CHIEF COMPLAINT: Altered Mental Status

PRESENT ILLNESS: 52F patient w/ HIV last cd4 134 ([**12/2140**]) and viral load 239
([**9-/2140**]) discharged from [**Hospital1 2177**] yesterday, went home and did crack
cocaine, was found unresponsive at [**Location (un) **]T stop. Admits
crack yesterday, denies any drug use today. Remains altered but
through ED course MS has improved and pt. has been able to wake
up and answer questions and was A/Ox3. Some labs faxed over from
[**Hospital1 2177**] (unable to locate them in the chart but per ED notes says
they had them) but pt. has not been able to consent for records
release yet. pt. did endorse Hx of cocaine CMP. Serum tox in the
ED was negative and on labs was noted to have hypoglycemia, ARF
and hyponatremia similar to recent [**1-9**] [**Hospital1 2177**] labs.
.
In ED has altered between sleeping and agitation. Workup showed
hyponatremia which is apparently old as Na a week ago at [**Hospital1 2177**] was
128 per ED attending notes, acute on chronic renal failure (last
cr at [**Hospital1 2177**] was 5.2 now 7), elevated BNP at 4200, mildly elevated
trop (0.06 X 2) with new TWF in inferior leads and TWI V4-V6.
Tox screen was positive for cocaine only. CXR showed right-sided
effusion. Received ASA. CT head showed a small SDH. neurosurgery
was consulted and did not recommend any intervention currently
but Q2H neuro checks and repeat CT in 12 hours. Seizure ppx also
needed -> dilantin ordered . Sleeping currently. Ua was positive
for blood after foley inserted and 300 Ketones. Patient was also
noted to be hypoglycemic to 50s in ED so was given an amp.
.
Admitted to ICU for Q2H neuro checks.
.
VS prior to transfer: 98, 87, 135/76, 15, 95% RA.
.
On arrival to the floor patient was sleeping but arousable. Able
to answer questions and knows where she is and the date. Denied
pain and shortness of breath. Other ROS unable to obtain as
patient does not answer questions.

MEDICAL HISTORY: # ? cocaine CMP
# ? CKD with creatinine one week ago at [**Hospital1 2177**] 5.2
# HIV - CD4 138, VL 239 on [**9-13**]
# Histoplasmosis (pulmonary)
# Cocaine use
# Renal Failure (?chronic)
# HTN
# CVA (ischemic left parietal and hemorraghic pons)
# HCV (genotype I)
# Beta thalassemia/G6PD Defeciency
# Hypothyroidism
# Hypothyroid cancer s/p thyroidectomy

MEDICATION ON ADMISSION: From [**Hospital1 2177**] discharge [**2141-1-10**]:
Synthroid 125 mcg daily
plavix 75 mg daily
Fluticasone inhaler 44 mcg 2 puffs [**Hospital1 **]
albuterol inhaler
Famotidine 20 daily
Itraconazole 200 mg [**Hospital1 **]
cefpodoxime 200 mg x 5 days
atovaquone 1500 mg daily
Aranesp 40 qWednesday
Calcium carbonate 1000 tid
Ferrous gluconate 324 mg tid
Vit D [**Numeric Identifier 1871**] U Qsunday
Calcitriol 0.25 mcg daily
Zofran 4 mg q8hr prn
Diltiazem XL 240 daily
lasix 80 daily
NaHCO3 650 mg tid
calcium acetate 667 mg tid
Colace
APAP

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
Vitals: T: 97 BP: 130/79 P: 90 R: 15 O2: 97% RA
General: Somnolent, will arouse after repeated voice prompts and
give one word answers before going back to sleep. No acute
distress, skin very dry appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: able to bend chin to chest passively and easy movement
side to side, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple small round slightly raised lesions on the skin
of the arms and legs
Neuro: Pupils sluggish but reactive bilaterally. A+OX 2, speech
slightly slurred. Moving all for extremities.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives with her uncle. Does not want her uncle or mother to be
involved in her medical care. Cocaine use +, and alcohol use in
past per OSH records, currently denies other drugs.
Human immunodeficiency virus [HIV] disease,Cerebral artery occlusion, unspecified with cerebral infarction,Other encephalopathy,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Histoplasmosis, unspecified, other,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases,Postsurgical hypothyroidism,Hypoglycemia, unspecified,Unspecified fall,Personal history of malignant neoplasm of thyroid,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Asthma, unspecified type, unspecified,Chronic hepatitis C without mention of hepatic coma,Cocaine dependence, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Epistaxis
Human immuno virus dis,Crbl art ocl NOS w infrc,Encephalopathy NEC,Subdural hem w/o coma,Acute kidney failure NOS,Chr systolic hrt failure,Hyp kid NOS w cr kid V,Chron kidney dis stage V,Ac posthemorrhag anemia,Hyposmolality,Histoplasmosis NEC,Malaise and fatigue NEC,Late eff infect dis NEC,Postsurgical hypothyroid,Hypoglycemia NOS,Fall NOS,Hx of thyroid malignancy,Hx TIA/stroke w/o resid,Asthma NOS,Chrnc hpt C wo hpat coma,Cocaine depend-unspec,Hx of past noncompliance,Epistaxis
Admission Date:  [**2141-1-11**]              Discharge Date:   [**2141-2-6**]

Date of Birth:  [**2088-8-24**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Altered Mental Status

Major Surgical or Invasive Procedure:
None

History of Present Illness:
52F patient w/ HIV last cd4 134 ([**12/2140**]) and viral load 239
([**9-/2140**]) discharged from [**Hospital1 2177**] yesterday, went home and did crack
cocaine, was found unresponsive at [**Location (un) **]T stop. Admits
crack yesterday, denies any drug use today. Remains altered but
through ED course MS has improved and pt. has been able to wake
up and answer questions and was A/Ox3. Some labs faxed over from
[**Hospital1 2177**] (unable to locate them in the chart but per ED notes says
they had them) but pt. has not been able to consent for records
release yet. pt. did endorse Hx of cocaine CMP. Serum tox in the
ED was negative and on labs was noted to have hypoglycemia, ARF
and hyponatremia similar to recent [**1-9**] [**Hospital1 2177**] labs.
.
In ED has altered between sleeping and agitation. Workup showed
hyponatremia which is apparently old as Na a week ago at [**Hospital1 2177**] was
128 per ED attending notes, acute on chronic renal failure (last
cr at [**Hospital1 2177**] was 5.2 now 7), elevated BNP at 4200, mildly elevated
trop (0.06 X 2) with new TWF in inferior leads and TWI V4-V6.
Tox screen was positive for cocaine only. CXR showed right-sided
effusion. Received ASA. CT head showed a small SDH. neurosurgery
was consulted and did not recommend any intervention currently
but Q2H neuro checks and repeat CT in 12 hours. Seizure ppx also
needed -> dilantin ordered . Sleeping currently. Ua was positive
for blood after foley inserted and 300 Ketones. Patient was also
noted to be hypoglycemic to 50s in ED so was given an amp.
.
Admitted to ICU for Q2H neuro checks.
.
VS prior to transfer: 98, 87, 135/76, 15, 95% RA.
.
On arrival to the floor patient was sleeping but arousable. Able
to answer questions and knows where she is and the date. Denied
pain and shortness of breath. Other ROS unable to obtain as
patient does not answer questions.


Past Medical History:
# ? cocaine CMP
# ? CKD with creatinine one week ago at [**Hospital1 2177**] 5.2
# HIV - CD4 138, VL 239 on [**9-13**]
# Histoplasmosis (pulmonary)
# Cocaine use
# Renal Failure (?chronic)
# HTN
# CVA (ischemic left parietal and hemorraghic pons)
# HCV (genotype I)
# Beta thalassemia/G6PD Defeciency
# Hypothyroidism
# Hypothyroid cancer s/p thyroidectomy

Social History:
Lives with her uncle. Does not want her uncle or mother to be
involved in her medical care. Cocaine use +, and alcohol use in
past per OSH records, currently denies other drugs.

Family History:
Unknown

Physical Exam:
Admission Exam
Vitals: T: 97 BP: 130/79 P: 90 R: 15 O2: 97% RA
General: Somnolent, will arouse after repeated voice prompts and
give one word answers before going back to sleep. No acute
distress, skin very dry appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: able to bend chin to chest passively and easy movement
side to side, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple small round slightly raised lesions on the skin
of the arms and legs
Neuro: Pupils sluggish but reactive bilaterally. A+OX 2, speech
slightly slurred. Moving all for extremities.


Pertinent Results:
On admission:
[**2141-1-11**] 09:20PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-1-11**] 11:00PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2141-1-11**] 10:30PM   GLUCOSE-58* UREA N-47* CREAT-7.0* SODIUM-126*
POTASSIUM-4.3 CHLORIDE-90* TOTAL CO2-22 ANION GAP-18
[**2141-1-11**] 09:24PM   GLUCOSE-56* LACTATE-1.7 K+-4.8
[**2141-1-11**] 10:30PM   CALCIUM-8.5 PHOSPHATE-5.2*# MAGNESIUM-2.0
[**2141-1-11**] 09:20PM   ALT(SGPT)-5 AST(SGOT)-30 ALK PHOS-58 TOT
BILI-0.3
[**2141-1-11**] 09:20PM   WBC-7.1 RBC-4.08* HGB-10.2* HCT-31.7*
MCV-78*# MCH-25.0*# MCHC-32.2 RDW-19.0*
.
Pre Discharge
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2141-2-4**] 06:40    841 38* 4.2* 128* 4.0 102 17* 13

.
PEP                                IgG IgA IgM IFE
[**2141-1-14**] 04:18    NO SPECIFI1 3898* [**Telephone/Fax (1) 101814**]* INCREASES 2
T LYMPHOCYTE SUBSET [**2141-1-23**] 09:50
WBC Lymph Abs [**Last Name (un) **] CD3% Abs CD3 CD4% Abs   CD4 CD8% AbsCD8
CD4/CD8
5.6  17*   [**Telephone/Fax (2) 101815**]        195* 71    677  0.3*

Imaging:
CT head ([**1-11**]): IMPRESSION: Small right parietal subdural
hematoma measures 5mm in thickness. Chronic white matter
disease, could be related to HIV.

Follow up CT Head:
. Stable 5-mm right parietal subdural hemorrhage.
2. Small vessel ischemic disease and cerebral volume loss out of
proportion
to age, which could be related to HIV.

CXR ([**1-11**]): Cardiomegaly with pulmonary edema. Cannot exclude
superinfection. Followup post-diuresis recommended.

CXR [**1-14**]:
FINDINGS: As compared to the previous radiograph, there is
marked
improvement. The pre-existing pulmonary edema has cleared. The
size of the
cardiac silhouette is minimally smaller than on the previous
examination. No
pleural effusions. No focal parenchymal opacity suggesting
pneumonia. Mild
tortuosity of the thoracic aorta. Known right healed rib
fractures

Renal US:
IMPRESSION: Echogenic kidneys bilaterally, indicative of medical
renal
disease. There is no hydronephrosis
.
CT Chest:
1. Diffuse nodular ground-glass opacities, most pronounced in
the left upper
lobe; the differential for which is somewhat broad, but includes
inflammatory
or infectious (atypical pathogens) etiologies.
2. Widespread lymphadenopathy.
3. Small right and trace left pleural effusions.
4. Post-surgical changes seen in the right upper lung lobe and
around the
thyroid.
.
.
.
TEE [**2141-2-2**]
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. Right atrial
appendage ejection velocity is good (>20 cm/s). No thrombus is
seen in the right atrial appendage No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (patient intermittenty cooperative). No
late contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is moderate global left
ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 45 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. There is no aortic valve stenosis. Mild to moderate
([**2-5**]+) aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. No mass or vegetation is seen on the
mitral valve. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.

IMPRESSION: No intracardiac source of thromboembolism
identified. Moderately depressed global left ventricular
systolic function. Mild to moderate aortic regurgitation.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.


.
Microbiology
Sputum: AFBx negative x3

TOXOPLASMA IgG ANTIBODY (Final [**2141-2-2**]):
      NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
      0.0 IU/ML.
      Reference Range:  Negative < 4 IU/ml, Positive >= 8 IU/ml.

      If acute infection is suspected request IgM antibody
testing and/or
      submit convalescent serum in [**3-9**] weeks.

CMV Viral Load (Final [**2141-1-31**]):
      CMV DNA not detected.
      Performed by PCR.
      Detection Range: 600 - 100,000 copies/ml.
      FOR RESEARCH USE ONLY. NOT FOR USE IN DIAGNOSTIC
PROCEDURES.
      This test has been validated by the Microbiology
laboratory at [**Hospital1 18**].

CRYPTOCOCCAL ANTIGEN (Final [**2141-1-29**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
      Performed by latex agglutination.
           (Reference Range-Negative).
      A negative serum does not rule out localized or
disseminated
      cryptococcal infection.
      Appropriate specimens should be sent for culture.

HIV-1 Viral Load/Ultrasensitive (Final [**2141-1-26**]):
      12,000 copies/ml.
      Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
      Detection range: 48 - 10,000,000 copies/ml.
      This test is approved for monitoring HIV-1 viral load in
known
      HIV-positive patients. It is not approved for diagnosis of
acute HIV
      infection.

[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2141-1-26**]):    POSITIVE BY
EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2141-1-26**]):    POSITIVE
BY EIA.

   [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2141-1-26**]):
      NEGATIVE <1:10 BY IFA.


CSF Studies
 GRAM STAIN (Final [**2141-1-19**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..
   FLUID CULTURE (Final [**2141-1-25**]):    NO GROWTH.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
   VIRAL CULTURE (Preliminary):    No Virus isolated so far.
CRYPTOCOCCAL ANTIGEN (Final [**2141-1-19**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
           (Reference Range-Negative).
   HIV-1 Viral Load/Ultrasensitive (Final [**2141-1-20**]):
      9,280 copies/ml.
      Performed using the Cobas Ampliprep / Cobas Taqman HIV-1
Test.
      Detection range: 48 - 10,000,000 copies/ml.
            [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS QUANTITATIVE-COMPETITIVE PCR
                          LABORATORY REPORT

Test Result- CSF
-----------
   200       EBV genomes/10(5) lymphocytes

 RAPID PLASMA REAGIN TEST (Final [**2141-1-15**]):
      NONREACTIVE.
      Reference Range: Non-Reactive.


Brief Hospital Course:
52F HIV/AIDS admitted for encephalopathy and subdural hematoma
after crack cocaine use, found to have subdural hematoma,
myxedema coma, acute on chronic CRI, chronic systolic CHF, ruled
out for TB and worked up for abnormal brain MRI signals before
discharge to [**Hospital3 **].
.
ACTIVE ISSUES:
# Multifactorial Encephalopathy: Presented with acute changes in
mental status in setting of recent history of crack/cocaine and
medication non-compliance after discharge from [**Hospital3 9947**]. Etiology likely multifactorial including myxedema coma,
drug effects/withdrawal, HIV encephalopathy, concussion in
setting of recent fall, hypothyroidism, and hyponatremia.
Hypothyroidism was treated with IV levothyroxine (see below).
The patient had evidence for a small subdural hematoma, but this
was unlikely to be contributing given the small size
(Neurosurgery and Nueorlogy consulted). Other infectious work-up
negative (I.D. Consulted) Patient underwent two LPs that
revealed EBV in CSF but negative workup for primary CNS
lymphoma. The patient was AOX3 at the time of discharge.
.
# Myxedema Coma: s/p thyroidectomry and radioiodine ablation for
papillary thyroid cancer. Hx of non-compliant with her
levothyroixine as her TSH was severely elevated (greater then
assay). Endo consulted. Repleted with levothyroxine 100mcg
daily. Adrenal insuficiency was investigated in setting of both
hypothyrodism + hypoglycemia. [**Last Name (un) **] stim test was negative,
cortisol had appropriate increase 17-->33. Thyroglobulin test
was negative, without  signs of relapsed cancer. Pt's TSH
improved during hospitalization from >100 to 63.
-- Follow-up TSH within 4 weeks of discharge
.
# Multiple Cerebral Emboli: Pt complained of vertigo [**1-14**] with
both motion and when lying down. negative Epley . Neurology was
consulted. 1st LP with lymphocytic pleocytosis with elevated
protein that was thought most likely [**3-8**] HIV neuro-cognitive
disorder. CSF EBV PCR was positive. Pt's vertigo improved during
the hospitalization and it was ultimately attributed to
post-concussion vs phenytoin use vs thromboemoblic event with
cerebellar involvement. MRI brain was performed which revealed
possible thromboembolic event (multiple small acute-subacute
infarcts crossing vascular territories) in addition to FLAIR
hyperintensity along the splenium of the corpus callosum which
might represent. 2nd LP ruled out Primary CNS lymphoma was
negative. TTE was negative. TEE showed no intracardiac
defects/asd and no valvular vegetations.
--neurology recommends f/u MRI and Protein C,S and ATIII as
outpatient.  F/u in late [**2140-2-5**].  Will arrange MRI at the
time as necessary.
.
# Acute on Chronic Kidnery: Unclear baseline Cr. Cr peaked at 7
and trended down until time of discharge. Renal US [**Hospital 101816**]
medical renal disease (echogenic kidneys bilaterally). DDx
includes cocaine induced, systolic CHF exacerabation (see below)
HIV related. The pt was diuresed with 80 PO lasix daily.  Lasix
was held for hyponatremia, and restarted at 40 mg PO qday for
diuresis.  Can be held for persistent hyponatremia or increased
for fluid overload in the presence of acute worsening of heart
failure.
- f/u chem panel within 1 week of discharge.
- f/u with outpatient Nephrologist
.
# Subdural Hematoma: Small subdural hematoma on CT (right
parietal lobe).Stable on repeat CT. Neurosurgery consulted and
recommended no intervetion. Provided phenytoin for seixure
prophylaxis x 1 week.
--follow up with neurosurgery to have repeat head CT.
.
# Epistaxis: Pt had epistaxis episode during hospitalization.
Possibly [**3-8**] recent cocaine use. Pt had HCT drop from 31-->18.8.
Profuse bleeding possible complicated by uremic platelets. Her
nose was packed and she was given nasal spray, Oxymetazoline.
She was transfused 4 U PRBC and HCT stabalized.
.
# Hyponateremia: The patient's serum sodium dropped as low as
125. Hyponatremia was thought to be due to poor nutrition and
poor PO intake coupled with SIADH due to pulmonary/intracranial
issues. It improved after giving fluids, po food, and holding of
Lasix.  Stabalized at 128.  Fluctuates to as low as 125.
Patient non-complaint with urine electrolyte testing, IVF
repelteition.  Hyponatremia is a chronic issue and most likely
not etiology of admission MS changes.  Restarted on 40 mg po
lasix for ICM, should recheck sodium.
--recheck sodium within 5 days of discharge.

# Elevated lipase: The patient's lipase was elevated at 200 and
trended down to 169. She has history of chronic pancreatitis. Pt
clinically had no signs of pancreatitis and was tolerating foods
with no abd pain.
.
# Crack/cocaine use: Social work was consulted to offer support
and resources to pt. She declined resources at this time.
.
# HIV: The patient's most recent CD4 count was CD4 138 on
[**1-/2141**] , VL 239 on 8/[**2140**]. Pt has had PCP and histoplasmosis,
for which she takes atovaquone and itraconazole. She was
continued on these medications but consistently would refuse the
atovaquone. ID was consulted to start HAART therapy to treat the
EBV positive CSF in addition to protecting against future
opportunistic infections. She was restarted on ARVs and arranged
follow up with [**Hospital 2177**] [**Hospital **] clinic.
.
# ECG changes: The patients ECG had T-wave changes concerning
for ischemia. Her cardiac enzymes were stable x3 (0.06-0.04
range) and she denied any chest pain, nausea, vomiting, or
diaphoresis. Pt with renal failure, likely explaining her
elevated troponins.
.
#CHF: Pt with known cardiomyopathy with depressed EF of 30%. Was
given lasix for diuresis and started on low dose B-Blockers.
Discharged on 40 mg po lasix qday.
-f/u metabolic panel for electrolyte status
.
.
PENDING LABS AT DISCHARGE: None
Transitional Issues:  Patient continues to have issues with
noncompliance with medications.  Stressed importance of at least
taking AIDS medications as scheduled everyday.  Regarding
cocaine use, patient said she would stop but declined addiction
counseling at this interval.

Medications on Admission:
From [**Hospital1 2177**] discharge [**2141-1-10**]:
Synthroid 125 mcg daily
plavix 75 mg daily
Fluticasone inhaler 44 mcg 2 puffs [**Hospital1 **]
albuterol inhaler
Famotidine 20 daily
Itraconazole 200 mg [**Hospital1 **]
cefpodoxime 200 mg x 5 days
atovaquone 1500 mg daily
Aranesp 40 qWednesday
Calcium carbonate 1000 tid
Ferrous gluconate 324 mg tid
Vit D [**Numeric Identifier 1871**] U Qsunday
Calcitriol 0.25 mcg daily
Zofran 4 mg q8hr prn
Diltiazem XL 240 daily
lasix 80 daily
NaHCO3 650 mg tid
calcium acetate 667 mg tid
Colace
APAP

Discharge Medications:
1. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed for
wgeezing, SOB.
5. atovaquone 750 mg/5 mL Suspension Sig: Two (2)  PO DAILY
(Daily).
6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
12. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. lamivudine 10 mg/mL Solution Sig: Five (5)  PO DAILY
(Daily).
14. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
16. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
18. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary Diagnoses:
- Subdural Hematoma
- Encephalopathy
- Hypothyroidism
- Acute Renal failure
- Anemia
- Epistaxis
- Vertigo
.
Secondary Diagnosis:
-Acquired Immunodeficiency Syndrome
-Chronic Histoplasmosis
-Hyponatremia


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


Discharge Instructions:
Ms. [**Known lastname 449**],

You were admitted to the hospital for a bleed in your brain. You
fell and hit your head. Fortunately, the bleed was small and you
suffered no permanent neurological changes. You were given
dilantin, a medication to prevent seizures. You no longer need
to take this medication.
.
Your kidneys showed signs of renal failure. It is very important
to follow up with your kidney doctors [**First Name (Titles) **] [**Last Name (Titles) 2177**].
.
You were found to be severely hypothyroid, a condition where you
do not produce enough throid hormone. This is likely from not
remembering to take your thyroid medications every day. It is
very important to remember your medications every single day.
Severe hypothyroidism can cause you to be very sleepy and even
go into a coma if it is not controlled.
.
You had some dizziness for several days. The dizziness was
ultimately attributed to your concussion from the fall as well
as maybe from the phenytoin that we gave you. We stopped the
phenytoin.
.
There have been several changes to your medications:
.
YOU HAVE RESTARTED YOUR HIV MEDICATION.  PLEASE CONTINUE TO TAKE
AS DIRECTED AND FOLLOW UP WITH YOUR INFECTIOUS DISEASE DOCTOR
FOR FURTHER CHANGES
.
 LaMIVudine 50 mg DAILY
 Abacavir Sulfate 300 mg [**Hospital1 **]
 Raltegravir 400 mg [**Hospital1 **]
.
Other Medications:
Levothyroxine Sodium 150 mcg - take everday for your
hypothyroidism!
Metoprolol Tartrate 25 mg [**Hospital1 **] (increased from 12.5 mg)
Atovaquone Suspension 1500 mg by mouth DAILY
Calcitriol 0.25 mcg by mouth DAILY
Calcium Acetate 667 mg by mouth three times a day W/MEALS
FoLIC Acid 1 mg DAILY
Itraconazole 200 mg 2x a day with [**Location (un) 2452**] juice or cola
Thiamine 100 mg daily
Lasix 40 mg daily
..
It has been a pleasure taking care of you [**Known firstname **]!

Followup Instructions:
Department: Nephrology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 101817**]
When: Tuesday, [**2-7**] at 2pm
Location: [**Hospital6 **], [**Location (un) 20473**] Family Bldg.
[**Location (un) **], [**Location (un) **],[**Numeric Identifier 101818**], [**Location (un) **], RENAL DEPT.
Phone: [**Telephone/Fax (1) 55132**]

Department: Primary Care
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4427**]
When: Tuesday [**2141-1-24**] at 10:30 AM
Location: [**University/College **] ST NEIGHBORHOOD HEALTH CTR
Address: [**Hospital3 **], [**Location (un) **],[**Numeric Identifier 81399**]
Phone: [**Telephone/Fax (1) 35879**]
Notes:** A request from your inpatient hospital team has been
made for you to see an ENDOCRINOLOGIST, this is very important.
Please discuss this request with your Primary Care Provider at
this visit.Please ask him to refer you to a new Endocrinologist
if you dont have one involved in your care**

Department: RADIOLOGY
When: TUESDAY [**2141-2-14**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: SPINE CENTER
When: TUESDAY [**2141-2-14**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NEUROLOGY
When: WEDNESDAY [**2141-3-1**] at 1 PM
With: [**Name6 (MD) 2341**] [**Last Name (NamePattern4) 2342**], M.D. [**Telephone/Fax (1) 2343**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
{'Human immunodeficiency virus [HIV] disease,Cerebral artery occlusion, unspecified with cerebral infarction,Other encephalopathy,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Histoplasmosis, unspecified, other,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases,Postsurgical hypothyroidism,Hypoglycemia, unspecified,Unspecified fall,Personal history of malignant neoplasm of thyroid,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Asthma, unspecified type, unspecified,Chronic hepatitis C without mention of hepatic coma,Cocaine dependence, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Epistaxis'}


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: Altered Mental Status

PRESENT ILLNESS: 52F patient w/ HIV last cd4 134 ([**12/2140**]) and viral load 239
([**9-/2140**]) discharged from [**Hospital1 2177**] yesterday, went home and did crack
cocaine, was found unresponsive at [**Location (un) **]T stop. Admits
crack yesterday, denies any drug use today. Remains altered but
through ED course MS has improved and pt. has been able to wake
up and answer questions and was A/Ox3. Some labs faxed over from
[**Hospital1 2177**] (unable to locate them in the chart but per ED notes says
they had them) but pt. has not been able to consent for records
release yet. pt. did endorse Hx of cocaine CMP. Serum tox in the
ED was negative and on labs was noted to have hypoglycemia, ARF
and hyponatremia similar to recent [**1-9**] [**Hospital1 2177**] labs.
.
In ED has altered between sleeping and agitation. Workup showed
hyponatremia which is apparently old as Na a week ago at [**Hospital1 2177**] was
128 per ED attending notes, acute on chronic renal failure (last
cr at [**Hospital1 2177**] was 5.2 now 7), elevated BNP at 4200, mildly elevated
trop (0.06 X 2) with new TWF in inferior leads and TWI V4-V6.
Tox screen was positive for cocaine only. CXR showed right-sided
effusion. Received ASA. CT head showed a small SDH. neurosurgery
was consulted and did not recommend any intervention currently
but Q2H neuro checks and repeat CT in 12 hours. Seizure ppx also
needed -> dilantin ordered . Sleeping currently. Ua was positive
for blood after foley inserted and 300 Ketones. Patient was also
noted to be hypoglycemic to 50s in ED so was given an amp.
.
Admitted to ICU for Q2H neuro checks.
.
VS prior to transfer: 98, 87, 135/76, 15, 95% RA.
.
On arrival to the floor patient was sleeping but arousable. Able
to answer questions and knows where she is and the date. Denied
pain and shortness of breath. Other ROS unable to obtain as
patient does not answer questions.

MEDICAL HISTORY: # ? cocaine CMP
# ? CKD with creatinine one week ago at [**Hospital1 2177**] 5.2
# HIV - CD4 138, VL 239 on [**9-13**]
# Histoplasmosis (pulmonary)
# Cocaine use
# Renal Failure (?chronic)
# HTN
# CVA (ischemic left parietal and hemorraghic pons)
# HCV (genotype I)
# Beta thalassemia/G6PD Defeciency
# Hypothyroidism
# Hypothyroid cancer s/p thyroidectomy

MEDICATION ON ADMISSION: From [**Hospital1 2177**] discharge [**2141-1-10**]:
Synthroid 125 mcg daily
plavix 75 mg daily
Fluticasone inhaler 44 mcg 2 puffs [**Hospital1 **]
albuterol inhaler
Famotidine 20 daily
Itraconazole 200 mg [**Hospital1 **]
cefpodoxime 200 mg x 5 days
atovaquone 1500 mg daily
Aranesp 40 qWednesday
Calcium carbonate 1000 tid
Ferrous gluconate 324 mg tid
Vit D [**Numeric Identifier 1871**] U Qsunday
Calcitriol 0.25 mcg daily
Zofran 4 mg q8hr prn
Diltiazem XL 240 daily
lasix 80 daily
NaHCO3 650 mg tid
calcium acetate 667 mg tid
Colace
APAP

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam
Vitals: T: 97 BP: 130/79 P: 90 R: 15 O2: 97% RA
General: Somnolent, will arouse after repeated voice prompts and
give one word answers before going back to sleep. No acute
distress, skin very dry appearing.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: able to bend chin to chest passively and easy movement
side to side, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Multiple small round slightly raised lesions on the skin
of the arms and legs
Neuro: Pupils sluggish but reactive bilaterally. A+OX 2, speech
slightly slurred. Moving all for extremities.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives with her uncle. Does not want her uncle or mother to be
involved in her medical care. Cocaine use +, and alcohol use in
past per OSH records, currently denies other drugs. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Cerebral artery occlusion, unspecified with cerebral infarction,Other encephalopathy,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute kidney failure, unspecified,Chronic systolic heart failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Acute posthemorrhagic anemia,Hyposmolality and/or hyponatremia,Histoplasmosis, unspecified, other,Other malaise and fatigue,Late effects of other and unspecified infectious and parasitic diseases,Postsurgical hypothyroidism,Hypoglycemia, unspecified,Unspecified fall,Personal history of malignant neoplasm of thyroid,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Asthma, unspecified type, unspecified,Chronic hepatitis C without mention of hepatic coma,Cocaine dependence, unspecified,Personal history of noncompliance with medical treatment, presenting hazards to health,Epistaxis'}
