CHIEF COMPLAINT: Pleural effusion

PRESENT ILLNESS: This is a 42 year-old woman with history of HIV, Hepatitis C
cirrhosis on the transplant list presenting from clinic with
right pleural effusion. She was recently admitted ([**Date range (1) 76893**])
for right pleural effusion and 1.2L were removed. It was
consistent with a transudate and no malignant cells were seen.
ECHO showed EF >55% and no liver lesions seen on MRI. The
effusion was thought to be a sympathetic effusion from ascites.
The patient did not receive a paracentesis at that time. She
states that in the interim her breathing improved and she was
comfortable. However, 1-2 weeks prior to admission she began to
become short of breath. She went to her physican in [**Hospital1 789**]
and a CXR was performed. The was not a large effusion present on
that CXR. However, she continued to worsen and states that over
the weekend her breathing worsened further. She is unable to
sleep because she needs to sleep propped up due to SOB when
supine. She also reports increasing lower ext edema and increase
in her abdominal girth. She denied any abdominal pain,
N/V/D/F/C. She does report a cough with clear sputum. She
returned to her doctor [**First Name (Titles) **] [**Last Name (Titles) 789**] and repeat CXR showed a
"large" effusion. She saw Dr. [**Last Name (STitle) 497**] in clinic today and was
admitted directly for further management.
.
Review of sytems otherwise unremarkable. She denies urinary
symptoms. She denies changes in bowel habits, denies melenotic
stools or hematochezia.

MEDICAL HISTORY: 1. HIV (CD4 670, vL ND [**1-/2178**])
- diagnosed in [**2157**], presumed from IVDU versus sexual
transmission from husband, who was long-term IV drug user
- started ART 1 year ago d/t elevated vL, low CD4 in setting of
acute illness, per patient not diagnosed with OI
2. Hepatitis C cirrhosis (HepC vL 1,090,000 [**3-/2177**])
- diagnosed in [**2176**]
- on transplant list
- complicated by ascites, encephalopathy, grade 1 varices
- history of elevated AFP without focal liver lesions
3. History of necrotizing fascitis [**2163**]

MEDICATION ON ADMISSION: Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg QHS
Raltegravir [Isentress] 400 mg [**Hospital1 **]
Spironolactone 100 mg DAILY
Lasix 60mg daily
Lactulose 30 mL 2-3 times a day
Clotrimazole 10 mg troche five times per day
Calcium Carbonate-Vitamin D3 600 mg-400 unit [**Hospital1 **]
Fe supplements

ALLERGIES: Atripla / Morphine

PHYSICAL EXAM: Admission:
VS: T 97, BP 114/76, HR 92, RR 18, 98% RA
GEN: middle-aged women, generally well appearing with
appropriate affect and behavior, who is lying in bed and
speaking comfortable in no apparent distress, not dyspenic or
tachypneic
HEENT: moist mucous membranes
NECK: supple, no JVD, no LAD
CV: S1&S2 RRR, 2/6 SEM
CHEST: decreased breath sounds on the right to [**Date range (1) 55744**] up the
lung field with dullness to percussion in the same region. No
R/W. Good breath sounds on the left
ABD: soft, slightly distended; non-tender, +BS, no rebound no
gaurding
EXT: +1 pitting edema; feet warm and well-perfused with 2+ DP
pulses

FAMILY HISTORY: Her mother is currently alive and doing well but suffers from
high blood pressure. The patient's father reportedly died in
[**2173**] from Parkinson's disease.

SOCIAL HISTORY: The patient lives with her mother and does not work due to
diability. She very occasionally used to smoke tobacco and last
smoked two years ago. The patient reported that she stopped
consuming alcohol two years ago and prior to that only consumed
very occasionally. History of other substance use includes IVDU
(stopped [**2156**]), cocaine and mushrooms, no current use.
Unspecified pleural effusion,Acute kidney failure, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Other diseases of lung, not elsewhere classified
Pleural effusion NOS,Acute kidney failure NOS,Asymp hiv infectn status,Hemorrhage complic proc,Ac posthemorrhag anemia,Hyposmolality,Cirrhosis of liver NOS,Chrnc hpt C wo hpat coma,Other lung disease NEC
Admission Date:  [**2178-4-1**]              Discharge Date:   [**2178-4-8**]

Date of Birth:  [**2136-1-30**]             Sex:   F

Service: MEDICINE

Allergies:
Atripla / Morphine

Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Pleural effusion

Major Surgical or Invasive Procedure:
Thoracentesis
Blood Transfusions
Central Line Placement
Pigtail Catheter Placement


History of Present Illness:
This is a 42 year-old woman with history of HIV, Hepatitis C
cirrhosis on the transplant list presenting from clinic with
right pleural effusion. She was recently admitted ([**Date range (1) 76893**])
for right pleural effusion and 1.2L were removed. It was
consistent with a transudate and no malignant cells were seen.
ECHO showed EF >55% and no liver lesions seen on MRI. The
effusion was thought to be a sympathetic effusion from ascites.
The patient did not receive a paracentesis at that time. She
states that in the interim her breathing improved and she was
comfortable. However, 1-2 weeks prior to admission she began to
become short of breath. She went to her physican in [**Hospital1 789**]
and a CXR was performed. The was not a large effusion present on
that CXR. However, she continued to worsen and states that over
the weekend her breathing worsened further. She is unable to
sleep because she needs to sleep propped up due to SOB when
supine. She also reports increasing lower ext edema and increase
in her abdominal girth. She denied any abdominal pain,
N/V/D/F/C. She does report a cough with clear sputum. She
returned to her doctor [**First Name (Titles) **] [**Last Name (Titles) 789**] and repeat CXR showed a
"large" effusion. She saw Dr. [**Last Name (STitle) 497**] in clinic today and was
admitted directly for further management.
.
Review of sytems otherwise unremarkable. She denies urinary
symptoms. She denies changes in bowel habits, denies melenotic
stools or hematochezia.


Past Medical History:
1. HIV (CD4 670, vL ND [**1-/2178**])
- diagnosed in [**2157**], presumed from IVDU versus sexual
transmission from husband, who was long-term IV drug user
- started ART 1 year ago d/t elevated vL, low CD4 in setting of
acute illness, per patient not diagnosed with OI
2. Hepatitis C cirrhosis (HepC vL 1,090,000 [**3-/2177**])
- diagnosed in [**2176**]
- on transplant list
- complicated by ascites, encephalopathy, grade 1 varices
- history of elevated AFP without focal liver lesions
3. History of necrotizing fascitis [**2163**]


Social History:
The patient lives with her mother and does not work due to
diability. She very occasionally used to smoke tobacco and last
smoked two years ago. The patient reported that she stopped
consuming alcohol two years ago and prior to that only consumed
very occasionally. History of other substance use includes IVDU
(stopped [**2156**]), cocaine and mushrooms, no current use.

Family History:
Her mother is currently alive and doing well but suffers from
high blood pressure. The patient's father reportedly died in
[**2173**] from Parkinson's disease.

Physical Exam:
Admission:
VS: T 97, BP 114/76, HR 92, RR 18, 98% RA
GEN: middle-aged women, generally well appearing with
appropriate affect and behavior, who is lying in bed and
speaking comfortable in no apparent distress, not dyspenic or
tachypneic
HEENT: moist mucous membranes
NECK: supple, no JVD, no LAD
CV: S1&S2 RRR, 2/6 SEM
CHEST: decreased breath sounds on the right to [**Date range (1) 55744**] up the
lung field with dullness to percussion in the same region. No
R/W. Good breath sounds on the left
ABD: soft, slightly distended; non-tender, +BS, no rebound no
gaurding
EXT: +1 pitting edema; feet warm and well-perfused with 2+ DP
pulses


Pertinent Results:
[**2178-4-1**] 03:35PM BLOOD WBC-8.1 RBC-3.01* Hgb-10.2* Hct-31.6*
MCV-105* MCH-34.0* MCHC-32.3 RDW-17.9* Plt Ct-100*
[**2178-4-1**] 03:35PM BLOOD PT-24.3* PTT-44.0* INR(PT)-2.4*
[**2178-4-1**] 03:35PM BLOOD Glucose-89 UreaN-10 Creat-0.9 Na-129*
K-3.3 Cl-98 HCO3-25 AnGap-9
[**2178-4-1**] 03:35PM BLOOD ALT-95* AST-189* LD(LDH)-328*
AlkPhos-341* TotBili-7.4*
[**2178-4-1**] 03:35PM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.6*
Mg-1.8
[**2178-4-7**] 06:00AM BLOOD calTIBC-267 Ferritn-258* TRF-205 Iron-75

[**2178-4-8**] 05:55AM BLOOD WBC-6.4 RBC-2.85* Hgb-9.4* Hct-28.8*
MCV-101* MCH-33.0* MCHC-32.6 RDW-21.3* Plt Ct-84*
[**2178-4-8**] 05:55AM BLOOD PT-20.7* PTT-36.2* INR(PT)-2.0*
[**2178-4-8**] 05:55AM BLOOD Glucose-66* UreaN-14 Creat-1.0 Na-136
K-4.3 Cl-99 HCO3-30 AnGap-11
[**2178-4-8**] 05:55AM BLOOD ALT-65* AST-119* LD(LDH)-256*
AlkPhos-197* TotBili-6.7*
[**2178-4-7**] 06:00AM BLOOD Albumin-3.0* Calcium-8.7 Phos-1.8* Mg-1.8

[**2178-4-4**] 12:44PM URINE Osmolal-325
[**2178-4-4**] 12:44PM URINE Hours-RANDOM Creat-23 Na-87
[**2178-4-4**] 12:49PM PLEURAL WBC-5222* Hct,Fl-22* Polys-63*
Lymphs-20* Monos-17*
[**2178-4-2**] 06:00PM PLEURAL WBC-420* RBC-780* Polys-2* Lymphs-47*
Monos-21* Meso-9* Macro-21*
[**2178-4-4**] 12:49PM PLEURAL Glucose-77 LD(LDH)-310 Albumin-1.7
[**2178-4-2**] 06:00PM PLEURAL TotProt-0.5 LD(LDH)-83 Albumin-LESS
THAN

[**2178-4-2**] 6:00 pm PLEURAL FLUID
                            **FINAL REPORT [**2178-4-8**]**
   GRAM STAIN (Final [**2178-4-2**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   FLUID CULTURE (Final [**2178-4-5**]):    NO GROWTH.
   ANAEROBIC CULTURE (Final [**2178-4-8**]):    NO GROWTH.

Cytology Pleural Fluid:
  NEGATIVE FOR MALIGNANT CELLS.

CXR: [**4-1**]
IMPRESSION: Large right pleural effusion, increased in size
since prior
study.

CXR: [**4-2**]
IMPRESSION: AP chest compared to [**2-4**] and [**4-1**]:

Right lung base is still elevated but there has been a
substantial decrease in
the volume of right pleural effusion. How much subpulmonic
effusion persists
is difficult to say, and might be detectable by decubitus views.
Substantial
right lower lobe atelectasis persists, though improved. Left
lung is clear,
heart size normal. No appreciable pneumothorax.

CXR: [**4-2**]
IMPRESSION: AP chest compared to [**4-2**] at 6:31 p.m.

Elevation of the right lung base due in part to subpulmonic
pleural effusion
has worsened, and volume of right pleural fluid layering
posteriorly and
collecting in fissures has increased. Severe atelectasis in the
right middle
and lower lobe persists. Left lung is clear, but mediastinum
remains shifted
to the left. No pneumothorax.

CT [**4-3**]
IMPRESSION:

1. Large right pleural effusion. No evidence of acute
hemothorax.

2. Complete right lower lobe and partial right middle lobe
collapse likely
secondary to the adjacent large right pleural effusion.

3. 6-mm peribronchovascular nodule in the superior segment of
the left lower
lobe which is new compared to the prior study and is most likely
infectious or
inflammatory in etiology. However, a small iatrogenic vascular
malformation
cannot be excluded (e.g., if the patient has undergone Swan Ganz
catheter
placement) and a followup contrast enhance CT is recommended in
three months
to ensure resolution or to further characterize if persistent.

4. Stable 2-mm right upper lobe nodule.

5. Stable compression fracture, of T10 vertebral body, unchanged
since chest
x-ray of [**2178-1-18**].

CXR [**4-4**]
The right internal jugular line tip is at the level of mid SVC.
The upper
portion is kinked but it's most likely external but should be
evaluated
clinically. There is no change in the right pigtail catheter.
There is no
change in the position of the right hemidiaphragm and the degree
of aeration
of the right lung base. The left basal atelectasis is new since
[**2178-4-3**],
chest radiograph but is not included in the field of view of the
study
obtained on [**2178-4-4**], at 4:24 p.m. No pneumothorax is
present.
Cardiomediastinal silhouette is unchanged and no failure is
seen.

CT Chest [**4-5**]
IMPRESSION:
1. Significant decrease in right pleural effusion. Small to
moderate right
pleural effusion remains. There is new minimal pneumothorax on
the right
following pigtail catheter placement.
2. New atelectasis at the left lung base.
3. Moderate loss of aeration in the right lower lobe. This could
be due to
atelectasis or pneumonia.
4. Indeterminate nodule in the superior segment of the left
lower lobe. This
measures about 7 mm. Followup to resolution with repeat scan in
three months
is recommended.

CXR [**4-7**]
FINDINGS: In comparison with the study of [**4-6**], the pigtail
catheter has
been removed. No change in the appearance of the right pleural
effusion and
no evidence of pneumothorax. The mild opacification in the
retrocardiac area
has reduced since the previous study.


Brief Hospital Course:
42 y.o. female with HIV, Hep C., on the transplant list,
transferred to the ICU with hemothorax and dropping Hct as well
as hypoxia.
.
# Hemothorax: The patient was found to have reaccumulation of
her right pleural effusion over a 4 week period.  A CXR on
admission showed right effusion likely a sympathetic effusion
secondary to ascites. The patient's INR was 2.2 and she recieved
4U of FFP and underwent thoracentesis at the bedside and 1.6L
were removed [**4-2**].  The fluid was consistent with a transudate,
cultures negative and cytology negative for malignant cells.
During the night the patient became hypoxic requiring 2-3L NC
and Hct drop to 22.8 from 27.2 . Repeat CXR showed
reaccumulation of some fluid, but the patient remained stable
and was able to be weaned to room air in the AM. The patient
under CT scan of the chest that showed large right pleural
effusion that was not consistent with hemothorax.  The patient
remained stable, but again became hypoxic on [**4-4**] requiring NRB
and continued Hct drop to 17.  A repeat diagnostic thorocentesis
revealed bloddy fluid.  The patient was transferred to the MICU
and pigatail catheter was placed and drained via chest tube.
The patient was also given 3 units PRBC, 5 units FFP, and 1 plt.
  The patient respiratory status improved, Hct remained stable
and catheter stopped draining fluid. Repeat CT scan and CXRs
showed continued small right pleural effusion.  On [**4-5**] the
patient came out of the ICU.  Her pigatil catheter was clamped
and then removed after CXR did not show reaccumulation.  She
recieved 1U FFP prior to removal and 1U FFP post-removal.  Her
Hct remained stable and respiratory status remained >95% on room
air.  She was continued on lasix 40mg and spironolactone 100mg
daily.  Her pain was controled with demerol and oxycodone.  She
was discharged on percocet.  She will follow-up with her PCP.
.
# Acute Renal Failure: The patient's creatinine peaked at 1.5 in
the setting of acute bleed.  Her creatinine improved to 1.0
after blood products.
.
# Hepatitis C: Currently on the transplant list.  She was
continued on lactulose. P
.
# HIV. CD4 670, VL ND 03/[**2177**].  She was continued on
Emtricitabine-Tenofovir, Raltegravir
.
#. Lung Nodule: CT-scan showed indeterminate nodule in the
superior segment of the left lower lobe, measures about 7 mm.
Followup to resolution with repeat scan in three months is
recommended.

# FEN: Low sodium
.
# Access: PIV
.
# PPx: Heparin SC
.
# Code: FULL

Medications on Admission:
Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg QHS
Raltegravir [Isentress] 400 mg [**Hospital1 **]
Spironolactone 100 mg DAILY
Lasix 60mg daily
Lactulose 30 mL 2-3 times a day
Clotrimazole 10 mg troche five times per day
Calcium Carbonate-Vitamin D3 600 mg-400 unit [**Hospital1 **]
Fe supplements


Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO QHS (once a day (at bedtime)).
2. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
6. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X A DAY ().
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Percocet 10-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain for 1 weeks: Do not drive while
taking this medication. This medication can make you
constipated.
Disp:*25 Tablet(s)* Refills:*0*
9. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: This is over the counter. It is recommended while you are
taking percocet. .


Discharge Disposition:
Home

Discharge Diagnosis:
Right Pleural effusion
Hemothorax

Seconadry:
HCV
HIV


Discharge Condition:
stable, O2 sat >95% on room air, ambulationg, normotensive


Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital.  You were admitted to [**Hospital1 18**] because of fluid in your
lungs.  You underwent a procedure to remove fluid that was
complicated by bleeding.  You were in the ICU for low
oxygentation, closer monitoring and given blood products.  You
had a catheter in your chest for drainage.  It was pulled out
and your respiratory status remained stable.  You improved and
are breathing well on room air.

Please follow the medications prescribed below.

Please follow up with the appointments below.

Please call your PCP or go to the ED if you experience chest
pain, palpitations, shortness of breath, nausea, vomiting,
fevers, chills, or other concerning symptoms.

Followup Instructions:
You have an appointment with your PCP on [**4-20**] @ 11:30am
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 76894**] [**Telephone/Fax (1) 76895**]

It is recommended that you have a repeat CT-scan in 3months to
re-evaluate a small lung nodule.

Dr.[**Name (NI) 948**] office will contact you with an appointment time for
next week.



Completed by:[**2178-4-8**]
{'Unspecified pleural effusion,Acute kidney failure, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Other diseases of lung, not elsewhere classified'}


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: Pleural effusion

PRESENT ILLNESS: This is a 42 year-old woman with history of HIV, Hepatitis C
cirrhosis on the transplant list presenting from clinic with
right pleural effusion. She was recently admitted ([**Date range (1) 76893**])
for right pleural effusion and 1.2L were removed. It was
consistent with a transudate and no malignant cells were seen.
ECHO showed EF >55% and no liver lesions seen on MRI. The
effusion was thought to be a sympathetic effusion from ascites.
The patient did not receive a paracentesis at that time. She
states that in the interim her breathing improved and she was
comfortable. However, 1-2 weeks prior to admission she began to
become short of breath. She went to her physican in [**Hospital1 789**]
and a CXR was performed. The was not a large effusion present on
that CXR. However, she continued to worsen and states that over
the weekend her breathing worsened further. She is unable to
sleep because she needs to sleep propped up due to SOB when
supine. She also reports increasing lower ext edema and increase
in her abdominal girth. She denied any abdominal pain,
N/V/D/F/C. She does report a cough with clear sputum. She
returned to her doctor [**First Name (Titles) **] [**Last Name (Titles) 789**] and repeat CXR showed a
"large" effusion. She saw Dr. [**Last Name (STitle) 497**] in clinic today and was
admitted directly for further management.
.
Review of sytems otherwise unremarkable. She denies urinary
symptoms. She denies changes in bowel habits, denies melenotic
stools or hematochezia.

MEDICAL HISTORY: 1. HIV (CD4 670, vL ND [**1-/2178**])
- diagnosed in [**2157**], presumed from IVDU versus sexual
transmission from husband, who was long-term IV drug user
- started ART 1 year ago d/t elevated vL, low CD4 in setting of
acute illness, per patient not diagnosed with OI
2. Hepatitis C cirrhosis (HepC vL 1,090,000 [**3-/2177**])
- diagnosed in [**2176**]
- on transplant list
- complicated by ascites, encephalopathy, grade 1 varices
- history of elevated AFP without focal liver lesions
3. History of necrotizing fascitis [**2163**]

MEDICATION ON ADMISSION: Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg QHS
Raltegravir [Isentress] 400 mg [**Hospital1 **]
Spironolactone 100 mg DAILY
Lasix 60mg daily
Lactulose 30 mL 2-3 times a day
Clotrimazole 10 mg troche five times per day
Calcium Carbonate-Vitamin D3 600 mg-400 unit [**Hospital1 **]
Fe supplements

ALLERGIES: Atripla / Morphine

PHYSICAL EXAM: Admission:
VS: T 97, BP 114/76, HR 92, RR 18, 98% RA
GEN: middle-aged women, generally well appearing with
appropriate affect and behavior, who is lying in bed and
speaking comfortable in no apparent distress, not dyspenic or
tachypneic
HEENT: moist mucous membranes
NECK: supple, no JVD, no LAD
CV: S1&S2 RRR, 2/6 SEM
CHEST: decreased breath sounds on the right to [**Date range (1) 55744**] up the
lung field with dullness to percussion in the same region. No
R/W. Good breath sounds on the left
ABD: soft, slightly distended; non-tender, +BS, no rebound no
gaurding
EXT: +1 pitting edema; feet warm and well-perfused with 2+ DP
pulses

FAMILY HISTORY: Her mother is currently alive and doing well but suffers from
high blood pressure. The patient's father reportedly died in
[**2173**] from Parkinson's disease.

SOCIAL HISTORY: The patient lives with her mother and does not work due to
diability. She very occasionally used to smoke tobacco and last
smoked two years ago. The patient reported that she stopped
consuming alcohol two years ago and prior to that only consumed
very occasionally. History of other substance use includes IVDU
(stopped [**2156**]), cocaine and mushrooms, no current use. 

### Response:
{'Unspecified pleural effusion,Acute kidney failure, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Other diseases of lung, not elsewhere classified'}
