CHIEF COMPLAINT: Leg Weakness

PRESENT ILLNESS: 25yoM with no significant [**Hospital **] transferred from an OSH with
bilateral leg weakness and acute renal failure. On [**10-8**] he had
3-4 beers, following which he "did [**1-11**] lines" of cocaine and
acknowledges potential snorting of Oxycontin. On [**10-9**] he woke up
upable to stand with weakness and associated numbness on the
anterior of his legs R > L. He presented to OSH and was found to
be in ARF with elevated CKs. He was transferred to the [**Hospital1 18**] and
admitted to MICU.
.
In the MICU he had foley placed and was treated for
rhabdomylosis with IVF. His labs inititally showed CK of [**Numeric Identifier 32925**],
AST of 1900, ALT of 1400 and Cr of 5.5. Most recently CK of
9000, AST of 800, ALT 600, tbili of 0.7 and cr of 6.4, INR 1.1.

MEDICAL HISTORY: Remote hx of Knee Surgery

MEDICATION ON ADMISSION: None

ALLERGIES: Dimetapp

PHYSICAL EXAM: VITALS: Afebrile.  Satting well on room air. Good urine output.

FAMILY HISTORY: Non-Contriburtory

SOCIAL HISTORY: Lives with mother, father and sister in [**Name (NI) 3494**]. Longshoreman
in [**Location 8391**]. [**3-14**] pack of cigarette daily for 2 years. EtOH
on [**3-14**] beers (up to 10), 3-4x/week since [**71**] and + coccaine 1x
/wk (snorting) for the last year. Denies IVDU or other drug use.
Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Rhabdomyolysis,Acidosis,Tobacco use disorder
Acute necrosis of liver,Ac kidny fail, tubr necr,Rhabdomyolysis,Acidosis,Tobacco use disorder
Admission Date:  [**2158-10-10**]              Discharge Date:   [**2158-10-16**]

Date of Birth:  [**2133-4-11**]             Sex:   M

Service: MEDICINE

Allergies:
Dimetapp

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Leg Weakness

Major Surgical or Invasive Procedure:
None


History of Present Illness:
25yoM with no significant [**Hospital **] transferred from an OSH with
bilateral leg weakness and acute renal failure. On [**10-8**] he had
3-4 beers, following which he "did [**1-11**] lines" of cocaine and
acknowledges potential snorting of Oxycontin. On [**10-9**] he woke up
upable to stand with weakness and associated numbness on the
anterior of his legs R > L. He presented to OSH and was found to
be in ARF with elevated CKs. He was transferred to the [**Hospital1 18**] and
admitted to MICU.
.
In the MICU he had foley placed and was treated for
rhabdomylosis with IVF. His labs inititally showed CK of [**Numeric Identifier 32925**],
AST of 1900, ALT of 1400 and Cr of 5.5. Most recently CK of
9000, AST of 800, ALT 600, tbili of 0.7 and cr of 6.4, INR 1.1.



Past Medical History:
Remote hx of Knee Surgery

Social History:
Lives with mother, father and sister in [**Name (NI) 3494**]. Longshoreman
in [**Location 8391**]. [**3-14**] pack of cigarette daily for 2 years. EtOH
on [**3-14**] beers (up to 10), 3-4x/week since [**71**] and + coccaine 1x
/wk (snorting) for the last year. Denies IVDU or other drug use.

Family History:
Non-Contriburtory

Physical Exam:
VITALS: Afebrile.  Satting well on room air. Good urine output.

GEN: NAD, A0x3
HEENT: PERRLA, EOMI, Anicteric Sclera, seborrheic dermatitis on
face
NECK: SUPPLE, NO LAD
RESP: CTAB b/l.
CARD: S1 S2 No Murmurs, Rubs or Gallops.
ABD: Soft Mild Tender on deep palpation LLQ, Non-Distended, BS+.
Negative Murphys
EXTR: No clubbing, cyanosis or edema. 2+ DP.
NEURO: A0x3.

Pertinent Results:
Admission Labs:
[**2158-10-10**] 11:45PM CEREBROSPINAL FLUID (CSF)  PROTEIN-21
GLUCOSE-83
[**2158-10-10**] 11:45PM CEREBROSPINAL FLUID (CSF)  WBC-1 RBC-3* POLYS-0
LYMPHS-60 MONOS-40
[**2158-10-10**] 10:14PM URINE  HOURS-RANDOM
[**2158-10-10**] 10:14PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
[**2158-10-10**] 10:14PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2158-10-10**] 10:14PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2158-10-10**] 10:14PM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2158-10-10**] 10:14PM URINE  GRANULAR-0-2
[**2158-10-10**] 10:14PM URINE  AMORPH-FEW
[**2158-10-10**] 05:47PM   COMMENTS-GREEN TOP
[**2158-10-10**] 05:47PM   LACTATE-1.5
[**2158-10-10**] 05:35PM   GLUCOSE-135* UREA N-57* CREAT-5.5* SODIUM-133
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-23 ANION GAP-21*
[**2158-10-10**] 05:35PM   estGFR-Using this
[**2158-10-10**] 05:35PM   ALT(SGPT)-1492* AST(SGOT)-[**2086**]* LD(LDH)-1843*
CK(CPK)-[**Numeric Identifier **]* ALK PHOS-82 AMYLASE-47 TOT BILI-0.8
[**2158-10-10**] 05:35PM   LIPASE-31
[**2158-10-10**] 05:35PM   CK-MB-168* MB INDX-0.8 cTropnT-0.15*
[**2158-10-10**] 05:35PM   ALBUMIN-4.2 CALCIUM-8.6 PHOSPHATE-2.1*
MAGNESIUM-1.8
[**2158-10-10**] 05:35PM   CRP-256.5*
[**2158-10-10**] 05:35PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-10-10**] 05:35PM   WBC-10.7 RBC-5.00 HGB-16.2 HCT-43.4 MCV-87
MCH-32.3* MCHC-37.2* RDW-13.2
[**2158-10-10**] 05:35PM   NEUTS-92.5* LYMPHS-5.7* MONOS-1.5* EOS-0.2
BASOS-0.1
[**2158-10-10**] 05:35PM   PLT COUNT-132*
[**2158-10-10**] 05:35PM   PT-13.0 PTT-26.1 INR(PT)-1.1
[**2158-10-10**] 05:35PM   SED RATE-21*

Hospital and Discharge pertinent labs:

CBC:
[**2158-10-16**] 05:25AM BLOOD WBC-11.2* RBC-4.37* Hgb-13.9* Hct-37.6*
MCV-86 MCH-31.8 MCHC-37.0* RDW-13.4 Plt Ct-232

Coags:
[**2158-10-12**] 03:00AM BLOOD PT-12.6 PTT-29.8 INR(PT)-1.1

ESR:
[**2158-10-12**] 03:00AM BLOOD ESR-30*

Chemistry:
[**2158-10-16**] 05:25AM BLOOD Glucose-86 UreaN-95* Creat-10.2* Na-137
K-4.0 Cl-100 HCO3-23 AnGap-18
[**2158-10-16**] 05:25AM BLOOD Calcium-8.9 Phos-7.5* Mg-2.5

LFTs:
[**2158-10-16**] 05:25AM BLOOD ALT-107* AST-22 LD(LDH)-346* AlkPhos-52
TotBili-0.6

CK:
[**2158-10-16**] CK(CPK)-154
[**2158-10-15**] 06:00AM BLOOD CK(CPK)-275*
[**2158-10-11**] 11:36AM BLOOD CK(CPK)-7015*
[**2158-10-10**] 05:35PM BLOOD CK(CPK)-[**Numeric Identifier **]*

Cardiac enzymes:
[**2158-10-13**] 04:25AM BLOOD CK-MB-6 cTropnT-0.42*
[**2158-10-12**] 02:57PM BLOOD CK-MB-9 cTropnT-0.35*

Lipids:
[**2158-10-11**] 11:36AM BLOOD Triglyc-277* HDL-22 CHOL/HD-5.3
LDLcalc-40

Hepatitis serologies:
[**2158-10-11**] 11:36AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HAV-NEGATIVE, BLOOD HCV
Ab-NEGATIVE

CRP:
[**2158-10-12**] 03:00AM BLOOD CRP-175.2*

HIV AB:
[**2158-10-12**] 02:57PM BLOOD HIV Ab-NEGATIVE

Blood tox screen:
[**2158-10-10**] 05:35PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Lactate:
[**2158-10-10**] 05:47PM BLOOD Lactate-1.5

MRI: Spine
IMPRESSION:
1. No evidence for cord compression or spinal canal narrowing.
2. Mild fluid accumulation in the right retroperitoneal space,
possibly
related to history of rhabdomyolysis.
3. Bilateral lobe opacities concerning for pneumonia.
2. No evidence for aortic dissection on this study, however,
this study is
inadequate to rule out dissection given significant flow related
and pulsation artifacts. Given the patient's acute renal
failure, would recommend non- contrast time-of-flight MRA to
further evaluate vascular structures.

Echo:
The left atrium is mildly dilated. The left ventricular cavity
is mildly dilated. Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. An aortic dissection cannot be
excluded. 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. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Mildly dilated left ventricular cavity (probably
normal when indexed to patient's body size). Normal global and
regional biventricular systolic function. No diastolic
dysfunction, pulmonary hypertension or significant valvular
disease seen. No evidence of aortic dissection however, the
sensitivity of trans-thoracic echo in detection of aortic
dissection is low.

MRA AB:
IMPRESSION:
1. No evidence of aortic dissection.
2. Widely patent appearance of both renal arteries.
3. Multifocal consolidation throughout both lungs but
predominantly in the
lower lobes, with small right-sided pleural effusion

CXR:
REASON FOR EXAMINATION: Followup of a patient with
rhabdomyolysis and acute renal failure.
Portable AP chest radiograph was compared to prior study
obtained on [**2158-10-10**].
The lung volumes are lower compared to the prior study with new
bibasal linear opacities that might represent atelectasis or
aspiration. The more
pronounced opacity is on the right and given it's progression
since [**10-10**], [**2158**], might represent infection. There is no evidence of
failure. There is no pneumothorax. The cardiomediastinal
silhouette is stable.


Brief Hospital Course:
25M with recent cocaine use now with lower extremity weakess
with rhabdomyolysis, ARF, Shock Liver, + Troponins

# Rhabdomylosis: CK >20K on admission this AM, 10K overnight. Pt
received 5L of fluid prior to coming to the floor. U/A with 0-2
RBCs but large blood indicative of myoglobin. Source is
potentially in legs given his focal weakness. However no focal
finds indicative of necrosis on exam. Lactate WNL. Pt seen by
Nephrology that recommended decreasing from 100ccc/hr and then
subsequently d/c'd.  CKs eventually trended down without any
intervention.  Patient was discharged with instructions to
follow up in renal clinic and with PCP.
.
# ARF: Pts Cr up to 5.8 from 5.0 at OSH on presentation from
presumed normal levels since no baseline levels availbale.
Initial etiology potentially mulit-factorial including:
glomerular damage secondary to myoglobinuria, pre-renal
secondary to cocaine vasoconstriction, ATN secondary to
hypotensive and/or ischemia from cocaine as evident by 0-2
granular casts. Pt was anuric on Sunday/Monday, patient had
20cc/hr during his hospital ICU course, and was given Lasix 20mg
IV x 1 without change in UOP. Creatinine increased to 11.2 and
started to trend down before discharge.  He was making good
urine and was not dialysed.  He will follow up in the renal
clinic.

# Transaminitis: AST/ALT in >1000 on admission. Etiologies
include shock liver in setting of cocaine use, less likley viral
hepatitis. During his ICU cours the patients transaminitis
improved, TB and INR remained stable.  His hepatitis serologies
were negative.  LFTs improved and were trending down on
discharge.

.
# + Troponins: Trop 0.15 on admission without CP. Pt without
known cardiac disease. Etiology potentially ischemia secondary
to cocaine with troponins remaining elevated in setting of ARF.
No troponins available found from OSH. The pt's transaminases
remained elevated in setting of ARF. TTE was performed and ECHO
found to have >60%.  Possible that patient had small infarct
with global preservation of heart function.

.
# Metabolic Acidosis: Pt presented with Gap Metabolic Acidosis
on presentation to E.D. with gap of 16 which resolved to 11 upon
arrival to the ICU. Since lactate not drawn prior to closure
unclear the etiology. Lactate WNL. Repeat ABG now with very mild
respiratory alkalosis with pt slightly tachypnic. The pts GAP
improved
.
# ?PNA: Pt afebrile, without leukocytosis, or increased sputum.
CXR and MR [**First Name (Titles) **] [**Last Name (Titles) **] demonstrated potential evolving PNA. Pt
receive Abx on arrival. Abx were held in the setting of low
clinical suspicion for PNA. The pt was given insentive
Spirometry and remained afebrile.  Given his lack of symptoms
clinically he was not treated for pneumonia.
.
# Neurologic Deficits: Patient complained of R Leg weakness and
decreased sensation anteriorly. Seen by neurology that stated
his deficits were possibly from lumbar plexopathy or upper
cervical involvement and unlikely a central involvement. Pt was
given acyclovir for ?HSV which was later held by the MICU team.
MR of the [**Last Name (Titles) **]  revealed a R Psoas fluid collection.  His
strength in his legs increased although was not back to his
baseline upon discharge.

# Medication changes:
Patient started on Docusate and Senna as needed for constipation
Started on Metoprolol 50mg [**Hospital1 **].  After discharge he was called
and sent a letter instructing him not to take metoprolol.
Amlodipine 5mg daily

Medications on Admission:
None

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Dextromethorphan Poly Complex 30 mg/5 mL Suspension,
Sust.Release 12 hr Sig: Ten (10) ML PO Q12H (every 12 hours) as
needed for cough.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2* --> Instructed to not take after
discharge.
6. Outpatient Lab Work
Check Chem-10 including creatinine.  Please fax results to [**Hospital 191**]
clinic attn Dr. [**Last Name (STitle) **] fax #[**Telephone/Fax (1) 6309**] and Dr. [**Last Name (STitle) 4920**] Fax
#[**Telephone/Fax (1) 26643**].


Discharge Disposition:
Home

Discharge Diagnosis:
Rhabdomyolysis
Acute Renal Failure
Cocaine Abuse
Alcohol Abuse


Discharge Condition:
All vital signs stable, kidney function improving.


Discharge Instructions:
You were admitted with acute muscle breakdown (likely caused by
cocaine use) that caused damage to your kidneys. Eventually this
your kidney began to heal from this damage without dialysis. You
should not take cocaine again. You should also avoid medications
such as ibuprofen, Advil, or Naproxen until your kidney function
returns to normal. You will need to follow up with a new primary
care physician and [**Name Initial (PRE) **] kidney doctor. You should also decrease
your alcohol intake as you are at risk for becoming and
alcoholic. You discussed options for treatment with the social
worker.

New Medications:
1) Metoprolol 50mg one tab twice a day
2) Amlidpine 5mg one tab daily
Please take all your medications as prescribed and attend all
your follow up appointments.

Please call your doctor or return to the emergency room if you
notice a sharp decrease in the amount of urine you make,
experience chest pain, shortness of breath or any other symptom
that concerns you.

Followup Instructions:
Provider: [**Name10 (NameIs) 2483**],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 191**] MEDICAL UNIT Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2158-11-1**] 1:00
{'Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Rhabdomyolysis,Acidosis,Tobacco use disorder'}


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: Leg Weakness

PRESENT ILLNESS: 25yoM with no significant [**Hospital **] transferred from an OSH with
bilateral leg weakness and acute renal failure. On [**10-8**] he had
3-4 beers, following which he "did [**1-11**] lines" of cocaine and
acknowledges potential snorting of Oxycontin. On [**10-9**] he woke up
upable to stand with weakness and associated numbness on the
anterior of his legs R > L. He presented to OSH and was found to
be in ARF with elevated CKs. He was transferred to the [**Hospital1 18**] and
admitted to MICU.
.
In the MICU he had foley placed and was treated for
rhabdomylosis with IVF. His labs inititally showed CK of [**Numeric Identifier 32925**],
AST of 1900, ALT of 1400 and Cr of 5.5. Most recently CK of
9000, AST of 800, ALT 600, tbili of 0.7 and cr of 6.4, INR 1.1.

MEDICAL HISTORY: Remote hx of Knee Surgery

MEDICATION ON ADMISSION: None

ALLERGIES: Dimetapp

PHYSICAL EXAM: VITALS: Afebrile.  Satting well on room air. Good urine output.

FAMILY HISTORY: Non-Contriburtory

SOCIAL HISTORY: Lives with mother, father and sister in [**Name (NI) 3494**]. Longshoreman
in [**Location 8391**]. [**3-14**] pack of cigarette daily for 2 years. EtOH
on [**3-14**] beers (up to 10), 3-4x/week since [**71**] and + coccaine 1x
/wk (snorting) for the last year. Denies IVDU or other drug use. 

### Response:
{'Acute and subacute necrosis of liver,Acute kidney failure with lesion of tubular necrosis,Rhabdomyolysis,Acidosis,Tobacco use disorder'}
