CHIEF COMPLAINT: headache, overall body malaise

PRESENT ILLNESS: 53 year old male Spanish speaking male (who speaks limited
English) with PMH significant for AIDS (last CD4 was 96 viral
load 189,000 in [**1-/2195**]) off of HARRT due to non-adherence,
toxoplasmosis, CMV, HBV, HCV, and a liver mass (AFP - WNL), who
presents with two weeks of generalized body aches. The patient
reports chronic headache (denies neck stiffness or photophobia),
pleuritic right sided chest pain, lower back pain, and LLE pain.
In addition he also notes drenching night sweats, 30lb weight
loss over several months and decreased P.O. intake. In reference
to his lower back pain, he does have a hx of nephrolithiasis.
However his sx today are not similar to his prior presentation.
He has a chronic cough, which at time produces a "jello"-like
sputum. He reports dysuria for the past year. He's been having
difficulty voiding for the past couple of days.
.
On presentation to [**Hospital1 18**] ED the patient had a T98.8, HR 100, BP
106/66, RR20, O2sat 96%RA. A chest CT was noteworthy for area of
consolidation in the RLL and a subpleural cavitary lesion. Head
CT showed sinusitis but no acute intracranial process. He
received the following doxycycline 100mg PO, ceftriaxone 1g IV
X1, bactrim 400mg IV X 1, and vancomycin 1g IV X 1, augmentin
500mg dose. An ECG was done whcih showed sinus tachycardia and
no PR prolongation.
.
The patient was transferred to the [**Hospital Unit Name 153**] for further management.
Of note the patient recently presented to [**Hospital1 2177**] with a similar
presentation. He was last seen here at [**Hospital1 18**] in [**2-19**] for
nephrolithiasis and PNA. He left AMA and was dicscharged on a
10day course of levaquin. During that time he had ruled out for
tb.

MEDICAL HISTORY: 1. HIV on HAART with last CD4 count 94. He has a history of
toxoplasmosis.
2. HBV
3. HCV
4. History of nephrolithiasis
5. Major depression
6. CNS toxo [**2187**]
7. MAC [**2187**]
8. oral candidiasis
9. pancreatitis on DDI [**2190**]

MEDICATION ON ADMISSION: none

ALLERGIES: Penicillins

PHYSICAL EXAM: T 97 BP 95/59 RR 13 HR 71 SpO2 97 RA
.
GEN: thin, unkempt male in NAD lying in bed
HEENT: PERRL, MMM extremely dry, JVP flat
HEART: nl rate, S1S2, no gmr
CHEST: decreased BS at the R lung base
BACK: b/l CVA tenderness
ABD: RLQ voluntary guarding, diffuse tenderness to palpation,
LLQ soft, non-tender, hypoactive BS overall
EXT: warm and well perfused, +DP b/l, no stigmata of
endocarditis, multiple tatoos

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: He lives @ [**Street Address(1) **] (shelter) He was in jail in [**2194-12-17**]
for 30 days. He smokes about a pack per day. He doesn't drink
alcohol. He uses heroin and last used 4 days ago by injection.
He uses about 3g/ day. He sells to support his habit. He
contracted HIV through IVDU.
Human immunodeficiency virus [HIV] disease,Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Severe sepsis,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Opioid type dependence, continuous,Chronic hepatitis C without mention of hepatic coma,Septic shock,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Depressive disorder, not elsewhere classified
Human immuno virus dis,Pneumococcal septicemia,Severe sepsis,Pneumococcal pneumonia,Opioid dependence-contin,Chrnc hpt C wo hpat coma,Septic shock,Other lung disease NEC,Anemia-other chronic dis,Depressive disorder NEC
Admission Date:  [**2195-9-9**]              Discharge Date:   [**2195-9-21**]

Date of Birth:  [**2141-12-8**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
headache, overall body malaise

Major Surgical or Invasive Procedure:
none

History of Present Illness:
53 year old male Spanish speaking male (who speaks limited
English) with PMH significant for AIDS (last CD4 was 96 viral
load 189,000 in [**1-/2195**]) off of HARRT due to non-adherence,
toxoplasmosis, CMV, HBV, HCV, and a liver mass (AFP - WNL), who
presents with two weeks of generalized body aches. The patient
reports chronic headache (denies neck stiffness or photophobia),
pleuritic right sided chest pain, lower back pain, and LLE pain.
In addition he also notes drenching night sweats, 30lb weight
loss over several months and decreased P.O. intake. In reference
to his lower back pain, he does have a hx of nephrolithiasis.
However his sx today are not similar to his prior presentation.
He has a chronic cough, which at time produces a "jello"-like
sputum. He reports dysuria for the past year. He's been having
difficulty voiding for the past couple of days.
.
On presentation to [**Hospital1 18**] ED the patient had a T98.8, HR 100, BP
106/66, RR20, O2sat 96%RA. A chest CT was noteworthy for area of
consolidation in the RLL and a subpleural cavitary lesion. Head
CT showed sinusitis but no acute intracranial process. He
received the following doxycycline 100mg PO, ceftriaxone 1g IV
X1, bactrim 400mg IV X 1, and vancomycin 1g IV X 1, augmentin
500mg dose. An ECG was done whcih showed sinus tachycardia and
no PR prolongation.
.
The patient was transferred to the [**Hospital Unit Name 153**] for further management.
Of note the patient recently presented to [**Hospital1 2177**] with a similar
presentation. He was last seen here at [**Hospital1 18**] in [**2-19**] for
nephrolithiasis and PNA. He left AMA and was dicscharged on a
10day course of levaquin. During that time he had ruled out for
tb.

Past Medical History:
1. HIV on HAART with last CD4 count 94. He has a history of
toxoplasmosis.
2. HBV
3. HCV
4. History of nephrolithiasis
5. Major depression
6. CNS toxo [**2187**]
7. MAC [**2187**]
8. oral candidiasis
9. pancreatitis on DDI [**2190**]

Social History:
He lives @ [**Street Address(1) **] (shelter) He was in jail in [**2194-12-17**]
for 30 days. He smokes about a pack per day. He doesn't drink
alcohol. He uses heroin and last used 4 days ago by injection.
He uses about 3g/ day. He sells to support his habit. He
contracted HIV through IVDU.

Family History:
Noncontributory.

Physical Exam:
T 97 BP 95/59 RR 13 HR 71 SpO2 97 RA
.
GEN: thin, unkempt male in NAD lying in bed
HEENT: PERRL, MMM extremely dry, JVP flat
HEART: nl rate, S1S2, no gmr
CHEST: decreased BS at the R lung base
BACK: b/l CVA tenderness
ABD: RLQ voluntary guarding, diffuse tenderness to palpation,
LLQ soft, non-tender, hypoactive BS overall
EXT: warm and well perfused, +DP b/l, no stigmata of
endocarditis, multiple tatoos


Pertinent Results:
[**2195-9-8**] 03:30PM   WBC-8.2# RBC-4.72 HGB-12.6* HCT-37.2*
MCV-79*# MCH-26.8*# MCHC-34.0 RDW-14.9
[**2195-9-8**] 03:30PM   NEUTS-82.4* LYMPHS-9.7* MONOS-6.4 EOS-0.9
BASOS-0.6
[**2195-9-8**] 03:30PM   PLT COUNT-203#
[**2195-9-8**] 03:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2195-9-8**] 03:30PM   CALCIUM-8.8 PHOSPHATE-1.9* MAGNESIUM-2.3
[**2195-9-8**] 03:30PM   CK-MB-NotDone
[**2195-9-8**] 03:30PM   cTropnT-<0.01
[**2195-9-8**] 03:30PM   LIPASE-25
[**2195-9-8**] 03:30PM   ALT(SGPT)-56* AST(SGOT)-145* CK(CPK)-67 ALK
PHOS-115 AMYLASE-60 TOT BILI-2.0*
[**2195-9-8**] 03:54PM   LACTATE-2.1*
[**2195-9-8**] 05:15PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5
LEUK-NEG
[**2195-9-8**] 05:15PM URINE  RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2195-9-8**] 05:15PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2195-9-8**] 11:08PM   D-DIMER-676*
[**2195-9-9**] 10:40AM   FIBRINOGE-432*
[**2195-9-9**] 10:40AM   PT-12.4 PTT-29.6 INR(PT)-1.1
[**2195-9-9**] 10:40AM   AFP-4.8
[**2195-9-9**] 10:40AM   CORTISOL-19.6
[**2195-9-9**] 10:40AM   calTIBC-238* HAPTOGLOB-232* FERRITIN-486*
TRF-183*
[**2195-9-9**] 10:40AM   ALBUMIN-2.6* CALCIUM-7.9* PHOSPHATE-1.8*
MAGNESIUM-2.3 IRON-29*
.
URINE CX [**9-8**]: NO GROWTH
.
CMV VL: NONE DETECTED
HCV VL:>700,000 IU/ml.
      Performed by RT-PCR.
      Detection range: 600 - 700,000 IU/ml.
HBV VL: NONE DETECTED
HIV VL:27,600 copies/ml.
      Performed by RT-PCR (ultrasensitive).
      Detection range: 50-100,000 copies/ml.
CRYPTO ANTIGEN: NEGATIVE
.
STOOL CX [**9-9**]:
   MICROSPORIDIA STAIN (Final [**2195-9-10**]):    NO MICROSPORIDIUM
SEEN.

   CYCLOSPORA STAIN (Final [**2195-9-10**]):    NO CYCLOSPORA SEEN.

   FECAL CULTURE (Final [**2195-9-11**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2195-9-11**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2195-9-10**]):
      NO OVA AND PARASITES SEEN.
      .
      This test does not reliably detect Cryptosporidium,
Cyclospora or
      Microsporidium. While most cases of Giardia are detected
by routine
      O+P, the Giardia antigen test may enhance detection when
organisms
      are rare.

   FECAL CULTURE - R/O VIBRIO (Final [**2195-9-11**]):    NO VIBRIO
FOUND.

   FECAL CULTURE - R/O YERSINIA (Final [**2195-9-11**]):    NO YERSINIA
FOUND.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2195-9-11**]):
      NO E.COLI 0157:H7 FOUND.

   Cryptosporidium/Giardia (DFA) (Final [**2195-9-10**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2195-9-10**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.
.
BLOOD CX [**9-9**], [**9-14**]: NEGATIVE
.
FUNGAL AFB BLOOD CX [**9-10**]: NO GROWTH
.
BLOOD CX [**9-8**] = [**2-17**] STREP PNEUMO (SENSITIVITIES BELOW)

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STREPTOCOCCUS PNEUMONIAE
                             |
CEFTRIAXONE-----------<=0.06 S
LEVOFLOXACIN---------- <=0.5 S
PENICILLIN------------<=0.06 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

.
SPUTUM [**2195-9-20**]: OROPHARYNGEAL FLORA
URINE LEGIONELLA ANTIGEN: NEGATIVE
.
SPUTUM IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2195-9-11**]):
      PNEUMOCYSTIS CARINII NOT SEEN.

   ACID FAST SMEAR (Final [**2195-9-12**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):
.
SPUTUM IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2195-9-10**]):
      PNEUMOCYSTIS CARINII NOT SEEN.

   ACID FAST SMEAR (Final [**2195-9-11**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):
.
SPUTUM GRAM STAIN (Final [**2195-9-9**]):
      <10 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2195-9-12**]):
      MODERATE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Please contact the Microbiology Laboratory ([**5-/2495**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

   LEGIONELLA CULTURE (Final [**2195-9-16**]):    NO LEGIONELLA
ISOLATED.

   IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2195-9-10**]):
      PNEUMOCYSTIS CARINII NOT SEEN.

   FUNGAL CULTURE (Preliminary):
      YEAST.

   ACID FAST SMEAR (Final [**2195-9-10**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):
.
ECG:
Sinus rhythm
Marked left axis deviation
Septal ST changes are nonspecific
Since previous tracing, limb lead voltage increased, R wave
progression
differences may be related to axis, lead placement, pulmonary
disease
Clinical correlation is suggested
.
MRI HEAD W/ AND W/O CONTRAST:
FINDINGS: There is a single focus of increased signal intensity
on FLAIR images near the cranial vertex in the right cerebral
hemisphere. Minimal increased FLAIR signal intensity is seen in
the periventricular white matter around both lateral ventricles.
There is no abnormal susceptibility artifact or area of
restricted diffusion. Normal flow voids are maintained on T2-
weighted images. Post-contrast images demonstrate no abnormal
enhancement.
There are no structural abnormalities. The ventricles and sulci
are normal.
There is mucosal thickening with the fluid levels seen in the
left maxillary sinus and some apparent thickening of the
maxillary sinus walls consistent with chronic sinusitis.
IMPRESSION:
No finding to specifically suggest present or past
toxoplasmosis. Single area of hyperintensity near the cranial
vertex in the right cerebral hemisphere is nonspecific. Chronic
left maxillary sinusitis.
.
ECHO:
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
3. No evidence of endocarditis seen.
.
BILATERAL LOWER EXTREMITY ULTRASOUND DOPPLERS:
IMPRESSION: No evidence of DVT in either lower extremity.
.
RUQ ULTRASOUND:
The gallbladder is surgically absent. The background
echogenicity of the liver is normal. Multiple foci of increased
echogenicity are noted throughout the liver. Six discrete areas
and several smaller areas of increased echogenicity likely
represent hemangiomas. The largest hemangioma is in the medial
portion of the right lobe of the liver, measuring 1.7 x 1.6 x
1.8 cm. There is no evidence of intra- or extra-hepatic biliary
ductal dilatation. The common duct measures 3 mm. The main
portal vein is patent with appropriate antegrade flow. There is
a right-sided pleural effusion. No evidence of ascites is seen.
IMPRESSION:
1. Multiple hemangiomas within the liver.
2. Patent portal venous vasculature. No evidence of biliary
obstruction.
3. Right pleural effusion.
.
CT ABD/PELVIS W/ CONTRAST:
FINDINGS: Note is made of diffusely increased attenuation of the
intraperitoneal fat; however, there is no discrete abscess. No
significant bowel dilatation or obstruction is noted. There is
small amount of ascites anterior to the liver. Note is made of
several small low densities in the left lobe of the liver,
measuring up to 1.5 cm. There is right lobe hepatic hemangioma.
Fatty liver is again noted. Again note is made of somewhat
prominent CBD, measuring up to 1 cm, in this patient with status
post cholecystitis, unchanged compared to the prior study. Main
pancreatic duct is somewhat prominent, measuring up to 3 mm, not
significantly changed compared to the prior study. Small
retroperitoneal nodes are seen; however, there is no significant
lymphadenopathy. Spleen, adrenal glands, kidneys, and the
visualized portion of large and small intestines are within
normal limits.

PELVIS: The visualized portion of large and small intestines are
within normal limits. No evidence of abscess is noted.
In the visualized portion of the lung bases, note is made of
consolidation in the right lower lobe and a cavitary lesion in
the right middle lobe as well as effusion, as demonstrated on
the CTA study performed on the same day. There is no suspicious
lytic or blastic lesion in skeletal structures.
IMPRESSION:
1. Diffuse increase of the attenuation of the intraperitoneal
fat in the abdomen with small amount of ascites anterior to the
liver, probably due to anasarca. No evidence of discrete
abscess. No evidence of bowel obstruction.
2. Low-density lesions in the left lobe of the liver. These
lesions can be evaluated by ultrasound.
3. Unchanged right lobe hepatic hemangioma.
4. Somewhat prominent CBD and main pancreatic duct, unchanged
compared to the prior study.
5. Right lower lobe consolidation and a cavitary lesion in the
right middle lobe with effusion, as noted on the prior CT study.
.
CT HEAD W/O CONTRAST:
FINDINGS: There is no evidence of intracranial hemorrhage, mass
effect, or shift of normally midline structures. [**Doctor Last Name **]-white
matter differentiation is preserved. The ventricles are normal
in size and symmetrical. There is no acute major vascular
territorial infarction. The visualized paranasal sinuses
demonstrate near complete opacification of the left maxillary
sinus and partial opacification of the left ethmoid sinuses. The
mastoid air cells are clear.
IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Near complete opacification of the left maxillary sinus.
Partial opacification of the left ethmoid sinuses. Although
there are no significant sclerotic bony changes to indicate
chronic disease, these findings are consistent with either acute
or chronic sinusitis. Recommend correlating with clinical
history and physical exam.
.
CT CHEST WITH IV CONTRAST: There are multiple non-pathologically
enlarged lymph nodes within the mediastinum. There is no hilar
or axillary lymphadenopathy.
There is dense consolidation present within the medial aspect of
the right lower lobe consistent with airspace disease. There is
an additional peripherally located opacity measuring 1.5 cm in
diameter containing a cavitation within the right middle lobe.
There are patchy areas of ground- glass opacity within the
medial aspect of the left lower lobe. Findings are concerning
for multifocal pneumonia among other entities.
CTA CHEST:
There are no evidence of filling defects within the pulmonary
arterial vasculature. There is no evidence of pulmonary
embolism. The aorta is of normal caliber throughout its
visualized course. The limited views of the upper abdomen
demonstrate no gross abnormalities. There are no suspicious
lytic or sclerotic bony lesions.
IMPRESSION:
1. Multifocal opacities with greatest area of consolidation
within the right lower lobe. There is a peripheral cavitary
lesion within the right middle lobe. Given the chronicity,
chronic airspace disease should be considered such as atypical
mycobacterium (e.g. MAC) or chronic aspiration. Neoplasm,
particularly bronchoalveolar cell carcinoma may present as
chronic air space disease, but is unlikely given multifocality.
If infectious the specific organism will be based on the
patient's immune status. Also given the area of cavitation and
multifocal nature of distribution, another possible etiology
includes septic emboli.
2. No pulmonary embolism.


Brief Hospital Course:
# Strep pneumo pneumonia with complicating strep pneumo
bacteremia:
Patient remained stable on room air throughout his admission.
Chest CT remarkable for multifocal infiltrate.  Induced sputum
negative for AFB, PCP, [**Name10 (NameIs) **] other fungus x 3.  Sputum culture
also negative for legionella.  Legionella urinary antigen
negative.  Sputum culture did grow a moderate amount of MRSA.
ID doubts this is a true pathogen, however, patient did receive
7 days IV vancomycin.  Four out of 4 blood cultures grew out
strep pneumonia sensitive to levofloxacin.  Patient will
complete a total of 14 days of levofloxacin for treatment.  TTE
was negative for endocarditis.  Given cultures cleared quickly
and no peripheral stigmata, ID agreed with deferring TEE.
Patient received both the pneumovax and influenza vaccine prior
to his discharge.  PPD was negative.
.
# Right cavitary lung lesion:
Suspect this is secondary to underlying pneumonia, but cannot
rule out malignancy.  Patient will be followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] from ID, who is aware of follow-up chest CT in 1 month
to monitor.  Induced sputum AFB and PCP negative [**Name Initial (PRE) **] 3.
.
# Bacillus:
Patient grew bacillus (not anthracis) out of 1 blood culture.
ID doubts this is a true pathogen, however, patient completed a
total of 7 days of IV vancomycin.  Ophthomalogy evaluation
showed no evidence of ophthmalmitis.
.
# Chronic Headache:
Patient complained of on/off headache while in house.  History
of toxoplasmosis but head MRI shows no evidence of past or
present toxo.  Crypto antigen negative.  Imaging remarkable for
chronic left maxillary sinusitis.  Patient taking ibuprofen prn
for his headaches.  He was given afrin nasal spray.
.
# Lower extremity swelling:
Patient developed 2 + pitting edema in his lower extremities
(right>left).  Lower extremity dopplers showed no evidence of
DVT.  Right upper quadrant ultrasound shows portal vein patent.
Albumin is low at 2.1 so suspect underlying anasarca.  Urine
with only trace protein.  Repeat albumin now up to 3.1 on
nutrition supplements.  Patient's edema resolved with diuresis
with qd lasix.  This medication can be restarted as needed for
recurrence with careful monitoring of his creatinine.
.
# RUQ/side pain:
Patient complains of right sided pain since admission.  He was
found to have a dense pneumonia with cavitation, which is likely
the source of his pain.  CT abd and RUQ u/s unremarkable for an
alternative source of his pain.  LFTs mildly elevated from
chronic hepatitis but are stable. T bili within normal limits.
Patient taking ibuprofen prn for his pain.
.
# HIV
Patient has been non-adherent to HAART in past.  ID followed
during his admission.  Patient was started on bactrim DS qd for
toxo and PCP [**Name Initial (PRE) 1102**].  He was also started on azithromycin
for MAC prophylaxis.  He will follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
as an outpatient to reinitiate HAART.
.
# Opiate dependence:
Prior to admission, patient abusing heroine and methadone.  He
exhibited strong motivation to seek treatment for his problem.
[**Name (NI) **] has been on a treatment program in the past.  He was started
on maintenance methadone for relief of withdrawl and this was
gradually weaned to off.  Patient has tolerated this well.  His
last dose of methadone 5 mg po x 1 was on Sunday, [**2195-9-20**].  He is going to a drug treatment program for continued
assistance with his addiction.  SW assisted with his dispo.
.
# Depression:
No suicidal ideation.  Mood stable off meds.  Psychiatry
consulted during the admission.  Patient will follow-up with
therapist at [**Hospital1 1680**] House.
.
# Hematuria:
History of nephrolithiasis.  No evidence of stones on CT.  Will
need outpatient follow-up and referral to urology if this
persists.
.
# Anemia:
Hematocrit stable at 32.  Folate, B12 were normal.  Iron studies
suggest anemia of chronic disease but need to be repeated when
patient is not actively infected.
.
# Chronic hepatitis C and history of hepatitis B: Patient's LFTs
remained stable except for an isolated elevated alk phos which
improved with lasix. AFP within the normal range.  RUQ U/S with
multiple hemangiomas.
.
# Contact [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 66082**]
.
# Full code
.
# Dispo: Patient discharged to [**Hospital 1680**] Hospital for continued
assistance with his opiate addiction.

Medications on Admission:
none

Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 2 weeks.
Disp:*280 ML(s)* Refills:*0*
3. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily): YOU CANNOT SMOKE WHEN YOU HAVE THIS
PATCH ON!!.
Disp:*30 Patch 24HR(s)* Refills:*0*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO qTuesday.
Disp:*8 Tablet(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital 1680**] Hospital - [**Location (un) 538**]

Discharge Diagnosis:
strep pneumonia
strep pneumonia bacteremia
anasarca
right lung cavitary lesion
opiate dependence
chronic headache
history of HIV
history of hep B and C


Discharge Condition:
good: afebrile, stable on room air


Discharge Instructions:
Please monitor for temperature > 101, shortness of breath,
diarrhea, or other concerning symptoms.

Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2195-9-28**] at
8:30 AM.  Phone: [**Telephone/Fax (1) 457**] (Please call for directions)

Please follow-up for your CT scan on [**2195-10-12**] at 10 AM.
 Location: [**Hospital1 18**], [**Hospital Ward Name 516**], [**Hospital Unit Name 1825**], [**Location (un) 470**].  YOU
CANNOT EAT 3 HOURS PRIOR TO THIS EXAM.
{'Human immunodeficiency virus [HIV] disease,Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Severe sepsis,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Opioid type dependence, continuous,Chronic hepatitis C without mention of hepatic coma,Septic shock,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Depressive disorder, 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: headache, overall body malaise

PRESENT ILLNESS: 53 year old male Spanish speaking male (who speaks limited
English) with PMH significant for AIDS (last CD4 was 96 viral
load 189,000 in [**1-/2195**]) off of HARRT due to non-adherence,
toxoplasmosis, CMV, HBV, HCV, and a liver mass (AFP - WNL), who
presents with two weeks of generalized body aches. The patient
reports chronic headache (denies neck stiffness or photophobia),
pleuritic right sided chest pain, lower back pain, and LLE pain.
In addition he also notes drenching night sweats, 30lb weight
loss over several months and decreased P.O. intake. In reference
to his lower back pain, he does have a hx of nephrolithiasis.
However his sx today are not similar to his prior presentation.
He has a chronic cough, which at time produces a "jello"-like
sputum. He reports dysuria for the past year. He's been having
difficulty voiding for the past couple of days.
.
On presentation to [**Hospital1 18**] ED the patient had a T98.8, HR 100, BP
106/66, RR20, O2sat 96%RA. A chest CT was noteworthy for area of
consolidation in the RLL and a subpleural cavitary lesion. Head
CT showed sinusitis but no acute intracranial process. He
received the following doxycycline 100mg PO, ceftriaxone 1g IV
X1, bactrim 400mg IV X 1, and vancomycin 1g IV X 1, augmentin
500mg dose. An ECG was done whcih showed sinus tachycardia and
no PR prolongation.
.
The patient was transferred to the [**Hospital Unit Name 153**] for further management.
Of note the patient recently presented to [**Hospital1 2177**] with a similar
presentation. He was last seen here at [**Hospital1 18**] in [**2-19**] for
nephrolithiasis and PNA. He left AMA and was dicscharged on a
10day course of levaquin. During that time he had ruled out for
tb.

MEDICAL HISTORY: 1. HIV on HAART with last CD4 count 94. He has a history of
toxoplasmosis.
2. HBV
3. HCV
4. History of nephrolithiasis
5. Major depression
6. CNS toxo [**2187**]
7. MAC [**2187**]
8. oral candidiasis
9. pancreatitis on DDI [**2190**]

MEDICATION ON ADMISSION: none

ALLERGIES: Penicillins

PHYSICAL EXAM: T 97 BP 95/59 RR 13 HR 71 SpO2 97 RA
.
GEN: thin, unkempt male in NAD lying in bed
HEENT: PERRL, MMM extremely dry, JVP flat
HEART: nl rate, S1S2, no gmr
CHEST: decreased BS at the R lung base
BACK: b/l CVA tenderness
ABD: RLQ voluntary guarding, diffuse tenderness to palpation,
LLQ soft, non-tender, hypoactive BS overall
EXT: warm and well perfused, +DP b/l, no stigmata of
endocarditis, multiple tatoos

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: He lives @ [**Street Address(1) **] (shelter) He was in jail in [**2194-12-17**]
for 30 days. He smokes about a pack per day. He doesn't drink
alcohol. He uses heroin and last used 4 days ago by injection.
He uses about 3g/ day. He sells to support his habit. He
contracted HIV through IVDU. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Pneumococcal septicemia [Streptococcus pneumoniae septicemia],Severe sepsis,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Opioid type dependence, continuous,Chronic hepatitis C without mention of hepatic coma,Septic shock,Other diseases of lung, not elsewhere classified,Anemia of other chronic disease,Depressive disorder, not elsewhere classified'}
