CHIEF COMPLAINT: Descending aortic ulcer

PRESENT ILLNESS: 74M w/ PVD s/p aorto-bifem by [**Doctor Last Name **] in '[**96**], ESRD on HD,
about a week ago during dialysis mentioned that he had been
having some chest and back pain, not too severe that comes and
goes. IN [**Hospital1 **] they got a CT scan to r/o any acute pathology
and found a descending aortic ulcer, 18mm, around T10-T11. Was
sent
into [**Location (un) 86**] to [**Hospital1 2177**] (their referring center) for further BP and
surgical management, then tx here to [**Hospital1 18**] because is a patient
of Dr[**Name (NI) 5695**]. Currently feels well without any complaints.
Denies any n/v/f/c/d/c/SP or BA pain currently.

MEDICAL HISTORY: Diastolic CHF (normal LVEF on TTE in [**12/2198**])
moderate mitral regurgitation
COPD
PVD
L renal artery stenosis
Chronic kidney disease (baseline creatinine [**3-25**])
Anemia of chronic kidney disease
hx H.pylori infection
hx of cellulitis
Gout
Colonic polyps
h/o herpes zoster
Claudication
Carotid Stenosis

MEDICATION ON ADMISSION: norvasc 10; Hydralazine 25'"; ASA 81, allopurinol 100',
atorvastatin 20, imdur 30', iron 325', folic acid, (recently on
prednisone 20' for gout flare)

ALLERGIES: Lisinopril / Cozaar / Losartan Potassium

PHYSICAL EXAM: T: 99,3  P: 76  BP: 118/42  RR: 13 Spo2 93%
Gen: NAD
Neuro: Alert and oriented x 3
Resp: CTA b/l
CV: RRR
Abd: soft, nt, nd
Pulses: palpable through-out
Left AV fistual +thrill/bruit

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives in [**Hospital1 392**] alone, has meals delivered. Quit smoking 3
months ago, used to smoke +1ppd x 50 yrs, no etoh x many years,
no drugs.
Thoracic aneurysm without mention of rupture,End stage renal disease,Diastolic heart failure, unspecified,Other primary cardiomyopathies,Anemia in chronic kidney disease,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified
Thoracic aortic aneurysm,End stage renal disease,Diastolc hrt failure NOS,Prim cardiomyopathy NEC,Anemia in chr kidney dis,Gout NOS,Chr airway obstruct NEC,Periph vascular dis NOS
Admission Date:  [**2200-1-23**]              Discharge Date:   [**2200-1-31**]

Date of Birth:  [**2125-5-11**]             Sex:   M

Service: SURGERY

Allergies:
Lisinopril / Cozaar / Losartan Potassium

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Descending aortic ulcer


Major Surgical or Invasive Procedure:
Descending aortic ulcer s/p TAG [**2200-1-28**]


History of Present Illness:
74M w/ PVD s/p aorto-bifem by [**Doctor Last Name **] in '[**96**], ESRD on HD,
about a week ago during dialysis mentioned that he had been
having some chest and back pain, not too severe that comes and
goes. IN [**Hospital1 **] they got a CT scan to r/o any acute pathology
and found a descending aortic ulcer, 18mm, around T10-T11. Was
sent
into [**Location (un) 86**] to [**Hospital1 2177**] (their referring center) for further BP and
surgical management, then tx here to [**Hospital1 18**] because is a patient
of Dr[**Name (NI) 5695**]. Currently feels well without any complaints.
Denies any n/v/f/c/d/c/SP or BA pain currently.


Past Medical History:
Diastolic CHF (normal LVEF on TTE in [**12/2198**])
moderate mitral regurgitation
COPD
PVD
L renal artery stenosis
Chronic kidney disease (baseline creatinine [**3-25**])
Anemia of chronic kidney disease
hx H.pylori infection
hx of cellulitis
Gout
Colonic polyps
h/o herpes zoster
Claudication
Carotid Stenosis

Social History:
Lives in [**Hospital1 392**] alone, has meals delivered. Quit smoking 3
months ago, used to smoke +1ppd x 50 yrs, no etoh x many years,
no drugs.


Family History:
Non-contributory

Physical Exam:
T: 99,3  P: 76  BP: 118/42  RR: 13 Spo2 93%
Gen: NAD
Neuro: Alert and oriented x 3
Resp: CTA b/l
CV: RRR
Abd: soft, nt, nd
Pulses: palpable through-out
Left AV fistual +thrill/bruit


Pertinent Results:
[**2200-1-31**] 05:25AM BLOOD WBC-22.5* RBC-3.11* Hgb-10.8* Hct-31.4*
MCV-101* MCH-34.7* MCHC-34.4 RDW-15.6* Plt Ct-421
[**2200-1-31**] 05:25AM BLOOD Plt Ct-421
[**2200-1-31**] 05:25AM BLOOD Glucose-103 UreaN-53* Creat-6.6*# Na-133
K-4.4 Cl-91* HCO3-28 AnGap-18
[**2200-1-31**] 05:25AM BLOOD Calcium-8.5 Phos-4.9* Mg-1.8
[**2200-1-29**] 01:41AM BLOOD calTIBC-185* Ferritn-945* TRF-142*

Name:  [**Known lastname 32335**], [**Known firstname 412**]
Unit No:  [**Numeric Identifier 32336**]
Service:
Date:  [**2200-1-29**]
Date of Birth:  [**2125-5-11**]
Sex:  M
Surgeon:

CO-SURGEONS:  Drs. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 914**] and  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].

ASSISTANTS:  Drs. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] and  [**First Name4 (NamePattern1) 11805**] [**Last Name (NamePattern1) 29316**].

PREOPERATIVE DIAGNOSES:
1. Symptomatic descending thoracic aortic penetrating
    ulcer.
2. Hypertension.
3. Chronic renal failure on hemodialysis.
4. Peripheral vascular disease status post an
    aortobifemoral bypass graft by Dr. [**Last Name (STitle) **].

PROCEDURES:
1. Repair of descending thoracic aortic penetrating ulcer
    with [**Doctor Last Name 4726**] TAG Endo graft 34 x 100 mm.  The [**Doctor Last Name 4726**] graft
    data is the following; catalog number
    [**Serial Number 32337**], lot number  [**Serial Number 32338**].
2. Thoracic aortography.
3. Repair of aortobifemoral bypass graft.

The patient is a 77-year-old gentleman with history of back
pain and thoracic CT scan showed a penetrating
atherosclerotic ulcer with no associated intramural hematoma.
The patient had continued back pain despite good medical
management of his hypertension.  The patient was referred to
Dr. [**Last Name (STitle) **] for consideration of repair.  After evaluating
the patient, Dr. [**Last Name (STitle) **] asked me to consider a combined
approach for an Endo graft repair of the descending thoracic
aortic pathology.  The patient understood the risks, benefits
and possible alternatives including but not limited to
bleeding, infection, myocardial infarction, stroke, death,
renal and  pulmonary insufficiency as well as the
possibility of paraplegia and blood transfusion and future
operations on his aorta and agreed to proceed. All questions
were answered to his satisfaction prior to proceeding with the
surgery.

OPERATIVE FINDINGS:  Thoracic aortography in a cross-table
lateral position showed that there was a fairly large
penetrating ulcer in the mid descending thoracic aorta.
Thoracic aortography performed after deployment of the stent
graft showed that there was initially a type 1 Endo leak, but
after additional balloon profiling a repeat thoracic
aortography showed that there was no type 1 Endo leak and
good positioning of the prosthesis and no filling of the
penetrating ulcer.

DESCRIPTION OF PROCEDURE IN DETAIL:  After informed consent
was obtained, the patient brought in the operating room and
placed in supine position.  General endotracheal tube
anesthesia was achieved without difficulty as well as full
hemodynamic monitoring. The patient's abdomen, chest and
groins, and upper legs were prepped and draped in the usual
sterile fashion.  A 9-French left femoral venous sheath was
placed for anesthesia due to the inability to place a line in
the neck.  Once this was done the right femoral dissection
was performed exposing the native circulation (common femoral
artery) as well as the right limb of the aortobifemoral both
proximally and distally.  Proximal and distal control was
obtained of the graft in the right groin. The left femoral
artery was then accessed using a micropuncture technique and
a 5-French sheath was placed in the left limb of the
aortobifemoral and a pigtail catheter advanced over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
wire into the descending thoracic aorta under fluoroscopic
guidance.  An 8-French sheath was then inserted after
heparinizing the patient with 5000 units of heparin into the
right limb of the aortobifemoral. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] wire was then
advanced into the descending thoracic aorta, Kumpe catheter
was exchanged over the [**Location (un) **] wire and a stiff Lunderquist
wire was then placed over the Kumpe catheter into the proximal
descending thoracic aorta.  The Kumpe catheter was withdrawn
and serial dilators were then used to dilate the right limb
of the aortobifemoral up to a 24-French dilator.  Initially
we had planned to use a 37 x 100 mm [**Doctor Last Name 4726**] TAG device, however,
the
24-French sheath that was necessary to deliver this would not
advance into the right limb of the aortobifemoral graft and
therefore, we chose to use a 34 x 100 mm graft and the 22-French
sheath was then advanced over the Lunderquist wire into the
right limb of the aortobifemoral bypass graft. Once this was
done the 34 x 10 [**Doctor Last Name 4726**] TAG device was then advanced over the
Lunderquist wire with some difficulty, but ultimately passed
fairly smoothly.  The [**Doctor Last Name 4726**] TAG  device was positioned in the
descending thoracic aorta and aortography was then performed
in the cross-table lateral orientation to observe the
posteriorly directed penetrating ulcer.  Once the ulcer was
identified the TAG device was then positioned so that the
ulcer was in the middle of the device.  We then deployed the
TAG graft and profile ballooned the device with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32339**]
balloon.  Once this was done, repeat thoracic aortography was
performed which showed a type 1 Endo leak from the proximal
seal zone, we therefore profile ballooned the proximal
landing zone several times and repeated the thoracic
aortography which revealed that there was no evidence of an
Endo leak at this time.  All catheters and sheaths were then
removed from the right limb of the aortobifemoral graft and
the graft was then closed with a running 5-0 Prolene stitch.
The left-sided femoral sheath was then removed. The patient
was then taken to the cardiothoracic surgical intensive care
unit in stable condition.

Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 914**] were co-surgeon's on this case
due to the complex nature of the disease process.  The new
technology
of stent grafting requires two separate but equally important
skill sets of
both the cardiothoracic surgeon and vascular surgeon to
safely facilitate deployment of these grafts.





Brief Hospital Course:
[**2200-1-23**]
Transferred from OSH for descending aortic ulcer. BP stable.
Repeat CT scan done on transfer. Nephrology consulted for ESRD
on HD.

[**2200-1-24**] Vitals, BP stable. CTA showed aortic ulcer. Underwent HD.
Pre-op'ed for an Endovascular repair.

[**2200-1-25**]
VSS. Cardiac Surgery consulted, recommended echo and pre-op
cardiac clearance. Pt continued on HD MWF. Renal following

[**2200-1-26**]
Vitals stable. No acute events. OR scheduled for Tuesday [**2200-1-28**].
Close monitoring for BP control

[**2200-1-27**]
Pre-op'ed for Endovascular repair of thoracic aneurysm. Pain
management for Left flank pain. HD today. No acute events.

[**2200-1-28**]
To OR (see attached op report). Tolerated procedure well without
complications. Transfer to ICU on nitro gtt.

[**2200-1-29**]
Vitals table. Neo weaned. Lopressor po started. Transferred to
VICU. Lumbar drain intact. Left groin site stable without
hematoma or bleed.

[**2200-1-30**]
Stable on floor status. Cleared by physical therapy. OOB
ambulating. Dispo planning.

[**2200-1-31**]
DC home without need for VNA services.

Medications on Admission:
norvasc 10; Hydralazine 25'"; ASA 81, allopurinol 100',
atorvastatin 20, imdur 30', iron 325', folic acid, (recently on
prednisone 20' for gout flare)

Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Methylprednisolone 2 mg Tablet Sig: One (1) Tablet PO once ()
for 1 doses: Take 6mg (three tablets) on [**2200-1-31**], Take 4mg (2
tablets) on [**2200-2-1**], Take 2mg (1tablet) on [**2200-2-2**] take 1mg ([**1-22**]
a tablet). Then stop .
Disp:*8 Tablet(s)* Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Take as needed at home
.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
hx: Cardiomyopathy (transient EF now normal 60%)
Hypertension
CRF on HD
Gout


Discharge Condition:
Stable


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Thoracic Aneurysm Repair Discharge Instructions

Medications:
??????	Take Aspirin 81mg once daily
??????	Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	Call and schedule an appointment to be seen in [**4-27**] weeks for
post procedure check and CTA

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:

Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2200-2-27**] 8:00

Please call Dr.[**Name (NI) 5695**] office [**Telephone/Fax (1) 3121**] to arrange an
office visit in 2 weeks. You will have a CTA prior to your
office visit.



Completed by:[**2200-1-31**]
{'Thoracic aneurysm without mention of rupture,End stage renal disease,Diastolic heart failure, unspecified,Other primary cardiomyopathies,Anemia in chronic kidney disease,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified'}


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: Descending aortic ulcer

PRESENT ILLNESS: 74M w/ PVD s/p aorto-bifem by [**Doctor Last Name **] in '[**96**], ESRD on HD,
about a week ago during dialysis mentioned that he had been
having some chest and back pain, not too severe that comes and
goes. IN [**Hospital1 **] they got a CT scan to r/o any acute pathology
and found a descending aortic ulcer, 18mm, around T10-T11. Was
sent
into [**Location (un) 86**] to [**Hospital1 2177**] (their referring center) for further BP and
surgical management, then tx here to [**Hospital1 18**] because is a patient
of Dr[**Name (NI) 5695**]. Currently feels well without any complaints.
Denies any n/v/f/c/d/c/SP or BA pain currently.

MEDICAL HISTORY: Diastolic CHF (normal LVEF on TTE in [**12/2198**])
moderate mitral regurgitation
COPD
PVD
L renal artery stenosis
Chronic kidney disease (baseline creatinine [**3-25**])
Anemia of chronic kidney disease
hx H.pylori infection
hx of cellulitis
Gout
Colonic polyps
h/o herpes zoster
Claudication
Carotid Stenosis

MEDICATION ON ADMISSION: norvasc 10; Hydralazine 25'"; ASA 81, allopurinol 100',
atorvastatin 20, imdur 30', iron 325', folic acid, (recently on
prednisone 20' for gout flare)

ALLERGIES: Lisinopril / Cozaar / Losartan Potassium

PHYSICAL EXAM: T: 99,3  P: 76  BP: 118/42  RR: 13 Spo2 93%
Gen: NAD
Neuro: Alert and oriented x 3
Resp: CTA b/l
CV: RRR
Abd: soft, nt, nd
Pulses: palpable through-out
Left AV fistual +thrill/bruit

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives in [**Hospital1 392**] alone, has meals delivered. Quit smoking 3
months ago, used to smoke +1ppd x 50 yrs, no etoh x many years,
no drugs. 

### Response:
{'Thoracic aneurysm without mention of rupture,End stage renal disease,Diastolic heart failure, unspecified,Other primary cardiomyopathies,Anemia in chronic kidney disease,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Peripheral vascular disease, unspecified'}
