CHIEF COMPLAINT: problems swallowing

PRESENT ILLNESS: The patient is a 34yo R-handed man iwth a hx of NIDDM,
hypertension who was sent to the ED from the [**Hospital 878**] clinic.

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: -metformin 1000mg PO BID
-Glyburide 10 mg [**Hospital1 **]
-Lisinopril 20 mg qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T98.6 HR107 BP141/97 RR21  sO2100%RA
GEN: NAD, bit shabby
HEENT: mmm, no icterus
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; no
rash

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

SOCIAL HISTORY: SOCIAL HISTORY:
Occupation: picks up "junk"
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Married: no; children: no.
Lives with aunt.
Myasthenia gravis with (acute) exacerbation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Myasthna gravs w ac exac,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2155-1-2**]              Discharge Date:   [**2155-1-9**]

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

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
problems swallowing

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The patient is a 34yo R-handed man iwth a hx of NIDDM,
hypertension who was sent to the ED from the [**Hospital 878**] clinic.

The patient has been having frequent choking episodes involving
all foods for about 7-8 days. These symptoms fluctuate: at times
he has no problems, other times he gets into trouble. He is
currently eating soft foods, taking tiny bites. He says he has
difficulty getting food to the back of his mouth. He has lost
some 15 pounds over the past month. He has noted that his voice
has become weak and soft, and that he also is slurring his
words.
He thinks this gets worse when he has been talking a lot.
In addition, he has weakness in his "hands", when asking further
this seems to involve his arms and especially lifting up heavy
objects or lifting things above the shoulder has become
difficult. This also fluctuates. He is able to walk up and
downstairs without problems. [**Name (NI) **] has been getting SOB during
activity more then before, especially during the past 7-8 days.
Then he has noted blurry vision, which also flucuates. More
prominent when looking in the distance. He denies frank blurry
vision.

ROS:
denies any fever, chills, hearing changes, headache, neckpain,
nausea, vomiting, tingling, numbness, bowel-bladder dysfunction,
chest pain, abdominal pain, dysuria, hematuria, or bright red
blood per rectum. Has been having some hamstring cramps. No
rash.


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:
SOCIAL HISTORY:
Occupation: picks up "junk"
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Married: no; children: no.
Lives with aunt.



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


Physical Exam:
VITALS: T98.6 HR107 BP141/97 RR21  sO2100%RA
GEN: NAD, bit shabby
HEENT: mmm, no icterus
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; no
rash

MENTAL STATUS:
Awake and alert, cooperative with exam, normal affect.
Oriented to place, month, day, and date, person.
Attention: unable to do MOYbw, but can do DOWbw
Memory: Registration: [**2-8**] items; Recall [**2-8**] at 5 min.
Language: fluent; repetition: intact; Naming intact;
Comprehension intact; marked dysarthria, no paraphasic errors.
[**Location (un) **]: intact;
No Apraxia. No Neglect.

CRANIAL NERVES:
II: Visual fields are full to confrontation, pupils equally
round
and reactive to light both directly and consensually, 3-->2 mm
bilaterally. Disc margins sharp, no pappilledema. No red desat.
III, IV, VI: Extraocular movements intact without nystagmus, but
possible decreased lateral gaze; denies double vision. Fixation
and saccades are normal. Marked ptosis. Ptosis is fatiguable;
cannot produce DV upon sustained upgaze. Could not get him to
count in one breath.
V: Facial sensation intact to light touch and pinprick.
VII: Facial movement symmetrical, but bifacial weakness in upper
and lower part
VIII: Hearing intact to finger rub bilaterally.
IX: Palate elevates in midline.
XII: Tongue protrudes in midline, no fasciculations, but
weakness
bilaterally.
[**Doctor First Name 81**]: Sternocleidomastoid 4+.
Neck extensors: full strength; Neck flexors: 4.

MOTOR SYSTEM: Normal bulk and tone bilaterally. No adventitious
movements, no tremor, no asterixis.
Strength in all extremities full.
No pronator drift. No rebound.

REFLEXES:
B T Br Pa Pl
Right 2 2 2 2 -
Left  2 2 2 2 -
Toes: downgoing bilaterally.

SENSORY SYSTEM: Sensation intact to light touch, pin prick,
temperature (cold), and proprioception in all extremities.
Vibration mildly decreased in both LE.

COORDINATION: Normal [**Last Name (LF) 11140**], [**First Name3 (LF) **], HTS. No dysmetria or
pastpointing.

GAIT: narrow based, normal arm swing, normal initiation.
Romberg:
negative. Able to do tandem gait, walk on toes, walk on heels.


Brief Hospital Course:
The patient was admitted to the neuro-ICU with the new diagnosis
of myasthenia [**Last Name (un) 2902**]. He did well and was transferred to the
neurology floor, where he was started on mestinon, which led to
improvement in fatigable weakness. He was started on low-dose
prednisone, with the plan on not increasing the dose, for fear
of exacerbating his diabetes. It should be kept at the current
dose for the next few months, while cellcept achieves
immunosuppression; cellcept will be kept on indefinitely for
long-term immunosuppression instead. He should be monitored
carefully for side effects of this medication - namely, severe
diarrhea which could impede absorption of mestinon.

[**Last Name (un) **] was consulted for management of his diabetes. They
started glipizide, in addition to the patient's regimen of
metformin. He should be followed closely on a humalog sliding
scale (with the lunch dosing increased by 2 units over the rest,
as steroids generally cause elevated blood sugar in the
evening). He will see them as an outpatient as well.

Extensive time was spent daily with patient education both for
diabetes teaching and management of his myasthenia. This will
need to continue, intensively, as he has demonstrated difficulty
with retaining this information.

He will need close neurology follow-up, every 2-4 weeks until
his myasthenia stabilizes.

It should be reiterated that any changes in his medication
regimen (outside of his diabetes) should be approved by
neurology.

The following medications can exacerbate myasthenia:
Antibiotics (eg, aminoglycosides, ciprofloxacin, erythromycin,
ampicillin)
Beta-adrenergic receptor blocking agents (eg, propranolol,
oxprenolol)
Lithium
Magnesium
Procainamide
Verapamil
Quinidine
Chloroquine
Prednisone
Timolol (ie, a topical beta-blocking [**Doctor Last Name 360**] used for glaucoma)
Anticholinergics (eg, trihexyphenidyl)

Neuromuscular blocking agents, including vecuronium and curare,
should be used cautiously in myasthenics to avoid prolonged
neuromuscular blockade.




Medications on Admission:
-metformin 1000mg PO BID
-Glyburide 10 mg [**Hospital1 **]
-Lisinopril 20 mg qday

Discharge Medications:
1. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1)
Tab,Sust Rel Osmotic Push 24HR PO DAILY (Daily).
Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2*
6. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale  Subcutaneous ASDIR (AS DIRECTED): see attached.
Disp:*30 vials* Refills:*2*
7. Insulin Admin Supplies     Insulin Pen Sig: One (1)
Subcutaneous per sliding scale.
Disp:*1 pen* Refills:*2*
8. Insulin Needles (Disposable) 29 X [**12-10**]   Needle Sig: as per
sliding scale  Miscellaneous as per sliding scale.
Disp:*100 needles* Refills:*5*
9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*
10. Blood Glucose Monitor Kit     Kit Sig: One (1)
Miscellaneous QACHS.
Disp:*1 kit* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Myasthenia [**Last Name (un) 2902**]
Diabetes mellitus


Discharge Condition:
Improved


Discharge Instructions:
Please continue to take all medication as prescribed. If you
have trouble breathing, go to the nearest emergency room.

Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-1-16**] 12:30

Provider: [**Last Name (NamePattern4) **].[**Name (NI) **]. Phone [**Telephone/Fax (1) 2384**] Date/Time: [**2155-1-12**] at
12pm.


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]

Completed by:[**2155-1-9**]
{'Myasthenia gravis with (acute) exacerbation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}


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: problems swallowing

PRESENT ILLNESS: The patient is a 34yo R-handed man iwth a hx of NIDDM,
hypertension who was sent to the ED from the [**Hospital 878**] clinic.

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: -metformin 1000mg PO BID
-Glyburide 10 mg [**Hospital1 **]
-Lisinopril 20 mg qday

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: T98.6 HR107 BP141/97 RR21  sO2100%RA
GEN: NAD, bit shabby
HEENT: mmm, no icterus
NECK: no LAD; no carotid bruits; full range neck movements
LUNGS: Clear to auscultation bilaterally
HEART: Regular rate and rhythm, normal S1 and S2, no murmurs,
gallops and rubs.
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema; no
rash

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

SOCIAL HISTORY: SOCIAL HISTORY:
Occupation: picks up "junk"
Smoking: 2ppd for 20 years, cut back to 1 ppd; EthOH: denies;
drug abuse: denies.
Married: no; children: no.
Lives with aunt. 

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