CHIEF COMPLAINT: Chest pain, fever, chills

PRESENT ILLNESS: 42 y/o M with advanced HIV/AIDS last CD4 1 ([**2163-2-2**]), h/o many OP
including PCP PNA multiple times and recently treated admitted
[**Date range (1) 15253**] and again [**Date range (1) 15354**] for PCP pneumonia [**Name Initial (PRE) **] at those times
was treated with clindamycin/primaquine/steroids (history of
Bactrim allergy->aseptic meningitis) and improved, also history
of lupus anticoagulant c/b DVT/PE and IMI in [**2157**] s/p RCA
stenting, on coumadin as outpt, now presenting to ED with CP
(described as chest pressure, like someone stepping on his
chest) radiating to his teeth, bilateral upper and lower
extremity tingling and +chills. Pt states that he woke up
morning of admission with complaint of substernal chest pain
radiating to his right jaw and bilateral upper and lower
extremity tingling sensation, [**6-6**] in intensity, unrelated to
exertion, and lasting for approximately 6 hrs. Pain stopped at 2
pm and pt presented to ED. Patient denies ever having this type
of pain before. States symptoms with last MI in [**2157**] were more
agitation (reports wandering around the hospital, very
agitated).
.
ROS on admission: increased night sweats x 2 days, HA at back of
head x 2 days intermittent with no n/v/photophobia but
completely resolved today, increased yellow drainage from right
nostril x 1 wk, no increased cough, no abd pain, no diarrhea. Pt
states these symptoms are not typical of his PCP infections
since he usually feels sob and cough with clear sputum.
.
In ED, VS were T 100.8 rectally, BP 93/56 which decreased to SBP
80s, RR 24, HR 90, sats 99% 5L. Pt remained hypotensive with SBP
as low as 75/36 and lactate returned back at 4.0. Given concern
for sepsis, RIJ sepsis CVL was placed, pt was given Vancomycin 1
gm IV and Levofloxacin 500 mg IV as well as ASA 325 mg, Decadron
6 mg IV x1, 4 L IVF, and Levophed started for hypotension. EKG
showed [**Street Address(2) 4793**] elevations inferiorly - cardiology was consulted
who felt that pt's EKG was similar to a previous EKG when pt had
been septic. Trop increased from 0.07 to 0.44. Heparin was
briefly started but then stopped per cards consult (then
restarted in ICU). ST elevations resolved on repeat EKG. On
subsequent labs with rehydration, Hct decreased from 38 to 27
and lactate decreased to 1.1. Pt was transferred to ICU for
further management.
.
In ICU, patient was treated with broad spectrum abx w/ vanc and
CTX, given stress dose steroids, otherwise maintained on his
outpatient medications. He was weaned off pressor support,
fevers resolved. He was re-started on hep gtt in ICU for r/i w/
CE. His lab values notable for stabilization of his Hct 28-30,
WBC of 3.9 with 6% bands on day of transfer, Cr resolved from
1.7 -> 1.2, CK 107 -> 202 -> 454 -> 440, MB 11 -> 38 -> 88 ->
72, Index 5.9 -> 18.8 -> 19.4 -> 16.6, Trop 0.07 -> 0.44 -> 1.39
-> 1.48. Clinically improved.
.
Currently patient feels well. States feel much improved from
yesterday. Denies any chest pain/pressure, SOB, headache, any
other complaints at this time.
.

MEDICAL HISTORY: 1. AIDS dx [**2142**]: [**5-1**] VL 23K; [**3-31**] CD4 1 VL 47K- initially on
monotherapy starting in [**2144**], now with variable degrees of
resistance to HAART. Recently started study drug Tipranavir. C/b
multiple opportunistic infections (see blow)
2. PCP x7: [**2146**](intubated) c/b perirectal HSV and pancreatitis
from pentamidine and/or steroids, [**1-/2155**] c/b LUE axillary vein
thrombosis, [**5-/2155**], [**7-/2155**], [**3-/2157**]
3. Disseminated MAC bacteremia [**2148**]
4. Didanosine associated pancreatitis [**6-/2150**]
5. Aseptic meningitis [**1-/2154**] secondary to TMP/SMX
6. Cerebral MAC (diff from [**2148**] organism) c/b seizures [**3-/2157**]
7. Necrotic HSV L chest wall lesion resistant to acyclovir and
ganciclovir and treated with Foscarnet [**3-30**]
8. Acyclovir resistant HSV R chest wall lesion [**5-1**] treated with

MEDICATION ON ADMISSION: 1. Acyclovir 400 mg Capsule PO BID
2. Nystatin 100,000 unit/mL Suspension Five (5) ML PO QID prn
3. Atazanavir 300 mg Capsule PO DAILY
4. Ritonavir 100 mg Capsule PO DAILY
5. Stavudine 30 mg Capsule PO Q12H
6. Levetiracetam 500 mg Tablet PO BID
7. Emtricitabine 200 mg Capsule PO Q24H
8. Tenofovir Disoproxil Fumarate 300 mg Tablet PO DAILY
9. Venlafaxine 150 mg SR Capsule PO DAILY .
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
daily
11. Morphine 45 mg Tablet Sustained Release PO Q8H .
12. Azithromycin 250 mg Capsule PO BID
13. Ciprofloxacin 500 mg Tablet PO Q12H.
14. Gabapentin 1200 mg Capsule PO Q8H.
15. Ethambutol 400 mg Tablet TID.
16. Primaquine 26.3 mg Tablet one tablet daily for 16 days, to
stop on [**2-27**]
17. Clindamycin HCl 450 mg PO Q6H for 16 days, to stop
18. Prednisone taper, was on 20 mg Tablet from [**2-16**] to [**2-26**]
19. Coumadin 2 mg Tablet PO QHS
20. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical four times a day as needed for itching.

ALLERGIES: Bactrim

PHYSICAL EXAM: PE on admission:
T 98.8 BP 100/63 P65-75 R13 Sat 95% 2L NC, CVP 10-11
Gen: A+O x3, lying comfortably, NAD
HEENT: PERRL, EOMI, OP clear with MMM
Neck: supple, NT, no meningismus, no LAD, no JVD
Pulm: bibasilar crackles
CV: RRR, no m/r/g
Abd: s/nt/nd +BS
Ext: no edema, warm with +2 DP pulses bilaterally
Neuro: CN 2-12 intact, no focal deficits
Skin: very mildly scaly rash on bilateral upper and lower
extremities

FAMILY HISTORY: Mom-mild HTN and hypercholesterolemia; brother- asthma, HTN. 3
sisters-alive and healthy

SOCIAL HISTORY: Divorced; contracted HIV from his ex-wife [**Name (NI) 15254**] who has since
died, lives alone with dog, intermittent part-time work; + tob-
1ppd x 2y, quit 8mos ago; denies EtOH; occ MJ for nausea; h/o
asbestos exposure on the job
Human immunodeficiency virus [HIV] disease,Unspecified septicemia,Sepsis,Acute myocardial infarction of other inferior wall, initial episode of care,Pneumonia, organism unspecified,Pressure ulcer, lower back,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to other cardiac device, implant, and graft,Primary hypercoagulable state,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Anemia, unspecified,Hypotension, unspecified,Diarrhea,Unspecified hereditary and idiopathic peripheral neuropathy,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
Human immuno virus dis,Septicemia NOS,Sepsis,AMI inferior wall, init,Pneumonia, organism NOS,Pressure ulcer, low back,Dehydration,Hyp kid NOS w cr kid V,Comp-oth cardiac device,Prim hypercoagulable st,Crnry athrscl natve vssl,Old myocardial infarct,Anemia NOS,Hypotension NOS,Diarrhea,Idio periph neurpthy NOS,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2163-2-25**]              Discharge Date:   [**2163-3-8**]

Date of Birth:  [**2121-2-5**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 15237**]
Chief Complaint:
Chest pain, fever, chills

Major Surgical or Invasive Procedure:
Cardiac catheterization
Central line placement
Transfusion of packed RBC
PICC line placement and removal


History of Present Illness:
42 y/o M with advanced HIV/AIDS last CD4 1 ([**2163-2-2**]), h/o many OP
including PCP PNA multiple times and recently treated admitted
[**Date range (1) 15253**] and again [**Date range (1) 15354**] for PCP pneumonia [**Name Initial (PRE) **] at those times
was treated with clindamycin/primaquine/steroids (history of
Bactrim allergy->aseptic meningitis) and improved, also history
of lupus anticoagulant c/b DVT/PE and IMI in [**2157**] s/p RCA
stenting, on coumadin as outpt, now presenting to ED with CP
(described as chest pressure, like someone stepping on his
chest) radiating to his teeth, bilateral upper and lower
extremity tingling and +chills. Pt states that he woke up
morning of admission with complaint of substernal chest pain
radiating to his right jaw and bilateral upper and lower
extremity tingling sensation, [**6-6**] in intensity, unrelated to
exertion, and lasting for approximately 6 hrs. Pain stopped at 2
pm and pt presented to ED. Patient denies ever having this type
of pain before. States symptoms with last MI in [**2157**] were more
agitation (reports wandering around the hospital, very
agitated).
.
ROS on admission: increased night sweats x 2 days, HA at back of
head x 2 days intermittent with no n/v/photophobia but
completely resolved today, increased yellow drainage from right
nostril x 1 wk, no increased cough, no abd pain, no diarrhea. Pt
states these symptoms are not typical of his PCP infections
since he usually feels sob and cough with clear sputum.
.
In ED, VS were T 100.8 rectally, BP 93/56 which decreased to SBP
80s, RR 24, HR 90, sats 99% 5L. Pt remained hypotensive with SBP
as low as 75/36 and lactate returned back at 4.0. Given concern
for sepsis, RIJ sepsis CVL was placed, pt was given Vancomycin 1
gm IV and Levofloxacin 500 mg IV as well as ASA 325 mg, Decadron
6 mg IV x1, 4 L IVF, and Levophed started for hypotension. EKG
showed [**Street Address(2) 4793**] elevations inferiorly - cardiology was consulted
who felt that pt's EKG was similar to a previous EKG when pt had
been septic. Trop increased from 0.07 to 0.44. Heparin was
briefly started but then stopped per cards consult (then
restarted in ICU). ST elevations resolved on repeat EKG. On
subsequent labs with rehydration, Hct decreased from 38 to 27
and lactate decreased to 1.1. Pt was transferred to ICU for
further management.
.
In ICU, patient was treated with broad spectrum abx w/ vanc and
CTX, given stress dose steroids, otherwise maintained on his
outpatient medications. He was weaned off pressor support,
fevers resolved. He was re-started on hep gtt in ICU for r/i w/
CE. His lab values notable for stabilization of his Hct 28-30,
WBC of 3.9 with 6% bands on day of transfer, Cr resolved from
1.7 -> 1.2, CK 107 -> 202 -> 454 -> 440, MB 11 -> 38 -> 88 ->
72, Index 5.9 -> 18.8 -> 19.4 -> 16.6, Trop 0.07 -> 0.44 -> 1.39
-> 1.48. Clinically improved.
.
Currently patient feels well. States feel much improved from
yesterday. Denies any chest pain/pressure, SOB, headache, any
other complaints at this time.
.


Past Medical History:
1. AIDS dx [**2142**]: [**5-1**] VL 23K; [**3-31**] CD4 1 VL 47K- initially on
monotherapy starting in [**2144**], now with variable degrees of
resistance to HAART. Recently started study drug Tipranavir. C/b
multiple opportunistic infections (see blow)
2. PCP x7: [**2146**](intubated) c/b perirectal HSV and pancreatitis
from pentamidine and/or steroids, [**1-/2155**] c/b LUE axillary vein
thrombosis, [**5-/2155**], [**7-/2155**], [**3-/2157**]
3. Disseminated MAC bacteremia [**2148**]
4. Didanosine associated pancreatitis [**6-/2150**]
5. Aseptic meningitis [**1-/2154**] secondary to TMP/SMX
6. Cerebral MAC (diff from [**2148**] organism) c/b seizures [**3-/2157**]
7. Necrotic HSV L chest wall lesion resistant to acyclovir and
ganciclovir and treated with Foscarnet [**3-30**]
8. Acyclovir resistant HSV R chest wall lesion [**5-1**] treated with

Foscarnet (to stop [**2161-7-2**])
9. Neurosurgical drainage of a R sided subdural fluid collection

[**11-28**] c/b post-op seizure and intubation for airway protection
10. HTN
11. Chronic peripheral neuropathy (legs>arms)
12. H/O Systolic CHF (Most recent TTE [**8-31**] EF >55% w/ 1+AR,
[**11-29**]+MR, 1+ TR)
13. Coagulopathy [**12-30**] lupus anticoagulant c/b DVT/PE [**4-28**] and
[**9-30**], on anticoagulation with IVC filter in place
14. IMI [**4-28**] (presumed [**12-30**] hypercoagulable state) s/p RCA
stenting
15. Aflutter s/p ablation [**1-1**]
16. Thrush-resistant to fluconazole, now on ampho swish and
swallow
17. Asthma
18. Chronic renal failure-baseline BUN 33/Cr 1.8
19. Hyperkalemia
20. Nephrolithiasis


Social History:
Divorced; contracted HIV from his ex-wife [**Name (NI) 15254**] who has since
died, lives alone with dog, intermittent part-time work; + tob-
1ppd x 2y, quit 8mos ago; denies EtOH; occ MJ for nausea; h/o
asbestos exposure on the job


Family History:
Mom-mild HTN and hypercholesterolemia; brother- asthma, HTN. 3
sisters-alive and healthy

Physical Exam:
PE on admission:
T 98.8 BP 100/63 P65-75 R13 Sat 95% 2L NC, CVP 10-11
Gen: A+O x3, lying comfortably, NAD
HEENT: PERRL, EOMI, OP clear with MMM
Neck: supple, NT, no meningismus, no LAD, no JVD
Pulm: bibasilar crackles
CV: RRR, no m/r/g
Abd: s/nt/nd +BS
Ext: no edema, warm with +2 DP pulses bilaterally
Neuro: CN 2-12 intact, no focal deficits
Skin: very mildly scaly rash on bilateral upper and lower
extremities


Pertinent Results:
Labs on admission:
[**2163-2-25**] 10:35AM BLOOD WBC-8.5 RBC-3.46* Hgb-11.8*# Hct-38.0*#
MCV-110*# MCH-34.1*# MCHC-31.1 RDW-22.4* Plt Ct-215#
[**2163-2-25**] 10:35AM BLOOD Neuts-68 Bands-6* Lymphs-8* Monos-10
Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-5*
[**2163-2-25**] 11:20AM BLOOD PT-21.3* PTT-57.6* INR(PT)-2.1*
[**2163-2-25**] 10:35AM BLOOD Glucose-137* UreaN-25* Creat-1.7* Na-138
K-7.4* Cl-103 HCO3-21* AnGap-21*
[**2163-2-25**] 12:30PM BLOOD ALT-20 AST-26 LD(LDH)-401* AlkPhos-35*
Amylase-40 TotBili-0.8
[**2163-2-25**] 12:30PM BLOOD TotProt-4.2* Albumin-2.7* Globuln-1.5*
[**2163-2-26**] 04:16AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.9
[**2163-2-26**] 02:42PM BLOOD calTIBC-291 VitB12-256 Folate-8.4
Ferritn-424* TRF-224
[**2163-2-25**] 10:45AM BLOOD Lactate-4.0*
.
Cardiac labs during hospitalization:
[**2163-2-25**] 10:35AM BLOOD CK(CPK)-187*
[**2163-2-25**] 01:55PM BLOOD CK(CPK)-202*
[**2163-2-26**] 12:05AM BLOOD CK(CPK)-454*
[**2163-2-26**] 04:16AM BLOOD CK(CPK)-440*
[**2163-2-26**] 02:42PM BLOOD CK(CPK)-284*
[**2163-2-27**] 05:45AM BLOOD CK(CPK)-191*
[**2163-2-28**] 06:00AM BLOOD CK(CPK)-79
[**2163-2-28**] 01:40PM BLOOD CK(CPK)-58
[**2163-2-28**] 10:04PM BLOOD CK(CPK)-82
[**2163-3-1**] 06:02AM BLOOD CK(CPK)-118
[**2163-3-1**] 11:00AM BLOOD CK(CPK)-123
[**2163-3-1**] 08:15PM BLOOD CK(CPK)-94
[**2163-3-2**] 04:10AM BLOOD ALT-55* AST-32 LD(LDH)-678* CK(CPK)-78
AlkPhos-18* TotBili-1.4 DirBili-0.3 IndBili-1.1
[**2163-2-25**] 10:35AM BLOOD CK-MB-11* MB Indx-5.9 cTropnT-0.07*
[**2163-2-25**] 01:55PM BLOOD CK-MB-38* MB Indx-18.8*
[**2163-2-25**] 01:55PM BLOOD cTropnT-0.44*
[**2163-2-26**] 12:05AM BLOOD CK-MB-88* MB Indx-19.4* cTropnT-1.39*
[**2163-2-26**] 04:16AM BLOOD CK-MB-72* MB Indx-16.4* cTropnT-1.48*
[**2163-2-26**] 02:42PM BLOOD CK-MB-36* MB Indx-12.7* cTropnT-1.37*
[**2163-2-27**] 05:45AM BLOOD CK-MB-12* MB Indx-6.3* cTropnT-1.26*
[**2163-2-28**] 06:00AM BLOOD CK-MB-NotDone cTropnT-1.20*
[**2163-2-28**] 01:40PM BLOOD CK-MB-NotDone cTropnT-1.44*
[**2163-3-1**] 06:02AM BLOOD CK-MB-12* MB Indx-10.2*
[**2163-3-1**] 11:00AM BLOOD CK-MB-11* MB Indx-8.9* cTropnT-2.50*
[**2163-3-1**] 08:15PM BLOOD CK-MB-NotDone cTropnT-1.85*
[**2163-3-2**] 04:10AM BLOOD CK-MB-5 cTropnT-1.56*
.
Labs on discharge:
[**2163-3-8**] 06:15AM BLOOD WBC-4.9 RBC-3.70* Hgb-12.2* Hct-37.2*
MCV-101* MCH-32.9* MCHC-32.7 RDW-22.4* Plt Ct-306
[**2163-3-8**] 06:15AM BLOOD PT-24.5* PTT-29.5 INR(PT)-2.5*
[**2163-3-8**] 06:15AM BLOOD Glucose-88 UreaN-29* Creat-1.5* Na-141
K-4.7 Cl-104 HCO3-26 AnGap-16
[**2163-3-8**] 06:15AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.0
.
Microbiology:
[**2163-2-25**] Blood cx - Negative
[**2163-2-25**] Urine cx - negative
[**2163-2-26**] Fungal/AFB blood cx - NGTD
[**2163-2-26**] Blood cx - negative
[**2163-2-26**] Cryptococcal Ag - negative
[**2163-2-26**] RPR - non-reactive
[**2163-2-26**] Urine legionella - negative
[**2163-2-27**] Sputum cx - oropharyngeal contaminant
[**2163-3-2**] Sputum cx - 4+ GPC, 4+ GNR, cx moderate oropharyngeal
growth, fungal culture prelim yeast, AFB smear neg, AFB culture
pending
[**2163-3-3**] Blood cx - negative
[**2163-3-4**] Blood cx - negative
[**2163-3-4**] Urine cx - negative
[**2163-3-4**] cath tip cx - negative
[**2163-3-4**] Stool cx - neg for mycrosporidium, neg for
cyclosporidium, neg for salmonella and shigella, neg for
campylobacter, neg for cryptosporidium, neg for C diff, neg for
O + P
[**2163-3-5**] C diff - negative
[**2163-3-5**] C diff - negative
.
Imaging:
[**2163-2-25**] CXR:  IMPRESSION: Improving left upper lobe pneumonia.
Follow up with plain films recommended to assess for possible
pneumatoceleS.
.
[**2163-2-26**] ECHO:
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.  Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size is normal. There is mild global right
ventricular free wall hypokinesis. The ascending aorta is
moderately dilated. The aortic valve leaflets are mildly
thickened. Mild to moderate ([**11-29**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the report of the prior study of [**2161-8-29**], there
may be more aortic regurgitation, left ventricular function is
unchanged.
.
[**2163-2-28**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
one vessel coronary artery disease.  The left main coronary
artery was
without angiographic evidence of obstructive coronary artery
disease.
The left anterior descending artery was without angiographic
evidence of
obstructive coronary artery disease in the proximal, mid, and
distal
vessel.  The left circumflex artery was without angiographic
evidence of
coronary artery disease in the proximal, mid, and distal vessel.
 The
right coronary artery was the dominant vessel.  There was a 80%
mid-RCA
in-stent restenosis with extensive intracoronary thrombus
(organized)
proximal to the stenosis and throughout the PDA suggestive of
spontaneous distal embolization.
2. Left heart catheterization revealed normal systemic blood
pressures.
3.  Successful stenting of the RCA with a 3.5 mm Vision stent,
post-dilated to 4.0 mm.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Successful stenting of the RCA.
.
[**2163-3-1**] CT Chest/abd/pelvis:
IMPRESSION:
1. Increase in interval opacification within the right middle
and right lower lobe, and relatively unchanged opacification
within the left lower lobe. These findings could represent
progressive infectious etiology. Increased opacification within
the left upper lobe adjacent to left hilar mass also appears
more consolidated, which also could represent infectious
process. Difficult to rule out pulmonary hemorrhage within these
regions, given similar appearance to pneumonia. However, no
markedly fluid collections are noted throughout the lung
parenchyma.
2. Stable left hilar mass.
3. Right simple renal cyst.
4. Abnormal femoral head, chronic, unchanged. [**Month (only) 116**] represent old
trauma or old avascular necrosis as mentioned previously.
.
[**2163-3-1**] CXR:
IMPRESSION:
1. Interval development of bilateral infrahilar patchy opacities
concerning for developing infectious process.
2. Left upper lobe pneumonia, unchanged.
3. Support line is unchanged. No evidence of pneumothorax.
.
[**2163-3-7**] CXR:  IMPRESSION: Slight improvement in multifocal
pneumonia of the mid and lower lung zones. Persistent
obstruction of left upper lobe apicoposterior segment bronchus.
Correlation with bronchoscopy is suggested to exclude neoplastic
mass.




Brief Hospital Course:
Mr. [**Known lastname 15225**] is a 42 year old man with HIV/AIDS (CD4 count of 1)
status post recent hospitalization for PCP pneumonia, history of
multiple opportunistic infections in the past including
disseminated MAC, cerebral MAC, chest wall HSV, many PCP
pneumonia infections, presented with fevers, chest pain,
elevated lactate, hypotension concerning for sepsis but also
with EKG changes and positive cardiac enzymes.
.
Initially on presentation, patient had evidence of both sepsis
(hypotension, fevers, elevated WBC with left shift) and of
myocardial infarction with chest pain and positive cardiac
enzymes
.
He was initially admitted to the Medical ICU.  There he was
transiently on levophed for blood pressure control, but that was
quickly weaned off with IV fluid hydration.  He was pan-cultured
and started on broad spectrum antibiotics with vancomycin and
ceftriaxone.  Also, because he was just finishing up a course of
treatment for PCP from his last hospitalization with
clindamycin, primaquine and prednisone, he was maintained on
this treatment and started stress dose steroids with hydrocort
and fludricort.  For his cardiac status, he was started on
heparin drip, had his coumadin held, was maintained on his
aspirin and plavix.  The day following admission, he was
considered stable to go to the floor.
.
Floor course notable for:
.
1.) Sepsis/infectious disease issues:  As stated above, patient
was thought to be septic based on initial presentation, had
numerous cultures sent, including checking for opportunistic
infections, and was started on broad spectrum antibiotics.
These cultures all returned negative, so his antibiotics were
discontinued after 5 days.  Given his CXR findings throughout
hospital course, it was thought that he likely had a pulmonic
source of his infection.  Given his history of recurrent PCP
pneumonia, he was initially maintained on his PCP treatment with
clindamycin and primaquine and steroids (via stress dose
steroids initially, eventually converted to prednisone taper).
Patient was started on zosyn transiently for episode of
decreased O2 saturation, associated with hemoptysis (see below)
to cover empirically for aspiration pneumonia.  However, he did
not show further signs of infection and his decreased O2
saturation could be explained by other causes (see below) so his
zosyn was discontinued.  The patient clinically improved
throughout hospital course without further fever spikes, WBC
remained low, no further episodes of hypotension.  He was
discharged on no further antibiotics and prednisone taper to
treat his pulmonary status.  He was discharged with appointment
to follow up with his ID physician as an outpatient.
.
2.) Shortness of breath/hemoptysis:  The patient's infectious
course was complicated by hemoptysis and decreased O2 saturation
following his cardiac catheterization for his myocardial
infarction (see below).  This was of unclear etiology initially,
with thoughts of perhaps a recurrent pneumonia vs bleeding of an
underlying pneumonia due to his anticoagulation post-cath.  Via
extensive work up including repeat cultures, CXR, sputum
cultures, and pulmonary consultation, it was believed that the
likely scenario was that the patient had an endo-bronchial
lesion (seen on previous bronchoscopy which biopsy was
consistent with PCP) that likely began to bleed with his
post-cath anticoagulation, and this bleeding caused is decreased
oxygen saturation.  These symptoms of Shortness of breath and
hemoptysis resolved on their own as he was able to come off
anticoagulation (integrilin, heparin once coumadin was
therapeutic).  Bronchoscopy was not performed during hospital
course as patient was too tenuous to be able to tolerate and he
improved without intervention, as stated.  As above, he was
discharged on prednisone taper and home oxygen and follow up
with his ID physician.
.
3.) Anemia:  The patient had an associated drop of his
hematocrit with the hemoptysis experienced above.  This required
a number of blood transfusions to keep his hematocrit [**Last Name (un) 15355**]
above 28 given his coronary artery disease.  Work up of this Hct
drop included chest/abd/pelvis CT scan to rule out a bleed, as
the patient had just undergone cardiac catheterization, and
therefore there was concern for retroperitoneal bleed.  This was
ruled out with the scans.  Therefore, the likely explanation was
that his Hct drop was due to his hemoptysis described above.
His Hct stabilized to low 30's prior to discharge, without
requiring further transfusions.
.
4.) Cardiac/Myocardial infarction:  As stated above, the patient
presented with chest pain and ruled in for a myocardial
infarction.  The patient dose have a history of CAD (1VD on
cardiac cath in [**2157**], s/p MI in [**2157**] with stent to RCA, thought
possibly secondary to his lupus anti-coagulant).  Therefore, the
patient was maintained on his outpatient aspirin and plavix,
started on metoprolol once his blood pressure tolerated and
maintained on a heparin drip.  Lipitor was not started given the
likely interactions with his HIV medications.  The patient
underwent cardiac catheterization during the hospital course
with stent re-placed to his RCA.  Post-cath complications only
hemoptysis as above.  He otherwise remained cardiologically
stable throughout hospital course, without recurrent episodes of
chest pain.  He was discharged on aspirin, plavix, atenolol.  He
was discharged with follow up with his ID physician and
instructed to get referral to cardiologist with whom he will
need to follow up for his cardiac issues.
.
5.) Diarrhea:  Patient had acute onset of copius, watery
diarrhea during hospital course.  He had C diff and stool
cultures sent off which were negative.  He was transiently
empirically started on PO flagyl, which was discontinued once he
ruled out for c diff.  His diarrhea was attributed to his
antibiotics administration during his hospital course and was
resolving at time of discharge.
.
6.) HIV/AIDS:  The patient was kept on his outpatient regimen of
HAART therapy along with his outpatient prophylactic
medications:  Cipro, Azithromycin, and ethambutol for MAC ppx,
acyclovir for HSV prophylaxis.  His recurrent PCP infections
were treated as above, with initial continuation of treatment
with clindamycin, primaquine and steroids.  However, he was
discharged on atovaquone prophylaxis and steroid taper.
.
7.) Lupus anticoagulant:  Patient has a known history of lupus
anticoagulant with history of DVT/PE last in ?[**2157**].  Also had
IMI in [**2157**] with RCA stent placed (as above) that was thought
possibly secondary to his hypercoaguable state.  He is on
coumadin as an outpatient.  Due to this history, the patient was
maintained on heparin drip while his coumadin was discontinued
(while awaiting cardiac catheterization) and once coumadin was
restarted, was maintained on heparin until his coumadin was
therapeutic.  He was discharged with a therapeutic INR, with
instructions to have INR monitered and adjust his coumadin dose
as instructed.
.
# Renal insufficiency:  Patient has a history of mild renal
insufficiency, baseline Cr difficult to assess, but ?1.1-1.7.
His Cr remained fairly stable throughout hospital course.  He
received IVF, bicarb, mucomyst peri-cardiac catheterization.
.
# Neuropathy:  Has severe neuropathy secondary to HIV.  He was
maintained on his outpatient neurontin therapy.
.
Patient was discharged home with VNA services and home oxygen
with follow up with his outpatient infectious diseases
physician.

Medications on Admission:
1. Acyclovir 400 mg Capsule PO BID
2. Nystatin 100,000 unit/mL Suspension Five (5) ML PO QID prn
3. Atazanavir 300 mg Capsule PO DAILY
4. Ritonavir 100 mg Capsule PO DAILY
5. Stavudine 30 mg Capsule PO Q12H
6. Levetiracetam 500 mg Tablet PO BID
7. Emtricitabine 200 mg Capsule PO Q24H
8. Tenofovir Disoproxil Fumarate 300 mg Tablet PO DAILY
9. Venlafaxine 150 mg SR Capsule PO DAILY .
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
daily
11. Morphine 45 mg Tablet Sustained Release PO Q8H .
12. Azithromycin 250 mg Capsule PO BID
13. Ciprofloxacin 500 mg Tablet PO Q12H.
14. Gabapentin 1200 mg Capsule PO Q8H.
15. Ethambutol 400 mg Tablet TID.
16. Primaquine 26.3 mg Tablet one tablet daily for 16 days, to
stop on [**2-27**]
17. Clindamycin HCl 450 mg PO Q6H for 16 days, to stop
18. Prednisone taper, was on 20 mg Tablet from [**2-16**] to [**2-26**]
19. Coumadin 2 mg Tablet PO QHS
20. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical four times a day as needed for itching.


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
3. Atazanavir 150 mg Capsule Sig: Two Capsules PO DAILY (Daily).

4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY.
7. Emtricitabine 200 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
8. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust.    Release 24HR PO DAILY (Daily).
9. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
12. Ethambutol 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Stavudine 30 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
17. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
Disp:*QS mL* Refills:*2*
18. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*50 Tablet Sustained Release(s)* Refills:*2*
19. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for
10 days: Please take 2 tablets (20mg) daily for 5 days
([**Date range (1) 15356**]), then take 1 tablet (10mg) daily for 5 days
([**Date range (1) 15357**]), then may discontinue.
Disp:*15 Tablet(s)* Refills:*0*
20. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
21. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
22. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please adjust dose as instructed based on your INR.
Disp:*30 Tablet(s)* Refills:*2*
23. Oxygen
Home oxygen continuous at 3 liters nasal cannula.


Discharge Disposition:
Home With Service

Facility:
[**Hospital 2255**] [**Name (NI) 2256**]

Discharge Diagnosis:
Sepsis
Myocardial infarction
pneumonia
pulmonary hemorrhage
Anemia


Discharge Condition:
Stable.  Patient with stable vital signs, ambulating.


Discharge Instructions:
Please contact physician if experience fevers/chills, shortness
of breath, chest pain/pressure, any other questions/concerns.
.
Please take medications as directed
.
Please follow up with appointments as directed.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 2148**] ([**Telephone/Fax (1) 4170**] on Friday,
[**2163-3-11**] at 1:30pm - you will need follow up with cardiology as
well.  Dr. [**Last Name (STitle) 2148**] can refer you to a cardiologist, whom you
should see in the next 1-2 months.
{'Human immunodeficiency virus [HIV] disease,Unspecified septicemia,Sepsis,Acute myocardial infarction of other inferior wall, initial episode of care,Pneumonia, organism unspecified,Pressure ulcer, lower back,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to other cardiac device, implant, and graft,Primary hypercoagulable state,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Anemia, unspecified,Hypotension, unspecified,Diarrhea,Unspecified hereditary and idiopathic peripheral neuropathy,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: Chest pain, fever, chills

PRESENT ILLNESS: 42 y/o M with advanced HIV/AIDS last CD4 1 ([**2163-2-2**]), h/o many OP
including PCP PNA multiple times and recently treated admitted
[**Date range (1) 15253**] and again [**Date range (1) 15354**] for PCP pneumonia [**Name Initial (PRE) **] at those times
was treated with clindamycin/primaquine/steroids (history of
Bactrim allergy->aseptic meningitis) and improved, also history
of lupus anticoagulant c/b DVT/PE and IMI in [**2157**] s/p RCA
stenting, on coumadin as outpt, now presenting to ED with CP
(described as chest pressure, like someone stepping on his
chest) radiating to his teeth, bilateral upper and lower
extremity tingling and +chills. Pt states that he woke up
morning of admission with complaint of substernal chest pain
radiating to his right jaw and bilateral upper and lower
extremity tingling sensation, [**6-6**] in intensity, unrelated to
exertion, and lasting for approximately 6 hrs. Pain stopped at 2
pm and pt presented to ED. Patient denies ever having this type
of pain before. States symptoms with last MI in [**2157**] were more
agitation (reports wandering around the hospital, very
agitated).
.
ROS on admission: increased night sweats x 2 days, HA at back of
head x 2 days intermittent with no n/v/photophobia but
completely resolved today, increased yellow drainage from right
nostril x 1 wk, no increased cough, no abd pain, no diarrhea. Pt
states these symptoms are not typical of his PCP infections
since he usually feels sob and cough with clear sputum.
.
In ED, VS were T 100.8 rectally, BP 93/56 which decreased to SBP
80s, RR 24, HR 90, sats 99% 5L. Pt remained hypotensive with SBP
as low as 75/36 and lactate returned back at 4.0. Given concern
for sepsis, RIJ sepsis CVL was placed, pt was given Vancomycin 1
gm IV and Levofloxacin 500 mg IV as well as ASA 325 mg, Decadron
6 mg IV x1, 4 L IVF, and Levophed started for hypotension. EKG
showed [**Street Address(2) 4793**] elevations inferiorly - cardiology was consulted
who felt that pt's EKG was similar to a previous EKG when pt had
been septic. Trop increased from 0.07 to 0.44. Heparin was
briefly started but then stopped per cards consult (then
restarted in ICU). ST elevations resolved on repeat EKG. On
subsequent labs with rehydration, Hct decreased from 38 to 27
and lactate decreased to 1.1. Pt was transferred to ICU for
further management.
.
In ICU, patient was treated with broad spectrum abx w/ vanc and
CTX, given stress dose steroids, otherwise maintained on his
outpatient medications. He was weaned off pressor support,
fevers resolved. He was re-started on hep gtt in ICU for r/i w/
CE. His lab values notable for stabilization of his Hct 28-30,
WBC of 3.9 with 6% bands on day of transfer, Cr resolved from
1.7 -> 1.2, CK 107 -> 202 -> 454 -> 440, MB 11 -> 38 -> 88 ->
72, Index 5.9 -> 18.8 -> 19.4 -> 16.6, Trop 0.07 -> 0.44 -> 1.39
-> 1.48. Clinically improved.
.
Currently patient feels well. States feel much improved from
yesterday. Denies any chest pain/pressure, SOB, headache, any
other complaints at this time.
.

MEDICAL HISTORY: 1. AIDS dx [**2142**]: [**5-1**] VL 23K; [**3-31**] CD4 1 VL 47K- initially on
monotherapy starting in [**2144**], now with variable degrees of
resistance to HAART. Recently started study drug Tipranavir. C/b
multiple opportunistic infections (see blow)
2. PCP x7: [**2146**](intubated) c/b perirectal HSV and pancreatitis
from pentamidine and/or steroids, [**1-/2155**] c/b LUE axillary vein
thrombosis, [**5-/2155**], [**7-/2155**], [**3-/2157**]
3. Disseminated MAC bacteremia [**2148**]
4. Didanosine associated pancreatitis [**6-/2150**]
5. Aseptic meningitis [**1-/2154**] secondary to TMP/SMX
6. Cerebral MAC (diff from [**2148**] organism) c/b seizures [**3-/2157**]
7. Necrotic HSV L chest wall lesion resistant to acyclovir and
ganciclovir and treated with Foscarnet [**3-30**]
8. Acyclovir resistant HSV R chest wall lesion [**5-1**] treated with

MEDICATION ON ADMISSION: 1. Acyclovir 400 mg Capsule PO BID
2. Nystatin 100,000 unit/mL Suspension Five (5) ML PO QID prn
3. Atazanavir 300 mg Capsule PO DAILY
4. Ritonavir 100 mg Capsule PO DAILY
5. Stavudine 30 mg Capsule PO Q12H
6. Levetiracetam 500 mg Tablet PO BID
7. Emtricitabine 200 mg Capsule PO Q24H
8. Tenofovir Disoproxil Fumarate 300 mg Tablet PO DAILY
9. Venlafaxine 150 mg SR Capsule PO DAILY .
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
daily
11. Morphine 45 mg Tablet Sustained Release PO Q8H .
12. Azithromycin 250 mg Capsule PO BID
13. Ciprofloxacin 500 mg Tablet PO Q12H.
14. Gabapentin 1200 mg Capsule PO Q8H.
15. Ethambutol 400 mg Tablet TID.
16. Primaquine 26.3 mg Tablet one tablet daily for 16 days, to
stop on [**2-27**]
17. Clindamycin HCl 450 mg PO Q6H for 16 days, to stop
18. Prednisone taper, was on 20 mg Tablet from [**2-16**] to [**2-26**]
19. Coumadin 2 mg Tablet PO QHS
20. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application
Topical four times a day as needed for itching.

ALLERGIES: Bactrim

PHYSICAL EXAM: PE on admission:
T 98.8 BP 100/63 P65-75 R13 Sat 95% 2L NC, CVP 10-11
Gen: A+O x3, lying comfortably, NAD
HEENT: PERRL, EOMI, OP clear with MMM
Neck: supple, NT, no meningismus, no LAD, no JVD
Pulm: bibasilar crackles
CV: RRR, no m/r/g
Abd: s/nt/nd +BS
Ext: no edema, warm with +2 DP pulses bilaterally
Neuro: CN 2-12 intact, no focal deficits
Skin: very mildly scaly rash on bilateral upper and lower
extremities

FAMILY HISTORY: Mom-mild HTN and hypercholesterolemia; brother- asthma, HTN. 3
sisters-alive and healthy

SOCIAL HISTORY: Divorced; contracted HIV from his ex-wife [**Name (NI) 15254**] who has since
died, lives alone with dog, intermittent part-time work; + tob-
1ppd x 2y, quit 8mos ago; denies EtOH; occ MJ for nausea; h/o
asbestos exposure on the job 

### Response:
{'Human immunodeficiency virus [HIV] disease,Unspecified septicemia,Sepsis,Acute myocardial infarction of other inferior wall, initial episode of care,Pneumonia, organism unspecified,Pressure ulcer, lower back,Dehydration,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Other complications due to other cardiac device, implant, and graft,Primary hypercoagulable state,Coronary atherosclerosis of native coronary artery,Old myocardial infarction,Anemia, unspecified,Hypotension, unspecified,Diarrhea,Unspecified hereditary and idiopathic peripheral neuropathy,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
