CHIEF COMPLAINT: hemoptysis, abdominal pain

PRESENT ILLNESS: 51 [**Last Name (un) **] with h/o HIV, IV drug use on methadone, TIIDM, Hep
Cirrhosis c/b portal HTN presents with abd pain. Pt states that
she has had progressively worsening abd pain for the past few
weeks. Pt states that she also began coughing up blood this
afternoon. Denies fever, chills. Denies N/V/D. Denies blood in
stool or melena. Has abd distension at baseline and does not
feel that her abd is worse than usual.

MEDICAL HISTORY: 1. HIV, diagnosed in [**2090**]. Has been on HAART in the past, but
now off medications has not kept f/u .
appts. Last CD4 280 ([**12-25**]), VL <5000.
2. Hepatitis C with cirrhosis
3. Opiate Dependence: IV heroine use
4. Cocaine Dependence: inhaled and IV.
5. Multiple abscesses, cellulitis
6. GERD
7. ERCP with sphincterotomy for ?HIV cholangiopathy
8. Diabetes type II diagnosed on HAART 2 years ago. Now
requiring insulin.
9. Thrombocytopenia: HIV and Cirrhosis related
10. Pancytopenia - likely myelosuppresion from HIV.
12.C diff colitis
11. S/p CCY 17 yrs ago

MEDICATION ON ADMISSION: methadone 20 mg qhs 40 mg QD,
Procrit 10,000 units subcutaneously twice a week,
spironolactone 150 mg a day,
Lasix 80 mg b.i.d.,
cholestyramine twice a day,
Seroquel 50 mg three times a day,
Remeron 22.5 mg at night,
Actigall 300 mg t.i.d.,
Humalog SS
Lantus 30 units at bedtime,

ALLERGIES: Codeine / Winrho Sdf

PHYSICAL EXAM: VS T:97.6 P:80 BP:130/90 RR:20 O2Sat:98% RA
Gen: thin and chronically ill appearing, NAD
HEENT: anicteric, MMM, no thrush, JVP nondistended, no LAD
CV: RRR, 2/6 SEM.
Resp: CTAB
Abd: +BS, soft, mildly distended, localized RUQ tenderness, no
rebound, no guarding, ND, + fluid
Back: No CVA tenderness.
Ext: 1+ pedal edema, multiple track marks on flexor surfaces of
arms and on feet.
Skin: excoriations diffusely on trunk and extremities
GUIAC neg.

FAMILY HISTORY: Family History:
6 sisters and 1 brother with diabetes
Grandmother with cancer of unknown etiology
brother died of heart surgery at 36
2 sisters with cardiac surgery NOS
2 sisters with hypercholesterolemia

SOCIAL HISTORY: Pt has a complex social history with significant history of
polysubstance and alcohol abuse. Most recently the pt was
incarcerated for three weeks in [**Month (only) 216**]. She denies any drug use
Human immunodeficiency virus [HIV] disease,Herpes zoster without mention of complication,Acute and subacute necrosis of liver,Chronic hepatitis C with hepatic coma,Acquired coagulation factor deficiency,Combinations of opioid type drug with any other drug dependence, continuous,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Acidosis,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified periodontal diseases,Splenomegaly,Long-term (current) use of insulin,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other specified disorders of biliary tract
Human immuno virus dis,Herpes zoster NOS,Acute necrosis of liver,Chrnc hpt C w hepat Coma,Acq coagul factor defic,Opioid/other dep-contin,Ac kidny fail, tubr necr,Hepatorenal syndrome,Acidosis,Urin tract infection NOS,DMII wo cmp nt st uncntr,Periodontal disease NEC,Splenomegaly,Long-term use of insulin,Tobacco use disorder,Hx of past noncompliance,Dis of biliary tract NEC
Admission Date:  [**2108-3-11**]              Discharge Date:   [**2108-4-11**]

Date of Birth:  [**2056-7-5**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Winrho Sdf

Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
hemoptysis, abdominal pain

Major Surgical or Invasive Procedure:
none

History of Present Illness:
51 [**Last Name (un) **] with h/o HIV, IV drug use on methadone, TIIDM, Hep
Cirrhosis c/b portal HTN presents with abd pain. Pt states that
she has had progressively worsening abd pain for the past few
weeks. Pt states that she also began coughing up blood this
afternoon. Denies fever, chills. Denies N/V/D. Denies blood in
stool or melena. Has abd distension at baseline and does not
feel that her abd is worse than usual.

Past Medical History:
1. HIV, diagnosed in [**2090**]. Has been on HAART in the past, but
now off medications has not kept f/u .
appts. Last CD4 280 ([**12-25**]), VL <5000.
2. Hepatitis C with cirrhosis
3. Opiate Dependence: IV heroine use
4. Cocaine Dependence: inhaled and IV.
5. Multiple abscesses, cellulitis
6. GERD
7. ERCP with sphincterotomy for ?HIV cholangiopathy
8. Diabetes type II diagnosed on HAART 2 years ago. Now
requiring insulin.
9. Thrombocytopenia: HIV and Cirrhosis related
10. Pancytopenia - likely myelosuppresion from HIV.
12.C diff colitis
11. S/p CCY 17 yrs ago

Social History:
Pt has a complex social history with significant history of
polysubstance and alcohol abuse. Most recently the pt was
incarcerated for three weeks in [**Month (only) 216**]. She denies any drug use

since her incarceration, but on last admission she was found
with >600 tabs of various sorts of narcotics and BNZ, as well as
syringes, spoons, etc. and tox screen was + for cocaine. She has
been given methodone at one of the facilities, but denies any
substance use. She denies any new sexual
partners, prior intercourse one year ago, has h/o a sexually
transmitted infection years ago that was treated with
antibiotics.
.
She is currently at [**Hospital 16662**] Rehab and has been clean x5months
.
In ED, she was found to be positive for cocaine in the U.tox.
Patient was confronted and then admitted to doing a line on her
way to court last week. Was unhappy because this will ruin her
chances to get a liver transplant.

Family History:
Family History:
6 sisters and 1 brother with diabetes
Grandmother with cancer of unknown etiology
brother died of heart surgery at 36
2 sisters with cardiac surgery NOS
2 sisters with hypercholesterolemia

Physical Exam:
VS T:97.6 P:80 BP:130/90 RR:20 O2Sat:98% RA
Gen: thin and chronically ill appearing, NAD
HEENT: anicteric, MMM, no thrush, JVP nondistended, no LAD
CV: RRR, 2/6 SEM.
Resp: CTAB
Abd: +BS, soft, mildly distended, localized RUQ tenderness, no
rebound, no guarding, ND, + fluid
Back: No CVA tenderness.
Ext: 1+ pedal edema, multiple track marks on flexor surfaces of
arms and on feet.
Skin: excoriations diffusely on trunk and extremities
GUIAC neg.

Pertinent Results:
[**2108-4-11**] 04:15PM BLOOD WBC-3.1*# RBC-2.84* Hgb-10.0* Hct-29.9*
MCV-106* MCH-35.1* MCHC-33.3 RDW-24.5* Plt Ct-27*
[**2108-4-11**] 06:20AM BLOOD WBC-1.8* RBC-2.59* Hgb-8.9* Hct-26.5*
MCV-103* MCH-34.4* MCHC-33.6 RDW-23.9* Plt Ct-27*
[**2108-4-10**] 09:05AM BLOOD WBC-2.6* RBC-2.81* Hgb-9.9* Hct-28.4*
MCV-101* MCH-35.1* MCHC-34.7 RDW-24.7* Plt Ct-43*
[**2108-4-9**] 07:30AM BLOOD WBC-3.1*# RBC-2.95* Hgb-9.8* Hct-29.7*
MCV-101* MCH-33.2* MCHC-33.0 RDW-24.3* Plt Ct-58*
[**2108-4-8**] 06:20AM BLOOD WBC-1.9* RBC-2.70* Hgb-8.8* Hct-26.5*
MCV-98 MCH-32.7* MCHC-33.3 RDW-23.3* Plt Ct-54*
[**2108-4-7**] 07:10AM BLOOD WBC-2.5* RBC-2.71* Hgb-9.0* Hct-26.4*
MCV-97 MCH-33.2* MCHC-34.1 RDW-23.3* Plt Ct-67*
[**2108-4-6**] 07:15AM BLOOD WBC-2.0*# RBC-2.78*# Hgb-9.1*# Hct-26.3*#
MCV-95 MCH-32.7* MCHC-34.6 RDW-21.2* Plt Ct-94*
[**2108-4-5**] 07:00AM BLOOD WBC-1.2* RBC-2.09* Hgb-6.8* Hct-20.5*
MCV-98 MCH-32.6* MCHC-33.3 RDW-20.6* Plt Ct-74*
[**2108-4-4**] 07:00AM BLOOD WBC-1.5* RBC-2.19* Hgb-7.1* Hct-21.1*
MCV-96 MCH-32.3* MCHC-33.5 RDW-18.8* Plt Ct-60*
[**2108-4-3**] 07:25AM BLOOD WBC-1.7* RBC-2.30* Hgb-7.5* Hct-22.3*
MCV-97 MCH-32.7* MCHC-33.8 RDW-18.3* Plt Ct-61*
[**2108-4-2**] 11:00AM BLOOD WBC-2.1*# RBC-2.37* Hgb-7.6* Hct-22.6*
MCV-95 MCH-32.1* MCHC-33.7 RDW-18.3* Plt Ct-49*
[**2108-4-1**] 12:49PM BLOOD WBC-4.4 RBC-2.73* Hgb-8.8* Hct-25.7*
MCV-94 MCH-32.3* MCHC-34.3 RDW-18.1* Plt Ct-48*
[**2108-4-1**] 07:00AM BLOOD WBC-3.4*# RBC-2.56* Hgb-8.2* Hct-24.2*
MCV-95 MCH-32.0 MCHC-33.9 RDW-18.1* Plt Ct-44*
[**2108-3-31**] 05:10PM BLOOD WBC-8.6 RBC-3.10* Hgb-9.9* Hct-29.0*
MCV-94 MCH-32.1* MCHC-34.2 RDW-18.2* Plt Ct-46*
[**2108-3-31**] 07:20AM BLOOD WBC-11.4*# RBC-2.99* Hgb-9.8* Hct-27.5*
MCV-92 MCH-32.7* MCHC-35.7* RDW-18.6* Plt Ct-38*#
[**2108-3-30**] 08:35AM BLOOD WBC-3.1*# RBC-3.53* Hgb-11.2* Hct-32.9*
MCV-93 MCH-31.7 MCHC-34.0 RDW-17.6* Plt Ct-20*
[**2108-3-29**] 07:10AM BLOOD WBC-1.9* RBC-3.26* Hgb-10.0* Hct-30.8*
MCV-95 MCH-30.7 MCHC-32.5 RDW-17.1* Plt Ct-15*
[**2108-3-23**] 07:40AM BLOOD WBC-2.7*# RBC-4.00* Hgb-12.2 Hct-37.5
MCV-94 MCH-30.5 MCHC-32.5 RDW-16.6* Plt Ct-11*#
[**2108-3-21**] 06:50AM BLOOD WBC-2.2* RBC-3.38* Hgb-10.1* Hct-31.6*
MCV-93 MCH-30.0 MCHC-32.2 RDW-16.6* Plt Ct-40*
[**2108-3-18**] 07:20AM BLOOD WBC-6.6 RBC-3.80* Hgb-11.2* Hct-34.8*
MCV-92 MCH-29.6 MCHC-32.3 RDW-17.2* Plt Ct-37*
[**2108-3-12**] 08:00AM BLOOD WBC-1.4* RBC-3.59* Hgb-11.0* Hct-32.5*
MCV-90 MCH-30.7 MCHC-33.9 RDW-16.6* Plt Ct-8*
[**2108-3-11**] 03:20AM BLOOD WBC-1.5*# RBC-3.69* Hgb-11.4* Hct-32.9*
MCV-89 MCH-30.8 MCHC-34.6 RDW-16.9* Plt Ct-10*#
[**2108-4-11**] 06:20AM BLOOD PT-19.3* PTT-39.2* INR(PT)-1.8*
[**2108-4-6**] 07:15AM BLOOD PT-21.0* PTT-38.9* INR(PT)-2.0*
[**2108-4-1**] 07:00AM BLOOD PT-16.8* PTT-35.0 INR(PT)-1.5*
[**2108-3-30**] 08:35AM BLOOD PT-15.5* PTT-34.4 INR(PT)-1.4*
[**2108-3-25**] 08:25AM BLOOD PT-15.8* PTT-32.4 INR(PT)-1.4*
[**2108-3-22**] 07:15AM BLOOD PT-17.7* PTT-29.8 INR(PT)-1.7*
[**2108-3-17**] 07:00AM BLOOD PT-15.8* PTT-29.6 INR(PT)-1.4*
[**2108-3-11**] 03:20AM BLOOD PT-17.5* PTT-35.3* INR(PT)-1.6*
[**2108-4-11**] 06:20AM BLOOD Glucose-80 UreaN-37* Creat-2.2* Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
[**2108-4-8**] 06:20AM BLOOD Glucose-92 UreaN-42* Creat-1.8* Na-137
K-4.3 Cl-106 HCO3-22 AnGap-13
[**2108-4-7**] 07:10AM BLOOD Glucose-97 UreaN-41* Creat-2.7* Na-140
K-4.6 Cl-109* HCO3-21* AnGap-15
[**2108-4-4**] 07:00AM BLOOD Glucose-88 UreaN-45* Creat-2.8* Na-139
K-5.1 Cl-109* HCO3-19* AnGap-16
[**2108-4-3**] 04:50PM BLOOD Glucose-43* UreaN-49* Creat-3.4* Na-138
K-5.5* Cl-109* HCO3-17* AnGap-18
[**2108-4-3**] 07:25AM BLOOD Glucose-139* UreaN-52* Creat-2.7* Na-135
K-5.6* Cl-108 HCO3-15* AnGap-18
[**2108-4-2**] 07:40PM BLOOD Glucose-112* UreaN-54* Creat-3.3* Na-136
K-5.0 Cl-109* HCO3-15* AnGap-17
[**2108-4-1**] 07:00AM BLOOD Glucose-117* UreaN-49* Creat-2.1* Na-137
K-4.4 Cl-109* HCO3-19* AnGap-13
[**2108-3-31**] 05:10PM BLOOD UreaN-42* Creat-1.8*
[**2108-3-31**] 07:20AM BLOOD Glucose-145* UreaN-34* Creat-1.4* Na-135
K-4.9 Cl-105 HCO3-20* AnGap-15
[**2108-3-11**] 03:20AM BLOOD Glucose-442* UreaN-23* Creat-0.9 Na-132*
K-5.2* Cl-104 HCO3-23 AnGap-10
[**2108-4-11**] 06:20AM BLOOD ALT-25 AST-64* LD(LDH)-245 AlkPhos-82
TotBili-14.3* DirBili-9.5* IndBili-4.8
[**2108-4-10**] 09:05AM BLOOD ALT-25 AST-74* LD(LDH)-271* AlkPhos-84
TotBili-16.1* DirBili-11.6* IndBili-4.5
[**2108-4-9**] 07:30AM BLOOD ALT-22 AST-55* LD(LDH)-261* AlkPhos-86
TotBili-16.1*
[**2108-4-8**] 06:20AM BLOOD ALT-19 AST-45* LD(LDH)-243 AlkPhos-77
TotBili-16.8*
[**2108-4-7**] 07:10AM BLOOD ALT-21 AST-49* LD(LDH)-266* AlkPhos-82
TotBili-17.6*
[**2108-4-6**] 07:15AM BLOOD ALT-19 AST-46* LD(LDH)-273* AlkPhos-83
TotBili-18.1*
[**2108-4-5**] 07:00AM BLOOD ALT-18 AST-39 LD(LDH)-245 AlkPhos-75
TotBili-16.5*
[**2108-4-4**] 07:00AM BLOOD ALT-19 AST-43* LD(LDH)-285* AlkPhos-88
TotBili-18.7* DirBili-14.0* IndBili-4.7
[**2108-4-3**] 07:25AM BLOOD ALT-23 AST-52* LD(LDH)-357* AlkPhos-102
TotBili-20.5*
[**2108-4-2**] 11:00AM BLOOD ALT-26 AST-62* LD(LDH)-389* AlkPhos-95
TotBili-22.6* DirBili-17.4* IndBili-5.2
[**2108-3-31**] 05:10PM BLOOD ALT-32 AST-90* LD(LDH)-610* AlkPhos-115
TotBili-20.6* DirBili-17.4* IndBili-3.2
[**2108-3-31**] 07:20AM BLOOD ALT-30 AST-87* LD(LDH)-619* AlkPhos-114
Amylase-80 TotBili-17.7* DirBili-15.3* IndBili-2.4
[**2108-3-30**] 08:35AM BLOOD LD(LDH)-192 TotBili-1.9* DirBili-1.4*
IndBili-0.5
[**2108-3-29**] 07:10AM BLOOD ALT-28 AST-40 LD(LDH)-154 AlkPhos-117
TotBili-1.8*
[**2108-3-24**] 06:35AM BLOOD ALT-36 AST-41* LD(LDH)-195 AlkPhos-105
TotBili-1.5
[**2108-3-23**] 07:40AM BLOOD ALT-47* AST-55* LD(LDH)-220 AlkPhos-107
TotBili-1.8*
[**2108-3-11**] 03:20AM BLOOD ALT-29 AST-49* AlkPhos-137* Amylase-109*
TotBili-1.6*
[**2108-4-3**] 08:30AM BLOOD Lactate-3.1*
[**2108-3-28**] 06:14PM BLOOD Lactate-2.0
[**2108-3-25**] 09:50AM BLOOD Lactate-2.1*
[**2108-3-21**] 08:07AM BLOOD Lactate-2.5*
[**2108-3-19**] 09:45PM BLOOD Lactate-4.7*
[**2108-3-18**] 09:11PM BLOOD Lactate-2.8*
[**2108-3-18**] 06:44PM BLOOD Lactate-4.4* K-5.6*
.
MICROBIOLOGY
CMV VL negative
[**2108-3-29**] 4:27 pm URINE

                            **FINAL REPORT [**2108-3-31**]**

   URINE CULTURE (Final [**2108-3-31**]):
      ENTEROBACTER AEROGENES.    >100,000 ORGANISMS/ML..
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROBACTER AEROGENES
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------    16 I
CIPROFLOXACIN---------     1 S
GENTAMICIN------------     2 S
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------     1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------    64 I
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R
.
Imaging:
CT Abd/pelvis [**3-11**]
1. Fecalization of small bowel contents in the left mid/lower
abdomen, which is of uncertain etiology in the absence of bowel
obstruction.
2. Small amount of ascites, less than on [**2107-10-23**].
3. Cirrhotic liver without focal lesions. Massive splenomegaly.
4. Pneumobilia, which may be related to previous sphincterotomy.

.
RUQ U/S [**3-11**]
1. Small amount of ascites, too small to mark for paracentesis.
2. Limited liver Doppler demonstrating patent main and posterior
right portal veins with normal direction of flow.
3. The left portal vein was visualized as patent.
.
CXR [**3-11**]
IMPRESSION: Linear atelectases left base. No change since prior
study [**2108-1-13**]. If clinically indicated by the presence
of hemoptysis CT exam may be obtained.
.
Chest CT [**3-12**]
1. New diffuse bilateral ground-glass opacities, concerning for
PCP given the history of HIV infection. Considering history of
hemoptysis, pulmonary hemorrhage is also possible but is not
typically this diffuse.
2. Resolution of large right pleural effusion and right middle
and lower lobe consolidation.
3. Cirrhosis, splenomegaly and ascites. New pneumobilia.
4. Retained secretions in cervical trachea. No evidence of
endobronchial lesion to account for hemoptysis but bronchoscopy
may be considered if symptoms persist.
5. Diffuse coronary artery calcifications.
6. Emphysema.
7. Two small noncalcified right upper lobe nodular opacities,
for which follow- up CT in 6 months is recommended.
.
MRCP [**3-13**]
1. Pneumobilia limiting MRCP for evaluation of the biliary tree.
 No intrahepatic biliary ductal dilatation or abnormal
enhancement surrounding the intra- or extra-hepatic biliary
tree. No specific evidence of HIV cholangiopathy.
2. Nodular external liver contour and enhancement
characteristics consistent with cirrhosis. Portal vein patent
with antegrade flow. Splenomegaly, likely secondary to portal
hypertension. Small amount of ascites.
3. 14-mm T2 hyperintense lesion within the uncinate process of
the pancreas. This is seen on the recent CT scan and is
unchanged, but the finding was not present on [**2103**] abdominal CT
scan. The differential diagnosis includes IPMT or other sequela
from pancreatitis. There is no abnormal enhancement or
dilatation of the pancreatic duct to indicate a pancreatic mass,
and followup in three to six months is recommended.
.
Noncontrast Head CT [**3-18**]
There is no evidence of hemorrhage, shift of normally midline
structures, mass effect or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. The density values of the brain
parenchyma are within normal limits. Bone windows demonstrate no
evidence of fracture within the surrounding osseous structures.
The mastoid air cells and visualized portions of the paranasal
sinuses are normally pneumatized.
.
Abd U/S [**3-29**]
IMPRESSION: Small to moderate amount of ascites in this patient
with findings consistent with known diagnosis of cirrhosis and
portal hypertension.
.
RUQ U/S [**4-1**]
1. Cirrhotic liver without evidence of focal hepatic masses.
2. Patent portal vein demonstrating appropriate direction of
flow.
3. No evidence of biliary obstruction.
4. Normal-appearing kidneys.
.
CXR [**4-3**]
IMPRESSION:
1. Findings consistent with mild volume overload.
2. Atelectasis at the left lung base. No definite evidence for
pneumonia.

Brief Hospital Course:
Assessment - This is a 51 y.o. F with HIV, HCV cirrhosis, who
presents with hemoptysis and abd pain.
.
1) Abd pain:
Pt has a hx of chronic abd pain with her exam essentially
unchanged from baseline. Abd U/S on admission was negative for
any PVT and only showed minimal ascites (cannot be tapped). Abd
CT showed decreased ascites, no signs of obstruction though
fecalization of small bowel loops.  No signs of perforation/free
air by CT scan. MRCP without evidence of cholangiopathy.  It was
thought that on admission, likely her pain was from
splenomegaly, and progressive ascites.  During her hospital
course, patient had fluctuating abdominal pain that at times was
thought to be mostly due to abdominal distension from ascites.
Due to her thrombocytopenia and ARF as below, diuretics and
therapeutic paracentesis were held.  Small dose of diuretics
were attempted to be initiated, but creatinine would increase
due to tenuous volume status.  Due to ARF as below, all
diuretics were held on discharge, and patient was to follow up
with her PCP as needed.
.
2) Hemoptysis:
Patient with a brief episode of hemoptysis thought due to her
thrombocytopenia and epistaxis.  However, due to patient's HIV
status, a CXR was performed that was negative for any
nodules/granulomas/masses; 3 sputums were sent that were
negative for AFB/TB culture.  Chest CT  did show ground-glass
opacities, and 2 small noncalcified right upper lobe nodular
opacities, for which follow-up CT in 6 months was recommended.
No further workup was required at this time and patient's
pulmonary status remained stable throughout.
.
3) Thrombocytopenia:
Patient with a baseline platelet count of 20-30,000, however on
admission her plt count was 8,000.  It was felt that the
etiology of her thrombocytopenia was multifactorial including
due to massive splenomegaly, HIV marrow suppression, cirrhosis
mediated thrombopoietin deficiency, and what was felt to be by
the hematology consulting team to be primary HIV associated
thrombocytopenia.  It was felt that for long term control, HIV
control with HAART would need to be the mainstay therapy, but
originally patient refused due to her precarious living
situation and probable noncompliance.  The hematology team
recommended Decadron 40mg IV qD x4 days, with dapsone for PCP
prophylaxis to address her PHAT.  Unfortunately, due to her
tenuous situation, her splenomegaly and cirrhosis could not be
addressed surgically.  Patient initially had a response to the
steroids, with her plts temporarily increasing to 40,000 for
about 1 week, although they then began to drift down to her
previous level of 10,000.  After continued consultation with the
hematology team, it was thought that WinRho (anti-D Ab) could be
used to address her component of PHAT, along with reinitiation
of her HAART therapy for long term viral suppression and control
of her PHAT.  The one time dose of WinRho and HAART therapy were
started on [**3-29**], with improvement of her platelets but it was
complicated by ARF and bilirubinemia as below.  Her platelets
steadily increased to 90,000 1 week after the WinRho, although
it had begun to fall shortly after and was down to 30,000 by
time of discharge.  Patient was to f/u as an outpatient to
reinitiate her HAART therapy for continued plt stability.
.
4) Acute renal failure:
Patient with stable creatinine on admission until patient was
given WinRho, and initiated HAART and acylovir on [**3-29**].
Patient's creat then increased to 3.0 and the renal team was
consulted for further management/diagnosis.  Urine lytes
revealed a FeNa of 0.8% with a UNa <10 and there was concern
that on top of prerenal azotemia from hypovolemia,
hyperbilirubinuria, a UTI, ATN and an element of hepatorenal
syndrome was contributing to her ARF.  Due to the low risk of
treatment, she was started on Octreotide SQ and Midodrine for
control of her HRS, along with IVF boluses prn for treatment of
prerenal azotemia.  Her Cr peaked at 3.4, but slowly improved on
HRS treatment and by the day of discharge, her Cr had decreased
to 2.2.  Due to issues with compliance, her Octreotide and
Midodrine were discontinue and her Cr was monitored off therapy,
which remained stable.  Patient was thus discharged without HRS
treatment to have f/u Cr as an outpatient.
.
5) Liver Failure/Hyperbilirubinemia
Patient with known cirrhosis from Hep C; followed by Dr. [**Last Name (STitle) 10949**]
as an outpatient. Pt states that she was going to be a candidate
for transplant, but due to her ongoing IV drug use, it was felt
that patient was not a transplant candidate at this time.
During her hospitalization after her WinRho treatment, patient's
bili increased to 20, with a mostly direct component, and her
INR steadily increased to 3.0.  The Hepatology team was
consulted for help with management and confusion regarding her
mostly direct bilirubinemia.  It was felt that likely the
hemolysis load caused a high bilirubin load that was able to be
conjugated, but due to intrahepatic cholestasis, was not able to
be excreted into the bile.  Cholestyramine and Ursodiol were
titrated up to help with conjugation and excretion of her
bilirubin, although this only slowly improved over the last 2
weeks of her hospitalization.  On discharge, her bili had
decreased to 14.5 and this was to be followed up by her PCP.
[**Name10 (NameIs) **] INR had increased to 2.0 (from 1.6 on admission), but this
slightly improved to 1.8 on discharge.  Patient was to f/u with
Hepatology as an outpatient as needed.  Due to her tenuous
status, and mod ascites as seen on scans, patient was placed on
Cipro 750mg po qweek for SBP prophylaxis per ID recommendations.

.
6) DM II:
Patient had a h/o DMII and was continually followed by the
[**Last Name (un) **] during her hospitalization.  In the setting of high dose
Decadron as above, she had marked hyperglycemia, which required
an increased insulin supplementation.  Once off the steroids,
and with her decreasing appetite due to her abdominal
distension, her insulin regimen was decreased appropriately per
the [**Last Name (un) **] recommendations.  Her insulin regimen was simplified
to Humulin 75/25 8units qAM, 6 units qPM to improve her
compliance at the expense of perfect glucose control.
.
7) HIV:
Her last CD4 prior to admission was 240 on [**12-25**]. She was being
followed closely now by Dr. [**First Name (STitle) 20069**] and Dr. [**First Name (STitle) **], with plans to
start HAART therapy.  Patient had been noncompliant, and was
still actively using IV drug use up until prior to admission.
Due to her persistent thrombocytopenia as above, patient was
convinced to be compliant with a HAART regimen that included
abacavir, 3TC and atazanavir.  This was started on [**3-29**] with her
first dose of WinRho and due to the markedly elevated LFTs from
the hemolysis and intrahepatic cholestasis, her HAART regimen
was held for the duration of her inpatient stay to be restarted
as an outpatient for viral suppression, and long term
thrombocytopenia prevention.  An HIV genotype was sent during
this admission to be followed up by Dr. [**First Name (STitle) **] for continued f/u
as an outpatient and tailored HAART therapy.
.
8) Polysubstance abuse:
Prior to admission, pt was in a rehab facility. Initially, she
denied drug abuse, but a tox screen drawn in the ED was positive
for cocaine and opioids.  Patient also found with cocaine,
heroin, multiple Percocets in room on admission which was
removed by security.  Patient was previously on a methadone
regimen which was continued during this admission but
continually titrated down to prevent oversedation.  By the day
of discharge, patient was down to 20mg po bid, and was sent out
on this regimen to be administered by Dr. [**Last Name (STitle) 1968**].  Patient was
continually counseled on the importance of staying clean and
patient agreed to continue to go to NA, and attend rehab as
needed.
.
9) Enterobacter UTI
Patient developed sx's c/w UTI during her admission with a
positive U/A and urine culture that grew Enterobacter.  Patient
was treated with a 3 day course of Ciprofloxacin, and improved.
.
10) Zoster
During her inpatient stay, patient developed an outbreak of
vesicles on her R abdomen that were c/w Zoster.  Patient was
placed on a 1 week treatment course of renally dosed Acyclovir
and this was discontinued once her course was completed.  As
this was her first outbreak, and patient still remained in an
element of ARF on discharge, no ppx Acyclovir was continued once
the treatment course was completed.
.
11) DISPO
After many discussion with pt and PCP, [**Name10 (NameIs) **] was made DNR/DNI
during this admission.  Patient was discharged with close f/u
with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1968**], along with ID f/u as needed.  Patient
requires f/u Chest CT in 6 months to f/u on her likely benign
pulmonary nodule as seen incidentally on her Chest CT as above.

Medications on Admission:
methadone 20 mg qhs 40 mg QD,
Procrit 10,000 units subcutaneously twice a week,
spironolactone 150 mg a day,
Lasix 80 mg b.i.d.,
cholestyramine twice a day,
Seroquel 50 mg three times a day,
Remeron 22.5 mg at night,
Actigall 300 mg t.i.d.,
Humalog SS
Lantus 30 units at bedtime,

Discharge Medications:
1. Insulin Lisp & Lisp Prot (Hum) 100 unit/mL (75-25) Suspension
Sig: One (1)  Subcutaneous twice a day: 8 units at breakfast, 6
units at supper.
Disp:*2 vials* Refills:*3*
2. Insulin Syringe Ultra Fine II     Syringe Sig: One (1)
Miscell.  twice a day: use insulin at breakfast and supper.
Disp:*300 syringes* Refills:*2*
3. One Touch II Test     Strip Sig: One (1)  Miscell.  four
times a day.
Disp:*300 strips* Refills:*2*
4. One Touch UltraSoft Lancets     Misc Sig: One (1)  Miscell.
four times a day.
Disp:*300 strips* Refills:*2*
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 tube* Refills:*0*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*qs ML(s)* Refills:*2*
9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Cholestyramine-Sucrose 4 g Packet Sig: as directed below  PO
twice a day: Take 2 pills in the morning, 1 pill in the evening.
Disp:*90 Packet(s)* Refills:*2*
11. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO 1X/WEEK
([**Doctor First Name **]).
Disp:*4 Tablet(s)* Refills:*0*
12. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*40 Tablet, Rapid Dissolve(s)* Refills:*0*
13. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*40 Tablet(s)* Refills:*0*
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*


Discharge Disposition:
Home

Facility:
[**Location (un) 16662**] - [**Street Address(1) **]

Discharge Diagnosis:
Primary Diagnoses:
Thrombocytopenia, multifactorial
Acute Renal Failure
HCV Cirrhosis with ascites
HIV associated thrombocytopenia
Pancytopenia due to HIV
Enterobacter UTI
Hemoptysis
Pulmonary Nodule, likely benign
Pancreatic lesion, likely sequelae of pancreatitis
Zoster

Discharge Condition:
Stable to be discharged

Discharge Instructions:
If develop any bleeding, fevers, neurologic symptoms like
weakness, or inability to move, or any other symptoms, please
call Dr. [**Last Name (STitle) 1968**] or report to the nearest ER.

Followup Instructions:
Please call Dr.[**Name (NI) 11632**] office at [**Telephone/Fax (1) 250**] to have your labs
checked on Friday, [**4-14**].
.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2108-3-21**]
12:15
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2108-3-21**] 1:40
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **] MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2108-4-25**]
9:30



Completed by:[**2108-4-27**]
{'Human immunodeficiency virus [HIV] disease,Herpes zoster without mention of complication,Acute and subacute necrosis of liver,Chronic hepatitis C with hepatic coma,Acquired coagulation factor deficiency,Combinations of opioid type drug with any other drug dependence, continuous,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Acidosis,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified periodontal diseases,Splenomegaly,Long-term (current) use of insulin,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other specified disorders of biliary tract'}


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: hemoptysis, abdominal pain

PRESENT ILLNESS: 51 [**Last Name (un) **] with h/o HIV, IV drug use on methadone, TIIDM, Hep
Cirrhosis c/b portal HTN presents with abd pain. Pt states that
she has had progressively worsening abd pain for the past few
weeks. Pt states that she also began coughing up blood this
afternoon. Denies fever, chills. Denies N/V/D. Denies blood in
stool or melena. Has abd distension at baseline and does not
feel that her abd is worse than usual.

MEDICAL HISTORY: 1. HIV, diagnosed in [**2090**]. Has been on HAART in the past, but
now off medications has not kept f/u .
appts. Last CD4 280 ([**12-25**]), VL <5000.
2. Hepatitis C with cirrhosis
3. Opiate Dependence: IV heroine use
4. Cocaine Dependence: inhaled and IV.
5. Multiple abscesses, cellulitis
6. GERD
7. ERCP with sphincterotomy for ?HIV cholangiopathy
8. Diabetes type II diagnosed on HAART 2 years ago. Now
requiring insulin.
9. Thrombocytopenia: HIV and Cirrhosis related
10. Pancytopenia - likely myelosuppresion from HIV.
12.C diff colitis
11. S/p CCY 17 yrs ago

MEDICATION ON ADMISSION: methadone 20 mg qhs 40 mg QD,
Procrit 10,000 units subcutaneously twice a week,
spironolactone 150 mg a day,
Lasix 80 mg b.i.d.,
cholestyramine twice a day,
Seroquel 50 mg three times a day,
Remeron 22.5 mg at night,
Actigall 300 mg t.i.d.,
Humalog SS
Lantus 30 units at bedtime,

ALLERGIES: Codeine / Winrho Sdf

PHYSICAL EXAM: VS T:97.6 P:80 BP:130/90 RR:20 O2Sat:98% RA
Gen: thin and chronically ill appearing, NAD
HEENT: anicteric, MMM, no thrush, JVP nondistended, no LAD
CV: RRR, 2/6 SEM.
Resp: CTAB
Abd: +BS, soft, mildly distended, localized RUQ tenderness, no
rebound, no guarding, ND, + fluid
Back: No CVA tenderness.
Ext: 1+ pedal edema, multiple track marks on flexor surfaces of
arms and on feet.
Skin: excoriations diffusely on trunk and extremities
GUIAC neg.

FAMILY HISTORY: Family History:
6 sisters and 1 brother with diabetes
Grandmother with cancer of unknown etiology
brother died of heart surgery at 36
2 sisters with cardiac surgery NOS
2 sisters with hypercholesterolemia

SOCIAL HISTORY: Pt has a complex social history with significant history of
polysubstance and alcohol abuse. Most recently the pt was
incarcerated for three weeks in [**Month (only) 216**]. She denies any drug use 

### Response:
{'Human immunodeficiency virus [HIV] disease,Herpes zoster without mention of complication,Acute and subacute necrosis of liver,Chronic hepatitis C with hepatic coma,Acquired coagulation factor deficiency,Combinations of opioid type drug with any other drug dependence, continuous,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Acidosis,Urinary tract infection, site not specified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other specified periodontal diseases,Splenomegaly,Long-term (current) use of insulin,Tobacco use disorder,Personal history of noncompliance with medical treatment, presenting hazards to health,Other specified disorders of biliary tract'}
