CHIEF COMPLAINT: Weakness, diarrhoea, poor oral intake

PRESENT ILLNESS: HPI: Ms. [**Known lastname **] is 62 year old woan with myasthenia [**Last Name (un) 2902**], ho
of compression spinal fractures after steroid use for MG who
presents to neurology for diarrhea, dehydration and weakness
after not taking prescribed narcotics x 1 week. Patient was
prescribed oxycodone and oxycontin to treat back pain from
compression fractures which developed after steroid use. She
reported having good control of her back pain this week and
decided not to refill oxycodone/oxycontin rx. This week she felt

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

MEDICATION ON ADMISSION: Medications prior to admission:
1. Mestinon 30 mg TID
2. Oxycontin 40 mg po qam and 20 mg po qPM
3. Oxycodone 10 mg tid prn pain
4. Lipitor 20 mg po qday
5. Inderal 40 mg po BID
6. Evista

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: O: Tm: 98.7 Tc: 99.3 BP:147 / 62 HR: 62-69

FAMILY HISTORY: Mother and father died of coronary artery disease in their 60s.
Sister died at age 5 of insulin dependent diabetes mellitus.

SOCIAL HISTORY: Patient is single and lives alone.  Limited social supports.
She is currently on disability.  She used to work as a histology
tech a [**Hospital1 18**].  She denies ETOH/tobacco.
Myasthenia gravis with (acute) exacerbation,Pathologic fracture of vertebrae,Dehydration,Drug withdrawal,Opioid abuse, continuous,Diarrhea,Shortness of breath,Unspecified essential hypertension,Pure hypercholesterolemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Adrenal cortical steroids causing adverse effects in therapeutic use
Myasthna gravs w ac exac,Path fx vertebrae,Dehydration,Drug withdrawal,Opioid abuse-continuous,Diarrhea,Shortness of breath,Hypertension NOS,Pure hypercholesterolem,Migrne unsp wo ntrc mgrn,Adv eff corticosteroids
Admission Date:  [**2172-12-11**]              Discharge Date:   [**2172-12-21**]

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

Service: NEUROLOGY

Allergies:
Prempro / Fiorinal / Erythromycin Base / Aleve

Attending:[**First Name3 (LF) 15373**]
Chief Complaint:
Weakness, diarrhoea, poor oral intake

Major Surgical or Invasive Procedure:
None


History of Present Illness:
HPI: Ms. [**Known lastname **] is 62 year old woan with myasthenia [**Last Name (un) 2902**], ho
of compression spinal fractures after steroid use for MG who
presents to neurology for diarrhea, dehydration and weakness
after not taking prescribed narcotics x 1 week. Patient was
prescribed oxycodone and oxycontin to treat back pain from
compression fractures which developed after steroid use. She
reported having good control of her back pain this week and
decided not to refill oxycodone/oxycontin rx. This week she felt

chills, "out of sorts", and developed abdominal cramps and
watery
diarrhea. Her diarrhea was nonbloody,watery and occured [**6-13**]
times
per day. No vomiting and no fevers. She was unable to take po
this week eating small amounts of rice and clear fluids. She
started feeling increasingly generalized weakness by the end of
the week and came to ED for evaluation via EMS.


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

3. hypercholesterolemia
4. ho migraines
5. seasonal allergies
6. HTN


Social History:
Patient is single and lives alone.  Limited social supports.
She is currently on disability.  She used to work as a histology
tech a [**Hospital1 18**].  She denies ETOH/tobacco.


Family History:
Mother and father died of coronary artery disease in their 60s.
Sister died at age 5 of insulin dependent diabetes mellitus.

Physical Exam:
O: Tm: 98.7 Tc: 99.3 BP:147 / 62 HR: 62-69

RR: 16 O2Sat.:97% NIFs >60 I/Os:NR
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, mild T in all quads, D, +NABS. No rebound or
guarding. No HSM.
Extrem: Warm and well-perfused. Mild edema bilat

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Registration intact.
Recall: [**4-10**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors. No apraxia,
no
neglect. [**Location (un) **] intact.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation. Optic
disc margins sharp.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus. Able to sustain upward gaze for 30 sec. Repeat EOMI
showed lag of left medial gaze. No diplopia or ptosis.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-12**] throughout. mild right pronator

drift. Neck flex/ext nml. Right arm changes [**6-12**] deltoid and 4-/5

after 50 arm flaps.
[**Doctor First Name **] Tri Bic WE WF FE FF
R 5- 5 5 5 5 5 5
L 5 5 5 5 5 5 5
IP HipAd HipAb Quads Hamstrings DF PF [**Last Name (un) 938**] TE TF
R 5 5 5 5 5 5 5 5 5 5
L 4 5 5 5- 5 5 5 5 5 5

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac 2+ throughout

Grasp reflex absent. Toes downgoing bilaterally.

Coordination: intention tremor in left UE. Nml finger taps and
no
FNT.

Gait: Shuffling gait with 5 steps before patient complains of
weakness

Pertinent Results:
[**2172-12-11**] WBC-11.1* RBC-4.19* Hgb-14.2 Hct-40.3 MCV-96 MCH-34.0*
MCHC-35.3* RDW-13.0 Plt Ct-156
[**2172-12-11**] Neuts-71.4* Lymphs-20.3 Monos-6.9 Eos-1.2 Baso-0.3
[**2172-12-11**]  Plt Ct-156
[**2172-12-11**] Glucose-84 UreaN-21* Creat-0.7 Na-142 K-2.7* Cl-107
HCO3-27 AnGap-11
[**2172-12-13**] Calcium-8.8 Phos-3.0 Mg-2.1
[**2172-12-19**] calTIBC-270 VitB12-270 Folate-12.3 Ferritn-368* TRF-208
[**2172-12-13**] TSH-2.0
[**2172-12-15**] IgA-281
[**2172-12-16**] ART pO2-68* pCO2-50* pH-7.41 calTCO2-33* BaseXS-5

Echo:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D  or color Doppler. Left ventricular wall
thickness, cavity size, and systolic  function are normal
(LVEF>55%). Regional left ventricular wall motion is  normal.
There is no ventricular septal defect. Right ventricular chamber
size  and free wall motion are normal. The aortic valve leaflets
(3) appear  structurally normal with good leaflet excursion and
no aortic regurgitation.  The mitral valve appears structurally
normal with trivial mitral  regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.  Compared with
the report of the prior study (images unavailable for review) of
 [**2169-5-5**], no change.

CTA chest:
1. No evidence of pulmonary embolism.
2. Linear opacities in both lower lobes which may represent
scarring or residua of prior infection

CXR: No acute cardiopulmonary process.

ECG: Sinus rhythm. Short P-R interval. Non-diagnostic Q waves in
leads II, III, aVF. Early R wave progression. Since the previous
tracing of [**2169-3-8**] T wave abnormalities are probably more marked
but baseline artifact precludes some compoarison in the lateral
precordial leads.


Brief Hospital Course:
62 yo woman with ho of myasthenia [**Last Name (un) 2902**], HTN, spinal
compression fractures treated  with narcotics, presented with
symptoms of narcotic withdrawal including chills, diarrhea,
dehydration and hypokalemia with possible exacerbation of
myasthenia [**Last Name (un) 2902**]. History of previous narcotic withdrawal after
discontinuation of narcotics. Right proximal UE weakness and
left LE proximal weakness. Mild lid lag with adduction of left
eye after 30 sec upward gaze, no diplopia or ptosis. Unable to
ambulate more than 5 steps without assistance and feeling very
fatigued.  Admitted for investigations and treatment.

Progress:

Neurology: Neurological examination was closely monitored as
symptoms of narcotic withdrawal resolved. With increasing
symptoms of shortness of breath, and exclusion of other
cardiorespirtory causes, there was concern for exaccerbation of
MG. The patient was managed for several days in the ICU then
returned to the step down unit. She continued on her usual dose
of mestinon. The team consulted with Dr [**Last Name (STitle) **] regarding other
treatments. The patient was treated with 5 days of IVIG which
was well tolerated.  Cellcept (mycophenolate) was also commenced
on [**2172-12-18**].  Strength was full with minimal fatiguability at
time of discharge.
.
Respiratory:
Increasing shortness of breath was associated with carbon
dioxide retention (arterial CO2 50). Investigations included CTA
on [**12-14**], which was negative for PE. There was no evidence
of heart failure or pneumonia on CXR. The pulmonary team were
consulted and followed during the admission. The patient was
supported with BiPAP ([**9-12**]) under close observation in the ICU
for several days prior to transfer back to [**Hospital1 **]. Oxygen via
nasal cannualae was required during the stay and weaned prior to
discharge.  VSS and NIFs were monitored throughout and stable on
discharge. Respiratory technicians were involved in establishing
BiPAP and providing patient education. The patient felt
comfortable and back to baseline at discharge. Outpatient PFTs,
pulmonary follow up and sleep study have been arranged.
.
CVS: Home doses of antihypertensives were maintained and blood
pressure was stable.
.
Haematology: The hemoglobin was low normal and hematocrit just
below normal. Risk factors for anaemia screened for in order to
address treatable causes which may be contributing to shortness
of breath. Iron studies showed elevated ferritin. Other
parameters normal as were B12 and folate.
.
Musculoskeletal:
The patient was restarted on her usual pain medication. She
expressed an interest in reducing doses wherever possible.  We
continued on standing doses and reduced prn doses of oxycodone.
Further decreases could be made in standing doses slowly if pain
remains well controlled. This should be done slowly. We stressed
the importance of not stopping medication suddenly.

ID: Urinalysis was positive and patient commenced on Bactrim.
Culture was mixed. Repeat culture was again negative prior to
commencement of cellcept.
.
FEN: Patient was rehydrated and electrolytes repleted and
monitored as diarrhoea resolved.
.
The patient was seen by PT and OT and cleared for discharge
home.


Medications on Admission:
Medications prior to admission:
1. Mestinon 30 mg TID
2. Oxycontin 40 mg po qam and 20 mg po qPM
3. Oxycodone 10 mg tid prn pain
4. Lipitor 20 mg po qday
5. Inderal 40 mg po BID
6. Evista

All:NKDA

Discharge Medications:
1. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q8H
(every 8 hours).
2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO QAM (once a day (in the
morning)).
Disp:*60 Tablet Sustained Release 12HR(s)* Refills:*2*
3. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QPM (once a day (in the
evening)).
Disp:*30 Tablet Sustained Release 12HR(s)* Refills:*2*
4. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
6. Propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Home

Discharge Diagnosis:
Myasthenia [**Last Name (un) 2902**]
Chronic back pain due to compression fractures post steroid use
Narcotic withdrawal


Discharge Condition:
Stable. Back pain controlled, power full and breathing at
baseline with establishment of BiPAP.


Discharge Instructions:
Take medications as prescribed. Ensure supply of medications to
avoid withdrawal symptoms in the future. Follow up as arranged
(see below). Seek medical advice for any symptoms of worsening
weakness or shortness of breath or other concerns.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. Date/Time:[**2172-12-28**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9899**], M.D. Phone:[**Telephone/Fax (1) 558**]
Date/Time:[**2173-1-4**] 1:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] [**Month (only) 1096**]
visit-date to be advised.
Sleep Study: [**2172-12-23**] 8.30pm [**Hospital3 **] Hospital [**Hospital Ward Name 5074**] Sleep Lab, [**Hospital Ward Name 2104**] Bldg [**Location (un) **]
Pulmonary Function Tests: [**2172-12-28**] 9.30am [**Hospital3 **]
Hospital [**Hospital Ward Name 23**] [**Location (un) 551**] Pulm function Lab/Rehab Services
{'Myasthenia gravis with (acute) exacerbation,Pathologic fracture of vertebrae,Dehydration,Drug withdrawal,Opioid abuse, continuous,Diarrhea,Shortness of breath,Unspecified essential hypertension,Pure hypercholesterolemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,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: Weakness, diarrhoea, poor oral intake

PRESENT ILLNESS: HPI: Ms. [**Known lastname **] is 62 year old woan with myasthenia [**Last Name (un) 2902**], ho
of compression spinal fractures after steroid use for MG who
presents to neurology for diarrhea, dehydration and weakness
after not taking prescribed narcotics x 1 week. Patient was
prescribed oxycodone and oxycontin to treat back pain from
compression fractures which developed after steroid use. She
reported having good control of her back pain this week and
decided not to refill oxycodone/oxycontin rx. This week she felt

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

MEDICATION ON ADMISSION: Medications prior to admission:
1. Mestinon 30 mg TID
2. Oxycontin 40 mg po qam and 20 mg po qPM
3. Oxycodone 10 mg tid prn pain
4. Lipitor 20 mg po qday
5. Inderal 40 mg po BID
6. Evista

ALLERGIES: Prempro / Fiorinal / Erythromycin Base / Aleve

PHYSICAL EXAM: O: Tm: 98.7 Tc: 99.3 BP:147 / 62 HR: 62-69

FAMILY HISTORY: Mother and father died of coronary artery disease in their 60s.
Sister died at age 5 of insulin dependent diabetes mellitus.

SOCIAL HISTORY: Patient is single and lives alone.  Limited social supports.
She is currently on disability.  She used to work as a histology
tech a [**Hospital1 18**].  She denies ETOH/tobacco. 

### Response:
{'Myasthenia gravis with (acute) exacerbation,Pathologic fracture of vertebrae,Dehydration,Drug withdrawal,Opioid abuse, continuous,Diarrhea,Shortness of breath,Unspecified essential hypertension,Pure hypercholesterolemia,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Adrenal cortical steroids causing adverse effects in therapeutic use'}
