CHIEF COMPLAINT: Fever

PRESENT ILLNESS: 57-year old man with a history of HIV CD4 373 in [**2148-6-14**],
history of asplenia, history of strep viridans septic shock in
[**2148-6-14**] presents with fevers and rigors, lightheadedness, and
elevated WBC who is admitted to the ICU for hypotension and
fever. He was well until he woke up this morning with rigors and
feeling of lightheadedness without syncope. He took a hot shower
that did not warm him up and decided to present to the ED given
that these symptoms were similar to his prior Strep viridans
septic shock. He denies any other localizing symptoms including
cough, rhinorrhea, nausea, vomiting, diarrhea, myalgias, chest
pain/pressure, SOB, calf pain, or rash. He recently travelled to
[**Country 12649**] and to [**Location (un) **] where he engaged in protected anal and oral
sex, ate mussels, but no other changes in diet or habits. No
animal exposures other than his pet chihuahua. No known sick
contacts. [**Name (NI) **] had pneumovax and flu vaccines.

MEDICAL HISTORY: HIV, CD4 379 [**6-22**], undetectable viral load and CD4 > 600 2 weeks
ago by report, never below 350 since diagnosis per patient.
Treated initially with Trisovir, now on Atripla (efavirenz-an
NNRTI, emtricitabine--a nucleoside RTI, and tenofavir--a
nucleoside RTI).
Hep B Diagnosed [**2117**]. ([**6-22**]: negative Hep B viral load; had
been on Atripla which includes emtricitabine and tenofovir, both
w anti-Hep B activity)
S/P Septic Shock with Xigris (activated protein C)
administration [**3-18**] strep viridans bacteremia c/b Acute Renal
Failure and CVVH, respiratory failure and thrombocytopenia in
[**6-22**]
History of splenic abscess s/p splenectomy in [**2135**]
DM type 2, on metformin
Obesity
Hypercholesterolemia, on lipitor
Asthma
R medial meniscal tear
History of severe bronchitis [**2146**]

MEDICATION ON ADMISSION: Metformin 250mg PO BID
Atripla 1 tab PO daily
Lisinopril 15mg PO daily
Lipitor 10mg PO daily
ASA 81mg PO daily
Ibuprofen 3 tabs TID
Prilosec 20 mg daily (?)
supplements including fish oil, L carnitine, glucosamine

ALLERGIES: Erythromycin Base / Biaxin / Ciprofloxacin

PHYSICAL EXAM: Vitals: T: 101.5 HR: 108 BP: 117/77 100% RA
General: Alert, oriented, no acute distress. Interactive and
pleasantly conversant.
HEENT: Sclerae anicteric, MMM, oropharynx clear without thrush
Neck: Supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Tachycardic, regular, normal S1 + S2, grade 2/6 systolic
murmur at LUSB, no detectable radiation, no rubs or gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
well-healed laparotomy scar noted
GU: foley in place
Ext: +erythema, swelling, and tenderness in left anterior lower
leg. there are skin abrasions on dorsal surface of both halluxes
as well as onychomycosis of some toe nails.

FAMILY HISTORY: Aunt with rheumatic fever, died [**2119**]
Mother with arrhythmia requiring pacemaker
Father died of lung ca, 60 year smoking history

SOCIAL HISTORY: In long term relationship w/ partner x 30 years. Works in
software quality assurance for [**Location (un) 12650**]. No smoking. Very
occasional alcohol. No drugs. Recently travelled to Barcelona
[**Country 12649**] with + oral/anal sex, all protected. Recent travel also to
[**Location (un) **]. Ate mussels x 2 in [**Country 12649**], no unpasteurized cheeses, no
animal contacts other than pet chihuahua, no bites, no travel to
SW US or tropics, no significant tick exposure.
Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Cellulitis and abscess of leg, except foot,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Anomalies of spleen,Severe sepsis,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Obesity, unspecified,Unspecified essential hypertension,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
Septicemia NOS,Acute kidney failure NOS,Septic shock,Cellulitis of leg,Hpt B acte wo cm wo dlta,Anomalies of spleen,Severe sepsis,Asymp hiv infectn status,DMII wo cmp nt st uncntr,Asthma NOS,Obesity NOS,Hypertension NOS,MRSA elsewhere/NOS,Meth resis Staph carrier
Admission Date:  [**2148-11-21**]              Discharge Date:   [**2148-11-25**]

Date of Birth:  [**2091-2-25**]             Sex:   M

Service: MEDICINE

Allergies:
Erythromycin Base / Biaxin / Ciprofloxacin

Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
Central line placement


History of Present Illness:
57-year old man with a history of HIV CD4 373 in [**2148-6-14**],
history of asplenia, history of strep viridans septic shock in
[**2148-6-14**] presents with fevers and rigors, lightheadedness, and
elevated WBC who is admitted to the ICU for hypotension and
fever. He was well until he woke up this morning with rigors and
feeling of lightheadedness without syncope. He took a hot shower
that did not warm him up and decided to present to the ED given
that these symptoms were similar to his prior Strep viridans
septic shock. He denies any other localizing symptoms including
cough, rhinorrhea, nausea, vomiting, diarrhea, myalgias, chest
pain/pressure, SOB, calf pain, or rash. He recently travelled to
[**Country 12649**] and to [**Location (un) **] where he engaged in protected anal and oral
sex, ate mussels, but no other changes in diet or habits. No
animal exposures other than his pet chihuahua. No known sick
contacts. [**Name (NI) **] had pneumovax and flu vaccines.

In the ED, initial vital signs were: T 98.1 P 122 BP 145/59 R 16
O2 sat 100%. His blood pressure dropped to 80's systolic and had
a temperature up to 103F. Vanco and zosyn were given in the ED.
Initial lactate was 2.2, elevated to 2.5 after 2nd liter of NS.
WBC was 21.3 with 88% neutrophils. CXR showed L retrocardiac
density concerning for pneumonia but later read as subsegmental
atelectasis.  Received total 6L NS, central line was placed.
Upon leaving the ED, vitals were HR 111 BP: 114/52 O2: 98%2L RR
21

In the [**Hospital Unit Name 153**], T: 101.5 HR: 108 BP: 117/77 100% RA.

Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.

Past Medical History:
HIV, CD4 379 [**6-22**], undetectable viral load and CD4 > 600 2 weeks
ago by report, never below 350 since diagnosis per patient.
Treated initially with Trisovir, now on Atripla (efavirenz-an
NNRTI, emtricitabine--a nucleoside RTI, and tenofavir--a
nucleoside RTI).
Hep B Diagnosed [**2117**]. ([**6-22**]: negative Hep B viral load; had
been on Atripla which includes emtricitabine and tenofovir, both
w anti-Hep B activity)
S/P Septic Shock with Xigris (activated protein C)
administration [**3-18**] strep viridans bacteremia c/b Acute Renal
Failure and CVVH, respiratory failure and thrombocytopenia in
[**6-22**]
History of splenic abscess s/p splenectomy in [**2135**]
DM type 2, on metformin
Obesity
Hypercholesterolemia, on lipitor
Asthma
R medial meniscal tear
History of severe bronchitis [**2146**]

Social History:
In long term relationship w/ partner x 30 years. Works in
software quality assurance for [**Location (un) 12650**]. No smoking. Very
occasional alcohol. No drugs. Recently travelled to Barcelona
[**Country 12649**] with + oral/anal sex, all protected. Recent travel also to
[**Location (un) **]. Ate mussels x 2 in [**Country 12649**], no unpasteurized cheeses, no
animal contacts other than pet chihuahua, no bites, no travel to
SW US or tropics, no significant tick exposure.

Family History:
Aunt with rheumatic fever, died [**2119**]
Mother with arrhythmia requiring pacemaker
Father died of lung ca, 60 year smoking history

Physical Exam:
Vitals: T: 101.5 HR: 108 BP: 117/77 100% RA
General: Alert, oriented, no acute distress. Interactive and
pleasantly conversant.
HEENT: Sclerae anicteric, MMM, oropharynx clear without thrush
Neck: Supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Tachycardic, regular, normal S1 + S2, grade 2/6 systolic
murmur at LUSB, no detectable radiation, no rubs or gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
well-healed laparotomy scar noted
GU: foley in place
Ext: +erythema, swelling, and tenderness in left anterior lower
leg. there are skin abrasions on dorsal surface of both halluxes
as well as onychomycosis of some toe nails.

Pertinent Results:
ADMISSION LABS:
[**2148-11-21**] 05:56PM   LACTATE-1.8
[**2148-11-21**] 06:29PM   URINE  HOURS-RANDOM UREA N-681 CREAT-60
SODIUM-126
[**2148-11-21**] 05:56PM   TYPE-[**Last Name (un) **] PH-7.36
[**2148-11-21**] 05:22PM   GLUCOSE-125* UREA N-29* CREAT-1.4* SODIUM-140
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-19* ANION GAP-14
[**2148-11-21**] 05:22PM   CALCIUM-8.9 PHOSPHATE-2.4*# MAGNESIUM-1.7
[**2148-11-21**] 05:22PM   WBC-28.1* RBC-3.63* HGB-11.2* HCT-34.6*
MCV-95 MCH-30.9 MCHC-32.4 RDW-15.1
[**2148-11-21**] 12:32PM   LACTATE-2.5*

MICROBIOLOGY:
[**2148-11-21**] Blood Cx pending as of day of discharge
[**2148-11-21**] Urine Cx negative
[**2148-11-21**] GC / Chlamydia negative
[**2148-11-22**] Cdiff negative
[**2148-11-22**] Stool Cx negative

STUDIES:
[**2148-11-21**] CXR - Mild cardiomegaly with sub-segmental atelectasis
in the left
lower lobe.

Brief Hospital Course:
57 year old asplenic male with HIV (per pt. most recent
CD4=600), h/o strep viridans sepsis in [**Month (only) 547**]/[**2148-6-14**], was
admitted with sepsis, most likely secondary to left leg
cellulitis.

1. Sepsis
Patient presented with fevers, tachycardia, elevated WBC, and
hypotension responsive to fluids.  Of note, the patient is
asplenic, so encapsulated organisms were of concern.  There was
concern for another episode of Strep Viridans sepsis as with his
previous hospitalization in [**2148-6-14**], but his blood cultures
have been negative so far. Initial interpretation of CXR was
possible PNA, but the patient did not have any respiratory
symptoms to support it.  A left lower extremity cellulitis was
the likely source of sepsis.  The cellulitis had no induration,
but the erythema and swelling appeared to increase slowly in
size for a full 24 hours on the intravenous antibiotic regimen
before it stabilized.

Vancomycin and Zosyn were continued for treatment of his
cellulitis because of his history of MRSA and to cover for
encapsulated organisms.  GC/Chlamydia swaps were negative.  ID
consult recommended transition to PO Bactrim and Augmentin as
outpatient therapy.  Will defer to PCP as to whether or not
patient should have penicillin prophylaxis because of his
asplenia.

2. Acute vs Chronic Renal Insufficiency:
Mr. [**Known lastname 12651**] creatinine was 1.3-1.4 on presentation. His
baseline creatinine is unclear. [**Name2 (NI) **] had acute renal failure
during his last hospitalization in [**Month (only) 116**], and it is unclear
whether his creatinine ever returned to his baseline.

3. HIV
Per patient, his last CD4 count was greater than 600, and his
viral load undetectable. During his hospitalization, he was
continued on Atripla.

4. Type 2 Diabetes Mellitus
He was initially maintained on insulin sliding scale but was
then transitioned to his home regimen of metformin.

5. Hypertension
His lisinopril was initially held during this admission and then
restarted once his blood pressure improved.

Medications on Admission:
Metformin 250mg PO BID
Atripla 1 tab PO daily
Lisinopril 15mg PO daily
Lipitor 10mg PO daily
ASA 81mg PO daily
Ibuprofen 3 tabs TID
Prilosec 20 mg daily (?)
supplements including fish oil, L carnitine, glucosamine


Discharge Medications:
1. Metformin 500 mg Tablet [**Month (only) **]: 0.5 Tablet PO BID (2 times a
day).
2. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO once a
day.
3. Lisinopril 5 mg Tablet [**Telephone/Fax (3) **]: Three (3) Tablet PO DAILY
(Daily).
4. Atorvastatin 10 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable [**Telephone/Fax (3) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Bactrim DS 160-800 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
7. Augmentin 875-125 mg Tablet [**Telephone/Fax (3) **]: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Cellulitis of the left lower leg.

SECONDARY DIAGNOSIS:
1. HIV
2. Asplenia
3. Type 2 Diabetes Mellitus
4. Hypertension

Discharge Condition:
Stable. Patient is ambulating, tolerating oral intake, and has
returned to his baseline condition.

Discharge Instructions:
You were admitted to the hospital with sepsis thought likely
related to your left lower leg cellulitis. You were started on
IV antibiotics with improvement in your blood pressure.

We have adding the following medications for treatment of your
cellulitis:
1. Bactrim DS one tablet twice daily for 10 days total
2. Augmentin 875mg one tablet twice daily for 10 days total

Please seek immediate medical attention if you develop fevers,
shaking chills, night sweats, light-headedness, dizziness,
passing out, worsened swelling in your left leg, shortness of
breath, abdominal pain, diarrhea, or cough.

Followup Instructions:
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2148-11-27**]
3:15

Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 6164**], within the next 10 days.
{'Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Cellulitis and abscess of leg, except foot,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Anomalies of spleen,Severe sepsis,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Obesity, unspecified,Unspecified essential hypertension,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus'}


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

PRESENT ILLNESS: 57-year old man with a history of HIV CD4 373 in [**2148-6-14**],
history of asplenia, history of strep viridans septic shock in
[**2148-6-14**] presents with fevers and rigors, lightheadedness, and
elevated WBC who is admitted to the ICU for hypotension and
fever. He was well until he woke up this morning with rigors and
feeling of lightheadedness without syncope. He took a hot shower
that did not warm him up and decided to present to the ED given
that these symptoms were similar to his prior Strep viridans
septic shock. He denies any other localizing symptoms including
cough, rhinorrhea, nausea, vomiting, diarrhea, myalgias, chest
pain/pressure, SOB, calf pain, or rash. He recently travelled to
[**Country 12649**] and to [**Location (un) **] where he engaged in protected anal and oral
sex, ate mussels, but no other changes in diet or habits. No
animal exposures other than his pet chihuahua. No known sick
contacts. [**Name (NI) **] had pneumovax and flu vaccines.

MEDICAL HISTORY: HIV, CD4 379 [**6-22**], undetectable viral load and CD4 > 600 2 weeks
ago by report, never below 350 since diagnosis per patient.
Treated initially with Trisovir, now on Atripla (efavirenz-an
NNRTI, emtricitabine--a nucleoside RTI, and tenofavir--a
nucleoside RTI).
Hep B Diagnosed [**2117**]. ([**6-22**]: negative Hep B viral load; had
been on Atripla which includes emtricitabine and tenofovir, both
w anti-Hep B activity)
S/P Septic Shock with Xigris (activated protein C)
administration [**3-18**] strep viridans bacteremia c/b Acute Renal
Failure and CVVH, respiratory failure and thrombocytopenia in
[**6-22**]
History of splenic abscess s/p splenectomy in [**2135**]
DM type 2, on metformin
Obesity
Hypercholesterolemia, on lipitor
Asthma
R medial meniscal tear
History of severe bronchitis [**2146**]

MEDICATION ON ADMISSION: Metformin 250mg PO BID
Atripla 1 tab PO daily
Lisinopril 15mg PO daily
Lipitor 10mg PO daily
ASA 81mg PO daily
Ibuprofen 3 tabs TID
Prilosec 20 mg daily (?)
supplements including fish oil, L carnitine, glucosamine

ALLERGIES: Erythromycin Base / Biaxin / Ciprofloxacin

PHYSICAL EXAM: Vitals: T: 101.5 HR: 108 BP: 117/77 100% RA
General: Alert, oriented, no acute distress. Interactive and
pleasantly conversant.
HEENT: Sclerae anicteric, MMM, oropharynx clear without thrush
Neck: Supple, JVP not appreciated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi.
CV: Tachycardic, regular, normal S1 + S2, grade 2/6 systolic
murmur at LUSB, no detectable radiation, no rubs or gallops
Abdomen: Obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
well-healed laparotomy scar noted
GU: foley in place
Ext: +erythema, swelling, and tenderness in left anterior lower
leg. there are skin abrasions on dorsal surface of both halluxes
as well as onychomycosis of some toe nails.

FAMILY HISTORY: Aunt with rheumatic fever, died [**2119**]
Mother with arrhythmia requiring pacemaker
Father died of lung ca, 60 year smoking history

SOCIAL HISTORY: In long term relationship w/ partner x 30 years. Works in
software quality assurance for [**Location (un) 12650**]. No smoking. Very
occasional alcohol. No drugs. Recently travelled to Barcelona
[**Country 12649**] with + oral/anal sex, all protected. Recent travel also to
[**Location (un) **]. Ate mussels x 2 in [**Country 12649**], no unpasteurized cheeses, no
animal contacts other than pet chihuahua, no bites, no travel to
SW US or tropics, no significant tick exposure. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Septic shock,Cellulitis and abscess of leg, except foot,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Anomalies of spleen,Severe sepsis,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Obesity, unspecified,Unspecified essential hypertension,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus'}
