CHIEF COMPLAINT: Fever, cough, dyspnea

PRESENT ILLNESS: This is an 81M with HIV, last CD4 369 in [**Month (only) 404**], prostate CA
s/p chemo/XRT recently stopped for treatment failure (no PSA
response) who presented to his PCP [**Name Initial (PRE) 151**] 3 days of worsening
generalized fatigue and malaise and dyspnea.  He also notes that
he and his partner had URTI about 2 weeks ago that improved and
he denied recent fever and cough. On admission, he required 0-2L
to maintain 02 >95%, he had WBC 13.6 (82%N, 0%B), acute on
chronic renal failure BUN/Cr 36/1.8. CXR showed a left lingular
PNA and he was started on Levofloxacin for presumed CAP.
.
The patient specifically denies chest pain, but does note some
dizziness.  His dyspnea is not positional. Since his retirement
2 years ago he has traveled extensively to [**Location (un) **], [**Country 26231**],
[**Country 3396**], [**Country 651**], most of Europe.  He denies any febrile
illnesses on any trip.  He also denies history of TB or known
exposure to TB, and had a PPD several years ago that was
negative.
.
On the inpatient floor, the patient felt well other than
reporting continued generalized weakness/fatigue that is not his
baseline. No cough.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: - HIV, diagnosed ~[**2089**], CD4 369 [**12/2107**]
- Prostate CA, s/p XRT/hormonal chemo (PSA unresponsive)
- HTN
- Hyperlipidemia

MEDICATION ON ADMISSION: - Aspirin 81 mg PO Daily
- One Daily Multivitamin PO daily
- Calcium PO daily
- Pravastatin 40 mg QHS
- Lopinavir-ritonavir 200 mg-50 mg 3 tablets [**Hospital1 **]
- Enalapril-hydrochlorothiazide 10 mg-25 mg PO Daily
- Acyclovir 400 mg PO Twice Daily
- Fish oil-fat acid comb8-herb comb137 1,200 mg (400
mg-400mg-400mg) PO daily
- Etravirine 100 mg 2 tablets PO daily
- Lorazepam 1 mg PO QHS
- desonide 0.05 % Topical Cream Topical [**Hospital1 **] to rash in ears
[- Bicalutamide 50 mg PO daily] stopped recently; PSA
nonresponsive
[- finasteride 5 mg PO daily] stopped recently; PSA
nonresponsive

ALLERGIES: Penicillins / metformin

PHYSICAL EXAM: ON ADMISSION:
VS - Temp 100.4F, BP 140/60, HR 78, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaking full sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no wheezing or rhonchi, min crackles at
bilateral bases, good air movement, resp unlabored, no accessory
muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no crepitus
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait not tested
.
ON ADMISSION TO ICU:
GENERAL - well-appearing man using abdominal muscles, but
stating he feels comfortable speaking full sentences but
somewhat short of breath at the end of his sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -
HEART - RRR, distant heart sounds, no rub appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: Mother deceased at [**Age over 90 **]yo; brother and sister alive at 82 and 83
with no medical problems.

SOCIAL HISTORY: Born in [**Country 26232**]. Has traveled extensively over past 2 years
to [**Location (un) **], [**Country 26231**], [**Country 3396**], [**Country 651**], most of Europe. Lives with
male partner who is a psychiatrist. Prior tobacco, quit 16y ago,
unclear pack-years. Denies ETOH. Former illicts, denies ever
IVDU, quit 18y ago.
Bacterial pneumonia, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dehydration,Asymptomatic human immunodeficiency virus [HIV] infection status,Diarrhea,Other and unspecified hyperlipidemia,Anemia, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of prostate
Bacterial pneumonia NOS,Acute respiratry failure,Acute kidney failure NOS,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Dehydration,Asymp hiv infectn status,Diarrhea,Hyperlipidemia NEC/NOS,Anemia NOS,Elev transaminase/ldh,Hx-prostatic malignancy
Admission Date:  [**2108-4-10**]              Discharge Date:   [**2108-4-22**]

Date of Birth:  [**2027-2-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / metformin

Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Fever, cough, dyspnea

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is an 81M with HIV, last CD4 369 in [**Month (only) 404**], prostate CA
s/p chemo/XRT recently stopped for treatment failure (no PSA
response) who presented to his PCP [**Name Initial (PRE) 151**] 3 days of worsening
generalized fatigue and malaise and dyspnea.  He also notes that
he and his partner had URTI about 2 weeks ago that improved and
he denied recent fever and cough. On admission, he required 0-2L
to maintain 02 >95%, he had WBC 13.6 (82%N, 0%B), acute on
chronic renal failure BUN/Cr 36/1.8. CXR showed a left lingular
PNA and he was started on Levofloxacin for presumed CAP.
.
The patient specifically denies chest pain, but does note some
dizziness.  His dyspnea is not positional. Since his retirement
2 years ago he has traveled extensively to [**Location (un) **], [**Country 26231**],
[**Country 3396**], [**Country 651**], most of Europe.  He denies any febrile
illnesses on any trip.  He also denies history of TB or known
exposure to TB, and had a PPD several years ago that was
negative.
.
On the inpatient floor, the patient felt well other than
reporting continued generalized weakness/fatigue that is not his
baseline. No cough.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

Past Medical History:
- HIV, diagnosed ~[**2089**], CD4 369 [**12/2107**]
- Prostate CA, s/p XRT/hormonal chemo (PSA unresponsive)
- HTN
- Hyperlipidemia

Social History:
Born in [**Country 26232**]. Has traveled extensively over past 2 years
to [**Location (un) **], [**Country 26231**], [**Country 3396**], [**Country 651**], most of Europe. Lives with
male partner who is a psychiatrist. Prior tobacco, quit 16y ago,
unclear pack-years. Denies ETOH. Former illicts, denies ever
IVDU, quit 18y ago.

Family History:
Mother deceased at [**Age over 90 **]yo; brother and sister alive at 82 and 83
with no medical problems.

Physical Exam:
ON ADMISSION:
VS - Temp 100.4F, BP 140/60, HR 78, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaking full sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no wheezing or rhonchi, min crackles at
bilateral bases, good air movement, resp unlabored, no accessory
muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no crepitus
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait not tested
.
ON ADMISSION TO ICU:
GENERAL - well-appearing man using abdominal muscles, but
stating he feels comfortable speaking full sentences but
somewhat short of breath at the end of his sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -
HEART - RRR, distant heart sounds, no rub appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred
.
ON DISCHARGE:
VS:  Tm 99.0 BP 95-141/74-90 HR 92-94 RR 18 94% on 3L
GENERAL: No acute distress, speaking full sentences without
accessory muscle use
HEENT: Sclerae anicteric and without injection, MMM, oropharynx
clear
NECK: Supple
LUNGS: Mild rhonchi in both bases, no wheeze
HEART: S1, S2, no murmurs auscultated
ABDOMEN: Soft, non-tender, no rebound/guarding, BS +
EXTREMITIES: WWP, no edema, 2+ radial/pedal pulses
NEURO: Awake, A&Ox3, CNs III-XII grossly intact, motor strength
grossly intact

Pertinent Results:
ADMISSION LABS:
[**2108-4-10**] 01:10PM BLOOD WBC-13.6* RBC-3.72* Hgb-12.2* Hct-34.6*
MCV-93 MCH-32.8* MCHC-35.3* RDW-12.5 Plt Ct-190
[**2108-4-10**] 01:10PM BLOOD Neuts-81.7* Lymphs-12.8* Monos-4.1
Eos-0.9 Baso-0.3
[**2108-4-10**] 01:10PM BLOOD Plt Ct-190
[**2108-4-12**] 06:45AM BLOOD  WBC-12.6* Lymph-12* Abs [**Last Name (un) **]-1512 CD3%-79
Abs CD3-1193 CD4%-7 Abs CD4-112* CD8%-72 Abs CD8-1092*
CD4/CD8-0.1*
[**2108-4-10**] 01:10PM BLOOD Glucose-116* UreaN-36* Creat-1.8* Na-136
K-4.1 Cl-99 HCO3-26 AnGap-15
[**2108-4-11**] 07:10AM BLOOD ALT-32 AST-54* AlkPhos-72 TotBili-1.5
[**2108-4-11**] 07:10AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.7
[**2108-4-15**] 03:51AM BLOOD Vanco-7.9*
[**2108-4-13**] 05:45PM BLOOD Type-ART FiO2-96 O2 Flow-2 pO2-53*
pCO2-31* pH-7.49* calTCO2-24 Base XS-1 AADO2-615 REQ O2-98
[**2108-4-13**] 05:45PM BLOOD Lactate-1.8
[**2108-4-14**] 05:26AM BLOOD freeCa-1.07*
.
DISCHARGE LABS:
[**2108-4-21**] 05:21AM BLOOD WBC-12.0* RBC-2.91* Hgb-9.8* Hct-28.2*
MCV-97 MCH-33.5* MCHC-34.6 RDW-13.1 Plt Ct-402
[**2108-4-21**] 05:21AM BLOOD Glucose-111* UreaN-40* Creat-1.5* Na-140
K-3.7 Cl-101 HCO3-28 AnGap-15
.
MICRO:
Blood Culture, Routine (Final [**2108-4-16**]):    NO GROWTH.
Blood Culture, Routine (Final [**2108-4-16**]):    NO GROWTH.
URINE CULTURE (Final [**2108-4-12**]):    <10,000 organisms/ml.
URINE CULTURE (Final [**2108-4-13**]):    NO GROWTH.
URINE CULTURE (Final [**2108-4-16**]):    NO GROWTH.
MRSA SCREEN (Final [**2108-4-16**]):    No MRSA isolated.
.
Legionella Urinary Antigen  (Final [**2108-4-13**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
HIV-1 Viral Load/Ultrasensitive (Final [**2108-4-13**]):
      HIV-1 RNA is not detected.
.
[**2108-4-12**] 8:30 pm SPUTUM      Source: Induced.
   GRAM STAIN (Final [**2108-4-12**]):
      <10 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI IN
CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.
   RESPIRATORY CULTURE (Final [**2108-4-14**]):
      MODERATE GROWTH Commensal Respiratory Flora.
   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
      [**2108-4-14**]):    NEGATIVE for Pneumocystis jirovecii
(carinii)..
   ACID FAST SMEAR (Final [**2108-4-13**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED.

.
[**2108-4-14**] 2:51 am SPUTUM      Source: Expectorated.
   GRAM STAIN (Final [**2108-4-14**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.
   RESPIRATORY CULTURE (Final [**2108-4-16**]):
      MODERATE GROWTH Commensal Respiratory Flora.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-14**]):
      SPECIMEN QNS FOR THIS TEST.
   ACID FAST SMEAR (Final [**2108-4-16**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      This is only a PRELIMINARY result.  If ruling out
tuberculosis, you
      must wait for confirmation by concentrated smear.
      DUE TO QUANTITY NOT SUFFICIENT concentrated smear not
available.
   ACID FAST CULTURE (Final [**2108-4-14**]):
      SPECIMEN QNS FOR THIS TEST.
.
[**2108-4-15**] 6:47 pm SPUTUM      Source: Induced.
   GRAM STAIN (Final [**2108-4-15**]):
      <10 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.
   ACID FAST SMEAR (Final [**2108-4-16**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
   ACID FAST CULTURE (Preliminary):
   RESPIRATORY CULTURE (Final [**2108-4-17**]):
      SPARSE GROWTH Commensal Respiratory Flora.
   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
   Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final [**2108-4-16**]):    NEGATIVE for Pneumocystis jirovecii
(carinii).
.
NEGATIVE
- PCP x 2
- AFBs
- ASPERGILLUS GALACTOMANNAN ANTIGEN
- B-GLUCAN
- MYCOPLASMA PNEUMONIAE ANTIBODIES
.
IMAGING:
[**2108-4-10**] CXR
PA and lateral views of the chest were obtained. Low lung
volumes result in bronchovascular crowding. Focal consolidation
in the left hilar region is a pneumonia. The cardiac and
mediastinal silhouettes are normal. No pneumothorax.
IMPRESSION: Lingular pneumonia. Recommend repeat radiograph in
four to six weeks to document resolution.
.
[**2108-4-12**] CXR
As compared to the previous radiograph, the lung volumes have
slightly decreased. On the left, in both the lung periphery and
the perihilar areas, the pre-described massive pneumonia is
visible in unchanged manner.
No newly appeared focal parenchymal opacities. No pulmonary
edema. No pleural effusions. No pneumothorax. Unchanged size of
the cardiac silhouette.
.
[**2108-4-13**] CXR
Comparison is made to the CT scan performed on the same day as
well as prior chest radiograph from [**2108-4-12**].
There are again noted areas of consolidation within the left
lung. These have increased particularly in the left upper lobe.
Cardiac silhouette is upper limits of normal. Small area of
consolidation at the right base medially is also present. There
are no pneumothoraces or large pleural effusions.
.
[**2108-4-13**] CT CHEST
IMPRESSION:
1. Multifocal pulmonary consolidation involving both lungs,
worse in the left upper and lower lobes, concerning for
multifocal pneumonia. There is no evidence of airway
obstruction. Recommended follow up imaging after treatment to
assess resolution.
2. Mild ectasia of the ascending thoracic aorta measuring 4 cm.
3. Indeterminate adrenal nodules.
.
[**2108-4-15**] CXR
IMPRESSION: Widespread alveolar opacities, some of which have a
nodular configuration. In a patient with HIV infection, this is
most consistent with multifocal pneumonia. Bacterial and fungal
organisms should be considered. Infection complicated by
organizing pneumonia is also possible.
.
[**2108-4-16**] CXR
As compared to the previous radiograph, there is unchanged
evidence of diffuse left parenchymal opacity strongly suggestive
of pneumonia. The opacities show a slightly peripheral
predominance. No evidence of pleural effusions. No other
pathologies, the right lung is unremarkable, except for a spot
of increased lung density in the region of the right apex that
could be caused by a projection phenomenon.
Normal size of the cardiac silhouette.
.

Brief Hospital Course:
81M with HIV, prostate CA s/p chemo/XRT now presenting with 3
days of SOB, non-productive cough, fevers and CXR concerning for
pneumonia. He was initially admitted to the inpatient general
medicine service and empirically treated with levofloxacin for
empiric CAP treatment.
.
On the day after admission, the patient spiked fever up to 101.4
so Vancomycin was empirically started. A CD4 at that time was
112 and VL undetectable.  CXR was repeated and was unchanged.
This morning, the patient was requiring 2L 02 and had another
fever so antibiotics were switched to
Vanco/Aztreonam/Azithromycin (Aztreonam because wanted to avoid
levofloxacin due to concern for TB and because he reports upper
airway swelling with PCN).  Induced sputum was sent which was
AFB smear negative, had 2+GPCs and 1+GNRs with growth of only
commensal respiratory flora.
.
Late in the afternoon the patient was noted to be tachypneic to
the 30s and he was satting the the low 90s.  ABG at this time
showed 7.49/31/53/24  and his 02 was increased to 6L.  His sats
improved but he was still visibly dyspneic so was transferred to
the MICU for closer monitoring. The remainder of his hospital
course is outlined below by problem.
.
# Hypoxic respiratory distress/Multifocal pneumonia, bacterial:
Pt had a clinical decompensation requiring MICU, admission and
despite extensive infectious work up, there was no bacterial
source identified.   Repeat imaging revealed diffuse multifocal
PNA.  PCP stains were negative x 2. Induced sputum for TB was
negative x 3 for AFB and sputum Cx were positive for oral flora
only.  Ultimately, pt developed a steady clinical response to
the combination of vancomycin, cefepime, and levofloxacin.
Pulmonary was consulted and felt that COP was a possible
underlying diagnosis but did not recommend treatment with
steroids or further work up at this time as pt seemed to having
consistent clinical response to the above antibiotic regimen.
Pt remained afebrile for >72hrs before discharge. The patient
should continue antibiotic coverage with vancomycin, cefepime &
Levaquin for 14 days for HCAP (final day [**2108-4-29**]). He may
continue albuterol and ipratriopium nebs with IS as needed.  Pt
was given referral to see [**Location (un) 2274**] pulmonary after discharge to
ensure resolution of PNA.
.
#. HIV: Most recent CD4 was 350 in [**Month (only) 404**] though he was noted
to have a low CD4 now in the setting of acute illness.  Unclear
why, but patient listed as taking an NNRTI (etravirine) +
boosted PI (lopinavir/ritonavir) which would not be a typical
outpatient MD, "he has had stable virologic suppression on this
two drug regimen. Initially he was on raltegravir in addition
but did not tolerate it - felt general malaise - and better off
of it. While a 2 drug HIV regimen is not standard of care for
initial therapy - there are a lot of studies confirming what he
has - which is prolonged stable virologic suppression and CD4
improvements on just 2 antivirals after suppression has been
achieved." Continued on home regimen.
.
# Leukocytosis: Etiology unknown.  Pt denied any new localizing
symptoms but has loose stools at baseline and wanted to use
immodium.   Cdiff toxin was negative x2 and UA was not
suggestive of infection. White count was resolving by the time
of discharge
.
# Acute-on-chronic renal failure: Recent baseline 1.3-1.6,
increased to 1.8 here with FENA consistent with prerenal
azotemia.  He received IV support and creatinine improved to
1.5. The patient's creatinine remained stable once po intake
improved.
.
# Hypertension: Enalapril and HCTZ restarted once patient's
creatinine had stabilized.
.
# Hyperlipidemia: Continued home statin/ASA.

Medications on Admission:
- Aspirin 81 mg PO Daily
- One Daily Multivitamin PO daily
- Calcium PO daily
- Pravastatin 40 mg QHS
- Lopinavir-ritonavir 200 mg-50 mg 3 tablets [**Hospital1 **]
- Enalapril-hydrochlorothiazide 10 mg-25 mg PO Daily
- Acyclovir 400 mg PO Twice Daily
- Fish oil-fat acid comb8-herb comb137 1,200 mg (400
mg-400mg-400mg) PO daily
- Etravirine 100 mg 2 tablets PO daily
- Lorazepam 1 mg PO QHS
- desonide 0.05 % Topical Cream Topical [**Hospital1 **] to rash in ears
[- Bicalutamide 50 mg PO daily] stopped recently; PSA
nonresponsive
[- finasteride 5 mg PO daily] stopped recently; PSA
nonresponsive

Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. lopinavir-ritonavir 200-50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
4. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. desonide 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) as needed for to rash in ears.
6. enalapril maleate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO
DAILY (Daily).
11. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO DAILY (Daily).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q2H (every 2
hours) as needed for SOB.
14. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
15. cefepime 2 gram Recon Soln Sig: Two (2) gram Injection Q12H
(every 12 hours) for 6 days: Continue through [**2108-4-29**].
16. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 6 days: Continue through
[**2108-4-29**].
17. levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q48H (every 48 hours) for 6
days: Continue through [**2108-4-29**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Nursing & Therapy Center [**Location 1268**]

Discharge Diagnosis:
Primary diagnosis: Pneumonia, bacterial

Secondary diagnoses:
HIV
Hypertension
Chronic kidney injury


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Mr. [**Known lastname 26233**],

It was a pleasure participating in your care at [**Hospital1 771**].

You were admitted because you had a pneumonia. After a brief
stay in the Intensive Care Unit, you remained stable with a
combination of antibiotics. You will go to a rehabilitation
facility that will continue these antibiotics for a total course
of 14 days.

During your stay, your home medications did not change. At the
rehabilitation facility, you will continue the antibiotics:
vancomycin, cefepime, levofloxacin. You will also have available
albuterol and ipratropium nebulizers if you feel short of
breath.

Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
**Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge. Also
please contact your provider to schedule an appointment within
2-4 weeks with Pulmonary**
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dehydration,Asymptomatic human immunodeficiency virus [HIV] infection status,Diarrhea,Other and unspecified hyperlipidemia,Anemia, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of prostate'}


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: Fever, cough, dyspnea

PRESENT ILLNESS: This is an 81M with HIV, last CD4 369 in [**Month (only) 404**], prostate CA
s/p chemo/XRT recently stopped for treatment failure (no PSA
response) who presented to his PCP [**Name Initial (PRE) 151**] 3 days of worsening
generalized fatigue and malaise and dyspnea.  He also notes that
he and his partner had URTI about 2 weeks ago that improved and
he denied recent fever and cough. On admission, he required 0-2L
to maintain 02 >95%, he had WBC 13.6 (82%N, 0%B), acute on
chronic renal failure BUN/Cr 36/1.8. CXR showed a left lingular
PNA and he was started on Levofloxacin for presumed CAP.
.
The patient specifically denies chest pain, but does note some
dizziness.  His dyspnea is not positional. Since his retirement
2 years ago he has traveled extensively to [**Location (un) **], [**Country 26231**],
[**Country 3396**], [**Country 651**], most of Europe.  He denies any febrile
illnesses on any trip.  He also denies history of TB or known
exposure to TB, and had a PPD several years ago that was
negative.
.
On the inpatient floor, the patient felt well other than
reporting continued generalized weakness/fatigue that is not his
baseline. No cough.
.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.

MEDICAL HISTORY: - HIV, diagnosed ~[**2089**], CD4 369 [**12/2107**]
- Prostate CA, s/p XRT/hormonal chemo (PSA unresponsive)
- HTN
- Hyperlipidemia

MEDICATION ON ADMISSION: - Aspirin 81 mg PO Daily
- One Daily Multivitamin PO daily
- Calcium PO daily
- Pravastatin 40 mg QHS
- Lopinavir-ritonavir 200 mg-50 mg 3 tablets [**Hospital1 **]
- Enalapril-hydrochlorothiazide 10 mg-25 mg PO Daily
- Acyclovir 400 mg PO Twice Daily
- Fish oil-fat acid comb8-herb comb137 1,200 mg (400
mg-400mg-400mg) PO daily
- Etravirine 100 mg 2 tablets PO daily
- Lorazepam 1 mg PO QHS
- desonide 0.05 % Topical Cream Topical [**Hospital1 **] to rash in ears
[- Bicalutamide 50 mg PO daily] stopped recently; PSA
nonresponsive
[- finasteride 5 mg PO daily] stopped recently; PSA
nonresponsive

ALLERGIES: Penicillins / metformin

PHYSICAL EXAM: ON ADMISSION:
VS - Temp 100.4F, BP 140/60, HR 78, R 26, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate,
speaking full sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no wheezing or rhonchi, min crackles at
bilateral bases, good air movement, resp unlabored, no accessory
muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no crepitus
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-12**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait not tested
.
ON ADMISSION TO ICU:
GENERAL - well-appearing man using abdominal muscles, but
stating he feels comfortable speaking full sentences but
somewhat short of breath at the end of his sentences
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -
HEART - RRR, distant heart sounds, no rub appreciated
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: Mother deceased at [**Age over 90 **]yo; brother and sister alive at 82 and 83
with no medical problems.

SOCIAL HISTORY: Born in [**Country 26232**]. Has traveled extensively over past 2 years
to [**Location (un) **], [**Country 26231**], [**Country 3396**], [**Country 651**], most of Europe. Lives with
male partner who is a psychiatrist. Prior tobacco, quit 16y ago,
unclear pack-years. Denies ETOH. Former illicts, denies ever
IVDU, quit 18y ago. 

### Response:
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Acute kidney failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Dehydration,Asymptomatic human immunodeficiency virus [HIV] infection status,Diarrhea,Other and unspecified hyperlipidemia,Anemia, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Personal history of malignant neoplasm of prostate'}
