CHIEF COMPLAINT: Worsening of generalized dystonia after PEG replacement

PRESENT ILLNESS: 36 F with 12-year hx of dystonia with some autonomic features,
followed by [**Last Name (NamePattern1) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 951**], [**Name5 (PTitle) 1834**] IR-guided
replacement of her G-tube on [**2129-3-29**]. Per a prior note from Dr.
[**First Name (STitle) 951**], she was to be pre-treated with 20 mg valium, followed by
10 mg Q3hrs for up to 3 doses after the procedure. This protocol
was deviated from somewhat. She received 30 mg valium during the
procedure, then recived 20 mg valium on admission to the PACU at
about noon on [**3-29**].

MEDICAL HISTORY: #. generalized dystonia - involving mainly her lower extremities

MEDICATION ON ADMISSION: 1.  Baclofen 20 mg three times a day.
2.  Nadolol 80 mg daily.
3.  Prilosec 20 mg twice a day.
4.  Zoloft 50 mg daily.
5.  Valium 5 mg at night three times a week.
6.  Midodrine which she takes only on p.r.n. basis and hardly
any
at all, although she had been prescribed to take it had 5-10 mg
three times a day.

ALLERGIES: Demerol / Dilaudid / Ciprofloxacin / Bacitracin / Neosporin /
Adhesive Tape / Latex / Optiray 300

PHYSICAL EXAM: T- 98.4 F BP- 97/48 HR- 80 RR- 12 O2Sat 98%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: contracted to the right
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS, soft, nontender; (+) G-tube and ostomy
Ext: no c/c/e; (+) small, red, nickel-sized circles on her LE
B/L, which she states is a staph infection.

FAMILY HISTORY: GF w/ h/o frequent sycnope; 3 deceased paternal uncles with
[**Name (NI) 5895**] Disease

SOCIAL HISTORY: Married and lives with husband. Not working and on disability.
Currently at [**Hospital1 **] for rehab.
Genetic torsion dystonia,Attention to gastrostomy,Unspecified disorder of autonomic nervous system,Dyspepsia and other specified disorders of function of stomach,Abnormal reflex,Ileostomy status,Iron deficiency anemia, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Other specified diseases of hair and hair follicles,Dysthymic disorder,Mydriasis (persistent), not due to mydriatics,Other artificial opening of urinary tract status
Genetic torsion dystonia,Atten to gastrostomy,Autonomic nerve dis NEC,Stomach function dis NEC,Abnormal reflex,Ileostomy status,Iron defic anemia NOS,Idio periph neurpthy NOS,Hair diseases NEC,Dysthymic disorder,Mydriasis not d/t mydrtc,Urinostomy status NEC
Admission Date:  [**2129-3-30**]              Discharge Date:   [**2129-4-6**]

Date of Birth:  [**2093-1-14**]             Sex:   F

Service: NEUROLOGY

Allergies:
Demerol / Dilaudid / Ciprofloxacin / Bacitracin / Neosporin /
Adhesive Tape / Latex / Optiray 300

Attending:[**Last Name (NamePattern1) 13561**]
Chief Complaint:
Worsening of generalized dystonia after PEG replacement

Major Surgical or Invasive Procedure:
PEG replacement

History of Present Illness:
36 F with 12-year hx of dystonia with some autonomic features,
followed by [**Last Name (NamePattern1) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 951**], [**Name5 (PTitle) 1834**] IR-guided
replacement of her G-tube on [**2129-3-29**]. Per a prior note from Dr.
[**First Name (STitle) 951**], she was to be pre-treated with 20 mg valium, followed by
10 mg Q3hrs for up to 3 doses after the procedure. This protocol
was deviated from somewhat. She received 30 mg valium during the
procedure, then recived 20 mg valium on admission to the PACU at
about noon on [**3-29**].

Over the course of the next 12 hours, she remained in the PACU
and received an
additional 32.5 mg valium plus 3 mg morphine. Although the plan
was for her to go home the same day, she took a long time to
rouse, and when she did, she continued to have worsened dystonia
from her baseline. This has improved over time, but she states
she is still not at her baseline. She will continue to be
observed in the PACU overnight.


Past Medical History:
#. generalized dystonia - involving mainly her lower extremities

and intermittently her arms, right more than left, occasionally
her neck and voice; provoked exacerbations of the symptoms
without a clear direct inducer[seen by Dr. [**Last Name (STitle) 13551**] at [**Hospital1 2025**] and Dr.
[**Last Name (STitle) 13552**] at [**Hospital1 1774**]]
#. dysautonomia with orthostasis, baseline SBP 80s-90s -
followed by Dr. [**First Name (STitle) **]
#. neuro-cardiogenic syncope s/p pacer in [**12/2120**]
#. Parkinsonism- occasional adventitious choreiform movements in

both  upper extremities induced by action
#. gastric dysmotility s/p g-tube placement
#. bladder areflexia s/p bladder stimulator implant and urostomy

[**2126**]
#. depression with h/o suicide attempt
#. peripheral neuropathy
#. h/o chronic pupillary dilation
#. s/p lap CCY
#  gastric dysmotility- with g-tube
#  bladder areflexia requiring ileostomy
# Chronic anemia- EGD in '[**27**] with gastritis, colonoscopy in '[**22**]
with firability

Social History:
Married and lives with husband. Not working and on disability.
Currently at [**Hospital1 **] for rehab.


Family History:
GF w/ h/o frequent sycnope; 3 deceased paternal uncles with
[**Name (NI) 5895**] Disease

Physical Exam:
T- 98.4 F BP- 97/48 HR- 80 RR- 12 O2Sat 98%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: contracted to the right
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS, soft, nontender; (+) G-tube and ostomy
Ext: no c/c/e; (+) small, red, nickel-sized circles on her LE
B/L, which she states is a staph infection.

Neurologic examination:
Mental status: sleeping but rousable, cooperative with exam, but
unable to open eyes (eyelid apraxia?) and actively opposes
forced opening. Voice very hypophonic. Oriented to person,
place, and date.  Attentive, says DOW backwards.  Speech is
fluent with normal comprehension and repetition; naming intact.
No dysarthria.  No evidence of apraxia or neglect.

Cranial Nerves:
Pupils equally round and reactive to light, 7 to 4 mm
bilaterally. Non-cooperative with extraocular movement testing.
Sensation intact V1-V3.  Facial movement symmetric.  Hearing
intact to finger rub bilaterally.  Palate elevation symmetrical.
Tongue midline, movements intact

Motor:
Normal bulk bilaterally. Significantly increased tone
throughout.

Neck contracted to the right, RUE flexor contracted and ADducted
(unable to break) LUE with some spontaneous mvmt at the delt (at
least a [**3-17**]) with
flexor contracted wrist and fingers in contracted pincer-grasp
LE (B/L): able to flex at the hip with full strength.
Non-voluntary, slow, low amplitude movements at the knees. Feet
are dorsi-flexor contracted and toes are flexor contracted

Sensation: decreased to PP and temp in the LE B/L to the
mid-thigh. Otherwise intact to light touch, pinprick throughout.
Proprioception unable to be tested properly.

Reflexes:
+2 and symmetric at the biceps, otherwise, unable to elicit
reflexes.
Toes unresponsive bilaterally

Coordination/Gait: unable to properly assess

Brief Hospital Course:
Patient is a 36-year-old woman with a 12-year history of
generalized dystonia without clear etiology,  with a history of
autonomic dysfunction, which seems to be less of a problem
lately, was admitted [**2129-3-29**] for elective replacement of her
G-tube by IR.

Neuro -
Although she was meant to go home following the procedure, she
required a long time to rouse post procedure and had worsened
dystonia from her baseline, particularly in her RUE.  Due to
concern after receiving total 97.5mg og valium within 24 hr
period including during the procedure and need for frequent
monitoring, patient was admitted to ICU overnight after spending
the night in PACU post-operatively.

She remained stable but fluctuations in muscle tone.  Tone
primarily increased in RUE, adducted with elbow, wrist and
fingers flexed.  Also plantarflexion and inversion of feet and
at times flexion at knees.  Intermittent torticollis with head
to L.  Intermittent spasm on R eyelid.  Voice remained a wisper
though varied in volume.  Overall she gradually improved with
some intermittent fluctuations.  She is not yet able to do
transfers to her wheelchair, will need to continue intensive
inpatient physical therapy.

Patient's home med regimen including baclofen was continued in
addition to Valium that was slowly titrated down and morphine
for pain as needed.  She also received benadryl prn to help with
discomfort related to increased tone.  On discharge getting
valium 5mg PG [**Hospital1 **] prn for dystonia.  Home regimen is 5mg up to
3x/week prn for increased tone.

FEN/GI - Continued TPN, nutrition consulted and helped with TPN
formulation.  TPN x5 days, [**4-5**] IVFs only. Speech and swallow
evaluated her for concerns regarding cough/gag with feeding.
She was having some difficulty, they recommended ground solids
and thin liquids.

ID - Patient spiked to 100.7 x1 but not persistently febrile. UA
showed mixed flora as expected with her ostomy.  Urology
recommended if persistently febrile could do sterile urine
sample from ostomy via catheter but she did not have further
fevers..  CXR was also obtained and LFTs were normal.  She does
have chronic, intermittent staph infections of skin and she did
have papules seen on lower extremities bilaterally.  Discussed
with dermatology re staph skin infection.  They recommended
swabs from wound site and nasal swab for MRSA, if positive would
treat with oral antibiotics.  MRSA nasal swab was negative,
wound culture with mixed skin flora.

Heme - Patient also has pancytopenia - she does have hx of
anemia that has been thoroughly worked up without clear
etiology.  Hematology consulted.  Anemia consistent with iron
deficiency anemia.  Iron 29, TIBC 316, ferritin 20, transferrin
243, haptolgobin 152.  B12 and folate normal.  Retics 1.7.
Transfused 1 unit pRBCs. Low hct 23.4, post transfusion 27.
Attempted IV iron dextran infusion, but stopped during test dose
as patient had a change in heart rythm.  After review with EP,
this is an expected paced rhythm that results when she becomes
bradycardic and thus not likely a complication from the iron
dextran infusion.  Nonetheless, iron infusion was discontinued
and can be reconsidered as an outpatient.  WBCs initially 2.8
improved to 4.6 on [**4-3**] with 63N 30L.  Platelets initially 74
improved to 113.  Blood smear not consistent with primary bone
marrow process.  Valium can cause neutropenia and
thrombocytopenia.  They recommended outpatient hematology f/u in
1 month, which was arranged.

CV - Patient has a pacemaker.  On 2 occassions during admission,
patient had a noted asymptomatic wide complex cardiac rythm.
Cardiology/EP consulted on [**4-5**].  Her pacemaker, dual chamber,
is programed to increase HR above set rate of 80 temporarily in
resonse to bradycardia in order to increase blood pressure and
avoid syncopal episodes.  They felt that the rhythm was
consistent with her dual chamber paced rhythm.

Psychiatry - Noted worsening of dystonia symptoms related to
increase in anxiety.  Patient recognizes anxiety esp when
difficulty speaking.  Arranged for outpatient psychiatry
appointment in behavioral neurology as outpatient.

Medications on Admission:
1.  Baclofen 20 mg three times a day.
2.  Nadolol 80 mg daily.
3.  Prilosec 20 mg twice a day.
4.  Zoloft 50 mg daily.
5.  Valium 5 mg at night three times a week.
6.  Midodrine which she takes only on p.r.n. basis and hardly
any
at all, although she had been prescribed to take it had 5-10 mg
three times a day.


Discharge Medications:
1. Baclofen 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a
day).
2. Nadolol 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
3. Sertraline 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).

4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
5. Trihexyphenidyl 2 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times
a day).
6. Trihexyphenidyl 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DINNER
(Dinner).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000)
units Injection TID (3 times a day).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
12. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12
hours) as needed.
13. Mupirocin Calcium 2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 7 days.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
primary:
generalized dystonia, acute exacerbation

secondary:
anemia
leukopenia and thrombocytopenia, improved
folliculitis
autonomic dysfunction


Discharge Condition:
stable


Discharge Instructions:
You were admitted to this hospital for GTube placement and
because of your medical condition you needed close observation.
Your valium was slowly weaned down then transitioned to enteral
valium.

You received a blood transfusion and were started on iron
supplementation.  Initially your white blood cell and platelet
counts were low but they improved prior to discharge.  You will
need to continue to follow with hematology.

Your skin infection improved with topical antibiotics.

Followup Instructions:
F/u with hematology at [**Hospital3 **] Hospital - Provider: [**Name10 (NameIs) 2295**] [**Name8 (MD) 13562**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2129-6-8**] 4:00

F/u with Neurology at [**Hospital3 **] Hopsital.  Provider: [**Name Initial (NameIs) 1220**].
[**Name5 (PTitle) **] & VADERHORST Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2129-6-14**] 4:00

Call to set up communication device consult with [**First Name5 (NamePattern1) 714**]
[**Last Name (NamePattern1) 13563**].  [**Telephone/Fax (1) 3731**].

Follow up with your primary care phsyician within 1-2 weeks of
discharge from rehab.

Psychiatry appointment in the behavioral neurology department.
[**Hospital3 **] Hospital [**Last Name (un) 13564**] building [**Location (un) **].Provider: [**First Name11 (Name Pattern1) **]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2129-4-22**] 11:00
{'Genetic torsion dystonia,Attention to gastrostomy,Unspecified disorder of autonomic nervous system,Dyspepsia and other specified disorders of function of stomach,Abnormal reflex,Ileostomy status,Iron deficiency anemia, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Other specified diseases of hair and hair follicles,Dysthymic disorder,Mydriasis (persistent), not due to mydriatics,Other artificial opening of urinary tract status'}


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: Worsening of generalized dystonia after PEG replacement

PRESENT ILLNESS: 36 F with 12-year hx of dystonia with some autonomic features,
followed by [**Last Name (NamePattern1) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 951**], [**Name5 (PTitle) 1834**] IR-guided
replacement of her G-tube on [**2129-3-29**]. Per a prior note from Dr.
[**First Name (STitle) 951**], she was to be pre-treated with 20 mg valium, followed by
10 mg Q3hrs for up to 3 doses after the procedure. This protocol
was deviated from somewhat. She received 30 mg valium during the
procedure, then recived 20 mg valium on admission to the PACU at
about noon on [**3-29**].

MEDICAL HISTORY: #. generalized dystonia - involving mainly her lower extremities

MEDICATION ON ADMISSION: 1.  Baclofen 20 mg three times a day.
2.  Nadolol 80 mg daily.
3.  Prilosec 20 mg twice a day.
4.  Zoloft 50 mg daily.
5.  Valium 5 mg at night three times a week.
6.  Midodrine which she takes only on p.r.n. basis and hardly
any
at all, although she had been prescribed to take it had 5-10 mg
three times a day.

ALLERGIES: Demerol / Dilaudid / Ciprofloxacin / Bacitracin / Neosporin /
Adhesive Tape / Latex / Optiray 300

PHYSICAL EXAM: T- 98.4 F BP- 97/48 HR- 80 RR- 12 O2Sat 98%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: contracted to the right
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS, soft, nontender; (+) G-tube and ostomy
Ext: no c/c/e; (+) small, red, nickel-sized circles on her LE
B/L, which she states is a staph infection.

FAMILY HISTORY: GF w/ h/o frequent sycnope; 3 deceased paternal uncles with
[**Name (NI) 5895**] Disease

SOCIAL HISTORY: Married and lives with husband. Not working and on disability.
Currently at [**Hospital1 **] for rehab. 

### Response:
{'Genetic torsion dystonia,Attention to gastrostomy,Unspecified disorder of autonomic nervous system,Dyspepsia and other specified disorders of function of stomach,Abnormal reflex,Ileostomy status,Iron deficiency anemia, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Other specified diseases of hair and hair follicles,Dysthymic disorder,Mydriasis (persistent), not due to mydriatics,Other artificial opening of urinary tract status'}
