CHIEF COMPLAINT: Fever

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67 year old male with history HIV on HAART and
colitis who presented to the ED on [**2104-10-28**] with severe
abdominal pain for 3 days, was admitted to the surgical service
for perforated diverticulum and is now s/p sigmoid colectomy,
who represented for fever [**2104-11-7**] and was found to have
multifocal PNA and was transferred to the MICU on [**2104-11-7**] with
respiratory distress. He was intubated and underwent BAL which
was not revealing. He was treated for 14 days with linezolid,
meropenem, and cipro and was extubated [**11-21**]. His MICU course was
complicated by delirium after extubation and he developed
diarrhea (neg for c. diff), was transferred to the floor on
[**11-23**]. His status declined and he was re-admitted to the MICU on
[**11-26**] and reintubated on [**2104-11-28**]. He was extubated on [**12-1**] and
had PEG placed for nutritional support on [**12-2**]. The patient was
stable on nasal cannula and therefore was called out to the
floor in the afternoon on [**12-2**]. Vital signs prior to transfer
were  96.5 99/75 81 32 97% 2L NC
.
On arrival to the floor patient denies any pain in chest,
abdomen, extremities or elsewhere. He denies nausea or vomiting

MEDICAL HISTORY: CAD with MI s/p stent in [**2097**]
HIV since [**2077**] (last CD4 was 540 (2 wks prior to admission) and
viral load was <75)
Crohn's vs. lymphocytic colitis diagnosed 6 month ago on
colonoscopy
Esophagitis
Adrenal suppression
Primary open angle glaucoma
MV insufficiency
Arthroscopic knee surgeries
Ankle sprain early [**Month (only) **]
Sacral decubitus ulcer since last admission
Cataract surgery

MEDICATION ON ADMISSION: Medications at rehab:
Nystatin s&s
dorzolamide-timolol drops
brimonidine eye drops
Darunavir 600mg [**Hospital1 **]
RiTONAvir 100mg [**Hospital1 **]
calcium carbonate
aspirin 325
MV
Metoprolol Succinate XL 12.5 daily
Tylenol
oxycodone PRN pain
.
Medications on transfer:
-Piperacillin-Tazobactam 4.5 g IV Q8H
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
-Aspirin 325 mg PO/NG DAILY
-Budesonide 3 mg PO DAILY
-Rosuvastatin Calcium 20 mg PO DAILY
-Ciprofloxacin 400 mg IV Q12H
-RiTONAvir 100 mg PO BID
-Darunavir 600 mg PO BID
-Metoprolol Succinate XL 12.5 mg PO DAILY
-Vancomycin 1000 mg IV ONCE
-Niacin 500 mg PO BID
-Vancomycin 1000 mg IV Q 12H

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission physical exam:
=========================
Vitals: T:99.7 BP:116/72 P:93 R:33 O2: 95% on 70% high flow
General: Alert, oriented, no acute distress, some tachypnea and
difficulty finishing sentences
HEENT: Sclera anicteric, MMM, high flow mask in place, crusted
abrasion on L face
Neck: supple, JVP not elevated, no LAD
Lungs: exp wheezes throughout, bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: open abd wound, with granulation tissue, no e/o
drainage or errythema.  Colostomy bag in place.  Mild TTP on R
side
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ edema to the mid calf
bilaterally, no calf tenderness.  Bruising around L ankle.
Petechial rash on R foot
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
SKIN: dressed decubitus ulcer

FAMILY HISTORY: father with DM, panc cancer, mother with [**Name2 (NI) 499**] cancer, CHF

SOCIAL HISTORY: 15 pack-year smoking quit 35yrs ago, social ETOH 10 drinks/wk,
occ marijuana. Lives independently in [**Hospital1 778**], however had been
in rehab since last hosp. Retired from engineering supply
business.
Unspecified septicemia,Asymptomatic human immunodeficiency virus [HIV] infection status,Acute respiratory failure,Abscess of lung,Toxic encephalopathy,Acute on chronic systolic heart failure,Nutritional marasmus,Pneumonitis due to inhalation of food or vomitus,Critical illness myopathy,Pressure ulcer, lower back,Unspecified pleural effusion,Candidiasis of mouth,Mixed acid-base balance disorder,Cachexia,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Cocaine abuse, episodic,Delirium due to conditions classified elsewhere,Regional enteritis of unspecified site,Body Mass Index less than 19, adult,Severe sepsis,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Primary open angle glaucoma,Other disorders of plasma protein metabolism,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Old myocardial infarction,Neutropenia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Hypocalcemia,Colostomy status
Septicemia NOS,Asymp hiv infectn status,Acute respiratry failure,Abscess of lung,Toxic encephalopathy,Ac on chr syst hrt fail,Nutritional marasmus,Food/vomit pneumonitis,Critical illness myopthy,Pressure ulcer, low back,Pleural effusion NOS,Thrush,Mixed acid-base bal dis,Cachexia,Chr blood loss anemia,Esophageal stricture,Cocaine abuse-episodic,Delirium d/t other cond,Regional enteritis NOS,BMI less than 19,adult,Severe sepsis,Crnry athrscl natve vssl,Mitral valve disorder,Prim open angle glaucoma,Dis plas protein met NEC,Anemia-other chronic dis,Hyperlipidemia NEC/NOS,Duodenal ulcer NOS,Old myocardial infarct,Neutropenia NOS,Diaphragmatic hernia,Hypocalcemia,Colostomy status
Admission Date:  [**2104-11-7**]              Discharge Date:   [**2104-12-12**]

Date of Birth:  [**2037-9-3**]             Sex:   M

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Fever

Major Surgical or Invasive Procedure:
Endotracheal Intubation [**2104-11-7**] and [**2104-11-28**]
Percutaneous endoscopic gastrostomy (PEG)


History of Present Illness:
Mr. [**Known lastname **] is a 67 year old male with history HIV on HAART and
colitis who presented to the ED on [**2104-10-28**] with severe
abdominal pain for 3 days, was admitted to the surgical service
for perforated diverticulum and is now s/p sigmoid colectomy,
who represented for fever [**2104-11-7**] and was found to have
multifocal PNA and was transferred to the MICU on [**2104-11-7**] with
respiratory distress. He was intubated and underwent BAL which
was not revealing. He was treated for 14 days with linezolid,
meropenem, and cipro and was extubated [**11-21**]. His MICU course was
complicated by delirium after extubation and he developed
diarrhea (neg for c. diff), was transferred to the floor on
[**11-23**]. His status declined and he was re-admitted to the MICU on
[**11-26**] and reintubated on [**2104-11-28**]. He was extubated on [**12-1**] and
had PEG placed for nutritional support on [**12-2**]. The patient was
stable on nasal cannula and therefore was called out to the
floor in the afternoon on [**12-2**]. Vital signs prior to transfer
were  96.5 99/75 81 32 97% 2L NC
.
On arrival to the floor patient denies any pain in chest,
abdomen, extremities or elsewhere. He denies nausea or vomiting


Past Medical History:
CAD with MI s/p stent in [**2097**]
HIV since [**2077**] (last CD4 was 540 (2 wks prior to admission) and
viral load was <75)
Crohn's vs. lymphocytic colitis diagnosed 6 month ago on
colonoscopy
Esophagitis
Adrenal suppression
Primary open angle glaucoma
MV insufficiency
Arthroscopic knee surgeries
Ankle sprain early [**Month (only) **]
Sacral decubitus ulcer since last admission
Cataract surgery

Social History:
15 pack-year smoking quit 35yrs ago, social ETOH 10 drinks/wk,
occ marijuana. Lives independently in [**Hospital1 778**], however had been
in rehab since last hosp. Retired from engineering supply
business.

Family History:
father with DM, panc cancer, mother with [**Name2 (NI) 499**] cancer, CHF

Physical Exam:
Admission physical exam:
=========================
Vitals: T:99.7 BP:116/72 P:93 R:33 O2: 95% on 70% high flow
General: Alert, oriented, no acute distress, some tachypnea and
difficulty finishing sentences
HEENT: Sclera anicteric, MMM, high flow mask in place, crusted
abrasion on L face
Neck: supple, JVP not elevated, no LAD
Lungs: exp wheezes throughout, bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: open abd wound, with granulation tissue, no e/o
drainage or errythema.  Colostomy bag in place.  Mild TTP on R
side
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ edema to the mid calf
bilaterally, no calf tenderness.  Bruising around L ankle.
Petechial rash on R foot
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
SKIN: dressed decubitus ulcer

Discharge Physical Exam:
========================
97.6 140/70 101 24 97% on 2L NC
General: A+OX1-2. Patient with frequent periods of confusion
with garbled speech. Weak phonation but speech intelligible when
patient is oriented and mouth appropriately lubricated.
HEENT: Sclera anicteric, MMM, NC in place
Neck: supple, JVP not elevated, no LAD
Lungs: faint scattered crackles. Tachypneic with rapid shallow
breaths 20-30 times per minute.
CV: Tachycardic, hyperdynamic heart sounds. normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: PEG in place. Colostomy bag in place. Surgical wound
clean. NABS, no TTP
Ext: warm, well perfused, 2+ pulses,
SKIN: dressed sacral decubitus ulcer


Pertinent Results:
Admission labs:
[**2104-11-6**] 06:15PM   WBC-4.5 RBC-3.04* HGB-9.9* HCT-28.5* MCV-94
MCH-32.6* MCHC-34.8 RDW-13.6
[**2104-11-6**] 06:15PM   NEUTS-76.1* LYMPHS-20.0 MONOS-3.3 EOS-0.3
BASOS-0.3
[**2104-11-6**] 06:15PM   PLT COUNT-207
[**2104-11-6**] 06:15PM   PT-14.4* PTT-25.3 INR(PT)-1.2*
[**2104-11-6**] 06:15PM   GLUCOSE-122* UREA N-17 CREAT-0.5 SODIUM-135
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-25 ANION GAP-10
[**2104-11-7**] 06:50AM   ALBUMIN-1.8* CALCIUM-6.2* PHOSPHATE-2.4*
MAGNESIUM-1.7
[**2104-11-7**] 09:03AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.041*
[**2104-11-7**] 09:03AM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2104-11-7**] 09:03AM URINE  RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0

CT torso [**2104-11-6**]:
IMPRESSION:
1. Multifocal opacities in the upper and lower lungs, consistent
with diffuse pneumonia. New irregular gas containing cavities
concerning for necrotizing pneumonia in the previously seen area
of right lower lobe consolidation.
2. Small bilateral pleural effusions, left greater than right.
3. Moderate amount of free fluid in the abdomen with
indeterminate
attenuation values, likely representing post-surgical fluid. No
confined
collection within the abdomen or pelvis to suggest abscess.
4. Normal post-surgical appearance of the Hartmann's pouch and
[**Month/Day/Year 499**]. No
evidence of obstruction, perforation, or leak.

[**2104-11-8**] Echo:
IMPRESSION: No echocardiographic evidence of endocarditis,
however cannot exclude due to subooptimal image quality.
Moderate focal left ventricular systolic dysfunction consistent
with inferior/inferolateral infarction. Mild mitral
regurgitation.

[**2104-11-13**] CT torso:
IMPRESSION:
1. Interval worsening alveolar pulmonary opacities with
crazy-paving pattern, which could be related to worsening
pneumonitis versus pulmonary edema and developing adult
respiratory distress syndrome. More organized and
necrotic-appearing right lower lobe necrotizing pneumonia.
Worsening pleural effusions.
2. New moderate bilateral pleural effusions.
3. Slight interval increase in abdominal and pelvic ascites.
4. Worsening anasarca.
5. Status post sigmoid colectomy and diverting colostomy.

[**2104-12-4**] CT abdomen:
1. Interval decrease in the size of a necrotic pneumonia in the
right lung
base measuring 3.5 x 3 cm today.
2. Consolidation in the left lower lobe consistent with
aspiration or
pneumonia.
3. Left greater than right moderate nonhemorrhagic effusions.
4. Nonhemorrhagic ascitic fluid with foci of free air, likely
related to
recent PEG insertion.

Micro data:
[**11-6**]: Blood Culture, Routine (Final [**2104-11-12**]):    NO GROWTH
[**11-6**] URINE CULTURE (Final [**2104-11-8**]):    NO GROWTH.
[**11-7**] SPUTUM: GRAM STAIN (Final [**2104-11-7**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
   RESPIRATORY CULTURE (Final [**2104-11-9**]):
      MODERATE GROWTH Commensal Respiratory Flora.
[**11-8**]:    DIRECT INFLUENZA A ANTIGEN TEST (Final [**2104-11-9**]):
      Negative for Influenza A.

   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2104-11-9**]):
      Negative for Influenza B.
[**11-11**] Sputum:
GRAM STAIN (Final [**2104-11-11**]):
      <10 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2104-11-13**]):    NO GROWTH.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2104-11-12**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):

Stool Culture:
Source: Stool.

                            **FINAL REPORT [**2104-12-1**]**

   MICROSPORIDIA STAIN (Final [**2104-12-1**]):    NO MICROSPORIDIUM
SEEN.

   CYCLOSPORA STAIN (Final [**2104-11-27**]):    NO CYCLOSPORA SEEN.

   FECAL CULTURE (Final [**2104-11-28**]):
      NO ENTERIC GRAM NEGATIVE RODS FOUND.
      NO SALMONELLA OR SHIGELLA FOUND.

   CAMPYLOBACTER CULTURE (Final [**2104-11-28**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2104-11-27**]):
      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 [**2104-11-28**]):    NO VIBRIO
FOUND.

   FECAL CULTURE - R/O YERSINIA (Final [**2104-11-28**]):    NO YERSINIA
FOUND.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2104-11-28**]):
      NO E.COLI 0157:H7 FOUND.

   Cryptosporidium/Giardia (DFA) (Final [**2104-11-28**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2104-11-27**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

BRONCHIAL LAVAGE LINGULA.

                            **FINAL REPORT [**2104-12-1**]**

   Respiratory Viral Culture (Final [**2104-12-1**]):
      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 [**2104-11-29**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.

RAPID PLASMA REAGIN TEST (Final [**2104-12-9**]):
      NONREACTIVE.
      Reference Range: Non-Reactive.

[**2104-11-28**] 10:45 pm BRONCHOALVEOLAR LAVAGE      BRONCHIAL LAVAGE
RLL.

   GRAM STAIN (Final [**2104-11-29**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2104-11-30**]):
      ~7000/ML Commensal Respiratory Flora.
      YEAST.    ~5000/ML.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.

   LEGIONELLA CULTURE (Final [**2104-12-5**]):    NO LEGIONELLA
ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2104-11-29**]):
      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
      [**2104-11-29**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..

   FUNGAL CULTURE (Final [**2104-12-12**]):
      YEAST.

   ACID FAST SMEAR (Final [**2104-12-1**]):
      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 (Final [**2104-12-2**]):
      TEST CANCELLED, PATIENT CREDITED.
      FURTHER [**Location (un) **] OF THE CULTURE WILL BE PERFORMED ON
REQUEST ONLY.
      Refer to CMV early antigen test result for further
information.

   CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
[**2104-12-2**]):
      Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 102541**] [**2104-12-2**]
2:39PM.
      POSITIVE FOR CYTOMEGALOVIRUS.
         Early antigen detected by immunofluorescence.

Discharge Labs:
================
[**2104-12-12**] 06:03AM BLOOD WBC-9.5 RBC-2.95* Hgb-8.8* Hct-27.5*
MCV-93 MCH-29.9 MCHC-32.1 RDW-15.0 Plt Ct-313
[**2104-12-12**] 06:03AM BLOOD Neuts-69.1 Lymphs-24.6 Monos-4.7 Eos-1.3
Baso-0.3
[**2104-12-10**] 05:29AM BLOOD PT-11.6 INR(PT)-1.1
[**2104-12-12**] 06:03AM BLOOD Glucose-115* UreaN-16 Creat-0.4* Na-143
K-3.5 Cl-108 HCO3-29 AnGap-10
[**2104-12-12**] 06:03AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.9 Mg-2.0

Brief Hospital Course:
Primary Reason for Hospitalization:
====================================
Mr. [**Known lastname **] is a 67 yo gentleman with history of HIV on HAART,
last CD4 ct >500 and VL undetectable, s/p recent colectomy on
[**2104-10-29**] for perforated diverticulum who presented on [**2104-11-7**]
with fever and was found to have multifocal PNA on CT requiring
intubation and an ICU course that was complicated by delirium
and malnutrition.
.
ACTIVE ISSUES:
===============
# Acute Respiratory failure: Due to bilateral, multifocal
necrotizing pneumonia, worst in the RLL. He was intially given
Vanc/Levaquin. However, after CT scan results, he was broadened
to vanc/cipro/meropenem given his recent hospitalization.
Shortly after transfer to the MICU, the patient had worsening
respiratory distress requiring intubation [**2104-11-8**]. He was
maintained on ARDS net ventilation settings. Antibiotic regimen
was adjusted to Linezolid/Cipro/meropenem. [**11-11**] he had
worsening oxygenation, with bronchoscopy showing a lot of thick
yellowish secretions. Sputum and BAL cultures were all negative.
Viral DFA negative, legionella urine antigen negative. Acid-fast
smears were negative x3. On [**11-13**] patient found on repeat CT
scan to have worsening bilateral R>L pleural effusions. 700cc of
light-coloured fluid drained from the left side, with elevated
LDH to suggest exudative effusion, but was considered to be
transudative given bland cell count and gross appearance. On
[**2104-11-20**] He was successfully extubated. He completed his
antibiotic course on [**2104-11-22**].  On [**11-26**] pt had respiratory
decompensation and increased O2 requirement.  He went from 99%
on 1L the evening of [**11-25**] to 85% on 3L the AM of [**11-26**].  He
received nebs and lasix but continued to require 6L O2 on floor
and had labored breathing with audible breath sounds at bedside.
 CXR showed diffuse hazy opacities bilaterally. EKG without
ischemia or right axis dev but ?Q wave in lead III.  He was
transferred to MICU for continued work of breathing and nursing
concern.  Restarted vanc/[**Last Name (un) 2830**]/cipro for suspicion of recurrent
pneumonia. He was reintubated [**11-28**] for increased work of
breathing. He was extubated on [**12-1**] and had PEG placed for
nutritional support on [**12-2**]. Since that time he has had a
consistent 1.5 to 2 liter oxygen requirement. He continues to
breath 20-30 times per minute with rapid shallow breathing,
however this has been stable for over a week. The source of his
continued breathing difficulties appears to be a combination of
severe necrotizing pneumonia which is slow to heal as well as a
possible component of respiratory muscle weakness due to
cachexia.  The neccessary duration of treatment for necrotizing
pneumonia is not well established and depends on response to
therapy. In consultation with thoracic surgery, a 6 week course
of antibiotics was planned to be completed [**2103-12-26**]. If the
patient continues to have respiratory difficulties at that point
a repeat CT scan of the chest should be considered. Because a
causative organism was never identified he will require
continued broad spectrum coverage with Vancomycin, Meropenem,
Ciprofloxacin, and Micafungin. Interventional Pulmonology
considered a tap of pleural fluid but felt that it was too risky
given the small amount of fluid.
.
#. HCAP/Fevers/chills: Thought to be due to necrotizing
pneumonia. All blood and urine cultures were negative.  Recent
CD4 ct >500 therefore unlikely opportunistic infection.  Given
recent surgery were initially concerned for intra-abdominal
infection, however no evidence of focal collection; moderate
free-fluid in abdomen likely represents normal post-surgical
changes. The surgery team followed along, but did not feel this
was a post-surgical infection.  TTE did not show endocarditis.
The ID team was consulted. Because of persistent fevers,
fluconazole was added [**11-11**]. Urine crypto antigen negative and
galactomannan negative. Beta-glucan and HHV8 were positive
however this was not considered clincially relevant by the
infectious disease service given improving clinical status.
[**11-12**], given continued fevers, vanco stopped and linezolid
started. The cytology from his pleural effusion fluid showed
"vesicular chromatin, irregular nuclear membranes and some
plasmacytoid cell", raising the possibility of malignancy
causing his continued fevers. The oncology team was consulted,
who recommended multiple viral markers, but felt that his lung
mass would be very atypical for a malignancy. CMV was positive
in the BAL. Ultimately because of response to therapy, it was
concluded that the fevers had been due to the pneumonia. The
patient was afebrile for over 10 days prior to discharge with
stable white count.
.
#. Malnutrition, severe: patient has recent history of chronic
diarrhea and weight loss from possible Crohn's vs microscopic
colitis. On admission had albumin 1.8, trended down to 1.2
despite initiating tube feeds. He was fed via dobhoff but he was
displaced several times. There was difficulty replacing it even
with endoscopy and he had a PEG placed on [**2104-12-1**]. With tube
feeds, albumin had trended up to 2.4 prior to discharge. Urine
protein to creatinine ratios were checked to look for an
alternative explanation for hypoalbuminemia. These were elevated
but not in nephrotic range and results can be falsely elevated
in the setting of cachexia. No other evidence of synthetic
dysfunction was found to suggest hepatic origin.
-- If persistently hypoalbuminemic despite treatment of
infection and appropriate nutritional support then should
consider further GI workup to investigate protein losing
enteropathy.
.
# Acute metabolic encephalopathy: Most likely related to
prolonged severe illness. No evidence of CNS infection. VBG
ruled out CO2 narcosis. Patient has many obligate tethers. TSH
and RPR are normal.
- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 102542**]
- Small dose of trazodone QHS to help sleep wake cycle.
.
# Possible Zenker's seen on EGD:
- video speech and swallow when patient improved from
respiratory standpoint
.
# s/p Colectomy: Patient had wound dehiscence, however the wound
remained clean and dry with granulation tissue and evidence of
adequate wound healing.
- Pouch change 2 x a week: Monday/Thursday
- Cleanse skin with warm water
- Pat dry
- Cut wafer to fit template pattern with supplies
- Apply [**Last Name (un) **] seal to back of wafer
- Center pouch over stoma and apply to abdomen and hold in place
x 2 minutes
.
# Sacral decubitis: Seen by wound care, has sacral coccygeal
ulcer measuring 4 x 3 cm that is covered with a black eschar.
Treated with special bed and dressing changes.
.
#. Anemia: lower than recent baseline, however pt does have
anemia at baseline.  [**Month (only) 116**] be in part due to blood loss during
surgery. Studies were checked which showed anemia of chronic
disease.  He had brown guaic postive stools. Endoscopy showed
Schatzki ring and non-bleeding duodenal ulcer. He was started on
pantoprazole. His HCT then trended up and has remained stable
for several days.
.
CHRONIC ISSUES:
===============
# HIV: continued home antiretrovirals, RiTONAvir 100 mg PO BID
and Darunavir 600 mg PO BID
.
# HLD: continued rosuvastatin
.
# CAD s/p NSTEMI in [**2097**]: rate well controlled. metoprolol held
in setting of hypotension, but later restarted. Continued
aspirin and rosuvastatin.
.
# Glaucoma: continued eye drops
.
TRANSITIONAL ISSUES:
====================
-- 6 week total course of antibiotics planned, which is to be
completed [**2103-12-26**]. If the patient continues to have respiratory
difficulties at that point a repeat CT scan of the chest should
be considered.
-- Video swallow when medically appropriate before starting
anything PO and also to investigate possible Zenker's
Diveriticulum.
-- GI follow-up outpatient to investigate protein losing
enteropathy
-- Questions about ostomy should be referred to Acute Care
Surgery (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] did the sigmoid Colectomy)


Medications on Admission:
Medications at rehab:
Nystatin s&s
dorzolamide-timolol drops
brimonidine eye drops
Darunavir 600mg [**Hospital1 **]
RiTONAvir 100mg [**Hospital1 **]
calcium carbonate
aspirin 325
MV
Metoprolol Succinate XL 12.5 daily
Tylenol
oxycodone PRN pain
.
Medications on transfer:
-Piperacillin-Tazobactam 4.5 g IV Q8H
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
-Aspirin 325 mg PO/NG DAILY
-Budesonide 3 mg PO DAILY
-Rosuvastatin Calcium 20 mg PO DAILY
-Ciprofloxacin 400 mg IV Q12H
-RiTONAvir 100 mg PO BID
-Darunavir 600 mg PO BID
-Metoprolol Succinate XL 12.5 mg PO DAILY
-Vancomycin 1000 mg IV ONCE
-Niacin 500 mg PO BID
-Vancomycin 1000 mg IV Q 12H

Discharge Medications:
1. rosuvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. niacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
3. ritonavir 80 mg/mL Solution [**Hospital1 **]: One Hundred (100) mg PO BID
(2 times a day).
4. darunavir 600 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
5. dorzolamide-timolol 2-0.5 % Drops [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. brimonidine 0.15 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
8. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day) as needed for itchiness.
9. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
10. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB/wheeze.
12. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB/wheeze.
13. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).

14. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.25 Tablet PO HS (at bedtime).

16. vancomycin in D5W 1 gram/200 mL Piggyback [**Last Name (STitle) **]: 1000 (1000)
mg Intravenous Q 12H (Every 12 Hours) for 13 days: Last dose
[**2103-12-26**].
17. meropenem 500 mg Recon Soln [**Month/Day/Year **]: Five Hundred (500) mg
Intravenous Q6H (every 6 hours): Last dose [**2103-12-26**].
18. micafungin 100 mg Recon Soln [**Month/Day/Year **]: One Hundred (100) mg
Intravenous Q24H (every 24 hours): Last dose [**2103-12-26**].
19. ciprofloxacin 750 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every
twelve (12) hours for 13 days: Last dose [**2103-12-26**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Primary:
- Necrotizing Pneumonia
- Acute on Chronic Systolic Heart Failure (EF 30-35%)
- Malnutrition
- Anemia
- Aspiration

Secondary:
- Coronary Artery Disease
- HIV
- Hyperlipidemia
- Glaucoma

Discharge Condition:
Respiratory rate 24-32 and SpO2 in mid 90s on 1.5-2 L oxygen at
recent baseline, stable for over one week.
HR 80s to 100s stable for over 1 week
Mental Status: Confused - always.
Speech: Garbled and Hypophonic. Improves with lubrication of
oral cavity.
Level of Consciousness: Alert
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure taking care of you here at [**Hospital1 18**].
You were admitted to the hospital on [**11-7**] because you
were having fevers at rehab after your surgery. You were
diagnosed with a very severe pneumonia and on two occassions you
required a breathing tube to help you breathe. On [**12-1**]
you were able to be taken off of the breathing machine. You have
been receiving a long course of multiple strong antibiotics. You
will continue to receive these antibiotics when you go to rehab.


Followup Instructions:
Questions about ostomy should be referred to Acute Care Surgery
(Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] did the sigmoid colectomy).

If patient's breathing not improving after completing antibiotic
course, consider repeating CT of the chest.
{'Unspecified septicemia,Asymptomatic human immunodeficiency virus [HIV] infection status,Acute respiratory failure,Abscess of lung,Toxic encephalopathy,Acute on chronic systolic heart failure,Nutritional marasmus,Pneumonitis due to inhalation of food or vomitus,Critical illness myopathy,Pressure ulcer, lower back,Unspecified pleural effusion,Candidiasis of mouth,Mixed acid-base balance disorder,Cachexia,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Cocaine abuse, episodic,Delirium due to conditions classified elsewhere,Regional enteritis of unspecified site,Body Mass Index less than 19, adult,Severe sepsis,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Primary open angle glaucoma,Other disorders of plasma protein metabolism,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Old myocardial infarction,Neutropenia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Hypocalcemia,Colostomy status'}


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: Fever

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67 year old male with history HIV on HAART and
colitis who presented to the ED on [**2104-10-28**] with severe
abdominal pain for 3 days, was admitted to the surgical service
for perforated diverticulum and is now s/p sigmoid colectomy,
who represented for fever [**2104-11-7**] and was found to have
multifocal PNA and was transferred to the MICU on [**2104-11-7**] with
respiratory distress. He was intubated and underwent BAL which
was not revealing. He was treated for 14 days with linezolid,
meropenem, and cipro and was extubated [**11-21**]. His MICU course was
complicated by delirium after extubation and he developed
diarrhea (neg for c. diff), was transferred to the floor on
[**11-23**]. His status declined and he was re-admitted to the MICU on
[**11-26**] and reintubated on [**2104-11-28**]. He was extubated on [**12-1**] and
had PEG placed for nutritional support on [**12-2**]. The patient was
stable on nasal cannula and therefore was called out to the
floor in the afternoon on [**12-2**]. Vital signs prior to transfer
were  96.5 99/75 81 32 97% 2L NC
.
On arrival to the floor patient denies any pain in chest,
abdomen, extremities or elsewhere. He denies nausea or vomiting

MEDICAL HISTORY: CAD with MI s/p stent in [**2097**]
HIV since [**2077**] (last CD4 was 540 (2 wks prior to admission) and
viral load was <75)
Crohn's vs. lymphocytic colitis diagnosed 6 month ago on
colonoscopy
Esophagitis
Adrenal suppression
Primary open angle glaucoma
MV insufficiency
Arthroscopic knee surgeries
Ankle sprain early [**Month (only) **]
Sacral decubitus ulcer since last admission
Cataract surgery

MEDICATION ON ADMISSION: Medications at rehab:
Nystatin s&s
dorzolamide-timolol drops
brimonidine eye drops
Darunavir 600mg [**Hospital1 **]
RiTONAvir 100mg [**Hospital1 **]
calcium carbonate
aspirin 325
MV
Metoprolol Succinate XL 12.5 daily
Tylenol
oxycodone PRN pain
.
Medications on transfer:
-Piperacillin-Tazobactam 4.5 g IV Q8H
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
-Aspirin 325 mg PO/NG DAILY
-Budesonide 3 mg PO DAILY
-Rosuvastatin Calcium 20 mg PO DAILY
-Ciprofloxacin 400 mg IV Q12H
-RiTONAvir 100 mg PO BID
-Darunavir 600 mg PO BID
-Metoprolol Succinate XL 12.5 mg PO DAILY
-Vancomycin 1000 mg IV ONCE
-Niacin 500 mg PO BID
-Vancomycin 1000 mg IV Q 12H

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: Admission physical exam:
=========================
Vitals: T:99.7 BP:116/72 P:93 R:33 O2: 95% on 70% high flow
General: Alert, oriented, no acute distress, some tachypnea and
difficulty finishing sentences
HEENT: Sclera anicteric, MMM, high flow mask in place, crusted
abrasion on L face
Neck: supple, JVP not elevated, no LAD
Lungs: exp wheezes throughout, bibasilar crackels
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: open abd wound, with granulation tissue, no e/o
drainage or errythema.  Colostomy bag in place.  Mild TTP on R
side
GU: no foley
Ext: warm, well perfused, 2+ pulses, 2+ edema to the mid calf
bilaterally, no calf tenderness.  Bruising around L ankle.
Petechial rash on R foot
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
SKIN: dressed decubitus ulcer

FAMILY HISTORY: father with DM, panc cancer, mother with [**Name2 (NI) 499**] cancer, CHF

SOCIAL HISTORY: 15 pack-year smoking quit 35yrs ago, social ETOH 10 drinks/wk,
occ marijuana. Lives independently in [**Hospital1 778**], however had been
in rehab since last hosp. Retired from engineering supply
business. 

### Response:
{'Unspecified septicemia,Asymptomatic human immunodeficiency virus [HIV] infection status,Acute respiratory failure,Abscess of lung,Toxic encephalopathy,Acute on chronic systolic heart failure,Nutritional marasmus,Pneumonitis due to inhalation of food or vomitus,Critical illness myopathy,Pressure ulcer, lower back,Unspecified pleural effusion,Candidiasis of mouth,Mixed acid-base balance disorder,Cachexia,Iron deficiency anemia secondary to blood loss (chronic),Stricture and stenosis of esophagus,Cocaine abuse, episodic,Delirium due to conditions classified elsewhere,Regional enteritis of unspecified site,Body Mass Index less than 19, adult,Severe sepsis,Coronary atherosclerosis of native coronary artery,Mitral valve disorders,Primary open angle glaucoma,Other disorders of plasma protein metabolism,Anemia of other chronic disease,Other and unspecified hyperlipidemia,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Old myocardial infarction,Neutropenia, unspecified,Diaphragmatic hernia without mention of obstruction or gangrene,Hypocalcemia,Colostomy status'}
