CHIEF COMPLAINT: Dyspnea in the setting of multiple sclerosis

PRESENT ILLNESS: 54 year-old man with secondary progressive MS (seen by Dr.
[**Last Name (STitle) 8760**] in [**2152-8-23**]), complicated by neurogenic bladder and
recurrent and recent UTI/urosepsis, s/p baclofen pump placement
for spasticity, and left leg DVT diagnosed three months ago, now
on warfarin, who presents as a transfer from [**Hospital3 3383**]
Hospital for dyspnea.

MEDICAL HISTORY: -Secondary progressive MS.  His course is well-described in the
prior note from [**Hospital **] clinic in [**Month (only) 359**].  Though he was diagnosed
with SPMS in [**2128**], it is though that his course may have begun
10 years before that date.  Prior relapses were localized to the
cord and left optic nerve.  He has had weakness of the legs
progressing to total paralysis in [**2145**].  He was diagnosed with
left optic neuritis in [**2134**], and had no recovery thereafter.  He
had a baclofen pump placed in [**2150**] for treatment of his
spasticity; he has had partial relief of his symptoms.  In the
past, he has been treated with Avonex, Copaxone, and  ovantrone.

MEDICATION ON ADMISSION: Medications (outpatient):
-Levothyroxine 175 mcg daily
-Lexapro 20 mg q hs
-Lasix 20 mg daily
-Baclofen pump 600 mcg daily, and additional 20 mg po TID
-Warfarin 10 mg daily
-Simvastatin 40 mg daily

ALLERGIES: Zofran

PHYSICAL EXAM: Vitals: T 95.9 F    BP 93/55   P 46    RR  12   SaO2 95 4LNC
General: NAD, well-nourished
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: reduced passive ROM on rotation, no nuchal rigidity, no
bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  baclofen pump in place along right flank, otherwise
soft, non-tender, non-distended, bowel sounds present
Ext: cool, + pedal edema, loss of hair below the knees, pedal
pulses appreciated, reduced ROM for abduction at the shoulders
Skin: no rashes

FAMILY HISTORY: No history of MS or other neurologic disease

SOCIAL HISTORY: Lives in the [**Location (un) 86**] Home long-term care facility with his
girlfriend. Divorced with three children; sister lives in the
area.  Worked as a landscaper until his symptoms became too
disabling, in [**2132**].  Smoked tobacco briefly for 1-2 years in his
20s.  He drinks four alcoholic beverages per week, including
Kamikazes and White Russians.  He has used marijuana for his MS
in the past, with good symptomatic relief.  He denies a history
of IVDU.
Multiple sclerosis,Urinary tract infection, site not specified,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Neurogenic bladder NOS,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Unspecified drug-induced mental disorder,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places,Hypotension, unspecified,Constipation, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Sulfonamides causing adverse effects in therapeutic use,Paraplegia
Multiple sclerosis,Urin tract infection NOS,Ac DVT/embl low ext NOS,Neurogenic bladder NOS,Hypothyroidism NOS,Depressive disorder NEC,Oth gram negatv bacteria,Drug mental disorder NOS,Adv eff corticosteroids,Accident in place NEC,Hypotension NOS,Constipation NOS,Long-term use anticoagul,Abnrml coagultion prfile,Adv eff sulfonamides,Paraplegia NOS
Admission Date:  [**2152-10-26**]              Discharge Date:   [**2152-11-6**]

Date of Birth:  [**2097-11-18**]             Sex:   M

Service: NEUROLOGY

Allergies:
Zofran

Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Dyspnea in the setting of multiple sclerosis

Major Surgical or Invasive Procedure:
Foley replacement


History of Present Illness:
54 year-old man with secondary progressive MS (seen by Dr.
[**Last Name (STitle) 8760**] in [**2152-8-23**]), complicated by neurogenic bladder and
recurrent and recent UTI/urosepsis, s/p baclofen pump placement
for spasticity, and left leg DVT diagnosed three months ago, now
on warfarin, who presents as a transfer from [**Hospital3 3383**]
Hospital for dyspnea.

The patient reports that he was admitted to [**Hospital3 3383**]
Hospital last week in the setting of fever, and was found to
have a urinary tract infection.  He was treated with antibiotics
for the infection and was apparently given steroids for concern
of a flare of his multiple sclerosis.  After three days, he was
discharged back to his group home.  Upon arrival home, he was
short of breath even after speaking two to three  words.  His
voice was somewhat "soft and squeaky."  He returned to [**Doctor Last Name 1263**]
for further evaluation of this complaint, and was admitted on
[**10-24**].

At [**Doctor Last Name 1263**], he underwent a full pulmonary evaluation, including a
CTA of the chest, which was reportedly negative for pulmonary
embolism and showed normal lung parenchyma.  An ABG on 3LNC was
7.49/50/104/98 on [**10-25**].  He did have a leukocytosis (15.1) and a
positive UA  (positive nitrites, small leukocyte esterase, 35-75
WBC, many bacteria).  He was treated with cefuroxime and changed
to ceftazidime for a presumed urinary tract infection.  A urine
culture was pending.  There was concern that his respiratory
difficulties could be related to progression of his multiple
sclerosis, or even an exacerbation.  He was started on 1 g
salmeterol daily that was reduced to 80 mg IV q 8 hours.  Given
the concern that his presentation could be related to his MS, he
was transferred to [**Hospital1 18**] (where he has seen Dr. [**Last Name (STitle) 8760**] for
further evaluation and management.

Review of Systems:
He denies current fever, nausea, vomiting, and headache.  His
vision is stable.  He denies dysphagia and reports that his
motor and sensory function is at baseline.  He denies chest pain
and reports that he is breathing comfortably.  He suffers from
chronic constipation.

Past Medical History:
-Secondary progressive MS.  His course is well-described in the
prior note from [**Hospital **] clinic in [**Month (only) 359**].  Though he was diagnosed
with SPMS in [**2128**], it is though that his course may have begun
10 years before that date.  Prior relapses were localized to the
cord and left optic nerve.  He has had weakness of the legs
progressing to total paralysis in [**2145**].  He was diagnosed with
left optic neuritis in [**2134**], and had no recovery thereafter.  He
had a baclofen pump placed in [**2150**] for treatment of his
spasticity; he has had partial relief of his symptoms.  In the
past, he has been treated with Avonex, Copaxone, and  ovantrone.

He was not a candidate for Tysabri when assessed in [**Month (only) 359**]
[**2151**].
-Neurogenic bladder with indwelling catheter and recurrent
UTI/urosepsis
-Dyslipidemia
-Lower extremity edema
-Hypothyroidism
-Depression
-s/p cholecystectomy 2.5 years ago

Social History:
Lives in the [**Location (un) 86**] Home long-term care facility with his
girlfriend. Divorced with three children; sister lives in the
area.  Worked as a landscaper until his symptoms became too
disabling, in [**2132**].  Smoked tobacco briefly for 1-2 years in his
20s.  He drinks four alcoholic beverages per week, including
Kamikazes and White Russians.  He has used marijuana for his MS
in the past, with good symptomatic relief.  He denies a history
of IVDU.

Family History:
No history of MS or other neurologic disease


Physical Exam:
Vitals: T 95.9 F    BP 93/55   P 46    RR  12   SaO2 95 4LNC
General: NAD, well-nourished
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: reduced passive ROM on rotation, no nuchal rigidity, no
bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  baclofen pump in place along right flank, otherwise
soft, non-tender, non-distended, bowel sounds present
Ext: cool, + pedal edema, loss of hair below the knees, pedal
pulses appreciated, reduced ROM for abduction at the shoulders
Skin: no rashes

Neurologic Examination:
Mental Status:
Awake and alert, able to relay history but seems to get confused
in his timeline, cooperative with exam, normal affect
Oriented to person, place, month and date, but not year ([**2149**])
Attention: can say days of week backward
Language: fluent, non-dysarthric speech, a bit soft at first, no
paraphasic errors, naming, comprehension, repetition intact;
[**Location (un) 1131**] intact
Calculation: can determine 7 quarters in $1.75
Fund of knowledge: normal, can accurately relay current events
Memory: registration: [**1-24**] items, recall [**1-24**] items at 3 minutes
No evidence of apraxia or neglect

Cranial Nerves:
Optic disc margins sharp on the left, but fundoscopy limited on
the right; visual fields appear full to confrontation. Pupils
equally round and reactive to light, 4 to 3 mm bilaterally.
Left APD.
Extraocular movements intact, gaze-evoked nystagmus horizontally
in both directions.  Facial sensation intact bilaterally.
Facial movement normal and symmetric.  Hearing intact to finger
rub bilaterally. Palate elevates midline.  Tongue protrudes
midline, no fasciculations.  Trapezii full strength bilaterally.


Motor:
Reduced bulk and spastic throughout. No tremor.  Has [**2-26**]
strength throughout all muscles of the upper extremities
bilaterally, except at finger extensors and finger flexors,
which are full.  His legs are completely plegic, with no
movement even to noxious.

Sensation: Reduced vibration sense in the legs to the ankles
(some of which may be related to edema).  No deficits to light
touch, pin prick, temperature (cold), and proprioception
throughout.

Reflexes:
Areflexic throughout, except at ankles, where there is clonus,
1-2 beats bilaterally.  Toes were equivocal bilaterally.

Coordination:
No intention tremor noted. No dysmetria on FNF.

Gait:  Could not be assessed

Pertinent Results:
On admission:
138  102  16
------------< 145   AGap=10
4.6  31  0.6
Ca: 8.0 Mg: 2.2 P: 2.7
ALT: 16 AP: 52 Tbili: 0.6 Alb: 3.2
AST: 12 LDH: 141
8.4 > 37.9 < 278
PT: 19.5  PTT: 30.4  INR: 1.8

[**2152-10-26**] 1:42 am URINE      Source: Catheter.

                            **FINAL REPORT [**2152-10-28**]**

   URINE CULTURE (Final [**2152-10-28**]):
      ACINETOBACTER BAUMANNII COMPLEX.    10,000-100,000
ORGANISMS/ML..
         "Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
         used, since therapeutic efficacy relies on intrinsic
activity of
         the sulbactam component".

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ACINETOBACTER BAUMANNII COMPLEX
                             |
AMPICILLIN/SULBACTAM--     4 S
CEFEPIME--------------    32 R
CEFTAZIDIME-----------  =>64 R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

On discharge:
138  100  11
-------------<95   AGap=8
4.6  35  0.6
Ca: 8.6 Mg: 2.4 P: 2.9
6.3 > 39.5 < 241
PT: 16.6  PTT: 31.8  INR: 1.5

Brief Hospital Course:
Mr. [**Name13 (STitle) 80280**] was admitted to [**Hospital1 18**] with dyspnea and weakness.
While in the critical care unit, Mr [**Name13 (STitle) 80280**] remained stable
from the respiratory point of view. He did not require
intubation. Pulmonary function tests are arranged as an
outpatient (NIF/FVC on discharge was -30 and 2.5L).

His steroids were stopped on [**10-27**] and he continued improving
clinically. Once in the floors, and as per Dr.[**Name (NI) 25950**] input,
the steroid course was restarted for 4 days, then stopped when
he developed steroid psychosis. This improved without
intervention.

Dr. [**Last Name (STitle) 8760**] ([**Hospital **] clinic) was called. He explained no further
neuroimaging was required as this point.  In addition, he feels
no disease modifying therapy would be helpful. Mr. [**Name13 (STitle) 80280**] was
scheduled to follow up with Dr. [**Last Name (STitle) 8760**] as an outpatient.

His UTI was empirically treated with ceftazidime initially,
given his previus UTIs and chronic cathether. This was then
changed to ceftriaxone and eventually changed to bactrim once
the culture evidenced an acinetobacter infection. He received a
couple days of unasyn due to elevated INR on the bactrim. Total
antibiotic course was 7 days. Urology was consulted and
recommended weekly foley flushes with Neomycin-Polymyxin B, and
outpatient follow up with Dr. [**Last Name (STitle) 770**].

He had supratherapeutic INRs while on bactrim, requiring the
coumadin to be held. It was restarted when the patient became
therapeutic and eventually returned to his home dose. He was
subtherapeutic with an INR of 1.5 and lovenox was started.

Another critical issue is the patient's rigidity. In this
regard, he currently is on baclofen pump plus po, and remains
quite spastic. The pain service was consulted to evaluate the
pump, and noted that he might benefit from a higher dose by
pump. It was not changed while inpatient. He was continued on
the baclofen dose that was arranged at [**Hospital 1263**] hospital.

In addition, there was a question of central apnea, and he might
benefit from outpatient polysomnogram. This can be scheduled as
an outpatient as indicated.

Medications on Admission:
Medications (outpatient):
-Levothyroxine 175 mcg daily
-Lexapro 20 mg q hs
-Lasix 20 mg daily
-Baclofen pump 600 mcg daily, and additional 20 mg po TID
-Warfarin 10 mg daily
-Simvastatin 40 mg daily

At Caritas:
-Solumedrol 80 mg IV q 8 hours
-Ceftazidime 1 gram IV q 8 hours
-Omeprazole 40 mg daily
-Levothyroxine 175 mcg daily
-Lexapro 20 mg q hs
-Lasix 20 mg daily
-Baclofen pump, and additional 10 mg po TID, and 40 mg qhs
-Warfarin 10 mg daily
-Simvastatin 80 mg daily
-Calcium carbonate 1250 mg TID
-Colace 100 mg [**Hospital1 **]
-Lactobacillus 1 mg [**Hospital1 **]
-Multivitamin 1 tablet daily
-Psyllium 1 packet daily
-Simethicone 80 mg TID and AC
-Tizanidine 8 mg qhs
-Sodium phosphate
-Tylenol 650 mg q 6 hours prn
-Zofran 4 mg q 6 hours prn
-Clonazepam 2 mg q hs prn
-Diazepam 10 mg q hs prn
Diazepam 10 mg q hs prn


Discharge Medications:
1. Neomycin-Polymyxin B GU 40-200,000 mg-unit/mL Solution Sig:
asdir ML Irrigation QSAT (every Saturday) as needed for chronic
indwelling cathether : Neomycin-Polymyxin B GU 1 mL / 1000 ml SW
IR QSAT chronic indwelling cathether
Each 1000mL bottle contains 1mL of Neosporin GU Irrigant.  .
2. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical Q12H
(every 12 hours).
4. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
5. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): At 9 am, 1 pm, 5 pm .
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lexapro 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Baclofen 10 mg Tablet Sig: Four (4) Tablet PO Q HS ().
9. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Tizanidine 2 mg Tablet Sig: Four (4) Tablet PO Q HS ().
11. Multivitamins     Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17)
grams PO DAILY (Daily).
14. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).

15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 86**] Home - [**Location (un) 86**]

Discharge Diagnosis:
Urinary tract infection
Multiple sclerosis exacerbation
Steroid psychosis


Discharge Condition:
The patient reports he is at baseline: he has significant
hypertonia in the RUE>LUE, decreased ROM of the deltoids
bilaterally with minimal left deltoid weakness, mild right
triceps weakness, and good strength distally. He is paraplegic.
He is not dyspneic. FVC 2.5, NIF -30.


Discharge Instructions:
Take all medications as prescribed. You were admitted with a
urinary tract infection and resulting MS exacerbation. You were
treated with antibiotics and started on foley catheter flushes
per the urologists. You have been started on lovenox injections
while waiting for your coumadin level to be therapeutic.

Take all medications as prescribed and follow up with Dr.
[**Last Name (STitle) 8760**].

Call your doctor or return the emergency room with any new
weakness, numbness, vision problems, confusion, lethargy, or
other problems.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 8760**] and Dr. [**Last Name (STitle) 8759**] on [**11-30**] at
9:30am. Call ([**Telephone/Fax (1) 80281**] with questions or to reschedule.

Please follow up in urology with Dr. [**Last Name (STitle) 770**] at 12/31 at 8:30am.
Call ([**Telephone/Fax (1) 22786**] with questions or to reschedule.

Pulmonary function tests are scheduled for Monday, [**11-13**] at 2pm.
Call ([**Telephone/Fax (1) 80282**] with questions or to reschedule.

Consider evaluation in the sleep clinic. This can be arranged by
calling ([**Telephone/Fax (1) 12195**].


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
{'Multiple sclerosis,Urinary tract infection, site not specified,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Neurogenic bladder NOS,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Unspecified drug-induced mental disorder,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places,Hypotension, unspecified,Constipation, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Sulfonamides causing adverse effects in therapeutic use,Paraplegia'}


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: Dyspnea in the setting of multiple sclerosis

PRESENT ILLNESS: 54 year-old man with secondary progressive MS (seen by Dr.
[**Last Name (STitle) 8760**] in [**2152-8-23**]), complicated by neurogenic bladder and
recurrent and recent UTI/urosepsis, s/p baclofen pump placement
for spasticity, and left leg DVT diagnosed three months ago, now
on warfarin, who presents as a transfer from [**Hospital3 3383**]
Hospital for dyspnea.

MEDICAL HISTORY: -Secondary progressive MS.  His course is well-described in the
prior note from [**Hospital **] clinic in [**Month (only) 359**].  Though he was diagnosed
with SPMS in [**2128**], it is though that his course may have begun
10 years before that date.  Prior relapses were localized to the
cord and left optic nerve.  He has had weakness of the legs
progressing to total paralysis in [**2145**].  He was diagnosed with
left optic neuritis in [**2134**], and had no recovery thereafter.  He
had a baclofen pump placed in [**2150**] for treatment of his
spasticity; he has had partial relief of his symptoms.  In the
past, he has been treated with Avonex, Copaxone, and  ovantrone.

MEDICATION ON ADMISSION: Medications (outpatient):
-Levothyroxine 175 mcg daily
-Lexapro 20 mg q hs
-Lasix 20 mg daily
-Baclofen pump 600 mcg daily, and additional 20 mg po TID
-Warfarin 10 mg daily
-Simvastatin 40 mg daily

ALLERGIES: Zofran

PHYSICAL EXAM: Vitals: T 95.9 F    BP 93/55   P 46    RR  12   SaO2 95 4LNC
General: NAD, well-nourished
HEENT: NC/AT, sclerae anicteric, MMM, no exudates in oropharynx
Neck: reduced passive ROM on rotation, no nuchal rigidity, no
bruits
Lungs: clear to auscultation
CV: regular rate and rhythm, no MMRG
Abdomen:  baclofen pump in place along right flank, otherwise
soft, non-tender, non-distended, bowel sounds present
Ext: cool, + pedal edema, loss of hair below the knees, pedal
pulses appreciated, reduced ROM for abduction at the shoulders
Skin: no rashes

FAMILY HISTORY: No history of MS or other neurologic disease

SOCIAL HISTORY: Lives in the [**Location (un) 86**] Home long-term care facility with his
girlfriend. Divorced with three children; sister lives in the
area.  Worked as a landscaper until his symptoms became too
disabling, in [**2132**].  Smoked tobacco briefly for 1-2 years in his
20s.  He drinks four alcoholic beverages per week, including
Kamikazes and White Russians.  He has used marijuana for his MS
in the past, with good symptomatic relief.  He denies a history
of IVDU. 

### Response:
{'Multiple sclerosis,Urinary tract infection, site not specified,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Neurogenic bladder NOS,Unspecified acquired hypothyroidism,Depressive disorder, not elsewhere classified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Unspecified drug-induced mental disorder,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places,Hypotension, unspecified,Constipation, unspecified,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Sulfonamides causing adverse effects in therapeutic use,Paraplegia'}
