CHIEF COMPLAINT: Acute aortic occlusion with bilateral lower extremity ischemia.

PRESENT ILLNESS: This 82-year-old lady who is demented was transferred here from
the [**Hospital 4068**] Hospital with acute limb ischemia. Both legs were
mottled to the hips. The patient was in respiratory failure and
had evidence of recent myocardial infarction. A CT scan was done
because she was complaining abdominal pain and this showed the
aorta was thrombosed distal to the renal arteries. Because of
the urgent nature of the situation and after careful discussion
with the family, she was taken emergently to the operating room
for an attempt at salvaging of her limbs.

MEDICAL HISTORY: PSHx: pacemaker '[**20**], CCY, cardiac cath with angioplasty/stent,
TAH, appy, c-section

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ASA 81', lipitor 10', digoxin 0.125', lasix 120',
glucophage 650', isordil 5", zoloft 25', lopressor 50", prilosec
20", diovan 80', premarin 0.625', RISS, MVI'

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: neg resp
neg pulse
neg hr
neg corneal reflex

FAMILY HISTORY: non contributary

SOCIAL HISTORY: no smoking
no alcohol
Subendocardial infarction, initial episode of care,Acute respiratory failure,Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Volume depletion, unspecified,Atherosclerosis of aorta,Other specified forms of chronic ischemic heart disease,Esophageal reflux,Unspecified essential hypertension
Subendo infarct, initial,Acute respiratry failure,Aortic valve disorder,Atrial fibrillation,CHF NOS,Volume depletion NOS,Aortic atherosclerosis,Chr ischemic hrt dis NEC,Esophageal reflux,Hypertension NOS
Admission Date:  [**2125-11-6**]              Discharge Date:   [**2125-11-8**]


Service: SURGERY

Allergies:
Penicillins / Codeine

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Acute aortic occlusion with bilateral lower extremity ischemia.

Major Surgical or Invasive Procedure:
1. Right axillobifemoral bypass with ring PTFE graft


History of Present Illness:
This 82-year-old lady who is demented was transferred here from
the [**Hospital 4068**] Hospital with acute limb ischemia. Both legs were
mottled to the hips. The patient was in respiratory failure and
had evidence of recent myocardial infarction. A CT scan was done
because she was complaining abdominal pain and this showed the
aorta was thrombosed distal to the renal arteries. Because of
the urgent nature of the situation and after careful discussion
with the family, she was taken emergently to the operating room
for an attempt at salvaging of her limbs.


Past Medical History:
PSHx: pacemaker '[**20**], CCY, cardiac cath with angioplasty/stent,
TAH, appy, c-section



Social History:
no smoking
no alcohol

Family History:
non contributary

Physical Exam:
neg resp
neg pulse
neg hr
neg corneal reflex


Pertinent Results:
echo

MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *7.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 30% to 40% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *3.4 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 50 mm Hg
Aortic Valve - Mean Gradient: 20 mm Hg
Aortic Valve - LVOT Peak Vel: 0.[**Age over 90 **] m/sec
Aortic Valve - LVOT Diam: 2.0 cm
Mitral Valve - E Wave: 1.2 m/sec
TR Gradient (+ RA = PASP): *33 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: *1.1 m/sec (nl <= 1.0 m/s)

INTERPRETATION:

Findings:

LEFT ATRIUM: Moderate LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and extending into the RV.

LEFT VENTRICLE: Normal LV wall thicknesses and cavity size.
Moderate regional
LV systolic dysfunction. TVI E/e' >15, suggesting PCWP>18mmHg.

LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
akinetic; basal inferior - akinetic; anterior apex - akinetic;

RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.

AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
Normal ascending aorta diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets. Aortic
valve mass. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild thickening of mitral valve chordae. Trivial
MR.

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild  PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Based on [**2116**] AHA endocarditis prophylaxis
recommendations, the echo findings indicate a moderate risk
(prophylaxis recommended). Clinical  decisions regarding the
need for prophylaxis should be based on clinical and
echocardiographic data. Echocardiographic results were reviewed
by telephone with the houseofficer caring for the patient.

Conclusions:
The left and right atrium is moderately dilated. Left
ventricular wall
thickness and cavity size are normal. There is moderate regional
left
ventricular systolic dysfunction with focal akinesis of the
basal inferior  wall and the distal half of the anterior wall.
The remaining segments contract well. Right ventricular chamber
size is normal with mild global free wall  hypokinesis. The
aortic valve leaflets are mildly thickened. There is
mild-moderate aortic valve stenosis. A 6mm, mobile, echodensity
is seen on the aortic side of the aortic valve, attached to the
non-coronary leaflet c/w  vegetation/thrombus/tumor. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The  tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery  systolic hypertension. There is no pericardial effusion.


IMPRESSION: Mobile aortic valve echodensity c/w thrombus vs
vegetation vs. ??.  Regional left ventriuclar systolic
dysfunction c/w CAD. Mild-moderate aortic  valve stenosis.



CHEST (PORTABLE AP)

Reason: eval effusion, consolidation

INDICATION: 82-year-old woman status post axillary bifemoral
bypass occlusion.

COMMENTS: Portable supine AP radiograph of the chest is
reviewed, and compared with the previous study of yesterday.

The tip of the endotracheal tube is identified at the thoracic
inlet. The right jugular Swan-Ganz catheter terminates in the
right main PA. The previously identified mild congestive heart
failure has been slightly improving. There is continued left
lower lobe patchy atelectasis. No pneumothorax is identified.
The pacemaker leads remain in place.

IMPRESSION: Improving mild congestive heart failure with
cardiomegaly. Continued left lower lobe patchy atelectasis.

   RADIOLOGY  Final Report

CTA CHEST W&W/O C &RECONS  [**2125-11-6**] 11:04 AM

CTA CHEST W&W/O C &RECONS; CTA ABD W&W/O C & RECONS

Reason: CTA: rule out dissection/PE. Has a elevated Cr. but is
[**Last Name (un) 10737**]
Field of view: 36 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
82 year old woman with chest pain, neck pain and leg pain in
setting of htn
REASON FOR THIS EXAMINATION:
CTA: rule out dissection/PE. Has a elevated Cr. but is being
pretreated.
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: Chest pain, neck pain, and leg pain, in setting of
hypertension. Evaluate for dissection or pulmonary embolism.

TECHNIQUE: CTA chest, abdomen, and pelvis, with images obtained
before and after the administration of IV contrast.

COMPARISONS: None.

FINDINGS:

CTA: There is no evidence of pulmonary embolism. No evidence of
dissection involving the thoracic aorta. Evaluation of the
abdominal aorta shows occlusion of the distal aorta, with
filling defect seen beginning at the level of the takeoff of the
SMAs, resulting in total occlusion of the distal abdominal
aorta. There is also filling defect seen extending into the
iliac arteries. On the delayed scan of the abdomen and pelvis,
there appears to be slight filling within the left external
iliac artery, although this is incompletely evaluated. Marked
atherosclerotic calcifications are seen involving the infrarenal
aorta. There is aneurysmal dilatation of the infrarenal aorta
measuring up to 3.7 x 3.2 cm in its infrarenal portion. No
definite dissection is seen. No dominant collateral vessels are
seen bypassing the area of aortic occlusion.

Note is also made that during the Smart Prep images obtained for
contrast timing evaluation, there was marked delay in the time
for contrast passage from the SVC to the pulmonary arteries and
to the ascending aorta, suggesting heart failure or markedly
decreased cardiac output.

CT OF THE CHEST WITHOUT AND WITH CONTRAST: There is pulmonary
vascular engorgement. There are patchy ground-glass opacities
seen throughout the lungs, with interstitial thickening as well
as engorgement of pulmonary venules. No consolidation, or
significant pleural effusion. Coronary artery calcifications are
seen, and there is a pacemaker present in the setting of marked
cardiomegaly. In addition, calcifications of the left ventricle
are seen, suggesting prior rheumatic disease.

CT OF THE ABDOMEN WITH CONTRAST: The liver has a nodular surface
appearance, suggesting cirrhosis. The gallbladder wall appears
slightly thickened, although the gallbladder is not totally
distended, likely related to congestive failure/fluid overload.
The spleen, adrenal glands, pancreas, stomach, and small bowel
are unremarkable. There is a renal cyst seen in the interpolar
portion of the right kidney, and several other cortical
low-density foci seen within both kidneys, more on the right
than on the left, which might represent small renal cysts, but
are too small to characterize on this study. The kidneys enhance
symmetrically.

CT OF THE PELVIS WITH CONTRAST: There are diverticula of the
sigmoid colon. Large bowel and bladder otherwise appear
unremarkable. The bladder is decompressed.

Examination of osseous structures shows degenerative changes and
suggests short pedicles of the lower lumbar spine. Multiple
healed rib fractures are seen both on the right and on the left.
No lytic or sclerotic lesions suspicious for malignancy are
present.

Coronally and sagittally reformatted images, as well as multiple
obliquely reformatted images were also obtained. In addition,
volume rendered images as well as MIP images were created at the
workstation to better depict the involvement of thrombosis. MPR
Value: 3.

IMPRESSION:
1. Thrombosis of the distal aorta, and extending into the iliac
arteries. There are no significant collateral vessels to suggest
chronic changes. There may be some flow seen in the left
external iliac artery on the delayed images.
2. No evidence of pulmonary embolism.
3. Pulmonary edema and marked cardiomegaly, with delayed transit
of contrast from the SVC to the aorta.

Findings were discussed in person with the emergency department
team taking care of the patient immediately after the completion
of this examination, and a wet read report was placed on
Emergency Department Dashboard subsequently.




Brief Hospital Course:
Pt admitted on [**2126-11-6**]

underwent a Right axillobifemoral bypass with ring PTFE graft
for acute aortic rupture / pt critical. Sent to the SICU in
critical condition. Pt Intubated.

Pt found to have multi sytem failure s/p acute aortic
occlussion.

All attempts to resusitate were made. Multiple tests were
obtained.

BP control very labile / multiple drips were used

Pt family contact[**Name (NI) **]

Pt made DNR / DNI / CMO

Pt expired [**2125-11-8**]


Medications on Admission:
[**Last Name (un) 1724**]: ASA 81', lipitor 10', digoxin 0.125', lasix 120',
glucophage 650', isordil 5", zoloft 25', lopressor 50", prilosec
20", diovan 80', premarin 0.625', RISS, MVI'

Discharge Medications:
n/a

Discharge Disposition:
Expired

Discharge Diagnosis:
Acute aortic disection
B/L extremity occlusion
MI
Dementie
CRI

Discharge Condition:
N/A

Discharge Instructions:
N/A

Followup Instructions:
n/a


Completed by:[**2126-3-8**]
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Volume depletion, unspecified,Atherosclerosis of aorta,Other specified forms of chronic ischemic heart disease,Esophageal reflux,Unspecified essential hypertension'}


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: Acute aortic occlusion with bilateral lower extremity ischemia.

PRESENT ILLNESS: This 82-year-old lady who is demented was transferred here from
the [**Hospital 4068**] Hospital with acute limb ischemia. Both legs were
mottled to the hips. The patient was in respiratory failure and
had evidence of recent myocardial infarction. A CT scan was done
because she was complaining abdominal pain and this showed the
aorta was thrombosed distal to the renal arteries. Because of
the urgent nature of the situation and after careful discussion
with the family, she was taken emergently to the operating room
for an attempt at salvaging of her limbs.

MEDICAL HISTORY: PSHx: pacemaker '[**20**], CCY, cardiac cath with angioplasty/stent,
TAH, appy, c-section

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ASA 81', lipitor 10', digoxin 0.125', lasix 120',
glucophage 650', isordil 5", zoloft 25', lopressor 50", prilosec
20", diovan 80', premarin 0.625', RISS, MVI'

ALLERGIES: Penicillins / Codeine

PHYSICAL EXAM: neg resp
neg pulse
neg hr
neg corneal reflex

FAMILY HISTORY: non contributary

SOCIAL HISTORY: no smoking
no alcohol 

### Response:
{'Subendocardial infarction, initial episode of care,Acute respiratory failure,Aortic valve disorders,Atrial fibrillation,Congestive heart failure, unspecified,Volume depletion, unspecified,Atherosclerosis of aorta,Other specified forms of chronic ischemic heart disease,Esophageal reflux,Unspecified essential hypertension'}
