CHIEF COMPLAINT: Tachycardia

PRESENT ILLNESS: 62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing.  On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.

MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

MEDICATION ON ADMISSION: Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: VS: 102.4   120  140/85  100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally

FAMILY HISTORY: Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

SOCIAL HISTORY: Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.
Other specified cardiac dysrhythmias,Myasthenia gravis without (acute) exacerbation,Acute respiratory failure,Hypoxemia,Unspecified drug dependence, continuous,Pathologic fracture of vertebrae,Orthostatic hypotension,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Other vitamin B12 deficiency anemia,Diarrhea,Cyst of kidney, acquired,Constipation, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use
Cardiac dysrhythmias NEC,Mysthna grvs w/o ac exac,Acute respiratry failure,Hypoxemia,Drug depend NOS-contin,Path fx vertebrae,Orthostatic hypotension,Hypertension NOS,Migrne unsp wo ntrc mgrn,Hyperlipidemia NEC/NOS,B12 defic anemia NEC,Diarrhea,Cyst of kidney, acquired,Constipation NOS,Adv eff corticosteroids
Admission Date:  [**2173-1-4**]              Discharge Date:   [**2173-1-11**]

Date of Birth:  [**2110-10-7**]             Sex:   F

Service: MEDICINE

Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve

Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Tachycardia

Major Surgical or Invasive Procedure:
none

History of Present Illness:
62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing.  On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.

Past Medical History:
1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

3. hypercholesterolemia
4. h/o migraines
5. seasonal allergies
6. HTN
7. osteoporosis

Social History:
Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications.

Family History:
Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

Physical Exam:
VS: 102.4   120  140/85  100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally

Pertinent Results:
[**2173-1-4**] 10:05PM   CK(CPK)-27
[**2173-1-4**] 10:05PM   CK-MB-NotDone cTropnT-<0.01 proBNP-<5
[**2173-1-4**] 10:05PM   TSH-1.4
[**2173-1-4**] 10:05PM   FREE T4-1.2
[**2173-1-4**] 10:05PM   D-DIMER-783*
[**2173-1-4**] 01:40PM   GLUCOSE-106* UREA N-26* CREAT-0.8 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2173-1-4**] 01:40PM   estGFR-Using this
[**2173-1-4**] 01:40PM   CK(CPK)-38
[**2173-1-4**] 01:40PM   CK-MB-NotDone
[**2173-1-4**] 01:40PM   CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.1
[**2173-1-4**] 01:40PM   WBC-8.5# RBC-3.71* HGB-12.6 HCT-36.8 MCV-99*
MCH-34.0* MCHC-34.3 RDW-15.3
[**2173-1-4**] 01:40PM   NEUTS-77.9* LYMPHS-16.6* MONOS-3.9 EOS-0.8
BASOS-0.9
[**2173-1-4**] 01:40PM   POIKILOCY-1+ MACROCYT-2+
[**2173-1-4**] 01:40PM   PLT COUNT-242#
[**2173-1-4**] 01:40PM   PT-12.1 PTT-23.2 INR(PT)-1.0

Brief Hospital Course:
1. Hypoxia:
This developed in the setting of IV narcotics use; quick
development and rapid improvement was most suggestive of
aspiration in the context of sedation. Contributing could have
been chronic low ventilatory state in the context of OSA and MG,
although MG crisis thought to be unlikely given 5/5 strength
otherwise.

The patient never required intubation and did well after being
dosed with narcan.  Overall, her respiratory status improved;
she was continued on BiPAP at night and NIFs/VCs were followed.
Her MG was treated as prior.

For the possible aspiration, initially treated with levo/flagyl,
then just levofloxacin.  [**2173-1-12**] is day 7 of planned seven day
course.

2. Tachycardia:
Sinus, likley reactive. PE ruled out, TSH normal. Anemia
slightly worse then normal but not sufficient to explain
tachycardia. This was felt to be either related to beta-blocker
withdrawal or narcotic withdrawal.  This resolved upon
resumption of narcotics (at home doses) and beta-blocker.  Later
in the admission, the beta-blocker was again d/c'd as the
indication was unclear.  Thereafter, the patient's HRs remained
<100.

3. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]:
There was no evidence for current flare. Cellcept and
pyridostigmine were continued; neurology followed the patient.

4. Anemia:
Previous baseline hct mid 40's, over the last month decreased to
mid 30's.  This was felt to be secondary to B12 deficiency with
the possible contribution of Cellcept.  The B12 level was low
end of normal.  MMA was checked and pending at d/c.  Given that
the patient has no reason for nutritional deficiency, pernicious
anemia was entertained and IF antibody was sent (pending at
d/c).

5. Headache:
Thought to be secondary to possible migraine headache versus med
withdrawal headache.
Was treated with tylenol PRN.

6. Spinal compression fractures:
Narcotics were initially held, but restarted many of the
patient's symptoms were felt to be secondary to withdrawal.

7. Hypertension:
The patient's propranolol had recently been stopped prior to
admission.  This was restarted, given the tachycardia.  Later in
the admission, the patient was not hypertensive so the
beta-blocker was again held given the prior episodes of
hypotension.  Her blood pressure and heart rate were normal on
discharge.

8. Hyperlipidemia:
Continued atorvastin.


Medications on Admission:
Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN

Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO qd () as
needed for osteoporosis.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for constipation.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO Q4H (every 4 hours) as needed for upset stomach.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-10**] Sprays Nasal
QID (4 times a day) as needed.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
1. Sinus tachycardia
2. Narcotic withdrawal
3. Myasthenia [**Last Name (un) 2902**]
4. Anemia
5. Renal cysts
Secondary:
1. Hypertension
2. Hyperlipidemia
3. Osteoporosis


Discharge Condition:
Improved; in normal sinus rhythm.


Discharge Instructions:
You were admitted with elevated heart rates and possibly
withdrawal from narcotics.  At this time, your heart rate is
normal and you do not have any symptoms of withdrawal.

If you experience worsening headaches, diarrhea, racing heart,
shortness of breath or have any other questions/concerns, please
call your PCP or go to the emergency room.

Followup Instructions:
You have the following appointments scheduled:

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**] Date/Time:[**2173-2-15**]
1:00
DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-2-23**]
8:00

Please be sure to schedule an appointment with your PCP to be
seen within 1-2 weeks: [**Last Name (LF) **],[**First Name3 (LF) 198**] W. [**Telephone/Fax (1) 250**]
{'Other specified cardiac dysrhythmias,Myasthenia gravis without (acute) exacerbation,Acute respiratory failure,Hypoxemia,Unspecified drug dependence, continuous,Pathologic fracture of vertebrae,Orthostatic hypotension,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Other vitamin B12 deficiency anemia,Diarrhea,Cyst of kidney, acquired,Constipation, unspecified,Adrenal cortical steroids 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: Tachycardia

PRESENT ILLNESS: 62 yo W w/h/o myasthenia [**Last Name (un) 2902**] on immunosuppression, htn,
hyperlipidemia, spinal compression fractures who initially
presented with tachycardia. ROS remarkable for intermittent
sinus pressure/HA, not unusual, no retroorbital pain, ear pain
or pressure, decreased hearing.  On admission she was ruled out
for PE. Subsequently she developed a HA, N, V and was treated
with phenergan and lorazepam. Neurology felt symptoms could be
due to narcotic withdrawal and the pt was given Dilaudid 2x 1mg.
Subsequently she became obtunded and hypoxic.

MEDICAL HISTORY: 1. Myasthenia [**Last Name (un) **]-first diagnosed in [**2163**], followed by Dr.
[**Last Name (STitle) **] at [**Hospital1 18**]
2. multiple spinal compression fractures s/p steroid use for MG

MEDICATION ON ADMISSION: Pyridostigmine Bromide 30 mg PO Q8H
Atorvastatin 20 mg PO HS
Mycophenolate Mofetil 1000 mg PO BID
Raloxifene *NF* 60 mg Oral qd osteoporosis
Senna 1 TAB PO HS:PRN constipation
Heparin 5000 UNIT SC TID
Cyanocobalamin 1000 mcg PO DAILY
Docusate Sodium 100 mg PO HS
Calcium Carbonate [**Telephone/Fax (1) 1999**] mg PO Q4H:PRN upset stomach
Dolasetron Mesylate 25 mg IV Q8H:PRN nausea
Acetaminophen 325-650 mg PO/PR Q4-6H:PRN pain
Sodium Chloride Nasal [**2-10**] SPRY NU QID:PRN

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: VS: 102.4   120  140/85  100% on 50% FM
General: NAD, pleasant well-appering woman
HEENT: PERRL, EOMI without nystagmus, no proptosis, MMM, OP
clear, conj pink/sclera white, hirsuit
Neck: supple, no lad, JVP: 8cm, no bruits
Resp: CTA, scant left basilar crackels, no rhonchi or wheezes
CV: RRR, s1, s2 present, no murmurs, rubs, gallops
Abdomen: protuberant, soft, nontender, nondistended, +BS, no
masses, no HSM
Ext: trace edema, no c/c, 2+ radial, DP pulses bilaterally
Neuro: CN II-XII intact, A&Ox3, motor [**6-12**] UE/LE, lid lag not
tested because of photophobia, good coordination, reflexes
intact 2+ bilaterally

FAMILY HISTORY: Mother: [**Name (NI) 77552**], first age 55, also CHF, deceased age 77; father
with rheumatic heart disease, deceased age 83 CVA; sister died
at age 5 of insulin dependent diabetes mellitus w/PNA.
.

SOCIAL HISTORY: Patient is single, lives alone. She is currently on disability.
She used to work as a histology tech a [**Hospital1 18**]. She denies
tobacco, illicit drugs, occ EToH but none since starting
narcotic medications. 

### Response:
{'Other specified cardiac dysrhythmias,Myasthenia gravis without (acute) exacerbation,Acute respiratory failure,Hypoxemia,Unspecified drug dependence, continuous,Pathologic fracture of vertebrae,Orthostatic hypotension,Unspecified essential hypertension,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Other and unspecified hyperlipidemia,Other vitamin B12 deficiency anemia,Diarrhea,Cyst of kidney, acquired,Constipation, unspecified,Adrenal cortical steroids causing adverse effects in therapeutic use'}
