CHIEF COMPLAINT: generalized weakness

PRESENT ILLNESS: Mr. [**Known lastname 1391**] is a 64 year old male with Type 2 DM, HTN, atrial
fibrillation on coumadin, CAD s/p CABG [**2127**] (4-vessel at [**Hospital1 336**]),
chronic surgical wound of left foot complicated by osteomyelitis
and status post debridement on intravenous vancomycin, who was
sent to the ED after evaluation in the podiatry clinic for HTN
and feeling unwell. At podiatry clinic he was noted to be pale
and weak.
.
The patient stated he has "not been feeling well" for the last
one week. Last week, he was trying to get up out of his recliner
and noticed that it felt like his legs were giving out
underneath him. He hit his hip on the sofa but otherwise had no
injuries. He denies any other associated symptoms especially
Lightheadedness or dizziness. Still states that he continued to
feel weak in his legs, occasionally he felt jittery. His
greatest difficulty comes with attempting to rise from a chair.
His knees ache constantly. Two nights ago he had some
discomfort/weakness while lifting a few folders from his kitchen
table. These light objects felt as though they were 12 pounds
heavy.
.
His sleep has also been poor over the last two to three weeks.
His wife thinks it is because he is short of breath but no PND
and stable 2 pillow orthopnea. He also noted increase in his
abdominal girth over the last one week.
.
His SOB has been ongoing since [**Month (only) 116**]. He says over all he thinks
it is about the same. It s more pronounced with walking; he only
walk small distance with a walker in his home. The patient had a
cough while on lisinopril. His wife described his breathing as
"labored." She also noted more lower extremity edema. This
evening he states it is easier for him to sit up to breath.
Denies CP/pressure, LH/dizziness.
.
Overall he feels unwell and has a difficult time honing in on
the exact nature of his symptoms.
.
In the [**Hospital1 18**] ED, he was afebrile, HR 80, BP 167/89, RR 18,
saturation of 94 % on Room Air. He was given Aspirin and Beta
Blocker, NS and TUMs in the ED. Head CT for history of a recent
fall at home was negative. Cardiology was consulted in ED.
.
Admitted for workup of muscle weakness, elevated troponin, and
SOB.
.
ROS: no F/C/+night sweats x a few months, no N/V/D/C/change in
stool or blood in stool, no LH/dizziness, no numbness/tingling,
no change in vision

MEDICAL HISTORY: IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th  ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]

MEDICATION ON ADMISSION: actos 45 mg qd
allopurinol 300 mg qd
amytriptilene 1 mg qd
avapro 300 mg qd
ASA 81 mg qd
catapress 0.3 qweek, changes on Sat.
diltizem CR 300 mg qd
lasix 40 mg qd
neurontin 600 mg [**Hospital1 **]
tricor 145 mg qd
coumadin 5 mg qhs x 6 days
zetia 10 mg qd
lopressor 25 mg [**Hospital1 **]
insulin: novolog 24 u qam/18qpm
fish oil 2 gm [**Hospital1 **]
.
Discontinued:
lisinopril 40 mg [**Hospital1 **]
glucophage 500 mg, pravacol 10 mg, indapamide 2.5 mg qd, norvasc
10 mg qd, zocor?
Temp meds:
rocephine, zyvox, zosyn, flagyl, levoquin, vancomycin (9 weeks)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM -
VS: 150/90, HR 77, RR 22, 89% RA, 94% 2L oxygen
Gen - Alert, no acute distress, some SOB with talking for
several minutes
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP difficult to assess, no cervical lymphadenopathy
Chest - [**Month (only) **] BS in LL, no crackles, no wheezing, some [**Month (only) **] BS on
right LL, surgical scar
CV - distant HS, nl S1/S2, IRRR
Abd - obese, nontender, +distended, with normoactive bowel
sounds, ?+fluid wave
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin on R, [**1-26**]+ in
LLE. 1+ DP pulses in right
Left leg: surgical scar on left leg, dressed left foot wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**3-29**])
Skin - No rash
MSK- no thigh, bicep, calf tenderness

FAMILY HISTORY: Mother died of liver cancer in her 70's

SOCIAL HISTORY: retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved
Rhabdomyolysis,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection (chronic) of amputation stump,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Atrial fibrillation,Gout, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Obstructive sleep apnea (adult)(pediatric)
Rhabdomyolysis,Acute & chronc resp fail,Ac kidny fail, tubr necr,CHF NOS,DMII renl nt st uncntrld,Hyp kid NOS w cr kid V,Infection amputat stump,Urin tract infection NOS,Chronic kidney dis NOS,Elev transaminase/ldh,Atrial fibrillation,Gout NOS,Pure hypercholesterolem,Crnry athrscl natve vssl,Aortocoronary bypass,Adv eff antilipemics,Long-term use anticoagul,Hypertension NOS,Periph vascular dis NOS,Obstructive sleep apnea
Admission Date:  [**2133-7-30**]              Discharge Date:   [**2133-8-9**]

Date of Birth:  [**2069-3-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
generalized weakness

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 1391**] is a 64 year old male with Type 2 DM, HTN, atrial
fibrillation on coumadin, CAD s/p CABG [**2127**] (4-vessel at [**Hospital1 336**]),
chronic surgical wound of left foot complicated by osteomyelitis
and status post debridement on intravenous vancomycin, who was
sent to the ED after evaluation in the podiatry clinic for HTN
and feeling unwell. At podiatry clinic he was noted to be pale
and weak.
.
The patient stated he has "not been feeling well" for the last
one week. Last week, he was trying to get up out of his recliner
and noticed that it felt like his legs were giving out
underneath him. He hit his hip on the sofa but otherwise had no
injuries. He denies any other associated symptoms especially
Lightheadedness or dizziness. Still states that he continued to
feel weak in his legs, occasionally he felt jittery. His
greatest difficulty comes with attempting to rise from a chair.
His knees ache constantly. Two nights ago he had some
discomfort/weakness while lifting a few folders from his kitchen
table. These light objects felt as though they were 12 pounds
heavy.
.
His sleep has also been poor over the last two to three weeks.
His wife thinks it is because he is short of breath but no PND
and stable 2 pillow orthopnea. He also noted increase in his
abdominal girth over the last one week.
.
His SOB has been ongoing since [**Month (only) 116**]. He says over all he thinks
it is about the same. It s more pronounced with walking; he only
walk small distance with a walker in his home. The patient had a
cough while on lisinopril. His wife described his breathing as
"labored." She also noted more lower extremity edema. This
evening he states it is easier for him to sit up to breath.
Denies CP/pressure, LH/dizziness.
.
Overall he feels unwell and has a difficult time honing in on
the exact nature of his symptoms.
.
In the [**Hospital1 18**] ED, he was afebrile, HR 80, BP 167/89, RR 18,
saturation of 94 % on Room Air. He was given Aspirin and Beta
Blocker, NS and TUMs in the ED. Head CT for history of a recent
fall at home was negative. Cardiology was consulted in ED.
.
Admitted for workup of muscle weakness, elevated troponin, and
SOB.
.
ROS: no F/C/+night sweats x a few months, no N/V/D/C/change in
stool or blood in stool, no LH/dizziness, no numbness/tingling,
no change in vision

Past Medical History:
IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th  ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]


Social History:
retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved

Family History:
Mother died of liver cancer in her 70's

Physical Exam:
PHYSICAL EXAM -
VS: 150/90, HR 77, RR 22, 89% RA, 94% 2L oxygen
Gen - Alert, no acute distress, some SOB with talking for
several minutes
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP difficult to assess, no cervical lymphadenopathy
Chest - [**Month (only) **] BS in LL, no crackles, no wheezing, some [**Month (only) **] BS on
right LL, surgical scar
CV - distant HS, nl S1/S2, IRRR
Abd - obese, nontender, +distended, with normoactive bowel
sounds, ?+fluid wave
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin on R, [**1-26**]+ in
LLE. 1+ DP pulses in right
Left leg: surgical scar on left leg, dressed left foot wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**3-29**])
Skin - No rash
MSK- no thigh, bicep, calf tenderness


Pertinent Results:
Labs: see below, notable for elevated CK/MB/troponin,
transaminitis, elevated BNP
.
EKG unchanged, low voltage - a fib, no ST changes.
.
[**2133-7-30**] CT head (prelim): No acute intracranial hemorrhage. Small
vessel ischemic changes and evidence of prior left parietal lobe
infarction.
.
[**2133-7-30**] CXR: Cardiomegaly without pulmonary edema. Left lower
lobe
atelectasis versus consolidation.

[**2133-7-30**] 04:10PM   CK(CPK)-[**Numeric Identifier 60242**]*
[**2133-7-30**] 04:10PM   CK-MB-100* MB INDX-0.8 cTropnT-0.27*
proBNP-1510*
[**2133-7-30**] 04:10PM   VIT B12-188* FOLATE-8.2
[**2133-7-30**] 04:10PM   TSH-3.0
[**2133-7-30**] 01:00PM   GLUCOSE-69* UREA N-22* CREAT-1.1 SODIUM-143
POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
[**2133-7-30**] 01:00PM   ALT(SGPT)-373* AST(SGOT)-433* CK(CPK)-[**Numeric Identifier 12181**]*
AMYLASE-41 TOT BILI-0.5
[**2133-7-30**] 01:00PM   LIPASE-28
[**2133-7-30**] 01:00PM   CK-MB-96* MB INDX-0.8 cTropnT-0.24*
[**2133-7-30**] 01:00PM   ALBUMIN-3.7 CALCIUM-8.0* PHOSPHATE-3.3
MAGNESIUM-1.7
[**2133-7-30**] 01:00PM   WBC-7.1 RBC-4.11* HGB-12.4* HCT-36.1* MCV-88
MCH-30.2 MCHC-34.3 RDW-15.9*
[**2133-7-30**] 01:00PM   NEUTS-77.4* LYMPHS-15.4* MONOS-4.8 EOS-2.0
BASOS-0.3
[**2133-7-30**] 01:00PM   PLT COUNT-195
[**2133-7-30**] 01:00PM   PT-26.3* PTT-26.7 INR(PT)-2.7*
[**2133-8-8**] 06:04AM BLOOD WBC-8.6 RBC-4.38* Hgb-13.0* Hct-38.0*
MCV-87 MCH-29.6 MCHC-34.2 RDW-16.3* Plt Ct-216
[**2133-7-30**] 01:00PM BLOOD Neuts-77.4* Lymphs-15.4* Monos-4.8
Eos-2.0 Baso-0.3
[**2133-8-8**] 06:04AM BLOOD Plt Ct-216
[**2133-8-8**] 06:04AM BLOOD Glucose-119* UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-100 HCO3-30 AnGap-14
[**2133-8-8**] 06:04AM BLOOD ALT-511* AST-525* CK(CPK)-[**Numeric Identifier 60243**]*
[**2133-8-7**] 05:58AM BLOOD ALT-474* AST-501* CK(CPK)-9940*
AlkPhos-48
[**2133-8-6**] 05:23AM BLOOD ALT-490* AST-535* CK(CPK)-[**Numeric Identifier **]*
AlkPhos-46
[**2133-8-3**] 04:59PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2133-8-6**] 05:23AM BLOOD HCV Ab-NEGATIVE
[**2133-7-31**] 06:30AM BLOOD HCV Ab-NEGATIVE
[**2133-8-6**] 05:23AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE

Brief Hospital Course:
Mr. [**Known lastname 1391**] is a 64 year old gentleman with DM2, HTN, AF, CAD
s/p CABG, and PVD who is admitted with diastolic CHF and
elevated CK's.
.
1. Rhabdomyolysis/Proximal muscle weakness-
Admission Creatine Kinase enzymes were found to be 11,419, this
value peaked 3 days later at 12,300 and reached a nadir of 9,200
during the hospitalization. His admission urinalysis was
supportive of rhabdomyolysis with the finding of large Heme
positivity with only scant RBC's. The patient was immediately
taken off his lipid lowering agents ezetimibe and tricor. The
patient had only a distant history of treatment with statins.
At first the patient was given gentle hydration to prevent renal
dysfunction in the setting of elevated CK's. However his kidney
function remained relatively stable throughout the
hospitalization with creatinine on admission at 1.1 peaking at
1.4 and reaching a nadir of 0.8. In this setting it was decided
to institute gentle diuresis with IV lasix to improve the
patient's respiratory status. With a net diuresis of [**1-25**].5
liters per day the patient reported improvement in his sensation
of shortness of breath. It was later felt that the patient may
have had diaphragmatic weakness in the setting of a thus far,
occult intraabdominal process. In the two weeks prior to
hospitalization the pt and his wife noted nearly a doubling in
the size of his abdomen. This in itself may explain a mechanical
deficit in the patient's ability to respire. Abdominal
ultrasound did not reveal any ascites, could not adequately
assess the patient's liver, but did note a mildly enlarged
spleen to 13.6cm.  Hepatitis B and C were negative, neurology
consultation was obtained at it was felt that the patient's long
term use of tricor in combination with the recent addition of
Ezetemibe were likely at cause for the patient's CK elevation.
Low vitamin B12 was treated with B12 injection for 7days. As
noted above, the patient's CK's fluctuated around 10,000
throughout the hospitalization without any clear alteration in
renal function. Daily physical therapy also greatly improved the
pt's functional status and he was soon ambulating with a walker
and able to climb a flight of stairs without difficulty.
Creatinine values exhibited some fluctation from 1.1-1.4-0.8 At
time of discharge it was thought the patient's CK elevation
could be due to lingering effects of Tricor/Zetia combination,
however an intrabdominal process that may explain the patient's
clinical picture could be be ruled out. MR scan with gadolinium
contrast was attempted, but the patient was unable to fit into
the MR machine due to his abdominal girth. An outpatient open
MRI is suggested to further evaluate the abdomen and
specifically the liver to assess for possible vascular or
intrahepatic process. CT abdomen with contrast was not obtained
due to the patient's baseline mild renal insufficiency.
.
2. Diastolic CHF/CAD/AFib-
Cardiology consultation was obtained on admission for evaluation
of elevated CK-MB and Troponin. The patient was not having an
acute coronary syndrome, but rather a demand mediated ischemia.
CK-MB enzymes trended down moderately, but remained elevated in
the setting of his general CK eleavtion. Transthoracic
Echocardiography revealed LVEF of 55%, and mildly dilated
[**Doctor Last Name 1754**], no wall motion abnormalities. Given the patient's body
habitus it was thought diastolic dysfunction may be a component
of his symptoms of shortness of breath. He was titrated to 50mg
PO BID of Metoprolol in this setting, and was tolerating the
therapy well. He was switched to his home dose of lasix 40mg PO
daily and continued on avapro, coumadin, aspirin, and fish oil.

 Of note, the patient's chest xray was never fully consistent
with a picture of heart failure, but rather demonstrated low
lung volumes. Pulmonary consultation was obtained to assess for
possible obstructive sleep apnea. They suggested an outpatient
sleep study with follow up by the sleep clinic at [**Hospital1 **] (or other facility of the PCP's choosing). Pulmonary
consult did concur with the fact that the patient seemed to be
exhibiting signs of diaphragmatic weakness. Further cause for
the need for abdominal evaluation
.
4. Transaminitis:
The patient AST was around 500 and ALT mid-high 400's.
Transaminase enzymes remained stable, but persistently elevated
throughout the admission. Hep B was negative, hep C was
negative.
.
5. Status post left foot debridement/osteomyelitis:
The patient was examined by podiatry for recommendations on
optimum care of pt's L TMA. The patient should continue to
follow up with podiatry as an outpatient. The patient's PICC
line used for IV vancomycin with his history of osteomyelitis
was removed just prior to discharge.
.
6. DM2:
The patient's blood glucose levels were optimally maintained on
NPH 18 U in AM, 12 U in the evening, in combination with a
humalog sliding scale.


Medications on Admission:
actos 45 mg qd
allopurinol 300 mg qd
amytriptilene 1 mg qd
avapro 300 mg qd
ASA 81 mg qd
catapress 0.3 qweek, changes on Sat.
diltizem CR 300 mg qd
lasix 40 mg qd
neurontin 600 mg [**Hospital1 **]
tricor 145 mg qd
coumadin 5 mg qhs x 6 days
zetia 10 mg qd
lopressor 25 mg [**Hospital1 **]
insulin: novolog 24 u qam/18qpm
fish oil 2 gm [**Hospital1 **]
.
Discontinued:
lisinopril 40 mg [**Hospital1 **]
glucophage 500 mg, pravacol 10 mg, indapamide 2.5 mg qd, norvasc
10 mg qd, zocor?
Temp meds:
rocephine, zyvox, zosyn, flagyl, levoquin, vancomycin (9 weeks)



Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
4. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO qd ().
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 6X/WEEK
(MO,TU,WE,TH,FR,SA).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Omega-3 Fatty Acids 550 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1)  Injection
DAILY (Daily) for 7 days.
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Suspension
Sig: Follow Insulin flow sheet attached  Subcutaneous twice a
day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: rhabdomyolysis
Secondary:
Diabetes Mellitis
Peripheral Vascular Disease
Diastolic Heart Dysfunction


Discharge Condition:
Good


Discharge Instructions:
You have been diagnosed with rhabdomyolysis that may be related
to the cholesterol lowering drugs Zetia and Tricor. There is
also a possibility that this could be related to an abnormality
with your liver or gastrointestinal tract and it is important
you follow up as an outpatient for an abdominal MRI.

Please contact your doctor or call 911 if you should experience
shortness of breath, chest pain, severe muscle pain or worsening
weakness, dizzyness, uncontrollable bleeding, increasing
abdominal girth, or any other concerning symptoms.

Followup Instructions:
1)You should follow up with Dr. [**First Name (STitle) 745**] within the next Thursday
to follow up on your condition after discharge. It is
recommended you have further evaluation of your liver, with an
MRI scan, as an outpatient. This will need to be scheduled at a
facility with an open MRI scanner.
2)You have been taken off of Zetia and Tricor and it is
important you follow up with your primary care provider, [**Last Name (NamePattern4) **].
[**First Name (STitle) 745**] to discuss alternative management of your cholesterol.
3)The pulmonary doctors have recommended [**Name5 (PTitle) **] have schedule a
sleep study due to their concern for obstructive sleep apnea and
how it may be affecting your heart. You can follow up with the
sleep clinic at [**Hospital1 18**] with the results from your sleep study if
you choose.
4)You should see your podiatrist for follow up care of your
foot.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]



Admission Date:  [**2133-8-13**]              Discharge Date:   [**2133-9-10**]

Date of Birth:  [**2069-3-21**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Weakness, increased abdominal girth,

Major Surgical or Invasive Procedure:
1. Tracheostomy Placement
2. PEG tube placement


History of Present Illness:
Pt is a 64 yo M with h/o DM2, CAD s/p recent hospitalization for
rhabdomyolyis and myopathy presenting with weakness. Pt states
that since d/c on [**8-9**] he has experienced progressively
worsening weakness. He states that he has the most difficulty
getting out of chair, changing clothes, not as much weakness at
the wrists or ankle. No diplopia or blurry vision, no dysphagia,
no headache or jaw pain. Pt denies any myalgias, no
paraesthesis. On the previous hospitalization his cholesterol
lowering agents were discontinued as it was thought that these
could be the possible culprits for rhabdomyolysis. During that
hospitalization neurology was consulted, and work up included nl
TSH, elevated ESR, negative [**Doctor First Name **]. Pt's health has been
deteriorating over the past year in the setting of a chronic
post surgical would infection at the left foot requiring most
recently vancomycin. He was started on zyvox 4 days prior to
this presentation. Of note, during his prior hospitalization he
complained of SOB and had an oxygen requirement. Echo
demonstrated an EF of % and it was felt that he possibly had
diastolic heart failure. He responded to gentle diuresis with
subjective improvement in symptoms. Pulmonary was consulted at
that time and recommended outpt sleep study. His hospital course
results were also remarkable for persistently elevated LFTs. An
MRI was planned to further evaluate but pt was unable to fit in
MRI due to abdominal girth.
.
In the ED his labs were notable for elevated CK to < [**Numeric Identifier 4731**]. This
was higher than the CK max at the prior hospitalization. He was
given 1L NS.
.
ROS: positive for mild SOB which he says is unchanged since
discharge - overall improved over the past month since starting
diuretics; denies CP/palp/cough/diarrhea/rash.


Past Medical History:
IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th  ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]


Social History:
retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved


Family History:
Mother died of liver cancer in her 70's

Physical Exam:
VS: 130/80, HR 87, RR 16, 89% RA, 96% 2L oxygen
Gen - NAD
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP 8cm, no cervical lymphadenopathy
Chest - CTA bl
CV - irrg/irreg nl s1 s2 no mrg
Abd - obese, nt, nd, nabs
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin bl
Left - foot surgical scar wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**4-29**]); sensation intact
Skin - No rash


Pertinent Results:
[**2133-8-13**] 05:30PM   GLUCOSE-120* UREA N-43* CREAT-1.4* SODIUM-138
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-14
[**2133-8-13**] 05:42PM   LACTATE-1.5
[**2133-8-13**] 05:30PM   ALT(SGPT)-542* AST(SGOT)-573* CK(CPK)-[**Numeric Identifier 37476**]*
ALK PHOS-63 TOT BILI-0.5
[**2133-8-13**] 05:30PM   LIPASE-39
[**2133-8-13**] 05:30PM   WBC-8.5 RBC-4.15* HGB-12.3* HCT-35.8* MCV-86
MCH-29.6 MCHC-34.4 RDW-16.4*
[**2133-8-13**] 05:30PM   NEUTS-79.3* LYMPHS-14.2* MONOS-4.6 EOS-1.6
BASOS-0.4
[**2133-8-13**] 05:30PM   ANISOCYT-1+ MICROCYT-1+
[**2133-8-13**] 05:30PM   PLT COUNT-192
.
CXR--Bibasilar atelectasis, cardiomegaly
.
.
FINAL DIAGNOSIS:



RIGHT DELTOID MUSCLE BIOPSY (including snap-frozen tissue):

Acute, recent, and chronic myopathy (chronic active myopathy)

Acute myofiber necrosis.

Scattered degenerating and regenerating myofibers and scattered
myophagocytosis, indicative of recent myofiber injury.

Increased endomysial connective tissue, increased frequency of
internalized nuclei, and scattered split myofibers, indicative
of chronic myopathy.

Scattered CD4 and CD8 T-lymphocytes, without direct association
with pathologic changes.

Coarse lipid and mitochondrial staining in degenerating
myofibers.

NOTE:

In addition to the findings identified in the preliminary
report, these special stains identify coarse lipid staining in
many of the degenerating myofibers, along with corresponding
changes in mitochondria. While not specific, they are consistent
with a metabolic myopathy affecting lipid metabolism, as can be
induced by toxic agents and several drugs. They are consistent
with effects of some cholesterol lower agents, especially
combinations of agents in elderly patients. Diagnostic changes
of an inflammatory myositis are not identified in this biopsy.

MICROSCOPIC DESCRIPTION:

H&E stain: increased internalized nuclei and split myofibers;
scattered myophagocytosis and frequent degenerating and
regenerating myofibers, including atrophic basophilic fibers;
moderate to marked variation in myofiber size; frequent small,
round or angulated myofibers; scattered acutely necrotic
myofibers having pale eosinophilic staining

Gomori trichrome stain: increased endomysial connective tissue
in sites of greatest degeneration; no ragged red fibers;
degenerating myofibers often show coarse staining of
sarcoplasmic mitochondria

PAS stain: normal distribution of glycogen

PAS + diastase stain: no diastase-resistant glycogen

Oil red "O" stain: coarse staining of degenerating myofibers

NADH histochemistry: coarse staining of degenerating myofibers
in a mitochondrial pattern (mitochondrial clumping)

ATPase (pH 4.3, 4.6, 9.5) histochemistry: type I myofiber
predominant; atrophic myofibers of both types - predominantly
type II; no diagnostic type grouping.

CD3 immunoperoxidase: non-contributory

CD4 immunoperoxidase: scattered T4 lymphocytes throughout
specimen; not directly associated with individual myofiber
injury

CD8 immunoperoxidase: scattered T8 lymphocytes throughout
specimen; not directly associated with individual myofiber
injury

CD68 immunoperoxidase: non-contributory

Factor VIII immunoperoxidase: normal numbers of vessels,
including endomysial capillaries


Brief Hospital Course:
A/P:
64yo man with h/o TIIDM, CAD, Afib, and Gout, presenting  with
myositis vs rhabdomyalysis, transferred now with tachypnea and
hypercapnia and acidemia.
.
#  Respiratory failure  Poor ventilation due to progressive
muscle weakness.  Rising PCO2 and respiratory acidemia
progressed to hypercarbic respiratory failure.  No evidence of
primary pulmonary process.
-  Pt intubated for worsening ventilation/oxygenation in setting
of worsening weakness
-  Remained intubated due to poor NIFs.  Very brief SBT failed
when pt had no respiratory effort.
-Given continued poor respiratory muscle strength, likelihood of
lengthy intubation, percutaneous tracheostomy performed on
[**2133-9-1**] and trach placed.  Complicated trach placement due to
subcutaneous emphysema on same day of trach placement.  Incision
site was widened and subcutaneous emphysema and swelling
decreased over the next two days.  No pneumothorax or
pneumomediastinum seen on CXR.
.
#  Myospathy:  rhabdomyolysis/myopathy, pathololgy from muscle
biopsy suggests myopathic changes, possibly drug-induced.
Rheumatology and neurology consulted.  Not thought that steroids
will help this disease process.  Off statins, will follow CK and
clinical picture, await gradual recovery.
.
#  ARF:  contrast nephropathy, ATN on chronic diabetic
nephrophathy.  patient briefly anuric.  Hemodialyzed, but now
with improving renal function, increased urine output, no
further need for dialysis at this time.
.
#  Transaminitis:  LFTs returned to NL; likely due to rhabdo.
hepatitis serologies negative.  CTA abdomen nondiagnostic
.
#  Foot wound:  patient completed 10days Linezolid per podiatry
recc's.  Podiatry following.
.
#  TIIDM: RISS + NPH for elevated blood sugars.
.
#  HTN:  metoprolol
.
#  FEN:  diabetic, cardiac diet; PEG placed on [**9-8**]
.
#  PPx:  SC heparin, po diet
.
#  Access:  PICC
.
#  Full Code

Medications on Admission:
Allopurinol 200 mg PO DAILY
Aspirin 81 mg PO DAILY
Clonidine 0.3 mg/24 hr Patch Weekly QSAT
Irbesartan 300 mg PO qd
Warfarin 5 mg PO 6X/WEEK (MO,TU,WE,TH,FR,SA)
Docusate Sodium 100 mg PO BID
Omega-3 Fatty Acids 550 mg PO BID
Gabapentin 300 mg PO BID
Folic Acid 1 mg PO DAILY
Cyanocobalamin 1,000 mcg/mL for 7 days.
Furosemide 40 mg PO DAILY
Metoprolol Tartrate 50 mg PO BID
Insulin NPH-Regular


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1)  PO DAILY (Daily).
10. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscell.  Q4-6H (every 4 to 6 hours) as needed.
11. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

16. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
17. Hydralazine 20 mg/mL Solution Sig: One (1)  Injection Q6H
(every 6 hours) as needed for SBP>155.
18. Vancomycin HCl 1000 mg IV Q 12H


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
1. Myopathy
2. Respiratory Failure


Discharge Condition:
Good


Discharge Instructions:
- Please take all medications as prescribed.
- Return if you have any worsening weakness, any worsening
muscle cramping, chest pain, dizziness, faintness, or any other
concerning symptoms.

Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.
{'Rhabdomyolysis,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection (chronic) of amputation stump,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Atrial fibrillation,Gout, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Obstructive sleep apnea (adult)(pediatric)'}


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: generalized weakness

PRESENT ILLNESS: Mr. [**Known lastname 1391**] is a 64 year old male with Type 2 DM, HTN, atrial
fibrillation on coumadin, CAD s/p CABG [**2127**] (4-vessel at [**Hospital1 336**]),
chronic surgical wound of left foot complicated by osteomyelitis
and status post debridement on intravenous vancomycin, who was
sent to the ED after evaluation in the podiatry clinic for HTN
and feeling unwell. At podiatry clinic he was noted to be pale
and weak.
.
The patient stated he has "not been feeling well" for the last
one week. Last week, he was trying to get up out of his recliner
and noticed that it felt like his legs were giving out
underneath him. He hit his hip on the sofa but otherwise had no
injuries. He denies any other associated symptoms especially
Lightheadedness or dizziness. Still states that he continued to
feel weak in his legs, occasionally he felt jittery. His
greatest difficulty comes with attempting to rise from a chair.
His knees ache constantly. Two nights ago he had some
discomfort/weakness while lifting a few folders from his kitchen
table. These light objects felt as though they were 12 pounds
heavy.
.
His sleep has also been poor over the last two to three weeks.
His wife thinks it is because he is short of breath but no PND
and stable 2 pillow orthopnea. He also noted increase in his
abdominal girth over the last one week.
.
His SOB has been ongoing since [**Month (only) 116**]. He says over all he thinks
it is about the same. It s more pronounced with walking; he only
walk small distance with a walker in his home. The patient had a
cough while on lisinopril. His wife described his breathing as
"labored." She also noted more lower extremity edema. This
evening he states it is easier for him to sit up to breath.
Denies CP/pressure, LH/dizziness.
.
Overall he feels unwell and has a difficult time honing in on
the exact nature of his symptoms.
.
In the [**Hospital1 18**] ED, he was afebrile, HR 80, BP 167/89, RR 18,
saturation of 94 % on Room Air. He was given Aspirin and Beta
Blocker, NS and TUMs in the ED. Head CT for history of a recent
fall at home was negative. Cardiology was consulted in ED.
.
Admitted for workup of muscle weakness, elevated troponin, and
SOB.
.
ROS: no F/C/+night sweats x a few months, no N/V/D/C/change in
stool or blood in stool, no LH/dizziness, no numbness/tingling,
no change in vision

MEDICAL HISTORY: IDDM, Htn, Afib w/ anticoagulation therapy
Gout, hypercholesterolemia, arthritis
CAD
PSH:
s/p L 5th  ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]

MEDICATION ON ADMISSION: actos 45 mg qd
allopurinol 300 mg qd
amytriptilene 1 mg qd
avapro 300 mg qd
ASA 81 mg qd
catapress 0.3 qweek, changes on Sat.
diltizem CR 300 mg qd
lasix 40 mg qd
neurontin 600 mg [**Hospital1 **]
tricor 145 mg qd
coumadin 5 mg qhs x 6 days
zetia 10 mg qd
lopressor 25 mg [**Hospital1 **]
insulin: novolog 24 u qam/18qpm
fish oil 2 gm [**Hospital1 **]
.
Discontinued:
lisinopril 40 mg [**Hospital1 **]
glucophage 500 mg, pravacol 10 mg, indapamide 2.5 mg qd, norvasc
10 mg qd, zocor?
Temp meds:
rocephine, zyvox, zosyn, flagyl, levoquin, vancomycin (9 weeks)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM -
VS: 150/90, HR 77, RR 22, 89% RA, 94% 2L oxygen
Gen - Alert, no acute distress, some SOB with talking for
several minutes
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist
Neck - JVP difficult to assess, no cervical lymphadenopathy
Chest - [**Month (only) **] BS in LL, no crackles, no wheezing, some [**Month (only) **] BS on
right LL, surgical scar
CV - distant HS, nl S1/S2, IRRR
Abd - obese, nontender, +distended, with normoactive bowel
sounds, ?+fluid wave
Back - No costovertebral angle tendernes, no sacral edema
Extr - No clubbing, cyanosis, 1+ edema to mid shin on R, [**1-26**]+ in
LLE. 1+ DP pulses in right
Left leg: surgical scar on left leg, dressed left foot wound
Neuro - Alert and oriented x 3, cranial nerves [**3-8**] intact, UE
strength 5/5 except for deltoid ([**4-29**]), LE [**5-29**] except for hip
extensors ([**3-29**])
Skin - No rash
MSK- no thigh, bicep, calf tenderness

FAMILY HISTORY: Mother died of liver cancer in her 70's

SOCIAL HISTORY: retired postal worker, married, 4 children, no tobacco, no drugs
use, ETOH qweek, wife involved 

### Response:
{'Rhabdomyolysis,Acute and chronic respiratory failure,Acute kidney failure with lesion of tubular necrosis,Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Infection (chronic) of amputation stump,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Atrial fibrillation,Gout, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Antilipemic and antiarteriosclerotic drugs causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Unspecified essential hypertension,Peripheral vascular disease, unspecified,Obstructive sleep apnea (adult)(pediatric)'}
