CHIEF COMPLAINT: "chemo"

PRESENT ILLNESS: Mr. [**Known lastname **] is a 30 yo M with HIV c/b CNS lymphoma who presents for
HD-MTX, cycle 6.  He has been having a cough "on and off" for
the past few weeks and has generally felt tired.  He also
reports that he doesn't always take his medications for HIV and
PCP [**Name Initial (PRE) 1102**].
.
Currently, he is in lots of pain and feels tired.  He denies
everything on review of systems except that he has left buttock
pain (no rash) and has had a cough for "some time".
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: Oncologic History:
High-grade B-cell lymphoma with mediastinal mass, LAD and CNS
involvement
- [**2156-1-23**] to [**2156-1-26**] - cycle 1 [**Hospital1 **]
- [**2156-2-1**] - cycle 1 Rituxan
- [**2156-2-7**] to [**2156-2-11**] - cycle 1 IVAC
- [**2156-2-27**] - IT cytarabine and cycle 2 Rituxan
- [**2156-3-1**] to [**2156-3-4**] - cycle 2 [**Hospital1 **]
- [**2156-4-1**] to [**2156-4-4**] - cycle 3 [**Hospital1 **]
- [**2156-4-9**]: Cycle 3 rituximab.
- [**2156-4-22**]: Cycle #4 [**Hospital1 **].
- [**2156-5-20**]: Cycle #5 [**Hospital1 **].
- [**Month (only) 205**],[**2156-8-2**]: 4 cycles high dose MTX

MEDICATION ON ADMISSION: topiramate 25 mg daily
ritonavir 100 mg [**Hospital1 **]
raltegravir 400 mg [**Hospital1 **]
darunavir 600 mg [**Hospital1 **]
acyclovir 400 mg q8h
atovaquone 1500 mg/10 mL daily
tizanidine 2 mg qid
emtricitabine-tenofovir 200-300 mg daily
levetiracetam 500 mg [**Hospital1 **]
olanzapine 5 mg daily
clonazepam 1 mg tid
vancomycin 125 mg q12h
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]
hydromorphone 5 mg q6h
morphine CR 60 mg q12h
acetaminophen 500 mg q6h
levothyroxine 125 mcg daily
hydrocortisone 20 mg qam, 10 mg qhs
Zofran 4 mg q8h

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - Temp 97.4F, BP 120/70, HR 107, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, moderately uncomfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP dry
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, seems mildly bloated, not tympanic to
percussion
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: Father with mesothelioma. Mother with asthma. Family history of
HTN and DM.

SOCIAL HISTORY: Pt lived with his aunt and uncle but his uncle recently died.
He is unemployed and collect [**Social Security Number 55849**]social security.  History of sex
work with male clients and unprotected, receptive anal
intercourse.  Hx of MDMA, crystal meth, and intranasal cocaine
use.  Denies ever IV drugs.  Diminished use recently of illicit
drugs but not abstinent.  Smokes about 1 pack per day of
cigarettes.  Social EtOH use.
Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other malignant lymphomas, lymph nodes of multiple sites,Intestinal infection due to Clostridium difficile,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pain in joint, pelvic region and thigh,Do not resuscitate status,Encounter for palliative care
Human immuno virus dis,Acute respiratry failure,Lymphomas NEC mult,Int inf clstrdium dfcile,Anemia NOS,DMII wo cmp nt st uncntr,Long-term use of insulin,Joint pain-pelvis,Do not resusctate status,Encountr palliative care
Admission Date:  [**2156-10-4**]              Discharge Date:   [**2156-10-23**]

Date of Birth:  [**2126-2-6**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
"chemo"

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Mr. [**Known lastname **] is a 30 yo M with HIV c/b CNS lymphoma who presents for
HD-MTX, cycle 6.  He has been having a cough "on and off" for
the past few weeks and has generally felt tired.  He also
reports that he doesn't always take his medications for HIV and
PCP [**Name Initial (PRE) 1102**].
.
Currently, he is in lots of pain and feels tired.  He denies
everything on review of systems except that he has left buttock
pain (no rash) and has had a cough for "some time".
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.


Past Medical History:
Oncologic History:
High-grade B-cell lymphoma with mediastinal mass, LAD and CNS
involvement
- [**2156-1-23**] to [**2156-1-26**] - cycle 1 [**Hospital1 **]
- [**2156-2-1**] - cycle 1 Rituxan
- [**2156-2-7**] to [**2156-2-11**] - cycle 1 IVAC
- [**2156-2-27**] - IT cytarabine and cycle 2 Rituxan
- [**2156-3-1**] to [**2156-3-4**] - cycle 2 [**Hospital1 **]
- [**2156-4-1**] to [**2156-4-4**] - cycle 3 [**Hospital1 **]
- [**2156-4-9**]: Cycle 3 rituximab.
- [**2156-4-22**]: Cycle #4 [**Hospital1 **].
- [**2156-5-20**]: Cycle #5 [**Hospital1 **].
- [**Month (only) 205**],[**2156-8-2**]: 4 cycles high dose MTX

OTHER HISTORY:
- HIV (dx in [**2145**], last CD4/vl was 179/last VL <48 in [**3-12**],
followed by Dr. [**Last Name (STitle) **] at [**Hospital3 55848**])
- Lymphadeonpathy with FNA in [**12-7**] showing a small population
of
CD10+ B-cells (2% on flow) of uncertain significance; refused
further workup.
- Mediastinal lymphadenopathy/mass noted as long ago as [**12-7**],
documented again in [**4-8**]; declinedfurther
workup.
- Strep pneumonia c/b empyema at [**Location (un) **] (years ago)
- Unknown PNA with parapneumonic effusion, drained in [**2154**] at
[**Location (un) 8973**]
- HSV, Herpes Zoster
- Syphilis (RPR 1:1 in early [**2155**]), question neurosyphilis (s/p
treatment)
- History Gonorrhea, chlamydia
- Multiple MRSA abscesses
- Polysubstance abuse (c. meth, MDMA, marijuana, IN cocaine)
- Anal atypia from HPV: [**2155-3-15**]
- Adrenal insufficiency
- Diabetes mellitus type 2


Social History:
Pt lived with his aunt and uncle but his uncle recently died.
He is unemployed and collect [**Social Security Number 55849**]social security.  History of sex
work with male clients and unprotected, receptive anal
intercourse.  Hx of MDMA, crystal meth, and intranasal cocaine
use.  Denies ever IV drugs.  Diminished use recently of illicit
drugs but not abstinent.  Smokes about 1 pack per day of
cigarettes.  Social EtOH use.


Family History:
 Father with mesothelioma. Mother with asthma. Family history of
HTN and DM.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.4F, BP 120/70, HR 107, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, moderately uncomfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP dry
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, seems mildly bloated, not tympanic to
percussion
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
LYMPH - no cervical, axillary LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-6**] throughout, sensation grossly intact throughout
.
TRANSFER PHYSICAL EXAM TO SICU:
97.0, 100/70S, 80-100, 18, 96% ra
Abd: much more distended than admission with very rigid to touch
although dull to percussion.  He was intermittently exquisitely
tender to palpation on the abdomen with rebound and guarding.
Ext:  his buttocks are intensely painful [**10-11**] and tender to the
touch bilaterally with radiation to the left thigh as well.
There is no rash or visible lesion, exacerbated by movement
.
DISCHARGE PHYSICAL EXAM:
expired

Pertinent Results:
ADMISSION LABS:
[**2156-10-4**] 02:00PM BLOOD WBC-8.0 RBC-3.85* Hgb-10.4* Hct-31.2*
MCV-81* MCH-27.1 MCHC-33.4 RDW-20.2* Plt Ct-184
[**2156-10-4**] 02:00PM BLOOD Neuts-61 Bands-3 Lymphs-16* Monos-18*
Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2156-10-4**] 02:00PM BLOOD PT-14.2* PTT-27.9 INR(PT)-1.2*
[**2156-10-4**] 02:00PM BLOOD UreaN-12 Creat-0.9 Na-135 K-3.2* Cl-98
HCO3-28 AnGap-12
[**2156-10-4**] 02:00PM BLOOD ALT-25 AST-16 LD(LDH)-802* AlkPhos-122
TotBili-0.3
[**2156-10-4**] 02:00PM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.7 Mg-2.2
[**2156-10-5**] 05:55AM BLOOD TSH-0.14*
[**2156-10-7**] 09:55AM BLOOD Lactate-2.5*
.
DISCHARGE LABS: expired
.
IMAGING:
[**10-5**] CT T/A/P: CT OF THE THORAX. The thyroid is normal, and
there is no supraclavicular lymph node enlargement. The lungs
are hypoinflated owing to a poor ventilatory effort which
hinders assessment of lung consolidations due to vascular
crowdings and difficults comparison with previous study.
Allowing for these limitations, there is diffuse ground-glass
opacities which are present in all the lobes of both the right
and left lung which seem significantly worsened with respect to
[**2156-9-14**]. There are no hilar, mediastinal, or axillary
lymphadenopathies. The airways are patent to the segmental
level. The patient has moderate but stable cardiomegaly, and the
pulmonary trunk has a diameter of 3.8 cm (2:21), which is mildly
increased in size since [**2156-9-14**]. The aorta is unremarkable.
CT OF THE ABDOMEN: The liver enhances homogeneously with the
exception of a 5 x 7 mm hypoattenuating and hypoenhancing lesion
in segment VII of the right lobe (2:47) which is unchanged with
respect to prior study. The gallbladder is decompressed. The
portal vein is patent without evidence of thrombosis. The
pancreas shows no focal lesions or peripancreatic stranding or
fluid collection. The spleen is normal in size and homogeneous.
The adrenal glands are unremarkable.
The right kidney shows no focal lesions while the left kidney
shows two tiny hypoenhancing lesions (2:63) that are unchanged
with respect to [**2156-9-14**]. The kidneys present a
symmetric nephrogram and excretion of contrast, and there is no
evidence of hydroureter or hydronephrosis. No perinephric
stranding is noted. The abdominal vessels are unremarkable
without evidence of thrombosis. Some prominent paraaortic lymph
nodes are noted; however, these nodes are not enlarged by CT
size criteria. There is no mesenteric lymph node enlargement. No
evidence of abdominal hernia, ascites, or free air.
The stomach, duodenum, and small bowel are unremarkable without
evidence of wall thickness. The terminal ileum is within normal
limits. the ascending colon shows peripheral fat stranding,
which is new compared to prior study. No evidence of colonic
obstruction.
PELVIC CT: The urinary bladder, terminal ureters, prostate, and
seminal
vesicles are unremarkable. There is no pelvic wall or inguinal
lymph node
enlargement.
.
[**10-6**] HRCT CHEST: Despite attempts to achieve both inspiratory
and expiratory imaging, most of the imaging appears to have
occured during expiration. On these predominantly expiratory
studies, there is a mosaic appearance at bilateral lung bases,
which becomes somewhat more prominent on the full expiratory
study, suggestive of a mild degree of airtrapping. No definite
ground-glass opacities, however, are present. Bibasilar
atelectasis and atelectasis adjacent to bilateral heart borders
is present. No pneumothorax or pleural effusion is present.
The heart is mildly enlarged with a pacer wire in the right
ventricle. The
main pulmonary artery is enlarged measuring up to 4 cm, similar
to the prior examination. No significant coronary artery
calcifications are present. The patient is mildly anemic.
In this young patient, there remains residual thymic tissue
(5:17) measuring 4.6 x 2.7 cm, decreased compared to a study
from [**2156-7-9**].
No significant axillary, hilar, or mediastinal lymphadenopathy.
The lobes of the thyroid appear normal.
Although not tailored for subdiaphragmatic evaluation, limited
views of the upper abdomen appear within normal limits. A
splenule is noted.
BONE WINDOWS: No suspicious bone lesions are present.
IMPRESSION:
1. Predominantly expiratory study causing airtrapping, which is
somewhat more pronounced on the full expiratory study. No
ground-glass opacities present to suggest the presence of a PCP
[**Name Initial (PRE) 2**]. The degree of heterogeneity in the lung parenchyma
could be due to the presence of pulmonary hypertension or air
trapping.
2. Enlarged large main pulmonary artery suggestive of pulmonary
hypertension. Moderate cardiomegaly.
3. Residual thymic tissue, which has decreased in size since
[**2156-7-9**].
OSSEOUS STRUCTURES: No lytic or blastic lesions concerning for
malignancy are noted. A sclerotic lesion in T10 is unchanged
since at least [**2156-5-2**].  Coronal and sagittal images were
reviewed confirming the axial findings.
IMPRESSIONS:
1. Fat stranding surrounding ascending colon is concerning for
colitis,
likely of infectious cause.
2. Diffuse ground-glass opacities in all lobes are significantly
worsened
with respect to prior CT, although severely hypoinflated lungs
limits
assessment and may be the explanation for this appearance. Given
this
patient's clinical features however, an HRCT of the lungs is
recommended to exclude Pneumocystis jiroveci pneumonia.
3. Mild interval increase in pulmonary trunk dilatation. This is
consistent
with worsening pulmonary hypertension.
4. Moderate cardiomegaly, stable from prior study. No nodal
masses in the
thorax or abdomen concerning for lymphoma.
.
[**10-8**] CT ABDOMEN/PELVIS: COMPARISON: CT of the torso [**2156-10-5**].
TECHNIQUE: Helical images were acquired of the abdomen and
pelvis following the administration of oral and intravenous
contrast. These were reformatted into coronal and sagittal
planes.
FINDINGS:
LUNG BASES: The lung bases are clear, with minimal bibasilar
atelectasis.
Note is made of bony bridging of the right lateral sixth and
seventh ribs.
ABDOMEN: 11 mm hypodensity is stable within segment VII of the
liver. The
liver is otherwise normal in appearance. The portal veins are
patent. There is no intrahepatic biliary ductal dilatation. The
gallbladder is normal in appearance without wall thickening or
radiopaque stones. The pancreas is unremarkable. The spleen is
normal. A splenule is seen anterior to the spleen. The adrenals
are normal in appearance bilaterally. The kidneys demonstrate
symmetric contrast enhancement. Note is again made of a
hypodensity within the right mid pole which is unchanged, but
not fully characterized. There is no hydronephrosis. The stomach
is normal appearing. Loops of small bowel are normal in caliber
and enhancement and are opacified by positive contrast. The
small bowel mesentery appears normal. The aorta is normal in
caliber along its visualized course, its major branches are
patent. Paraaortic lymphadenopathy is again noted, which is not
enlarged by CT size criteria. There is no intraperitoneal free
air.
PELVIS: The colon is opacified by positive contrast, and is
again noted to
demonstrate pan-colonic wall thickening and pericolonic
inflammatory change compatible with diagnosis of colitis. There
is a mild-to-moderate amount of abdominal ascites which is
increased compared with prior. No extraluminal contrast is seen.
The bladder and prostate appear normal. There is no pelvic side
wall lymphadenopathy.
BONE WINDOWS: There are no concerning lytic or blastic osseous
lesions.
IMPRESSION: Pancolitis, which appears to have progressed
compared with prior and is now associated with a moderate amount
of abdominal ascites. There is no evidence of perforation.
.
[**10-12**] MRI HEAD: COMPARISON: MRI head without and with contrast
dated [**2156-9-3**], [**2156-7-9**], and [**2156-1-16**].
TECHNIQUE: Sagittal T1, axial T1, T2, FLAIR, gradient echo, and
diffusion-weighted images were obtained of the brain prior to
administration of contrast. Sagittal MP-RAGE and axial
T1-weighted images were obtained after administration of
contrast with axial and coronal reconstructions.
FINDINGS: The previously noted enhancing suprasellar mass is not
noted in the present study, suggestive of its resolution.
Hypointense marrow is noted on T1 weighted images in the right
parietal bone, which has increased as compared to the prior
study. Hypointense marrow is also noted in the clivus and the
visualized cervical vertebrae suggestive of lymphomatous
involvement.
Enhancement is noted along 7-8th nerves in bilateral internal
auditory canals which may represent early leptomeningeal
enhancement.
There is no evidence of acute infarct or intracranial
hemorrhage. The
ventricles, cortical sulci, and extra-axial CSF spaces appear
normal.
Brainstem and cerebellum appear normal. The major flow voids are
patent.
There is mucosal thickening noted in the sphenoid sinus. T2
hyperintensity is noted in the right mastoid air cells
suggestive of fluid/mucosal thickening.  The orbits are
unremarkable.
IMPRESSION:
1. Resolution of the suprasellar mass, which was noted in the
previous study.
2. Lymphomatous involvement of the right parietal bone, clivus
and visualized cervical vertebrae. This has progressed since the
prior study.
3. Enhancement is noted along 7-8th nerves in bilateral internal
auditory
canals which may represent leptomeningeal enhancement.
3. No evidence of acute infarct or intracranial hemorrhage.
.
[**10-12**] MRI LUMBAR SPINE AND PELVIS: COMPARISON STUDY: None.
TECHNIQUE: Sagittal T1, T2, STIR and axial T1- and T2-weighted
images were
obtained of the lumbar spine prior to administration of
contrast. Sagittal
and axial T1-weighted images were obtained of the lumbar spine
after
administration of contrast.
FINDINGS: The normal curvature and alignment of the lumbar spine
is
maintained. The vertebral bodies are normal in height. The
vertebral bodies appear diffusely hypointense on T1- and
T2-weighted images.
Hyperintense signal is noted in right sided pedicles of L2 and
L3 vertebrae on STIR and T2 weighted images.
Heterogeneous marrow signal is noted in S1 vertebra and
subarticular region of left iliac bone posteriorly showing mixed
intensity on T1- and T2-weighted images. These show mild
heterogenous enhancement on post contrast images and there is
associated mild soft tissue along the left iliac bone.
The intervertebral discs are normal in height and signal
intensity.
At L3 and L4-L5 levels, there are diffuse posterior disc bulges
without
significant spinal canal stenosis. There is associated facet
arthropathy.
At L5-S1 level, there is diffuse posterior disc bulge without
significant
spinal canal stenosis. The disc with facet and endplate
osteophytes causes
mild left foraminal stenosis. There is associated facet
arthropathy.
The conus medullaris ends at T12-L1 level.
Hyperintense signal is noted in posterior paraspinal muscles and
soft tissues in the lumbar region on STIR images. This likely
represents edema.
IMPRESSION:
1. Lumbar vertebral bodies appear diffusely hypointense on T1-
and T2-weighted
images. This may represent marrow reconversion or diffuse marrow
infiltration by lymphoma.
2..Hyperintense signal in right sided pedicles of L2 and L3
vertebrae.
Heterogeneous marrow signal and enhancement in S1 vertebra and
subarticular region of left iliac bone posteriorly with
associated mild soft tissue along the left iliac bone. These may
represent focal areas of lymphomatous involvement.
3. Hyperintense signal in posterior paraspinal muscles and soft
tissues in the lumbar region. This likely represents edema.
.
MICRO:
[**2156-10-13**] 1:00 pm STOOL     CONSISTENCY: NOT APPLICABLE
      UNABLE TO ADD ON C.DFFICILE TOXIN AND VIRAL CULTURE (SENT
IN
      BACTERIAL TRANSPORT MEDIUM). CALLED TO DR.[**Last Name (STitle) **] ([**Numeric Identifier **]) ON
[**2156-10-14**] @
      15:45.

                            **FINAL REPORT [**2156-10-15**]**

   MICROSPORIDIA STAIN (Final [**2156-10-14**]):    NO MICROSPORIDIUM
SEEN.

   CYCLOSPORA STAIN (Final [**2156-10-14**]):    NO CYCLOSPORA SEEN.

   FECAL CULTURE (Final [**2156-10-15**]):    NO SALMONELLA OR SHIGELLA
FOUND.

   CAMPYLOBACTER CULTURE (Final [**2156-10-15**]):    NO CAMPYLOBACTER
FOUND.

   Cryptosporidium/Giardia (DFA) (Final [**2156-10-15**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
.
[**10-7**] CMV VIRAL LOAD SERUM NEGATIVE
.
10/13 L ILIAC BIOPSY    GRAM STAIN (Final [**2156-10-14**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Preliminary):    NO GROWTH.

   ACID FAST SMEAR (Final [**2156-10-15**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Preliminary):

   ANAEROBIC CULTURE (Preliminary):    NO GROWTH.


Brief Hospital Course:
Mr. [**Known lastname **] is a 30 year old male with history of poorly controlled
HIV (CD4 60) who presents for his 6th cycle of high-dose
methotrexate for CNS lymphoma.  Unfortunately, he had an
uncontrolled infectious colitis which was not completely
identified and did not respond to treatment with antibiotics.
Because of this, chemotherapy was never started.  His intense
left hip pain continued and he had an MRI which showed that he
had diffuse marrow involvement by lymphoma.
.
# CNS lymphoma:  He presented with elevated LDH. He also had
very severe buttock pain which did not improve with antibiotics.
 There was no cause identiied by the CT abdomen and pelvis, he
received an MRI lumbar/sacral spine which showed diffuse marrow
involvement by lymphoma. After a discussion with his family
indicating that he had very advanced lymphoma after he had
already undergone a complete course of chemotherapy and that
there were not more options we could give him for treatment, he
was transitioned to comfort measures and passed away.
.
# Infectious colitis:  He had a history of C.diff in [**7-/2156**] and
was supposed to be taking oral vancomycin as an outpatient.
However it is unclear whether he was actually taking the
medication.  During admission, he began to have increasing
abdominal pain and swelling with WBC rising, up to 43K.  Acute
abdominal series did not show megacolon or free air but repeat
CT abdomen [**10-12**] did show worsening pancolitis compared to [**10-8**]
despite treatment with po vancomycin, IV metronidazole, and
tigecycline.  The infectious disease team was consulted to
assist with possible other causes of leukocytosis and pancolitis
since his C. diff toxin and PCR was negative.  His CMV viral
load was negative.  His stool cultures were negative for all
pathogens.  He underwent a flexible sigmoidoscopy which showed
nodules which may have been consistent with pseudomembranous
colitis, however, the biopsies are still pending.
.
CHRONIC ISSUES BY PROBLEM:
# HIV: Last CD4 count 60 on [**9-19**] due to poor compliance with his
medications.  He has a social worker as an outpatient to assist
with adherence and getting medications.  His HIV viral load was
undetectable.  He was restarted on his home anti-retroviral
medications as well as his prophylaxis for PCP and herpes,
however, he did not take oral medications due to pain.
.
# Adrenal insufficiency:  Patient had a history of primary
adrenal insufficiency and he was on chronic replacement at home
with hydrocortisone.   Although this can cause abdominal pain
and diarrhea if he were in an adrenal crisis, he also had signs
of acute infectious colitis on the CT scan and leukocytosis.  He
was supported with higher doses of hydrocort IV while he was
acutely ill.


Medications on Admission:
topiramate 25 mg daily
ritonavir 100 mg [**Hospital1 **]
raltegravir 400 mg [**Hospital1 **]
darunavir 600 mg [**Hospital1 **]
acyclovir 400 mg q8h
atovaquone 1500 mg/10 mL daily
tizanidine 2 mg qid
emtricitabine-tenofovir 200-300 mg daily
levetiracetam 500 mg [**Hospital1 **]
olanzapine 5 mg daily
clonazepam 1 mg tid
vancomycin 125 mg q12h
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]
hydromorphone 5 mg q6h
morphine CR 60 mg q12h
acetaminophen 500 mg q6h
levothyroxine 125 mcg daily
hydrocortisone 20 mg qam, 10 mg qhs
Zofran 4 mg q8h

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Aggressive widespread, relapsed lymphoma
C. diff colitis
.
SECONDARY DIAGNOSIS:
Human immunodeficiency virus


Discharge Condition:
expired


Discharge Instructions:
expired

Followup Instructions:
expired
{'Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other malignant lymphomas, lymph nodes of multiple sites,Intestinal infection due to Clostridium difficile,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pain in joint, pelvic region and thigh,Do not resuscitate status,Encounter for palliative care'}


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: "chemo"

PRESENT ILLNESS: Mr. [**Known lastname **] is a 30 yo M with HIV c/b CNS lymphoma who presents for
HD-MTX, cycle 6.  He has been having a cough "on and off" for
the past few weeks and has generally felt tired.  He also
reports that he doesn't always take his medications for HIV and
PCP [**Name Initial (PRE) 1102**].
.
Currently, he is in lots of pain and feels tired.  He denies
everything on review of systems except that he has left buttock
pain (no rash) and has had a cough for "some time".
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: Oncologic History:
High-grade B-cell lymphoma with mediastinal mass, LAD and CNS
involvement
- [**2156-1-23**] to [**2156-1-26**] - cycle 1 [**Hospital1 **]
- [**2156-2-1**] - cycle 1 Rituxan
- [**2156-2-7**] to [**2156-2-11**] - cycle 1 IVAC
- [**2156-2-27**] - IT cytarabine and cycle 2 Rituxan
- [**2156-3-1**] to [**2156-3-4**] - cycle 2 [**Hospital1 **]
- [**2156-4-1**] to [**2156-4-4**] - cycle 3 [**Hospital1 **]
- [**2156-4-9**]: Cycle 3 rituximab.
- [**2156-4-22**]: Cycle #4 [**Hospital1 **].
- [**2156-5-20**]: Cycle #5 [**Hospital1 **].
- [**Month (only) 205**],[**2156-8-2**]: 4 cycles high dose MTX

MEDICATION ON ADMISSION: topiramate 25 mg daily
ritonavir 100 mg [**Hospital1 **]
raltegravir 400 mg [**Hospital1 **]
darunavir 600 mg [**Hospital1 **]
acyclovir 400 mg q8h
atovaquone 1500 mg/10 mL daily
tizanidine 2 mg qid
emtricitabine-tenofovir 200-300 mg daily
levetiracetam 500 mg [**Hospital1 **]
olanzapine 5 mg daily
clonazepam 1 mg tid
vancomycin 125 mg q12h
albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]
hydromorphone 5 mg q6h
morphine CR 60 mg q12h
acetaminophen 500 mg q6h
levothyroxine 125 mcg daily
hydrocortisone 20 mg qam, 10 mg qhs
Zofran 4 mg q8h

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS - Temp 97.4F, BP 120/70, HR 107, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, moderately uncomfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP dry
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding, seems mildly bloated, not tympanic to
percussion
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: Father with mesothelioma. Mother with asthma. Family history of
HTN and DM.

SOCIAL HISTORY: Pt lived with his aunt and uncle but his uncle recently died.
He is unemployed and collect [**Social Security Number 55849**]social security.  History of sex
work with male clients and unprotected, receptive anal
intercourse.  Hx of MDMA, crystal meth, and intranasal cocaine
use.  Denies ever IV drugs.  Diminished use recently of illicit
drugs but not abstinent.  Smokes about 1 pack per day of
cigarettes.  Social EtOH use. 

### Response:
{'Human immunodeficiency virus [HIV] disease,Acute respiratory failure,Other malignant lymphomas, lymph nodes of multiple sites,Intestinal infection due to Clostridium difficile,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Pain in joint, pelvic region and thigh,Do not resuscitate status,Encounter for palliative care'}
