CHIEF COMPLAINT: difficulty swallowing

PRESENT ILLNESS: HPI: Mr [**Known lastname **] is a 35 yo man with history of myasthenia [**Last Name (un) 2902**]
since [**12/2154**] managed with steroids, cellcept, and mestinon.  He
has been managed as an outpatient fairly stably, but he reported
today that he has been having some difficulty swallowing pills
or food X 1 day. Reports that they "get stuck in his throat" and
also reports that he "chokes".  Denies any trouble swallowing
water, but he has been unable to swallow any of his medications
since yesterday.  He denies any changes in his strength,
breathing or vision.  He did present to the ED late last night,
but left from
the waiting room as he was afraid of catching a respiratory
infection from other patients.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-DM, diagnosed some 4 years ago, but he has been having this for
a longer period of time
-pancreatitis some 15 yrs ago in setting of Ethoh
-s/p cyst removal L-groin-
-HTN
-denies hypercholesterolemia

MEDICATION ON ADMISSION: Mestinon 60mg [**Hospital1 **]
Cellcept 1500mg [**Hospital1 **]
Prednisone 20mg altern days
Metformin 1000mg [**Hospital1 **]
Glipizide 10 [**Hospital1 **]
Lisinopril 20 or 30mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-97.3 BP-148/95 HR-97 RR-16 (12 my exam) O2Sat 99% RA (observed
89-93% during exam)
Gen: Lying in bed, looks unwell, fatigued
HEENT: NC/AT, dry, coated tongue
Neck: normal ROM, supple,
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear bilaterally, decr BS, decr chest expansion
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: -DM, hypercholesterolemia, HTN, CAD
-no auto-immune disease

SOCIAL HISTORY: Occupation: Not currently employed
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Has fiance; children: 1 son.
Lives with aunt.
Myasthenia gravis with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Myasthna gravs w ac exac,Hypertension NOS,DMII wo cmp nt st uncntr
Admission Date:  [**2155-9-5**]              Discharge Date:   [**2155-9-14**]

Date of Birth:  [**2120-3-28**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
difficulty swallowing

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: Mr [**Known lastname **] is a 35 yo man with history of myasthenia [**Last Name (un) 2902**]
since [**12/2154**] managed with steroids, cellcept, and mestinon.  He
has been managed as an outpatient fairly stably, but he reported
today that he has been having some difficulty swallowing pills
or food X 1 day. Reports that they "get stuck in his throat" and
also reports that he "chokes".  Denies any trouble swallowing
water, but he has been unable to swallow any of his medications
since yesterday.  He denies any changes in his strength,
breathing or vision.  He did present to the ED late last night,
but left from
the waiting room as he was afraid of catching a respiratory
infection from other patients.

He denies infection, denies trouble breathing.

ROS:Neg except sl. constipation


Past Medical History:
PAST MEDICAL HISTORY:
-DM, diagnosed some 4 years ago, but he has been having this for
a longer period of time
-pancreatitis some 15 yrs ago in setting of Ethoh
-s/p cyst removal L-groin-
-HTN
-denies hypercholesterolemia



Social History:
Occupation: Not currently employed
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Has fiance; children: 1 son.
Lives with aunt.


Family History:
-DM, hypercholesterolemia, HTN, CAD
-no auto-immune disease


Physical Exam:
T-97.3 BP-148/95 HR-97 RR-16 (12 my exam) O2Sat 99% RA (observed
89-93% during exam)
Gen: Lying in bed, looks unwell, fatigued
HEENT: NC/AT, dry, coated tongue
Neck: normal ROM, supple,
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear bilaterally, decr BS, decr chest expansion
aBd: +BS soft, nontender
ext: no edema

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Oriented to person, place, and date.  Attentive, says
[**Doctor Last Name 1841**] backwards.  Speech is fluent with normal comprehension and
repetition; naming intact. Very dysarthric/dysphonic. [**Location (un) **]
intact.
Registers [**2-8**], recalls [**1-11**] in 10 minutes.  No right left
confusion. No evidence of apraxia.

Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Bilat partial ptosis, rapid closure with sustained
upgaze in 5s. Visual fields are full to confrontation.
Extraocular
movements: limited abduction bilaterally, no nystagmus. Not
endorsing diplopia but also says has it all the time. Sensation
intact V1-V3.  Facial movement symmetric.  Hearing intact to
finger rub bilaterally.  Palate elevation symmetrical.
Sternocleidomastoid and trapezius normal bilaterally. Tongue
midline, movements intact

Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor; No pronator drift; [**3-13**] neck flexors; 4+/5 neck extensors
  [**Doctor First Name **] Tri [**Hospital1 **]  WF WE FE FF  IP  H  Q DF PF TE TF
R  5   5   5  5  5  5  5   5   5  5  5  5  5  5
L  5   5   5  5  5  5  5   5   5  5  5  5  5  5
Fatiguable**

Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS

Reflexes:
+2 and symmetric throughout UE and 1+ LE. Toes downgoing
bilaterally

Coordination: finger-nose-finger normal, RAMs normal.

Gait: stands unassisted


Pertinent Results:
[**2155-9-5**] 06:28PM   GLUCOSE-140* UREA N-13 CREAT-0.8 SODIUM-144
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-36* ANION GAP-11
[**2155-9-5**] 06:28PM   CALCIUM-9.9 PHOSPHATE-3.8 MAGNESIUM-2.0
[**2155-9-5**] 06:28PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2155-9-5**] 06:28PM   WBC-12.3* RBC-4.76 HGB-13.0* HCT-37.9*
MCV-80* MCH-27.3 MCHC-34.4 RDW-13.3
[**2155-9-5**] 06:28PM   NEUTS-62.1 LYMPHS-31.2 MONOS-4.9 EOS-1.5
BASOS-0.3
[**2155-9-5**] 06:10PM   TYPE-ART PO2-72* PCO2-53* PH-7.43 TOTAL
CO2-36* BASE XS-8

Brief Hospital Course:
Pt initially admitted to ICU with concern for respiratory
compromise.  Pt received plasmapheresis on night of arrival with
significant improvement in functioning.  Pt however, pt HD 2
with continued dysphonia and poor bulbar function and motor
weakness. Pt continued to have plasmapheresis X 5 treatments
(QOD) with subsequent improvement in functioning.  After 5th
treatment, pt with 5/5 strength in all extremities with full
power in neck extensors and flexors.  pt with continued weakness
in his extraocular muscles but significantly improved as
compared to admission (able to maintain upward gaze ~12 seconds
prior to ptosis and stopping).  pt able to count to 30 with 1
deep breath.

Pt had NIFs and VC performed Q8 throughout stay and improved to
VC ~3 and NIFs in -50 range prior to discharge.  (as opposed to
VC of 1.3 and NIF of -20 - -30 upon admit).

Pt had speech and swallow evaluation where he was noted to have
silent aspiration.  Arrangement made for
cough/swallow/cough/swallow technique for PO intake.  However,
with increased treatment, pt with significant improvement and by
discharge, repeat swallow revealed no aspiration.  pt advanced
to regular diet by discharge without difficulty.

Pt initially with blunted affect and significant anger.
Psychiatry consulted and felt appropriate depressed mood in
response to diagnosis.  Multiple discussions with patient re:
possible pharmacotherapy, all of which were refused by patient.
Pt, however, with significantly improved mood/affect with
improvement in condition during stay.  Pt was recommended to
follow up with outpatient psych upon discharge.

Medications on Admission:
Mestinon 60mg [**Hospital1 **]
Cellcept 1500mg [**Hospital1 **]
Prednisone 20mg altern days
Metformin 1000mg [**Hospital1 **]
Glipizide 10 [**Hospital1 **]
Lisinopril 20 or 30mg daily


Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours).
Disp:*120 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Mycophenolate Mofetil 500 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
[**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
HTN
DM


Discharge Condition:
Stable


Discharge Instructions:
Please take all your medications as prescribed. Please call your
doctor or the closest ED if you have new symptoms.

Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-10-23**] 4:00



Completed by:[**2155-9-16**]
{'Myasthenia gravis with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: difficulty swallowing

PRESENT ILLNESS: HPI: Mr [**Known lastname **] is a 35 yo man with history of myasthenia [**Last Name (un) 2902**]
since [**12/2154**] managed with steroids, cellcept, and mestinon.  He
has been managed as an outpatient fairly stably, but he reported
today that he has been having some difficulty swallowing pills
or food X 1 day. Reports that they "get stuck in his throat" and
also reports that he "chokes".  Denies any trouble swallowing
water, but he has been unable to swallow any of his medications
since yesterday.  He denies any changes in his strength,
breathing or vision.  He did present to the ED late last night,
but left from
the waiting room as he was afraid of catching a respiratory
infection from other patients.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
-DM, diagnosed some 4 years ago, but he has been having this for
a longer period of time
-pancreatitis some 15 yrs ago in setting of Ethoh
-s/p cyst removal L-groin-
-HTN
-denies hypercholesterolemia

MEDICATION ON ADMISSION: Mestinon 60mg [**Hospital1 **]
Cellcept 1500mg [**Hospital1 **]
Prednisone 20mg altern days
Metformin 1000mg [**Hospital1 **]
Glipizide 10 [**Hospital1 **]
Lisinopril 20 or 30mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-97.3 BP-148/95 HR-97 RR-16 (12 my exam) O2Sat 99% RA (observed
89-93% during exam)
Gen: Lying in bed, looks unwell, fatigued
HEENT: NC/AT, dry, coated tongue
Neck: normal ROM, supple,
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear bilaterally, decr BS, decr chest expansion
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: -DM, hypercholesterolemia, HTN, CAD
-no auto-immune disease

SOCIAL HISTORY: Occupation: Not currently employed
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Has fiance; children: 1 son.
Lives with aunt. 

### Response:
{'Myasthenia gravis with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
