CHIEF COMPLAINT: dyspnea, cough

PRESENT ILLNESS: 47 yo F with HIV (last CD4 327 [**7-13**]) not on HAART, HCV, afib,
antiphospholipid ab syndrome, multiple VTEs, CM with EF 20%,
presents with fever, shortness of breath, cough, headache. She
complains of fevers, fatigue and productive cough with
green/yellow sputum. She complains of headache on the right side
for several days. Denies neck stiffness, chest pain, shortness
of breath or abdominal pain. No nausea or vomiting. Pt denies
diarrhea or melena.  She denies sick contacts, no recent
incarcerations.  Has lived in homeless shelter in the distant
past, not recently.
.
In the ED, initial vital signs were T 101.6, BP 86/57, HR 108,
O2sat 96% RA. Her lactate was 1.0. She was given 8L IVF in the
ED for low [**Month/Year (2) **] pressures in the 80-90's systolic. HR was
80-90s. RSCVL was placed. She was also started on levophed for
hypotension. Per report, she was mentating normally the entire
time.  She was given vancomycin for pneumonia on CXR.  She was
also given levafloxacin, ceftriaxone and bactrim and 60mg
prednisone for possible PCP. [**Name10 (NameIs) **] hCG was negative. [**Name10 (NameIs) **]
positive for trichomonas.
.
Currently, she continues to complain of cough and shortness of
breath.  No headache currently.  No abdominal pain, N/V.

MEDICAL HISTORY: 1. HIV/AIDS, diagnosed [**2176**], last CD4 count 327 [**7-13**]. Not on
ART. Has self d/c'd ART several times. most recently [**2183**].  was
not resumed due to poor compliance,
- acquired via sexual intercourse.
OI:
- HCV
- [**Doctor First Name **] pneumonia - [**1-/2182**] - +AFB in sputum. Was not complaint with
Rx.
-  Oral thrush
-  Recurrent episodes of pneumococcal pneumonia. Last episode -
[**12-6**].In each admission PCP and AFB's were neg.
- Lymphocytic pneumonitis - diagnosed by trans-bronchial bx.
Untreated.
TB risk factors: pt reports negative PPDs in the past, does not
recall most recent.  No hx of exposure to TB, no incarceration.
Has lived in homeless shelter in the past ~1 year.
2. Dilated cardiomyopathy-EF20-25%, last echo [**4-13**]. Unclear
etiology with clean coronaries [**2184**].
3. Hepatitis C, undetectable VL in the past
4. Multiple PNAs
5. [**Doctor First Name **]
6. LV thrombus
7. +Anti-cardiolipin antibody
8. Lower extremity arterial thrombus
9. Asthma/bronchiectasis
10. Myocardial infarction [**2184**], clean coronaries at that time
11. L MCA stroke
12. Cocaine abuse
13. Pulmonary Nodules on chest CT
14. Chronic Lymphoid Interstitial Pneumonitis

MEDICATION ON ADMISSION: bactrim DS 160/800mg 1 tab daily
ativan 0.5mg [**Hospital1 **]
lisinopril 2.5mg daily
fluconazole 100mg daily
warfarin 10mg daily
metoprolol SR 12.5mg daily
fluoxetine 20mg daily - pt not taking

ALLERGIES: Zidovudine

PHYSICAL EXAM: Exam on Admission:
vitals: BP 111/82, HR 94, RR 25, 95% 2L NC
General: ill-appearing disheavaled woman, moderate distress,
tachypneic
[**Month/Day (2) 4459**]: anicteric sclera, non-injected. white plaques on tongue.
MM appear dry. no LAD.
CV: RRR, no murmurs, rubs, gallops
Lungs: using accessory muscles, retractions but able to speak in
full sentences. [**Month/Day (2) **] rhonchi throughout. no wheezing
Abdomen: +BS, soft, non-tender. midline scar from prior
hysterectomy well healed.
EXT: no peripheral edema, no clubbing.
Neuro: alert and oriented X 3, CN intact II-XII, [**5-10**] muscle
strength throughout.

FAMILY HISTORY: Mother has DM.

SOCIAL HISTORY: smokes < [**1-6**] PPD X many years, social alcohol use, denies IV
drugs but reports smoking cocaine this morning.  Lives alone in
apartment, was previously living with daugther but no longer.
Unspecified septicemia,Acute kidney failure, unspecified,Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Severe sepsis,Unspecified essential hypertension
Septicemia NOS,Acute kidney failure NOS,Human immuno virus dis,Urin tract infection NOS,Severe sepsis,Hypertension NOS
Admission Date:  [**2190-11-28**]              Discharge Date:   [**2190-12-6**]

Date of Birth:  [**2143-7-12**]             Sex:   F

Service: MEDICINE

Allergies:
Zidovudine

Attending:[**First Name3 (LF) 759**]
Chief Complaint:
dyspnea, cough

Major Surgical or Invasive Procedure:
none

History of Present Illness:
47 yo F with HIV (last CD4 327 [**7-13**]) not on HAART, HCV, afib,
antiphospholipid ab syndrome, multiple VTEs, CM with EF 20%,
presents with fever, shortness of breath, cough, headache. She
complains of fevers, fatigue and productive cough with
green/yellow sputum. She complains of headache on the right side
for several days. Denies neck stiffness, chest pain, shortness
of breath or abdominal pain. No nausea or vomiting. Pt denies
diarrhea or melena.  She denies sick contacts, no recent
incarcerations.  Has lived in homeless shelter in the distant
past, not recently.
.
In the ED, initial vital signs were T 101.6, BP 86/57, HR 108,
O2sat 96% RA. Her lactate was 1.0. She was given 8L IVF in the
ED for low [**Month/Year (2) **] pressures in the 80-90's systolic. HR was
80-90s. RSCVL was placed. She was also started on levophed for
hypotension. Per report, she was mentating normally the entire
time.  She was given vancomycin for pneumonia on CXR.  She was
also given levafloxacin, ceftriaxone and bactrim and 60mg
prednisone for possible PCP. [**Name10 (NameIs) **] hCG was negative. [**Name10 (NameIs) **]
positive for trichomonas.
.
Currently, she continues to complain of cough and shortness of
breath.  No headache currently.  No abdominal pain, N/V.

Past Medical History:
1. HIV/AIDS, diagnosed [**2176**], last CD4 count 327 [**7-13**]. Not on
ART. Has self d/c'd ART several times. most recently [**2183**].  was
not resumed due to poor compliance,
- acquired via sexual intercourse.
OI:
- HCV
- [**Doctor First Name **] pneumonia - [**1-/2182**] - +AFB in sputum. Was not complaint with
Rx.
-  Oral thrush
-  Recurrent episodes of pneumococcal pneumonia. Last episode -
[**12-6**].In each admission PCP and AFB's were neg.
- Lymphocytic pneumonitis - diagnosed by trans-bronchial bx.
Untreated.
TB risk factors: pt reports negative PPDs in the past, does not
recall most recent.  No hx of exposure to TB, no incarceration.
Has lived in homeless shelter in the past ~1 year.
2. Dilated cardiomyopathy-EF20-25%, last echo [**4-13**]. Unclear
etiology with clean coronaries [**2184**].
3. Hepatitis C, undetectable VL in the past
4. Multiple PNAs
5. [**Doctor First Name **]
6. LV thrombus
7. +Anti-cardiolipin antibody
8. Lower extremity arterial thrombus
9. Asthma/bronchiectasis
10. Myocardial infarction [**2184**], clean coronaries at that time
11. L MCA stroke
12. Cocaine abuse
13. Pulmonary Nodules on chest CT
14. Chronic Lymphoid Interstitial Pneumonitis

Social History:
smokes < [**1-6**] PPD X many years, social alcohol use, denies IV
drugs but reports smoking cocaine this morning.  Lives alone in
apartment, was previously living with daugther but no longer.

Family History:
Mother has DM.


Physical Exam:
Exam on Admission:
vitals: BP 111/82, HR 94, RR 25, 95% 2L NC
General: ill-appearing disheavaled woman, moderate distress,
tachypneic
[**Month/Day (2) 4459**]: anicteric sclera, non-injected. white plaques on tongue.
MM appear dry. no LAD.
CV: RRR, no murmurs, rubs, gallops
Lungs: using accessory muscles, retractions but able to speak in
full sentences. [**Month/Day (2) **] rhonchi throughout. no wheezing
Abdomen: +BS, soft, non-tender. midline scar from prior
hysterectomy well healed.
EXT: no peripheral edema, no clubbing.
Neuro: alert and oriented X 3, CN intact II-XII, [**5-10**] muscle
strength throughout.

Pertinent Results:
Labs on admission:

[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] WBC-3.9* RBC-3.61* Hgb-10.5* Hct-30.3*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.6 Plt Ct-142*
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] Neuts-63.2 Lymphs-31.6 Monos-4.6 Eos-0.2
Baso-0.4
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] PT-33.6* PTT-41.8* INR(PT)-3.5*
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**]  WBC-3.9* Lymph-32 Abs [**Last Name (un) **]-1248 CD3%-96
Abs CD3-1201 CD4%-15 Abs CD4-184* CD8%-80 Abs CD8-1003*
CD4/CD8-0.2*
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] Glucose-89 UreaN-27* Creat-1.4* Na-131*
K-3.6 Cl-102 HCO3-19* AnGap-14
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] ALT-18 AST-29 AlkPhos-56 TotBili-0.6
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**] Cortsol-21.6*
[**2190-11-28**] 08:03PM [**Month/Day/Year 3143**] LD(LDH)-188
.
Labs on discharge:
[**2190-12-4**] 04:55AM [**Month/Day/Year 3143**] WBC-2.1* RBC-3.25* Hgb-9.5* Hct-27.6*
MCV-85 MCH-29.3 MCHC-34.6 RDW-15.4 Plt Ct-238
[**2190-12-4**] 04:55AM [**Month/Day/Year 3143**] PT-25.0* PTT-34.9 INR(PT)-2.5*
[**2190-11-28**] 01:45PM [**Month/Day/Year 3143**]  WBC-3.9* Lymph-32 Abs [**Last Name (un) **]-1248 CD3%-96
Abs CD3-1201 CD4%-15 Abs CD4-184* CD8%-80 Abs CD8-1003*
CD4/CD8-0.2*
[**2190-12-4**] 04:55AM [**Month/Day/Year 3143**] Ret Aut-0.9*
[**2190-12-4**] 04:55AM [**Month/Day/Year 3143**] Glucose-83 UreaN-14 Creat-1.1 Na-135
K-4.2 Cl-110* HCO3-20* AnGap-9
[**2190-12-2**] 06:06AM [**Month/Day/Year 3143**] ALT-15 AST-28 LD(LDH)-173 AlkPhos-51
Amylase-154* TotBili-0.2
[**2190-12-3**] 05:19AM [**Month/Day/Year 3143**] Calcium-7.9* Phos-3.6 Mg-1.6
[**2190-11-29**] 04:26AM [**Month/Day/Year 3143**] CK-MB-3 cTropnT-<0.01
[**2190-11-30**] 06:08AM [**Month/Day/Year 3143**] CK-MB-NotDone cTropnT-<0.01
[**2190-11-29**] 04:26AM [**Month/Day/Year 3143**] calTIBC-163* Ferritn-369* TRF-125*
[**2190-12-2**] 11:51AM [**Month/Day/Year 3143**] Cortsol-30.0*
[**2190-12-2**] 09:33AM [**Month/Day/Year 3143**] Cortsol-9.4
[**2190-11-30**] 06:08AM [**Month/Day/Year 3143**] B-GLUCAN-PND
[**2190-11-28**] 03:50PM [**Month/Day/Year 14246**] RBC-[**6-15**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2190-12-1**] 12:40PM [**Month/Day/Year 14246**] RBC-[**11-25**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2190-11-28**] 03:50PM [**Month/Day/Year 14246**] [**Month/Day/Year **]-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-MOD
[**2190-12-1**] 12:40PM [**Month/Day/Year 14246**] [**Month/Day/Year **]-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2190-11-28**] 03:50PM [**Month/Day/Year 14246**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2190-12-1**] 12:40PM [**Month/Day/Year 14246**] Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
.
Microbiology:
.
[**2190-12-4**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2190-12-3**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2190-12-3**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-PRELIMINARY - Pending;
.
FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2190-12-2**] STOOL OVA + PARASITES-FINAL; OVA + PARASITES (Final
[**2190-12-3**]):
      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 [**2190-12-3**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
[**2190-12-1**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2190-11-30**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
.
[**2190-11-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
FUNGAL CULTURE-PRELIMINARY INPATIENT - poor sample
[**2190-11-30**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2190-11-29**] SEROLOGY/[**Year (4 digits) 3143**] CRYPTOCOCCAL ANTIGEN-negative.
.
[**2190-11-29**] Rapid Respiratory Viral Screen & Culture Rapid
Respiratory
[**2190-11-29**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT - poor sample
[**2190-11-28**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT - poor sample
[**2190-11-28**] [**Year (4 digits) 14246**] Legionella Urinary Antigen - Negative
[**2190-11-28**] [**Year (4 digits) 14246**] [**Year (4 digits) 14246**] CULTURE-negative
[**2190-11-28**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS, COAGULASE
NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2190-11-28**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-FINAL EMERGENCY
[**Hospital1 **]
.
LABS ON DISCHARGE
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2190-12-6**] 07:30AM    2.9* 3.51* 10.2* 29.4* 84 29.2 34.8 15.5
277
PT PTT  INR(PT)
[**2190-12-6**] 07:30AM    21.2* 33.9   2.0*
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2190-12-6**] 07:30AM    105 19 1.0 136 4.3 105 24 11
.
Imaging/Studies:
[**2190-11-28**] Head CT: No acute intracranial process. Stable
appearance of cystic encephalomalacia involving the left MCA
territory. If there is [**Month/Day/Year **] suspicion for acute ischemic
insult, MRI with diffusion-weighted imaging could be performed
for further characterization.
.
[**2190-11-28**] CXR: Findings consistent with multifocal pneumonia.
.
CT chest [**11-30**]
. Extensive rapidly progressive pneumonia in both lungs.
Although there
could be existing fungal infection, the findings are most
readily explained by
aggressive bacterial pneumonia. Small bilateral pleural
effusions do not have
characteristics of empyema.
2. Improving extensive chronic lymphadenopathy. Chronic
pulmonary
micronodulation, attributed to non tuberculous mycobacterial
infection.
3. Cardiomegaly, anemia.
4. Chronic enlargement of right thyroid lobe

CT chest [**12-3**]
1. Resolution of bilateral pleural effusions.

2. Bilateral [**Month/Year (2) **] airspace opacities, likely multifocal
pneumonia which
has dramatically improved.

3. Multiple lung cysts which may be due to prior lymphocytic
interstitial
pneumonitis.

ECHO - [**2190-11-29**]  (LVEF = 25 %).
IMPRESSION: Moderate left ventricular dilatation with severe,
global hypokinesis and extensive trabeculation suggestive of
myocardial non-compaction. Moderate pulmonary artery
hypertension. Mild-moderet mitral regurgitation.
Compared to the prior study (images reviewed) of [**2190-4-14**], the
left ventricular cavity is more dilated with similar systolic
function. The severity of mitral regurgitation and the estimated
pulmonary artery systolic pressure are higher


Brief Hospital Course:
MICU Course:
.
The patient was admitted to the MICU with possible pneumonia and
possible sepsis after recieving 8L IV fluids in the ED and a
lactate of 1.0.  She was quickly weaned off Levophed upon
arrival to the ICU.  She was initially treated with
broad-spectrum antibiotics with Vancomycin, Ceftriaxone and
Levofloxacin.  The vancomycin was stopped on [**2190-11-29**] due to low
suspicion for gram positive pneumonia.  She was started on
Bactrim DS 2 tabs q8 hours for possible PCP.  [**Name Initial (NameIs) **] CD4 count was
rechecked and was 184.  She was given Prednisone 60mg PO in the
ED but steroids were not continued because her O2 sats were high
on minimal oxygen and LDH was normal and this was not felt to be
severe PCP.  [**Name10 (NameIs) **] was ordered for induced sputum for PCP and
nasal aspirate to check for rapid viral antigens.  She was
continued on fluconazole for oral thrush and nystatin oral rinse
was added.
.
Her metoprolol and lisinopril were stopped due to hypotension.
She had a repeat echo to assess her CHF, which showed LV cavity
more dilated from [**4-13**] with similar systolic function.  The
severity of MR and the PASP were higher.  She was not felt to be
in heart failure on arrival to the ICU.  She was put on a
low-salt diet.
.
Floor Course:
.
Pt. was transferred to floor on [**11-30**] and she continued to
complain of occasional cough and shortness of breath.  She
denied other Sx. Her Vitals were 96.2F, 102.68, 96, 18, 99% RA.
.
# Fevers/cough/dyspnea.  These were felt to be [**2-6**] to multifocal
CAP, or PCP and patient was continued on Ceftriaxone,
Levofloxacin and Bactrim DS TID.  She underwent a CT of chest
which showed extensive rapidly progressive pneumonia in both
lungs, small bilateral pleural effusions, improving extensive
chronic lymphadenopathy.  She was intremittently treated with
Vancomycin IV x 1d for GPC in BCx from [**11-28**] w/ GPC that turned
out to be coag negative staph, vancomycin was thus discontinued.
 Her Legionella Ag was negative and her Levofloxacin was thus
discontinued on [**2190-12-2**]. Cryptococcal Ag was negative as were
respiratory viral rapid screens.  Patient improved clinically
significantly, w/ O2 saturations on RA 94-97% and ambulation of
> 50 yards w/o DOE.  Her induced sputums were repeatedly of poor
quiality and could not be assessed for PCP [**Name Initial (PRE) 23426**].  A
bronchoscopy was considered, however in consultation with ID and
Pulmonary team it was decided against it due to patient's
[**Name Initial (PRE) **] improvement and hypotension (see below).  Her repeat CT
chest on [**12-3**] showed much improved infiltrates b/l consistent
w/ [**Month/Year (2) **] improvement.  Her dyspnea, cough and fatigue
continued to improve.  She was afebrile throughout the hosptial
stay w/ good perfusion on exam.  Due to progressive leukopenia,
ANC 580, her Bactrim was switched to Atovaquone (total 21-day
course of 750mg PO bid, day 4 on day of discharge, then 1500mg
qday for prophylaxis) with subsequent return of WBC count to 2.5
and ANC to 1180.
On [**12-5**], her Ceftriaxone IV was switched to Cefpodoxime 200mg
PO BID.  She should complete the course of total of 14days of
Ceftriaxone/Cefpodoxime.  Repeat induced sputum smear/Cx [**12-3**]
showed oropharygeal flora. PCP smear was pending.  Beta glucan
was pending at time of discharge. Pt will require CT within 2
weeks and ID f/u within 2 weeks with Dr. [**First Name (STitle) **] for re-check of
ANC.
.
Patient's previously "positive" TST were documented as negative
upon chart review with ID.  She was treated for [**Doctor First Name **] in the past,
but this was felt to be a colonizer.  Please see note from ID
staff on [**2190-11-29**] for more detail.
.
# Hypotension.  Patient was triggered for hypotension, SBPs
70s/palp on [**12-1**] and [**12-3**].  She was asymptomatic during this
time (no dizziness, lightheadedness, chest pain, shortness of
breath, changes in MS). Her baseline from [**7-13**] OP visit was SBP
of 90mmHg.  She responded to 500cc bolus and maitenance fluids
to 90mmHg.  Patient was signficantly volume negative on I/Os,
felt to be secondary to post ATN diuresis. She was ruled out for
adrenal insufficiency w/ a negative cortosyn stimulation test.
Poor contractility given CHF w/ EF 20% and falling off
Frank-starling curve were considered, but patient was perfusing
well and was asymptomatic througout this time.  She was also
started on low dose digoxin, 62.5mcg to improve forward flow.  K
was closely monitored and remained wnl throughout hospital stay.
 Upon maintaining fluid balance over next 3 HDs w/ IVF boluses
and maintenance fluids, her SBPs returned to 80-100mmHg.  Her
Metoprolol and Lisinopril were held throughout this time.  These
were restarted at metoprolol XL 12.5 and Lisinopril 2.5. He was
continued on 0.0625 mg of digoxin to aid w/ contractility.
Culture data as mentioned above were pending at time of
discharge.
.
# Leukopenia. Patient developed leukopenia 3.8-->1.9->2.1->
2.5-> 2.9, ANC 1170. Improved after D/ced bactrim ([**12-3**]). WBC
from her previous hospitalizations ranged 2.5-4K.  This was felt
to be likely [**2-6**] Bactrim, or HIV itself.  There were no [**Month/Day (2) **]
signs of MAC, Histoplasma, EBV, hepatitis (which pt has), CMV.
Her retic count was hypoproliferative.  Fe studies were
consistent w/ ACD.  Folate/B12 were wnl.  ANC troughed at 580,
and improved to 1170 on day of discharge.
.
# ARF. Cr elevated to 1.4 on admission, likely [**2-6**] sepsis.  It
improved temporarily and then increased to 1.4 within 5d of
admission with increased U/O consistent with post ATN duiresis.
FeNa was > 6%.  U/A showed no evidence of a glomerular process
nor casts.  Efforts were made to keep patient I/Os even.  At
time of discharge, her Cr. improved to 0.9 and her U/O
stabilized.
.
#  Chronic pulmonary micronodulation on CT.  Previously
attributed to non tuberculous mycobacterial infection.  This
actually improved on CT scans while hospitalized.  LAD had also
decreased on repeat scans.  Etiology of these is unclear and
outpatient follow up was recommeneded.
.
# Cardiomyopathy.  Pt. was euvolemic on exam. Has chronic,
systolic, HIV related vs. cocaine related, non-ischemic CHF: EF
20-25%.  Echo this admission with increased LV dilatation and
increased PA pressures. This was likely [**2-6**] IVF and increase
pulmonary resistance [**2-6**] PNA.  Pt. had new inversion of Tw in
inferior leads and old lateral lead inversions. CE were negative
x2.  No events noted on telemetry suggestive of ischemia.  [**Month/Day (2) 8213**]
was initially held [**2-6**] to hypotension as was BBK.  This as well
as metoprolol and digoxin were resumed as BP improved, and
continued at time of discharge. Patient was maintained on low Na
diet.
.
# Substance Abuse.  Pt denied cocaine on this interview but had
a positive tox screen.  Social work consult was obtained. She
endorsed illusions to SW staff, but denied these to medical
staff.  She was not interested in discussing this topic further.

.
# Afib Hx in chart, but could not locate documentation in OMR.
Patient was in sinus rhythm throughout hospitalization.
.
# Antiphospholipid syndrome. Multiple VTEs.  Patient's coumadin
was held [**Date range (1) 101140**] [**2-6**] supratherapeutic INRs, likely [**2-6**]
fluconazole and levofloxacin.  Her coumadin was restarted at 5mg
QD and titrated to target INR of [**2-7**]. She was strongly advised
not to miss [**First Name (Titles) **] [**Last Name (Titles) 28229**] follow-up appointment for INR re-check.
.
# HIV/AIDS. CD4 count 184. VL 254K. Patient will likely require
HAART, but previously not on therapy due to poor compliance.
Already on fluconazole for PPx. No need for CMV ppx as CD4 > 50.
Discussed with ID, patient will likely start HAART as outpatient
once adherence to appts can be documented.  Continued atovaquone
and fluconazole.
.
# Depression w/ hx of anxeity sx. per patient, fluoxetine was
not helping and she was not currently taking it. Continue
ativan. Pt. is willing to try celexa as outpatient.
.
# Difficulties adhering to care. Contributed to by difficult
home situation (one daughter jailed) and the other daughter
reportedly not supportive at home. In addition, patient
reporting difficulties getting to her appointments.  After
discussion with social work and case managment, pt was set up
with transportation assistance.
.
Patient was discharged home in a hemodynamically stable
condition with multiple follow-up appointments.

Medications on Admission:
bactrim DS 160/800mg 1 tab daily
ativan 0.5mg [**Hospital1 **]
lisinopril 2.5mg daily
fluconazole 100mg daily
warfarin 10mg daily
metoprolol SR 12.5mg daily
fluoxetine 20mg daily - pt not taking

Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
4. Digoxin 125 mcg Tablet Sig: one half Tablet PO DAILY (Daily).
Disp:*030 Tablet(s)* Refills:*2*
5. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please adjust daily dose as directed by [**Hospital 191**] [**Hospital **]
Clinic.
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
VNA Services:
Please draw Coumadin level on Tuesday, [**2190-12-7**].
Please draw Coumadin level, CBC with differential, and Digoxin
level on Thursday, [**2190-12-9**].
Please fax Coumadin results above to [**Hospital 191**] [**Hospital **] Clinic
(Fax([**Telephone/Fax (1) 3053**]).
Please fax CBC with diff and Dig level results to [**Hospital 191**] Clinic,
Attn: PCP [**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**] (Fax:([**Telephone/Fax (1) 16691**].)
10. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
once a day: Please take this medication indefinitely.
Disp:*qs mg* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
 Primary: Pneumonia, Sepsis
Secondary: Heart failure, HIV/AIDS, coronary artery disease,
multiple pulmonary emboli


Discharge Condition:
Hemodynamically and respiratory stable


Discharge Instructions:
You were admitted to [**Hospital1 18**] with severe lung infection requiring
Intensive Care Unit management.  You were treated with
intravenous fluids and given intravenous antibiotics.  With this
treatment your lung function improved, including improved
breathing and oxygen levels.  At time of discharge, you were
being given an antibiotic called Cefpodoxime.  You should
continue to take this medication as prescribed. Your dose of
Coumadin was also adjusted, because your levels were high when
you came in. Please take the Coumadin as prescribed.

Because of your HIV, you were also treated with additional
antibiotic that you should continue upon discharge from the
hospital.  This is called Atovaquone.  You should continue this
indefinitely.  In addition, we checked the markers of activity
of your HIV virus, and these were elevated, thus you should
follow up with an infectious disease specialist upon discharge
to discuss initiation of treatment for HIV.  You were also
continued on Fluconazole.  You should continue to take this
medication.

While hospitalized, you had low [**Hospital1 **] pressures.  While this was
the case, your metoprolol and lisinopril were withheld.  As your
[**Hospital1 **] pressures improved, Metoprolol and Lisinopril were
restarted. A new medication, Digoxin, was also added to help
with your heart failure. Your [**Hospital1 **] pressures were stable on
discharge.

Because you have a condition called heart failure, your should
weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.  You do not have a fluid
restriction.

You will be receiving Visiting Nurse services to help monitor
your Coumadin levels, Digoxin medication level, and your white
[**Name8 (MD) **] cell count given your HIV. They will be visiting you
tomorrow and Thursday to draw your [**Name8 (MD) **]. You will be contact[**Name (NI) **]
by the [**Name (NI) 191**] [**Name (NI) **] clinic regarding how to dose your
Coumadin based on the [**Name (NI) **] levels.

Should you experience any worsening shortness of breath, fever,
chills, productive cough, coughing up [**Name (NI) **], chest pain, leg
swelling or any other symptom concerning to you, please call
your primary care doctor or go to the nearest emergency room.

Because of your HIV and other medical conditions, it is very
important for you to follow up with your primary care doctor and
an infectious disease specialist (please see below for
appointments).

Followup Instructions:
1. Appointment with Nurse Practitioner: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**],
[**Name12 (NameIs) 280**] Phone:[**Telephone/Fax (1) 5808**] Date/Time:[**2190-12-8**] 4:00.
- She will follow-up with you for your pneumonia.

2: Appointment with PCP,[**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2190-12-14**] 2:00
- She will follow with you for your pneumonia, Digoxin dosing,
and HIV.
- She will help you to set up a repeat CT scan in 2 weeks.
- She will also advise you about your PCP medications once the
final results of your PCP culture have returned.

3. Appt with Infectious Disease
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1085**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2190-12-15**] 8:30am
- It is very important that you keep this appointment to
establish a plan for treatment of your HIV.

4. Please repeat a chest CT scan in 2 weeks. Dr. [**Last Name (STitle) 3766**] will
helping you to set that up.

5. The [**Hospital 191**] [**Hospital **] clinic will be following up with
your regarding your Coumadin dose.



Completed by:[**2191-2-19**]
{'Unspecified septicemia,Acute kidney failure, unspecified,Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Severe sepsis,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: dyspnea, cough

PRESENT ILLNESS: 47 yo F with HIV (last CD4 327 [**7-13**]) not on HAART, HCV, afib,
antiphospholipid ab syndrome, multiple VTEs, CM with EF 20%,
presents with fever, shortness of breath, cough, headache. She
complains of fevers, fatigue and productive cough with
green/yellow sputum. She complains of headache on the right side
for several days. Denies neck stiffness, chest pain, shortness
of breath or abdominal pain. No nausea or vomiting. Pt denies
diarrhea or melena.  She denies sick contacts, no recent
incarcerations.  Has lived in homeless shelter in the distant
past, not recently.
.
In the ED, initial vital signs were T 101.6, BP 86/57, HR 108,
O2sat 96% RA. Her lactate was 1.0. She was given 8L IVF in the
ED for low [**Month/Year (2) **] pressures in the 80-90's systolic. HR was
80-90s. RSCVL was placed. She was also started on levophed for
hypotension. Per report, she was mentating normally the entire
time.  She was given vancomycin for pneumonia on CXR.  She was
also given levafloxacin, ceftriaxone and bactrim and 60mg
prednisone for possible PCP. [**Name10 (NameIs) **] hCG was negative. [**Name10 (NameIs) **]
positive for trichomonas.
.
Currently, she continues to complain of cough and shortness of
breath.  No headache currently.  No abdominal pain, N/V.

MEDICAL HISTORY: 1. HIV/AIDS, diagnosed [**2176**], last CD4 count 327 [**7-13**]. Not on
ART. Has self d/c'd ART several times. most recently [**2183**].  was
not resumed due to poor compliance,
- acquired via sexual intercourse.
OI:
- HCV
- [**Doctor First Name **] pneumonia - [**1-/2182**] - +AFB in sputum. Was not complaint with
Rx.
-  Oral thrush
-  Recurrent episodes of pneumococcal pneumonia. Last episode -
[**12-6**].In each admission PCP and AFB's were neg.
- Lymphocytic pneumonitis - diagnosed by trans-bronchial bx.
Untreated.
TB risk factors: pt reports negative PPDs in the past, does not
recall most recent.  No hx of exposure to TB, no incarceration.
Has lived in homeless shelter in the past ~1 year.
2. Dilated cardiomyopathy-EF20-25%, last echo [**4-13**]. Unclear
etiology with clean coronaries [**2184**].
3. Hepatitis C, undetectable VL in the past
4. Multiple PNAs
5. [**Doctor First Name **]
6. LV thrombus
7. +Anti-cardiolipin antibody
8. Lower extremity arterial thrombus
9. Asthma/bronchiectasis
10. Myocardial infarction [**2184**], clean coronaries at that time
11. L MCA stroke
12. Cocaine abuse
13. Pulmonary Nodules on chest CT
14. Chronic Lymphoid Interstitial Pneumonitis

MEDICATION ON ADMISSION: bactrim DS 160/800mg 1 tab daily
ativan 0.5mg [**Hospital1 **]
lisinopril 2.5mg daily
fluconazole 100mg daily
warfarin 10mg daily
metoprolol SR 12.5mg daily
fluoxetine 20mg daily - pt not taking

ALLERGIES: Zidovudine

PHYSICAL EXAM: Exam on Admission:
vitals: BP 111/82, HR 94, RR 25, 95% 2L NC
General: ill-appearing disheavaled woman, moderate distress,
tachypneic
[**Month/Day (2) 4459**]: anicteric sclera, non-injected. white plaques on tongue.
MM appear dry. no LAD.
CV: RRR, no murmurs, rubs, gallops
Lungs: using accessory muscles, retractions but able to speak in
full sentences. [**Month/Day (2) **] rhonchi throughout. no wheezing
Abdomen: +BS, soft, non-tender. midline scar from prior
hysterectomy well healed.
EXT: no peripheral edema, no clubbing.
Neuro: alert and oriented X 3, CN intact II-XII, [**5-10**] muscle
strength throughout.

FAMILY HISTORY: Mother has DM.

SOCIAL HISTORY: smokes < [**1-6**] PPD X many years, social alcohol use, denies IV
drugs but reports smoking cocaine this morning.  Lives alone in
apartment, was previously living with daugther but no longer. 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Human immunodeficiency virus [HIV] disease,Urinary tract infection, site not specified,Severe sepsis,Unspecified essential hypertension'}
