CHIEF COMPLAINT: fever and diarrhea

PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 55 yo man with history of HIV (CD4 490, VL <48
[**1-1**]) s/p renal transplant in [**2139**] for HIV nephropathy with
recent refractory humoral rejection in summer [**2144**], type II DM,
and chronic pancreatitis who presented to [**Hospital1 18**] ED with fevers
and two days of diarrhea. History limited by patient's metnal
status and collected mostly from ED records and OMR. The patient
reported having [**6-30**] non-bloody bowel movements per day for the
past 2 days. He reports minimal abdominal pain and had some
nausea, but denies vomiting. He also reported having fevers the
day of admission when he presented to the [**Hospital1 18**] ED. In the ED,
besides fever and diarrhea, the patient was complaining of dry
mouth and lightheadedness.
.
In the ED, initial vs were: T 104.7 P 108 BP 163/116 R 25 O2
sat. 96 RA. The patient was uncomfortable and lethargic. He was
given 4L NS, 500 mg PO Vancomycin, 400 mg IV cipro and 500 mg IV
flagyl in addition to kayexylate, insulin and calcium gluconate
for hyperkalemia to 6.1. Patient also given 1 gm tylenol PO. Lab
studies showed nearly elevated creatinine of 4.2 above baseline
of ~2.5 with dirty UA, and WBC 4.6. A CT abdomen/pelvis was
ordered without contrast which showed no gross bowel pathology
and stable transplant kidney morphology though pyelonephritis
could not be excluded.

MEDICAL HISTORY: HIV (CD4 719, VL pending from [**2142-10-9**]) on HAART. Dx in [**2127**].
ESRD secondary to HIV nephropathy, FSGS, previously on PD for 6

MEDICATION ON ADMISSION: Acyclovir - 400 mg daily
Alendronate - 70mg weekly
Atovaquone - 750mg/5mL - 10 mL daily
Azathioprine - 25mg daily (half of 50mg tablet)
Calcitriol - 0.25 mcg daily
Gabapentin - 300/600mg qAM/PM
Lamivudine - 150 mg daily (1.5 tablets)
Ultrase EC - 250 mg [**Hospital1 **]
Lisinopril - 5 mg daily
Loperamide - 4 mg [**Hospital1 **]
Metoprolol succinate - 100mg/50mg qAM/PM
Omeprazole - 20 mg daily
Pioglitazone - 15 mg daily
Prednisone - 5 mg daily
Raltegravir - 400 mg [**Hospital1 **]
Tacrolimus - 5 mg [**Hospital1 **] (not positive about dose)
Tenofovir - 300 mg q48h
Insulin sliding scale

ALLERGIES: Bactrim DS / Abacavir Sulfate

PHYSICAL EXAM: T 100.7 (axillary) P 111 BP 138/85 R 22 O2 Sat 98 RA
General: Lethargic, only briefly arousable
HEENT: Sclera injected, anicteric, dry mucous membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: very warm, hyperdynamic pulses

FAMILY HISTORY: His mother died at the age of 84 of a CVA; she also had problems
with CAD and hypertension. His father died at the age of 93 from
respiratory failure and he had prostate cancer. He has 3
brothers and 2 sisters of whom 1 has had a CVA, 1 sister has HIV
infection, and he has lost 5 siblings to motor vehicle
accidents, lung cancer and MIs.

SOCIAL HISTORY: Mr. [**Known lastname 174**] was born and raised in Missippi, and he moved to
[**Location (un) 86**] in [**2107**]. He used to work for an electric company, but has
been on disability since [**2129**]. He has 3 children from a prior
marriage, and they are healthy. He is remarried and lives in
[**Location 686**] with his wife.  [**Name (NI) **] used to smoke 1 ppd, and gave this
up in [**2127**]. He quit drinking ethanol in [**2127**], prior to which he
had some heavy intake.  He has been HIV positive since [**2127**],
risk factor was heterosexual contact.
.
Human immunodeficiency virus [HIV] disease,Acute kidney failure with lesion of tubular necrosis,Septicemia due to escherichia coli [E. coli],Sepsis,Acidosis,Urinary tract infection, site not specified,Rhabdomyolysis,Complications of transplanted kidney,Glucocorticoid deficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified hereditary and idiopathic peripheral neuropathy,Diarrhea,Thrombocytopenia, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypocalcemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified
Human immuno virus dis,Ac kidny fail, tubr necr,E coli septicemia,Sepsis,Acidosis,Urin tract infection NOS,Rhabdomyolysis,Compl kidney transplant,Glucocorticoid deficient,DMII wo cmp nt st uncntr,Idio periph neurpthy NOS,Diarrhea,Thrombocytopenia NOS,Abn react-org transplant,Hypocalcemia,Atrial fibrillation,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS
Admission Date:  [**2145-3-5**]              Discharge Date:   [**2145-3-11**]

Date of Birth:  [**2090-1-7**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim DS / Abacavir Sulfate

Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
fever and diarrhea

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname 174**] is a 55 yo man with history of HIV (CD4 490, VL <48
[**1-1**]) s/p renal transplant in [**2139**] for HIV nephropathy with
recent refractory humoral rejection in summer [**2144**], type II DM,
and chronic pancreatitis who presented to [**Hospital1 18**] ED with fevers
and two days of diarrhea. History limited by patient's metnal
status and collected mostly from ED records and OMR. The patient
reported having [**6-30**] non-bloody bowel movements per day for the
past 2 days. He reports minimal abdominal pain and had some
nausea, but denies vomiting. He also reported having fevers the
day of admission when he presented to the [**Hospital1 18**] ED. In the ED,
besides fever and diarrhea, the patient was complaining of dry
mouth and lightheadedness.
.
In the ED, initial vs were: T 104.7 P 108 BP 163/116 R 25 O2
sat. 96 RA. The patient was uncomfortable and lethargic. He was
given 4L NS, 500 mg PO Vancomycin, 400 mg IV cipro and 500 mg IV
flagyl in addition to kayexylate, insulin and calcium gluconate
for hyperkalemia to 6.1. Patient also given 1 gm tylenol PO. Lab
studies showed nearly elevated creatinine of 4.2 above baseline
of ~2.5 with dirty UA, and WBC 4.6. A CT abdomen/pelvis was
ordered without contrast which showed no gross bowel pathology
and stable transplant kidney morphology though pyelonephritis
could not be excluded.

The patient was transfered to the general medical floor, but
spiked a fever up to 106.7F and was in acute distress, agitated
and diaphoretic, in addition to having continuing watery,
non-bloody stools. He was given more tylneol and zofran, in
addition to PO + IV vancomycin, IV flagyl, meropenem and
ganciclovir in addition to continuing IV fluids. He was also put
on a cooling blanket. His initial vitals were T 100.7 (axillary)
P 111 BP 138/85 R 22 O2 Sat 98 RA. He continued to be lethargic,
though arousable and able to answer questions and follow
commands.


Past Medical History:
HIV (CD4 719, VL pending from [**2142-10-9**]) on HAART. Dx in [**2127**].
ESRD secondary to HIV nephropathy, FSGS, previously on PD for 6

years, now status post DCD transplant [**9-/2139**]
    - Refractory humoral rejection beginning in [**2144-7-23**]
    - Failed plasmapheresis and steroid treatment, now s/p
rituximab
      treatment with undetectable CD19/CD20+ cells, with
significant
      humoral rejection still
    - Now on triple immunosuppression with azathioprine +
tacrolimus
      and predisone
Type II diabetes
Chronic pancreatitis
h/o alcohol abuse
Gout
Genital herpes on suppressive acyclovir
Peripheral neuropathy
Benign renal transplant cyst
Renal osteodystrophy
GERD
h/o CMV - positive IgG in [**2141**]
h/o strongyloides
h/o c. difficile
h/o pericardial effusion with tamponade in [**2139**]
HBV by serology, VL negative


Social History:
Mr. [**Known lastname 174**] was born and raised in Missippi, and he moved to
[**Location (un) 86**] in [**2107**]. He used to work for an electric company, but has
been on disability since [**2129**]. He has 3 children from a prior
marriage, and they are healthy. He is remarried and lives in
[**Location 686**] with his wife.  [**Name (NI) **] used to smoke 1 ppd, and gave this
up in [**2127**]. He quit drinking ethanol in [**2127**], prior to which he
had some heavy intake.  He has been HIV positive since [**2127**],
risk factor was heterosexual contact.
.


Family History:
His mother died at the age of 84 of a CVA; she also had problems
with CAD and hypertension. His father died at the age of 93 from
respiratory failure and he had prostate cancer. He has 3
brothers and 2 sisters of whom 1 has had a CVA, 1 sister has HIV
infection, and he has lost 5 siblings to motor vehicle
accidents, lung cancer and MIs.


Physical Exam:
T 100.7 (axillary) P 111 BP 138/85 R 22 O2 Sat 98 RA
General: Lethargic, only briefly arousable
HEENT: Sclera injected, anicteric, dry mucous membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: very warm, hyperdynamic pulses


Pertinent Results:
ADMISSION LABS
[**2145-3-5**] 04:14PM   LACTATE-1.9
[**2145-3-5**] 04:19PM   WBC-4.6# RBC-3.32* HGB-10.9* HCT-33.4*
MCV-101* MCH-32.9* MCHC-32.7 RDW-14.8
[**2145-3-5**] 04:19PM   NEUTS-77* BANDS-2 LYMPHS-12* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2145-3-5**] 04:19PM   LIPASE-36
[**2145-3-5**] 04:19PM   ALT(SGPT)-34 AST(SGOT)-220* ALK PHOS-93 TOT
BILI-1.0
[**2145-3-5**] 04:19PM   GLUCOSE-305* UREA N-67* CREAT-4.2*#
SODIUM-135 POTASSIUM-6.1* CHLORIDE-109* TOTAL CO2-12* ANION
GAP-20
[**2145-3-5**] 04:50PM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2145-3-5**] 04:50PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
[**2145-3-5**] 04:50PM URINE  RBC-[**3-27**]* WBC-[**12-12**]* BACTERIA-MANY
YEAST-NONE EPI-<1
[**2145-3-5**] 04:50PM URINE  GRANULAR-[**3-27**]*
[**2145-3-5**] 07:16PM   K+-4.9
[**2145-3-5**] 11:34PM   WBC-1.6*# RBC-3.15* HGB-10.6* HCT-31.5*
MCV-100* MCH-33.5* MCHC-33.6 RDW-14.8
[**2145-3-5**] 11:34PM   CALCIUM-6.5* PHOSPHATE-2.7# MAGNESIUM-1.8
[**2145-3-5**] 11:34PM   CK(CPK)-[**Numeric Identifier 12144**]*
[**2145-3-5**] 11:34PM   GLUCOSE-440* UREA N-64* CREAT-3.9* SODIUM-135
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-14* ANION GAP-17
.
PERTINENT LABS:
[**2145-3-10**] 04:20AM BLOOD Ferritn-1699*
[**2145-3-9**] 08:55AM BLOOD Hapto-151
[**2145-3-10**] 04:20AM BLOOD Triglyc-353*
[**2145-3-9**] 05:30AM BLOOD PTH-466*
[**2145-3-6**] 09:11AM BLOOD Cortsol-29.8*
[**2145-3-6**] 03:44AM BLOOD Cortsol-31.4*
[**2145-3-9**] 05:30AM BLOOD PT-14.5* PTT-30.7 INR(PT)-1.3*
[**2145-3-8**] 03:33AM BLOOD Plt Ct-51*
[**2145-3-7**] 03:14PM BLOOD Fibrino-623*#
[**2145-3-6**] 07:21AM BLOOD Lactate-3.4* K-4.4
[**2145-3-6**] 05:27PM BLOOD Lactate-2.8*
[**2145-3-7**] 07:25AM BLOOD Lactate-1.6
[**2145-3-8**] 04:00AM BLOOD Lactate-1.2
.
MICROBIOLOGY:
[**2145-3-6**] B-Glucan: 264 (Positive)
[**2145-3-6**] Aspergillus Antigen (galactomannan): 0.2 (indeterminate)
[**2145-3-6**] Strongyloides IgG: negative
[**2145-3-9**] Adenovirus PCR: negative
[**2145-3-9**] [**Doctor Last Name 3271**]-[**Doctor Last Name **] Virus PCR: not-detected
[**2145-3-9**] PARVOVIRUS B19 DNA Results Pending
Blood Culture, Routine (Final [**2145-3-8**]):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

   Anaerobic Bottle Gram Stain (Final [**2145-3-6**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 5:56A [**2145-3-6**].
      GRAM NEGATIVE RODS.

   Aerobic Bottle Gram Stain (Final [**2145-3-6**]):    GRAM NEGATIVE
ROD(S).
[**2145-3-5**] 4:17 pm BLOOD CULTURE      1617.

                            **FINAL REPORT [**2145-3-11**]**

   Blood Culture, Routine (Final [**2145-3-11**]):
      ESCHERICHIA COLI.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
315-9086B
         [**2145-3-5**].

   Anaerobic Bottle Gram Stain (Final [**2145-3-6**]):    GRAM
NEGATIVE RODS.
URINE CULTURE (Final [**2145-3-7**]):    NO GROWTH.
CMV Viral Load (Final [**2145-3-9**]): CMV DNA not detected.
[**2145-3-6**] 3:44 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)

   BLOOD/FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   BLOOD/AFB CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

[**2145-3-6**] 3:45 am STOOL     CONSISTENCY: LOOSE      Source:
Stool.

   FECAL CULTURE (Final [**2145-3-9**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2145-3-8**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2145-3-8**]):
      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 [**2145-3-8**]):    NO VIBRIO
FOUND.

   FECAL CULTURE - R/O YERSINIA (Final [**2145-3-8**]):    NO YERSINIA
FOUND.

   FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2145-3-9**]):
      NO E.COLI 0157:H7 FOUND.

   Cryptosporidium/Giardia (DFA) (Final [**2145-3-8**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-3-7**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

   VIRAL CULTURE (Preliminary):    NO VIRUS ISOLATED.
Blood Culture, Routine (Final [**2145-3-12**]):    NO GROWTH.
OVA + PARASITES (Final [**2145-3-8**]):   NO OVA AND PARASITES SEEN.
[**2145-3-7**] 3:44 am BLOOD CULTURE: Pending
[**2145-3-7**] 8:24 am BLOOD CULTURE: Pending
[**2145-3-7**] 3:06 pm STOOL     CONSISTENCY: LOOSE      Source:
Stool.

                            **FINAL REPORT [**2145-3-11**]**

   MICROSPORIDIA STAIN (Final [**2145-3-8**]):    NO MICROSPORIDIUM
SEEN.

   FECAL CULTURE (Final [**2145-3-11**]):
      NO ENTERIC GRAM NEGATIVE RODS FOUND.
      NO SALMONELLA OR SHIGELLA FOUND.

   CAMPYLOBACTER CULTURE (Final [**2145-3-9**]):    NO CAMPYLOBACTER
FOUND.

   OVA + PARASITES (Final [**2145-3-8**]):
      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.

   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-3-8**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).

[**2145-3-8**] 3:33 am BLOOD CULTURE: Pending
OVA + PARASITES (Final [**2145-3-9**]):  NO OVA AND PARASITES SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-3-9**]):Feces
negative for C.difficile toxin A & B by EIA.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2145-3-10**]):No VRE
isolated.
.
DISCHARGE LABS:
[**2145-3-11**] 03:35AM BLOOD WBC-1.9* RBC-2.21* Hgb-7.5* Hct-22.7*
MCV-103* MCH-34.1* MCHC-33.2 RDW-14.4 Plt Ct-106*
[**2145-3-10**] 04:20AM BLOOD Neuts-45* Bands-0 Lymphs-37 Monos-17*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2145-3-10**] 04:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Schisto-OCCASIONAL
[**2145-3-11**] 03:35AM BLOOD Plt Ct-106*
[**2145-3-10**] 04:20AM BLOOD Gran Ct-855*
[**2145-3-10**] 04:20AM BLOOD Ret Aut-0.9*
[**2145-3-11**] 03:35AM BLOOD Glucose-174* UreaN-64* Creat-2.8* Na-139
K-3.6 Cl-110* HCO3-24 AnGap-9
[**2145-3-11**] 03:35AM BLOOD ALT-44* AST-70* LD(LDH)-380* AlkPhos-57
TotBili-0.9
[**2145-3-11**] 03:35AM BLOOD Albumin-2.2* Calcium-7.6* Phos-3.7 Mg-2.0
[**2145-3-11**] 08:30AM BLOOD tacroFK-6.8

Brief Hospital Course:
Mr. [**Known lastname 174**] is a 55 yo man with history of HIV (CD4 490, VL <48
[**1-1**]) s/p renal transplant in [**2139**] for HIV nephropathy with
recent refractory humoral rejection in summer [**2144**], type II DM,
and chronic pancreatitis who presented to [**Hospital1 18**] ED with
fevers and two days of diarrhea.
.
#SIRS in setting of immunosuppresion: The patient satisfied [**4-26**]
criteria for SIRS, with pronounced fever, leukopenia,
tachycardia and tachypnea. Patient's altered mental status was
likely secondary to his marked fever. In the MICU, his fever was
treated with passive cooling with cooling blanket in addition to
tylenol PRN. He was started on broad empiric coverage with
Flagyl IV and PO Vancomycin in addition to IV Vancomycin,
Meropenem and Ganciclovir. Several infectious disease labs and
culutres were gathered, including comprehensive stool, urine,
blood cultures, stool ova and parasites, C. diff assay and funal
assays. He responded quickly to antibiotics and defervesced
within 24 hours and returned to baseline mental status. In less
than 24 hours, his blood cultures grew GNR which were further
speciated to pan-sensitive E. coli. In light of this, his
antibiotic coverage was narrowed to Cipro.  He will finish a 14
day course.
.
# Pancytopenia:  The patient developed leukopenia to 1.9 and
anemia to a hct of 22.7 prior to discharge.  Platelets decreased
from 103 to 51 but rebounded to 106 prior to discharge.  His
white cell count and red cell count continued to decrease
despite clinical imporvement from infectious illness.  Lactate
was elevated, likely from rhabdomyolysis as there wsa no other
evidence of hemolysis (nl bili, haptoglobin).  Reticulocyte
count was inappropriately low at 0.9.  Fibrinogen was high and
coags Ferritin was elevated at 1699 and triglycerides were
elevated at 353.  There was concern for post-transplant
lymphoproliferative disease.  The patient declined to stay for
further work-up.  He will follow-up with Heme-Onc for possible
bone marrow biopsy.  Adenovirus PCR and EBV PCR were negative
and parvovirus B19 was pending at the time of discharge.
.
#Diarrhea: Likely manifestation of a gastrointenstinal
infection, perhaps due to viral or C. difficile infection. His
stool is non-bloody but profuse, with several BMs occuring while
patient on the floor. Of note, the patient also has baseline
chronic diarrhea secondary to HAART. Patient was treated on the
MICU floor with aggresive IVF hydration, with resolution of his
watery diarrhea to more baseline loose stools.  Stool cultures
and C.Diff [**Doctor First Name **] were negative.  On the medicine floor, he was
back to baseline of [**1-24**] loose stools daily for which he takes
loperamide at home.  He was kept on po vancomycin of which he
will complete a 7 day course.  CMV viral load was negative.
C.Diff PCR was pending at the time of discharge.  Strongyloides
serology was negative, as was adenovirus.  B-glucan and
galactomannan were positive.
.
#Acute kidney injury: Patient's creatinine increased from
baseline of ~2.5 to 4.2 with additional hyperkalemia and
metabolic acidosis. The most likely cause of the [**Last Name (un) **] was felt to
be a combination of pre-renal, urinary tract infection, and
rhabdomyolysis. His rhabdomyolysis was treated with diuresis and
agressive IVF hydration with D5 + Bicarb for a goal UOP of
100cc/hr. The patient responded well with excellenet UPO and
decrease in creatinine to 3.5 from a high of 4.2.  On the
medicine floor his Cr continued to improved and was down to 2.8
at the time of discharge which is near his baseline.
.
#UTI: Patient had infected UA x2 highly suggestive for UTI.
Patient has grown enterococcus and E. coli in urine cultures in
the past 2-3 years. He was covered broadly with vancomycin and
meropenem.  Urine culture was negative, but it was unclear
whether or not he received antibiotics prior to culture.  He was
transitioned to ciprofloxacin which he will complete as an
outpatient.
.
#s/p renal transplant: Held patient's tacrolimus and
azathioprine in setting of acute illness, but continued on
stress dose steroids, changing to home dose of 5mg prednisone
daily.  Tacrolimus was restarted at 8 mg daily but azathioprine
was held.  The patient will follow-up with Dr. [**Last Name (STitle) **].
.
#Hyperkalemia: Likely secondary to [**Last Name (un) **], acidosis, especially
marked given his likely severe GI losses through diarrhea.
Received insulin, CA gluconate and kayexylate in ED with
improvement of K of 6.1 and normalization of EKG changes.
Discharged with consistently normal potassium levels.
.
#Rhabdomyolysis: CK elevated at maximum above 37,000, likely
contributing to hypokalemia and renal failure. Treated
aggresively with D5W and HCO3- IVF with diuretics for goal UOP
of 100cc/hr. Rhabdo likely secondary to extreme rigors and
shivering from prolonged, severe fever. CK improved to ~3,000 by
time of [**Hospital 12145**] transfer to floor and continued to normalize on the
medicine floor.
.
#Metabolic acidosis: Simultaneous gap and non-gap acidosis.
Multiple potential causes: lactic acidosis, GI bicarbonate
losses, hyperkalemia, and acute renal failure. Treated with
agressive IVF and HCO3- and improved.
.
#DM/Hyperglycemia - Patient was quite hyperglycemic with glucose
>300-400, with known DM on top of acute illness and hyperadrenal
state. Patient was put on augmented ISS.  Glucose control
improved and the patient was discharged on his home insulin
regimen.
.
#Elevated AST: Markedly elevated AST above ALT on admission,
likely secondary to EtOH given patient's history of EtOH abuse.
No other LFTs are elevated.  AST and ALT both trended down
throughout the hospitalization.
.
#HIV: Continued home meds: Raltegravir, tenofovir, lamivudine in
addition to prophylaxis: atovaquone + acyclovir.  The patient
will follow-up with Dr. [**Last Name (STitle) 724**] from ID.
.
#Pending LABS: parvovirus B19, blood cultures from [**3-7**] and
[**3-8**], blood cultures for AFB and fungus from [**3-6**].


Medications on Admission:
Acyclovir - 400 mg daily
Alendronate - 70mg weekly
Atovaquone - 750mg/5mL - 10 mL daily
Azathioprine - 25mg daily (half of 50mg tablet)
Calcitriol - 0.25 mcg daily
Gabapentin - 300/600mg qAM/PM
Lamivudine - 150 mg daily (1.5 tablets)
Ultrase EC - 250 mg [**Hospital1 **]
Lisinopril - 5 mg daily
Loperamide - 4 mg [**Hospital1 **]
Metoprolol succinate - 100mg/50mg qAM/PM
Omeprazole - 20 mg daily
Pioglitazone - 15 mg daily
Prednisone - 5 mg daily
Raltegravir - 400 mg [**Hospital1 **]
Tacrolimus - 5 mg [**Hospital1 **] (not positive about dose)
Tenofovir - 300 mg q48h
Insulin sliding scale


Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
Disp:*6 Tablet(s)* Refills:*0*
2. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
3. acyclovir 400 mg Tablet Sig: One (1) Tablet PO once a day.
4. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO once a
day.
5. gabapentin 300 mg Capsule Sig: [**1-24**] Capsules PO twice a day:
Take 1 capsule in the morning and 1 capsule in the evening.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. tacrolimus 1 mg Capsule Sig: Eight (8) Capsule PO twice a
day.
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO twice a day: Take 2
tablets every morning and 1 tablet every evening.
11. Ultrase EC 250 mg (4,500 -25K-20K unit) Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
twice a day.
12. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.

13. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO once a day

14. insulin lispro 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: Take as directed by sliding scale.
15. insulin glargine 100 unit/mL Solution Sig: Nineteen (19)
units Subcutaneous at bedtime.
16. Outpatient Lab Work
Please have blood drawn for CBC with Diff and Chem 7 and
tacrolimus level on Monday [**2145-3-15**].  Please fax
results to Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 12146**] and to Dr. [**Last Name (STitle) 724**] at
([**Telephone/Fax (1) 12147**].
17. lamivudine 150 mg Tablet Sig: One (1) Tablet PO once a day.

18. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO every other day.
19. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
20. loperamide 2 mg Tablet Sig: Two (2) Tablet PO twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis: E.Coli bacteremia, leukopenia,
rhabdomyolysis, acute renal failure
Secondary Diagnosis: HIV, End Stage Renal Disease, Type II
Diabetes Mellitus


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


Discharge Instructions:
You were admitted to the hospital for very high fevers and
diarrhea.  You were found to have an infection in your blood
that may have been causing your diarrhea as well.  During your
hospitalization, the levels of white and red blood cells in your
blood went down.  This is very concerning and should be followed
up as an outpatient.  You will follow-up with Dr. [**Last Name (STitle) **],
Dr. [**Last Name (STitle) 724**], and a hematology (blood) doctor.
.
The following changes were made to your medications:
You were STARTED on Ciprofloxacin which you should continue for
6 more days.
You were STARTED on Vancomycin which you should continue for 3
more days.
Your tacrolimus dose was INCREASED.
Your imuran (azathioprine) was STOPPED.

Followup Instructions:
You will need to follow-up with both Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 724**]
within the next 4-10 days.  Their offices are currently working
on finding you an appointment and will call you with the time
and date.
.
You should have your blood drawn on Monday and have the results
sent to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 724**].
.
Department: HEMATOLOGY/BMT
When: TUESDAY [**2145-3-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: TRANSPLANT
When: TUESDAY [**2145-4-6**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: TRANSPLANT CENTER
When: TUESDAY [**2145-4-6**] at 1:40 PM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
{'Human immunodeficiency virus [HIV] disease,Acute kidney failure with lesion of tubular necrosis,Septicemia due to escherichia coli [E. coli],Sepsis,Acidosis,Urinary tract infection, site not specified,Rhabdomyolysis,Complications of transplanted kidney,Glucocorticoid deficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified hereditary and idiopathic peripheral neuropathy,Diarrhea,Thrombocytopenia, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypocalcemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}


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 and diarrhea

PRESENT ILLNESS: Mr. [**Known lastname 174**] is a 55 yo man with history of HIV (CD4 490, VL <48
[**1-1**]) s/p renal transplant in [**2139**] for HIV nephropathy with
recent refractory humoral rejection in summer [**2144**], type II DM,
and chronic pancreatitis who presented to [**Hospital1 18**] ED with fevers
and two days of diarrhea. History limited by patient's metnal
status and collected mostly from ED records and OMR. The patient
reported having [**6-30**] non-bloody bowel movements per day for the
past 2 days. He reports minimal abdominal pain and had some
nausea, but denies vomiting. He also reported having fevers the
day of admission when he presented to the [**Hospital1 18**] ED. In the ED,
besides fever and diarrhea, the patient was complaining of dry
mouth and lightheadedness.
.
In the ED, initial vs were: T 104.7 P 108 BP 163/116 R 25 O2
sat. 96 RA. The patient was uncomfortable and lethargic. He was
given 4L NS, 500 mg PO Vancomycin, 400 mg IV cipro and 500 mg IV
flagyl in addition to kayexylate, insulin and calcium gluconate
for hyperkalemia to 6.1. Patient also given 1 gm tylenol PO. Lab
studies showed nearly elevated creatinine of 4.2 above baseline
of ~2.5 with dirty UA, and WBC 4.6. A CT abdomen/pelvis was
ordered without contrast which showed no gross bowel pathology
and stable transplant kidney morphology though pyelonephritis
could not be excluded.

MEDICAL HISTORY: HIV (CD4 719, VL pending from [**2142-10-9**]) on HAART. Dx in [**2127**].
ESRD secondary to HIV nephropathy, FSGS, previously on PD for 6

MEDICATION ON ADMISSION: Acyclovir - 400 mg daily
Alendronate - 70mg weekly
Atovaquone - 750mg/5mL - 10 mL daily
Azathioprine - 25mg daily (half of 50mg tablet)
Calcitriol - 0.25 mcg daily
Gabapentin - 300/600mg qAM/PM
Lamivudine - 150 mg daily (1.5 tablets)
Ultrase EC - 250 mg [**Hospital1 **]
Lisinopril - 5 mg daily
Loperamide - 4 mg [**Hospital1 **]
Metoprolol succinate - 100mg/50mg qAM/PM
Omeprazole - 20 mg daily
Pioglitazone - 15 mg daily
Prednisone - 5 mg daily
Raltegravir - 400 mg [**Hospital1 **]
Tacrolimus - 5 mg [**Hospital1 **] (not positive about dose)
Tenofovir - 300 mg q48h
Insulin sliding scale

ALLERGIES: Bactrim DS / Abacavir Sulfate

PHYSICAL EXAM: T 100.7 (axillary) P 111 BP 138/85 R 22 O2 Sat 98 RA
General: Lethargic, only briefly arousable
HEENT: Sclera injected, anicteric, dry mucous membranes,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: very warm, hyperdynamic pulses

FAMILY HISTORY: His mother died at the age of 84 of a CVA; she also had problems
with CAD and hypertension. His father died at the age of 93 from
respiratory failure and he had prostate cancer. He has 3
brothers and 2 sisters of whom 1 has had a CVA, 1 sister has HIV
infection, and he has lost 5 siblings to motor vehicle
accidents, lung cancer and MIs.

SOCIAL HISTORY: Mr. [**Known lastname 174**] was born and raised in Missippi, and he moved to
[**Location (un) 86**] in [**2107**]. He used to work for an electric company, but has
been on disability since [**2129**]. He has 3 children from a prior
marriage, and they are healthy. He is remarried and lives in
[**Location 686**] with his wife.  [**Name (NI) **] used to smoke 1 ppd, and gave this
up in [**2127**]. He quit drinking ethanol in [**2127**], prior to which he
had some heavy intake.  He has been HIV positive since [**2127**],
risk factor was heterosexual contact.
. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Acute kidney failure with lesion of tubular necrosis,Septicemia due to escherichia coli [E. coli],Sepsis,Acidosis,Urinary tract infection, site not specified,Rhabdomyolysis,Complications of transplanted kidney,Glucocorticoid deficiency,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified hereditary and idiopathic peripheral neuropathy,Diarrhea,Thrombocytopenia, unspecified,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Hypocalcemia,Atrial fibrillation,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified'}
