CHIEF COMPLAINT: bone biopsy concerning for histoplasmosis

PRESENT ILLNESS: The patient is a 73-year-old African-American female with
history of sarcoidosis (suggestive of liver involvement but no
granulomas seen), cryptogenic cirrhosis complicated by portal
hypertension and ascites. Noted onset of left-sided rib pain [**2-6**]
months ago and subsequent imaging revealed a pathologic fracture
of the left anterolateral fifth rib. Associated with a mass seen
on CT and underwent a CT-guided bone biopsy with results
suggesive of histoplasmosis.
.
Currently, patient feels fine but has felt better. Has had
increased abdominal distention and leg swelling over the past
two weeks. Related to the abdominal distention is a shooting
pain along the lower right abdomen, a pain she often gets when
she has a lot of fluid on. Notes that she has had decreased
energy for the past two weeks. Has poor appetite as well though
that is more chronic. Notes chills but no fevers or night
sweats. Denies any headache, vision changes, pain or trouble
swallowing, chest pain, cough, shortness of breath, diarrhea,
nausea, vomiting.
.
Of note, patient was discharged on [**7-6**] after hypokalemia to 2.4
in setting of lasix.
.
ROS: per HPI, also denies BRBPR, melena, dysuria. Endorses
dyspnea on exertion and inability to take deep breath when
abdomen is distended

MEDICAL HISTORY: -Type 2 Diabetes, diet controlled
-HTN
-Cryptogenic cirrhosis (complicated by ascites and coagulopathy)
-s/p hysterectomy for fibroids

MEDICATION ON ADMISSION: 1. Amiloride HCl 10 mg PO DAILY
2. Estrogens Conjugated 0.625 mg PO DAILY
3. Calcium Carbonate 600 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
5. Senna 2 TAB PO DAILY
hold for loose stools
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
7. Boost *NF* (food supplement, lactose-free) 1 unit Oral daily

ALLERGIES: Spironolactone / Oxycodone

PHYSICAL EXAM: ADMISSION exam
VS: 97.8 127/64 70 18 100%RA
GENERAL: Well appearing in NAD. Thin, cachectic appearing,
pleasant
HEENT: Anicteric sclera, MMM, whitish film over tongue, no
lesions
CARDIAC: RRR with 2/6 systolic murmur over LUSB, no JVD
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, tender to palpation only over
suprapubic/RLQ. No guarding or rebound. Dullness to percussion
over dependent areas but tympanic anteriorly. No appreciable HSM

FAMILY HISTORY: -Paternal aunts with cancers of some sort, unclear what kind.
-Mom, [**Name (NI) **] and Sister all with Diabetes

SOCIAL HISTORY: -Tobacco history: Distant as a teenager, none currently
-ETOH: distant, only occasional
-Illicit drugs: None
-Home: 2 fam house; She lives in 1 unit and grand-daughter in
other. Worked as a tutor for 34 years. Divorced and has one
daughter who works as a pharmacist in [**Doctor First Name 5256**]
-Grew up in [**State 108**] and [**Doctor First Name 26692**] then moved to [**Location (un) 86**].
Father was in the military. Never been to [**State 5111**] river
valley
Cryptococcosis,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Other ascites,Unspecified intestinal obstruction,Acquired coagulation factor deficiency,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia of other chronic disease
Cryptococcosis,Hepatic encephalopathy,Ac kidny fail, tubr necr,Acute lung edema NOS,Ascites NEC,Intestinal obstruct NOS,Acq coagul factor defic,Cirrhosis of liver NOS,Sarcoidosis,DMII wo cmp nt st uncntr,Hypertension NOS,Anemia-other chronic dis
Admission Date:  [**2130-7-20**]              Discharge Date:   [**2130-8-7**]

Date of Birth:  [**2057-6-24**]             Sex:   F

Service: MEDICINE

Allergies:
Spironolactone / Oxycodone

Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
bone biopsy concerning for histoplasmosis

Major Surgical or Invasive Procedure:
Paracentesis
Flexible Sigmoidoscopy
NG tube

History of Present Illness:
The patient is a 73-year-old African-American female with
history of sarcoidosis (suggestive of liver involvement but no
granulomas seen), cryptogenic cirrhosis complicated by portal
hypertension and ascites. Noted onset of left-sided rib pain [**2-6**]
months ago and subsequent imaging revealed a pathologic fracture
of the left anterolateral fifth rib. Associated with a mass seen
on CT and underwent a CT-guided bone biopsy with results
suggesive of histoplasmosis.
.
Currently, patient feels fine but has felt better. Has had
increased abdominal distention and leg swelling over the past
two weeks. Related to the abdominal distention is a shooting
pain along the lower right abdomen, a pain she often gets when
she has a lot of fluid on. Notes that she has had decreased
energy for the past two weeks. Has poor appetite as well though
that is more chronic. Notes chills but no fevers or night
sweats. Denies any headache, vision changes, pain or trouble
swallowing, chest pain, cough, shortness of breath, diarrhea,
nausea, vomiting.
.
Of note, patient was discharged on [**7-6**] after hypokalemia to 2.4
in setting of lasix.
.
ROS: per HPI, also denies BRBPR, melena, dysuria. Endorses
dyspnea on exertion and inability to take deep breath when
abdomen is distended


Past Medical History:
-Type 2 Diabetes, diet controlled
-HTN
-Cryptogenic cirrhosis (complicated by ascites and coagulopathy)
-s/p hysterectomy for fibroids


Social History:
-Tobacco history: Distant as a teenager, none currently
-ETOH: distant, only occasional
-Illicit drugs: None
-Home: 2 fam house; She lives in 1 unit and grand-daughter in
other. Worked as a tutor for 34 years. Divorced and has one
daughter who works as a pharmacist in [**Doctor First Name 5256**]
-Grew up in [**State 108**] and [**Doctor First Name 26692**] then moved to [**Location (un) 86**].
Father was in the military. Never been to [**State 5111**] river
valley


Family History:
-Paternal aunts with cancers of some sort, unclear what kind.
-Mom, [**Name (NI) **] and Sister all with Diabetes


Physical Exam:
ADMISSION exam
VS: 97.8 127/64 70 18 100%RA
GENERAL: Well appearing in NAD. Thin, cachectic appearing,
pleasant
HEENT: Anicteric sclera, MMM, whitish film over tongue, no
lesions
CARDIAC: RRR with 2/6 systolic murmur over LUSB, no JVD
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, tender to palpation only over
suprapubic/RLQ. No guarding or rebound. Dullness to percussion
over dependent areas but tympanic anteriorly. No appreciable HSM

EXTREMITIES: 1+ edema to thighs b/l.  Warm and well perfused, no
clubbing or cyanosis.
NEUROLOGY: No asterixis, AOx3, CNs intact, 5/5 strength
throughout, gait normal, intact FTN b/l
SKIN: no lesions noted
LYMPH: no axillary, supraclavicular, cervical, or inguinal LAD

Discharge exam
97.9 99/50 59 18 100%ra
GENERAL: elderly AA female in NAD
HEENT: Anicteric sclera, moist membranes. Small cut on tip of
nose
CARDIAC: S1, S2 reg rhythm, 2/6 systolic murmur at LUSB and at
apex radiating to axilla.
LUNGS: CTA b/l with no wheezing, rales, or rhonchi
ABDOMEN: Distended and tenser than yesterday, mildly tender. No
rebound/guarding.
EXTREMITIES: trace b/l LE edema to thighs. Warm and well
perfused.
NEUROLOGY: no asterixis, CN2-12 intact. Gait steady. A+Ox3


Pertinent Results:
ADMISSION labs
[**2130-7-20**] 09:10PM BLOOD WBC-3.4* RBC-3.54* Hgb-9.8* Hct-32.0*
MCV-91 MCH-27.8 MCHC-30.7* RDW-17.1* Plt Ct-62*
[**2130-7-25**] 05:21AM BLOOD Neuts-91.0* Lymphs-4.4* Monos-4.1 Eos-0.1
Baso-0.4
[**2130-7-20**] 09:10PM BLOOD PT-18.2* PTT-37.0* INR(PT)-1.7*
[**2130-7-20**] 09:10PM BLOOD Glucose-118* UreaN-11 Creat-1.0 Na-135
K-4.2 Cl-105 HCO3-26 AnGap-8
[**2130-7-20**] 09:10PM BLOOD ALT-18 AST-41* LD(LDH)-274* AlkPhos-93
TotBili-1.2
[**2130-7-20**] 09:10PM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.1 Mg-1.9
[**2130-7-25**] 11:35PM BLOOD Lactate-2.3*
.
MICU labs
[**2130-7-28**] 02:05AM BLOOD WBC-8.8 RBC-3.62* Hgb-10.7* Hct-32.0*
MCV-89 MCH-29.7 MCHC-33.6 RDW-17.4* Plt Ct-38*
[**2130-7-28**] 02:05AM BLOOD Plt Ct-38*
[**2130-7-28**] 02:05AM BLOOD Glucose-86 UreaN-46* Creat-3.7* Na-135
K-3.9 Cl-100 HCO3-20* AnGap-19
[**2130-7-28**] 02:05AM BLOOD ALT-15 AST-26 LD(LDH)-210 AlkPhos-46
TotBili-3.1*
[**2130-7-28**] 02:05AM BLOOD Calcium-7.7* Phos-5.2* Mg-2.1
Histoplasma Ag - negative
Histoplasma Ab - negative
Blood mycolytic cultures - negative
rpt Histoplasma Ag - pending
rpt bld cx - pending
.
Discharge labs
[**2130-8-7**] 05:55AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.5* Hct-28.9*
MCV-92 MCH-29.9 MCHC-32.7 RDW-19.7* Plt Ct-111*
[**2130-8-7**] 05:55AM BLOOD PT-22.8* PTT-61.0* INR(PT)-2.2*
[**2130-8-7**] 05:55AM BLOOD Glucose-151* UreaN-47* Creat-2.0* Na-141
K-3.8 Cl-107 HCO3-26 AnGap-12
[**2130-8-7**] 05:55AM BLOOD ALT-16 AST-35 AlkPhos-83 TotBili-2.0*
[**2130-8-7**] 05:55AM BLOOD TotProt-5.7* Calcium-8.9 Phos-3.6 Mg-1.8
.
Imaging:
Head CT [**8-4**]: Mildly rotated position of the head is noted.
There is no evidence of acute intracranial hemorrhage, discrete
masses, mass effect, or shift of normally midline structures.
The ventricles and sulci are mildly prominent, consistent with
age-related involutional changes.  Periventricular and
subcortical low-attenuating white matter lesions appear
consistent with sequelae of chronic small vessel ischemic
disease.  There is no evidence of acute major vascular territory
infarction.  Bilateral mastoid air cells and visualized
paranasal sinuses are clear.

KUB [**8-4**]:  Radiographs are limited due to motion and patient
positioning.  Given these limitations, there is a
non-obstructive bowel gas pattern with no dilated loops of small
bowel visualized and air within the colon.  There is no large
amount of free air.  Osseous structures are grossly
unremarkable. IMPRESSION:  Non-obstructive bowel gas pattern.

CXR [**7-28**]: Moderate cardiomegaly, severe pulmonary edema, and
small bilateral effusions, larger on the left side, are
unchanged.  There is no pneumothorax. Left PICC tip is in the
upper SVC.  NG tube tip is in the stomach. Lesion in the lateral
aspect of the left fifth rib is better seen in prior CT from
[**5-3**].
.
KUB [**7-27**]: Dilated loops of small bowel and air within the colon,
most
consistent with partial small-bowel obstruction.  NG tube in the
stomach.
.
ECHO [**7-27**]: The left atrium is mildly dilated. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Tissue Doppler imaging suggests
a normal left ventricular filling pressure (PCWP<12mmHg). The
right ventricular cavity is dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**2-6**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Normal left ventricular cavity size and wall
thickness with preserved global and regional biventricular
systolic function. Dilated right ventricle. Mild to moderate
mitral regurgitation. Moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hyeprtension.

EKG [**7-26**]: Sinus rhythm. Left axis deviation. Left anterior
fascicular block. Non-specific repolarization abnormalities.
Compared to the previous tracing of [**2130-7-5**] there is no
diagnostic change.

Abd CT [**7-25**]: 1.  Multiple dilated loops of small bowel with
collapsed terminal ileum are compatible with a small bowel
obstruction.  Probable transition point is seen in the left
lower quadrant.  There is no free air to suggest perforation.
2.  Large volume ascites, cirrhosis, and splenomegaly.
3.  Trace bilateral pleural effusions.



Brief Hospital Course:
73F with cryptogenic cirrhosis c/b recurrent ascites p/w rib
lesion suggestive of histoplasmosis admitted for treatment and
evaluation, now with abdominal pain and distention concerning
for SBO, altered mental status, acute kidney injury, transferred
to MICU for closer monitoring, improved and now discharged to
rehab.
.
#[**Last Name (un) **]: Patient had rising BUN, Cr since admission, baseline 1.0,
up to 3.7 this admission. Multifactorial: likely [**3-9**] pre-renal
(FeNa and FeUrea both low when transferred to MICU) from
underresuscitation of SBO/third spacing, two paracentesis, and
treatment with ambisome. Prior to transfer to MICU, patient
became oliguric and was given an albumin challenge with no
immediate results. Diuretics were held and ambisome was
discontinued. Patient was given about 2L crystalloid as well as
about 125g albumin total. Her Hct was also found to be low, and
she was given 2 units of blood. Since early [**7-28**] am, patient has
been making more urine, and it would appear that some of her
kidney damage is reversible, from ATN, and the decision was made
to hold off dialysis and trend lytes, kidney function, urine
lytes. Over the next few days her creatinine trended down and it
was determined there would be no need for dialysis.  Octreotide
was stopped as HRS seemed less likely. Cr 2.0 on discharge. She
will get weekly labs per below, including lytes and Cr/BUN.
.
#SBO: patient states that she has been having abdominal pain for
the past week, worst [**Date range (1) 34558**], and appeared very sick. Lactate
was 2.3. KUB and CT confirmed SBO, at ileo-cecal jxn, no free
air. Patient a couple of days prior had a flex sig to assess for
granulomatous lesions previously seen, although it is unlikely
that this could have caused any sort of obstructive process. She
also has a hx of TAH many years ago and adhesions may be the
cause. No h/o SBO.
-NGT was placed, serial abd exams showed large distended abd but
soft. Tender to palpation, but no guarding/rebound. Lactulose
was held. Patient was deemed not to be surgical candidate by
surgery. Patient was started on Cipro/Flagyl and was switched to
Zosyn upon arrival to MICU. Pain control with IV tylenol and IV
dialudid 0.125 q6h prn pain. While narcotics in treatment of SBO
not ideal, patient required some IV analgesic for symptom
control. Around the same time that patient's UOP improved,
abdominal pain also improved and patient began to start passing
gas. She then began to have regular bowel movements. She had no
bowel movements despite lactulose while in MICU [**2048-8-2**], NGT was
placed [**8-4**]. KUB [**8-4**] showed nonobstructive bowel gas pattern.
SBO resolved by time of discharge.
.
#CIRRHOSIS, with decompensation: Cryptogenic c/b by large volume
ascites and grade I varices (EGD in [**12/2129**]), but no SBP in past
or on cell count here. Patient generally had one paracentesis
every few months for comfort, but since admission, required 2
paracentesis, one on [**2130-7-21**] with removal of 5L, and one on
[**2130-7-26**], both of which were NOT consistent with SBP. As
patient's SBO and [**Last Name (un) **] developed, she appeared to have had a
slight hepatic decompensation, as demonstrated by worsening
mental status (while lactulose was held, MS improved once SBO
and UOP improved prior to initiation of lactulose). In addition
to rising Cr, worsening ascites, and encephalopathy, patient
also started to exhibit asterixis, coagulopathy. Patient was
started on Midodrine and Octreotide for management of possible
concominant HRS.  However, her renal function improved with
decreasing creatinine and octreotide was stopped.  In
anticipation of discharge to rehab, therapeutic paracentesis was
performed with removal of 1.5L of ascitic fluid on [**8-3**].
Patient became more altered prior to MICU transfer [**8-4**], head CT
negative, lactulose restarted. Her HE was improved at time of
discharge, and she is now on lactulose and rifaximin. He got a
paracentesis that removed 3.5L on [**8-7**], w/ 25g albumin IV
afterwards. If she has close f/u with the liver clinic, but if
she develops ascites before than and tense abdomen, liver clinic
should be called to set up paracentesis (([**Telephone/Fax (1) 1582**]).

#Hypotension: Baseline pressures low due to cirrhosis (patient's
BP's ranged from 80-100s during initial admission. However, upon
transfer to MICU, BPs remained 80-100/40-50s despite treatment
with 125g albumin, 2 units of blood, and 2L of crystalloid.
Concern for sepsis in setting of SBO. A-line revealed SBP in
120-130s range initially in ICU, which eventually settled out to
100s range. As above, patient was treated with
midodrine/octreotide. As patient got first liter of fluids after
finishing blood in MICU, she went into flash pulm edema and had
mild SOB, and required 1-3L NC. This improved once UOP picked
up. All fluids were held at that point. No prior echo records
were found, and an echo demonstrated preserved EF but mod TR,
MR, and pulm hypertension. Given that BPs had been stable
throughout MICU stay, A-line was d/c'ed.  When the patient was
transferred to the floor, she had stable blood pressures with
systolics in the high 80s-90s and was asymptomatic at these
pressures.  However, on the night of [**8-4**] the patient became
hypotensive to the 70s/30s with dizziness and was transferred to
the MICU for pressor support. She did not require pressors while
in the MICU as she had been fluid responsive while still on the
floor. BP improved and she did not require further fluid boluses
before being transferred back to the floor. her BP was stable on
the floor, ranging 90-110 systolic.
.
#FUNGAL INFECTION: Bone biopsy suggestive of histoplasma.
Previously had biopsies of GI tract suggestive of granulomatous
process thought to be sarcoid but could be c/w histo. Otherwise
has no known exposures or systemic symptoms. Fungal culture in
blood and peritoneal fluid was negative; Histo Ag, Ab negative
as well. Patient was treated with Ambisome with plans for tx for
1-2 weeks followed by Itraconazole for at least a year. Patient
developed pancytopenia and renal failure concerning for ambisome
effects, and this was stopped.  After further evaluation by
world's expert on histo, it appears that perhaps bone biopsy's
findings were misleading and diagnosis of histoplasma was likely
an artifact.  Later in her course, new pathology slides were
reviewed and it was confirmed that fungal elements truly were
seen in the biopsy.  Cryptococcus was suggested as the possible
cause given its similarity in appearance.  A serum cryptococcal
antigen was weakly positive at 1:32 (though this can be falsely
elevated with cirrhosis) and the patient was started on
fluconazole, with the plan to follow up with ID for likely >8
week course. LP was performed [**8-4**] with negative CSF
cryptococcal antigen and 1 WBC. Will need monitoring of
CBCw/diff, BUN/Cr, weekly LFTs while on fluconazole, please fax
to [**Telephone/Fax (1) 1419**] attn: [**Last Name (un) **].
.
#Anemia: Patient with worsening anemia, appeared to be c/w
anemia of chronic disease. Smear without schistocytes, but did
show abn associated with chronic liver disease so sequestration
and damage from spleen may be playing role. Hct stable upon
discharge
.
#DMII - diet controlled, may cover with ISS should patient
require
.
#CODE: Full
#CONTACT: sister, HCP is [**Name (NI) 41890**] [**Name (NI) 2072**]> Daughter (lives in North
[**Doctor First Name **]) [**Telephone/Fax (1) 93375**]
===================================
TRANSITIONAL ISSUES
#   will need monitoring of CBCw/diff, BUN/Cr, weekly LFTs while
on fluconazole, please fax to [**Telephone/Fax (1) 1419**] attn: [**Last Name (un) **].
# f/u pending SPEP/UPEP, sent to assess for underlying heme or
malignant process that may have predisposed her to crypto
infection

Medications on Admission:
1. Amiloride HCl 10 mg PO DAILY
2. Estrogens Conjugated 0.625 mg PO DAILY
3. Calcium Carbonate 600 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
5. Senna 2 TAB PO DAILY
hold for loose stools
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
7. Boost *NF* (food supplement, lactose-free) 1 unit Oral daily


Discharge Medications:
1. Amiloride HCl 10 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
3. Fluconazole 200 mg PO Q24H
4. Lactulose 30 mL PO TID
5. Midodrine 5 mg PO TID
6. Rifaximin 550 mg PO BID
7. Boost *NF* (food supplement, lactose-free) 1 unit Oral daily
8. Calcium Carbonate 600 mg PO BID
9. Estrogens Conjugated 0.625 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
11. Senna 2 TAB PO DAILY
hold for loose stools
12. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Disseminated cryptococcus
cryptogenic cirrhosis
type 2 diabetes mellitus


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms [**Known lastname 10935**],

It was a pleasure taking care of you at [**Hospital1 18**]. You were found to
have an infection from a fungus called cryptococcus. For this,
you will be on an anti-fungal medication for a long time
(several months at least). Your hospital course was also
complicated by having a low blood pressure and altered mental
status, which required stays in the ICU. However, you are doing
much better now. Please call your doctor or return to medical
care if you start to feel sick in any way.

Followup Instructions:
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 11962**]

Department: INFECTIOUS DISEASE
When: TUESDAY [**2130-8-8**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: LIVER CENTER
When: WEDNESDAY [**2130-8-16**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: LIVER CENTER
When: WEDNESDAY [**2130-9-13**] at 9:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
{'Cryptococcosis,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Other ascites,Unspecified intestinal obstruction,Acquired coagulation factor deficiency,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia of other chronic disease'}


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: bone biopsy concerning for histoplasmosis

PRESENT ILLNESS: The patient is a 73-year-old African-American female with
history of sarcoidosis (suggestive of liver involvement but no
granulomas seen), cryptogenic cirrhosis complicated by portal
hypertension and ascites. Noted onset of left-sided rib pain [**2-6**]
months ago and subsequent imaging revealed a pathologic fracture
of the left anterolateral fifth rib. Associated with a mass seen
on CT and underwent a CT-guided bone biopsy with results
suggesive of histoplasmosis.
.
Currently, patient feels fine but has felt better. Has had
increased abdominal distention and leg swelling over the past
two weeks. Related to the abdominal distention is a shooting
pain along the lower right abdomen, a pain she often gets when
she has a lot of fluid on. Notes that she has had decreased
energy for the past two weeks. Has poor appetite as well though
that is more chronic. Notes chills but no fevers or night
sweats. Denies any headache, vision changes, pain or trouble
swallowing, chest pain, cough, shortness of breath, diarrhea,
nausea, vomiting.
.
Of note, patient was discharged on [**7-6**] after hypokalemia to 2.4
in setting of lasix.
.
ROS: per HPI, also denies BRBPR, melena, dysuria. Endorses
dyspnea on exertion and inability to take deep breath when
abdomen is distended

MEDICAL HISTORY: -Type 2 Diabetes, diet controlled
-HTN
-Cryptogenic cirrhosis (complicated by ascites and coagulopathy)
-s/p hysterectomy for fibroids

MEDICATION ON ADMISSION: 1. Amiloride HCl 10 mg PO DAILY
2. Estrogens Conjugated 0.625 mg PO DAILY
3. Calcium Carbonate 600 mg PO BID
4. Fluticasone Propionate NASAL 2 SPRY NU [**Hospital1 **]:PRN congestion
5. Senna 2 TAB PO DAILY
hold for loose stools
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
7. Boost *NF* (food supplement, lactose-free) 1 unit Oral daily

ALLERGIES: Spironolactone / Oxycodone

PHYSICAL EXAM: ADMISSION exam
VS: 97.8 127/64 70 18 100%RA
GENERAL: Well appearing in NAD. Thin, cachectic appearing,
pleasant
HEENT: Anicteric sclera, MMM, whitish film over tongue, no
lesions
CARDIAC: RRR with 2/6 systolic murmur over LUSB, no JVD
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Distended but Soft, tender to palpation only over
suprapubic/RLQ. No guarding or rebound. Dullness to percussion
over dependent areas but tympanic anteriorly. No appreciable HSM

FAMILY HISTORY: -Paternal aunts with cancers of some sort, unclear what kind.
-Mom, [**Name (NI) **] and Sister all with Diabetes

SOCIAL HISTORY: -Tobacco history: Distant as a teenager, none currently
-ETOH: distant, only occasional
-Illicit drugs: None
-Home: 2 fam house; She lives in 1 unit and grand-daughter in
other. Worked as a tutor for 34 years. Divorced and has one
daughter who works as a pharmacist in [**Doctor First Name 5256**]
-Grew up in [**State 108**] and [**Doctor First Name 26692**] then moved to [**Location (un) 86**].
Father was in the military. Never been to [**State 5111**] river
valley 

### Response:
{'Cryptococcosis,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Acute edema of lung, unspecified,Other ascites,Unspecified intestinal obstruction,Acquired coagulation factor deficiency,Cirrhosis of liver without mention of alcohol,Sarcoidosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Anemia of other chronic disease'}
