CHIEF COMPLAINT: Headache

PRESENT ILLNESS: This is a 23 year old biologically female who identifies as a
male, with PMH significant for HIV (recently started [**Month/Day/Year 2775**]),
untreated Hep C, recent admission to [**Hospital1 18**] for zoster, but never
filled acyclovir script after he was discharged now presents
with fever, nausea and vomiting, dizzyness and lightheadedness.
.
The pt reports that he "can't keep anything down," and feels
like head is "being squeezed," and has a history of tension
headaches and migraines. He says this head pain "does not feel
like the usual migraine." Of note, the pt started [**Hospital1 2775**]
(Truvada, Reyataz, Norvir) on [**2197-2-21**]. The pt denies
photophobia, meningismus, endorses fever to 102 at home. He
endorses cough, sore throat, no chest pain or palpitations. He
endorses diarrhea "for a long time," nausea and vomiting for the
past two days. Labs on [**2197-2-7**] showed HIV VL: 931 cd4: 318.
.
In the ED, initial vs were: T 98.1, P 71, BP 130/79, RR 16, POx
100%.
CT head was unremarkable. Patient had an LP (opening pressure
was 15) and pt received: Ondansetron, Morphine, Acetaminophen,
Lorazepam, Dilaudid, CeftriaXONE, Ibuprofen, Acyclovir,
Vancomycin. During LP pt became more tachycardic, got morphine
as HR increased to 140. Tmax in ED was 103 with rigors. EKG at
pulse of 160 showed sinus tachycardia. On transfer to the ICU
the pt had received 4L NS, with pulse in the 130's. On exam pt
has faint rash over the left deltoid. Pt still uncomfortable,
with headache.

MEDICAL HISTORY: -Cerebral Palsy, s/p multiple achilles tendon surgeries, no
residual deficits per patient, mild urinary retentiona at times.
-HIV (not on [**Date Range 2775**]), dx approx 2 yrs ago. Took PMTCT 1 yr ago
successfully.  ([**2196-10-6**]) CD4 = 412, VL 2400
-Asthma, mild intermittent:  Has received FLU vaccine [**10-10**]
-Prior Thrush due to Advair for asthma
-Hepatitis C diagnosed in [**9-6**], no IFN therapy, last Hep C VL
not detected
-s/p Appendectom [**12-7**]
-Depression: Sees Dr. [**Last Name (STitle) 57035**] at [**Hospital3 55848**] Health Center,
Prozac tapered off 1 week ago, was to begin Cymbalta per her
report.
-History of Suicide Attempts:  last SA was in [**10-8**], requiring
ICU admission at [**Hospital 8**] Hospital. Pt overdosed on his
medications at that point (Prozac, Trileptal, Seroquel). Pt
-reports hx of 2 SA by OD, and 2 SA by cutting.  First SA at age
13-14. Self Cutting, last circa [**2191**], self reports near fatal
cut and has stopped Anorexia/bulimia, currently with active
behaviors including restricting and purging
-PTSD - rape survivor
-ADHD - on Concerta
-OCD
-Trauma/Abuse: last time this occured that patient is willing to
acknowledge is [**1-/2194**] but will not discuss incident.
h/o + UA/UTIs

MEDICATION ON ADMISSION: Truvada (Emtricitabine NRTI, Tenofovir nRTI)
Reyataz (Atazanavir protease inhibitor)
Norvir (Ritonavir protease inhibitor)
Cymbalta
Adderall
Trileptal

ALLERGIES: Latex / Fentanyl / Risperidone

PHYSICAL EXAM: Vitals: BP: 119/69 P: 106 R: 18 O2: 97% RA
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, unable to cooperate to
assess meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, otherwise normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No evidence of vesicles, erythema or crusting. Areas on
left upper extremities that may be former vesicles, now bland
appearing with no erythema
Neuro: A+Ox3, CN II-XII intact
Motor: [**4-5**] Upper and Lower extremities
Sensation: Intact
Gait assessment deferred

FAMILY HISTORY: Grandmother: Gallbladder issues
Aunt: Diabetes
Mother Cervical, ovarian, uterine [**Last Name (un) 3711**]

SOCIAL HISTORY: Complicated social history. Female-to-male gender, has all
female organs, does not take hormones. Currently lives in
[**Location 17065**] with 1 yo son. Hx of crystal meth per his report
today -- states has been clean for 4 years, though past records
indicate more recent use and prior use of heroin, cocaine use.
Occasional EtOH, last drink 1 wk ago (40oz beer daily). [**12-3**] PPD
tobacco.
Unspecified viral infection,Urinary tract infection, site not specified,Reaction to spinal or lumbar puncture,Asymptomatic human immunodeficiency virus [HIV] infection status,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Trans-sexualism with unspecified sexual history,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,Obsessive-compulsive disorders,Tobacco use disorder,Infantile cerebral palsy, unspecified,Leukocytopenia, unspecified,Disorders of bilirubin excretion,History of physical abuse,Personal history, urinary (tract) infection,Other acquired absence of organ,Phenothiazine-based tranquilizers causing adverse effects in therapeutic use
Viral infection NOS,Urin tract infection NOS,Lumbar puncture reaction,Asymp hiv infectn status,Chrnc hpt C wo hpat coma,Asthma NOS,Depressive disorder NEC,Trans-sexualism NOS,Posttraumatic stress dis,Attn deficit w hyperact,Obsessive-compulsive dis,Tobacco use disorder,Cerebral palsy NOS,Leukocytopenia NOS,Dis bilirubin excretion,Hx of physical abuse,Personal history UTI,Acq absence of organ NEC,Adv eff phenothiaz tranq
Admission Date:  [**2197-2-23**]              Discharge Date:   [**2197-3-1**]

Date of Birth:  [**2173-9-6**]             Sex:   F

Service: MEDICINE

Allergies:
Latex / Fentanyl / Risperidone

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Headache

Major Surgical or Invasive Procedure:
Lumbar puncture, blood patch [**2197-3-1**].

History of Present Illness:
This is a 23 year old biologically female who identifies as a
male, with PMH significant for HIV (recently started [**Month/Day/Year 2775**]),
untreated Hep C, recent admission to [**Hospital1 18**] for zoster, but never
filled acyclovir script after he was discharged now presents
with fever, nausea and vomiting, dizzyness and lightheadedness.
.
The pt reports that he "can't keep anything down," and feels
like head is "being squeezed," and has a history of tension
headaches and migraines. He says this head pain "does not feel
like the usual migraine." Of note, the pt started [**Hospital1 2775**]
(Truvada, Reyataz, Norvir) on [**2197-2-21**]. The pt denies
photophobia, meningismus, endorses fever to 102 at home. He
endorses cough, sore throat, no chest pain or palpitations. He
endorses diarrhea "for a long time," nausea and vomiting for the
past two days. Labs on [**2197-2-7**] showed HIV VL: 931 cd4: 318.
.
In the ED, initial vs were: T 98.1, P 71, BP 130/79, RR 16, POx
100%.
CT head was unremarkable. Patient had an LP (opening pressure
was 15) and pt received: Ondansetron, Morphine, Acetaminophen,
Lorazepam, Dilaudid, CeftriaXONE, Ibuprofen, Acyclovir,
Vancomycin. During LP pt became more tachycardic, got morphine
as HR increased to 140. Tmax in ED was 103 with rigors. EKG at
pulse of 160 showed sinus tachycardia. On transfer to the ICU
the pt had received 4L NS, with pulse in the 130's. On exam pt
has faint rash over the left deltoid. Pt still uncomfortable,
with headache.

After arriving in the ICU the patient appeared uncomfortable and
was tachycardic and tachypnic.

Past Medical History:
-Cerebral Palsy, s/p multiple achilles tendon surgeries, no
residual deficits per patient, mild urinary retentiona at times.
-HIV (not on [**Date Range 2775**]), dx approx 2 yrs ago. Took PMTCT 1 yr ago
successfully.  ([**2196-10-6**]) CD4 = 412, VL 2400
-Asthma, mild intermittent:  Has received FLU vaccine [**10-10**]
-Prior Thrush due to Advair for asthma
-Hepatitis C diagnosed in [**9-6**], no IFN therapy, last Hep C VL
not detected
-s/p Appendectom [**12-7**]
-Depression: Sees Dr. [**Last Name (STitle) 57035**] at [**Hospital3 55848**] Health Center,
Prozac tapered off 1 week ago, was to begin Cymbalta per her
report.
-History of Suicide Attempts:  last SA was in [**10-8**], requiring
ICU admission at [**Hospital 8**] Hospital. Pt overdosed on his
medications at that point (Prozac, Trileptal, Seroquel). Pt
-reports hx of 2 SA by OD, and 2 SA by cutting.  First SA at age
13-14. Self Cutting, last circa [**2191**], self reports near fatal
cut and has stopped Anorexia/bulimia, currently with active
behaviors including restricting and purging
-PTSD - rape survivor
-ADHD - on Concerta
-OCD
-Trauma/Abuse: last time this occured that patient is willing to
acknowledge is [**1-/2194**] but will not discuss incident.
h/o + UA/UTIs


Social History:
Complicated social history. Female-to-male gender, has all
female organs, does not take hormones. Currently lives in
[**Location 17065**] with 1 yo son. Hx of crystal meth per his report
today -- states has been clean for 4 years, though past records
indicate more recent use and prior use of heroin, cocaine use.
Occasional EtOH, last drink 1 wk ago (40oz beer daily). [**12-3**] PPD
tobacco.


Family History:
Grandmother: Gallbladder issues
Aunt: Diabetes
Mother Cervical, ovarian, uterine [**Last Name (un) 3711**]


Physical Exam:
Vitals: BP: 119/69 P: 106 R: 18 O2: 97% RA
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, unable to cooperate to
assess meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, otherwise normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No evidence of vesicles, erythema or crusting. Areas on
left upper extremities that may be former vesicles, now bland
appearing with no erythema
Neuro: A+Ox3, CN II-XII intact
Motor: [**4-5**] Upper and Lower extremities
Sensation: Intact
Gait assessment deferred

Pertinent Results:
LABORATORY DATA:
Complete Blood Count:
[**2197-2-23**] 03:10PM BLOOD WBC-5.0# RBC-4.46 Hgb-11.6* Hct-35.8*
MCV-80* MCH-26.1* MCHC-32.6 RDW-12.7 Plt Ct-272
[**2197-2-24**] 03:32AM BLOOD WBC-11.8*# RBC-3.93* Hgb-9.9* Hct-30.8*
MCV-79* MCH-25.2* MCHC-32.1 RDW-12.6 Plt Ct-157
[**2197-2-25**] 08:05AM BLOOD WBC-4.6# RBC-3.92* Hgb-10.0* Hct-30.9*
MCV-79* MCH-25.5* MCHC-32.4 RDW-12.9 Plt Ct-135*
[**2197-2-26**] 08:30AM BLOOD WBC-3.3* RBC-3.98* Hgb-10.0* Hct-31.3*
MCV-79* MCH-25.2* MCHC-32.0 RDW-12.8 Plt Ct-104*
[**2197-2-27**] 07:50AM BLOOD WBC-3.4* RBC-3.98* Hgb-10.1* Hct-31.6*
MCV-79* MCH-25.2* MCHC-31.8 RDW-13.1 Plt Ct-154
[**2197-2-28**] 08:05AM BLOOD WBC-3.8* RBC-4.06* Hgb-10.6* Hct-32.2*
MCV-79* MCH-26.2* MCHC-33.1 RDW-13.0 Plt Ct-215
[**2197-3-1**] 07:40AM BLOOD WBC-4.4 RBC-4.52 Hgb-11.2* Hct-35.6*
MCV-79* MCH-24.8* MCHC-31.5 RDW-13.0 Plt Ct-252
[**2197-2-23**] 03:10PM BLOOD Neuts-69.3 Lymphs-25.9 Monos-3.3 Eos-0.6
Baso-0.9
.
Coagulation Profile:
[**2197-3-1**] 07:40AM BLOOD PT-12.5 PTT-30.1 INR(PT)-1.1
.
Basic Metabolic Profile:
[**2197-2-23**] 03:10PM BLOOD Glucose-93 UreaN-5* Creat-0.7 Na-138
K-3.4 Cl-103 HCO3-26 AnGap-12
[**2197-3-1**] 07:40AM BLOOD Glucose-89 UreaN-6 Creat-0.6 Na-139 K-3.7
Cl-103 HCO3-27 AnGap-13
[**2197-2-24**] 03:32AM BLOOD Calcium-7.5* Phos-3.8 Mg-1.3*
[**2197-3-1**] 07:40AM BLOOD Calcium-8.8 Phos-4.8* Mg-1.9
.
Liver Function Tests:
[**2197-2-23**] 03:10PM BLOOD ALT-31 AST-34 LD(LDH)-146 AlkPhos-76
TotBili-2.9* DirBili-0.4* IndBili-2.5
[**2197-2-25**] 08:05AM BLOOD ALT-21 AST-29 LD(LDH)-162 AlkPhos-67
TotBili-3.4*
.
[**2197-2-24**] 03:32AM BLOOD Hapto-143
[**2197-2-23**] 03:10PM BLOOD TSH-0.67
[**2197-2-23**] 07:05PM BLOOD Lactate-1.5
.
Urine:
[**2197-2-23**] 03:45PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2197-2-23**] 03:45PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2197-2-23**] 03:45PM URINE RBC-[**5-11**]* WBC-[**2-3**] Bacteri-MOD Yeast-NONE
Epi-[**5-11**]
.
MICROBIOLOGY:
[**2197-2-25**] 08:05AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
NEGATIVE
[**2197-2-25**] 08:05AM BLOOD B-GLUCAN-Test NEGATIVE
[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
NEGATIVE
[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test POSITIVE

[**2197-2-24**] 10:16AM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-Test NEGATIVE
.
Blood Culture: [**2197-2-23**]: no growth to date.
.
CSF Analysis: [**2197-2-23**]:
 GRAM STAIN (Final [**2197-2-23**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
 FLUID CULTURE (Final [**2197-2-26**]):    NO GROWTH.

 CRYPTOCOCCAL ANTIGEN (Final [**2197-2-24**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
           (Reference Range-Negative).
      Performed by latex agglutination.
      Results should be evaluated in light of culture results
and clinical
      presentation.

 FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
CSF Viral Culture: [**2197-2-23**]: No virus isolated thus far.
.
URINE CULTURE (Final [**2197-2-25**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
.
Monospot Test: [**2197-2-24**]: MONOSPOT (Final [**2197-2-25**]): NEGATIVE by
Latex Agglutination.
.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2197-2-27**]):    NEGATIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2197-2-27**]):    NEGATIVE BY
EIA. [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2197-2-27**]):
      NEGATIVE <1:10 BY IFA.
      INTERPRETATION:  NO ANTIBODY DETECTED.
      In most populations, 90% of adults have been infected at
sometime
      with EBV and will have measurable VCA IgG and EBNA
antibodies.
      Antibodies to EBNA develop 6-8 weeks after primary
infection and
      remain present for life. Presence of VCA IgM antibodies
indicates
      recent primary infection.
.
CMV Viral Load [**2197-2-25**]: CMV DNA not detected.
.
HCV VIRAL LOAD (Final [**2197-2-27**]): 558,000 IU/mL.
.
ECG ([**2197-2-23**]): Narrow complex tachycardia which is likely sinus
tachycardia. Compared to the previous tracing of [**2194-12-31**] the
rate has increased.
.
ECG ([**2197-2-26**]): Sinus bradycardia with atrial premature beats.
Compared to the previous tracing of [**2197-2-23**] the rate has
decreased. ST-T wave changes are not seen on the current
tracing.
.
CT Head ([**2197-2-23**]): IMPRESSION: No acute intracranial process.
.
CXR ([**2197-2-23**]): IMPRESSION: No acute pulmonary process.

Brief Hospital Course:
23 year old biologically female who identifies as male gender
with a history of HIV, Hepatitis C, and recent admission for
zoster presents with fever, tachycardia and headache a few days
after initiation of [**Month/Day/Year 2775**].
.
# Headache: Presented to ED with fever, tachycardia, and mild
headache.  The initial differential for headache in this patient
included viral meningitis given recent history of zoster
infection and incomplete acyclovir course, bacterial meningitis,
and reaction to [**Month/Day/Year 2775**] meds.  Head CT was without acute
pathology.  Patient was empirically started on vancomycin,
ceftriaxone, and acyclovir, which were discontinued after CSF
did not suggest bacterial meningitis.  Acyclovir was empirically
continued due to persistent headache until CSF HSV PCR was
negative.  Pain control was provided initially with IV Dilaudid
which was transitioned to PO morphine.  IV caffeine and fiorocet
were both attempted without success.  Due to suspicion that
worsening headache was secondary to lumbar puncture, pain
service was consulted and blood patch was placed on [**2197-3-1**] with
good effect.  Patient was discharged home with short supply of
PO morphine.  [**Date Range 2775**] medication was held upon admission and per
PCP, [**Name10 (NameIs) **] held at the time of discharge.  PCP to have
discussions with patient in regards to her [**Name10 (NameIs) 2775**] medication.
.
# Fever: Unknown etiology, but possible secondary to to viral
syndrome, NOS.  Blood, CSF and urine cultures did not yield any
organisms to date.  Chest xray was unremarkable.  Head CT and LP
WNL.  [**Month (only) 116**] have also been a hypersensitivity reaction to [**Month (only) 2775**]
meds.  Empiric antibactial antibiotics were discontinued as
fevers resolved and no clear source of infection could be
identified.
.
# Tachycardia: The patient was tachycardic on presentation.
Sinus tachycardia seen on EKG.  Likely secondary to pain,
headache, or viral syndrome.  Pt denied chest pain,
palpitations, shortness of breath.  The patient did endorse a
fire-like pain over L UE, which may be secondary to
post-herpetic neuralgia.  The patient was maintained on
telemetry overnight, given IV hydration and pain control as
above.
.
# Hyperbilirubinemia: No evidence of jaundice on exam.  Mild
tenderness to palpation over abdomen on exam.  LDH was normal,
and anemia was at baseline, so unlikely elevated bili due to
hemolysis.  Likely due to current [**Month (only) 2775**] regimen.  Possibly
secondary to [**Doctor Last Name **] Syndrome in the setting of poor PO intake.
Lactate is 1.5 which made cholangitis less likely.  No further
imaging was performed.
.
# HIV: The patient was diagnosed with HIV several years ago, and
had not been on [**Doctor Last Name 2775**] until this past week.  Most recent labs
showed VL: 931, CD4: 318. Given fever, tachycardia and headache,
which may all be secondary to [**Doctor Last Name 2775**] side effects, [**Doctor Last Name 2775**] was held
on admission.  After discussions with PCP, [**Name10 (NameIs) 2775**] was
discontinued at the time of discharge.
.
# Hepatitis C: Never treated.  Hepatology follow up is in place.

.
# History of Anorexia/Bulemia:  Monitored intake and
electrolytes.

Medications on Admission:
Truvada (Emtricitabine NRTI, Tenofovir nRTI)
Reyataz (Atazanavir protease inhibitor)
Norvir (Ritonavir protease inhibitor)
Cymbalta
Adderall
Trileptal


Discharge Medications:
1. Oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
Disp:*15 Tablet(s)* Refills:*0*
4. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Medication
Adderall - please continue taking the dose that you were
previously taking.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Viral syndrome, NOS
- Post Lumbar puncture headache

Secondary:
- Cerebral palsy
- HIV

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


Discharge Instructions:
You were admitted to the hospital because you developed a severe
headache, nausea, vomiting and fevers.  We performed a lumbar
punture as we were concerned that this was due to bacterial
meningitis, however it did not appear to be the case.  You were
initially started on antibiotics, but these were discontinued
after we confirmed that you did not have meningitis.  Your
symptoms improved, fevers resolved and you are ready to go home.
 You had a blood patch done on [**3-1**] to help relieve your
headache.

We made the following changes to your medications:

We STARTED you on Morphine 15mg every six hours as needed for
pain.  Please do not drive or drink alcohol while taking this
medication.  Please arrainge for assistance to care of your
child when taking this medication.

We STOPPED your medications for HIV.  Please follow up with Dr.
[**Last Name (STitle) **] before resuming these medications.

Please continue to take all your other medications as
prescribed.

Please follow up with your primary care doctor as shown below.

Followup Instructions:
You have the following follow-up appointments:

Please follow up with Dr. [**First Name4 (NamePattern1) 2855**] [**Last Name (NamePattern1) **] on [**3-8**] at 2pm. His
phone number is [**Telephone/Fax (1) 43944**].

Hepatology:
Please follow up with:
Department: LIVER CENTER
When: THURSDAY [**2197-5-4**] at 9:15 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST    Best Parking: [**Hospital Ward Name **] Garage
{'Unspecified viral infection,Urinary tract infection, site not specified,Reaction to spinal or lumbar puncture,Asymptomatic human immunodeficiency virus [HIV] infection status,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Trans-sexualism with unspecified sexual history,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,Obsessive-compulsive disorders,Tobacco use disorder,Infantile cerebral palsy, unspecified,Leukocytopenia, unspecified,Disorders of bilirubin excretion,History of physical abuse,Personal history, urinary (tract) infection,Other acquired absence of organ,Phenothiazine-based tranquilizers causing adverse effects in therapeutic use'}


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: Headache

PRESENT ILLNESS: This is a 23 year old biologically female who identifies as a
male, with PMH significant for HIV (recently started [**Month/Day/Year 2775**]),
untreated Hep C, recent admission to [**Hospital1 18**] for zoster, but never
filled acyclovir script after he was discharged now presents
with fever, nausea and vomiting, dizzyness and lightheadedness.
.
The pt reports that he "can't keep anything down," and feels
like head is "being squeezed," and has a history of tension
headaches and migraines. He says this head pain "does not feel
like the usual migraine." Of note, the pt started [**Hospital1 2775**]
(Truvada, Reyataz, Norvir) on [**2197-2-21**]. The pt denies
photophobia, meningismus, endorses fever to 102 at home. He
endorses cough, sore throat, no chest pain or palpitations. He
endorses diarrhea "for a long time," nausea and vomiting for the
past two days. Labs on [**2197-2-7**] showed HIV VL: 931 cd4: 318.
.
In the ED, initial vs were: T 98.1, P 71, BP 130/79, RR 16, POx
100%.
CT head was unremarkable. Patient had an LP (opening pressure
was 15) and pt received: Ondansetron, Morphine, Acetaminophen,
Lorazepam, Dilaudid, CeftriaXONE, Ibuprofen, Acyclovir,
Vancomycin. During LP pt became more tachycardic, got morphine
as HR increased to 140. Tmax in ED was 103 with rigors. EKG at
pulse of 160 showed sinus tachycardia. On transfer to the ICU
the pt had received 4L NS, with pulse in the 130's. On exam pt
has faint rash over the left deltoid. Pt still uncomfortable,
with headache.

MEDICAL HISTORY: -Cerebral Palsy, s/p multiple achilles tendon surgeries, no
residual deficits per patient, mild urinary retentiona at times.
-HIV (not on [**Date Range 2775**]), dx approx 2 yrs ago. Took PMTCT 1 yr ago
successfully.  ([**2196-10-6**]) CD4 = 412, VL 2400
-Asthma, mild intermittent:  Has received FLU vaccine [**10-10**]
-Prior Thrush due to Advair for asthma
-Hepatitis C diagnosed in [**9-6**], no IFN therapy, last Hep C VL
not detected
-s/p Appendectom [**12-7**]
-Depression: Sees Dr. [**Last Name (STitle) 57035**] at [**Hospital3 55848**] Health Center,
Prozac tapered off 1 week ago, was to begin Cymbalta per her
report.
-History of Suicide Attempts:  last SA was in [**10-8**], requiring
ICU admission at [**Hospital 8**] Hospital. Pt overdosed on his
medications at that point (Prozac, Trileptal, Seroquel). Pt
-reports hx of 2 SA by OD, and 2 SA by cutting.  First SA at age
13-14. Self Cutting, last circa [**2191**], self reports near fatal
cut and has stopped Anorexia/bulimia, currently with active
behaviors including restricting and purging
-PTSD - rape survivor
-ADHD - on Concerta
-OCD
-Trauma/Abuse: last time this occured that patient is willing to
acknowledge is [**1-/2194**] but will not discuss incident.
h/o + UA/UTIs

MEDICATION ON ADMISSION: Truvada (Emtricitabine NRTI, Tenofovir nRTI)
Reyataz (Atazanavir protease inhibitor)
Norvir (Ritonavir protease inhibitor)
Cymbalta
Adderall
Trileptal

ALLERGIES: Latex / Fentanyl / Risperidone

PHYSICAL EXAM: Vitals: BP: 119/69 P: 106 R: 18 O2: 97% RA
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, unable to cooperate to
assess meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, otherwise normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No evidence of vesicles, erythema or crusting. Areas on
left upper extremities that may be former vesicles, now bland
appearing with no erythema
Neuro: A+Ox3, CN II-XII intact
Motor: [**4-5**] Upper and Lower extremities
Sensation: Intact
Gait assessment deferred

FAMILY HISTORY: Grandmother: Gallbladder issues
Aunt: Diabetes
Mother Cervical, ovarian, uterine [**Last Name (un) 3711**]

SOCIAL HISTORY: Complicated social history. Female-to-male gender, has all
female organs, does not take hormones. Currently lives in
[**Location 17065**] with 1 yo son. Hx of crystal meth per his report
today -- states has been clean for 4 years, though past records
indicate more recent use and prior use of heroin, cocaine use.
Occasional EtOH, last drink 1 wk ago (40oz beer daily). [**12-3**] PPD
tobacco. 

### Response:
{'Unspecified viral infection,Urinary tract infection, site not specified,Reaction to spinal or lumbar puncture,Asymptomatic human immunodeficiency virus [HIV] infection status,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Depressive disorder, not elsewhere classified,Trans-sexualism with unspecified sexual history,Posttraumatic stress disorder,Attention deficit disorder with hyperactivity,Obsessive-compulsive disorders,Tobacco use disorder,Infantile cerebral palsy, unspecified,Leukocytopenia, unspecified,Disorders of bilirubin excretion,History of physical abuse,Personal history, urinary (tract) infection,Other acquired absence of organ,Phenothiazine-based tranquilizers causing adverse effects in therapeutic use'}
