CHIEF COMPLAINT: Follow up for ascending aortic dilatation
with no symptoms.

PRESENT ILLNESS: Patient presented with a
complaint of flutter and palpitations.  An echo showed that
the patient had enlarged aorta.  CAT scan done following the
echo revealed a 5 cm ascending aortic aneurysm.  MIBI in
[**9-/2138**] showed an ejection fraction of 40 percent with an
inferior myocardial infarction and no ischemia.  Cardiac
catheterization showed an ejection fraction of 58 percent
with a large aortic aneurysm, distal right coronary artery
lesion of 70 percent, a D1 lesion of 40 percent, an LV EDP of
11.

MEDICAL HISTORY: Significant for hypertension, diabetes
mellitus type 2, GERD, chronic sinusitis, CAD status post
myocardial infarction, obesity.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient states no known drug allergies, although
he also states that he could not tolerate statins.

PHYSICAL EXAM: 

FAMILY HISTORY: Mother is alive and well at 81.  Father died
of Alzheimer's at age 88.

SOCIAL HISTORY: Occupation:  Maintenance manager.  Lives
with wife.  Remote tobacco history; quit in [**2116**].  Occasional
alcohol use; 1 beer per week.  No other drug use.
Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Acute and subacute necrosis of liver,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Other pulmonary insufficiency, not elsewhere classified
Crnry athrscl natve vssl,Acute kidney failure NOS,Surg compl-heart,Acute necrosis of liver,React-oth vasc dev/graft,Bacteremia,Other pulmonary insuff
Admission Date: [**2139-10-5**]        Discharge Date: [**2139-11-4**]

Date of Birth:  [**2081-5-31**]        Sex:  M

Service:  CSU


Mr. [**Known lastname 16033**] is a postoperative admission.

CHIEF COMPLAINT:  Follow up for ascending aortic dilatation
with no symptoms.

HISTORY OF PRESENT ILLNESS:  Patient presented with a
complaint of flutter and palpitations.  An echo showed that
the patient had enlarged aorta.  CAT scan done following the
echo revealed a 5 cm ascending aortic aneurysm.  MIBI in
[**9-/2138**] showed an ejection fraction of 40 percent with an
inferior myocardial infarction and no ischemia.  Cardiac
catheterization showed an ejection fraction of 58 percent
with a large aortic aneurysm, distal right coronary artery
lesion of 70 percent, a D1 lesion of 40 percent, an LV EDP of
11.

PAST MEDICAL HISTORY:  Significant for hypertension, diabetes
mellitus type 2, GERD, chronic sinusitis, CAD status post
myocardial infarction, obesity.

PAST SURGICAL HISTORY:  Significant for hemorrhoidectomy in
[**2119**], appendectomy in [**2112**], tonsillectomy.

MEDICATIONS PRIOR TO ADMISSION:
1. Mavik 4 mg b.i.d.
2. Glucotrol, no dose
3. Prilosec, no dose
4. Flonase, no frequency
5. Zyrtec, no dose
6. Aspirin 81 mg once daily


ALLERGIES:  Patient states no known drug allergies, although
he also states that he could not tolerate statins.

FAMILY HISTORY:  Mother is alive and well at 81.  Father died
of Alzheimer's at age 88.

SOCIAL HISTORY:  Occupation:  Maintenance manager.  Lives
with wife.  Remote tobacco history; quit in [**2116**].  Occasional
alcohol use; 1 beer per week.  No other drug use.

CAT scan done in [**5-/2139**] showed 5 cm ascending aortic root.
The rest of the aorta was normal.  Chest showed no
infiltrates or masses.

PHYSICAL EXAMINATION:  VITAL SIGNS:  Heart rate 84 and
regular, blood pressure 146/88, height 5 feet, 11 inches,
weight 239 pounds.
GENERAL:  Obese, young man.
SKIN:  No obvious lesions.
HEENT:  Pupils equally round and reactive to light.
Extraocular movements intact; anicteric; not injected.
NECK:  Supple with no bruits and no JVD.
CHEST:  Clear to auscultation bilaterally.
CARDIOVASCULAR:  Regular rate and rhythm; S1, S2 with a IV/VI
systolic ejection murmur that does not radiate.
ABDOMEN:  Obese, soft, nontender, with positive bowel sounds.
No hepatosplenomegaly.
EXTREMITIES:  Warm and well perfused with no clubbing,
cyanosis, or edema.  No varicosities, although he does have
mild spider veins bilateral lower extremities.
NEURO:  Cranial nerves II-XII grossly intact and nonfocal
exam.
PULSES:  Femoral 1 plus bilaterally, dorsalis pedis and
posterior tibial 2 plus bilaterally, radial 2 plus
bilaterally.

HOSPITAL COURSE:  As stated previously, patient was a
postoperative admit.  He was directly admitted to the
Operating Room on [**2139-10-5**], where he underwent an ascending
aortic root replacement, _________, with a hemiarch repair
using a 26 Gel weave, also a coronary artery bypass graft
times 2 with a saphenous vein graft to the RPL and RPDA
sequentially.  His bypass time was 158 minutes with a cross-
clamp time of 102 minutes and circulatory arrest time of 14
minutes.  The patient was transferred from the Operating Room
to the Cardiothoracic Intensive Care Unit in the sinus rhythm
at 68 beats per minute with mean arterial pressure of 67 and
a CVP of 11.  He had Neo-Synephrine at 0.3 mcg/kg/minute and
propofol at 20 mcg/kg/minute.
Patient did well in the immediate postoperative period.  He
was reversed from his anesthesia, weaned from the ventilator
and successfully extubated.

On postoperative day 1 he remained hemodynamically stable.
However, the patient did complain of increasing respiratory
distress and was experiencing decreasing urine output.  At
that time a transthoracic echo was done that showed no
pericardial effusion; however, the echo was unable to
visualize the arch.

On postoperative day 2 the patient's creatinine was noted to
be elevated, and a Renal consult was called.  Renal service
felt patient was in acute renal failure, and renal ultrasound
was done at that time that proved to be negative.  The
patient also had increasing liver function tests and coags,
and at that time a General Surgery consult was called to
assess for causes of the elevated liver function test shock
liver.  The patient had an MRI at that time to rule out a
descending dissection.  Additionally, the patient was
reintubated on postoperative day 2, and a Pulmonary consult
was called due to poor gas exchange.  Furthermore, the
patient experienced rapid atrial fibrillation and was
cardioverted with 200 Joules to sinus rhythm.  At that time a
Cardiology consult was also called.  Given the patient's
oliguric renal failure, the patient was also begun on CVVHD
on postoperative day 2.

On postoperative day 3 the patient continued to experience
elevated LFTs, coags, BUN, and creatinine.  Additionally, the
patient had an elevated white blood cell count with a
decreased SVR, and Infectious Diseases consult was called.
Patient was started on broad spectrum antibiotics at that
time but continued to experience difficulty ventilating the
patient.  He was fully sedated and, on postoperative day 4,
he was chemically paralyzed and put on pressure-control
ventilation.

Over the next 2 weeks the patient experienced severe multi-
organ failure with an AST that peaked at 11,759, an ALT that
peaked at 5874 with total bilirubin that peaked at 13.6.
Additionally, patient required pressure-control ventilation
with nitric oxide to further enhance gas exchange and CVVHD
to supplement his renal function.  He continued to be
followed by the Hepatobiliary service, the Renal service, the
ID service, the Cardiology service, and the Critical Care
service, as well as the Pulmonary service.  Ultimately, the
patient's paralytics were discontinued by postoperative day 9
with gradual weaning of the nitric, following that was
ultimately weaned by postoperative day 11 followed by a
gradual wean from sedation.

On postoperative day 14 he was finally able to be weaned from
pressure-control ventilation followed by a change to IMV
ventilation and ultimately to pressure-support ventilation by
postoperative day 15.

On postoperative day 18 the patient was finally extubated.
By this point the only intravenous medication the patient was
on, besides antibiotics, was nitroglycerin for blood pressure
control.  Over the next week the patient's pulmonary status
was closely monitored.  He remained in the Intensive Care
Unit for vigorous pulmonary toilet.  He had an ENT consult
that ultimately showed bilateral vocal cord paralysis.  He
was transitioned from intravenous medications to oral
medications, and on postoperative day 24 the patient was
transferred from the Intensive Care Unit to _____ floor for
continuing postoperative care and cardiac rehabilitation.

Once on the floor patient had an uneventful hospital course.
His activity was increased gradually with the assistance of
the nursing staff as well as Physical Therapy.  His diet was
advanced.  He had a repeat ENT consult and video stroboscopy.

On postoperative day 29 it was decided that the patient would
be stable and ready to be transferred to rehabilitation on
the following day.  At the time of this dictation patient's
physical exam is as follows:

VITAL SIGNS:  Temperature 98.2, heart rate 62, blood pressure
100/60, respiratory rate 18, O2 sat 96 percent on room air,
weight currently 101.4 kg, preoperatively 113.6 kg.

LABORATORY DATA:  White count 7.2, hematocrit 30.5, platelets
147, sodium 135, potassium 4.3, chloride 102, CO2 24, BUN 18,
creatinine 0.7, glucose 99.

PHYSICAL EXAMINATION:  NEURO:  Alert and oriented times 3;
moves all extremities; follows commands; very weak, unable to
walk independently; able to finally pivot from bed to chair,
unassisted, the day prior to transfer.
CARDIOVASCULAR:  Regular rate and rhythm; S1, S2 with a II/VI
systolic ejection murmur.
RESPIRATORY:  Clear to auscultation bilaterally.
ABDOMEN:  Soft, nontender, nondistended, with positive bowel
sounds.
EXTREMITIES:  Warm and well perfused with no edema.
SKIN:  Sternum is stable.  Incision healing well.  Left
saphenous vein graft harvest site healing well.  Incision
open to air, clean and dry.

DISCHARGE CONDITION:  Good.

FINAL DIAGNOSES:  Status post ascending aortic hemiarch
repair with a No. 26 gel weave

Coronary artery bypass graft times 2 with a saphenous vein
graft to the RPL, sequentially to the RPDA, complicated by
multi-organ failure and bilateral vocal cord paralysis.

Hypertension.

Diabetes mellitus type 2.

Gastroesophageal reflux disease.

Hypercholesterolemia.

DISPOSITION:  The patient is to be discharged to
rehabilitation at [**Hospital3 7665**] Center in _________.

FOLLOW UP:  He is to have follow up with Dr. [**First Name (STitle) **] _______ in
2 to 3 weeks following his discharge from rehabilitation.

Follow up with Dr. __________ of the [**Hospital **] Clinic in 1 week.

Fo[**Last Name (STitle) **]p with Dr. [**Last Name (Prefixes) **] in 4 weeks.  Patient is to
call for the last 2 appointments.

DISCHARGE MEDICATIONS:
1. Aspirin 325 once daily
2. Heparin 5000 units subcutaneously t.i.d.
3. Norvasc 10 mg once daily
4. Labetalol 800 mg t.i.d.
5. Glipizide 5 mg b.i.d.
6. Trazodone 50 mg at bedtime p.r.n.
7. Amiodarone 200 mg once daily
8. Percocet 5/325, 1 to 2 tabs, q. 4-6 hours p.r.n.
9. Beclomethasone aerosol spray, 2 sprays, b.i.d. p.r.n.
10.      Pantoprazole 40 mg b.i.d.




                        [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]

Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D:  [**2139-11-3**] 20:42:35
T:  [**2139-11-4**] 00:34:15
Job#:  [**Job Number 16034**]
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Acute and subacute necrosis of liver,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Other pulmonary insufficiency, not elsewhere classified'}


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: Follow up for ascending aortic dilatation
with no symptoms.

PRESENT ILLNESS: Patient presented with a
complaint of flutter and palpitations.  An echo showed that
the patient had enlarged aorta.  CAT scan done following the
echo revealed a 5 cm ascending aortic aneurysm.  MIBI in
[**9-/2138**] showed an ejection fraction of 40 percent with an
inferior myocardial infarction and no ischemia.  Cardiac
catheterization showed an ejection fraction of 58 percent
with a large aortic aneurysm, distal right coronary artery
lesion of 70 percent, a D1 lesion of 40 percent, an LV EDP of
11.

MEDICAL HISTORY: Significant for hypertension, diabetes
mellitus type 2, GERD, chronic sinusitis, CAD status post
myocardial infarction, obesity.

MEDICATION ON ADMISSION: 

ALLERGIES: Patient states no known drug allergies, although
he also states that he could not tolerate statins.

PHYSICAL EXAM: 

FAMILY HISTORY: Mother is alive and well at 81.  Father died
of Alzheimer's at age 88.

SOCIAL HISTORY: Occupation:  Maintenance manager.  Lives
with wife.  Remote tobacco history; quit in [**2116**].  Occasional
alcohol use; 1 beer per week.  No other drug use. 

### Response:
{'Coronary atherosclerosis of native coronary artery,Acute kidney failure, unspecified,Cardiac complications, not elsewhere classified,Acute and subacute necrosis of liver,Infection and inflammatory reaction due to other vascular device, implant, and graft,Bacteremia,Other pulmonary insufficiency, not elsewhere classified'}
