CHIEF COMPLAINT: Fever, lethargy

PRESENT ILLNESS: HPI: Patient is a 46 yo female with history of poorly controlled
HIV/AIDS, not on HAART, with  last CD4 9, VL 329,000 who
presents for fever, lethargy, and latered mental status. The
patient was seen in the E.D. by covering attending, Dr.
[**Last Name (STitle) 71526**] prior to transfer to floor.
The patient is reported to have poor mental status at baseline,
following some commands, but without significant interaction.
The patient has been noted over the last 2 -3 days to have
increasing lethargy, ? increasing secretions from her mouth, and
now feves to 102 today at nursinf facility where she lives. The
patient is transferred to [**Hospital1 18**] for further eval of these
symptoms.
.
In the ED the patient had WBC of 7.4 with left shit, 5% bands,
lactate 2.6. A CXR was negative for acute process but UA was +
with leuks. A CT Head was performed, initially interpeted as
negative, although second eval by ED raised question of a ring
enhancing lesion. Given this lesion, decision was made not to
perform LP at this time but treat empirically with CTX/Vanc at
meningeal dosing. Blood and urine cultures were obtained and the
patient is now transferred to the floor for further eval.
Attempts were made to obtain an MRI in the ED but patient's
brother/HCP were not successful.
.
The patient was seen previously at [**Hospital1 2177**] in [**Month (only) **] [**Numeric Identifier **] for
altered mental status although at that time was without fever or
white count. The patient refused MRI and LP with a non-reactive
RPR. Patient seen by psych and assessed to be without capacity.
The patient's son [**Name (NI) 653**] and gave consent. MRI at that time
revealed significant atrophy and periventricular white matter
densities likely related to HIV, and no other acute process. The
patient's delta MS at that time was thought likely [**12-27**] seizure
disorder and or HIV dementia and patient was D/C back to
facilty.
.
.
Labs/Data:
UA:+
WBC: 7.4 ( N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1) <- 1.3 on
[**2120-10-22**]
Hct: 32.3
Plt: 77
Lactate: 2.6
CK: 3078  MB 3  Trop: < .01
Blood/Urine cxs pending
.
[**2120-11-24**]:
WBC 4.0
Hct: 27.4
Plt: 67
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
Imaging:
.
[**2120-11-25**]: CT Head
There is no intra- or extra-axial hemorrhage, mass effect, or
shift
of normally midline structures.  There is no major vascular
territorial infarction.  Diffuse low attenuation in the
periventricular white matter is consistent with chronic
microvascular infarction.  Moderately large air-fluid levels are
seen in bilateral maxillary sinuses.  A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells.  No fracture is identified.
.
[**2120-11-25**]: Portable Chest
1. No acute pulmonary process.
2. Speckled calcifications in the abdomen adjacent to the L2 and
L3 vertebral bodies consistent with pancreatic calcifictions
from prior episodes of pancreatitis.
.
.
A/P: Patient is a 46 year old female with med history
significant for poorly controlled HIV/AIDS, seizure disorder,
history of FTT/AIDS dementia who now presents with altered
mental status, fevers with left shift concerning for underlying
infectious process
.
#. Fever/Delta MS - Patient with altered MS in setting of likely
infection. Patient with +UA but prudent to treat for meningitis
until this can be ruled out. Given ? for ring enhacing lesion in
ED, LP not performed until MRI could be performed, however no
shift or edema noted. Plan to continue empiric treatment
otherwise as per attending on admission
- patient received CTX, Vanc in [**Last Name (LF) **], [**First Name3 (LF) **] continue this. Given
HIV/AIDS status however would add Ampicillin for Listeria
coverage at this time until Bacterial meningitis ruled out
- patient with MRI in late Novemeber without ring enhancing
lesion, not clear one is present now given CT read by rads. If
present, less likely malignancy such as lymphoma but could be
infectious such as toxo/crypto, although patient reportedly on
toxo ppx, also seems like this would be rapid development of
lesion as well
- continue attempts to reach family for MRI consent
- ID curbsided overnight who agrees with plan for empiric
coverage, MRI in a.m. LP will definitely be needed with CSF sent
[**Male First Name (un) 2326**] virus to eval for PML, Crypto, toxo, TB, etc. LP unable to be
performed overnight but not clear that MRI necessary first given
no evidence of elevated ICP on CT. Will check coags in the a.m.
in anticipation of LP
- toxo IgG in a.m., crypto serologies
- follow up blood/urine cultures
- significance of sinus air-fluid levels not clear, however
sinusitis would be covered with above coverage
- if symptoms persist EEG in a.m. for ? seizure activity
- continue outpatient anti-epileptics as possible
- as per outpatient notes as well, discussions regarding Code
Status prudent, full code currently
.
#. HIV/AIDS - patient with poorly controlled HIV, not on HAART
- repeat CD4/VL in a.m., unclear when last values from
- would not start HAART in acute setting given concern for
potential infection, particularly concern would be for
meningitis and immune reconstitution syndrome
.
#. Seizure disorder - patient's oral secretions may have been
[**12-27**] seizure, although still copious.
- continue Keppra per outpatient dosing, will attempt to place
NGT tonight given likely inability to take POs reliably
- consider EEG if symptoms persist
.
#. Pancytopenia - likely from underlying HIV, levels at baseline
currently
- monitor daily
.
#. FEN - NPO for now given delta MS
.
#. Access: PIV
.
#. PPx: SQ heparin, seizure ppx, PPI
.
#. Code: Full for now, need to discuss with family members
.
#. Dispo: Pending eval/improvement
.
#. Communication: [**Name (NI) **] [**Name (NI) 731**] -
Brother: [**Name (NI) **] [**Name (NI) 71527**] [**Telephone/Fax (1) 71528**]
Son: [**Telephone/Fax (1) 71529**]

MEDICAL HISTORY: HIV/AIDS: CD4 < 4, VL 329,000 not on HAART
- ? AIDS dementia/FTT
- PPD negative [**2120-11-3**]
- Pneumovax [**2120-10-24**]
Seizure Disorder
S/p Right MCA CVA [**2116**]
Pancytopenia
GERD
Bladder Incontinence

MEDICATION ON ADMISSION: Ferrous Sulfate 325 tid
Omeprazole 20mg daily
Batrim SS daily
Thiamine 100 daily
Folic Acid 1mg daily
MVI daily
Keppra 500mg [**Hospital1 **]
Azithromax 1200mg q Tuesday
Flonase daily
Nystatin S+S
Ensure

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T - 99.4 BP: 112/81 HR: 108 RR: 18 O2: 96% on 2L
General: Patient is a chornically ill appearing African-American
female. Patient is awake and looks around but does not interact.
Patient closes eyes to command but follows no other simple
commands. Patient resists mouth opening.
HEENT: NCAT, EOMI grossly. OP: Exam not performed, patient does
not open mouth, resists passive opening
Neck: Supple, no JVD
Chest: Relatively CTA anterior and laterally.
Cor: RRR, normal S1/S2. No M/R/G
Abdomen: Soft, NT, ND. +BS
Extremity: no C/C/E. DP 2+ bilaterally
Skin: No obvious rashes
Neuro: Patient awakre, orientation?. Closes eyes to command but
follows no other commands, non-verbal but cries out
intermittently during exam
CN II-XII without obvious defect, limited by cooperation
Motor/Sensation: Difficult to test

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient is a resident at [**Hospital **] [**Hospital 731**] nursing home. She is
reported to follow commands but have altered communication at
baseline
Tobacco: Previous use, unknown
ETOH: Previous abuse, amount unknown
Illicits: None reported
Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Hemorrhage complicating a procedure,Dementia in conditions classified elsewhere without behavioral disturbance,Angioneurotic edema, not elsewhere classified,Unspecified antibiotic causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy
Human immuno virus dis,Urin tract infection NOS,Hemorrhage complic proc,Dementia w/o behav dist,Angioneurotic edema,Adv eff antibiotic NOS,Epilep NOS w/o intr epil
Admission Date:  [**2120-11-25**]              Discharge Date:   [**2120-12-8**]

Date of Birth:  [**2074-4-6**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 14037**]
Chief Complaint:
Fever, lethargy

Major Surgical or Invasive Procedure:
Gastric tube placement [**2120-12-4**].


History of Present Illness:
HPI: Patient is a 46 yo female with history of poorly controlled
HIV/AIDS, not on HAART, with  last CD4 9, VL 329,000 who
presents for fever, lethargy, and latered mental status. The
patient was seen in the E.D. by covering attending, Dr.
[**Last Name (STitle) 71526**] prior to transfer to floor.
The patient is reported to have poor mental status at baseline,
following some commands, but without significant interaction.
The patient has been noted over the last 2 -3 days to have
increasing lethargy, ? increasing secretions from her mouth, and
now feves to 102 today at nursinf facility where she lives. The
patient is transferred to [**Hospital1 18**] for further eval of these
symptoms.
.
In the ED the patient had WBC of 7.4 with left shit, 5% bands,
lactate 2.6. A CXR was negative for acute process but UA was +
with leuks. A CT Head was performed, initially interpeted as
negative, although second eval by ED raised question of a ring
enhancing lesion. Given this lesion, decision was made not to
perform LP at this time but treat empirically with CTX/Vanc at
meningeal dosing. Blood and urine cultures were obtained and the
patient is now transferred to the floor for further eval.
Attempts were made to obtain an MRI in the ED but patient's
brother/HCP were not successful.
.
The patient was seen previously at [**Hospital1 2177**] in [**Month (only) **] [**Numeric Identifier **] for
altered mental status although at that time was without fever or
white count. The patient refused MRI and LP with a non-reactive
RPR. Patient seen by psych and assessed to be without capacity.
The patient's son [**Name (NI) 653**] and gave consent. MRI at that time
revealed significant atrophy and periventricular white matter
densities likely related to HIV, and no other acute process. The
patient's delta MS at that time was thought likely [**12-27**] seizure
disorder and or HIV dementia and patient was D/C back to
facilty.
.
.
Labs/Data:
UA:+
WBC: 7.4 ( N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1) <- 1.3 on
[**2120-10-22**]
Hct: 32.3
Plt: 77
Lactate: 2.6
CK: 3078  MB 3  Trop: < .01
Blood/Urine cxs pending
.
[**2120-11-24**]:
WBC 4.0
Hct: 27.4
Plt: 67
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
Imaging:
.
[**2120-11-25**]: CT Head
There is no intra- or extra-axial hemorrhage, mass effect, or
shift
of normally midline structures.  There is no major vascular
territorial infarction.  Diffuse low attenuation in the
periventricular white matter is consistent with chronic
microvascular infarction.  Moderately large air-fluid levels are
seen in bilateral maxillary sinuses.  A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells.  No fracture is identified.
.
[**2120-11-25**]: Portable Chest
1. No acute pulmonary process.
2. Speckled calcifications in the abdomen adjacent to the L2 and
L3 vertebral bodies consistent with pancreatic calcifictions
from prior episodes of pancreatitis.
.
.
A/P: Patient is a 46 year old female with med history
significant for poorly controlled HIV/AIDS, seizure disorder,
history of FTT/AIDS dementia who now presents with altered
mental status, fevers with left shift concerning for underlying
infectious process
.
#. Fever/Delta MS - Patient with altered MS in setting of likely
infection. Patient with +UA but prudent to treat for meningitis
until this can be ruled out. Given ? for ring enhacing lesion in
ED, LP not performed until MRI could be performed, however no
shift or edema noted. Plan to continue empiric treatment
otherwise as per attending on admission
- patient received CTX, Vanc in [**Last Name (LF) **], [**First Name3 (LF) **] continue this. Given
HIV/AIDS status however would add Ampicillin for Listeria
coverage at this time until Bacterial meningitis ruled out
- patient with MRI in late Novemeber without ring enhancing
lesion, not clear one is present now given CT read by rads. If
present, less likely malignancy such as lymphoma but could be
infectious such as toxo/crypto, although patient reportedly on
toxo ppx, also seems like this would be rapid development of
lesion as well
- continue attempts to reach family for MRI consent
- ID curbsided overnight who agrees with plan for empiric
coverage, MRI in a.m. LP will definitely be needed with CSF sent
[**Male First Name (un) 2326**] virus to eval for PML, Crypto, toxo, TB, etc. LP unable to be
performed overnight but not clear that MRI necessary first given
no evidence of elevated ICP on CT. Will check coags in the a.m.
in anticipation of LP
- toxo IgG in a.m., crypto serologies
- follow up blood/urine cultures
- significance of sinus air-fluid levels not clear, however
sinusitis would be covered with above coverage
- if symptoms persist EEG in a.m. for ? seizure activity
- continue outpatient anti-epileptics as possible
- as per outpatient notes as well, discussions regarding Code
Status prudent, full code currently
.
#. HIV/AIDS - patient with poorly controlled HIV, not on HAART
- repeat CD4/VL in a.m., unclear when last values from
- would not start HAART in acute setting given concern for
potential infection, particularly concern would be for
meningitis and immune reconstitution syndrome
.
#. Seizure disorder - patient's oral secretions may have been
[**12-27**] seizure, although still copious.
- continue Keppra per outpatient dosing, will attempt to place
NGT tonight given likely inability to take POs reliably
- consider EEG if symptoms persist
.
#. Pancytopenia - likely from underlying HIV, levels at baseline
currently
- monitor daily
.
#. FEN - NPO for now given delta MS
.
#. Access: PIV
.
#. PPx: SQ heparin, seizure ppx, PPI
.
#. Code: Full for now, need to discuss with family members
.
#. Dispo: Pending eval/improvement
.
#. Communication: [**Name (NI) **] [**Name (NI) 731**] -
Brother: [**Name (NI) **] [**Name (NI) 71527**] [**Telephone/Fax (1) 71528**]
Son: [**Telephone/Fax (1) 71529**]

Past Medical History:
HIV/AIDS: CD4 < 4, VL 329,000 not on HAART
- ? AIDS dementia/FTT
- PPD negative [**2120-11-3**]
- Pneumovax [**2120-10-24**]
Seizure Disorder
S/p Right MCA CVA [**2116**]
Pancytopenia
GERD
Bladder Incontinence


Social History:
The patient is a resident at [**Hospital **] [**Hospital 731**] nursing home. She is
reported to follow commands but have altered communication at
baseline
Tobacco: Previous use, unknown
ETOH: Previous abuse, amount unknown
Illicits: None reported


Family History:
NC

Physical Exam:
Vitals: T - 99.4 BP: 112/81 HR: 108 RR: 18 O2: 96% on 2L
General: Patient is a chornically ill appearing African-American
female. Patient is awake and looks around but does not interact.
Patient closes eyes to command but follows no other simple
commands. Patient resists mouth opening.
HEENT: NCAT, EOMI grossly. OP: Exam not performed, patient does
not open mouth, resists passive opening
Neck: Supple, no JVD
Chest: Relatively CTA anterior and laterally.
Cor: RRR, normal S1/S2. No M/R/G
Abdomen: Soft, NT, ND. +BS
Extremity: no C/C/E. DP 2+ bilaterally
Skin: No obvious rashes
Neuro: Patient awakre, orientation?. Closes eyes to command but
follows no other commands, non-verbal but cries out
intermittently during exam
CN II-XII without obvious defect, limited by cooperation
Motor/Sensation: Difficult to test


Pertinent Results:
Admission Labs:
142  106  41
------------<178
4.9  22  1.0
estGFR: 60/72 (click for details)
CK: 3078  MB: 3
.
   11.5
7.4>---<77
   32.3
N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1
Comments: Plt-Ct: Verified By Smear
Plt-Est: Very Low
.
Urine Cx: STAPHYLOCOCCUS, COAGULASE NEGATIVE
LP showed: WBC..RBC....Polys..lymphs..monos
tube#1.....[**Telephone/Fax (1) 71530**]...94.....3.......3
tube#4.....941..[**Numeric Identifier 42617**]..90.....4.......6
CSF gram stain negative
CSF culture negative
CSF cryptococcal negative
CSF viral ngtd
Serum showed:
serum toxoplasma negative
serum cryptococcal negative
EBV-PCR negative
HERPES 6 PCR negative
HERPES SIMPLEX VIRUS PCR negative
[**Male First Name (un) 2326**] VIRUS (JCV) DNA PCR negative
TOXOPLASMA GONDII PCR negative
.
CXR showed: Confluent opacity left base.
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
CT head w/o contrast [**2120-11-25**]:
FINDINGS:  There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures.  There is no
major vascular territorial infarction.  Diffuse low attenuation
in the periventricular white matter is consistent with chronic
microvascular infarction.  Moderately large air-fluid levels are
seen in bilateral maxillary sinuses.  A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells.  No fracture is identified.
NOTE ADDED AT ATTENDING REVIEW:  There are no prior exams for
comparison.
The patient is considered to young for the amount large amounts
of
periventricular white matter hypodensity, which is greater on
the right.  In addition, there is hypodensity of the right
caudate head.  An underlying lesion cannot be excluded and an
MRI with gadolinium is needed for further evaluation.
.
Portable CXR [**2120-11-26**]:
A nasogastric tube has been inserted.  Its tip overlies the
antrum of the stomach.  The cardiac and mediastinal contours are
normal.  The may be a small amount of retrocardiac left lower
lobe opacity. There is mild persistent elevation of the left
hemidiaphragm.  No pleural effusion or pneumothorax is seen.
The osseous structures appear unremarkable.
IMPRESSION:
1.  Nasogastric tube tip overlying the antrum of the stomach.
2.  Possible left lower lobe opacity.  Correlation with a
lateral view
recommended.


Brief Hospital Course:
A/P: 46 F w/ AIDS (CD4=9, VL=>300,000, not on HAART), prior
stroke, seizure disorder, and baseline dementia who presented on
[**2119-11-26**] with fever and altered mental status, diagnosed w/ ?
meningitis though determined to be unlikely per ID, ? pneumonia
(improved on CXR [**12-1**]), UTI, and angiodema s/p intubation for
airway protection improving on dexamethasone taper but unable to
swallow so s/p G tube placement.
.
1. Angioedema: Most likely reaction to B-lactam antibiotic in
context of PCN allergy. Pt did not receive asa, nsaids, acei,
although lack of pruritis and urticaria, as well as, location in
oral area suggestive of kinin-mediated agioedema. Improved after
dexamthasone, diphenhydramine and famotidine, taper dex starting
[**12-2**]. C4 normal, pointing away from C1 inhibitor, CH 50 NL,
parvovirus B19 pending neg, C1 inhibitor NL, other studies
pending. Edema improved and she is discharged on a steroid
taper.
.
2. CNS lesions: CSF difficult to interpret, but likely does not
represent meningitis. Spoke with pt's PCP, [**Name10 (NameIs) 1023**] agreed with
minimizing invasive tests such as reepat LP. Currently unable to
get MRI as she can not tolerate lying flat/managing her
secretions. No further CSF to send for flow cytometry. Otherwise
all studies negative to date, cultures no [**Last Name (un) 4904**] to date, monitor
mental/neurologic status.
.
3. UTI: positive for coag negative staph, s/p vanc x3 days,
surveillance UA with yeast, otherwise not looking infected,
foley d/c'd, no further treatment.
.
4. Seizure: No seizure activity noted, EEG suggesting
encephalitic picture, f/u neuro recs, continue Keppra IV, when
GI access will change to PO.
.
5. Mental status: Reportedly poor at baseline, likely below
where she previously was but stable, could represent clinical
impact of CNS lesions. Multiple causes for change in mental
status - infection, stroke, worsening HIV dementia.
.
6. GI access: Not able to swallow speech and swallow assessed
her and she needed PEG tube for alimentation which was placed by
IR [**2120-12-4**], with 2 packs platelets, but despite this and nl
coags (plt count increased appropriately) she continued to ooze
(hemodynamicly stable, hct stable). IR injected with thrombin
[**2120-12-6**] and placed prothrombotic dressing with improved but
minimally continuing oozing can attempted to feed via g tube
successfully. Of note had repeat speech and swallow [**2120-12-6**] and
found to be aspirating so recomended to remain NPO. Started on
hyoscyamine for copious oral secretions.
.
7. HIV/AIDS: (CD4=9, VL=>300,000, not on HAART), ID following
here, on azithromycin q week and SS bactrim daily for PPx.
.
8. Pancytopenia: Noted this hospital course, dropping wbc and
hct (unclear etiology), chronically low platelets (stable).
Could be that initial wbc represented stress response, and is
now back to baseline for pt with end-stage AIDS. Alternate would
be drug effect. Noted to have guaiac + stool [**2120-12-2**] but on
pantoprazole, hct stable. Pt recieved 2 uPRBC's [**2120-11-30**] with
appropriate improvement in hct that has been relatively stable,
will continue to monitor, guaiac all stools (+ [**2120-12-2**]). Pt also
received 2 packs of platelets prior to G tube placement.
.
9. Hyperglycemia: no known DM, likely [**12-27**] dexamethasone used to
treat angioedema, covered with SSHI, QID accu checks, will need
to continue this until blood glucose improved.
.
10. Inability to swallow: After angioedema pt noted not to be
able to swallow, had formal speech and swallow eval which she
failed, so she had G tube placed by IR. 24 hours after tube
placed she started tube feeds per nutrition recs, and tolerated
those. She was noted to have some blood oozing at the site 24
hours later. She will need to have the cotton-ball like anchors
(held by wires) removed on [**2120-12-8**] following discharge.

.
11. CODE: DNR/DNI-MICU team verified with son.
.
12. Communication: [**Name (NI) **] (son) [**Telephone/Fax (1) 71529**], [**Female First Name (un) 71531**]
[**Telephone/Fax (1) 71532**]


Medications on Admission:
Ferrous Sulfate 325 tid
Omeprazole 20mg daily
Batrim SS daily
Thiamine 100 daily
Folic Acid 1mg daily
MVI daily
Keppra 500mg [**Hospital1 **]
Azithromax 1200mg q Tuesday
Flonase daily
Nystatin S+S
Ensure


Discharge Medications:
1. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO every
thursday: via gtube.
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily): via gtube.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Insulin Lispro (Human) 100 unit/mL Solution Sig: 2-8 units
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale: 150-199 2
units,
200-249 4 units,
250-299 6 units,
300-349 8 units .
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
via gtube.
6. Keppra 100 mg/mL Solution Sig: Five Hundred (500) mg PO twice
a day: via gtube.
7. Prevacid 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day: via gtube.
8. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours): as needed for pain, not to exceed 4
gm in 24 hours.
9. Hyoscyamine 0.15 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for copious oral secretions.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] [**Location (un) 731**]

Discharge Diagnosis:
HIV with AIDS dementia, angioedema.
.
Seizure disorder, right MCA CVA in [**2116**], pancytopenia, urinary
incintinence


Discharge Condition:
Stable.


Discharge Instructions:
Please keep all follow-up appointments, please take all
medications as prescribed. Please notify your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] ([**Telephone/Fax (1) 8417**] or return to the
Emergency department if you experience any chest pain,
difficulty breathing, bleeding, nausea, vomiting, diarrhea,
constipation, fevers, chills, cough, worsening of tongue or lip
swelling, change in mentation or any symptoms that concern you.

Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5762**] after discharge.
{'Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Hemorrhage complicating a procedure,Dementia in conditions classified elsewhere without behavioral disturbance,Angioneurotic edema, not elsewhere classified,Unspecified antibiotic causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy'}


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, lethargy

PRESENT ILLNESS: HPI: Patient is a 46 yo female with history of poorly controlled
HIV/AIDS, not on HAART, with  last CD4 9, VL 329,000 who
presents for fever, lethargy, and latered mental status. The
patient was seen in the E.D. by covering attending, Dr.
[**Last Name (STitle) 71526**] prior to transfer to floor.
The patient is reported to have poor mental status at baseline,
following some commands, but without significant interaction.
The patient has been noted over the last 2 -3 days to have
increasing lethargy, ? increasing secretions from her mouth, and
now feves to 102 today at nursinf facility where she lives. The
patient is transferred to [**Hospital1 18**] for further eval of these
symptoms.
.
In the ED the patient had WBC of 7.4 with left shit, 5% bands,
lactate 2.6. A CXR was negative for acute process but UA was +
with leuks. A CT Head was performed, initially interpeted as
negative, although second eval by ED raised question of a ring
enhancing lesion. Given this lesion, decision was made not to
perform LP at this time but treat empirically with CTX/Vanc at
meningeal dosing. Blood and urine cultures were obtained and the
patient is now transferred to the floor for further eval.
Attempts were made to obtain an MRI in the ED but patient's
brother/HCP were not successful.
.
The patient was seen previously at [**Hospital1 2177**] in [**Month (only) **] [**Numeric Identifier **] for
altered mental status although at that time was without fever or
white count. The patient refused MRI and LP with a non-reactive
RPR. Patient seen by psych and assessed to be without capacity.
The patient's son [**Name (NI) 653**] and gave consent. MRI at that time
revealed significant atrophy and periventricular white matter
densities likely related to HIV, and no other acute process. The
patient's delta MS at that time was thought likely [**12-27**] seizure
disorder and or HIV dementia and patient was D/C back to
facilty.
.
.
Labs/Data:
UA:+
WBC: 7.4 ( N:77 Band:5 L:6 M:12 E:0 Bas:0 Nrbc: 1) <- 1.3 on
[**2120-10-22**]
Hct: 32.3
Plt: 77
Lactate: 2.6
CK: 3078  MB 3  Trop: < .01
Blood/Urine cxs pending
.
[**2120-11-24**]:
WBC 4.0
Hct: 27.4
Plt: 67
.
ECG: ST, 136, nml axis, nml intervals. No acute ST or TW changes
.
Imaging:
.
[**2120-11-25**]: CT Head
There is no intra- or extra-axial hemorrhage, mass effect, or
shift
of normally midline structures.  There is no major vascular
territorial infarction.  Diffuse low attenuation in the
periventricular white matter is consistent with chronic
microvascular infarction.  Moderately large air-fluid levels are
seen in bilateral maxillary sinuses.  A small amount of fluid is
seen within the sphenoid air cells bilaterally, and scattered
ethmoid air cells.  No fracture is identified.
.
[**2120-11-25**]: Portable Chest
1. No acute pulmonary process.
2. Speckled calcifications in the abdomen adjacent to the L2 and
L3 vertebral bodies consistent with pancreatic calcifictions
from prior episodes of pancreatitis.
.
.
A/P: Patient is a 46 year old female with med history
significant for poorly controlled HIV/AIDS, seizure disorder,
history of FTT/AIDS dementia who now presents with altered
mental status, fevers with left shift concerning for underlying
infectious process
.
#. Fever/Delta MS - Patient with altered MS in setting of likely
infection. Patient with +UA but prudent to treat for meningitis
until this can be ruled out. Given ? for ring enhacing lesion in
ED, LP not performed until MRI could be performed, however no
shift or edema noted. Plan to continue empiric treatment
otherwise as per attending on admission
- patient received CTX, Vanc in [**Last Name (LF) **], [**First Name3 (LF) **] continue this. Given
HIV/AIDS status however would add Ampicillin for Listeria
coverage at this time until Bacterial meningitis ruled out
- patient with MRI in late Novemeber without ring enhancing
lesion, not clear one is present now given CT read by rads. If
present, less likely malignancy such as lymphoma but could be
infectious such as toxo/crypto, although patient reportedly on
toxo ppx, also seems like this would be rapid development of
lesion as well
- continue attempts to reach family for MRI consent
- ID curbsided overnight who agrees with plan for empiric
coverage, MRI in a.m. LP will definitely be needed with CSF sent
[**Male First Name (un) 2326**] virus to eval for PML, Crypto, toxo, TB, etc. LP unable to be
performed overnight but not clear that MRI necessary first given
no evidence of elevated ICP on CT. Will check coags in the a.m.
in anticipation of LP
- toxo IgG in a.m., crypto serologies
- follow up blood/urine cultures
- significance of sinus air-fluid levels not clear, however
sinusitis would be covered with above coverage
- if symptoms persist EEG in a.m. for ? seizure activity
- continue outpatient anti-epileptics as possible
- as per outpatient notes as well, discussions regarding Code
Status prudent, full code currently
.
#. HIV/AIDS - patient with poorly controlled HIV, not on HAART
- repeat CD4/VL in a.m., unclear when last values from
- would not start HAART in acute setting given concern for
potential infection, particularly concern would be for
meningitis and immune reconstitution syndrome
.
#. Seizure disorder - patient's oral secretions may have been
[**12-27**] seizure, although still copious.
- continue Keppra per outpatient dosing, will attempt to place
NGT tonight given likely inability to take POs reliably
- consider EEG if symptoms persist
.
#. Pancytopenia - likely from underlying HIV, levels at baseline
currently
- monitor daily
.
#. FEN - NPO for now given delta MS
.
#. Access: PIV
.
#. PPx: SQ heparin, seizure ppx, PPI
.
#. Code: Full for now, need to discuss with family members
.
#. Dispo: Pending eval/improvement
.
#. Communication: [**Name (NI) **] [**Name (NI) 731**] -
Brother: [**Name (NI) **] [**Name (NI) 71527**] [**Telephone/Fax (1) 71528**]
Son: [**Telephone/Fax (1) 71529**]

MEDICAL HISTORY: HIV/AIDS: CD4 < 4, VL 329,000 not on HAART
- ? AIDS dementia/FTT
- PPD negative [**2120-11-3**]
- Pneumovax [**2120-10-24**]
Seizure Disorder
S/p Right MCA CVA [**2116**]
Pancytopenia
GERD
Bladder Incontinence

MEDICATION ON ADMISSION: Ferrous Sulfate 325 tid
Omeprazole 20mg daily
Batrim SS daily
Thiamine 100 daily
Folic Acid 1mg daily
MVI daily
Keppra 500mg [**Hospital1 **]
Azithromax 1200mg q Tuesday
Flonase daily
Nystatin S+S
Ensure

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: T - 99.4 BP: 112/81 HR: 108 RR: 18 O2: 96% on 2L
General: Patient is a chornically ill appearing African-American
female. Patient is awake and looks around but does not interact.
Patient closes eyes to command but follows no other simple
commands. Patient resists mouth opening.
HEENT: NCAT, EOMI grossly. OP: Exam not performed, patient does
not open mouth, resists passive opening
Neck: Supple, no JVD
Chest: Relatively CTA anterior and laterally.
Cor: RRR, normal S1/S2. No M/R/G
Abdomen: Soft, NT, ND. +BS
Extremity: no C/C/E. DP 2+ bilaterally
Skin: No obvious rashes
Neuro: Patient awakre, orientation?. Closes eyes to command but
follows no other commands, non-verbal but cries out
intermittently during exam
CN II-XII without obvious defect, limited by cooperation
Motor/Sensation: Difficult to test

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient is a resident at [**Hospital **] [**Hospital 731**] nursing home. She is
reported to follow commands but have altered communication at
baseline
Tobacco: Previous use, unknown
ETOH: Previous abuse, amount unknown
Illicits: None reported 

### Response:
{'Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Hemorrhage complicating a procedure,Dementia in conditions classified elsewhere without behavioral disturbance,Angioneurotic edema, not elsewhere classified,Unspecified antibiotic causing adverse effects in therapeutic use,Epilepsy, unspecified, without mention of intractable epilepsy'}
