CHIEF COMPLAINT: Altered mental status.

PRESENT ILLNESS: 45 y/o M with HIV on HAART, brought to ED by EMS after
reportedly injecting cocaine last night, and subsequently
developing substernal chest pain. He was given nitro spray x2 by
EMS, with no result.
.
On arrival to the ED, triage vital signs included BP 150/80, HR
170, RR 14, and PO2 79% on NRB. He was also reportedly altered.
He was later found to be febrile to 107.8. He was given 0.4 mg
of narcan, with marginal improvement in his mental status. As
the ED team was preparing to intubate the patient for airway
protection, he developed seizure like activity. He was given
lorazepam, and subsequently intubated. He was started on a
midazolam gtt, and was also given propofol. CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriazone, azithromycin, and vancomycin. Interestingly,
the patient's tox screen was negative for cocaine, but positive
for opiates and amphetamines. Toxicology was consulted, and
recommended treating the patient with benzodiazepines. The
patient underwent aggressive cooling, with subsequent
improvement in his fever, tachycardia, and hypertension. ECG
revealed sinus tachycardia rate-related ST depressions in the
lateral leads. At around 0600, the patient became hypotensive
and he was given aggressive IVF resuscitation with 5L
crystalloid. A CVL was placed, and the patient was started on a
norepinephrine gtt.
.
ABG at 4:30 am on 550x20, PEEP 10, FIO2 100% was 7.22/62/155/27.
He was then switched to 550x26, PEEP 10, FIO2 100%.
.
On arrival to the [**Hospital Unit Name 153**], patient is following commands and nods
his head to denote that he is not having any pain.

MEDICAL HISTORY: HIV/AIDS hx PCP PNA and CMV PNA, last CD4 600, VL undetectable
HCV
DM: on lantus and aspart sliding scale
Major Depressive Disorder
Daily migraines on prophylaxis
Chronic sinusitis s/p surgery [**4-20**]
Thigh cellulitis
Substance Abuse

MEDICATION ON ADMISSION: -venlafaxine 150 mg PO daily
-oxycodone 40 mg Sustained Release Q12H
-oxycodone 10 mg PO Q4-6 hours PRN
-pseudoephedrine HCl 30 mg PO Q6H PRN
-omeprazole 40 mg PO DAILY
-insulin glargine 30 units SC QHS
-Novolog sliding scale
-cyclobenzaprine 10 mg PO HS
-gabapentin 600 mg PO Q8H
-Norflex 30 mg/mL Solution Inj QID PRN
-zolpidem 10 mg PO HS PRN
-atorvastatin 40 mg PO DAILY
-verapamil 240 mg Tablet Sustained Release PO daily
-valacyclovir 1000 mg PO QDAILY
-darunavir 800 mg PO daily
-ritonavir 100 mg PO DAILY
-emtricitabine-tenofovir 200-300 mg PO DAILY
-aspirin 81 mg PO daily
-clonazepam 2 mg PO BID
-albuterol sulfate HFA Two Puff Q4H PRN SOB
- advair [**Hospital1 **]
-EpiPen PRN

ALLERGIES: Bactrim / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Prochlorperazine / Penicillins / Quinolones

PHYSICAL EXAM: Upon admission:
GEN: intubated, opens eyes to voice and follows commands
HEENT: OP without lesions, pupils constricted
RESP: rhochi b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive BS, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, some pinpoint lesions
on left thigh
GU: foley in place with good UOP
Neuro: 2+ patellar and biceps reflexes, minimal rigidity (not
lead pipe), no clonus

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Smokes 1 ppd, no etoh, remote history of IV drug use (had a 2
day relapse in 2/[**2169**]). Unemployed, used to work in catering
management, on disability.  Recently denied temporary housing.
Lives with roommates at halfway house named [**Name (NI) 35095**] house.
Followed closely by his counselor [**Doctor Last Name 636**].
Poisoning by amphetamines,Acute respiratory failure,Pneumonia, organism unspecified,Drug-induced delirium,Acute kidney failure, unspecified,Bacteremia,Other convulsions,Accidental poisoning by psychostimulants,Precordial pain,Unspecified essential hypertension,Asymptomatic human immunodeficiency virus [HIV] infection status,Hypotension, unspecified,Tobacco use disorder,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic pain syndrome,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Chronic hepatitis C without mention of hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Accidents occurring in unspecified place
Poisoning by amphetamine,Acute respiratry failure,Pneumonia, organism NOS,Drug-induced delirium,Acute kidney failure NOS,Bacteremia,Convulsions NEC,Acc poisn-psychstimulant,Precordial pain,Hypertension NOS,Asymp hiv infectn status,Hypotension NOS,Tobacco use disorder,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Chronic pain syndrome,Depressive disorder NEC,Migrne unsp wo ntrc mgrn,Chrnc hpt C wo hpat coma,Other staphylococcus,Accident in place NOS
Admission Date:  [**2169-12-29**]              Discharge Date:   [**2170-1-12**]

Date of Birth:  [**2124-1-22**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Prochlorperazine / Penicillins / Quinolones

Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Altered mental status.

Major Surgical or Invasive Procedure:
1. Intubation
2. Lumbar puncture
3. Central Line Placement and removal

History of Present Illness:
45 y/o M with HIV on HAART, brought to ED by EMS after
reportedly injecting cocaine last night, and subsequently
developing substernal chest pain. He was given nitro spray x2 by
EMS, with no result.
.
On arrival to the ED, triage vital signs included BP 150/80, HR
170, RR 14, and PO2 79% on NRB. He was also reportedly altered.
He was later found to be febrile to 107.8. He was given 0.4 mg
of narcan, with marginal improvement in his mental status. As
the ED team was preparing to intubate the patient for airway
protection, he developed seizure like activity. He was given
lorazepam, and subsequently intubated. He was started on a
midazolam gtt, and was also given propofol. CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriazone, azithromycin, and vancomycin. Interestingly,
the patient's tox screen was negative for cocaine, but positive
for opiates and amphetamines. Toxicology was consulted, and
recommended treating the patient with benzodiazepines. The
patient underwent aggressive cooling, with subsequent
improvement in his fever, tachycardia, and hypertension. ECG
revealed sinus tachycardia rate-related ST depressions in the
lateral leads. At around 0600, the patient became hypotensive
and he was given aggressive IVF resuscitation with 5L
crystalloid. A CVL was placed, and the patient was started on a
norepinephrine gtt.
.
ABG at 4:30 am on 550x20, PEEP 10, FIO2 100% was 7.22/62/155/27.
He was then switched to 550x26, PEEP 10, FIO2 100%.
.
On arrival to the [**Hospital Unit Name 153**], patient is following commands and nods
his head to denote that he is not having any pain.

Past Medical History:
HIV/AIDS hx PCP PNA and CMV PNA, last CD4 600, VL undetectable
HCV
DM: on lantus and aspart sliding scale
Major Depressive Disorder
Daily migraines on prophylaxis
Chronic sinusitis s/p surgery [**4-20**]
Thigh cellulitis
Substance Abuse

Social History:
Smokes 1 ppd, no etoh, remote history of IV drug use (had a 2
day relapse in 2/[**2169**]). Unemployed, used to work in catering
management, on disability.  Recently denied temporary housing.
Lives with roommates at halfway house named [**Name (NI) 35095**] house.
Followed closely by his counselor [**Doctor Last Name 636**].


Family History:
Unable to obtain.

Physical Exam:
Upon admission:
GEN: intubated, opens eyes to voice and follows commands
HEENT: OP without lesions, pupils constricted
RESP: rhochi b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive BS, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, some pinpoint lesions
on left thigh
GU: foley in place with good UOP
Neuro: 2+ patellar and biceps reflexes, minimal rigidity (not
lead pipe), no clonus

At discharge:
VS: Tm98.3, Tc95.7, BP110s-130s/70s-80s, P80s-90s, 20, 93/RA
Gen: Well appearing, stutters frequently
HEENT: MMM, small scab over prior RIJ site, pupils 2mm b/l
Lungs: CTAB, no rhonchi, rales, wheezes
CV: RRR, normal S1/S2, no m/r/b
Abdomen: +BS, soft, nt/nd
Ext: no edema, 2+ DP's bilaterally


Pertinent Results:
Labs upon admission:
[**2169-12-29**] 03:30AM BLOOD WBC-8.1 RBC-4.84 Hgb-13.7* Hct-41.3
MCV-85 MCH-28.3 MCHC-33.2 RDW-16.6* Plt Ct-212
[**2169-12-29**] 03:30AM BLOOD Neuts-73.2* Lymphs-22.3 Monos-3.0 Eos-0.6
Baso-0.8
[**2169-12-29**] 03:30AM BLOOD PT-14.4* PTT-32.4 INR(PT)-1.2*
[**2169-12-29**] 10:43AM BLOOD Fibrino-368
[**2169-12-29**] 03:30AM BLOOD  WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2169-12-29**] 03:30AM BLOOD Glucose-71 UreaN-23* Creat-1.1 Na-139
K-4.1 Cl-105 HCO3-26 AnGap-12
[**2169-12-29**] 03:30AM BLOOD ALT-209* AST-246* LD(LDH)-378*
CK(CPK)-3195* TotBili-0.7
[**2169-12-29**] 03:30AM BLOOD CK-MB-17* MB Indx-0.5
[**2169-12-29**] 03:30AM BLOOD cTropnT-<0.01
[**2169-12-29**] 10:43AM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 05:01PM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 03:30AM BLOOD Albumin-4.0 Calcium-8.5 Phos-1.4*# Mg-1.7
[**2170-1-3**] 04:47AM BLOOD TSH-3.2
[**2169-12-29**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-12-29**] 04:06AM BLOOD Type-ART Temp-40.2 Rates-/20 Tidal V-550
PEEP-10 FiO2-100 pO2-155* pCO2-62* pH-7.22* calTCO2-27 Base
XS--3 AADO2-508 REQ O2-84 -ASSIST/CON Intubat-INTUBATED
[**2169-12-29**] 03:34AM BLOOD Lactate-1.5
[**2169-12-29**] 05:25PM BLOOD O2 Sat-91
[**2169-12-29**] 11:07AM BLOOD freeCa-1.12
.
Other:

[**2169-12-29**] 03:30AM BLOOD  WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2169-12-29**] 03:30AM BLOOD Lipase-17
[**2169-12-29**] 03:30AM BLOOD CK-MB-17* MB Indx-0.5
[**2169-12-29**] 03:30AM BLOOD cTropnT-<0.01
[**2169-12-29**] 10:43AM BLOOD CK-MB-7 cTropnT-<0.01
[**2169-12-29**] 05:01PM BLOOD CK-MB-7 cTropnT-<0.01
[**2170-1-3**] 04:47AM BLOOD TSH-3.2
[**2169-12-29**] 03:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-12-29**] 03:34AM BLOOD Lactate-1.5
[**2169-12-29**] 11:07AM BLOOD Lactate-0.6
[**2169-12-29**] 12:47PM BLOOD Lactate-0.6
[**2169-12-29**] 05:25PM BLOOD Lactate-0.6
[**2169-12-29**] 07:32PM BLOOD Lactate-0.8
[**2169-12-30**] 05:31PM BLOOD Lactate-0.5
.
ABGs
[**2169-12-29**] 04:06AM BLOOD Type-ART Temp-40.2 Rates-/20 Tidal V-550
PEEP-10 FiO2-100 pO2-155* pCO2-62* pH-7.22* calTCO2-27 Base
XS--3 AADO2-508 REQ O2-84 -ASSIST/CON Intubat-INTUBATED
[**2169-12-29**] 11:07AM BLOOD Type-ART pO2-211* pCO2-49* pH-7.30*
calTCO2-25 Base XS--2
[**2169-12-29**] 12:47PM BLOOD Type-ART pO2-74* pCO2-42 pH-7.34*
calTCO2-24 Base XS--2
[**2169-12-29**] 05:25PM BLOOD Type-ART Temp-38.8 pO2-60* pCO2-41
pH-7.37 calTCO2-25 Base XS--1 Intubat-INTUBATED
[**2169-12-29**] 07:32PM BLOOD Type-ART pO2-114* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
[**2169-12-30**] 01:12AM BLOOD Type-ART Temp-38.3 Rates-22/ PEEP-10
FiO2-50 pO2-97 pCO2-43 pH-7.34* calTCO2-24 Base XS--2
Intubat-INTUBATED Vent-CONTROLLED
[**2169-12-30**] 10:49AM BLOOD Type-ART Temp-38.1 Rates-/18 PEEP-10
pO2-121* pCO2-38 pH-7.35 calTCO2-22 Base XS--3 Intubat-INTUBATED
Vent-SPONTANEOU
[**2169-12-30**] 05:31PM BLOOD Type-ART pO2-102 pCO2-40 pH-7.43
calTCO2-27 Base XS-1
[**2169-12-31**] 09:07AM BLOOD Type-ART Temp-37.1 Rates-/19 Tidal V-461
PEEP-5 FiO2-40 pO2-105 pCO2-49* pH-7.39 calTCO2-31* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-1**] 04:00AM BLOOD Type-ART pO2-89 pCO2-48* pH-7.43
calTCO2-33* Base XS-6
[**2170-1-1**] 11:41AM BLOOD Type-ART Temp-37.6 Rates-/35 Tidal V-563
PEEP-5 FiO2-40 pO2-98 pCO2-36 pH-7.50* calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-1**] 01:28PM BLOOD Type-ART Temp-37.0 Rates-/32 PEEP-5
pO2-99 pCO2-34* pH-7.49* calTCO2-27 Base XS-2
[**2170-1-1**] 05:08PM BLOOD Type-ART Temp-37.2 Rates-/27 Tidal V-459
PEEP-5 FiO2-40 pO2-126* pCO2-42 pH-7.44 calTCO2-29 Base XS-4
Intubat-INTUBATED Vent-SPONTANEOU
[**2170-1-2**] 04:21AM BLOOD Type-ART pO2-116* pCO2-38 pH-7.45
calTCO2-27 Base XS-3
[**2170-1-2**] 06:40PM BLOOD Type-ART Temp-39.1 pO2-78* pCO2-29*
pH-7.53* calTCO2-25 Base XS-2 Intubat-NOT INTUBA
[**2170-1-3**] 02:29PM BLOOD Type-ART pO2-113* pCO2-35 pH-7.46*
calTCO2-26 Base XS-1 Comment-SPECIMEN I
[**2170-1-4**] 04:46PM BLOOD Type-ART pO2-75* pCO2-36 pH-7.48*
calTCO2-28 Base XS-3
.
.
Urine:
[**2169-12-29**] 03:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2169-12-29**] 03:50AM URINE Blood-SM Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-12-29**] 03:50AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2170-1-3**] 02:07AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2170-1-3**] 02:07AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-6.0 Leuks-NEG
[**2170-1-3**] 02:07AM URINE RBC-18* WBC-18* Bacteri-NONE Yeast-NONE
Epi-0
[**2170-1-5**] 09:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2170-1-5**] 09:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2170-1-5**] 09:35PM URINE RBC-11* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
[**2170-1-5**] 09:35PM URINE Mucous-FEW
[**2169-12-29**] 06:05PM URINE Hours-RANDOM UreaN-713 Creat-113 Na-106
K-57 Cl-145
[**2169-12-29**] 06:05PM URINE Osmolal-673
[**2169-12-29**] 03:50AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-POS mthdone-NEG
[**2170-1-3**] 02:07AM URINE cocaine-NEG
.
.
BC [**12-29**] x2, [**12-31**] x2 -ve
BC [**1-3**] [**1-5**] NG to date
UCx [**1-5**] -ve
.
[**2169-12-29**] 4:30 am SPUTUM

                            **FINAL REPORT [**2169-12-31**]**

   GRAM STAIN (Final [**2169-12-29**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2169-12-31**]):
      SPARSE GROWTH Commensal Respiratory Flora.
.
[**2170-1-3**] 4:47 am SEROLOGY/BLOOD      RPR ADDED TO CHEM#[**Serial Number 82687**]H.

                            **FINAL REPORT [**2170-1-4**]**

   RAPID PLASMA REAGIN TEST (Final [**2170-1-4**]):
      NONREACTIVE.
      Reference Range: Non-Reactive.
.
[**2170-1-3**] 8:35 pm CSF;SPINAL FLUID      Source: LP #4.

                            **FINAL REPORT [**2170-1-4**]**

   CRYPTOCOCCAL ANTIGEN (Final [**2170-1-4**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
.
[**2170-1-3**] 8:35 pm CSF;SPINAL FLUID      SOURCE; LP #2.

   GRAM STAIN (Final [**2170-1-3**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2170-1-6**]):    NO GROWTH.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.
.
[**2170-1-4**] 10:29 am STOOL     CONSISTENCY: SOFT      Source:
Stool.

                            **FINAL REPORT [**2170-1-5**]**

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2170-1-5**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
[**2170-1-5**] 9:49 pm SPUTUM      Source: Expectorated.

   GRAM STAIN (Final [**2170-1-5**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2170-1-7**]):
      SPARSE GROWTH Commensal Respiratory Flora.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   FUNGAL CULTURE (Preliminary):
      YEAST.

[**2170-1-6**] 12:12 pm BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2170-1-10**]**

   Blood Culture, Routine (Final [**2170-1-10**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         Isolated from only one set in the previous five days.
         SENSITIVITIES PERFORMED ON REQUEST..

   Aerobic Bottle Gram Stain (Final [**2170-1-7**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20**] ON [**2170-1-7**] AT [**2094**].

   Anaerobic Bottle Gram Stain (Final [**2170-1-8**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.

[**2170-1-10**] 5:47 pm SPUTUM      Source: Induced.

                            **FINAL REPORT [**2170-1-11**]**

   GRAM STAIN (Final [**2170-1-10**]):
      [**10-30**] PMNs and >10 epithelial cells/100X field.
      Gram stain indicates extensive contamination with upper
respiratory
      secretions. Bacterial culture results are invalid.
      PLEASE SUBMIT ANOTHER SPECIMEN.

   RESPIRATORY CULTURE (Final [**2170-1-10**]):
      TEST CANCELLED, PATIENT CREDITED.

   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2170-1-11**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

PERTINENT LABS
[**2169-12-29**] 03:30AM BLOOD  WBC-8.1 Lymph-22 Abs [**Last Name (un) **]-1782 CD3%-76
Abs CD3-1347 CD4%-12 Abs CD4-215* CD8%-62 Abs CD8-1101*
CD4/CD8-0.2*
[**2170-1-10**] 07:20AM BLOOD CRP-35.3*
[**2170-1-10**] 07:20AM BLOOD ESR-65*
[**2170-1-10**] 10:29AM BLOOD B-GLUCAN-Test
[**2170-1-4**] 04:31AM BLOOD ALT-92* AST-79* LD(LDH)-466* AlkPhos-130
TotBili-0.6

ADMISSION CXR
IMPRESSION:
1. Multifocal pneumonia.
2. Central pulmonary vascular congestion with moderate pulmonary
edema.
3. ET tube terminating 6.6 cm above the carina.

CXR DAY PRIOR TO DISCHARGE
FINDINGS: In comparison with the study of [**1-8**], there is still
some mild
opacification in the right upper lobe that could reflect some
clearing
consolidation. Minimal increased opacification in the left upper
zone also may reflect clearing infectious process. There is
better aeration at the left base with only mild atelectatic
changes. The region of the azygos node and vein is within normal
limits at this time.

If there is serious clinical concern for an underlying
infectious process or lymphadenopathy, CT would be the next
imaging procedure.

ECHOCARDIOGRAM [**2170-1-8**]
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Transmitral and tissue Doppler imaging suggests normal diastolic
function, and a normal left ventricular filling pressure
(PCWP<12mmHg). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.

IMPRESSION: No echocardiographic evidence of endocarditis.
Normal regional and global biventricular systolic function. No
pathologic valvular abnormality seen.

If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.

Compared with the report of the prior study (images unavailable
for review) of [**2169-10-4**], the findings are similar.

RENAL US [**2170-1-9**]
IMPRESSION:
Unremarkable renal ultrasound.

CT CHEST [**2170-1-9**]
IMPRESSION:

1. Bilateral upper lobe ground-glass opacities suggest improving
infection.
These could be followed with standard radiograph, beginning with
a radiograph
today to serve as a baseline for comparison with this study.

2. Overall stable mediastinal lymph node enlargement except for
slight
increase in subcarinal node, now 16 mm.


Brief Hospital Course:
45 year old male with HIV, HCV, DM, presenting with altered
mental status and seizures, with hypertension, tachycardia, and
severe hyperthermia.

# Altered mental status: On initial presentation, the patient
was hypertensive, tachycardic, tremulous, and febrile, all of
which were consistent with amphetamine toxicity per his tox
screen.  The patient was initially intubated in the ED for
airway protection, and was extubated on [**1-1**]; unfortunately he
had to be re-intubated on [**2170-1-2**] for agitation.  The [**2170-1-2**]
reintubation was in the setting of having received several doses
of valium, as well as three doses of Haldol, but to no effect.
During hospitialization, the patient was also tried on precedex,
although this was not able to control his AMS/HTN/Tachycardia.
The patient's HR and HTN resolved on propofol, which sedated him
while he was intubated.  Given intermittent fevers, an LP at the
time was unrevealing.  The patient was extubated on [**2170-1-5**],
and was AAOx3. On [**2169-1-6**], the patient once again became
tachycardiac and hypertensive, but this time presented with
paranoia and fear.  Psychiatry was consulted, who recommended
holding venlafaxine in setting of altered mental status.
Toxicology was consulted and felt that this was consistent with
benzodiazepine withdrawal as he only received occaisional doses
of valium on [**1-2**] and he typically takes Klonopin 2mg [**Hospital1 **] at
home.  Subsequently, the patient was placed on an aggressive
Valium scale Q30min for agitation.  He required extremely high
doses of valium but responded well.  His mental status continued
to improve throughout his ICU stay with Valium weaned.  Prior to
transfer he was alert and oriented X3, back at his baseline per
his outpatient counselor.
.
After transfer to the medicine floor, his valium was weaned to
Q6H prn.  Of note, he usually takes Clonazepam at home, however
given that he will soon be in the [**Hospital **] clinic, they felt
that valium would be easier to taper over time.  Psychiatry c/s
continued to follow and felt that the stuttering that restarted
may be a lingering manifestation of ICU stress, anoxic brain
injury, or possible [**2-7**] venlafaxine discontinuation.  They
recommended commencing venlafaxine administration which was
done.  The patient was noted to be AAOx3 throughout his stay on
the medicine floor.
.
# Respiratory Failure: Patient initially intubated in ED for
airway protection, and a CXR at that time showed some pulmonary
edema and a retrocardiac opacity. The patient was started on
broad HCAP coverage given a recent hopsitalization with
Vanc/Meropenam/Azithro given a documented allergy to penicillins
and quinolones. These antibiotics were continued until [**2170-1-5**]
for a total 8 day course. The patient was initally extubated on
[**1-1**], but had to be reinbuated on [**2170-1-2**] for agitation. He
was then extubated on [**2170-1-5**]. On [**2169-1-6**] the patient was noted
to have a slight O2 requirement of 2L, satting 93. Respiratory
status continued to improve during hospitalization.  A chest
xray should be obtained in six weeks for follow up of his
radiographic findings.
.
Upon transfer to the Medicine floor, the patient continued to
sat in the mid to upper 90s on room air.  A CT chest that was
done in the unit revealed GGO thought to be resolving PNA vs.
PCP.  [**Name10 (NameIs) 6**] ambulatory sat was done which was nonrevealing (pt
remained 100% on RA throughout).  The CT chest final read felt
the GGO are likely [**2-7**] resolving PNA.  A baseline CXR was
obtained on [**2170-1-11**], and a repeat CXR can be obtained in ~6 weeks
time.
.
# Fevers/Infectious work-up. Throughout MICU stay patient
experienced intermittent fevers. On admission, CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriaxone, azithromycin, and vancomycin initially.  The
patient's tox screen was negative for cocaine despite reporting
IV cocaine use.  The tox screen was positive for opiates and
amphetamines.  It was thought that his initial fever to 108 was
likely amphetamine toxicity.  The patient underwent aggressive
cooling, with subsequent improvement in his fever, tachycardia,
and hypertension. He then became hypotensive and he was given
aggressive IVF resuscitation with 5L crystalloid.  He was
started on a norepinephrine gtt.  On admission to the ICU, he
was continued on Vancomycin but changed to Meropenem for the
concern of PNA.  He was delirious on [**1-2**] which raised concern
for meningitis as he was persistently spiking fevers.  The
patient was continued on Vancomycin, Meropenem (allergy to PCN
and sulfa), and started on Acyclovir although HSV was felt to be
unlikely in the context of daily Valacyclovir suppressive
therapy.  Acyclovir was stopped when HSV PCR returned negative.
On [**1-3**] the patient underwent LP with results 0 WBC (PMN 0, L
94), 1 RBC, protein 46, glucose 58. With these results, his
antibiotics were changed back to PNA dosing and his CVL was
discontinued. On [**1-5**] the patient's antibiotics were
discontinued and he was extubated.  The patient had persistent
fever with Tm of 102.1 on [**1-6**] and blood culture returned with
GPC in clusters in [**2-7**] bottles.  Vancomycin was restarted and ID
was consulted.  TTE was performed without evidence of
vegetation.  Acyclovir was discontinued on [**1-8**] after return of
negative HSV PCR.  On transfer to floor patient was still
receiving vancomycin for total 5 day course treatment of
presumed line infection.  His fevers subsided during this
course.
.
On the medicine floor, he remained afebrile.  A work up of
possible PCP was undertaken, and results in the previous section
reveal that immunofluoresence for PCP on induced sputum was
negative, ambulatory sat was wnl.  His vancomycin was d/c'ed
after 5 days (as above).
.
# Hypotension: On presentation patient was hypotensive and
aggressively fluid resuscitated and started on levophed.  The
patient's LFTs were elevated, but this was thought secondary to
muscle etiology, rather than shock liver given the degree of
elevation, the elevated CPK, the appropriate UOP, and lactate
levels.  The patient's hypotension was initially thought
secondary to sedation.  Hypotension quickly improved and patient
weaned off pressors.
.
# Hypertension/Tachycardia: Patient without history of essential
hypertension. The patient was noted on multiple occasions during
ICU stay to be both tachycardic and severly hypertensive. His
clinical presentation appeared to be a likely sympathomimetic
toxidrome in setting of amphetamine use.  Later in
hospitalization recurrent hypertension/agitation was thought
secondary to a benzodiazpine withdrawal.  Over the course of his
stay, he was briefly started on hydralazine and captopril in
addition to propofol gtt.  Toxicology consult favored frequent
checks for tachycardia/hypertension/tremulousness, and to treat
aggressively with Valium, which was done.  The patient's
HTN/Tachycardia ultimately improved and at time of transfer to
the floor. His VS remained stable on the floor.
.
# Chest pain: Rate related lateral ST depressions on initial
EKG, now resolved and patient in sinus rhythm.  Cardiac enzymes
were negative and the patient did not complain of any chest pain
throughout the rest of his admission.
.
# HIV: Patient reported last known CD4 to be 600 with an
undetectable viral load.  Patient's CD4 was repeated in hospital
and was 215, clearly in the setting of acute illness.  A viral
load was not obtained.  He was continued on his home HIV
medications of Darunavir, Ritonavir, and Truvada.  Per his PCP
at [**Name9 (PRE) 778**], Bactrim PPX for PCP was not started.  Further w/u of
HIV and cause of drop in CD4 was deferred for the outpatient
arena.
.
# DM: Borderline hypoglycemia on admission labs. On
basal/sliding scale insulin as outpatient. Patient was on SSI
during admission.  At the end of his admission, he was not
requiring any SSI so his outpatient long and short acting
insulin was discontinued at time of discharge.
.
# Seizure: On admission the patient was hypoxic and with an
altered mental status. He was found to be febrile to 107.8. The
patient subsequently developed seizure like activity prior to
intubation.  He was given lorazepam, and subsequently intubated.
He was started on a midazolam gtt, and was also given propofol.
Initial seizure likely secondary to hyperthermia from
amphetamine toxicity.
.
# Elevated transaminases: Patient has had elevations in
transaminases in the past secondary to HCV, but current
elevation on admission was felt secondary to muscle breakdown in
the setting of withdrawal/seizures, as both transaminitis and CK
improved over the course of hosptialization with hydration. LFTs
were trending down and improved prior to discharge.
.
# Elevated Creatinine: Creatinine elevated on admission to 1.1
from baseline of 0.9. Initially improved with hydration however
bumped again thought secondary to ATN (FEUrea >36% and FENa >1 %
in keeping with ATN) with iatrogenic contribution from
vancomycin or captopril. Renal function trended, nephrotoxic
drus were avoided.  Upon discharge, Cr improved to 1.4.  Further
w/u was deferred to the outpatient setting.
.
# Depression: Initially held antidepressive medications
(venlafaxine/trazadone) in the setting of concern for seritonin
syndrome. Psychaitry was consulted, who recommended holding
Effexor in the MICU in setting of altered mental status.  As
above, Effexor was restarted on the floor as per psych
recomendations.
.
# Chronic pain syndrome: He was continued on his home dose of
gabapentin and oxycodone.  Oxycontin was stopped given its
extreme sedative effect on the patient, and adequate control
with prn oxycodone.  His oxycodone was tapered to Q6h, however
he required oxycodone more frequently at Q4h.  He ultimately is
hoping to enter the [**Hospital **] clinic, and as such will continue
tapering the medications in the outpatient setting with his PCP.
 [**Name10 (NameIs) **] was discharged on 10 mg oxycodone Q4-6h prn pain with a
short course to f/u with his PCP.
.
# HA: Pt noted to have HA on the medicine floor.  Of note, tests
for nuchal rigidity and meningismus were non revealing (negative
Kernig, Brudzinski, Jolt signs).  Pt was treated with Norflex
and oxycodone for HA.  Of note, had nausea as well, but is
allergic to compazine which would have been ideal to treat both.
 Zofran prn upon discharge for nausea.
.
# FOLLOWUP
- CXR should be obtained 6 weeks after discharge regarding
resolving infx.
- HIV (drop in CD4) and ARF w/u pending outpatient work up.

Medications on Admission:
-venlafaxine 150 mg PO daily
-oxycodone 40 mg Sustained Release Q12H
-oxycodone 10 mg PO Q4-6 hours PRN
-pseudoephedrine HCl 30 mg PO Q6H PRN
-omeprazole 40 mg PO DAILY
-insulin glargine 30 units SC QHS
-Novolog sliding scale
-cyclobenzaprine 10 mg PO HS
-gabapentin 600 mg PO Q8H
-Norflex 30 mg/mL Solution Inj QID PRN
-zolpidem 10 mg PO HS PRN
-atorvastatin 40 mg PO DAILY
-verapamil 240 mg Tablet Sustained Release PO daily
-valacyclovir 1000 mg PO QDAILY
-darunavir 800 mg PO daily
-ritonavir 100 mg PO DAILY
-emtricitabine-tenofovir 200-300 mg PO DAILY
-aspirin 81 mg PO daily
-clonazepam 2 mg PO BID
-albuterol sulfate HFA Two Puff Q4H PRN SOB
- advair [**Hospital1 **]
-EpiPen PRN

Discharge Medications:
1. venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
2. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*40 Tablet(s)* Refills:*1*
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
5. orphenadrine citrate 30 mg/mL Solution Injection
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. verapamil 240 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
8. pseudoephedrine HCl  Oral
9. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
10. valacyclovir 1 g Tablet Sig: One (1) Tablet PO once a day.
11. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea for
14 days.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
16. diazepam 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for agitation/anxiety for 14 days.
Disp:*30 Tablet(s)* Refills:*1*
17. EpiPen  Intramuscular
18. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 disk* Refills:*2*
20. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Amphetamine overdose

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

Discharge Instructions:
You were admitted to [**Hospital1 18**] for hypertension, fast heart rate,
and a fever due to an overdose.  You were intubated for airway
protection and kept safe in the ICU.  After you were able to be
weaned from the machine, you were transferred to the floor for
further titrating of your valium and oxycodone.  You had a lung
and blood infection and these were treated with antibiotics.  We
also monitored you to make sure you did not have PCP [**Name Initial (PRE) 1064**].
Your blood sugars in the hospital have been fine, so we stopped
your insulin.

PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP taking your LANTUS
- STOP taking your NOVOLOG
- STOP taking KLONOPIN
- STOP taking OXYCONTIN
- START taking VALIUM 10 mg every 6 hours as needed for anxiety
- CONTINUE taking OXYCODONE 10 mg every 4 hours as needed for
pain
- START taking ZOFRAN 4 mg every 8 hours as needed for nausea

Please follow up with your physicians as indicated below.

Followup Instructions:
Please call Dr. [**Last Name (STitle) 6420**] to see if you can get an earlier
appointment.

Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: [**Last Name (LF) 2974**], [**2170-1-26**]:50AM

Name: [**Last Name (LF) **], [**First Name3 (LF) **]
Location: [**Hospital6 **] Center
Address: [**Location (un) **]., [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 798**]
*Someone from [**Hospital1 778**] will contact you to schedule an
appointment. If you dont hear from them by Monday, [**1-15**], please
call Dr. [**Last Name (STitle) **] to schedule an appointment within 2-4 weeks.


                             [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU

Completed by:[**2170-1-12**]
{'Poisoning by amphetamines,Acute respiratory failure,Pneumonia, organism unspecified,Drug-induced delirium,Acute kidney failure, unspecified,Bacteremia,Other convulsions,Accidental poisoning by psychostimulants,Precordial pain,Unspecified essential hypertension,Asymptomatic human immunodeficiency virus [HIV] infection status,Hypotension, unspecified,Tobacco use disorder,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic pain syndrome,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Chronic hepatitis C without mention of hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Accidents occurring in unspecified place'}


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: Altered mental status.

PRESENT ILLNESS: 45 y/o M with HIV on HAART, brought to ED by EMS after
reportedly injecting cocaine last night, and subsequently
developing substernal chest pain. He was given nitro spray x2 by
EMS, with no result.
.
On arrival to the ED, triage vital signs included BP 150/80, HR
170, RR 14, and PO2 79% on NRB. He was also reportedly altered.
He was later found to be febrile to 107.8. He was given 0.4 mg
of narcan, with marginal improvement in his mental status. As
the ED team was preparing to intubate the patient for airway
protection, he developed seizure like activity. He was given
lorazepam, and subsequently intubated. He was started on a
midazolam gtt, and was also given propofol. CXR revealed
bilateral lower lobe infiltrates, for which the patient was
given ceftriazone, azithromycin, and vancomycin. Interestingly,
the patient's tox screen was negative for cocaine, but positive
for opiates and amphetamines. Toxicology was consulted, and
recommended treating the patient with benzodiazepines. The
patient underwent aggressive cooling, with subsequent
improvement in his fever, tachycardia, and hypertension. ECG
revealed sinus tachycardia rate-related ST depressions in the
lateral leads. At around 0600, the patient became hypotensive
and he was given aggressive IVF resuscitation with 5L
crystalloid. A CVL was placed, and the patient was started on a
norepinephrine gtt.
.
ABG at 4:30 am on 550x20, PEEP 10, FIO2 100% was 7.22/62/155/27.
He was then switched to 550x26, PEEP 10, FIO2 100%.
.
On arrival to the [**Hospital Unit Name 153**], patient is following commands and nods
his head to denote that he is not having any pain.

MEDICAL HISTORY: HIV/AIDS hx PCP PNA and CMV PNA, last CD4 600, VL undetectable
HCV
DM: on lantus and aspart sliding scale
Major Depressive Disorder
Daily migraines on prophylaxis
Chronic sinusitis s/p surgery [**4-20**]
Thigh cellulitis
Substance Abuse

MEDICATION ON ADMISSION: -venlafaxine 150 mg PO daily
-oxycodone 40 mg Sustained Release Q12H
-oxycodone 10 mg PO Q4-6 hours PRN
-pseudoephedrine HCl 30 mg PO Q6H PRN
-omeprazole 40 mg PO DAILY
-insulin glargine 30 units SC QHS
-Novolog sliding scale
-cyclobenzaprine 10 mg PO HS
-gabapentin 600 mg PO Q8H
-Norflex 30 mg/mL Solution Inj QID PRN
-zolpidem 10 mg PO HS PRN
-atorvastatin 40 mg PO DAILY
-verapamil 240 mg Tablet Sustained Release PO daily
-valacyclovir 1000 mg PO QDAILY
-darunavir 800 mg PO daily
-ritonavir 100 mg PO DAILY
-emtricitabine-tenofovir 200-300 mg PO DAILY
-aspirin 81 mg PO daily
-clonazepam 2 mg PO BID
-albuterol sulfate HFA Two Puff Q4H PRN SOB
- advair [**Hospital1 **]
-EpiPen PRN

ALLERGIES: Bactrim / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Prochlorperazine / Penicillins / Quinolones

PHYSICAL EXAM: Upon admission:
GEN: intubated, opens eyes to voice and follows commands
HEENT: OP without lesions, pupils constricted
RESP: rhochi b/l
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, hypoactive BS, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters, some pinpoint lesions
on left thigh
GU: foley in place with good UOP
Neuro: 2+ patellar and biceps reflexes, minimal rigidity (not
lead pipe), no clonus

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: Smokes 1 ppd, no etoh, remote history of IV drug use (had a 2
day relapse in 2/[**2169**]). Unemployed, used to work in catering
management, on disability.  Recently denied temporary housing.
Lives with roommates at halfway house named [**Name (NI) 35095**] house.
Followed closely by his counselor [**Doctor Last Name 636**]. 

### Response:
{'Poisoning by amphetamines,Acute respiratory failure,Pneumonia, organism unspecified,Drug-induced delirium,Acute kidney failure, unspecified,Bacteremia,Other convulsions,Accidental poisoning by psychostimulants,Precordial pain,Unspecified essential hypertension,Asymptomatic human immunodeficiency virus [HIV] infection status,Hypotension, unspecified,Tobacco use disorder,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Chronic pain syndrome,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Chronic hepatitis C without mention of hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Accidents occurring in unspecified place'}
