CHIEF COMPLAINT: fevers, malaise, cough

PRESENT ILLNESS: 48 year-old [**Country **] Rican male with HIV (dx '[**01**], last CD4 370 in
[**3-/2116**], VL ~9000) self-discontinued antiretrovirals (b/c he felt
depressed on them), who was in his USOH until around 3 days ago
when he began to experience drenching night sweats, low-grade
fevers, chills and dry non-productive cough. He felt the night
sweats were occuring because it was hot outside, so did not seek
medical attention. He had URI Sx a few weeks ago and was told by
a friend to see a doctor at the time but he declined. He also
endorses losing 20 lbs in the past month or so, but believes
this has to do with moving from the 2nd to the [**Location (un) **] of his
building. Additionally, he reports nocturia, frequent urination
that began the night prior to admission and dysuria at the end
of his stream, which is new. Denies urethral/penile discharge
although has hx STIs in the past as continues unprotected
intercourse w/ male partners. Denies nausea, vomiting, decreased
PO intake, bloody stools, chest pain and hemoptysis. He
presented to the ED due to worsening fever, dizziness,
difficulty breathing, dry cough and upper back pain.
.
In the ED, initial VS: 99.5 82/51 132 20 100% RA- CXR showed a
dense opacity in the right apex. Worsening O2 sats in ED, led
him to be on 4L NC prior to transfer to [**Hospital Unit Name 153**].

MEDICAL HISTORY: -HIV diagnosed in [**2101**]; no ARVs for many years. Sees Dr. [**Last Name (STitle) 724**]
[**Name (STitle) 26955**] b/l MRSA + buttock abscesses
-Right epididymo-orchitis w/ assoc right pyocele

MEDICATION ON ADMISSION: (self discontinued anti-HIV medications)
terbinafine

ALLERGIES: Bactrim

PHYSICAL EXAM: VS:  afebrile, HR 103 BP 113/64 SaO2 99% 4L NC
GEN: thin chronically-ill appearing Hispanic M in mild
respiratory distress, on 4L NC, diaphoretic, warm, flushed
HEENT: EOMI, PERRLA, no scleral icterus
LUNGS: CTAB/L no wheeze B/L
CV: tachycardic, nl S1, S2 no murmurs appreciated
ABD:  +BS soft, non-tender, non-distended
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: alert, oriented, limited medical knowledge, no focal
neurologic deficits
.
on discharge
Vitals: 97.7  99.9  98/59  93  18  97%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: no thrush, mmm
CV: RRR, no m
Resp: CTAB, no crackles, no wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: circular erythematous patches RLE>LLE are now
hyperpigmented, no blister. L forearm with well demarkated
erythema improved
psych: appropriate
.

FAMILY HISTORY: no h/o HIV

SOCIAL HISTORY: Born in [**Male First Name (un) 1056**], moved to the US 27 yrs ago. Sexually active
with males, contracted HIV in [**2101**] from unprotected intercourse.
Has a HIV+ boyfriend with whom he is currently sexually active
(without protection), who may not be monogamous. Denies tobacco
use, occasional EtOH ([**4-16**] drinks/wknd) and marijuana use. Last
crystal meth use 3 yrs ago. No IVDU. Used to work in a hotel.
Never been in prison, never been homeless. Last PPD negative in
[**2116-3-16**] per patient w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Location (un) 12091**].
Pneumonia, organism unspecified,Acute hepatitis C without mention of hepatic coma,Rash and other nonspecific skin eruption,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Asymptomatic human immunodeficiency virus [HIV] infection status
Pneumonia, organism NOS,Hpt C acute wo hpat coma,Nonspecif skin erupt NEC,Elev transaminase/ldh,Asymp hiv infectn status
Admission Date:  [**2116-7-3**]              Discharge Date:   [**2116-7-9**]

Date of Birth:  [**2067-7-28**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
fevers, malaise, cough

Major Surgical or Invasive Procedure:
R IJ placement and removal
Rash-biopsy [**7-9**]


History of Present Illness:
48 year-old [**Country **] Rican male with HIV (dx '[**01**], last CD4 370 in
[**3-/2116**], VL ~9000) self-discontinued antiretrovirals (b/c he felt
depressed on them), who was in his USOH until around 3 days ago
when he began to experience drenching night sweats, low-grade
fevers, chills and dry non-productive cough. He felt the night
sweats were occuring because it was hot outside, so did not seek
medical attention. He had URI Sx a few weeks ago and was told by
a friend to see a doctor at the time but he declined. He also
endorses losing 20 lbs in the past month or so, but believes
this has to do with moving from the 2nd to the [**Location (un) **] of his
building. Additionally, he reports nocturia, frequent urination
that began the night prior to admission and dysuria at the end
of his stream, which is new. Denies urethral/penile discharge
although has hx STIs in the past as continues unprotected
intercourse w/ male partners. Denies nausea, vomiting, decreased
PO intake, bloody stools, chest pain and hemoptysis. He
presented to the ED due to worsening fever, dizziness,
difficulty breathing, dry cough and upper back pain.
.
In the ED, initial VS: 99.5 82/51 132 20 100% RA- CXR showed a
dense opacity in the right apex. Worsening O2 sats in ED, led
him to be on 4L NC prior to transfer to [**Hospital Unit Name 153**].

He was given 2L NS, Vanc/ Zosyn/ Levo for HAP, and started on
levophed due to SBPs in the 80s. CVL was placed and he was sent
to the [**Hospital Unit Name 153**] for further mgt.

Past Medical History:
-HIV diagnosed in [**2101**]; no ARVs for many years. Sees Dr. [**Last Name (STitle) 724**]
[**Name (STitle) 26955**] b/l MRSA + buttock abscesses
-Right epididymo-orchitis w/ assoc right pyocele

Social History:
Born in [**Male First Name (un) 1056**], moved to the US 27 yrs ago. Sexually active
with males, contracted HIV in [**2101**] from unprotected intercourse.
Has a HIV+ boyfriend with whom he is currently sexually active
(without protection), who may not be monogamous. Denies tobacco
use, occasional EtOH ([**4-16**] drinks/wknd) and marijuana use. Last
crystal meth use 3 yrs ago. No IVDU. Used to work in a hotel.
Never been in prison, never been homeless. Last PPD negative in
[**2116-3-16**] per patient w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Location (un) 12091**].

Family History:
no h/o HIV

Physical Exam:
VS:  afebrile, HR 103 BP 113/64 SaO2 99% 4L NC
GEN: thin chronically-ill appearing Hispanic M in mild
respiratory distress, on 4L NC, diaphoretic, warm, flushed
HEENT: EOMI, PERRLA, no scleral icterus
LUNGS: CTAB/L no wheeze B/L
CV: tachycardic, nl S1, S2 no murmurs appreciated
ABD:  +BS soft, non-tender, non-distended
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: alert, oriented, limited medical knowledge, no focal
neurologic deficits
.
on discharge
Vitals: 97.7  99.9  98/59  93  18  97%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: no thrush, mmm
CV: RRR, no m
Resp: CTAB, no crackles, no wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: circular erythematous patches RLE>LLE are now
hyperpigmented, no blister. L forearm with well demarkated
erythema improved
psych: appropriate
.

Pertinent Results:
wbc 32-->8ss
hgb [**12-25**] stable
plt wnl
.
BUN/creat 13/0.7 (1.6 on [**7-3**])
.
LDH 1193-->227
.
AST/ALT 540/392->344/252 (fluctuating levels), new since [**12-22**]
alk phos 108->199
t bili 1.4
albumin 2.7
.
INR 1.5->1.1
.
B2 glucan [**7-4**] pending
.
sputum cx [**7-5**] >10epis
.
AFB [**7-5**] negative poor quality
[**7-6**] negative poor quality
[**7-7**] negative
.
Cath tip  negative
.
UA neg, Ucx neg
.
RPR NR
Hep C Ab postiive and VL 899K
HCV genotype pending
Hep B sAg and VL negative
monospot negative

crypto ag neg
hep A neg
Urine legionella neg
blood cx X2 [**7-3**] NTD

.
.
Imaging/results:
CXR [**7-3**]
IMPRESSION: Dense opacity in the right apex. Underlying
pulmonary mass is favored, although infectious consolidation is
also considered in light of clinical symptoms. Given the apical
location, tuberculosis must be excluded and appropriate
precautions taken. CT scan is recommended for further
characterization.
.
CXR [**7-4**] Pa/Lat
The infiltrate in the right upper lung is less pronounced, but
somewhat more spread suggesting that some reexpansion has
occurred. Air bronchograms can still be seen. Atelectasis is
present at the left base. The rounded shadow overlying the left
lower lobe is considered to be a nipple shadow. Small bilateral
effusions may be present.
.
RUQ US
1. No evidence for biliary ductal dilatation. Gallbladder
collapsed, thus excluding acute cholecystitis.
2. 3-cm vascular lesion with apparent large feeding vessel from
right portal vein, and large draining vessel emptying into IVC.
Findings consistent with portosystemic shunt, possibly
congenital if the patient has not had prior procedure of the
liver. Dynamic study is recommended for further assessment, such
as multiphasic CT or MRI.

.
.


Brief Hospital Course:
48 year old man with uncontrolled HIV (CD4 370 in [**3-/2116**], VL
~9000) off ARVs admitted [**7-3**] with fevers, sweats, cough X
3days. Was found to have RUL PNA in ER, febrile, hypoxic,
hypotensive. Started on broad Abx with Vanc/Ctx/Azithro. Was
hypotensive in ER and initially admitted to [**Hospital Unit Name 153**]. Improved with
broad IV Abx over next couple days. Transfered to floor on [**7-5**].
Wbc improved from 32-->8 on discharge, pt was afebrile for many
days, blood cx all negative, no good sputum sample sent.  Was
changed to Levo only on [**7-7**] and completed total 7days of
Antibiotics. Given RUL distribution, radiology felt he needed to
be ruled out for TB, had AFB smears X3 done (poor quality),
however ID felt given acute history, recent negative PPD and no
new exposure, this was very unlikely so respiratory isolation
stopped. He did well from this perspective. We did not check CD4
count or viral load in setting of acute infection. We have
arranged follow up with Dr. [**Last Name (STitle) 724**], who follows this patient at
[**Hospital1 **].
.
However, he was found to have new transaminitis (200-400s AST,
ALT) since [**12-22**]. NOt on any meds at home. He endorsed a hisotry
of significant daily etoh abuse but would have expected LFTs to
come down after several days of hospitalization. Same thing with
shock liver (and would have expected more severe elevation). He
was ruled out for HAV and EBV. He has a h/o clearing Hep B and
his hep B sAg was negative. He had a negative hep C in [**6-20**] but
repeat hep C here was POSITIVE and VL high reflecting likely
acute hep C (pt later admitted to IVDU). His liver function was
otherwise okay. HCV genotype pending. Dr. [**Last Name (STitle) 724**] will see him as
outpt to discuss treatment of both HIV and Hep C. Of note, he
had circular erythematous pruritic nonpainful nonblistering rash
develop in his LE after admisison. Initially patient and MICU
felt this was secondary to the one dose of bactrim he reiceved
(now listed as an allergy), however, ID did not feel this was a
typical drug rash. We considered secondary sphyllis in setting
of transamnitis and rash, but RPR negative. Later, when his test
revealed positive HCV, they wanted to r/o hep C related rash.
Derm was consulted and they performed biopsy of this rash on the
day of discharge [**7-9**].  They will contact patient with results
and appropriate follow up.
.
Of note, in the work up of his transaminitis, he had a RUQ US
which showed RUQ with 3-cm vascular lesion with apparent large
feeding vessel from right portal vein, and large draining vessel
emptying into IVC->consistent with portosystemic shunt, possibly
congenital if the patient has not had prior procedure of the
liver. Unlikey this is causing acute elevation in LFTs as pt
likely has had this for long time. We reccommend a dynamic study
is recommended for further assessment, such as multiphasic CT or
MRI


Medications on Admission:
(self discontinued anti-HIV medications)
terbinafine

Discharge Medications:
1. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.

3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
RUL pneumonia
Acute Hep C
Untreated HIV
Rash in legs-unclear etiology (for now listed as bactrim allergy
but not clear)-biopsy done


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
you were admitted with fevers, cough and found to have
pneumonia. you improved with 7 days of antibiotics.
Your liver tests were elevated. this is because of your alcohol
use. you were also found to have new hepatitis C infection.
These two things together can be very very dangerous for your
liver.  Stop drinking!
please see Dr. [**Last Name (STitle) 724**] on [**7-16**] to discuss treatment for your HIV and
Hepatitis C.
You had a rash on your legs that we were not sure about.
Dermatology saw you before you left hospital and biopsied. they
will call you with hte results of this biopsy and for follow up.
Please keep this area clean.
Please discuss getting MRI or your liver with Dr. [**Last Name (STitle) 4888**]


Followup Instructions:
Appointment
When: THURSDAY, [**2117-7-16**] AM
Where: [**Hospital3 26956**], [**Hospital1 26957**], [**Location (un) 669**], [**Numeric Identifier 18406**]
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
([**Telephone/Fax (1) 9256**]
{'Pneumonia, organism unspecified,Acute hepatitis C without mention of hepatic coma,Rash and other nonspecific skin eruption,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Asymptomatic human immunodeficiency virus [HIV] infection status'}


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: fevers, malaise, cough

PRESENT ILLNESS: 48 year-old [**Country **] Rican male with HIV (dx '[**01**], last CD4 370 in
[**3-/2116**], VL ~9000) self-discontinued antiretrovirals (b/c he felt
depressed on them), who was in his USOH until around 3 days ago
when he began to experience drenching night sweats, low-grade
fevers, chills and dry non-productive cough. He felt the night
sweats were occuring because it was hot outside, so did not seek
medical attention. He had URI Sx a few weeks ago and was told by
a friend to see a doctor at the time but he declined. He also
endorses losing 20 lbs in the past month or so, but believes
this has to do with moving from the 2nd to the [**Location (un) **] of his
building. Additionally, he reports nocturia, frequent urination
that began the night prior to admission and dysuria at the end
of his stream, which is new. Denies urethral/penile discharge
although has hx STIs in the past as continues unprotected
intercourse w/ male partners. Denies nausea, vomiting, decreased
PO intake, bloody stools, chest pain and hemoptysis. He
presented to the ED due to worsening fever, dizziness,
difficulty breathing, dry cough and upper back pain.
.
In the ED, initial VS: 99.5 82/51 132 20 100% RA- CXR showed a
dense opacity in the right apex. Worsening O2 sats in ED, led
him to be on 4L NC prior to transfer to [**Hospital Unit Name 153**].

MEDICAL HISTORY: -HIV diagnosed in [**2101**]; no ARVs for many years. Sees Dr. [**Last Name (STitle) 724**]
[**Name (STitle) 26955**] b/l MRSA + buttock abscesses
-Right epididymo-orchitis w/ assoc right pyocele

MEDICATION ON ADMISSION: (self discontinued anti-HIV medications)
terbinafine

ALLERGIES: Bactrim

PHYSICAL EXAM: VS:  afebrile, HR 103 BP 113/64 SaO2 99% 4L NC
GEN: thin chronically-ill appearing Hispanic M in mild
respiratory distress, on 4L NC, diaphoretic, warm, flushed
HEENT: EOMI, PERRLA, no scleral icterus
LUNGS: CTAB/L no wheeze B/L
CV: tachycardic, nl S1, S2 no murmurs appreciated
ABD:  +BS soft, non-tender, non-distended
EXT: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: alert, oriented, limited medical knowledge, no focal
neurologic deficits
.
on discharge
Vitals: 97.7  99.9  98/59  93  18  97%RA
Pain: denies
Access: PIV
Gen: nad
HEENT: no thrush, mmm
CV: RRR, no m
Resp: CTAB, no crackles, no wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: A&OX3, nonfocal
Skin: circular erythematous patches RLE>LLE are now
hyperpigmented, no blister. L forearm with well demarkated
erythema improved
psych: appropriate
.

FAMILY HISTORY: no h/o HIV

SOCIAL HISTORY: Born in [**Male First Name (un) 1056**], moved to the US 27 yrs ago. Sexually active
with males, contracted HIV in [**2101**] from unprotected intercourse.
Has a HIV+ boyfriend with whom he is currently sexually active
(without protection), who may not be monogamous. Denies tobacco
use, occasional EtOH ([**4-16**] drinks/wknd) and marijuana use. Last
crystal meth use 3 yrs ago. No IVDU. Used to work in a hotel.
Never been in prison, never been homeless. Last PPD negative in
[**2116-3-16**] per patient w/ Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at [**Location (un) 12091**]. 

### Response:
{'Pneumonia, organism unspecified,Acute hepatitis C without mention of hepatic coma,Rash and other nonspecific skin eruption,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Asymptomatic human immunodeficiency virus [HIV] infection status'}
