CHIEF COMPLAINT: respiratory distress

PRESENT ILLNESS: 73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin presents with 4 days
of increasing SOB and cough with green sputum. His symptoms have
been going on for about 4 days. He denied any fevers, chills,
sweats. He also denied any chest pain, nausea, vomitting. He did
report acute on chronic abdominal pain, which has had an
extensive and negative outpatient work up. Of note, he was
recently discharged from [**Hospital1 18**] in early [**2113-3-10**] for UTI,
superficial ulcer. Because his symptoms worsened over time, he
developed
.
In the ED, the patient presented with the following vital signs:
96.8   147/70   94   34   96%12L NRB. He was thought to be
initially with acute COPD was given 500cc NS and duonebs when he
became acutely dyspneic and was thought to have acute pulmonary
edema. He was given nitro SL to no avail. He was given nitro
paste again with no significant help. He then was given lasix
20mg IV ONCE but made no urine from this. He then was given
nitro gtt, which per ED resident seemed to help him, as did
bipap. He was given morphine for abdominal pain and respiratory
distress. He was also given levofloxacin 750mg IV ONCE,
azithromycin 500mg PO ONCE, ceftriaxone 1gm IV ONCE. His last
set of vitals were 67  111/76   21   98% on CPAP FIO2 60, PEEP
of 10.

MEDICAL HISTORY: # HIV disease, dx [**9-15**] likely secondary to heterosexual
transmission. ATRIPLA started [**12-17**]. Self-d/c meds due to side
effects. Last CD4 count [**2112-9-9**] was 123.
# Chronic kidney disease (baseline cr 1.0)
# Atrial fibrillation - off coumadin due to GI bleed
# Prostate cancer - Diagnosed 15 yrs ago, in remission s/p
hormonal and radiation therapy
# COPD, long ex-tobacco history, severe emphysema on radiography

MEDICATION ON ADMISSION: 1. abacavir-lamivudine 600-300 mg Tablet Sig: One (1) Tablet PO
once a day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-11**] puff Inhalation every four (4) hours as needed for shortness

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
GEN: Elderly man in moderate distress, tachypneic, diaphoretic
HEENT: anicteric,
RESP: CTA b/l with good air movement throughout, scattered
crackles, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild LUQ tenderness, no masses or
hepatosplenomegaly
EXT: no c/c 2+ edema bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.

FAMILY HISTORY: per OMR) No history of lung disease, cancer or CAD.

SOCIAL HISTORY: (per OMR and patient) He lives with his wife in [**Location (un) 686**] at an
[**Hospital3 **] and denies alcohol or drug use. He smoked for 60
years and quit recently.
Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of prostate,Other emphysema,Esophageal reflux,Gout, unspecified,Depressive disorder, not elsewhere classified,Other abnormal glucose,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site
Human immuno virus dis,Acute respiratry failure,K. pneumoniae pneumonia,Ac on chr diast hrt fail,Acute kidney failure NOS,Hyposmolality,Urin tract infection NOS,Delirium d/t other cond,Thrush,Atrial fibrillation,Hx-ven thrombosis/embols,Long-term use anticoagul,Chronic kidney dis NOS,Hx-prostatic malignancy,Emphysema NEC,Esophageal reflux,Gout NOS,Depressive disorder NEC,Abnormal glucose NEC,Klebsiella pneumoniae
Admission Date:  [**2113-4-7**]              Discharge Date:   [**2113-4-19**]

Date of Birth:  [**2039-4-17**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
respiratory distress

Major Surgical or Invasive Procedure:
intubation

History of Present Illness:
73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin presents with 4 days
of increasing SOB and cough with green sputum. His symptoms have
been going on for about 4 days. He denied any fevers, chills,
sweats. He also denied any chest pain, nausea, vomitting. He did
report acute on chronic abdominal pain, which has had an
extensive and negative outpatient work up. Of note, he was
recently discharged from [**Hospital1 18**] in early [**2113-3-10**] for UTI,
superficial ulcer. Because his symptoms worsened over time, he
developed
.
In the ED, the patient presented with the following vital signs:
96.8   147/70   94   34   96%12L NRB. He was thought to be
initially with acute COPD was given 500cc NS and duonebs when he
became acutely dyspneic and was thought to have acute pulmonary
edema. He was given nitro SL to no avail. He was given nitro
paste again with no significant help. He then was given lasix
20mg IV ONCE but made no urine from this. He then was given
nitro gtt, which per ED resident seemed to help him, as did
bipap. He was given morphine for abdominal pain and respiratory
distress. He was also given levofloxacin 750mg IV ONCE,
azithromycin 500mg PO ONCE, ceftriaxone 1gm IV ONCE. His last
set of vitals were 67  111/76   21   98% on CPAP FIO2 60, PEEP
of 10.


Past Medical History:
# HIV disease, dx [**9-15**] likely secondary to heterosexual
transmission. ATRIPLA started [**12-17**]. Self-d/c meds due to side
effects. Last CD4 count [**2112-9-9**] was 123.
# Chronic kidney disease (baseline cr 1.0)
# Atrial fibrillation - off coumadin due to GI bleed
# Prostate cancer - Diagnosed 15 yrs ago, in remission s/p
hormonal and radiation therapy
# COPD, long ex-tobacco history, severe emphysema on radiography

# Pumonary Nodule: 2mm LUL lung nodule detected on CT chest
[**9-15**]
# GERD
# PUD, Had 'surgery' 40 yrs ago, likely a Billroth
# Anemia
# Lumbar radiculopathy, spinal stenosis
# Left shoulder rotator cuff tear with repair in [**10/2105**]
# Trichomonas
# Gout
# Hx of esophageal candidiasis
# Chronic left-sided abdominal pain, follows with GI here,
extensive negative workup as an outpatient
# Infrarenal abdominal aneurysm, measuring 3.6 cm on [**2111-12-31**]


Social History:
(per OMR and patient) He lives with his wife in [**Location (un) 686**] at an
[**Hospital3 **] and denies alcohol or drug use. He smoked for 60
years and quit recently.


Family History:
per OMR) No history of lung disease, cancer or CAD.

Physical Exam:
On admission:
GEN: Elderly man in moderate distress, tachypneic, diaphoretic
HEENT: anicteric,
RESP: CTA b/l with good air movement throughout, scattered
crackles, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild LUQ tenderness, no masses or
hepatosplenomegaly
EXT: no c/c 2+ edema bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.

Pertinent Results:
On admission:

[**2113-4-7**] 07:05PM BLOOD WBC-9.7# RBC-3.43* Hgb-11.7* Hct-35.9*
MCV-105* MCH-34.1* MCHC-32.6 RDW-16.5* Plt Ct-213
[**2113-4-7**] 07:05PM BLOOD Neuts-89.8* Lymphs-8.5* Monos-1.4*
Eos-0.1 Baso-0.3
[**2113-4-7**] 07:05PM BLOOD PT-23.5* PTT-23.9 INR(PT)-2.2*
[**2113-4-7**] 07:05PM BLOOD Glucose-127* UreaN-32* Creat-2.0* Na-138
K-4.9 Cl-105 HCO3-22 AnGap-16
[**2113-4-8**] 02:25AM BLOOD Glucose-165* UreaN-38* Creat-2.5* Na-136
K-5.4* Cl-106 HCO3-19* AnGap-16
[**2113-4-7**] 07:05PM BLOOD ALT-22 AST-21 LD(LDH)-397* AlkPhos-54
TotBili-0.5
[**2113-4-8**] 02:25AM BLOOD CK-MB-6 cTropnT-0.15*
[**2113-4-7**] 10:51PM BLOOD Type-ART Temp-37.8 PEEP-8 FiO2-60 pO2-32*
pCO2-51* pH-7.23* calTCO2-22 Base XS--7 Intubat-NOT INTUBA
[**2113-4-8**] 12:10AM BLOOD Type-ART PEEP-10 pO2-77* pCO2-33* pH-7.36
calTCO2-19* Base XS--5 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2113-4-8**] 06:11AM BLOOD Type-ART pO2-83* pCO2-42 pH-7.29*
calTCO2-21 Base XS--5
[**2113-4-7**] 07:53PM URINE RBC-50* WBC->182* Bacteri-MANY Yeast-NONE
Epi-2
[**2113-4-7**] 07:53PM URINE CastGr-4* CastHy-21*
CXR on admission:
IMPRESSION: Given profound low lung volumes, it is difficult to
definitively diagnose a superimposed acute process above the
extensive linear reticular scarring seen at the lung bases.
Conceivably, there may be a superimposed consolidation at the
left lung base although this is not entirely clear. If clinical
management is dependent on determination, consider repeat x-ray
or CT for further characterization.
INDICATION: History of HIV, intubated in ICU for respiratory
failure.

COMPARISON: CT available from [**2113-3-13**] and [**2112-12-22**].

TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were
obtained without the use of IV contrast. Coronal and sagittal
reformations were performed at 5-mm slice thickness. 1.25-mm
axial reconstructions were also obtained for further evaluation
of the pulmonary parenchyma.

FINDINGS: Again seen is severe centrilobular emphysema with
paraseptal blebs, the largest measuring 21 mm in diameter
located at the right base (3:32).  There is increased
ground-glass opacity and atelectasis within the right upper and
middle lobes, partially obscuring a right upper lobe mass (3:22)
better seen on prior examinations. Increased septal thickening,
predominantly at the lung bases (3:34) are reflective of
mild-to-moderate pulmonary edema, worse since the [**2113-3-13**]
examination. A left lower lobe consolidation (3:37) is new.
Trace bilateral pleural effusions are present. The heart is
mildly enlarged. There is no pericardial effusion. The great
vessels are normal in caliber, re-demonstrating mild
atherosclerotic calcifications. Crescentic narrowing of the
trachea is reflective of tracheomalacia.
Prominent prevascular nodes measure up to 9 mm in diameter
(2:17), increased since the prior examination. Other scattered
axillary lymph nodes do not meet CT criteria for
lymphadenopathy.
Included views of the upper abdomen demonstrate transesophageal
catheter
terminating within the stomach lumen. Non-contrast enhanced
images of the
liver, gallbladder, pancreas, kidneys, spleen, small splenule
(2:43), and
adrenal glands are normal.

IMPRESSION:
1. Left lower lobe pneumonia.
2. Bilateral pleural effusions.
3. Increase in right upper and middle lobe atelectasis and
diffuse
mild-to-moderate pulmonary edema.
4. Spiculated right upper lobe nodule, obscured by neighboring
atelectasis
and edema, better appreciated on the [**2113-3-13**] examination,
remains
concerning for neoplasm.

MICRO:
URINE CULTURE (Final [**2113-4-11**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMIKACIN--------------  =>64 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------    32 R
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     8 I
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO-----       I
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R
.
Blood Cultures: [**4-7**] and [**4-8**]: negative
.
CRYPTOCOCCAL ANTIGEN (Final [**2113-4-8**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
           (Reference Range-Negative).
.
Legionella Urinary Antigen  (Final [**2113-4-9**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
      Performed by Immunochromogenic assay.
      A negative result does not rule out infection due to other
L.
      pneumophila serogroups or other Legionella species.
Furthermore, in
      infected patients the excretion of antigen in urine may
vary.
.
MRSA SCREEN (Final [**2113-4-10**]):    No MRSA isolated.
.
Respiratory Viral Culture (Final [**2113-4-12**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
      Detection of viruses other than those listed above will
only be
      performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
      within 1 week if additional testing is needed.

   Respiratory Viral Antigen Screen (Final [**2113-4-10**]):
      Less than 60 columnar epithelial cells;.
      Specimen inadequate for detecting respiratory viral
infection by DFA
      testing.
      Interpret all negative results from this specimen with
caution.
      Negative results should not be used to discontinue
precautions.
      Refer to respiratory viral culture results.
      Recommend new sample be submitted for confirmation.
      Reported to and read back by DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**] [**2113-4-10**] AT
12:18.
.
BAL: GRAM STAIN (Final [**2113-4-8**]):
     RESPIRATORY CULTURE (Final [**2113-4-10**]):
      >100,000 ORGANISMS/ML. Commensal Respiratory Flora.
      YEAST.    ~3000/ML.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.
   LEGIONELLA CULTURE (Final [**2113-4-15**]):    NO LEGIONELLA
ISOLATED.
   POTASSIUM HYDROXIDE PREPARATION (Final [**2113-4-8**]):
      Test cancelled by laboratory.
      PATIENT CREDITED.
      This is a low yield procedure based on our in-house
studies.
      if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
      Aspergillosis or Mucormycosis is strongly suspected,
contact the
      Microbiology Laboratory (7-2306).
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2113-4-9**]):    NEGATIVE for Pneumocystis jirovecii
(carinii).
   FUNGAL CULTURE (Preliminary):       YEAST.
   ACID FAST SMEAR (Final [**2113-4-10**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

   VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
      No Cytomegalovirus (CMV) isolated.
.
STOOL:
  MICROSPORIDIA STAIN (Final [**2113-4-12**]):    NO MICROSPORIDIUM
SEEN.
   CYCLOSPORA STAIN (Final [**2113-4-12**]):    NO CYCLOSPORA SEEN.
   FECAL CULTURE (Final [**2113-4-13**]):    NO SALMONELLA OR SHIGELLA
FOUND.
   CAMPYLOBACTER CULTURE (Final [**2113-4-13**]):    NO CAMPYLOBACTER
FOUND.
   OVA + PARASITES (Final [**2113-4-12**]):
      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.
   Cryptosporidium/Giardia (DFA) (Final [**2113-4-12**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-4-12**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
Catheter tip CULTURE (Final [**2113-4-17**]):    No significant growth.

.
BDGlucan and Galactomman: NEGATIVE
.
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC   Hgb   Hct  MCV   MCH  MCHC RDW
Plt Ct
[**2113-4-19**] 04:05     7.2 2.63* 9.2* 28.0* 106* 35.0* 32.9 17.5*
307
  DIFFERENTIAL     Neuts   Bands Lymphs Monos  Eos
[**2113-4-19**] 04:05    87.1*   9.7* 2.4     0.7   0.1
  BASIC COAGULATION  PT    PTT  INR(PT)
[**2113-4-19**] 04:05    21.0* 24.9   1.9*

Chemistry
  RENAL & GLUCOSE   Glucose UreaN Creat  Na  K   Cl HCO3 AnGap
[**2113-4-19**] 04:05    104*1     24*  1.3* 137 4.3 104  25  12




Brief Hospital Course:
73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin.
.
# Hypoxic respiratory failure: Patient presented with 4 days of
increasing SOB and cough with green sputum and admitted to the
MICU on a NRB.  CXR appeared to have LLL infiltrate so he was
empirically started on treatment for hospital acquired pneumonia
with Vanc/Cefepime/levofloxacin.  On the night of admission, he
was intubated for clinically worsening respiratory failure.  CT
chest showed consolidation in the LLL and emphysematous changes
throughout the rest of the lung.  [**Last Name (un) **] and BAL was performed
which revealed frank pus in the left lower lobe which was
plugging the distal bronchioles.  BAL sent for infectious
organisms but did not grow any bacteria, it did grow yeast but
B-glucan and galactomman were negative so this was felt to be a
contaminant.  PCP and viral cultures were negative.  ESBL
Klebsiella grew from the patient's urine (taken in the ED prior
to antibiotics) and this was presumed to be the cause of his
pneumonia as well.  Therefore ABX were changed to
Vanc/[**Last Name (un) **]/Levoflox and he completed an 8 day course.  Patient
was weaned from the vent and successfully extubated on HD #9.
He did well post-extubation and was weaned down to 4L-5L 02 via
NC by HD #12.  He was continued on nebs post-extubation.
-patient will require pulmonary rehab
-patient will follow up with his outpatient pulmonologist as he
missed an appointment in the hospital.
-volume overload was contributing to his hypoxia in the hospital
and he was diuresed with 40 IV lasix daily for several days.  He
appears to be more euvolemic now and has been restarted on his
home lasix 20mg po daily but may require additional doses of 40
IV lasix for volume overload
-Patient should remain on 1.5L Fluid restriction
.
#. UTI: Culture grew Klebsiella resistant to all ABX except
meropenem.  He completed 8 days of meropenem.
.
#. Acute Kidney injury: On admission, creatinine was 2.6.  This
resolved with IVF in the ICU and remained 1.1 to 1.3 for the
rest of his stay.  His lamivudine and valganciclovir were
initially renally dosed and then changed back to full dose as
his creatinine improved.
-patient should have weekly chem7 particularly if he is
requiring diuresis with IV lasix.
.
#.  Atrial fibrillation: Patient was admitted in afib with rates
<100.  The patient developed a wide complex tachycardia and
cardiology looked at his strips and felt it was consistent with
Afib with RVR and abberence.  He was started on diltiazem and
his rate improved and he had no more wide complex tachycardia.
When patient stabilized he was restarted on his home coumadin
1mg PO daily (restarted [**2113-4-18**])
-patient will need daily INRs until stabilized (INR on the day
of discharge is 1.9)
-patient should be monitored closely for bleeding as he
developed hemoptysis in the ICU while on heparin.
.
# Hemoptysis: Patient was put on heparin gtt given his history
of afib and PE.  However he developed hemoptysis.  Bronch did
not reveal a source of bleeding.  Heparin was held and the
patient's hemoptysis slowly resolved.  Patient was restarted on
his home coumadin on HD 11 and he had no more hemoptysis.
.
# HIV: Patient was continued on his home HAART, initially dose
adjusted Lamivudine for renal failure.  Also continued on
Bactrim prophylaxis and valgancyclovir for CMV prophylaxis.
Patient's outpatient ID provider was [**Name (NI) 653**].
.
# Depression: Patient's home fluoxetine and mirtazipine held due
to his intubation.  These medications were not initially
restarted after extubation due to delerium.  Mirtazipine and
fluoxetine restarted on discharge.
-can uptitrate fluoxetine as needed as an outpatient
.
# Hyperglycemia: Patient is not a known diabetic.  He was
intermittently hyperglycemic in the setting of acute illness and
has required a small dose of sliding scale insulin with humalog.

-He should be worked up for diabetes as an outpatient and may
reqiore oral hypoglycemics.
.
# Thrush: Patient noted to have oral thrush.  Given his
immunocompromised status he was started on fluconazole for 14
days starting [**4-19**]
-needs LFTs checked in 1 week
-monitor INR very closely while patient on fluconazole

Medications on Admission:
1. abacavir-lamivudine 600-300 mg Tablet Sig: One (1) Tablet PO
once a day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-11**] puff Inhalation every four (4) hours as needed for shortness

of breath or wheezing.
3. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO at bedtime.


4. DILT-CD 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day. Capsule, Ext Release
24 hr(s)
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
9. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.


13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty
(20) mL PO QID (4 times a day).
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H as needed
for pain.
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)

Tablet PO DAILY (Daily).
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
18. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.


Discharge Medications:
1. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day.
3. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO once a
day.
5. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR ([**Month/Day (2) 766**] -Wednesday-Friday).
8. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
11. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for abdominal pain.
13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. insulin lispro 100 unit/mL Cartridge Sig: One (1) unit
Subcutaneous four times a day as needed for hyperglycemia: per
sliding scale.
15. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.

16. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.

17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 14 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - LTC

Discharge Diagnosis:
Acute Respiratory Failure secondary to Pneumonia
Afib w/RVR and abherency
COPD
HIV


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


Discharge Instructions:
You came to the hospital with difficulty breathing.  We believe
this was from pneumonia and we treated you with antibiotics.
You required intubation and mechanical ventilation. You were
able to wean off the ventilator.  You also had a urinary tract
infection that we also treated with antibiotics.
.
Please follow up with your doctors as below.

Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2113-5-4**] at 4:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2113-5-4**] at 4:30 PM
With: DR. [**Last Name (STitle) 11071**] / DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Hospital Ward Name **], [**Name8 (MD) **] MD
Location: [**Hospital1 **]
DIVISION OF INFECTIOUS DISEASE
Address: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 457**]
*Please call the above number to schedule an appointment to see
Dr. [**Last Name (STitle) **] within 2 weeks.



Completed by:[**2113-4-19**]
{"Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of prostate,Other emphysema,Esophageal reflux,Gout, unspecified,Depressive disorder, not elsewhere classified,Other abnormal glucose,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site"}


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: respiratory distress

PRESENT ILLNESS: 73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin presents with 4 days
of increasing SOB and cough with green sputum. His symptoms have
been going on for about 4 days. He denied any fevers, chills,
sweats. He also denied any chest pain, nausea, vomitting. He did
report acute on chronic abdominal pain, which has had an
extensive and negative outpatient work up. Of note, he was
recently discharged from [**Hospital1 18**] in early [**2113-3-10**] for UTI,
superficial ulcer. Because his symptoms worsened over time, he
developed
.
In the ED, the patient presented with the following vital signs:
96.8   147/70   94   34   96%12L NRB. He was thought to be
initially with acute COPD was given 500cc NS and duonebs when he
became acutely dyspneic and was thought to have acute pulmonary
edema. He was given nitro SL to no avail. He was given nitro
paste again with no significant help. He then was given lasix
20mg IV ONCE but made no urine from this. He then was given
nitro gtt, which per ED resident seemed to help him, as did
bipap. He was given morphine for abdominal pain and respiratory
distress. He was also given levofloxacin 750mg IV ONCE,
azithromycin 500mg PO ONCE, ceftriaxone 1gm IV ONCE. His last
set of vitals were 67  111/76   21   98% on CPAP FIO2 60, PEEP
of 10.

MEDICAL HISTORY: # HIV disease, dx [**9-15**] likely secondary to heterosexual
transmission. ATRIPLA started [**12-17**]. Self-d/c meds due to side
effects. Last CD4 count [**2112-9-9**] was 123.
# Chronic kidney disease (baseline cr 1.0)
# Atrial fibrillation - off coumadin due to GI bleed
# Prostate cancer - Diagnosed 15 yrs ago, in remission s/p
hormonal and radiation therapy
# COPD, long ex-tobacco history, severe emphysema on radiography

MEDICATION ON ADMISSION: 1. abacavir-lamivudine 600-300 mg Tablet Sig: One (1) Tablet PO
once a day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-11**] puff Inhalation every four (4) hours as needed for shortness

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission:
GEN: Elderly man in moderate distress, tachypneic, diaphoretic
HEENT: anicteric,
RESP: CTA b/l with good air movement throughout, scattered
crackles, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild LUQ tenderness, no masses or
hepatosplenomegaly
EXT: no c/c 2+ edema bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.

FAMILY HISTORY: per OMR) No history of lung disease, cancer or CAD.

SOCIAL HISTORY: (per OMR and patient) He lives with his wife in [**Location (un) 686**] at an
[**Hospital3 **] and denies alcohol or drug use. He smoked for 60
years and quit recently. 

### Response:
{"Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Pneumonia due to Klebsiella pneumoniae,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Candidiasis of mouth,Atrial fibrillation,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Chronic kidney disease, unspecified,Personal history of malignant neoplasm of prostate,Other emphysema,Esophageal reflux,Gout, unspecified,Depressive disorder, not elsewhere classified,Other abnormal glucose,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site"}
