CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient was a 64-year-old
male who presented with excruciating back pain on [**2150-5-5**] which was diagnosed as an [**Year (4 digits) 8813**] arch dissection
extended from the innominate artery to the iliacs with right
renal artery in the false lumen.  The patient, based on CT
scan and ultrasound, was found to have compromised slow to
the right renal artery based over the left renal artery
ostium is in the true lumen of the abdominal aorta and has
intact blood flow.  The dissection was classified as [**Location (un) 11916**]
B and Debakey 3.  The patient was hemodynamically stable and
extubated after going to CT surgery service following his
arrival in the Emergency Room.

MEDICAL HISTORY: Only hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Dissection of aorta, thoracic,Acute kidney failure, unspecified,Pulmonary collapse,Unspecified protein-calorie malnutrition,Pneumonitis due to inhalation of food or vomitus,Acute glomerulonephritis with unspecified pathological lesion in kidney,Acute sinusitis, unspecified,Chronic glomerulonephritis with unspecified pathological lesion in kidney
Dsct of thoracic aorta,Acute kidney failure NOS,Pulmonary collapse,Protein-cal malnutr NOS,Food/vomit pneumonitis,Acute nephritis NOS,Acute sinusitis NOS,Chronic nephritis NOS
Admission Date:  [**2150-5-5**]       Discharge Date:  [**2150-6-5**]

Date of Birth:   [**2085-11-28**]       Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  The patient was a 64-year-old
male who presented with excruciating back pain on [**2150-5-5**] which was diagnosed as an [**Year (4 digits) 8813**] arch dissection
extended from the innominate artery to the iliacs with right
renal artery in the false lumen.  The patient, based on CT
scan and ultrasound, was found to have compromised slow to
the right renal artery based over the left renal artery
ostium is in the true lumen of the abdominal aorta and has
intact blood flow.  The dissection was classified as [**Location (un) 11916**]
B and Debakey 3.  The patient was hemodynamically stable and
extubated after going to CT surgery service following his
arrival in the Emergency Room.

PAST MEDICAL HISTORY:  Only hypertension.

MEDICATIONS PRIOR TO ARRIVAL:
1.  Zestril
2.  Aspirin

PHYSICAL EXAM ON PRESENTATION TO CCU:
VITAL SIGNS:  T-max 99.2??????, T-current 98.9??????.  Pulse was 64.
His blood pressure was 114/57.  His respiratory rate was 15.
He was saturating 96% on CPAP with PEEP of 5, pressure
support of 10.
GENERAL:  Generally, the patient was intubated.  He responded
to stimulation, withdrew to pain.  Occasionally followed
commands, no acute distress, obese male.
HEAD, EARS, EYES, NOSE AND THROAT:  The patient had intact
corneal reflexes and spontaneously opened his eyes.
NECK:  At times, his neck exam was edematous, no jugular
venous pressure appreciable.  The patient's neck exam was
significant for plethora.
CARDIOVASCULAR:  Difficult due respirator, revealed regular
rate without any murmurs, rubs or gallops.
RESPIRATORY:  The patient had bronchial breath sounds
bilaterally.  No wheezes, no crackles, no rubs.
ABDOMEN:  Nontender, nondistended, positive active bowel
sounds.
EXTREMITIES:  Significant for anasarca, 3+ pitting edema.
NEUROLOGIC:  The patient had bilateral downgoing Babinski's,
1+ deep tendon reflexes bilaterally.
EXTREMITIES:  On upper and lower extremities, he had
symmetrically diminished tone and 2/5 strength when the
patient was cooperative.

HOSPITAL COURSE:
CARDIOVASCULAR:  1.  [**Location (un) **] dissection, main goal of therapy
throughout the patient's hospitalization has been blood
pressure control which is initially managed with a Nipride
drip on the cardiothoracic surgery team and then
nitroglycerin drips.  The Nipride drip was discontinued on
[**5-7**] due to the high risk of ............. toxicity in
the setting of compromised renal function.  Per renal
request, the patient was also started on a Lopressor drip and
po amlodipine, as well as a clonidine patch.  Additionally,
on [**5-7**], an intravenous fenoldopam drip was started for
blood pressure control due to the lack of renal toxicity.
The patient was transferred to the CCU team on [**5-26**], at
which time he was switched from his labetalol drip to his po
labetalol which was titrated up to 800 mg tid.  Additionally,
after he was transferred to the CCU, the patient was started
on captopril and that was titrated up to a final dose of 50
tid which was then switched to a once a day 20 mg dose of
lisinopril.  The patient's blood pressure ranged from 120 to
130 systolic while on the regimen of 800 tid of labetalol and
50 tid of captopril along with 10 mg of amlodipine.  The
patient was weaned off the clonidine patch prior to
discharge.

2.  Vascular Surgery Consult:  The Vascular Surgery
recommended good blood pressure control throughout the
patient's hospitalization.  They mentioned that they would
consider taking the patient to surgery for ascending [**Month (only) 8813**]
arch stabilization after the patient had completely recovered
from his initial .............  The patient will be followed
up on an outpatient basis with the Vascular Surgery team.

PULMONARY:  1.  The patient had been intubated upon admission
to the Cardiothoracic Surgical Intensive Care Unit.  He had a
failed auto extubation on [**5-10**] which lead to his
re-intubation on [**5-11**] due to hypoxia and tachypnea.  He
then had another failed extubation on [**5-25**].  He had to be
reintubated [**5-26**] due to hypoxia and respiratory distress.
The patient was then finally successfully extubated on [**6-2**] after he had been weaned for assist control ventilation
to pressure support of 5 and PEEP of 5 on 40% FIO2.  The
patient was weaned off oxygen completely on [**6-4**] and had
no further episodes of respiratory distress during his
hospitalization.  The patient had a pulmonary consult on [**5-12**] and due to his respiratory distress pulmonary had
recommended at that time to broaden antibiotic coverage to
vancomycin with the suspicion of a hospital acquired
pneumonia after the patient was reintubated.  They also did a
bronchoscopy which showed a small clot obstructing the single
left lower lobe segment.  This may have been what had been
prior read as pneumonia on his chest x-ray.

2.  Pneumonia:  The patient was treated for three weeks for
suspected aspiration pneumonia after his intubation.  He was
initially treated with multiple antibiotics, all of which
were weaned off on [**5-26**], since the patient had been
afebrile for several weeks without a white count with
improving chest x-rays.  The patient had been restarted on an
antibiotic on [**5-29**] after spiking a fever and having just
had been reintubated under the suspicion of another
aspiration pneumonia.  The patient's respiratory status
improved significantly after he was diuresed aggressively
towards the end of his hospitalization which was, we think,
responsible for his final successful extubation.

RENAL:  1.  Renal Consult which was acquired on [**5-7**].
They recommended stopping the Nipride drip and starting
labetalol drip along with fenoldopam.  Additionally, they
recommended avoidance of nephrotoxic medications and gentle
hydration along with blood pressure management.  The
patient's creatinine bumped to 2.8 within the first several
days of his hospitalization which was thought to be a result
of the involvement of the right renal artery and decreased
renal perfusion.  The patient's creatinine remained stable at
2.8 and then trended down throughout his hospitalization with
good blood pressure management and was 1.6 at the time of
discharge.

3.  Diuresis:  When the patient was transferred to the
Coronary Critical Care Unit, it was noted that he was up 15
liters throughout his length of stay at the hospital.  He was
therefore diuresed aggressively per renal recommendation with
a Lasix drip that ranged from 10 to 15 mg per hour. He was
diuresed to the point that his length of stay fluid balance
was negative.  He put out over 17 liters in four days which
led to a marked improvement in his respiratory status and
anasarca as noted above.  In the meantime, his creatinine
continued to decrease to his discharge level of 1.6.  The
patient's electrolytes were repleted as necessary in light of
the aggressive diuresis.

INFECTIOUS DISEASE:  1.  The patient had been initially
started on Levaquin, renally dosed on [**5-7**] and was kept
on that until [**5-26**] due to spiking temperatures and a
positive H. influenza sputum culture that was obtained upon
admission after the patient had been intubated.  The
patient's antibiotics were changed to vancomycin and Ceptaz
on [**5-12**] to broaden coverage.  Ceptaz was discontinued
and Levaquin restarted on [**5-16**] and then the vancomycin
was discontinued on [**5-17**].  As noted above, the patient
was taken off all antibiotics on [**5-26**] and then restarted
[**5-29**] on ceftriaxone for aspiration pneumonia.  This was
discontinued on [**6-4**] as a result of a reticular truncal
rash noted on the patient a few days after starting
ceftriaxone.  It was thought that this was a drug reaction to
ceftriaxone.  It should be noted that THE PATIENT IS ALLERGIC
TO CEFTRIAXONE in the future.  The patient was not started on
antibiotics after the ceftriaxone was discontinued due to
resolution of pneumonia per chest x-ray, white count and
fever curve.

FLUIDS, ELECTROLYTES AND NUTRITION/GASTROINTESTINAL:  The
patient was intermittently given tube feeds throughout his
hospitalization, but was discontinued on several occasions
due to hopeful extubations.  The patient was also given
several days of TPN per nutrition consult's recommendations.
This was also discontinued when patient was extubated and
able to take po.  The patient finally was able to take the po
feeds on [**6-3**] after receiving a speech therapy
swallowing evaluation which showed that he was able to
tolerate pureed foods.  The patient was not able to tolerate
solid foods when he was discharged, however it was thought
that when his neurological status improved that he would be
able to take solid food, as his neurosensory mechanisms were
intact.

NEUROLOGY:  1.  Decreased Mental Status:  Initially, when the
patient was transferred to the Coronary Critical Care Unit,
it was thought that his respiratory distress was a result of
his neurological dysfunction.  The patient received a head CT
scan which showed no evidence of acute bleed and no evidence
of increased cranial pressure.  The patient also had an EEG
per neurology's recommendations that showed diffuse swellings
consistent with encephalopathy induced by either medications
or hypoperfusion.  Neurology was concerned that much of the
sedative medications the patient had received throughout his
hospitalization while intubated may have had an enhanced
effect in the setting of the patient's mild renal
insufficiency.  The patient was weaned off all sedatives
several days prior to his extubation and then restarted on
propofol for short term sedation while he was intubated.
This was also weaned on the day of extubation and the
patient's mental status improved each day after he was
extubated, however, the patient was not oriented to time or
place.  When he was discharged, he was oriented to person and
he was alert and he was able to follow commands.  He was able
to answer some questions appropriately.

PROPHYLAXIS:  The patient was given Protonix throughout his
hospitalization for peptic ulcer disease prophylaxis.  He was
also given Pneumo boots throughout his hospitalization for
deep venous thrombosis prophylaxis.  He was not started on
heparin for deep venous thrombosis prophylaxis due to the
nature of his dissecting aorta which may have worsened with
the administration of heparin.

HEME:  The patient's hematocrit initially dropped during his
hospitalization likely as a result to his [**Month (only) 8813**] dissection
and multiple sticks for a blood test.  However, it stabilized
with a hematocrit between 27 to 30 throughout the latter
portion of his hospitalization and at discharge.

GENITOURINARY:  The patient had a Foley catheter in place
throughout the majority of this hospitalization.  He had no
issues with this catheter and it was discontinued prior to
his discharge.

FOLLOW UP:  The patient is to follow up with CT surgery and
vascular surgery to evaluate him for future surgical
treatment of his ascending [**Month (only) 8813**] arch which has not
dissected at this time.  However, there is notably dilated
aorta starting from the [**Month (only) 8813**] root and continuing up to
where the dissection starts and the [**Month (only) 8813**] arch.  It was
thought that surgical treatment could be considered on an
elective basis, stabilize the ascending aorta and prevent a
continuation of the dissection into the [**Month (only) 8813**] root.
Additionally, surgical replacement of the [**Month (only) 8813**] valve may be
considered in light of [**Month (only) 8813**] insufficiency noted on
echocardiogram.  Additionally, it should be noted that
treatment of the existing extensive [**Month (only) 8813**] dissection will be
medical with good blood pressure control per the regimen the
patient was sent home with consisting of labetalol,
lisinopril and Norvasc.

RADIOLOGY:  An abdominal and chest CT was done with and
without contrast upon admission.  Impression was [**Month (only) 8813**]
dissection originating at the level of the takeoff with the
innominate artery extending into the left subclavian and
inferiorly to the level of both iliac arteries.  Renal
ultrasound showed normal vascular flow to the left kidney
with no son[**Name (NI) 493**] evidence of flow within the right kidney
parenchyma.  The study was done on [**2150-5-8**].  Head CT
done on [**5-29**] showed no evidence of major vascular
territorial infarct.  Note that CT can miss a small early
infarct.  It was also noted that if clinically warranted, a
diffusion weighted MRI would be recommended to exclude acute
infarct.  It also noted a left maxillary and sphenoid
sinusitis likely related to nasogastric tube placement.  The
patient also had lower extremity Dopplers done on [**2150-5-14**] which showed no evidence of deep venous thrombosis.

DISCHARGE MEDICATIONS:
1.  Lisinopril 20 mg po q day
2.  Labetalol 800 mg po tid
3.  Amlodipine 10 mg po bid

DISCHARGE CONDITION:  Fair

DISCHARGE STATUS:  The patient was discharged to a long term
rehabilitation facility.

DISCHARGE DIAGNOSES:
1.  [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8813**] dissection
2.  Hypertension
3.  Pneumonia
4.  Aspiration pneumonia
5.  Pulmonary edema
6.  Respiratory distress/respiratory failure
7.  Renal insufficiency, acute
8.  Renal insufficiency, chronic
9.  Delirium
10. Altered mental status
11. Acute sinusitis
12. Dysphagia
13. Anasarca
14. Malnutrition
15. Drug related rash




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D.  [**MD Number(1) 5211**]

Dictated By:[**Last Name (NamePattern1) 11117**]
MEDQUIST36

D:  [**2150-6-4**]  14:09
T:  [**2150-6-4**]  14:21
JOB#:  [**Job Number 42723**]


Name:  [**Known lastname 7743**], [**Known firstname **]                 Unit No:  [**Numeric Identifier 7744**]

Admission Date:  [**2150-5-5**]       Discharge Date:  [**2150-6-5**]

Date of Birth:   [**2085-11-28**]       Sex:  M

Service:  Coronary Critical Care Unit

NOTE:  This is an addendum to the discharge summary that was
dictated on [**2150-6-5**].

HOSPITAL COURSE:
1.  ABDOMINAL PAIN:  The patient developed abdominal pain on
the day prior to admission after eating.  The patient was
otherwise asymptomatic and he reported passing stools the day
prior to his symptoms and passing flatus with resolution of
his pain on the day of his symptoms.  However, the pain had
returned and initially was unremitting.  A KUB was done to
rule out small bowel obstruction which was negative and
unremarkable.  The patient's lipase and amylase were noted to
be mildly elevated.  Lipase was 260 and his amylase was 240.
The patient's bilirubin was normal.  The patient's symptoms
remitted after being NPO for 18 hours and the patient was
able to tolerate his breakfast in the morning without
recurrence of symptoms.  The patient's lipase and amylase
diminished the day following his symptoms.  It was thought
that the patient had a mild elevation of his enzymes as a
result of either mild acute pancreatitis or remitting
acalculous/calculous cholecystitis in the setting of
decreased po intake.  The patient never reported any nausea,
no vomiting, never had evidence of either condition,
pancreatitis, acalculous or calculous cholecystitis via
radiographic evidence.  The patient could be followed up in
an outpatient fashion with a right upper quadrant ultrasound
if his symptoms recur.

2.  BLOOD PRESSURE:  The patient's blood pressure remained
well controlled on his antihypertensive regimen.  His
lisinopril dose was increased to 10 mg [**Hospital1 **] for blood pressure
control.

3.  MENTAL STATUS CHANGES:  The patient's mental status
improved throughout his hospitalization after intubation and
especially in the last few days prior to discharge.

4.  ACTIVITY:  The patient was able to control and manipulate
more of his body weight each day after physical therapy has
worked with him.  It was thought that short term physical
rehabilitation will be critical and return this patient to
pre-hospitalization functioning.

DISCHARGE MEDICATIONS:
1.  Labetalol 800 mg po tid
2.  Lisinopril 10 mg [**Hospital1 **]
3.  Amlodipine 10 mg [**Hospital1 **]

DISCHARGE CONDITION:  The patient was discharged in good
condition.

DISCHARGE STATUS:  The patient was discharged to outside
extended care facility.

DISCHARGE DIAGNOSES are as per initial discharge summary.





                            [**First Name11 (Name Pattern1) 448**] [**Last Name (NamePattern4) 2130**], M.D.  [**MD Number(1) 4055**]

Dictated By:[**Last Name (NamePattern1) 7745**]
MEDQUIST36

D:  [**2150-6-8**]  11:51
T:  [**2150-6-8**]  12:25
JOB#:  [**Job Number 7746**]
{'Dissection of aorta, thoracic,Acute kidney failure, unspecified,Pulmonary collapse,Unspecified protein-calorie malnutrition,Pneumonitis due to inhalation of food or vomitus,Acute glomerulonephritis with unspecified pathological lesion in kidney,Acute sinusitis, unspecified,Chronic glomerulonephritis with unspecified pathological lesion in kidney'}


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: The patient was a 64-year-old
male who presented with excruciating back pain on [**2150-5-5**] which was diagnosed as an [**Year (4 digits) 8813**] arch dissection
extended from the innominate artery to the iliacs with right
renal artery in the false lumen.  The patient, based on CT
scan and ultrasound, was found to have compromised slow to
the right renal artery based over the left renal artery
ostium is in the true lumen of the abdominal aorta and has
intact blood flow.  The dissection was classified as [**Location (un) 11916**]
B and Debakey 3.  The patient was hemodynamically stable and
extubated after going to CT surgery service following his
arrival in the Emergency Room.

MEDICAL HISTORY: Only hypertension.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Dissection of aorta, thoracic,Acute kidney failure, unspecified,Pulmonary collapse,Unspecified protein-calorie malnutrition,Pneumonitis due to inhalation of food or vomitus,Acute glomerulonephritis with unspecified pathological lesion in kidney,Acute sinusitis, unspecified,Chronic glomerulonephritis with unspecified pathological lesion in kidney'}
