CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: History is as described above.  The
patient also has hypertension, prostate cancer,
hypothyroidism, congestive heart failure, obstructive sleep
apnea, and gout.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient does not smoke or drink.  The
patient is married with step children.  The patient worked in
construction record keeping.  The patient had a distant
alcohol and tobacco use in the [**2103**].  The patient has not
smoked or drank since that time.
Atrial fibrillation,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Other complications due to genitourinary device, implant, and graft,Iatrogenic pneumothorax,Bacteremia
Atrial fibrillation,Malignant neo colon NEC,CHF NOS,Food/vomit pneumonitis,Comp-genitourin dev/grft,Iatrogenic pneumothorax,Bacteremia
Admission Date:  [**2165-7-16**]       Discharge Date: [**2165-9-12**]


Service:  NEUROMEDICINE
patient was admitted under Dr. [**Last Name (STitle) **], attending
physician; changed to Dr. [**Last Name (STitle) 2442**] and then to
Dr. [**Last Name (STitle) 851**].


right-handed man with myasthenia [**Last Name (un) 2902**], who presents with
four to five month history of progressive weakness and
increased shortness of breath.  He notes reduction in his
activity level last summer.  In [**2164-12-29**], he had right
hip surgery and since then he has never recovered to this
late [**Month (only) 956**] or early [**Month (only) 958**], he developed a pneumonia.
Since then he has had progressive weakness and fatigue.  His
worsened in recent months, especially in the past week.  He
has lost about 40 pounds since the hip surgery.  He was seen
in the Movement [**Hospital 2980**] Clinic on [**2165-7-9**].  At this point,
the Mestinon dose had been recently doubled to 180 mg b.i.d.
He was seen again in the clinic yesterday.  He was seen again
in the clinic yesterday, and he complained that he was unable
to walk more than a few steps in his house without becoming
more short of breath than he had previously.  Additionally,
he is having increased problem swallowing.  [**Name2 (NI) **] has been
constipated and requiring manual disimpaction for the past
several weeks.

Mr. [**Known lastname **] began having symptoms of dysphasia approximately 1??????
to two years ago.  He reports that he meant to choose a
primary care physician in the spring of [**2163**].  EMG done in
[**2164-4-29**] done at [**Hospital1 69**]
showed electrophysiologic evidence of single-fiber
examination for a generalized disorder of neuromuscular
transmission, but there were also features of a mild
myopathic process of denervating features and
mild-to-moderate sensory motor polyneuropathy, predominately
axonal in nature.  He also had a positive
acetylcholine-receptor antibody titer of 6.2 nanomoles per
liter.  He was started on Mestinon at that point and
apparently had some improvement in his symptoms.  In the past
three weeks he has also had visual hallucinations awakening
him from sleep.  On one or two occasions, he has also had
hallucinations during the daytime.  He denies headaches.

PAST MEDICAL HISTORY:  History is as described above.  The
patient also has hypertension, prostate cancer,
hypothyroidism, congestive heart failure, obstructive sleep
apnea, and gout.

CURRENT MEDICATIONS:
1.  Mestinon, slow release 180 mg two tabs q.d.
2.  Lopressor 100 mg b.i.d.
3.  Cardizem, dose unknown.
4.  Zantac.
5.  Allopurinol 450 mg PO q.d.
6.  Thyroxine.
7.  Detrol LA 4 mg PO q.d.
8.  Lipitor 10 mg q.d.
9.  Flonase.
10. Darvocet.
11. Aspirin.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient does not smoke or drink.  The
patient is married with step children.  The patient worked in
construction record keeping.  The patient had a distant
alcohol and tobacco use in the [**2103**].  The patient has not
smoked or drank since that time.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:  Examination revealed the following:
VITAL SIGNS:  Temperature 96.4, pulse 64, blood pressure
116/67, 18 respirations per minute 93% on room air.  Vital
capacity of two liters, negative NIS, negative 44.  GENERAL:
The patient was a pleasant, interactive, well-developed,
well-nourished man in no acute distress.  HEAD:
Normocephalic, atraumatic, sclerae were white.  The patient
had some slight erythema and crusting around the right
lateral eye.  Oropharynx was clear without lesions.  Mucous
membranes were moist.  Neck was supple, no JVD, no bruits.
CARDIAC:  Examination revealed normal S1 and S2, regular rate
with some ectopic beats, no murmurs, rubs, or gallops.
LUNGS:  Lungs were clear to auscultation bilaterally, but
with diminished breath sounds at the bases.  EXTREMITIES:
Without edema, warm, distal pulses intact.  NEUROLOGICAL:
The patient is alert, oriented, cooperative.  He had good
knowledge of recent and past events, but difficulty with
timing of the events.  Months of the year forward and
backwards, serial 7's intact.  Object naming was intact.
Registration intact, 2 out of 3 at 5 minutes.  The patient
follows three-step commands, no apraxia or left-to-right
confusion.  The patient interprets complex visual scene.
Cube and house drawing is adequate and he can write a
sentence.  Speech is fluent and with paraphrasias.  Voice is
soft, nasal, and slightly slurred.  Cranial nerves
examination revealed pupils 3 mm, equal, round, and reactive,
2 mm with disk margins not able to be visualized.  Visual
fields are full to confrontation.  Extraocular muscles are
intact.  There is no nystagmus.  The patient does have
diplopia on up and lateral gaze to the right, but there is no
ptosis.  Face is symmetrical and intact to light touch and
pinprick.  Hearing is intact to light finger rub.  Tongue and
palate are midline.  He is dysarthric with nasal voice.  He
has a weak cough and wet voice after sips of water.  MOTOR:
Examination revealed the following:  Neck flexors are [**5-3**],
and neck extensors [**6-2**].  He has 4/5 strength in the right
deltoid, biceps, triceps, 4+/5 of the left deltoid and
triceps, [**5-3**] in both iliopsoas, [**5-3**] at the right hamstring
and 4+/5 at the left hamstring.  Distal strength is [**6-2**].
There is no pronator drift.  Fifteen repetitions of right arm
shoulder extension strength becomes [**5-3**] at the deltoid.  Deep
tendon reflexes are 2+ of the biceps and triceps, 1+ at the
right brachioradialis, 2+ at the left brachioradialis tendon.
Deep tendon reflexes cannot be elicited of the right lower
extremity.  Plantar response is flexion on the left and
extension on the right.  Bulk was increased in the bilateral
lower extremities.  Sensory examination revealed diminished
light touch, pinprick and temperature and stocking
distribution left to the knee and right to the mid shin.  He
makes errors on joint position sense, left greater than
right.  Vibration is reduced below the hips.  He also has an
anesthetic patch in the left lower femoral cutaneous
distribution that is old.  Coordination is intact with rapid
alternating movements and finger-to-nose testing.
Heel-to-shin is limited by right leg weakness.  Gait testing
was deferred as the patient complained of dyspnea on exertion
throughout the examination.  He did have short-shuffling
steps, no Romberg, and he was unable to tandem.

LABORATORY DATA:  Admission labs revealed the following:
Bicarbonate 32, BUN 22, glucose 106, CBC normal, 71%
neutrophils, 28% lymphs, urinalysis normal, coagulations
normal.  Chest x-ray revealed possible right effusion and a
questionable nodule at the left base.

Cardiac perfusion scan of [**2165-5-29**] revealed the following:
Chest CT results currently are all not available.  PFTs from
[**2165-5-29**], results are consistent with moderate restrictive
lung disease in which there was no improvement with
bronchodilators.  There was a moderate reduction in maximal
breathing capacity.  Lung volumes, however, are normal and
gastric change was not impaired.  These results may indicate
the reduced spirometry related to obesity, moderate hypoxemia
with PO2 of 61, pCO2 of 47, indicating mild respiratory
acidosis.

ADDENDUM:  The patient has had three visits to the [**Location (un) 620**]
Emergency Department for dyspnea in the past month.

HOSPITAL COURSE:  Mr. [**Known lastname **] was admitted to the Neuromedicine
Service on [**2165-7-16**].  He had a swallowing study
performed on the 20th, which revealed aspiration of barium.
Mr. [**Known lastname **] was made NPO at that point.  He was started on
Prednisone 10 mg and this was increased to 25 mg on the 20th.
Plan was to gradually increase this dose over the course of
his hospital stay.

The patient was on telemetry and several episodes of
bradycardia and PVCs were noted.

On the [**7-19**], he was transferred to the Medical
Service for the complexity of his medical issues, especially
cardiac.

On [**7-21**], he had a cardiac event of bradycardia and
apnea.  He was bradycardiac to the 20s and hypoxic.  Pulse
and blood pressure were 70s/40s.  He was started on
Neo-Synephrine drip having normal saline wide open and he was
intubated.  He was transferred to the PACU for further
management.  ABG showed a pH of 7.26, pO2 of 70, and pCO2 of
166.

On the 24th, the patient was transferred to the MICU for
further treatment and monitoring.  He had been stable until
then.  At this point, for the myasthenia [**Last Name (un) 2902**] he was
receiving IVIG and Solu-Medrol, which was up to 20 mg IV,
60 mg Mestinon q.4h.  While in the MICU, it was discovered
that Mr. [**Known lastname **] had an aspiration pneumonitis versus pneumonia.
He was treated with antibiotics.

On the [**7-26**], the patient remained with little
changes.  He was breathing on his own at this point, but very
weak with cough.  The family had made him DNR, but he
remained intubated.  On the 28th, the patient was extubated
and transferred to the East MICU.  While there, when he was
able to speak again, he asked that his code status be changed
to full.

On [**8-1**], Mr. [**Known lastname **] was transferred from the MICU to the
Neuromedicine Service.  At this time, the treatment for the
myasthenia [**Last Name (un) 2902**] was Prednisone 60 mg PO q.d.  CellCept was
being considered, but had not yet been started.  IVIG course
was completed.  He was kept on the course of Ceftriaxone.
The cardiac issues appeared to be improving, as he was no
longer having brachycardiac episodes, but he remained with
persistent tachycardia on Lopressor 50 mg PO q.i.d.

Vital capacities were being checked q. six hours to monitor
the respiratory status.  The patient was started on CellCept
a steroid-sparing [**Doctor Last Name 360**], and he was continued with Mestinon
60 mg q. four hours and Prednisone 60 mg q.d.

For tachycardia, he was started on Diltiazem.  He was on
Lopressor, which was decided to be slowly weaned.  He was
started on Lovenox and Coumadin, as well.

As the patient continued to be weak, he was started back on
Solu-Medrol IV at a continuous rate over 24 hours as this
seemed to have worked better while the patient was in the
Intensive Care Unit.

On [**8-3**], the patient was transferred back to the unit for
worsening weakness to the Neurological Intensive Care Unit.
The patient continued to strengthen gradually on the floor,
still on the same dosage of medications.  However, the
tachycardia was still difficult to control by increasing
Diltiazem doses up to 120 mg q.i.d.

On [**8-7**], the PEG tube was placed successfully by the GI
Department.  PIC line was placed on the [**8-8**].

On the 16th, the patient was noted to have some bleeding
around the PEG tube site with a small drop in the hematocrit.
Anticoagulation was discontinued.  Bleeding was treated by
the GI Department.  For the continuing arrhythmias and atrial
fibrillation the patient was started on Digoxin.  The
Lopressor was re-instituted and he was also put on
Amiodarone.
On the 17th, Mr. [**Known lastname **] was transferred to the Neurological ICU
after having more difficulty breathing; also he was generally
weaker throughout.

During the stay, the patient had a pacer placement, DDI
programmed to a rate of 80.  He tolerated the procedure well.
He was transferred back to the floor on [**8-17**].  He was
started on a course of plasmapheresis at this time as the
cardiac issues were now stable.  All of the cardiac
medications, other than the Amiodarone, were discontinued
after the pacer.

On the 22nd, the Foley tube was replaced, while the patient
was on Far 3.  Unfortunately, it was passed into the
prostatic bed.  The Department of Urology was consulted.
They removed the Foley catheter, replacing it with a #16
French catheter placed under flexible cystoscopy.  The
patient continued to have bloody output from the Foley.  The
hematocrit did continue to drop.  He was transfused one unit
of packed red blood cells overnight on the 25th after
reaching a nadir of 9.3 hemoglobin.  The next morning, the
patient was significantly more short of breath.   He had a
respiratory rate of 40. He had a 20% bandemia and chest x-ray
that showed bilateral pleural effusions and atelectasis mainly in
the right middle lobe with pulmonary edema.  He was again
transferred to the Neurological ICU.  Plasmapheresis catheter
was pulled.  The patient was treated with Levofloxacin,
Vancomycin, and Flagyl.  He was transferred back to the floor
on the 27th, still on those three antibiotics.  Urine culture
was returned showing infection.

On the 28th, plasmapheresis was decided to be permanently
discontinued and instead he was put on Prednisone 150 mg PO
q.o.d.  He was continued on the CellCept and Mestinon 60 mg
PO q.i.d.

After urine cultures were returned, he was stopped on the
Vancomycin and continued on the Levofloxacin and Flagyl to
continue with a two-week course.  Citrobacter freundii
complex was grown out from the urine.

In the 30th, the patient's Foley catheter was removed.  The
patient tolerated this well with good urine output.

On [**9-2**], modified barium swallow was performed, which
showed that the patient was capable of swallowing
honey-thickened liquids.  He was put back on an oral diet.
He was also started on Allopurinol for foot pain, which
alleviated much of the pain.  The hematocrit continued to
fall back on anticoagulation again.  CT of the abdomen was
done, which revealed no active acute bleeding.  However,
there were renal hemorrhagic cysts.  He received two units of
packed red cells and the hematocrit responded with increase
to 33.  The anticoagulation was stopped again.

On [**9-3**], colonoscopy was performed to look into the
source of the GI bleeding and frond-like villous nonbleeding
greater than 5 cm mass was found at the hepatic flexure.  The
mass caused partial obstruction.  Biopsy was performed for
histology.  This was inconclusive showing cancer in the
biopsy, but nondiagnostic.

Over the next few days, the patient's status for
surgery was discussed with the family and numerous
consultants.  Sleep study was performed and the results
pending at this point.

A Tensilon test was performed and the patient weakened on it.
The Mestinon dose was decreased by 25%.

On the 11th, a second Tensilon test was performed and the
patient continued to weaken.  The dose was again decreased to
30 mg PO q.i.d.

Pulmonary function tests were performed, which showed FVC of
1.86, 38% of predicated, FEV1 of 1.26, 42% of predicted, MMF
of 0.71, 30% predicted and a FEV1:FVC ratio of 68, which is
108% of predicted.

Sleep apnea results stated that no abnormal events occurred
during the recording.

The patient decided between the 11th and 12th to go ahead
with surgery.  He was placed on the schedule for Thursday,
[**9-12**].  Over the past two weeks that has been little change in
the myasthenia [**Last Name (un) 2902**].  He is considered optimized for
surgery at this point and will be transferred to the surgical
service following his procedure.




                            [**Last Name (LF) **],[**First Name3 (LF) 7495**] 13-229

Dictated By:[**Last Name (NamePattern1) 660**]
MEDQUIST36

D:  [**2165-9-12**]  10:24
T:  [**2165-9-12**]  10:48
JOB#:  [**Job Number **]


Name:  [**Known lastname **], [**Known firstname **] K                        Unit No:  [**Numeric Identifier 6192**]

Admission Date:  [**2165-7-16**]     Discharge Date:  [**2165-9-26**]

Date of Birth:   [**2083-1-11**]     Sex:  M

Service:  Medicine

Addendum:

The patient went to surgery on [**9-12**], having an
ileocolectomy secondary to a colonic mass.  There were no
intraoperative complications.  The patient went to the floor
and started developing increased oxygen requirement, as well
as elevated white count.  He was hypoxemic.  He was admitted,
over the course of a few days worsened, entered an acute
hypoxemic respiratory failure state thought to be secondary
to aspiration pneumonitis.  As it worsened, he was put on
antibiotics and admitted to the Medical Intensive Care Unit.
There, he was intubated, diuresed aggressively.  There were
bilateral pleural effusions on chest x-ray.  This was
complicated by pneumothorax.  A chest tube was placed.  Once
the pneumothorax resolved, the chest tube was pulled on the
26th.

The patient, at this time, was having increasing white cell
count and on [**9-23**], had a new infiltrate on chest x-ray
and this was believed to be a persistent aspiration
pneumonia.  At this point, the family decided to not add
anymore care, to not further work up.  When the patient was
on the floor on the 27th, the family decided to remove
[**First Name9 (NamePattern2) 6193**] [**Last Name (un) 6194**] medication, antibiotics, lines and to stop
any work up for the pneumonia as well as anything invasive.
Therefore, on the 28th, the respiratory rate dropped to 6 per
minute.

There will be an addendum to possibly change the discharge
date.




                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 522**]

Dictated By:[**Last Name (NamePattern1) 6195**]

MEDQUIST36

D:  [**2165-9-25**]  15:45
T:  [**2165-9-27**]  09:44
JOB#:  [**Job Number 6196**]
{'Atrial fibrillation,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Other complications due to genitourinary device, implant, and graft,Iatrogenic pneumothorax,Bacteremia'}


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: 

PRESENT ILLNESS: 

MEDICAL HISTORY: History is as described above.  The
patient also has hypertension, prostate cancer,
hypothyroidism, congestive heart failure, obstructive sleep
apnea, and gout.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient does not smoke or drink.  The
patient is married with step children.  The patient worked in
construction record keeping.  The patient had a distant
alcohol and tobacco use in the [**2103**].  The patient has not
smoked or drank since that time. 

### Response:
{'Atrial fibrillation,Malignant neoplasm of other specified sites of large intestine,Congestive heart failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Other complications due to genitourinary device, implant, and graft,Iatrogenic pneumothorax,Bacteremia'}
