CHIEF COMPLAINT: admitted to rule out tuberculosis

PRESENT ILLNESS: This is a 50 year old woman with autoimmune hepatitis/PBC
overlap syndrome on imuran and prednisone and essential
hypertension who was transferred from [**Hospital 12017**] Hospital in New
[**Location (un) **] being admitted for history of fevers, chills,
nonproductive cough and status treatment for pneumonia with no
improvement. Chest CT shows miliary lesions in lung, liver and
spleen. She will be admitted to rule out tuberculosis.
.
Patient presented to outside hospital on [**2192-3-22**] with fever,
chills and nonproductive cough. Patient reported a one week
history of easy fatigability, shorntess of breath on exertion,
pleuritic chest pain and nonproductive cough. She also developed
chills and subjective fevers. In OSH ED, chest x-ray did not
show infiltrate and blood culture grew gram positive cocci in
clusters in 1 out of 4 bottles. She subsequently went home and
returned the following morning on [**2192-3-23**] to the OSH ED, with
recurrence of chills and temp in ED measured as 103.5 rectally.
Patient was admitted for further workup. She received 2 doses of
Rocephin and has since been afebrile. Patient denies hemoptysis,
phlegm production but does have some slight nausea. Denies
contact with suspected or confirmed casese of tuberculosis. No
recent travel or pets at home. Infectious disease was consulted
and recommended treatment of CAP in an immunocompromised host.
Covered with ceftriaxone and azithromycin that was switched to
levaquin on [**2192-3-26**]. Patient continued to spike at night to temp
of 102-103. Chest/abdominal CT revealed miliary lesions in lung,
liver and spleen. She was subsequently transferred to BIMDC to
rule out tuberculosis and for further workup.
.
ROS: Denied headache, dizziness, chest pain, vomitting,
abdominal or urinary complaints.

MEDICAL HISTORY: 1. autoimmune hepatitis (dx'd 30 yrs ago and has been on Imuran
and prednisone.
2. essential hypertension
3. s/p tonsillectomy
4. s/p myomectomy for uterine fibroids
5. s/p appendectomy
6. s/p liver biopsy

MEDICATION ON ADMISSION: Imuran, Prednisone, Ursodiol

ALLERGIES: Penicillins / Vicodin

PHYSICAL EXAM: 101.9     98/66     104      18       95% room air
GEN: in bed under multiple covers and a down jacket
SKIN: no rashes or lesions appreciated, warm to touch
HEENT: PERRL, small white plaque on lateral sides of tongue, OP
nl, no LAD appreciated, neck supple
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
PULM: fine rales R>L, no wheeze
ABD: soft, nontender, +BS, nondistended
EXT: nonedematous, good pulses
NEURO: AOx3, nonfocal

FAMILY HISTORY: F died at age 69 of heart disease.

SOCIAL HISTORY: Lives with husband of 26 years in [**Location (un) 82229**]. Nonsmoker and
nondrinker. No illicit drug use.
Reticulosarcoma, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Severe sepsis,Pneumocystosis,Biliary cirrhosis,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified essential hypertension
Retclsrc unsp xtrndl org,Septicemia NOS,Severe sepsis,Pneumocystosis,Biliary cirrhosis,Acidosis,Acute kidney failure NOS,Acute respiratry failure,Hypertension NOS
Admission Date:  [**2192-3-26**]              Discharge Date:   [**2192-3-31**]

Date of Birth:  [**2142-3-12**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Vicodin

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
admitted to rule out tuberculosis

Major Surgical or Invasive Procedure:
Exploratory Laparotmy [**3-29**]

History of Present Illness:
This is a 50 year old woman with autoimmune hepatitis/PBC
overlap syndrome on imuran and prednisone and essential
hypertension who was transferred from [**Hospital 12017**] Hospital in New
[**Location (un) **] being admitted for history of fevers, chills,
nonproductive cough and status treatment for pneumonia with no
improvement. Chest CT shows miliary lesions in lung, liver and
spleen. She will be admitted to rule out tuberculosis.
.
Patient presented to outside hospital on [**2192-3-22**] with fever,
chills and nonproductive cough. Patient reported a one week
history of easy fatigability, shorntess of breath on exertion,
pleuritic chest pain and nonproductive cough. She also developed
chills and subjective fevers. In OSH ED, chest x-ray did not
show infiltrate and blood culture grew gram positive cocci in
clusters in 1 out of 4 bottles. She subsequently went home and
returned the following morning on [**2192-3-23**] to the OSH ED, with
recurrence of chills and temp in ED measured as 103.5 rectally.
Patient was admitted for further workup. She received 2 doses of
Rocephin and has since been afebrile. Patient denies hemoptysis,
phlegm production but does have some slight nausea. Denies
contact with suspected or confirmed casese of tuberculosis. No
recent travel or pets at home. Infectious disease was consulted
and recommended treatment of CAP in an immunocompromised host.
Covered with ceftriaxone and azithromycin that was switched to
levaquin on [**2192-3-26**]. Patient continued to spike at night to temp
of 102-103. Chest/abdominal CT revealed miliary lesions in lung,
liver and spleen. She was subsequently transferred to BIMDC to
rule out tuberculosis and for further workup.
.
ROS: Denied headache, dizziness, chest pain, vomitting,
abdominal or urinary complaints.


Past Medical History:
1. autoimmune hepatitis (dx'd 30 yrs ago and has been on Imuran
and prednisone.
2. essential hypertension
3. s/p tonsillectomy
4. s/p myomectomy for uterine fibroids
5. s/p appendectomy
6. s/p liver biopsy


Social History:
Lives with husband of 26 years in [**Location (un) 82229**]. Nonsmoker and
nondrinker. No illicit drug use.

Family History:
F died at age 69 of heart disease.

Physical Exam:
101.9     98/66     104      18       95% room air
GEN: in bed under multiple covers and a down jacket
SKIN: no rashes or lesions appreciated, warm to touch
HEENT: PERRL, small white plaque on lateral sides of tongue, OP
nl, no LAD appreciated, neck supple
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
PULM: fine rales R>L, no wheeze
ABD: soft, nontender, +BS, nondistended
EXT: nonedematous, good pulses
NEURO: AOx3, nonfocal


Pertinent Results:
At OPH:
lying    HR 146   BP 119/71
sitting  HR 150   BP 111/80
standing HR 160   BP 94/60
.
[**2192-3-22**] WBC 2.5  Hct 31.8   Plat 94
Alb 3.0  Ca 7.8   Bili 2.3   Ast 95   Alt 75
.
[**2192-3-23**] WBC 2.6  H and H 12.2  35.1. Plat 57
N 44  Bands 37  L11   M 5   atyp lymphocytes 2  Burr cells 2+
.
Na 136   K 3.7   Cl 103   HCO3 25   BUN 13   Cr 0.8   Gluc 84
.
TP 6.7   Alb 2.7   Ca 7.9   TB 4.0
AST/ALT   97/77 (per Dr.[**Name (NI) 104008**] note, LFTs chronically
elevated)
Alk phos 86
.
urine uribilinogen 8
urine pneumococcal Ag: PND
legionella Ag: PND
mycoplasma IgM: PND
chlamydia IgM: PND
cryptococcal Ag: PND
aspergillus Ab, Ag: PND
histoplasmosis Ab: PND
urine histoplasma Ag: PND
influenza A/B: negative
Sputum cx [**2192-3-24**]: PND
Bld cxs x2 [**3-23**]: NGTD
AFB cx: PND
Urine cx [**3-23**]: NGTD
UA: negative
C diff [**3-22**]: negative
Urine cx [**3-22**]: 10-50,000 CFU g negative bacillus
Bld cxs x2 [**3-22**]: coag neg staph in 1 out of 4 bottles
.
Imaging:
CXR [**3-22**]: elevated right hemidiaphragm with atelectasis of the
right lung base
.
CXR [**3-23**]: interval presence of an increased density in the right
upper lobe which was consistent with pneumonia.
.
EKG: 135 sinus tachycardia, nl axis, no acute ST-T changes
unchanged from prior.
.
LABS At [**Hospital1 18**]: PENDING
STUDIES:
LIVER BLOOD POOL STUDY [**2192-2-24**]: Focal increased tracer uptake in
the liver which correlates with the suspicious lesion seen on
MRI, consistent with hemangioma.
.
MRI/MRA ABDOMEN [**2192-1-19**]:
Cirrhotic liver with an atypical 2.1-cm segment [**Doctor First Name 690**] lesion.
Because there has been equivocal enlargement of this lesion when
compared to prior examination, additional imaging is
recommended. Most likely this lesion is an atypical hemangioma.
A technetium-[**Age over 90 **]m-labeled red blood cell study (nuclear medicine
study) is recommended for further evaluation (this nuclear
medicine study could potentially confirm that this lesion is in
fact a hemangioma).
No other significant change from prior examination.
.
CHEST, TWO VIEWS [**2192-10-18**]: No active lung disease.

Brief Hospital Course:
Briefly, 50W w/autoimmune hepatitis/primary biliary cirrhosis
overlap syndrome on chronic immunosuppressants p/w fever,
nonproductive cough and miliary lesions in lung, liver and
spleen seen on outside chest/abd CT.
.
*. Fever: unclear etiology. Differential diagnosis includes TB,
CAP, UTI or abdominal infection. Given chronic immunosuppresion,
infectious etiology should be broad to include fungal and
parasitic infections. RUL infiltrate seen on OSH chest x-ray
suggestive of pneumonia and miliary lesions in multiple organs
suggestive of miliary TB, MAC or fungal infection.
--rec'd ceftriaxone and azithromycin [**Date range (1) 71671**] at OSH, then
changed to levaquin on [**3-26**]
--continue levaquin for now to cover CAP and atypical PNA
--f/u OSH test results
--repeat bld cxsx2, mycolytic, UA/urine cx
--induced sputum x3 to rule out TB
--repeat CXR and chest/abd CT
--respiratory precautions for now
--consult pulm in am, may need bronchoscopy if unsuccess with
induced sputums
--CIS >100.4, tylenol 325mg PRN not to exceed 2g/day
--follow fever curve
.
*. Nonproductive cough: unclear etiology. Differential diagnosis
includes GERD, asthma, post-nasal drip, pneumonia/pneumonitis,
bronchitis or upper respiratory infectio. Influenza a/b antigen
negative at OSH.
--cont levaquin for now
--induced sputum x3 to rule out TB
--PPI
--no wheezes on exam, hold off on nebs
.
*. Chronic liver disease: autoimmune hepatitis and PBC.
Continued prednisone and Imuran.
--follow LFTs
--apprec liver recs
.
*. Miliary lesion in multiple organs: Lung, liver and spleen
involvement. Differential diagnosis includes TB, atypical
mycobacteria, histoplasmosis. Less likely include other endemic
fungi (coccidioidomycosis, blastomycosis,
paracoccidioidomycosis), bacterial (legionella, nocardiosis),
viral (varicella, CMV), parasitic (toxo), neoplastic (lymphoma,
lymphangitic spread of carcinoma), sarcoid, hypersensitivity
pneumonitis, pneumoconioses.
--rule out TB
--repeat chest/abd CT
--pulm consult and consider bronchoscopy/BAL/?Bx
--consider CT guided biopsy of lesion and send for path and
microbiology
.
*. Hypertension: Continue to monitor.
.
*. FEN: cardiac healthy/diabetic diet and NPO after midnight for
possible bronch in am, replete lytes as needed, D5W w/3 amps
bicarb at 75cc/hr overnight prior to CT scan
.
*. PPX: SQ heparin, PPI, bowel regimen as needed, respiratory
droplet precautions.

On the evening of [**2192-3-27**], the pt was transferred to the MICU
for hypotensive episodes and worsening dyspnea. The hypotension
responded to fluid challenges. On [**2192-3-28**], the patient was
intubated for bronchoscopy. The bronchoalveolar lavage was
positive for pneumocystis carinii pneumonia, and the patient
remained intubated.

On [**2192-3-29**], a CT scan of the torso was performed to rule out
other causes of sepsis and respiratory failure. Initial read of
the CT showed "free air" in the pelvis. Exploratory laparotomy
performed on [**3-29**] which was found to be negative for any
intraabdominal pathology.  Liver biopsies were performed.
Post-operatively the patients prior acidosis continued and
worsened, despite resucitation.  Lactate climbed to 25.  CVVH
was initiated and her acidosis improved, however her lactate
continued to rise.  She developed a fatal arrythmia and was
pronounced dead on [**2192-3-31**].  The family declined a post-mortem
examination.

ADDENDUM: A few days after the patient expired, the final path
report on the liver biopsy showed non-Hodgkin B-cell lymphoma,
diffuse large B-cell type, high grade.

Medications on Admission:
Imuran, Prednisone, Ursodiol

Discharge Disposition:
Expired

Facility:
[**Hospital1 18**]

Discharge Diagnosis:
Liver failure
Spesis
MSOF


Discharge Condition:
Cardiac death


Completed by:[**2192-4-2**]
{'Reticulosarcoma, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Severe sepsis,Pneumocystosis,Biliary cirrhosis,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified essential hypertension'}


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: admitted to rule out tuberculosis

PRESENT ILLNESS: This is a 50 year old woman with autoimmune hepatitis/PBC
overlap syndrome on imuran and prednisone and essential
hypertension who was transferred from [**Hospital 12017**] Hospital in New
[**Location (un) **] being admitted for history of fevers, chills,
nonproductive cough and status treatment for pneumonia with no
improvement. Chest CT shows miliary lesions in lung, liver and
spleen. She will be admitted to rule out tuberculosis.
.
Patient presented to outside hospital on [**2192-3-22**] with fever,
chills and nonproductive cough. Patient reported a one week
history of easy fatigability, shorntess of breath on exertion,
pleuritic chest pain and nonproductive cough. She also developed
chills and subjective fevers. In OSH ED, chest x-ray did not
show infiltrate and blood culture grew gram positive cocci in
clusters in 1 out of 4 bottles. She subsequently went home and
returned the following morning on [**2192-3-23**] to the OSH ED, with
recurrence of chills and temp in ED measured as 103.5 rectally.
Patient was admitted for further workup. She received 2 doses of
Rocephin and has since been afebrile. Patient denies hemoptysis,
phlegm production but does have some slight nausea. Denies
contact with suspected or confirmed casese of tuberculosis. No
recent travel or pets at home. Infectious disease was consulted
and recommended treatment of CAP in an immunocompromised host.
Covered with ceftriaxone and azithromycin that was switched to
levaquin on [**2192-3-26**]. Patient continued to spike at night to temp
of 102-103. Chest/abdominal CT revealed miliary lesions in lung,
liver and spleen. She was subsequently transferred to BIMDC to
rule out tuberculosis and for further workup.
.
ROS: Denied headache, dizziness, chest pain, vomitting,
abdominal or urinary complaints.

MEDICAL HISTORY: 1. autoimmune hepatitis (dx'd 30 yrs ago and has been on Imuran
and prednisone.
2. essential hypertension
3. s/p tonsillectomy
4. s/p myomectomy for uterine fibroids
5. s/p appendectomy
6. s/p liver biopsy

MEDICATION ON ADMISSION: Imuran, Prednisone, Ursodiol

ALLERGIES: Penicillins / Vicodin

PHYSICAL EXAM: 101.9     98/66     104      18       95% room air
GEN: in bed under multiple covers and a down jacket
SKIN: no rashes or lesions appreciated, warm to touch
HEENT: PERRL, small white plaque on lateral sides of tongue, OP
nl, no LAD appreciated, neck supple
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
PULM: fine rales R>L, no wheeze
ABD: soft, nontender, +BS, nondistended
EXT: nonedematous, good pulses
NEURO: AOx3, nonfocal

FAMILY HISTORY: F died at age 69 of heart disease.

SOCIAL HISTORY: Lives with husband of 26 years in [**Location (un) 82229**]. Nonsmoker and
nondrinker. No illicit drug use. 

### Response:
{'Reticulosarcoma, unspecified site, extranodal and solid organ sites,Unspecified septicemia,Severe sepsis,Pneumocystosis,Biliary cirrhosis,Acidosis,Acute kidney failure, unspecified,Acute respiratory failure,Unspecified essential hypertension'}
