CHIEF COMPLAINT: Knee pain and mental status changes

PRESENT ILLNESS: 54 yo female with hx of polysubstance abuse, HIV, and recurrent
knee and chest pain presents with knee pain and confusion.
Unable to obtain history as pt will not respond to verbal
command. Pt is well known to the ED and often presents
complaining of chest pain and knee pain requesting pain
medications. Per ED team the patient presented complaining of
her usual knee pain but was somewhat more agitated. She denied
using any illicit substances but became severely agitated and
was given IM haldol 5mg. She seen putting something in her pants
and on exam the staff found a glass pipe. AP view of the pelvis
was performed to rule out foreign body which was negative.  LP
was performed which revealed lymphocytic pleocytosis and she was
started on vancomycin, ceftriaxone, and acyclovir. Labs revealed
that she was in acute renal failure with elevated CK's with tox
screen positive for opiates and cocaine. Her only complaint at
this time is rt knee pain. She denies fever, chills, neck
stiffness or photophobia.

MEDICAL HISTORY: 1. HIV secondary to intravenous drug use x16 years. CD4
count as discussed above.
2. Has a history of MSSA bacteremia in [**2126-8-22**].
3. Pneumonia.
4. Bronchitis.
5. Asthma.
6. Hypertension.
7. Herniated disk.
8. Neuropathy secondary to HIV.
9. Remote history of polysubstance abuse.
10. ? ovarian cancer

MEDICATION ON ADMISSION: (Not taking this meds consistently prior to admission)
1. Sertraline
2. Lamivudine
3. Indinavir
4. Nevirapine
5. Percocet
6. Moexipril

ALLERGIES: Penicillin G

PHYSICAL EXAM: T 98.3 HR 110 BP 120/64 RR 14 O2Sat 98% [**Female First Name (un) **]
Gen-arousable to loud voice, otherwise NAD
HEENT-PERRL, exophthalmos, neck supple, ant and supraclavic
shoody LAD, thyroid not enlarged and no bruit
Hrt-tachy RR, nS1S2 diffuse flow murmur across the precordium
Lungs-CTA bilat
Abd-soft, NT, ND, no HSM, NABS
Extrem-2+ rad and dp pulses, left knee effusion which is warm
but no erythema, painful ROM of left knee but able to flex to
120 degrees and fully extend
Neuro-pt noncompliant with exam
Skin-no clear injection sites

FAMILY HISTORY: Family hx: Mother had MI (unknown age)

SOCIAL HISTORY: SOCIAL HISTORY: Patient is homeless and lives in a shelter.
She has an autistic son. She smokes [**2-24**] cigarettes per day.
Denies any use of alcohol or drugs - although previous records
indicate opiate and cocaine use
Acute kidney failure, unspecified,Cocaine dependence, unspecified,Human immunodeficiency virus [HIV] disease,Rhabdomyolysis,Hypovolemia,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Mononeuritis of lower limb, unspecified,Other specified cardiac dysrhythmias,Sprains and strains of unspecified site of knee and leg,Unspecified fall,Unspecified essential hypertension,Asthma, unspecified type, unspecified
Acute kidney failure NOS,Cocaine depend-unspec,Human immuno virus dis,Rhabdomyolysis,Hypovolemia,Loc osteoarth NOS-l/leg,Mononeuritis leg NOS,Cardiac dysrhythmias NEC,Sprain of knee & leg NOS,Fall NOS,Hypertension NOS,Asthma NOS
Admission Date:  [**2131-2-25**]              Discharge Date:   [**2131-3-6**]

Date of Birth:  [**2076-9-7**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillin G

Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Knee pain and mental status changes

Major Surgical or Invasive Procedure:
Lumbar puncture
arthocentesis
Steroid injection into R knee

History of Present Illness:
54 yo female with hx of polysubstance abuse, HIV, and recurrent
knee and chest pain presents with knee pain and confusion.
Unable to obtain history as pt will not respond to verbal
command. Pt is well known to the ED and often presents
complaining of chest pain and knee pain requesting pain
medications. Per ED team the patient presented complaining of
her usual knee pain but was somewhat more agitated. She denied
using any illicit substances but became severely agitated and
was given IM haldol 5mg. She seen putting something in her pants
and on exam the staff found a glass pipe. AP view of the pelvis
was performed to rule out foreign body which was negative.  LP
was performed which revealed lymphocytic pleocytosis and she was
started on vancomycin, ceftriaxone, and acyclovir. Labs revealed
that she was in acute renal failure with elevated CK's with tox
screen positive for opiates and cocaine. Her only complaint at
this time is rt knee pain. She denies fever, chills, neck
stiffness or photophobia.

Past Medical History:
1. HIV secondary to intravenous drug use x16 years. CD4
count as discussed above.
2. Has a history of MSSA bacteremia in [**2126-8-22**].
3. Pneumonia.
4. Bronchitis.
5. Asthma.
6. Hypertension.
7. Herniated disk.
8. Neuropathy secondary to HIV.
9. Remote history of polysubstance abuse.
10. ? ovarian cancer

Social History:
SOCIAL HISTORY: Patient is homeless and lives in a shelter.
She has an autistic son. She smokes [**2-24**] cigarettes per day.
Denies any use of alcohol or drugs - although previous records
indicate opiate and cocaine use


Family History:
Family hx: Mother had MI (unknown age)

Physical Exam:
T 98.3 HR 110 BP 120/64 RR 14 O2Sat 98% [**Female First Name (un) **]
Gen-arousable to loud voice, otherwise NAD
HEENT-PERRL, exophthalmos, neck supple, ant and supraclavic
shoody LAD, thyroid not enlarged and no bruit
Hrt-tachy RR, nS1S2 diffuse flow murmur across the precordium
Lungs-CTA bilat
Abd-soft, NT, ND, no HSM, NABS
Extrem-2+ rad and dp pulses, left knee effusion which is warm
but no erythema, painful ROM of left knee but able to flex to
120 degrees and fully extend
Neuro-pt noncompliant with exam
Skin-no clear injection sites

Pertinent Results:
[**2131-2-25**] 09:27PM JOINT FLUID  WBC-900* RBC-[**Numeric Identifier **]* POLYS-36*
LYMPHS-16 MONOS-46 MACROPHAG-2
[**2131-2-25**] 09:27PM JOINT FLUID  NUMBER-NONE
[**2131-2-25**] 08:58PM   GLUCOSE-98 UREA N-44* CREAT-1.6*# SODIUM-136
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-15
[**2131-2-25**] 08:58PM   CK(CPK)-1337*
[**2131-2-25**] 08:58PM   CK-MB-29* MB INDX-2.2 cTropnT-0.03*
[**2131-2-25**] 08:58PM   CALCIUM-7.4* PHOSPHATE-3.2# MAGNESIUM-2.3
[**2131-2-25**] 08:58PM   TSH-0.023*
[**2131-2-25**] 01:35PM   CK(CPK)-1464*
[**2131-2-25**] 12:00PM CEREBROSPINAL FLUID (CSF)  PROTEIN-39
GLUCOSE-64
[**2131-2-25**] 12:00PM CEREBROSPINAL FLUID (CSF)  WBC-9 RBC-0 POLYS-0
LYMPHS-97 MONOS-3
[**2131-2-25**] 12:00PM CEREBROSPINAL FLUID (CSF)  WBC-29 RBC-12*
POLYS-0 LYMPHS-90 MONOS-10
[**2131-2-25**] 11:45AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2131-2-25**] 11:45AM URINE  COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
[**2131-2-25**] 11:45AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
[**2131-2-25**] 11:45AM URINE  RBC-0-2 WBC-[**3-26**] BACTERIA-NONE YEAST-NONE
EPI-<1
[**2131-2-25**] 11:45AM URINE  GRANULAR-0-2
[**2131-2-25**] 10:09AM   TYPE-[**Last Name (un) **] COMMENTS-GREEN
[**2131-2-25**] 10:09AM   LACTATE-3.2*
[**2131-2-25**] 10:00AM   GLUCOSE-74 UREA N-55* CREAT-3.6*# SODIUM-138
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-21* ANION GAP-27*
[**2131-2-25**] 10:00AM   estGFR-Using this
[**2131-2-25**] 10:00AM   ALT(SGPT)-42* AST(SGOT)-93* CK(CPK)-2118* ALK
PHOS-90 AMYLASE-227* TOT BILI-0.6
[**2131-2-25**] 10:00AM   LIPASE-43
[**2131-2-25**] 10:00AM   cTropnT-0.13*
[**2131-2-25**] 10:00AM   CALCIUM-8.3* PHOSPHATE-10.2*# MAGNESIUM-2.0
[**2131-2-25**] 10:00AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-2-25**] 10:00AM   NEUTS-78.5* LYMPHS-14.7* MONOS-6.1 EOS-0.4
BASOS-0.2
[**2131-2-25**] 10:00AM   PLT COUNT-343
[**2131-2-25**] 10:00AM   PT-11.8 PTT-29.9 INR(PT)-1.0.
.
Pelvic XR
IMPRESSION: Small radiodensities over the left pelvis annot be
localized on this single projection, but are likely vascular
calcifications
.
Knee XR
IMPRESSION: No acute fracture or dislocation. Extensive
degenerative change of the lateral compartment as above. Small
right knee joint effusion
.
Admission CXR
IMPRESSION: No acute pulmonary process.
.
CT Head
IMPRESSION:
1. No acute hemorrhage or mass effect.
2. No significant change from [**2129-1-1**], including small subtle
low attenuation focus of the left frontal periventricular white
matter consistent with remote lacunar infarct.
.
R knee CT scan:
IMPRESSION:
1. Extensive erosive changes and destruction of the lateral
joint compartment of the knee with relative sparing of the
medial compartment and patellofemoral compartment. These changes
have steadily progressed dating back to previous radiographs
from [**2129-5-8**]. The most likely etiology would be an low
grade infectious process and given the HIV status of the
patient, atypical infections (TB, fungal) should be considered.
Other inflammatory arthropathies and synovial proliferative
processes such as rheumatoid arthritis, PVNS and gout also
should be considered.
2. No evidence of fracture.
3. Small loose bodies within the joint space. Large, joint
effusion.
.
TTE:
Conclusions:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall  left ventricular systolic function is normal
(LVEF>55%). Transmitral Doppler  and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal.  The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. Physiologic mitral regurgitation is seen (within normal
limits). The left ventricular inflow pattern suggests impaired
relaxation. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro
[**2131-2-25**] 09:27PM    900* [**Numeric Identifier **]* 36* 16 46 2
Source: Knee
JOINT FLUID  Crystal
[**2131-2-25**] 09:27PM    NONE
Source: Knee
.
[**2131-2-25**] 9:27 pm JOINT FLUID      Source: Knee.
      ACU & DAS ADDED PER DR.[**First Name (STitle) **] [**Doctor Last Name 9406**] ([**Numeric Identifier **]) [**2129-3-1**].
GRAM STAIN (Final [**2131-2-25**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2131-2-28**]):    NO GROWTH.
ACID FAST SMEAR (Final [**2131-3-2**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):


Brief Hospital Course:
A/P 54 yo female with hx of polysubstance abuse, HIV, and
recurrent knee and chest pain presents with knee pain and
confusion. s/p tap of R knee.
.
Mental Status change-Most likely etiology is cocaine overdose.
Believe elevated CK on admission was from cocaine as well.  Head
CT negative, no trauma.  Lymphocytic pleocytosis on LP not
concerning for bacterial meningitis and CSF did not grow
bacteria. TSH was checked and was low but T3/4 were normal.  Can
recheck as outpatient.  Mental status was back to normal by time
transferred to floor [**2131-2-28**].
.
Knee effusion- s/p arthrocentesis, no crystals on analysis of
joint fluid.  No evidence of septic joint.  C/w hemarthrosis
from mechanical fall.  See by ortho and had CT scan of knee.
Patient would benefit from TKR and should follow up with ortho
as an outpatient.  Given injection into R knee of ketalog and
lidocaine on [**3-6**].  Maintained on MS Contin 15mg [**Hospital1 **] with
percocets prn.  Was able to ambulate with walker and cleared by
PT for discharge.
.
ARF-Likely related to poor PO intake and not likely elevated CK.
Returned to baseline with IV hydration.
.
HIV-Prior CD4 count of 701.  Patient said no HAART for over a
year.  Recommend follow up with [**Hospital3 6616**] for further
evaluation.
.
HTN-Very elevated blood pressure.  Evidence of mild diastolic
dysfunction on TTE.  Want to avoid beta blockers with active
cocaine use.  Given clonidine patch and lisinopril.
.
SVT-On evening of [**2130-2-27**] had run for apparent AVNRT.  Broke with
adenosine.  TTE structurally normal.  Not using beta blockers
because of cocaine use.  No further intervention.
.
Polysubstance abuse-Seen extensively by social work for both
substance abuse and homelessness.  No bed available at [**First Name8 (NamePattern2) 2048**]
[**Last Name (NamePattern1) **] house but placed on wait list.  Given emotional support
while here.  Did not require valium on [**Doctor Last Name **] scale.
.
Elevated troponin-no ischemic ECG changes. Troponin elevation
due to cocaine and ARF. Troponins have trended down.
.
Uterine cancer: Question of history in past.  Encouraged
patient, esp with h/o HIV, to follow up for gyn appointment and
pap smear.  She did not want an appointment made for her.
.
Infection-Patient given 7 days levofloxacin while in house.
Unclear source of infection and no fevers.

Medications on Admission:
(Not taking this meds consistently prior to admission)
1. Sertraline
2. Lamivudine
3. Indinavir
4. Nevirapine
5. Percocet
6. Moexipril


Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*45 Tablet Sustained Release(s)* Refills:*0*
3. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 1* Refills:*2*
4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
Disp:*4 Patch Weekly(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Cocaine abuse
Prerenal azotemia leading to acute renal failure
HIV disease
Hypertension
Osteoarthritis and hemarthrosis


Discharge Condition:
Good


Discharge Instructions:
You were admitted with change in mental status believed to be
from cocaine use.  Please stop taking cocaine.  It is dangerous
to continue.
.
You have HIV and need to follow up in [**Hospital3 6616**] for further
management of the disease.
.
You have significant hypertension that could become dangerous if
it becomes more elevated.  Please change the clonidine patch
once a week (Tuesday) and take the lisinopril daily.  You need
to follow up with a primary care clinic in the next 2 weeks to
get your blood pressure and lab work rechecked (to check that
your kidneys are ok).
.
You have a follow up appointment for your right knee to be
evaluated for further injections and possible repair.

Followup Instructions:
Please make a follow up appointment with your a primary care
doctor in the next 2 weeks.
Please make a follow up appointment with a gynecologist in the
next month for a pap smear and follow up of ?uterine cancer.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2131-4-10**]
9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2131-4-13**] 3:20
{'Acute kidney failure, unspecified,Cocaine dependence, unspecified,Human immunodeficiency virus [HIV] disease,Rhabdomyolysis,Hypovolemia,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Mononeuritis of lower limb, unspecified,Other specified cardiac dysrhythmias,Sprains and strains of unspecified site of knee and leg,Unspecified fall,Unspecified essential hypertension,Asthma, unspecified type, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Knee pain and mental status changes

PRESENT ILLNESS: 54 yo female with hx of polysubstance abuse, HIV, and recurrent
knee and chest pain presents with knee pain and confusion.
Unable to obtain history as pt will not respond to verbal
command. Pt is well known to the ED and often presents
complaining of chest pain and knee pain requesting pain
medications. Per ED team the patient presented complaining of
her usual knee pain but was somewhat more agitated. She denied
using any illicit substances but became severely agitated and
was given IM haldol 5mg. She seen putting something in her pants
and on exam the staff found a glass pipe. AP view of the pelvis
was performed to rule out foreign body which was negative.  LP
was performed which revealed lymphocytic pleocytosis and she was
started on vancomycin, ceftriaxone, and acyclovir. Labs revealed
that she was in acute renal failure with elevated CK's with tox
screen positive for opiates and cocaine. Her only complaint at
this time is rt knee pain. She denies fever, chills, neck
stiffness or photophobia.

MEDICAL HISTORY: 1. HIV secondary to intravenous drug use x16 years. CD4
count as discussed above.
2. Has a history of MSSA bacteremia in [**2126-8-22**].
3. Pneumonia.
4. Bronchitis.
5. Asthma.
6. Hypertension.
7. Herniated disk.
8. Neuropathy secondary to HIV.
9. Remote history of polysubstance abuse.
10. ? ovarian cancer

MEDICATION ON ADMISSION: (Not taking this meds consistently prior to admission)
1. Sertraline
2. Lamivudine
3. Indinavir
4. Nevirapine
5. Percocet
6. Moexipril

ALLERGIES: Penicillin G

PHYSICAL EXAM: T 98.3 HR 110 BP 120/64 RR 14 O2Sat 98% [**Female First Name (un) **]
Gen-arousable to loud voice, otherwise NAD
HEENT-PERRL, exophthalmos, neck supple, ant and supraclavic
shoody LAD, thyroid not enlarged and no bruit
Hrt-tachy RR, nS1S2 diffuse flow murmur across the precordium
Lungs-CTA bilat
Abd-soft, NT, ND, no HSM, NABS
Extrem-2+ rad and dp pulses, left knee effusion which is warm
but no erythema, painful ROM of left knee but able to flex to
120 degrees and fully extend
Neuro-pt noncompliant with exam
Skin-no clear injection sites

FAMILY HISTORY: Family hx: Mother had MI (unknown age)

SOCIAL HISTORY: SOCIAL HISTORY: Patient is homeless and lives in a shelter.
She has an autistic son. She smokes [**2-24**] cigarettes per day.
Denies any use of alcohol or drugs - although previous records
indicate opiate and cocaine use 

### Response:
{'Acute kidney failure, unspecified,Cocaine dependence, unspecified,Human immunodeficiency virus [HIV] disease,Rhabdomyolysis,Hypovolemia,Osteoarthrosis, localized, not specified whether primary or secondary, lower leg,Mononeuritis of lower limb, unspecified,Other specified cardiac dysrhythmias,Sprains and strains of unspecified site of knee and leg,Unspecified fall,Unspecified essential hypertension,Asthma, unspecified type, unspecified'}
