CHIEF COMPLAINT: diarrhea, tachycardia

PRESENT ILLNESS: 49M w/PMHx HIV (CD4 114 in [**5-/2138**], kaposi's sarcoma) referred in
from primary care office due to tachycardia in the setting of
diarrhea, nausea, and vomiting x 5 days although nothing since
the AM (non bloody, no bilious). Pt reports diarrhea/loose
stools once a day x 5 days, non bloody, decreased apetite,
fatigue and malaise. He was feeling better today but decided to
see PCP. [**Name10 (NameIs) **] PCP office, patient noted to behypoxemic to low 90s
and tachycardic so he was sent to the ED.

MEDICAL HISTORY: --HIV: diagnosed [**11/2124**] in setting of Cryptosporidium diarrhea,
CD4 19, viral load 133,000. Treatment [**2124**]-[**2134**]: D4t, 3TC,
efavirenz (had resistant mutations K103N, M184V) [**2134**]-present:
3TC/TDF, atazanavir/rtv
-- kaposis sarcoma of feet and LE, stage I-II per bx and CXR
--sialadenitis, resolved
--ASCUS on anal papsmear-->high res biopsies then neg
--HepB infection-cleared
-- mod-severe MR
[**Name13 (STitle) **]/o positive PPD with CXR negative in [**2114**], repeat PPD
negative
[**2125**]

MEDICATION ON ADMISSION: Atazanavir 300mg
emtricitabine-tenofovir (truvada) 200-300mg, daily
Ritonavir (Norvir) 100mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals:  HR 101, 157/90, 95%on 2L
General: Alert, oriented, no acute distress, conversant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, sinus tachy, 3/6 systolic murmur
left sternal border, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, normal active bowel
sounds
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis,possible vry trace edema bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation.
No LAD of groin, axilla, neck

FAMILY HISTORY: uncle was an alcoholic. Family member with heart valve problem.

SOCIAL HISTORY: originally from [**Last Name (LF) 90491**], [**First Name3 (LF) **]. Has a brother--also gay--and a
sister. Educational background: has a J.D. and an interest in
history.  He works in research administration at the [**Hospital **]
Hospital. Has had a tumultuous
living situation over the past few months due to a breakup with
his recent partner of several years. He now lives alone in an
apartment [**Location (un) 90492**]. He has never smoked, denies
ever having used drugs, including IVD, and drinks about 2 EtOH
drinks a day (beer). He is not currently sexually active and
says his last sexual activity was over a year ago. When sexually
active, he engages in receptive anal sex and oral sex. No IV
drugs, no cocaine or heroine.
Human immunodeficiency virus [HIV] disease,Other pulmonary embolism and infarction,Kaposi's sarcoma, soft tissue,Acidosis,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other pancytopenia,Neoplasm of uncertain behavior of retroperitoneum and peritoneum,Diarrhea,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other specified cardiac dysrhythmias,Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US),Mitral valve disorders,Nonspecific reaction to tuberculin skin test without active tuberculosis,Anemia, unspecified,Other B-complex deficiencies
Human immuno virus dis,Pulm embol/infarct NEC,Sft tisue - kpsi's srcma,Acidosis,Hpt B acte wo cm wo dlta,Other pancytopenia,Unc behav neo peritoneum,Diarrhea,Elev transaminase/ldh,Cardiac dysrhythmias NEC,Pap smear anus w ASC-US,Mitral valve disorder,Nonsp rea skn test wo tb,Anemia NOS,B-complex defic NEC
Admission Date:  [**2138-9-26**]              Discharge Date:   [**2138-9-30**]

Date of Birth:  [**2089-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
diarrhea, tachycardia

Major Surgical or Invasive Procedure:
None


History of Present Illness:
49M w/PMHx HIV (CD4 114 in [**5-/2138**], kaposi's sarcoma) referred in
from primary care office due to tachycardia in the setting of
diarrhea, nausea, and vomiting x 5 days although nothing since
the AM (non bloody, no bilious). Pt reports diarrhea/loose
stools once a day x 5 days, non bloody, decreased apetite,
fatigue and malaise. He was feeling better today but decided to
see PCP. [**Name10 (NameIs) **] PCP office, patient noted to behypoxemic to low 90s
and tachycardic so he was sent to the ED.

Pt reported to the [**Name (NI) **], pt was hypoxemic 92% on RA and tachy in
the 130s. CT torso was performed and showed bilateral PEs for
which he was started on heparin gtt wtih bolus. CT also revealed
mesenteric mass suggestive of possible carcinoid tumor vs
chronic sclerosing mesenteritis, amyloidosis, calcified
metastatic implants, peritoneal echinococcus. Lactate was
elevated at 7.8 and he was given 2L IVF and cefepime and
vancomycin.

In the ED, initial VS were: 99.5 135 162/110   92
Labs: lactate 7.8, Lytes Na 136, K 3.6, Cl 96, bicarb 23, BUN
15, Cr 0.6, Gluc 188
UA sg 1025, pH 6.5, Urobil 2, sm blood, tr protein
WBC: 4.1, HCT 41, PLT 93, MCV 134, Neut 78, L 16, D Dimer 8882
Imaging notable for bilateral PEs and mesenteric mass 8x2x2cm,
Given 2g cefepime, 1g vano, heparin gtt.

Given total of 2L of IVF.

Access: 18 g x2
Vitals prior to transfer: HR 101, 157/90, 95%on 2L, comfortable
appearing, eating food in the ED.
On arrival to the MICU, pt is comfortable, well-appearing, no
acute distress, conversant. Vitals T 99.4, HR 103, 130/63, RR
20, 97% on 2L. He denies any flushing, no bronchospasm, no
telangiectasias.


Past Medical History:
--HIV: diagnosed [**11/2124**] in setting of Cryptosporidium diarrhea,
CD4 19, viral load 133,000. Treatment [**2124**]-[**2134**]: D4t, 3TC,
efavirenz (had resistant mutations K103N, M184V) [**2134**]-present:
3TC/TDF, atazanavir/rtv
-- kaposis sarcoma of feet and LE, stage I-II per bx and CXR
--sialadenitis, resolved
--ASCUS on anal papsmear-->high res biopsies then neg
--HepB infection-cleared
-- mod-severe MR
[**Name13 (STitle) **]/o positive PPD with CXR negative in [**2114**], repeat PPD
negative
[**2125**]


Social History:
originally from [**Last Name (LF) 90491**], [**First Name3 (LF) **]. Has a brother--also gay--and a
sister. Educational background: has a J.D. and an interest in
history.  He works in research administration at the [**Hospital **]
Hospital. Has had a tumultuous
living situation over the past few months due to a breakup with
his recent partner of several years. He now lives alone in an
apartment [**Location (un) 90492**]. He has never smoked, denies
ever having used drugs, including IVD, and drinks about 2 EtOH
drinks a day (beer). He is not currently sexually active and
says his last sexual activity was over a year ago. When sexually
active, he engages in receptive anal sex and oral sex. No IV
drugs, no cocaine or heroine.


Family History:
uncle was an alcoholic. Family member with heart valve problem.


Physical Exam:
ADMISSION
Vitals:  HR 101, 157/90, 95%on 2L
General: Alert, oriented, no acute distress, conversant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, sinus tachy, 3/6 systolic murmur
left sternal border, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, normal active bowel
sounds
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis,possible vry trace edema bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation.
No LAD of groin, axilla, neck


Pertinent Results:
Admissions Labs:
[**2138-9-26**] 01:10PM BLOOD WBC-4.1 RBC-3.10* Hgb-13.4* Hct-41.3
MCV-134* MCH-43.4* MCHC-32.5 RDW-12.9 Plt Ct-93*#
[**2138-9-26**] 01:10PM BLOOD Neuts-78.7* Lymphs-16.9* Monos-3.2
Eos-0.4 Baso-0.8
[**2138-9-26**] 10:50PM BLOOD PT-10.4 PTT-78.1* INR(PT)-1.0
[**2138-9-26**] 01:10PM BLOOD Glucose-188* UreaN-15 Creat-0.6 Na-136
K-3.6 Cl-96 HCO3-23 AnGap-21*
[**2138-9-26**] 01:10PM BLOOD ALT-45* AST-96* AlkPhos-67 TotBili-3.2*
[**2138-9-26**] 01:10PM BLOOD Albumin-4.3
[**2138-9-26**] 01:10PM BLOOD D-Dimer-8882*

Discharge Labs:
[**2138-9-30**] 07:20AM BLOOD WBC-3.1* RBC-2.83* Hgb-12.4* Hct-37.1*
MCV-131* MCH-43.7* MCHC-33.4 RDW-13.6 Plt Ct-106*
[**2138-9-30**] 07:20AM BLOOD PT-9.5 PTT-55.8* INR(PT)-0.9
[**2138-9-30**] 07:20AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-138
K-4.0 Cl-102 HCO3-29 AnGap-11
[**2138-9-29**] 06:16AM BLOOD ALT-40 AST-67* LD(LDH)-171 AlkPhos-46
TotBili-2.7*
[**2138-9-30**] 07:20AM BLOOD TotProt-6.2* Calcium-8.9 Phos-4.4 Mg-2.2

Other Labs:
[**2138-9-27**] 05:10AM BLOOD  WBC-3.4* Lymph-29 Abs [**Last Name (un) **]-986 CD3%-92
Abs CD3-906 CD4%-12 Abs CD4-114* CD8%-80 Abs CD8-786*
CD4/CD8-0.1*
[**2138-9-29**] 06:16AM BLOOD Ret Aut-3.2
[**2138-9-28**] 05:55AM BLOOD VitB12-397 Folate-3.6
[**2138-9-30**] 07:20AM BLOOD TSH-4.1
[**2138-9-27**] 05:10AM BLOOD IgM HAV-NEGATIVE
[**2138-9-30**] 07:20AM BLOOD PEP-NO SPECIFI
[**2138-9-27**] 05:10AM BLOOD HCV Ab-NEGATIVE

[**2138-9-26**] 01:18PM BLOOD Lactate-7.8*
[**2138-9-26**] 02:33PM BLOOD Lactate-6.1*
[**2138-9-27**] 12:02AM BLOOD Lactate-1.8

[**2138-9-27**] 05:10AM BLOOD Hapto-5*
[**2138-9-27**] 04:45PM BLOOD Hapto-25*
[**2138-9-29**] 06:16AM BLOOD Hapto-36

[**2138-9-27**] 01:51AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
[**2138-9-27**] 01:51AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-8* pH-7.0 Leuks-NEG
[**2138-9-27**] 01:51AM URINE RBC-1 WBC-0 Bacteri-NONE Yeast-NONE Epi-0

Pending Labs:
[**2138-9-30**] 07:20AM BLOOD METHYLMALONIC ACID-PND
[**2138-9-29**] 06:16AM BLOOD HERPESVIRUS 8 (HHV-8) DNA, QUALITATIVE
PCR W/REFLEX TO [**Doctor Last Name **]-PND
[**2138-9-28**] URINE HISTOPLASMA ANTIGEN-PND
[**2138-9-30**] STOOL [**Location (un) **]-LIKE VIRUS (NLV) ANTIGEN, EIA-PND
[**2138-9-30**]	STOOL VIRAL CULTURE-PENDING
[**2138-9-26**] BLOOD CULTURES PENDING x 2

Micro Studies:
C. difficile DNA amplification assay (Final [**2138-9-27**]): Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
FECAL CULTURE (Final [**2138-9-28**]):    NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2138-9-29**]):    NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2138-9-29**]): NO OVA AND PARASITES SEEN.
FECAL CULTURE - R/O VIBRIO (Final [**2138-9-29**]):    NO VIBRIO FOUND.

FECAL CULTURE - R/O YERSINIA (Final [**2138-9-29**]):    NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2138-9-28**]):  NO E.COLI
0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final [**2138-9-29**]):  NO
CRYPTOSPORIDIUM OR GIARDIA SEEN.
HIV-1 Viral Load/Ultrasensitive (Final [**2138-9-30**]):153 copies/ml.
HBV Viral Load (Final [**2138-9-30**]): HBV DNA not detected.
CMV Viral Load (Final [**2138-9-30**]): CMV DNA not detected.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2138-9-29**]):    POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2138-9-29**]):    POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2138-9-29**]):    NEGATIVE
<1:10 BY IFA.
      -INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.

Radiology:
CXR - FINDINGS:  The heart size is at the upper limits of
normal.  The mediastinal and hilar contours are normal.  The
lungs are clear.  There is no pleural effusion or pneumothorax.
IMPRESSION:  No acute cardiopulmonary process; please refer to
the report from chest CTA performed on the same day.

CTA Chest, CT A/P:
FINDINGS:
CHEST CTA: Enhanced pulmonary vasculature demonstrates multiple
bilateral
filling defects consistent with acute pulmonary emboli involving
most lobar,
segmental and subsegmental pulmonary arteries with relative
sparing of the
left upper lobe branches.  The aorta and major branches are
normal.  There is
no axillary, hilar, or mediastinal lymphadenopathy. The airways
are patent to
the subsegmental levels.  There is mild bibasilar atelectasis,
but the lungs
are without focal consolidation, effusion, or pneumothorax.  A
tiny granuloma
is noted in the right apex (2:8).
CT OF THE ABDOMEN WITH IV CONTRAST:  The liver is diffusely
hypodense
suggestive of fatty replacement. Otherwise, the liver,
gallbladder, spleen,
pancreas, bilateral kidneys, bilateral adrenal glands, stomach,
visualized
loops of small and large bowel are within normal limits.  The
celiac, SMA, and
[**Female First Name (un) 899**] are widely patent. The portal and splenic veins are patent.
There is no
free fluid or free air in the abdomen.  There is no mesenteric
or
retroperitoneal lymphadenopathy by CT size criteria.
A calcified soft tissue mass is noted in the root of mesentery
with irregular
margins and finger-like projections. There is adjacent tethering
of bowel
without bowel obstruction. The major venous structures appear
patent though
given the presence of mild mesenteric edema, venous compromise
is likely
present to some degree.  Approximate measurements of this mass
are 0.9 cm
(transverse) x 2.3 cm (craniocaudal) x 1.9 cm
(anterior-posterior).
CT OF THE PELVIS WITH IV CONTRAST:  The bladder, rectum,
prostate, and sigmoid
colon are within normal limits.  There is no free fluid or free
air in the
abdomen.  There is no pelvic or inguinal lymphadenopathy by CT
size criteria.
OSSEOUS STRUCTURES:  A sclerotic focus is noted in the right
femoral head
likely represent a bone island (3B:158).  There are no lytic or
sclerotic foci
suspicious for malignancy.  Mild degenerative changes are
visualized
throughout the thoracolumbar spine with disc vacuum phenomenon
at L5-S1.
IMPRESSION:
1.  Bilateral pulmonary emboli.
2.  Calcified mass in the root of small bowel mesentery
measuring
approximately 7.9 x 2.3 x 1.9 cm with tethering of adjacent
small bowel. Ddx
includes carcinoid tumor vs chronic sclerosing mesenteritis, vs
less likely
amyloidosis.

ECHO:
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Diastolic function could not be assessed. There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate/severe
posterior leaflet mitral valve prolapse. A late systolic jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate to severe prolapse of the posterior leaflet
of the mitral valve with moderate to severe mid-systolic mitral
regurgitation. Mild elevation of pulmonary artery systolic
pressure.


Brief Hospital Course:
49M w/PMHx HIV (CD4 114 in [**5-/2138**], kaposi's sarcoma) referred in
from primary care office due to tachycardia, diarrhea, fatigue
x5 days with CT Torso revealing bilateral PEs as well as
mesenteric mass.

# Diarrhea/Vomiting: Given patient's immunosuppression, the
differential diagnosis was broad. Stool studies were sent and
were negative for c.diff, salmonella, shigella, campylobacter,
O&P, vibrio, yersinia, e.coli, crypto, giardia. Stool viral
culture and vibrio were pending at the time of discharge. Pt has
mesenteric mass that may represent carcinoid tumor which can
also manifest as diarrhea/tachycardia/mitral regurge murmur.
However, diarrhea self-resolved several days after admission and
did not recur.

# Tachycardia: Etiology is likely multifactorial and includes
?carcinoid syndrome, tachycardia secondary to hypovolemic state
in setting of diarrhea, PE induced sinus tachycardia.
Tachycardia improved with treatment of PE and was resolved by
the time of discharge.

# Bilateral PEs: pt at risk given possible underlying
malignancy. Started on heparin drip and then transitioned to
lovenox. Pt will remain on lovenox until after his mesenteric
mass is excised.

# Mesenteric Mass: Surgery was consulted for excisional biopsy;
however, it was decided to wait a few weeks to allow for PE clot
burden to decrease. Pt will follow in surgery clinic for surgery
planning. Pt was seen by [**Location (un) 2274**] onc who will follow up with him
after biopsy is performed.

# Transaminitis:  Admission transaminases were ALT 40, AST 90,
[**Female First Name (un) **] 3.2. EBV studies showed prior infection. CMV, HBV, and HCV
were negative. It was felt that bilirubinemia (which was
predominately indirect) could be related to atazanavir. However,
transaminases remained mildly elevated. This will need to be
followed in the outpatient setting.

# Thrombocytopenia: PLT baseline 130-200s, was 90s on admission.
Differential includes destruction (Ex: ITP, TTP, DIC), poor
production (marrow involvement), splenic sequestration. TTP
unlikely since preserved HCT, no shisto on peripheral lab count.
HIV is often associated with thrombocytopenia independently.
Platelet count remained stable. Other viral studies were
negative as above. Plt count will need to be followed in
outpatient setting.

# Anemia: Initially with some suggestion of hemolysis (low
hapto), however, hap to returned to [**Location 213**]. MCV quite elevated.
B12 and folate borderline low, so supplementation was started.
Will need further evaluation as an outpatient.

# Mitral Regurgitation: Pt with history of severe MR, confirmed
on echo during this admission.

# HIV/AIDS: Has biopsy proven stage I-II kaposis sarcoma.
Continued home meds: Atazanavir 300mg daily, truvada 200-300
daily, norvir 100mg daily. CD4 count 114. Viral load153. Pt was
seen by ID during admission and will follow in [**Hospital 18**] [**Hospital **] clinic
after discharge.

Transitional Issues:
- PENDING labs - MMA, HHV8 viral load, urine histoplasma Ag,
stool norovirus Ag, stool viral cutlure, blood cultures
- will need outpt surgery eval for mass excision
- will remain on lovenox until after excision, then should be
transitioned to coumadin
- all need [**Location (un) 2274**] onc f/u after mass is excised
- will need further outpatient evaluation of thrombocytopenia,
anemia, and transaminitis

Medications on Admission:
Atazanavir 300mg
emtricitabine-tenofovir (truvada) 200-300mg, daily
Ritonavir (Norvir) 100mg daily


Discharge Medications:
1. Atazanavir 300 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. RiTONAvir 100 mg PO DAILY
4. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone [Mepron] 750 mg/5 mL 10 mL(s) by mouth daily Disp
#*900 Milliliter Refills:*0
RX *atovaquone [Mepron] 750 mg/5 mL 10 mL by mouth daily Disp
#*40 Milliliter Refills:*0
5. Cyanocobalamin 250 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 250 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Enoxaparin Sodium 80 mg SC Q12H
RX *enoxaparin 80 mg/0.8 mL inject 0.8 mL every 12 hours Disp
#*60 Syringe Refills:*0
RX *enoxaparin 80 mg/0.8 mL inject one syringe (80 mg) every 12
hours Disp #*8 Syringe Refills:*0
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
Primary
Diarrha, NOS
Pulmonary Embolus
Mesenteric Mass

Secondary
HIV/AIDS


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


Discharge Instructions:
You were admitted to the hospital with diarrhea and a fast heart
rate. You had a CAT scan which showed blood clots in the lungs
and a mass in your abdomen.

For your diarrhea, you were seen by the infectious disease
doctors.  Stool studies were sent.  At the time of discharge,
all of your stool studies were either negative or still pending.
 These will be followed up by your PCP.  [**Name10 (NameIs) 2172**] diarrhea had
resolved at the time of discharge.

For your blood clots, you were started on blood thinners
(heparin, then switched to lovenox).  You will ultimately need
to be started on coumadin.  However, this will not happen until
after your mass is removed.

For your abdominal mass, you were seen by the surgeons and the
oncologists.  It was decided to wait a few weeks before removing
the mass to allow you to recover from the blood clots.  You will
follow-up with the surgeons to plan this procedure.  After your
mass is removed, you should also follow-up with the [**Location (un) 2274**]
oncologists.

MEDICATION CHANGES
- start lovenox for your blood clots
- start vitamin B12 and folic acid
- start atovaquone (to prevent pneumonia)
- continue your HIV medications as you were taking them

*** You were given a short supply of the Lovenox and atovaquone
until your mail order medications arrive. ***

It was a pleasure taking part in your medical care.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2890**] M.
Location: [**Hospital1 641**]
Address: [**University/College 2899**], [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 2115**]
**APPOINTMENT Monday [**2137-10-5**]:30am**

With: [**Last Name (LF) 853**],[**First Name3 (LF) **] R.
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2138-10-6**] at 2:30 PM
ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23870**], MD [**Telephone/Fax (1) 457**]
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2138-11-12**] at 11:00 AM
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{"Human immunodeficiency virus [HIV] disease,Other pulmonary embolism and infarction,Kaposi's sarcoma, soft tissue,Acidosis,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other pancytopenia,Neoplasm of uncertain behavior of retroperitoneum and peritoneum,Diarrhea,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other specified cardiac dysrhythmias,Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US),Mitral valve disorders,Nonspecific reaction to tuberculin skin test without active tuberculosis,Anemia, unspecified,Other B-complex deficiencies"}


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: diarrhea, tachycardia

PRESENT ILLNESS: 49M w/PMHx HIV (CD4 114 in [**5-/2138**], kaposi's sarcoma) referred in
from primary care office due to tachycardia in the setting of
diarrhea, nausea, and vomiting x 5 days although nothing since
the AM (non bloody, no bilious). Pt reports diarrhea/loose
stools once a day x 5 days, non bloody, decreased apetite,
fatigue and malaise. He was feeling better today but decided to
see PCP. [**Name10 (NameIs) **] PCP office, patient noted to behypoxemic to low 90s
and tachycardic so he was sent to the ED.

MEDICAL HISTORY: --HIV: diagnosed [**11/2124**] in setting of Cryptosporidium diarrhea,
CD4 19, viral load 133,000. Treatment [**2124**]-[**2134**]: D4t, 3TC,
efavirenz (had resistant mutations K103N, M184V) [**2134**]-present:
3TC/TDF, atazanavir/rtv
-- kaposis sarcoma of feet and LE, stage I-II per bx and CXR
--sialadenitis, resolved
--ASCUS on anal papsmear-->high res biopsies then neg
--HepB infection-cleared
-- mod-severe MR
[**Name13 (STitle) **]/o positive PPD with CXR negative in [**2114**], repeat PPD
negative
[**2125**]

MEDICATION ON ADMISSION: Atazanavir 300mg
emtricitabine-tenofovir (truvada) 200-300mg, daily
Ritonavir (Norvir) 100mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION
Vitals:  HR 101, 157/90, 95%on 2L
General: Alert, oriented, no acute distress, conversant
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, sinus tachy, 3/6 systolic murmur
left sternal border, no rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, normal active bowel
sounds
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis,possible vry trace edema bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation.
No LAD of groin, axilla, neck

FAMILY HISTORY: uncle was an alcoholic. Family member with heart valve problem.

SOCIAL HISTORY: originally from [**Last Name (LF) 90491**], [**First Name3 (LF) **]. Has a brother--also gay--and a
sister. Educational background: has a J.D. and an interest in
history.  He works in research administration at the [**Hospital **]
Hospital. Has had a tumultuous
living situation over the past few months due to a breakup with
his recent partner of several years. He now lives alone in an
apartment [**Location (un) 90492**]. He has never smoked, denies
ever having used drugs, including IVD, and drinks about 2 EtOH
drinks a day (beer). He is not currently sexually active and
says his last sexual activity was over a year ago. When sexually
active, he engages in receptive anal sex and oral sex. No IV
drugs, no cocaine or heroine. 

### Response:
{"Human immunodeficiency virus [HIV] disease,Other pulmonary embolism and infarction,Kaposi's sarcoma, soft tissue,Acidosis,Viral hepatitis B without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta,Other pancytopenia,Neoplasm of uncertain behavior of retroperitoneum and peritoneum,Diarrhea,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Other specified cardiac dysrhythmias,Papanicolaou smear of anus with atypical squamous cells of undetermined significance (ASC-US),Mitral valve disorders,Nonspecific reaction to tuberculin skin test without active tuberculosis,Anemia, unspecified,Other B-complex deficiencies"}
