CHIEF COMPLAINT: Type B aortic dissection

PRESENT ILLNESS: 51 M presents as an OSH transfer for Type B aortic
dissection and pulseless RLE.  Patient presented to [**Hospital6 31672**] with abdominal pain radiating to the back
associated with decreased sensation of his lower extremities.
The progressed to RLE paresis.  In the ED here, at [**Hospital1 18**] ,he was
found to have no pulses of his RLE with a cool foot.  CTA
demonstrates a type B
aortic dissection from the take-off L subclavian with a
concentric filling defect within the proximal left subclavian
artery.  The dissection extends throughout the thoracic aorta.
The true and false lumen enhance equally.  The dissection
extends
into the upper abdomen and extends into both iliac afteries.
There is moderate narrowing of the left EIA.  There is complete
occlusion of the distal right CIA.  There is reconstitution of
the distal R internal iliac artery.  There is small narrowing of
the lumen.  There is a dissection extending into the right renal
artery with enhancement of the right kidney.  The dissection
likely extends into the left kidney with minimal enhancement.
the left renal artery does reconstitute distal to the proximal
severe narrowing. He is taken emergently to the OR for repair.

MEDICAL HISTORY: None per patient (was not under care of physician [**Name Initial (PRE) **])

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VSS, afebrile

FAMILY HISTORY: unknown

SOCIAL HISTORY: 1ppd smoker. + EtOH (pt unclear on how much). Denies drug
use.
Dissection of aorta, thoracoabdominal,Acute respiratory failure,Acute kidney failure, unspecified,Rhabdomyolysis,Nontraumatic compartment syndrome of lower extremity,Unspecified essential hypertension,Tobacco use disorder,Other specified complications of procedures not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
Dsct of thoracoabd aorta,Acute respiratry failure,Acute kidney failure NOS,Rhabdomyolysis,Nontraum comp syn-low ex,Hypertension NOS,Tobacco use disorder,Oth spcf cmplc procd NEC,Abn react-procedure NEC,Accid in resident instit
Admission Date:  [**2149-3-13**]              Discharge Date:   [**2149-3-26**]

Date of Birth:  [**2097-11-13**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Type B aortic dissection

Major Surgical or Invasive Procedure:
[**2149-3-13**]:
1. Bilateral femoral artery exposure with catheter
    placement in the proximal thoracic aorta.
2. Endovascular aortic fenestration using Pioneer catheter.
3. Intravascular ultrasound.
4. Thoracic aortic stent graft.
5. Right renal artery stenting.
6. Right iliac, femoropopliteal thromboembolectomy.
7. Right lower extremity 4-compartment fasciotomy.
8. Right thigh complete fasciotomy.


History of Present Illness:
51 M presents as an OSH transfer for Type B aortic
dissection and pulseless RLE.  Patient presented to [**Hospital6 31672**] with abdominal pain radiating to the back
associated with decreased sensation of his lower extremities.
The progressed to RLE paresis.  In the ED here, at [**Hospital1 18**] ,he was
found to have no pulses of his RLE with a cool foot.  CTA
demonstrates a type B
aortic dissection from the take-off L subclavian with a
concentric filling defect within the proximal left subclavian
artery.  The dissection extends throughout the thoracic aorta.
The true and false lumen enhance equally.  The dissection
extends
into the upper abdomen and extends into both iliac afteries.
There is moderate narrowing of the left EIA.  There is complete
occlusion of the distal right CIA.  There is reconstitution of
the distal R internal iliac artery.  There is small narrowing of
the lumen.  There is a dissection extending into the right renal
artery with enhancement of the right kidney.  The dissection
likely extends into the left kidney with minimal enhancement.
the left renal artery does reconstitute distal to the proximal
severe narrowing. He is taken emergently to the OR for repair.


Past Medical History:
None per patient (was not under care of physician [**Name Initial (PRE) **])

Social History:
1ppd smoker. + EtOH (pt unclear on how much). Denies drug
use.

living independently prior to this admission

Family History:
unknown

Physical Exam:
VSS, afebrile

Gen: Thin, frail male, appearing older than stated age.
Card: RRR
Lungs: CTA bilat
Abd: Soft, no masses or tenderness
Neuro: Alert and oriented x 3, Full strength in the bilateral
upper
extremities. No movement in bilateral lower extremities - 0/5
strength. No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception in bilateral upper extremities.
No sensation, including proprioception in the bilateral lower
extremities. Senory level is just above umbilicus, approximately
T8-T9.
Extremities: Bilateral fasciotomy sites healing well - packed
with wet to dry.


Pertinent Results:
[**2149-3-13**] 12:41PM BLOOD Glucose-135* UreaN-10 Creat-1.0 Na-137
K-5.8* Cl-107 HCO3-20* AnGap-16
[**2149-3-14**] 01:45AM BLOOD Glucose-109* UreaN-12 Creat-1.0 Na-142
K-3.9 Cl-111* HCO3-24 AnGap-11
[**2149-3-15**] 01:39AM BLOOD Glucose-127* UreaN-20 Creat-1.9* Na-142
K-4.4 Cl-107 HCO3-21* AnGap-18
[**2149-3-15**] 02:15PM BLOOD Glucose-118* UreaN-24* Creat-2.6* Na-142
K-4.1 Cl-107 HCO3-21* AnGap-18
[**2149-3-16**] 11:33AM BLOOD Glucose-118* UreaN-37* Creat-4.1* Na-142
K-4.3 Cl-108 HCO3-23 AnGap-15
[**2149-3-17**] 12:19AM BLOOD Glucose-130* UreaN-48* Creat-5.2*# Na-140
K-4.3 Cl-106 HCO3-22 AnGap-16
[**2149-3-18**] 05:10AM BLOOD Glucose-120* UreaN-81* Creat-6.2* Na-138
K-5.1 Cl-103 HCO3-23 AnGap-17
[**2149-3-19**] 02:25AM BLOOD Glucose-116* UreaN-99* Creat-6.9* Na-137
K-5.2* Cl-102 HCO3-22 AnGap-18
[**2149-3-20**] 04:50AM BLOOD Glucose-108* UreaN-116* Creat-6.8* Na-137
K-4.8 Cl-99 HCO3-25 AnGap-18
[**2149-3-21**] 06:04AM BLOOD Glucose-117* UreaN-127* Creat-6.5* Na-135
K-4.3 Cl-97 HCO3-25 AnGap-17
[**2149-3-22**] 08:30AM BLOOD Glucose-110* UreaN-129* Creat-5.5* Na-136
K-4.2 Cl-94* HCO3-27 AnGap-19
[**2149-3-23**] 07:45AM BLOOD Glucose-120* UreaN-117* Creat-4.1*#
Na-135 K-4.4 Cl-96 HCO3-27 AnGap-16
[**2149-3-24**] 06:40AM BLOOD Glucose-112* UreaN-96* Creat-3.1* Na-136
K-4.7 Cl-99 HCO3-28 AnGap-14
[**2149-3-25**] 06:10AM BLOOD Glucose-104* UreaN-75* Creat-2.2* Na-136
K-4.6 Cl-100 HCO3-29 AnGap-12
[**2149-3-26**] 06:50AM BLOOD Glucose-112* UreaN-57* Creat-1.7* Na-139
K-5.0 Cl-102 HCO3-27 AnGap-15
[**2149-3-13**] 06:16AM BLOOD WBC-18.6* RBC-3.78* Hgb-12.0* Hct-36.9*
MCV-98 MCH-31.7 MCHC-32.4 RDW-12.2 Plt Ct-345
[**2149-3-14**] 01:45AM BLOOD WBC-10.0 RBC-2.94* Hgb-9.3* Hct-28.3*
MCV-96 MCH-31.6 MCHC-32.8 RDW-13.6 Plt Ct-208
[**2149-3-15**] 01:39AM BLOOD WBC-12.7* RBC-3.42* Hgb-10.6* Hct-32.4*
MCV-95 MCH-31.0 MCHC-32.7 RDW-14.8 Plt Ct-141*
[**2149-3-16**] 05:20AM BLOOD WBC-11.0 RBC-2.98* Hgb-9.2* Hct-28.4*
MCV-95 MCH-30.8 MCHC-32.3 RDW-14.7 Plt Ct-135*
[**2149-3-17**] 12:19AM BLOOD WBC-13.6* RBC-2.94* Hgb-8.8* Hct-27.9*
MCV-95 MCH-30.1 MCHC-31.7 RDW-14.4 Plt Ct-162
[**2149-3-18**] 05:10AM BLOOD WBC-11.7* RBC-2.85* Hgb-8.8* Hct-27.8*
MCV-98 MCH-30.9 MCHC-31.6 RDW-14.5 Plt Ct-168
[**2149-3-19**] 02:25AM BLOOD WBC-11.0 RBC-3.13* Hgb-9.6* Hct-30.4*
MCV-97 MCH-30.8 MCHC-31.8 RDW-14.5 Plt Ct-221
[**2149-3-20**] 04:50AM BLOOD WBC-12.4* RBC-3.07* Hgb-9.4* Hct-28.9*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.7 Plt Ct-287
[**2149-3-21**] 06:04AM BLOOD WBC-15.0* RBC-2.91* Hgb-9.0* Hct-27.1*
MCV-93 MCH-30.8 MCHC-33.2 RDW-13.6 Plt Ct-348
[**2149-3-22**] 08:30AM BLOOD WBC-16.5* RBC-3.18* Hgb-9.7* Hct-30.8*
MCV-97 MCH-30.6 MCHC-31.7 RDW-14.1 Plt Ct-446*
[**2149-3-23**] 07:45AM BLOOD WBC-16.3* RBC-3.03* Hgb-9.3* Hct-29.5*
MCV-97 MCH-30.8 MCHC-31.6 RDW-14.0 Plt Ct-552*
[**2149-3-24**] 06:40AM BLOOD WBC-17.6* RBC-2.99* Hgb-9.0* Hct-29.3*
MCV-98 MCH-30.2 MCHC-30.8* RDW-13.8 Plt Ct-645*
[**2149-3-25**] 06:10AM BLOOD WBC-18.4* RBC-3.03* Hgb-9.2* Hct-29.8*
MCV-99* MCH-30.4 MCHC-30.9* RDW-13.7 Plt Ct-730*
[**2149-3-26**] 06:50AM BLOOD WBC-18.8* RBC-2.69* Hgb-8.1* Hct-26.8*
MCV-100* MCH-30.2 MCHC-30.4* RDW-13.9 Plt Ct-744*

[**2149-3-13**] 12:41 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2149-3-15**]**

   MRSA SCREEN (Final [**2149-3-15**]):    No MRSA isolated.

DUPLEX DOP ABD/PEL LIMITED Study Date of [**2149-3-15**] 1:29 PM
Bilaterally symmetric systolic flow is visualized in right and
left main renal
arteries and intrarenal arteries with no son[**Name (NI) 5326**] evident
diastolic
flow, consistent with high-resistance parenchymal beds.
Appropriate flow noted
in bilateral main renal veins.

These findings suggest high parenchymal resistance may be due to
acute tubular
necrosis or other intrinsic renal interstitial disease or edema
in bilateral
kidneys.

UNILAT LOWER EXT VEINS LEFT Study Date of [**2149-3-22**] 11:57 AM
 No evidence of deep venous thrombosis in the left lower
extremity.


RENAL U.S. Study Date of [**2149-3-22**] 11:58 AM
 Patent renal arteries bilaterally with unchanged waveforms and
velocities. Unchanged echogenic appearance of both kidneys. No
hydronephrosis.

[**2149-3-22**] 5:54 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2149-3-24**]**

   URINE CULTURE (Final [**2149-3-24**]):    NO GROWTH.

[**2149-3-15**] 4:49 pm BLOOD CULTURE      Source: Line-rij.

                            **FINAL REPORT [**2149-3-21**]**

   Blood Culture, Routine (Final [**2149-3-21**]):    NO GROWTH.

[**2149-3-15**] 4:28 pm BLOOD CULTURE      Source: Line-16 guage.

                            **FINAL REPORT [**2149-3-21**]**

   Blood Culture, Routine (Final [**2149-3-21**]):    NO GROWTH.


Brief Hospital Course:
Mr. [**Known lastname 110706**] was admitted with an extensive type B dissection,
cool, pulseless RLE and compartment syndrome and was taken
emergently to the OR on [**3-13**] where he underwent:
1. Bilateral femoral artery exposure with catheter
    placement in the proximal thoracic aorta.
2. Endovascular aortic fenestration using Pioneer catheter.
3. Intravascular ultrasound.
4. Thoracic aortic stent graft.
5. Right renal artery stenting.
6. Right iliac, femoropopliteal thromboembolectomy.
7. Right lower extremity 4-compartment fasciotomy.
8. Right thigh complete fasciotomy.

Post operatively he was taken to the CVICU intubated. He was
montiored closely. His creatinine and CKs were rising and he was
started on a bicarb drip for rhabdomyolysis. On POD 1 it was
noted that he was not moving his lower extremities. His lumbar
drain remained in place and was functioning well. Neurosurgery
and neurology got involved and felt that the pt had a spinal
cord infarct around the level of t8-t9. With his rising SCr and
CKs, he was aggressively hydrated. On [**3-16**] a nephrology consult
was obtained for acute kidney injury. They suggested that we
diurese with lasix and continue to monitor, feeling that his
kidney's would recover. On [**3-19**] his lumbar drain was removed by
neurosurgery. His creatinine began trending down and his urine
output remained great. His meds were oralized and he tolerated a
regular diet. VAC dressings were applied to his fasciotomy
sites.  On [**3-20**] he was transfered to the VICU. He continued to
be monitored closely. He worked with PT and OT and began working
on transfers to a wheel chair. His creatinine continued to
improve and the renal team signed off, letting the patient know
that they expected him to make a full renal recovery.  On [**3-25**]
his indwelling foley catheter was removed and straight cath-ing
q4h was initiated. The pt began teaching on self-cathing. Of
note his white blood cell count was elevated, but there was no
source of infection found and no fevers. This was thought to be
benign.  Mr. [**Known lastname 110706**] was stable for discharge to a rehab
facility on [**3-26**]. He will continue to pt and ot and
catherterization training. He will have wound VACs to his
fasciotomy sites at rehab and will follow up in vascular clinic
in 1 week for wound checks.

Medications on Admission:
none

Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection
injection Injection [**Hospital1 **] (2 times a day).
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for hr<50, sbp<95.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): decrease dose as indicated.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for sob/wheezing.
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
10. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-9**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
11. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO HS
(at bedtime).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for constipation.
14. STRAIGHT CATH
EVERY 4 HOURS

please continue teaching pt to self straight cath


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
1. Type B thoracoabdominal aortic dissection, acute with
visceral and right leg malperfusion
2. Bilateral lower extremity paralysis secondary to spinal cord
infacrction at level of T8-T9
3. Acute kidney injury - resolving
4. HTN


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.([**Doctor Last Name **] lift - pt is paraplegic)


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Discharge Instructions

You were admitted with a large dissection in your aorta which
started high in the chest, and went down through your abdomen
and into the iliac arteries in your lower extremities. You
underwent emergent surgery where we put a stent graft into your
aorta, as well as your right renal artery, and opened your right
iliac and femoropopliteal artery to remove thrombus(clot).  You
then had fasciotomies of both legs (cuts to release pressure).
Unfortunately as a result of your dissection, you had a spinal
cord infarction and you're now paralyzed from the level of
T8-T9, down (your lower extremities).

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
??????	You were started on numerous new medications that you will
need to take for the rest of your life. Do not stop any
medications without talking to your PCP or Vascular doctor
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when leave:
You are going to a rehabilitation facility where you will get
PT/OT and medical care.

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:
	Your groin incisions 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
        Your leg fasciotomy sites will be dressed with wound
VACs to help with closure.

??????

What to report to office:
??????	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.


Followup Instructions:
Vascular Surgery
[**Hospital1 18**] [**Hospital Ward Name **] - [**Hospital Unit Name **] [**Hospital Unit Name **]
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD
Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2149-4-3**] 9:30



Completed by:[**2149-3-26**]
{'Dissection of aorta, thoracoabdominal,Acute respiratory failure,Acute kidney failure, unspecified,Rhabdomyolysis,Nontraumatic compartment syndrome of lower extremity,Unspecified essential hypertension,Tobacco use disorder,Other specified complications of procedures not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}


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: Type B aortic dissection

PRESENT ILLNESS: 51 M presents as an OSH transfer for Type B aortic
dissection and pulseless RLE.  Patient presented to [**Hospital6 31672**] with abdominal pain radiating to the back
associated with decreased sensation of his lower extremities.
The progressed to RLE paresis.  In the ED here, at [**Hospital1 18**] ,he was
found to have no pulses of his RLE with a cool foot.  CTA
demonstrates a type B
aortic dissection from the take-off L subclavian with a
concentric filling defect within the proximal left subclavian
artery.  The dissection extends throughout the thoracic aorta.
The true and false lumen enhance equally.  The dissection
extends
into the upper abdomen and extends into both iliac afteries.
There is moderate narrowing of the left EIA.  There is complete
occlusion of the distal right CIA.  There is reconstitution of
the distal R internal iliac artery.  There is small narrowing of
the lumen.  There is a dissection extending into the right renal
artery with enhancement of the right kidney.  The dissection
likely extends into the left kidney with minimal enhancement.
the left renal artery does reconstitute distal to the proximal
severe narrowing. He is taken emergently to the OR for repair.

MEDICAL HISTORY: None per patient (was not under care of physician [**Name Initial (PRE) **])

MEDICATION ON ADMISSION: none

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VSS, afebrile

FAMILY HISTORY: unknown

SOCIAL HISTORY: 1ppd smoker. + EtOH (pt unclear on how much). Denies drug
use. 

### Response:
{'Dissection of aorta, thoracoabdominal,Acute respiratory failure,Acute kidney failure, unspecified,Rhabdomyolysis,Nontraumatic compartment syndrome of lower extremity,Unspecified essential hypertension,Tobacco use disorder,Other specified complications of procedures not elsewhere classified,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}
