CHIEF COMPLAINT: Failure to thrive

PRESENT ILLNESS: This is a 44 year old F with HIV (last CD4 count of 181 in
[**2192-1-18**] recently started on HAART), severe pulmonary hypertension
on 4 L home O2, likely anti-phospholipid syndrome on
anticoagulation with recent supratherapeutic INR, who presents
with poor po intake, lethargy, hypoxia, and mental status
changes. She was transferred from [**Hospital6 33**] ED to
[**Hospital1 18**] ED for managment of hypoxia. Her PCP, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], received
a call from the pts daughter, [**Name (NI) 13788**], telling him that the
patient is essentially failing to thrive. She was described as
listless, no appetite with poor po intake, minimally
interactive, fighting medications, and sleeping alot. The family
has had difficulty trying to keep the pts oxygen on. She has
only been drinking a can or two of boost a day and minimal
fluids.
.
The patient was hospitalized last month and had a complicated
course. She was febrile and hypoxic at home. On admission,
progressive centrilobular nodular densities were noted on chest
imaging studies. There was concern for an infectious process;
BAL fluid demonstrated growth of both Moraxella and
Pneumococcus. A course of antibiotics was administered, and the
patient's fever and hypoxia resolved. Although there was concern
for other pulmonary infectious possibilities, including
Cryptococcus, Legionella, and Mycobacterial infection
(tuberculous or atypical), no evidence of any of these entities
was found on culture. She also had a L thalamic infarct thought
to be due to probable diagnosis of antiphospholipid antibody
syndrome. She was started on coumadin. She also developed a R
wrist drop thought to be due to plexopathy. This issue resolved.

MEDICAL HISTORY: 1. HIV/AIDS diagnosed [**2174**] (last CD4 count 181 on [**2192-1-18**], viral
load 1,620,000 [**2192-1-18**]) started HAART with atazanavir and epzicom
on [**2192-1-24**]
2. Hepatitis C, genotype 1a/b: Her most recent HCV viral load
was 1 million IU/mL on [**2191-12-28**]. Liver ultrasound performed on
[**2191-12-30**] demonstrated a liver that is normal in size and
contour; never has had liver bx;
3. Pulmonary hypertension (thought to be primary or secondary to

MEDICATION ON ADMISSION: warfarin--unknown dosing
premarin 1.25 mg daily
methadone 15 mg tid
percocet tid prn--pt rarely takes
nystatin S and S qid prn for thrush
Abacavir-Lamivudine daily
Atazanavir 400 mg daily
Atovaquone monthly--pt has not started taking
Azithromycin 1200 mg weekly--pt has not started taking
Sildenafil 25 mg q 8 hr--pt has not received prior authorization

ALLERGIES: Codeine / Ms Contin / Amitriptyline

PHYSICAL EXAM: VS: Temp: 97 BP: 84/56 HR: 96 RR: O2sat 93% on NRB ABG
7.35/30/75 on 100% NRB
GEN: sleepy, mumbling indistinguishable words, not answering all
questions appropriately
HEENT: PERRL, EOMI, +icteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules, no palpable R
carotid hematoma
RESP: decreased breath sounds diffusely but greater over R lung,
no wheezing or rales
CV: tachycardic, split S2 vs. S3, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes
NEURO: sleepy. moving all 4 extremities symmetrically. No
sensory deficits to light touch appreciated.
GU: Foley draining clear urine

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient lives at home with her son. She is still an active
smoker, smoking 5 cigarettes daily. She has a h/o IVDU but is
not using currently
Acute respiratory failure,Pneumonia, organism unspecified,Human immunodeficiency virus [HIV] disease,Hematoma complicating a procedure,Unspecified pleural effusion,Acute pancreatitis,Other and unspecified coagulation defects,Primary pulmonary hypertension,Candidiasis of mouth,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic hepatitis C without mention of hepatic coma
Acute respiratry failure,Pneumonia, organism NOS,Human immuno virus dis,Hematoma complic proc,Pleural effusion NOS,Acute pancreatitis,Coagulat defect NEC/NOS,Prim pulm hypertension,Thrush,Thrombocytopenia NOS,Anemia NOS,Chrnc hpt C wo hpat coma
Admission Date:  [**2192-2-2**]              Discharge Date:   [**2192-2-11**]

Date of Birth:  [**2147-11-14**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Ms Contin / Amitriptyline

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Failure to thrive

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This is a 44 year old F with HIV (last CD4 count of 181 in
[**2192-1-18**] recently started on HAART), severe pulmonary hypertension
on 4 L home O2, likely anti-phospholipid syndrome on
anticoagulation with recent supratherapeutic INR, who presents
with poor po intake, lethargy, hypoxia, and mental status
changes. She was transferred from [**Hospital6 33**] ED to
[**Hospital1 18**] ED for managment of hypoxia. Her PCP, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], received
a call from the pts daughter, [**Name (NI) 13788**], telling him that the
patient is essentially failing to thrive. She was described as
listless, no appetite with poor po intake, minimally
interactive, fighting medications, and sleeping alot. The family
has had difficulty trying to keep the pts oxygen on. She has
only been drinking a can or two of boost a day and minimal
fluids.
.
The patient was hospitalized last month and had a complicated
course. She was febrile and hypoxic at home. On admission,
progressive centrilobular nodular densities were noted on chest
imaging studies. There was concern for an infectious process;
BAL fluid demonstrated growth of both Moraxella and
Pneumococcus. A course of antibiotics was administered, and the
patient's fever and hypoxia resolved. Although there was concern
for other pulmonary infectious possibilities, including
Cryptococcus, Legionella, and Mycobacterial infection
(tuberculous or atypical), no evidence of any of these entities
was found on culture. She also had a L thalamic infarct thought
to be due to probable diagnosis of antiphospholipid antibody
syndrome. She was started on coumadin. She also developed a R
wrist drop thought to be due to plexopathy. This issue resolved.

.
In the ED, the pts vitals were: Tm 103.4, BP 80-114/40-84, HR
104-130, Sat 96-100%NRB. She was initially found to be satting
91% on 100% NRB with ABG of: 7.41/24/63. She was given
Levofloxacin 500 mg IV x1, Ceftriaxone 1 gm IV x1, and Vancmycin
1 gm IV x1. Upon presentation to the ED, the patient had a temp
of 103, SBPs in the 70-80s. She was started on a peripheral
levophed gtt. Attempt was made at placing an IJ, however her
internal carotid was punctured. She was found to have a 2x2 cm
hematoma around the R internal carotid and 3X5 cm hematoma
extending into the mediastinum. INR was >5. Patient received 5mg
of vitK sc and FFP. Vascular surgery was consulted. Repeat CT
chest showed no active carotid bleed. For her electrolyte
abnormalities she also received Neutraphos 2 packets, 2 amps of
Calcium gluconate, 2 gm IV magnesium sulfate. She received 7L NS
for resusitation.
.
The pt states that she has felt very fatigued recently, and
notes occasional subjective fevers. She has an occasional
nonproductive cough. She describes nausea but no vomiting over
the past several days. She denies HA, diarrhea, constipation,
abdominal pain, dysuria, chest pain, sore throat, rhinorrhea, or
feeling SOB. She has not been taking her atovaquone or
azithromycin prophylaxis as she states pharmacy was having
difficulty filling these prescriptions for her.
.


Past Medical History:
1. HIV/AIDS diagnosed [**2174**] (last CD4 count 181 on [**2192-1-18**], viral
load 1,620,000 [**2192-1-18**]) started HAART with atazanavir and epzicom
on [**2192-1-24**]
2. Hepatitis C, genotype 1a/b: Her most recent HCV viral load
was 1 million IU/mL on [**2191-12-28**]. Liver ultrasound performed on
[**2191-12-30**] demonstrated a liver that is normal in size and
contour; never has had liver bx;
3. Pulmonary hypertension (thought to be primary or secondary to

HIV), R heart cath [**11-16**] with PASP of 73, wedge of 5, refractory
to O2 and NO. Last spirometry [**2191**] normal with FEV1/FVC 95%
predicted--followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
4. History of meningitis, details unknown
5. Cervical cancer: s/p hysterectomy, partial vaginectomy, XRT
6. Esophageal candititis
7. Neuropathy, chronic pain: on methadone, neurontin
8. History of IVDU, none for several years
9. Mitral Valve Prolapse
10. Lower back pain
11. R posterior thalamus infarct [**12-16**]
12. Antiphospholipid syndrome on coumadin
13. RV systolic dysfunction globally with [**Last Name (LF) 17972**], [**First Name3 (LF) **] 55%
11/07


Social History:
The patient lives at home with her son. She is still an active
smoker, smoking 5 cigarettes daily. She has a h/o IVDU but is
not using currently

Family History:
NC

Physical Exam:
VS: Temp: 97 BP: 84/56 HR: 96 RR: O2sat 93% on NRB ABG
7.35/30/75 on 100% NRB
GEN: sleepy, mumbling indistinguishable words, not answering all
questions appropriately
HEENT: PERRL, EOMI, +icteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules, no palpable R
carotid hematoma
RESP: decreased breath sounds diffusely but greater over R lung,
no wheezing or rales
CV: tachycardic, split S2 vs. S3, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes
NEURO: sleepy. moving all 4 extremities symmetrically. No
sensory deficits to light touch appreciated.
GU: Foley draining clear urine


Pertinent Results:
ADMISSIONS LABS
.
[**2192-2-1**] 11:44PM BLOOD WBC-6.9# RBC-2.57* Hgb-8.8* Hct-26.0*
MCV-101* MCH-34.3* MCHC-33.9 RDW-15.9* Plt Ct-72*
[**2192-2-1**] 11:44PM BLOOD Neuts-95* Bands-2 Lymphs-3* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2192-2-1**] 11:44PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+ Burr-1+
[**2192-2-1**] 11:44PM BLOOD PT-47.2* PTT-64.5* INR(PT)-5.3*
[**2192-2-1**] 11:44PM BLOOD Glucose-93 UreaN-27* Creat-0.8 Na-138
K-3.6 Cl-114* HCO3-16* AnGap-12
[**2192-2-1**] 11:44PM BLOOD ALT-24 AST-54* LD(LDH)-242 CK(CPK)-409*
AlkPhos-63 Amylase-52 TotBili-3.5*
[**2192-2-1**] 11:44PM BLOOD CK-MB-3
[**2192-2-1**] 11:44PM BLOOD Lipase-45
[**2192-2-1**] 11:44PM BLOOD Albumin-2.1* Calcium-6.6* Phos-1.2*#
Mg-1.5*
[**2192-2-2**] 06:50AM BLOOD calTIBC-195* VitB12-412 Folate-12.4
Hapto-130 Ferritn-413* TRF-150*
[**2192-2-2**] 06:50AM BLOOD Cortsol-43.8*
[**2192-2-2**] 12:00AM BLOOD Type-ART Temp-39.7 Rates-/34 FiO2-100 O2
Flow-10 pO2-63* pCO2-24* pH-7.41 calTCO2-16* Base XS--6
AADO2-641 REQ O2-100 Intubat-NOT INTUBA Vent-SPONTANEOU
Comment-NON-REBREA
[**2192-2-2**] 07:41AM BLOOD Lactate-0.9 K-3.8
[**2192-2-2**] 07:41AM BLOOD O2 Sat-93
[**2192-2-2**] 07:41AM BLOOD freeCa-1.08*
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2192-2-2**] 1:00 AM
.
FINDINGS: A large hematoma tracking along the right carotid
sheath and extending into the anterior mediastinum is likely
iatrogenic, related to the several recent right subclavian
central line placement attempts. Within the neck, the hematoma
measures 2.7 x 2.6 cm in maximal axial dimension. In the
anterior mediastinum, the hematoma measures up to 4.4 x 2.7 cm.
On the contrast-enhanced images, there is a 4-mm rounded
hyperdensity isointense to the adjacent right subclavian artery
(3:16), new since the previous study, in context concerning for
possible pseudoaneurysm or, less likely, active extravasation.
The imaged airway is widely patent. No filling defects are seen
within the pulmonary arterial vasculature to indicate pulmonary
embolus. The thoracic aorta is normal in caliber without
evidence for dissection. The main pulmonary artery measures up
to 2.5 cm consistent with history of pulmonary hypertension.
Multiple borderline enlarged paratracheal and subcarinal lymph
nodes are likely reactive. There is no axillary lymphadenopathy.
The lungs demonstrate dense consolidation of the posterior basal
segment of the right upper lobe with associated air
bronchograms. Moderate emphysema with subpleural blebs appears
similar when compared to the previous study of [**2191-12-28**].
Ground-glass and peribronchiolar nodular opacities noted
throughout the right lower lobe are likely related to the same
infectious process. The left lung is grossly clear. There is a
moderate low attenuation right pleural effusion, increased from
the prior study. The airways are patent to level of the
subsegmental bronchi, bilaterally.
.
In the imaged upper abdomen, the visualized liver dome, stomach,
spleen and adrenal glands appear unremarkable. There are no
osseous findings suspicious for malignancy.
.
IMPRESSION:
1. Large iatrogenic hematoma extending along the right carotid
sheath into the mediastinum without evidence for airway
compromise. A 4-mm rounded hyperdensity anterior to the distal
subclavian artery is associated with the hematoma and may
represent pseudoaneurysm or, less likely, active extravasation.
2. Dense right upper lobe consolidation and peribronchiolar
opacities in the right lower lobe likely representing lobar
pneumonia with a parapneumonic effusion. Mediastinal
lyphadenopathy is likely reactive.
3. No evidence of pulmonary embolus.
4. Enlargement of the main pulmonary artery suggestive of
pulmonary arterial hypertension.
DUPLEX DOP ABD/PEL LIMITED  [**2192-2-2**] 10:52 AM
.
FINDINGS: There is normal echotexture of the liver. There are no
intrahepatic lesions identified. There is no intrahepatic or
extrahepatic biliary dilatation. The patient is status post
cholecystectomy. The common bile duct measures 6 mm. Color flow
and Doppler waveforms of the hepatic arterial, hepatic venous
and portal venous systems are normal. A large right- sided
pleural effusion is identified. The spleen measures 11.2 cm. A
trace amount of free fluid is identified near the porta hepatis.
.
IMPRESSION:
1. Hepatic arterial, hepatic venous and portal venous systems
are patent.
2. Right pleural effusion.
3. Minimal amount of free fluid identified in the abdomen.

.
ART DUP EXT UP UNI OR LMTD PORT  [**2192-2-6**] 3:11 PM
.
The right vasculature was evaluated with B-mode, color and
spectral Doppler ultrasound modes. The right internal jugular
vein presents with normal color Doppler flow and phasicity.
.
The right internal carotid and common carotid arteries present
with normal color Doppler flow and waveforms with no areas of AV
fistula seen.
.
COMPARISON: None available.
IMPRESSION: Color Doppler evaluation of vasculature at the right
neck demonstrates no pseudoaneurysm or AV fistula. The right IJ,
common and internal carotids present within normal limits.
.
TTE [**2192-2-6**]
.
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-5 mmHg. The right ventricular cavity is markedly dilated
with moderate global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No masses or vegetations are seen on the aortic valve.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. Moderate
to severe [3+] tricuspid regurgitation is seen. There is severe
pulmonary artery systolic hypertension. There is a small
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2191-11-21**],
the severity of mitral regurgitation and tricuspid regurgitation
has increased. No vegetation was identified; however, if
clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Electronically signed by [**Name6 (MD) **] [**Name8 (MD) **], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2192-2-6**] 19:42
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2192-2-9**] 2:06 PM
.
CT OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no
filling defects present within the pulmonary arterial
vasculature consistent with pulmonary embolism. The pulmonary
artery remains enlarged, measuring 3.6 cm in diameter (3:30).
Density surrounding the right common carotid artery consistent
with previously known hematoma, is slightly decreased in size
compared to [**2192-2-3**]. There is a small pericardial effusion. The
heart is mildly enlarged in size. The aorta is normal in caliber
and contour.
.
A precarinal lymph node measures 8 mm in short axis dimension
(3:26). An 8-mm prevascular lymph node is also noted (3:20). A
few other scattered mediastinal lymph nodes are present, but
none meet criteria for pathology by CT. Nasogastric tube is in
place. There has been interval extubation. There are no
pathologically enlarged hilar or axillary lymph nodes.
.
Lung windows demonstrate the presence of a large right pleural
effusion with a subpulmonic component, which has increased in
size significantly compared to the previous examination. There
is interval worsening in terms of collapse of the right lower
lobe. A few air bronchograms are noted within this collapsed
lung which is surrounded by fluid, likely contributing to
collapse. Right upper lobe consolidation has improved compared
to the previous examination. A few areas of low attenuation just
inferior to the right lower lobe are consistent with
extrapleural fat (3:76; 3:72). A small left pleural effusion is
relatively unchanged in size. A small area of adjacent
consolidation within the left lower lobe which is linear in
configuration is also unchanged compared to the previous
examination. Note is again made of diffuse centrilobular
emphysematous change. A large left anterior apical bleb is also
unchanged.
.
A nasogastric tube terminates with tip located in the distal
stomach. The visualized portions of the upper abdomen are
unremarkable.
Bone windows demonstrate no lytic or sclerotic lesions.

IMPRESSION:
.
1. No pulmonary embolism.
2. Interval worsening of right-sided pleural effusion with a
subpulmonic component, large in size, and new right lower lobe
collapse.
3. Interval improvement of right upper lobe pneumonia.
4. Centrilobular emphysema.
5. Slight improvement in superior mediastinal hematoma.
6. Pulmonary arterial hypertension.
7. Unchanged small pericardial effusion.

These findings were discussed with Dr. [**First Name (STitle) 4223**] by Dr. [**First Name (STitle) 7747**]
over the telephone on [**2192-2-9**] at 3:30 p.m.
.


Brief Hospital Course:
Mrs. [**Known lastname 3265**] was a pleasant 44 year old female with a history of
(CD4 181 in [**2192-1-18**], started atazanavir and epzicom [**2192-1-24**]),
HIV-related pulmonary hypertension home o2 of 4L (R heart cath
[**11-16**]: PASP 73, wedge 5, refractory to O2 and NO), likely
anti-phospholipid syndrome on warfarin with supratherapeutic
INR, presented with failure to thrive, hypotension, fever, and
hypoxia.
.
During placement of her R IJ her R carotid artery was punctured.
She developed a hematoma which was stable on ultrasound. No
extension was noted to occur into the mediastinum on initial and
repeat CTA.
.
She had a baseline pulmonary HTN, emphysema per CT lung, 4L home
O2. She was admitted with a new RML consolidation per CTA, with
increasing RUL opacification per CXR on [**2-9**]. Her clinical
picture was consistent with a mulilobar pneumonia. She was
intubated on [**2-2**] for respiratory failure and extubated [**2-7**]. A
Bronchial alveolar lavage on [**2-2**] showed thrush under ETT. She
was being treated with 10 days of zosyn starting [**2-2**] for her
pneumonia. She was receiving fluconazole for her thrush.
.
She was extubated on [**2-7**], but exhibited resp distress,
tachypnea and persistent tachycardia after extubation. Patients
sinus tachycardia did not respond to fluids, ativan, morphine,
methadone. There was concern that patient had developed a
pulmonary embolism, as she has a history of anti-phospholipid
antibody syndrome and temporarily had a subtherapeutic ptt.
Repeat CTA of the chest was negative for pulmonary embolism.
Patient was noted to have a R sided effusion worse on R then the
left, it was felt that removal of this effusion might help rule
out empyema and ease patients resp distress. During the
thoracentesis there was a complication of moderate pneumothorax.
A chest tube was placed and a liter of serosanguinous fluid was
drained off. Pt remained in resp distress. Non-invasive positive
pressure ventilation was started and tolerated for most of the
day. Near 4pm, pt had an episode of emesis while wearing the
positive pressure mask. There was question of aspiration.
Patient had an unreliable pulse oximetry pleth during her stay,
but she was having difficulty maintaining oxygen saturations
above 85%. At 5pm patient agreed to intubation. She was
re-intubated, but was still having difficulty maintaining her
oxygenation by blood gas. Pt had an axillary arterial line
placed and a left IJ central line placed.
.
Patient at this time continued to deteriorate clinically. She
developed a lactic acidosis with an anion gap of 20, and an
increasing lactate 8.3 maxing at 10.; LDH 400, Amylase 265,
Tbili 2.2, Lipase 518.
.
The finding of elevated lipase and amylase was consistent with a
pancreatitis. Patient had not had any prior complaints of
abdominal pain, and had been very lucid even post-intubation. It
is unclear if the lactic acidosis was caused by hypoxia alone.
The acidosis may have been more pronounced as a result of the
patient being on HAART medication. Pancreatitis may have been
secondary to HAART medication (atazanavir, abacavir, lamivudine)
in the setting of other acute illness. It is not completely
clear what caused the pancreatitis if pt did indeed have
pancreatitis. When it was seen that Mrs. [**Known lastname 38132**] condition was
detiorating, HAART was stopped [**2192-2-10**].
.
Along with hypoxia, and worsening acidosis, pt developed a
pronounced coagulopathy the night of [**2192-2-10**]. She died early
morning on [**2-11**] from hypotension. She was DNR therefore no code
was performed.
.
The cause of death was respiratory failure. Patient had several
pulmonary problems that lead to this failure, pulmonary
effusion, multilobar pneumonia, question of emphysema, severe
pulmonary hypertension, pneumothorax and likely aspiration
pneumonia in the setting of cpap. Lactic acidosis and possible
pancreatitis likely also contributed to death.
.
The family agreed to an autopsy.
.
[**Hospital 38133**] healthcare proxy was friend [**Name (NI) **] [**Name (NI) 10132**] cell
[**Telephone/Fax (1) 38134**], home [**Telephone/Fax (1) 38135**]; alternate HCP [**Name (NI) **] [**Name (NI) 38136**]
(sister) [**Telephone/Fax (1) 38137**]
.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] MD

Medications on Admission:
warfarin--unknown dosing
premarin 1.25 mg daily
methadone 15 mg tid
percocet tid prn--pt rarely takes
nystatin S and S qid prn for thrush
Abacavir-Lamivudine daily
Atazanavir 400 mg daily
Atovaquone monthly--pt has not started taking
Azithromycin 1200 mg weekly--pt has not started taking
Sildenafil 25 mg q 8 hr--pt has not received prior authorization

Neurontin 300 mg [**Hospital1 **]--pt is not taking
Xanax 1 mg tid prn


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
pt expired

Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none

                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Acute respiratory failure,Pneumonia, organism unspecified,Human immunodeficiency virus [HIV] disease,Hematoma complicating a procedure,Unspecified pleural effusion,Acute pancreatitis,Other and unspecified coagulation defects,Primary pulmonary hypertension,Candidiasis of mouth,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic hepatitis C without mention of hepatic coma'}


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: Failure to thrive

PRESENT ILLNESS: This is a 44 year old F with HIV (last CD4 count of 181 in
[**2192-1-18**] recently started on HAART), severe pulmonary hypertension
on 4 L home O2, likely anti-phospholipid syndrome on
anticoagulation with recent supratherapeutic INR, who presents
with poor po intake, lethargy, hypoxia, and mental status
changes. She was transferred from [**Hospital6 33**] ED to
[**Hospital1 18**] ED for managment of hypoxia. Her PCP, [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], received
a call from the pts daughter, [**Name (NI) 13788**], telling him that the
patient is essentially failing to thrive. She was described as
listless, no appetite with poor po intake, minimally
interactive, fighting medications, and sleeping alot. The family
has had difficulty trying to keep the pts oxygen on. She has
only been drinking a can or two of boost a day and minimal
fluids.
.
The patient was hospitalized last month and had a complicated
course. She was febrile and hypoxic at home. On admission,
progressive centrilobular nodular densities were noted on chest
imaging studies. There was concern for an infectious process;
BAL fluid demonstrated growth of both Moraxella and
Pneumococcus. A course of antibiotics was administered, and the
patient's fever and hypoxia resolved. Although there was concern
for other pulmonary infectious possibilities, including
Cryptococcus, Legionella, and Mycobacterial infection
(tuberculous or atypical), no evidence of any of these entities
was found on culture. She also had a L thalamic infarct thought
to be due to probable diagnosis of antiphospholipid antibody
syndrome. She was started on coumadin. She also developed a R
wrist drop thought to be due to plexopathy. This issue resolved.

MEDICAL HISTORY: 1. HIV/AIDS diagnosed [**2174**] (last CD4 count 181 on [**2192-1-18**], viral
load 1,620,000 [**2192-1-18**]) started HAART with atazanavir and epzicom
on [**2192-1-24**]
2. Hepatitis C, genotype 1a/b: Her most recent HCV viral load
was 1 million IU/mL on [**2191-12-28**]. Liver ultrasound performed on
[**2191-12-30**] demonstrated a liver that is normal in size and
contour; never has had liver bx;
3. Pulmonary hypertension (thought to be primary or secondary to

MEDICATION ON ADMISSION: warfarin--unknown dosing
premarin 1.25 mg daily
methadone 15 mg tid
percocet tid prn--pt rarely takes
nystatin S and S qid prn for thrush
Abacavir-Lamivudine daily
Atazanavir 400 mg daily
Atovaquone monthly--pt has not started taking
Azithromycin 1200 mg weekly--pt has not started taking
Sildenafil 25 mg q 8 hr--pt has not received prior authorization

ALLERGIES: Codeine / Ms Contin / Amitriptyline

PHYSICAL EXAM: VS: Temp: 97 BP: 84/56 HR: 96 RR: O2sat 93% on NRB ABG
7.35/30/75 on 100% NRB
GEN: sleepy, mumbling indistinguishable words, not answering all
questions appropriately
HEENT: PERRL, EOMI, +icteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules, no palpable R
carotid hematoma
RESP: decreased breath sounds diffusely but greater over R lung,
no wheezing or rales
CV: tachycardic, split S2 vs. S3, no murmurs
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses
SKIN: no rashes
NEURO: sleepy. moving all 4 extremities symmetrically. No
sensory deficits to light touch appreciated.
GU: Foley draining clear urine

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient lives at home with her son. She is still an active
smoker, smoking 5 cigarettes daily. She has a h/o IVDU but is
not using currently 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Human immunodeficiency virus [HIV] disease,Hematoma complicating a procedure,Unspecified pleural effusion,Acute pancreatitis,Other and unspecified coagulation defects,Primary pulmonary hypertension,Candidiasis of mouth,Thrombocytopenia, unspecified,Anemia, unspecified,Chronic hepatitis C without mention of hepatic coma'}
