CHIEF COMPLAINT: respiratory weakness

PRESENT ILLNESS: 24yo diagnosed with myasthenia [**Last Name (un) 2902**] in [**11-15**], when he
presented with bulbar symptoms and diplopia, subsequently found
to have high AChR titers, positive rep stim testing with a
decrement and started on mestinon (Chest CT negative), but then
lost to follow-up at [**Hospital1 112**]. He presented today to neuromuscular
clinic with "progressively worse bulbar symptoms, sob, diplopia
slurred speech" and on exam, he had a respiratory rate of 14,
could count to 10 in one breath and had "left ptosis, bil facial
weakness, dificulty handling saliva, poor gag, normal tongue,
jaw
and limb strength" but would not permit assessment of
fatigability". He also had "normal reflexes and sensation, mild
pupillary asymmetry, right 4 mm l 3mm reactive".

MEDICAL HISTORY: Myasthenia, as above
Schizoaffective disorder

MEDICATION ON ADMISSION: ALL: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 98.1; HR 78; BP 112/61; RR 60 satting in 80's room air
Gen Awake, cooperative, in apparent distress
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home
Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Schizoaffective disorder, unspecified
Acute respiratry failure,Myasthna gravs w ac exac,Subendo infarct, initial,Schizoaffective dis NOS
Admission Date:  [**2101-8-9**]              Discharge Date:   [**2101-8-14**]

Date of Birth:  [**2076-10-15**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
respiratory weakness


Major Surgical or Invasive Procedure:
(1) intubation
(2) plasmapheresis


History of Present Illness:
24yo diagnosed with myasthenia [**Last Name (un) 2902**] in [**11-15**], when he
presented with bulbar symptoms and diplopia, subsequently found
to have high AChR titers, positive rep stim testing with a
decrement and started on mestinon (Chest CT negative), but then
lost to follow-up at [**Hospital1 112**]. He presented today to neuromuscular
clinic with "progressively worse bulbar symptoms, sob, diplopia
slurred speech" and on exam, he had a respiratory rate of 14,
could count to 10 in one breath and had "left ptosis, bil facial
weakness, dificulty handling saliva, poor gag, normal tongue,
jaw
and limb strength" but would not permit assessment of
fatigability". He also had "normal reflexes and sensation, mild
pupillary asymmetry, right 4 mm l 3mm reactive".

He is accompanied here by his father; on my arrival, he was in
respiratory distress, speaking in one-word sentences, writing
"everything but breathing is TOO MUCH". His father said that
this
breathing difficulty is much worse than usual. The patient
endorses increased fatigue since his evaluation this morning. He
endorses horizontal diplopia with left gaze, as well as
difficulty swallowing his saliva, which he is spitting into a
basin.

He has had no signs of illness recently.

ROS: On review of systems, the pt denied recent fever or chills.

No night sweats or recent weight loss or gain. Denied cough,
shortness of breath.  Denied chest pain or tightness,
palpitations.  Denied nausea, vomiting, diarrhea, constipation
or
abdominal pain.  No recent change in bowel or bladder habits.
No
dysuria.  Denied arthralgias or myalgias. Denied rash.


Past Medical History:
Myasthenia, as above
Schizoaffective disorder


Social History:
lives at home


Family History:
NC


Physical Exam:
VS T 98.1; HR 78; BP 112/61; RR 60 satting in 80's room air
Gen Awake, cooperative, in apparent distress
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted

NEURO (my exam is limited by need for intubation/pt lack of
cooperation)
MS Awake, alert. Speaks in one-word sentences.

CN
CN I: not tested
CN II: visual fields deferred. Pupils R 4->3, L 3->2.
CN III, IV, VI: +horizontal diplopia to the left; will not
cooperate with further testing. +L ptosis
CN V: intact to LT throughout
CN VII: will not cooperate with testing
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**4-16**] and symmetric
CN XII: tongue midline and agile

Motor
Refuses testing

Sensory deferred

Reflexes deferred

Coordination/gait deferred


Pertinent Results:
Labs:
GLUCOSE-92 UREA N-9 CREAT-1.0 SODIUM-140 POTASSIUM-3.9
CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
WBC-6.8 RBC-5.62 HGB-17.4 HCT-48.2 MCV-86 MCH-31.0 MCHC-36.1*
RDW-13.5
CK(CPK)-378* CK-MB-32* MB INDX-8.5*
PT-13.5* PTT-125.1* INR(PT)-1.2*
<br>

IMAGING
CXR: ETT in satisfactory position. No acute cardiopulmonary
process.
<br>
ECHO: The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.


Brief Hospital Course:
Mr. [**Known lastname 73935**] is a 24-year-old man with a history of myasthenia
[**Last Name (un) 2902**] and schizoaffective disorder who presented in respiratory
distress after being seen in
neuromuscular clinic. His brief hospital course was as follows:

1. Neuro: Myasthenic Crisis. He appeared significantly worse
than he was at the clinic, and he was intubated for respiratory
distress. He was admitted to the ICU and plasmapheresis was
initiated, with a pheresis line placed by surgery. All
exacerbating medications were avoided, and he was also started
on high-dose steroids. His NIFs and VCs were followed [**Hospital1 **], and
he improved markedly in 2 days. He was extubated on [**8-11**] and
transferred to the floor. He received 3 of his planned 5
pheresis treatments before becoming agitated about leaving. He
was discharged with a Prednisone dose pack and plans to complete
the pheresis course as an outpatient.

2. CV: elevated cardiac enzymes. Cardiology was consulted and
felt this was due to demand ischemia during his crisis. The
enzymes trended down and he had no further cardiac issues.

3. Psychiatry: Schizoaffective disorder. He refused psychiatric
evaluation on multiple occasions. He was discharged with
instructions to follow-up with psychiatry as an outpatient.


Medications on Admission:
ALL: NKDA

MEDS:
Protonix only


Discharge Medications:
1. Protonix  Oral
2. Prednisone 10 mg Tablets, Dose Pack Sig: Three (3) Tablets,
Dose Pack PO once a day for 3 days: (starting tomorrow -
[**2101-8-15**]): (1) prednisone 30mg [3 tablets] by mouth once a day for
3 days (2)on [**2101-8-18**]: prednisone 20mg (2 tablets) by mouth once a
day for 3 days (3)on [**2101-8-21**]: take 10mg (1 tablet) by mouth for 3
more days.
Disp:*18 Tablets, Dose Pack(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
myasthenic crisis


Discharge Condition:
good; VC 4.5L, NIFs > -80; ptosis mild on right with 4+/5
strength on bilateral deltoid; counting to 30 in one breath; [**3-17**]
strength in neck flexors; otherwise normal.


Discharge Instructions:
You were evaluated for weakness and found to have a myasthenic
crisis. Please take all medications as directed and keep all
follow-up appointments. If you have worsening weakness or
difficulty breathing, call your doctor or 911 or go to the
nearest hospital.

Followup Instructions:
(1) Follow up in Neuromuscular with Dr. [**First Name (STitle) **] [**Name (STitle) **] in
[**6-21**] days: ([**Telephone/Fax (1) 13172**]
(2) PLASMAPHERESIS,BED ONE PHERESIS ROOMS Date/Time:[**2101-8-16**]
9:15
(3) PLASMAPHERESIS,BED EIGHT PHERESIS ROOMS Date/Time:[**2101-8-18**]
10:15


                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2101-8-16**]
{'Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Schizoaffective disorder, 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: respiratory weakness

PRESENT ILLNESS: 24yo diagnosed with myasthenia [**Last Name (un) 2902**] in [**11-15**], when he
presented with bulbar symptoms and diplopia, subsequently found
to have high AChR titers, positive rep stim testing with a
decrement and started on mestinon (Chest CT negative), but then
lost to follow-up at [**Hospital1 112**]. He presented today to neuromuscular
clinic with "progressively worse bulbar symptoms, sob, diplopia
slurred speech" and on exam, he had a respiratory rate of 14,
could count to 10 in one breath and had "left ptosis, bil facial
weakness, dificulty handling saliva, poor gag, normal tongue,
jaw
and limb strength" but would not permit assessment of
fatigability". He also had "normal reflexes and sensation, mild
pupillary asymmetry, right 4 mm l 3mm reactive".

MEDICAL HISTORY: Myasthenia, as above
Schizoaffective disorder

MEDICATION ON ADMISSION: ALL: NKDA

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS T 98.1; HR 78; BP 112/61; RR 60 satting in 80's room air
Gen Awake, cooperative, in apparent distress
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted

FAMILY HISTORY: NC

SOCIAL HISTORY: lives at home 

### Response:
{'Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Subendocardial infarction, initial episode of care,Schizoaffective disorder, unspecified'}
