CHIEF COMPLAINT: Chest Pain, Abdominal Pain, Nausea/Vomiting, Right Leg Numbness

PRESENT ILLNESS: This is a 59 y.o. male who was initially seen at [**Hospital3 62353**] on [**2146-9-14**] for abdominal pain, chest pain, and
nausea starting that morning. He also noted numbness in his
right leg with this presentation. He denied fevers, chills, or
emesis. During this admission he became agitated, irritable, but
maintained by behavioral redirection. He was started on CIWA
protocal for history of heavy drinking per his girlfriend. [**Name (NI) **]
received Valium at this time. He was found to have a type B
aortic dissection per imaging and transfered to [**Hospital1 18**] for
evaluation and management. He again became combative upon
arrival and was sedated and intubated on [**2146-9-16**]. Vascular
surgery consulted on [**2146-9-14**] and recommended [**Year (4 digits) **] pressure
control with close monitoring for end organ ischemia.
Neurosurgery consulted on [**2146-9-16**] for possible subdural
hemmorhage on CT. Recomended seizure protocol and frequent
neurological evaluations. Patient had a repeat head CT which
showed no signs of subdural hemmorage at that time. Patient was
on moderate sedation and on [**2146-9-16**] became febrile,
hypertensive, and combative requiring physicial restraints. At
this time he was placed on propofol and intubated. PICC line
placed on [**2146-9-16**].

MEDICAL HISTORY: Vascetomy in the past

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tm 101.6  Tc 100.5 , BP 127/49 (97-152), HR 66 (53-76), RR
21, O2 95% on FiO2 40%  pressure support; PEEP 10 PS 10
Last 24 I/O: 4844/2275 (+2569)  since MN: [**2143**]/1430 (+575)
Gen: WDWN middle aged male in intubated, no response to stimuli.

FAMILY HISTORY: There is family history of coronary artery disease of a brother
who died at 62 with a history of Myocardial Infarction.

SOCIAL HISTORY: Patient stated he drinks 2 glasses of wine on the weekends. Upon
further discussion with the girlfriend, he had been drinking on
average 6 beers a night for a few months and possibly more. He
occasionally smokes cigars. He is employed at a law office in
the area.
Dissection of aorta, unspecified site,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Acidosis,Subdural hemorrhage,Urinary tract infection, site not specified,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumonia due to other gram-negative bacteria,Other complications due to other vascular device, implant, and graft,Encephalopathy, unspecified,Vascular disorders of kidney,Other and unspecified complications of medical care, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atherosclerosis of renal artery,Other and unspecified alcohol dependence, unspecified,Other and unspecified special symptoms or syndromes, not elsewhere classified,Anemia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders of circulatory system
Dsct of aorta unsp site,Acute kidney failure NOS,Delirium tremens,Acidosis,Subdural hemorrhage,Urin tract infection NOS,Pneumococcal pneumonia,Pneumo oth grm-neg bact,Comp-oth vasc dev/graft,Encephalopathy NOS,Renal vascular disorder,Complic med care NEC/NOS,Hy kid NOS w cr kid I-IV,Renal artery atheroscler,Alcoh dep NEC/NOS-unspec,Special symptom NEC/NOS,Anemia NOS,Abn react-procedure NEC,Circulatory disease NEC
Admission Date:  [**2146-9-15**]              Discharge Date:   [**2146-10-12**]

Date of Birth:  [**2087-4-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Chest Pain, Abdominal Pain, Nausea/Vomiting, Right Leg Numbness

Major Surgical or Invasive Procedure:
Intubated on [**2146-9-16**]

History of Present Illness:
 This is a 59 y.o. male who was initially seen at [**Hospital3 62353**] on [**2146-9-14**] for abdominal pain, chest pain, and
nausea starting that morning. He also noted numbness in his
right leg with this presentation. He denied fevers, chills, or
emesis. During this admission he became agitated, irritable, but
maintained by behavioral redirection. He was started on CIWA
protocal for history of heavy drinking per his girlfriend. [**Name (NI) **]
received Valium at this time. He was found to have a type B
aortic dissection per imaging and transfered to [**Hospital1 18**] for
evaluation and management. He again became combative upon
arrival and was sedated and intubated on [**2146-9-16**]. Vascular
surgery consulted on [**2146-9-14**] and recommended [**Year (4 digits) **] pressure
control with close monitoring for end organ ischemia.
Neurosurgery consulted on [**2146-9-16**] for possible subdural
hemmorhage on CT. Recomended seizure protocol and frequent
neurological evaluations. Patient had a repeat head CT which
showed no signs of subdural hemmorage at that time. Patient was
on moderate sedation and on [**2146-9-16**] became febrile,
hypertensive, and combative requiring physicial restraints. At
this time he was placed on propofol and intubated. PICC line
placed on [**2146-9-16**].

On initial review of symptoms per initial notes, he denied any
prior history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, hemoptysis, black stools or red stools. He denied
recent fevers, chills or rigors. He denied exertional buttock or
calf pain. All of the other review of systems were negative. At
time of this exam patient was intubated and unable to
communicate a review of systems.

Cardiac review of systems was notable for chest pain at initial
presentation to OSH. He denied dyspnea on exertion, paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.  During tranfer, the patient was intubated and
could not communicate.


Past Medical History:
Vascetomy in the past

Social History:
Patient stated he drinks 2 glasses of wine on the weekends. Upon
further discussion with the girlfriend, he had been drinking on
average 6 beers a night for a few months and possibly more. He
occasionally smokes cigars. He is employed at a law office in
the area.

Family History:
There is family history of coronary artery disease of a brother
who died at 62 with a history of Myocardial Infarction.

Physical Exam:
VS: Tm 101.6  Tc 100.5 , BP 127/49 (97-152), HR 66 (53-76), RR
21, O2 95% on FiO2 40%  pressure support; PEEP 10 PS 10
Last 24 I/O: 4844/2275 (+2569)  since MN: [**2143**]/1430 (+575)
Gen: WDWN middle aged male in intubated, no response to stimuli.

HEENT: NCAT. Sclera anicteric. no pallor or cyanosis of the oral
mucosa.
Neck: Supple with no JVD noted.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3. [**1-4**] soft systolic murmur at
RUSB
Chest: intubated, mechanical BS.  few scattered rhonchi in right
anterior lung field.
Abd: Obese, soft, ND, faint abdominial bruit near umbilicus
Ext: No cyanosis or clubbing.  1+ BLE edema to ankles.  [**11-30**]+ BUE
edema, R>L
Skin: No stasis dermatitis, ulcers
Pulses:
Right: Carotid 2+ faint bruit; Femoral 2+ without bruit; 1+ DP,
could not palpate PT pulse
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 3+
bounding DP, 2+ PT pulse
Neuro: intubated; equal constricted pupils 2 mm, reflective to
light.

Pertinent Results:
[**2146-9-14**] 11:15PM   WBC-8.0 RBC-4.13* HGB-13.7* HCT-40.5 MCV-98
MCH-33.3* MCHC-34.0 RDW-13.0
[**2146-9-14**] 11:15PM   GLUCOSE-114* UREA N-17 CREAT-1.5* SODIUM-135
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-22 ANION GAP-16

Brief Hospital Course:
Patient was transferred to the CCU on Hospital day 6 from the
MICU. The patient was seen and evaluated in the MICU by the CCU
team prior to transfer. The patient was transferred in a guarded
condition.
.
Hospital Course By System:
   1. Vascular: Patient was initially admitted to the vascular
service. He was evaluated and it was determined that surgical
intervention in his case is not warranted at this time. His
management has consisted of [**Month/Day/Year **] pressure control, and
monitoring for signs of vascular compromise. Initial management
of hypertension required multiple PO medications in combination
with IV antihypertensives. Initially due to the rising creatine
in the setting of vascular compromise to one or both kidneys,
ACEi and ARBs were held due to concern about further
hypoperfusion to the kidney. Renal medicine was consulted on
[**9-27**] and approved the use of an ACEi. The patient responded
well to this and was able to remove all IV antihypertensive
medications. His pressure has remained stable with occasional
elevations in systolic [**Month/Year (2) **] pressures related to agitation in
periods of light sedation. Quality of pulses were followed and
saw improvement in right lower extremety pulses over his
hospitalization. Lactate levels were drawn along with serial
abdominal exams to evaluate for signs of bowel ischemia. He was
guaiac negative and had no other signs of acute bowel ischemia.
Extremeties remained warm with good capillary refill. Creatine
stabilized with a maximum value of 2.1 on hospital day 12.  On
discharge the creatinine had trended down to 1.2.  No signs of
acute ischemic injury to the carotid arteries. During physical
therapy and daily ambulation, he denies any claudication or
numbness to either legs. Renal perfusion scan performed on [**10-5**]
showed 29% function in the right kidney and 71% of renal
function performed by the left kidney. Pt was slowly weaned off
bp medications as his agitation and kidney function improved.
He was discharged on Propanolol 160mg [**Hospital1 **], Amlodipine 10mg
daily, and Lisinopril 10mg po bid for [**Hospital1 **] pressure management.
He will follow up with Dr. [**Last Name (STitle) **] in Cardiology and Dr.
[**Last Name (STitle) **]. Patient will make a follow up appointment with a
PCP in the [**Location (un) 5503**] area.  On discharge pt's bllod pressure
was [**Last Name (un) 74635**] well controlled at 110s/70s.
.
   2. Respiratory: Patient was initially intubated on [**9-16**] for
increasing agitation and poor [**Month/Year (2) **] pressure control secondary
to the agitation. During the first days of the admission, he
became increasingly agitated and at time of intubation, required
4 security guards to restrain him for his own safety. He was
initially started on AC but switched to SIMV+PS as tolerated. On
[**9-18**] chest x-ray showed signs of a right middle lobe
infiltrate. He was started on Vancomycin, Levofloxican, and
Zosyn for broad coverage. Culture results indicated the presence
of streptococcus pneumoniae (oxacillin sensitive) and Moraxella
Catastalsis. Antibiotic regimen was changed to Zosyn only and
dosed appropriately for renal function. Patient completed the 10
day course on [**9-30**]. Ventilator settings were decreased as
tolerated in anticipation of weaning the ventilator and the
patient was successfully extubated on [**9-30**]. Repeat CXRs showed
gradual improvement in lung function and resolving infiltrates.
Patient had spiked another fever on [**9-30**] with worsening CXR and
noted infiltrates. He was started on Vancomycin and Ceftazidime
for 7 day course. At time of discharge there were no respiratory
issues and pt had remained afebrile without a oxygen requirement
during ambulation as well as at rest.
.
  3. DVT: On [**9-20**] the patient's right arm was disproportantly
larger and firm compared to the left arm. The patient underwent
a duplex ultrasound which showed non obstructing DVT in the
axillary vein not extending to the subclavian. PICC line in the
right AC was removed. The patient was not a candidate for
anticoagulation due to his other issues and was followed
clinically with no further complications with a resolution of
the swelling in his arm prior to d/c.
.
  4. Pain Control / Sedation: Patient was initially started on
propofol in the MICU and switched to Dexmedetomidine with
Dilaudid bolus PRN. On transfer to the CCU he was switched to
Versed and Fentanyl. During his admission, he required
increasing doses of sedative with frequent boluses. On Hospital
day 13 he was started on Methadone as an alternative to
Fentanyl. He also was switched to PRN boluses of Ativan instead
with good control. For further sedation, he was started on
standing does of Haldol with good result. After extubation,
sedation and pain control was titrated down to patient comfort
and the patient's mental status improved. Neurology was
consulted for evaluation of mental status. As the patient's
cognition improved with time and removal of sedating medication,
the recommendation was an EEG which showed diffuse slowing
consistent with a toxic/metabolic picture. Patient's mental
status improved with the removal of all sedating medications. At
time of discharge he was able to make appropriate cognitive
decisions and was believed to be able to manage his care at
home. Patient was cleared to go home by Occupational Therapy and
was discharged home in a stable condition.

Medications on Admission:
None

Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Propranolol 80 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
4. Multivitamin     Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Type B Aortic Disection
.
Secondary Diagnosis:
Acute Renal Failure
ventialtor associated pneumonia
alcohol abuse

Discharge Condition:
Good, [**Month/Year (2) **] pressure stable


Discharge Instructions:
You were diagnosed with an Aortic Disection. This is a condition
where the large artery that runs through your chest and abdomen
has split into two seperate openings that can cause problems
with [**Name2 (NI) **] flow to organs such as intestines and Kidneys. The
best treatment for your type of disection is to keep your [**Name2 (NI) **]
pressure below 120/80 with medications. You will need to limit
the amount of salt in yor diet and follow up with a primary care
provider of your choosing and a cardologist at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]
[**Last Name (NamePattern1) **].
If you start having worsening chest pains, discomfort in your
legs while walking, or problems thinking clearly you should
visit your local emergency room for treatment.
.
You were seen by cardiothoracic surgery as well as vascular
surgery.  You will need to followup with them in clinic.

You were also seen by the Renal service for your worsening
kidney function due to your aortic dissection.  Prior to
discharge, your kidney function had markedly improved.

You were also seen by our physical therapists who felt that you
would benefit from 24 hour supervision initially and
rehabilitation.  You did not want to go to an inpatient
rehabilitation facility, therefore you will need to have 24 hour
supervision at home.

You were also seen by our psychiatry team and neurology team for
your extreme agitation.  This was likely due to alcohol
withdrawal.  You were treated with medications for this, and
after extubation, your mental status slowly improved.

Please take all your medications as prescribed.  Please go to
all appointments as scheduled.  Please refrain from alcohol or
tobacco use as these both may increase your [**Last Name (NamePattern1) **] pressure.

If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: chest pain, shortness of breath,
abdominal pain, diarrhea, bloody stools, inability to tolerate
oral food/liquids, leg pains, cold feet, or blue toes/fingers.

Followup Instructions:
You have an apointment with Dr. [**Last Name (STitle) **] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] Hospital on Tuesday Februray 12th [**2146**] at 2:40pm.

You have an apointment with Dr. [**Last Name (STitle) 74636**] on [**11-9**] at
3:30pm at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Hospital .

Please choose a primary care physician to see in [**Location (un) 5503**] for
a follow up apointment within the next 2-4 weeks.
{'Dissection of aorta, unspecified site,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Acidosis,Subdural hemorrhage,Urinary tract infection, site not specified,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumonia due to other gram-negative bacteria,Other complications due to other vascular device, implant, and graft,Encephalopathy, unspecified,Vascular disorders of kidney,Other and unspecified complications of medical care, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atherosclerosis of renal artery,Other and unspecified alcohol dependence, unspecified,Other and unspecified special symptoms or syndromes, not elsewhere classified,Anemia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders of circulatory system'}


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: Chest Pain, Abdominal Pain, Nausea/Vomiting, Right Leg Numbness

PRESENT ILLNESS: This is a 59 y.o. male who was initially seen at [**Hospital3 62353**] on [**2146-9-14**] for abdominal pain, chest pain, and
nausea starting that morning. He also noted numbness in his
right leg with this presentation. He denied fevers, chills, or
emesis. During this admission he became agitated, irritable, but
maintained by behavioral redirection. He was started on CIWA
protocal for history of heavy drinking per his girlfriend. [**Name (NI) **]
received Valium at this time. He was found to have a type B
aortic dissection per imaging and transfered to [**Hospital1 18**] for
evaluation and management. He again became combative upon
arrival and was sedated and intubated on [**2146-9-16**]. Vascular
surgery consulted on [**2146-9-14**] and recommended [**Year (4 digits) **] pressure
control with close monitoring for end organ ischemia.
Neurosurgery consulted on [**2146-9-16**] for possible subdural
hemmorhage on CT. Recomended seizure protocol and frequent
neurological evaluations. Patient had a repeat head CT which
showed no signs of subdural hemmorage at that time. Patient was
on moderate sedation and on [**2146-9-16**] became febrile,
hypertensive, and combative requiring physicial restraints. At
this time he was placed on propofol and intubated. PICC line
placed on [**2146-9-16**].

MEDICAL HISTORY: Vascetomy in the past

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Tm 101.6  Tc 100.5 , BP 127/49 (97-152), HR 66 (53-76), RR
21, O2 95% on FiO2 40%  pressure support; PEEP 10 PS 10
Last 24 I/O: 4844/2275 (+2569)  since MN: [**2143**]/1430 (+575)
Gen: WDWN middle aged male in intubated, no response to stimuli.

FAMILY HISTORY: There is family history of coronary artery disease of a brother
who died at 62 with a history of Myocardial Infarction.

SOCIAL HISTORY: Patient stated he drinks 2 glasses of wine on the weekends. Upon
further discussion with the girlfriend, he had been drinking on
average 6 beers a night for a few months and possibly more. He
occasionally smokes cigars. He is employed at a law office in
the area. 

### Response:
{'Dissection of aorta, unspecified site,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Acidosis,Subdural hemorrhage,Urinary tract infection, site not specified,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Pneumonia due to other gram-negative bacteria,Other complications due to other vascular device, implant, and graft,Encephalopathy, unspecified,Vascular disorders of kidney,Other and unspecified complications of medical care, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Atherosclerosis of renal artery,Other and unspecified alcohol dependence, unspecified,Other and unspecified special symptoms or syndromes, not elsewhere classified,Anemia, unspecified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified disorders of circulatory system'}
