyperosis
also grade 2.  During the course of her treatment patient
developed numbness of her hands and erythema at the injection
sites for interferon which began a week after therapy
started.  She also developed low grade fever.  Her hemoglobin
fell in the first month from 13.7 to 11.3, so patient was
enrolled in the Procrit trial for the past six months.
Patient also developed oral ulcers and brash plus continued
anemia with hemoglobin dropping from 12 to 10 on admission.
Patient developed a rash on the face, arms, chest and back on
and off with associated pruritus which was partially relieved
by [**Doctor First Name **].  Oral lesions were controlled with triamcinolone
ointment.  Patient also reported a fever each time the day
after Procrit treatment.  Patient also became hypothyroid
during her therapy and has been on Synthroid since [**2123-1-22**].  Viral load in [**2122-10-24**] was approximately 29,000.
For two weeks prior to admission on [**2123-7-15**], patient
had worsening rash and worsening fever.  The fever had spiked
approximately four times a day associated with chills and
shakes.  Temperature would peak at approximately 101 to 104.5
degrees Fahrenheit daily.  Also had daily, watery, nonbloody
diarrhea.  Patient took a leave of absence from work as a
church administrator because of the fever the week before
admission.  She had three bouts of post prandial vomiting
which would occur approximately 45 minutes after each meal.
Vomiting was described as nonbloody.  She also reports a 30
pound weight loss since she began ribavirin interferon
treatment.  Patient had been off ribavirin since [**6-23**] and
also off interferon since [**2123-6-26**].  Viral load on
[**2123-6-28**], was undetectable.

MEDICAL HISTORY: Patient had transfusions after each of
her three normal spontaneous vaginal deliveries which were in
[**2092**], [**2094**] and [**2103**].  These transfusions are believed to be
the source of her hepatitis C.  Patient is also HIV negative.
Had tonsillectomy in the past.  Was PPE negative 18 months
ago.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient notes a rash with wool contact.  [**Name (NI) **] known
drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Notable for mother with ovarian cancer and
father with prostate cancer.

SOCIAL HISTORY: She has four children, three of her own, one
adopted.  She is married.  She is a church administrator and
was about to take a new job as a medical office worker.
Denies smoking.  Drinks occasional alcohol.  No IV or other
illicit drug use.  Has two dogs, no cats.  Hobbies include
gardening, but she has not done that for the past two months.
No recent consumption of raw foods.
Other specified hypersensitivity angiitis,Defibrination syndrome,Chronic hepatitis C without mention of hepatic coma,Unspecified acquired hypothyroidism
Hypersensit angiitis NEC,Defibrination syndrome,Chrnc hpt C wo hpat coma,Hypothyroidism NOS
Admission Date:  [**2123-7-16**]     Discharge Date:  [**2123-8-3**]

Date of Birth:   [**2069-4-4**]     Sex:  F

Service:  ETA MED
CHIEF COMPLAINT:  Fever and rash.

HISTORY OF PRESENT ILLNESS:  This is a 54 year old woman with
a history of hepatitis C status post interferon ribavirin
treatment.  Patient had been diagnosed with hepatitis C
screen for her new job as a medical office worker.  It is
believed that she had acquired hepatitis C due to
transfusions in the past.  Patient had been treated with
pegylated interferon 120 mcg per week and ribavirin 1000 mg a
week starting in [**2122-9-24**].  In [**2121-8-24**] patient also
received hepatitis A and B vaccines.  Her initial evaluation
was by Dr. [**Last Name (STitle) 35720**] [**Name (STitle) 15844**] and at that time patient was
upper quadrant pain, no nausea, vomiting, fever, chills or
fatigue, hepatosplenomegaly, jaundice or encephalopathy.
However, her viral load at that time was greater than one
million particles.  ALT was 38.  Hepatitis C was genotyped
1B.  Liver biopsy at that time obtained on [**2122-8-13**], showed mild inflammation grade 2 and moderate hyperosis
also grade 2.  During the course of her treatment patient
developed numbness of her hands and erythema at the injection
sites for interferon which began a week after therapy
started.  She also developed low grade fever.  Her hemoglobin
fell in the first month from 13.7 to 11.3, so patient was
enrolled in the Procrit trial for the past six months.
Patient also developed oral ulcers and brash plus continued
anemia with hemoglobin dropping from 12 to 10 on admission.
Patient developed a rash on the face, arms, chest and back on
and off with associated pruritus which was partially relieved
by [**Doctor First Name **].  Oral lesions were controlled with triamcinolone
ointment.  Patient also reported a fever each time the day
after Procrit treatment.  Patient also became hypothyroid
during her therapy and has been on Synthroid since [**2123-1-22**].  Viral load in [**2122-10-24**] was approximately 29,000.
For two weeks prior to admission on [**2123-7-15**], patient
had worsening rash and worsening fever.  The fever had spiked
approximately four times a day associated with chills and
shakes.  Temperature would peak at approximately 101 to 104.5
degrees Fahrenheit daily.  Also had daily, watery, nonbloody
diarrhea.  Patient took a leave of absence from work as a
church administrator because of the fever the week before
admission.  She had three bouts of post prandial vomiting
which would occur approximately 45 minutes after each meal.
Vomiting was described as nonbloody.  She also reports a 30
pound weight loss since she began ribavirin interferon
treatment.  Patient had been off ribavirin since [**6-23**] and
also off interferon since [**2123-6-26**].  Viral load on
[**2123-6-28**], was undetectable.

PAST MEDICAL HISTORY:  Patient had transfusions after each of
her three normal spontaneous vaginal deliveries which were in
[**2092**], [**2094**] and [**2103**].  These transfusions are believed to be
the source of her hepatitis C.  Patient is also HIV negative.
Had tonsillectomy in the past.  Was PPE negative 18 months
ago.

OUTPATIENT MEDICATIONS:  Include Celexa 20 mg q.d. which was
started eight months ago, Synthroid 75 mcg q.d. started five
months ago, Tylenol, Zantac started eight months ago,
Compazine, triamcinolone, Imodium, weekly Procrit.  Patient
notes that she does not take any herbal medications or
over-the-counter medications.

ALLERGIES:  Patient notes a rash with wool contact.  [**Name (NI) **] known
drug allergies.

SOCIAL HISTORY:  She has four children, three of her own, one
adopted.  She is married.  She is a church administrator and
was about to take a new job as a medical office worker.
Denies smoking.  Drinks occasional alcohol.  No IV or other
illicit drug use.  Has two dogs, no cats.  Hobbies include
gardening, but she has not done that for the past two months.
No recent consumption of raw foods.

FAMILY HISTORY:  Notable for mother with ovarian cancer and
father with prostate cancer.

TRAVEL HISTORY:  Travel history is quite extensive.  Patient
has been to [**Country 35721**] [**Country **] from [**2097**] to [**2099**] when she lived
there with her first husband.  She lived in [**Location 35722**] from [**2099**]
to [**2101**].  She lived in [**Location **] from [**2101**] to [**2103**] and recently
traveled there approximately 12 months ago.  She visited
[**Country 11150**] once 20 years, had been to [**Country 9819**] 20 years ago.  She
was in Zimbawe on a visit eight years ago.  Had been in [**Location (un) 35723**] 13 years ago.  Had been in [**Country 6171**].  Lived in [**State 760**]
recently until about three years ago.  Has visited [**State 108**]
many times.  Been to [**Location (un) 5354**].  Was in [**State 3914**] a month
before admission.  Was in [**Hospital3 **] a week before admission.

PHYSICAL EXAMINATION:  On presentation temperature was 102.5,
blood pressure 118/70, heart rate 100, respiratory rate 20,
breathing 90% in room air.  General appearance: she was a
middle aged woman in no apparent distress, alert and oriented
times three.  Pupils were equally round and reactive to
light.  There was no scleral icterus.  Tympanic membranes
were clear.  No oral ulcers.  No thyromegaly or
lymphadenopathy.  Lungs were bilaterally clear to
auscultation.  Heart had normal S1, S2 and a 1/6 systolic
ejection murmur at the left upper sternal border.  Abdomen
was soft, nontender, normal bowel sounds.  Back had no CVA
tenderness.  Skin was notable for a diffuse maculopapular
rash on the head, face, shoulders and back, on the extensor
surfaces of the arms and legs.  The rash was worse on the
upper back.  There was no rash on the palms or the soles of
the feet.  There were no finger nodules and no nail findings.

LABORATORY DATA:  White blood cells were 25, hemoglobin 10,
hematocrit 31.4, MCV 96, platelets 319.  Differential
included 53% neutrophils, 3% bands, 26% lymphs, 3% monos, 7%
eos, 2% basophils.  PT was 13.7, PTT 28.9, INR 1.3.  Chem-7
notable for BUN of 7, creatinine 0.6, glucose 75.  Urinalysis
was negative for esterase and nitrites and otherwise normal.
ALT was 9, AST 20, LDH 41, alkaline phosphatase 90, total
bilirubin 0.4, albumin 3.4.  Initial two blood cultures sent
were negative.  Other labs were sent including fungal and AFB
cultures which were negative.  RPR was negative.  ASO was
negative.  Cryptococcal antigen negative.  CMV cultures times
three were also negative.  C.diff was negative.

HOSPITAL COURSE:  During [**Hospital 228**] hospital course the source
of her rash and her fevers remained a mystery.  The initial
thought was perhaps a reaction to her antiviral therapy.
Consults were called including hematology/oncology,
infectious disease, dermatology.  Skin biopsy was performed
by dermatology.  AFB stain on the sample was negative.  Gram
stain was also negative for organisms.  Fungal cultures were
also negative.  Pathology of the skin biopsy was positive for
leukocytoclastic vasculitis with dermal lymphoid eosinophilic
infiltrate.  Immunofluorescence detected no IgG, IgA or IgM.
To rule out potential lymphoma patient's peripheral blood was
sent off for flow cytometry.  This was sent off twice and
both times there was no evidence of lymphoma or nonspecific
reactive lymphoid profile.  Bone marrow was also sent twice.
The first time was notable for the presence of
non-necrotizing granuloma occupying about 25% of the bone
marrow.  AFB stain was negative.  Subsequent repeat bone
marrow biopsy was notable for the absence of these
granulomas.  Repeat HCV viral load on [**7-20**] revealed
still undetectable viral load.

Chest x-ray revealed some atelectasis, but no pneumonia or
effusion.  CT abdomen revealed no abscess or fluid
collection.  Some borderline retroperitoneal adenopathy.
Large spleen measuring about 14.5 cm.  CT of the chest was
notable for pulmonary nodule in association with a minor
fissure.  Radiology report indicated it may be a granuloma
versus an intrapulmonary lymph node.  Ultrasound of the upper
quadrants revealed nonspecific gallbladder distension,
minimal pericholecystic fluid, 4.8 cm gallbladder with no
stones or ductal dilatation.

Polyarteritis nodosa was also considered.  MRA of the chest
was done and revealed no evidence of vasculitis, therefore
ruling against PAN.  During patient's hospitalization,
unfortunately, she developed a DIC-like picture.  Patient was
temporarily transferred to the ICU where she received fresh
frozen plasma as well as packed RBCs.  She was then later
transferred back to the floor when her DIC stabilized,
although she did require subsequent transfusions of FFP,
packed red blood cells as well as platelet transfusions.
However, her symptoms did improve on high dose steroids.
While the patient was on the unit she has also been started
on several antifungal and antibacterial and antiparasitic
agents given the unknown etiology of her symptoms.  In
consultation with infectious disease patient was on the
following antibacterial agents including levofloxacin and
metronidazole.  Antifungal agents included orconazole.
Patient was also on ivermectin for antiparasitic coverage.
These agents were gradually discontinued during her
hospitalization after she returned to the floor.

By the time of discharge on [**2123-8-3**], patient's
thrombocytopenia and anemia had stabilized.  Patient no
longer required platelets or FFP transfusions or RBC
transfusions.  Fevers had resolved and also the rash had
resolved.  It should be noted that during the DIC episode the
rash changed in appearance from maculopapular to purpuric in
appearance.  By the time of discharge on [**8-3**], the
rash resolved and assumed a freckle-like appearance.
Neurology had also been consulted after patient had been
transferred from the ICU back to the floor.  Patient had
noted some difficulty writing and the medical team noted that
she had some difficulty with fine motor actions including
touching finger to nose.  Neurology consult noted that
patient had some muscular weakness including difficulty
rising from a chair and unsteady gait.  However, they noted
that the patient had asterixis which suggested to them that
patient's condition was metabolic in nature.  Patient's serum
ammonia level was found to be elevated so patient was put on
a low protein diet.  Lactulose was considered, but given
patient's diarrhea at this time and also loss of electrolytes
through her diarrhea, lactulose was held.

Patient was discharged in stable condition on [**8-3**] on
the following medications.  Th etiology of her illness was felt
to be a sarcoid like reaction to the IFN with systemic
granulomatous reaction.


DISCHARGE MEDICATIONS:
1.  Tums 500 mg t.i.d.
2.  Vitamin D 400 IU daily.
3.  Celexa 20 mg p.o. daily.
4.  Doxycycline 100 mg p.o. times three days.
5.  Folate 2 mg q.d.
6.  Synthroid 75 mcg daily.
7.  Protonix 40 mg daily.
8.  Prednisone 100 mg daily, the dose of which would be
tapered off as directed by Dr. [**Last Name (STitle) 15844**].
9.  Ambien 5 mg q.h.s.

The patient will be followed up in liver clinic with
Dr. [**Last Name (STitle) 15844**] and also followed up with her PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 636**]
[**Last Name (NamePattern1) **], at [**Hospital3 **] Medical Center.






                          [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Last Name (NamePattern1) 6838**]

MEDQUIST36

D:  [**2123-8-21**]  18:23
T:  [**2123-8-27**]  08:05
JOB#:  [**Job Number 35724**]
{'Other specified hypersensitivity angiitis,Defibrination syndrome,Chronic hepatitis C without mention of hepatic coma,Unspecified acquired hypothyroidism'}


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 and rash.

PRESENT ILLNESS: This is a 54 year old woman with
a history of hepatitis C status post interferon ribavirin
treatment.  Patient had been diagnosed with hepatitis C
screen for her new job as a medical office worker.  It is
believed that she had acquired hepatitis C due to
transfusions in the past.  Patient had been treated with
pegylated interferon 120 mcg per week and ribavirin 1000 mg a
week starting in [**2122-9-24**].  In [**2121-8-24**] patient also
received hepatitis A and B vaccines.  Her initial evaluation
was by Dr. [**Last Name (STitle) 35720**] [**Name (STitle) 15844**] and at that time patient was
upper quadrant pain, no nausea, vomiting, fever, chills or
fatigue, hepatosplenomegaly, jaundice or encephalopathy.
However, her viral load at that time was greater than one
million particles.  ALT was 38.  Hepatitis C was genotyped
1B.  Liver biopsy at that time obtained on [**2122-8-13**], showed mild inflammation grade 2 and moderate hyperosis
also grade 2.  During the course of her treatment patient
developed numbness of her hands and erythema at the injection
sites for interferon which began a week after therapy
started.  She also developed low grade fever.  Her hemoglobin
fell in the first month from 13.7 to 11.3, so patient was
enrolled in the Procrit trial for the past six months.
Patient also developed oral ulcers and brash plus continued
anemia with hemoglobin dropping from 12 to 10 on admission.
Patient developed a rash on the face, arms, chest and back on
and off with associated pruritus which was partially relieved
by [**Doctor First Name **].  Oral lesions were controlled with triamcinolone
ointment.  Patient also reported a fever each time the day
after Procrit treatment.  Patient also became hypothyroid
during her therapy and has been on Synthroid since [**2123-1-22**].  Viral load in [**2122-10-24**] was approximately 29,000.
For two weeks prior to admission on [**2123-7-15**], patient
had worsening rash and worsening fever.  The fever had spiked
approximately four times a day associated with chills and
shakes.  Temperature would peak at approximately 101 to 104.5
degrees Fahrenheit daily.  Also had daily, watery, nonbloody
diarrhea.  Patient took a leave of absence from work as a
church administrator because of the fever the week before
admission.  She had three bouts of post prandial vomiting
which would occur approximately 45 minutes after each meal.
Vomiting was described as nonbloody.  She also reports a 30
pound weight loss since she began ribavirin interferon
treatment.  Patient had been off ribavirin since [**6-23**] and
also off interferon since [**2123-6-26**].  Viral load on
[**2123-6-28**], was undetectable.

MEDICAL HISTORY: Patient had transfusions after each of
her three normal spontaneous vaginal deliveries which were in
[**2092**], [**2094**] and [**2103**].  These transfusions are believed to be
the source of her hepatitis C.  Patient is also HIV negative.
Had tonsillectomy in the past.  Was PPE negative 18 months
ago.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient notes a rash with wool contact.  [**Name (NI) **] known
drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Notable for mother with ovarian cancer and
father with prostate cancer.

SOCIAL HISTORY: She has four children, three of her own, one
adopted.  She is married.  She is a church administrator and
was about to take a new job as a medical office worker.
Denies smoking.  Drinks occasional alcohol.  No IV or other
illicit drug use.  Has two dogs, no cats.  Hobbies include
gardening, but she has not done that for the past two months.
No recent consumption of raw foods. 

### Response:
{'Other specified hypersensitivity angiitis,Defibrination syndrome,Chronic hepatitis C without mention of hepatic coma,Unspecified acquired hypothyroidism'}
