CHIEF COMPLAINT: 64 year old male w/ type A dissection

PRESENT ILLNESS: 64 y/o male with h/o hypertension, ETOHISM, colon CA, GERD,
depression pressent to ER c/o aching all over and back pain.  CT
scan at [**Hospital **] Hospital showed Type A dissection originating at
level of aortic root and extending to level of left renal
artery.
Dissections extends into both innominate artery and LCCA.  CT of
head does not show evidence of CVA. Required nipride and esmolol
in flight.

MEDICAL HISTORY: Type A Aortic Dissection, s/p Bentall [**2112-2-13**]
Post-op A-fib
Intracranial Bleed
Left Lower Lobe Infiltrate
Respiratory Failure

MEDICATION ON ADMISSION: amiodipine 5 mg Q am, Effexor XR 75 mg Zqm, Lisinoprim 10 mg Q
am, Mirrazapine 30 mg Qhs, MVI 1 tab Q am, Neurontin 400 mg TID,
Prilosec 20 mg Q am, Seroquel 100 mg TID, Dulcolax 5 mg Q 6 hr
prn, Ibuprofen 600 mg Q 6 hr prn, Maglox 30 cc Q 4 hours prn,
MOM 30 cc QD prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE: BP 118/56  HR 81 (SR)  RR 22 Sats 92%
General - trembling, appears anxious
HEENT - EOMI, PERRLA
Neck - Full ROM
Lungs - CTA
Cardio - Nl S1 and S2, no S3, S4, murmur
Abdomen - soft, nontender, well-healed lower abdominal incisions
Ext- no edema, warm

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: divorced Caucasian man, father of one son.
Dissection of aorta, thoracic,Intracerebral hemorrhage,Toxic encephalopathy,Cardiac arrest,Hematoma complicating a procedure,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Major depressive affective disorder, recurrent episode, unspecified,Acute venous embolism and thrombosis of deep veins of upper extremity,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified alcohol dependence, in remission,Fever, unspecified,Anxiety state, unspecified,Leukocytosis, unspecified,Thrombocytopenia, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Acquired absence of intestine (large) (small),Do not resuscitate status,Personal history of malignant neoplasm of large intestine,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use
Dsct of thoracic aorta,Intracerebral hemorrhage,Toxic encephalopathy,Cardiac arrest,Hematoma complic proc,Acute kidney failure NOS,Delirium d/t other cond,Ac posthemorrhag anemia,Recurr depr psychos-unsp,Ac DVT/embl up ext,Surg comp-peri vasc syst,Hyperosmolality,Hypertension NOS,Alcoh dep NEC/NOS-remiss,Fever NOS,Anxiety state NOS,Leukocytosis NOS,Thrombocytopenia NOS,Esophageal reflux,Hx-prostatic malignancy,Acquire absnce intestine,Do not resusctate status,Hx of colonic malignancy,Abn react-anastom/graft,Adv eff anticoagulants
Admission Date:  [**2112-2-13**]              Discharge Date:   [**2112-3-9**]

Date of Birth:  [**2047-8-23**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 922**]
Chief Complaint:
64 year old male w/ type A dissection

Major Surgical or Invasive Procedure:
[**2112-3-4**] Percutaneous tracheostomy tube and percutaneous
endoscopic gastrotomy tube

[**2112-2-17**] Sternal washout and removal of packing and
closure

[**2112-2-14**] 1. Mediastinal re-exploration.
2. Evacuation of hematoma and ongoing blood.
3. Oversewing of left ventricular laceration.
4. Cardiopulmonary resuscitation.

[**2112-2-13**] 1. Bentall procedure with a 27-mm St. [**Male First Name (un) 923**] mechanical
    composite valve graft with coronary button
    reimplantation.
2. Ascending aortic replacement, ascending aorta and hemi
    arch replacement, with a 28-mm Dacron tube graft using
    deep hypothermic circulatory arrest.  The composite
    valve graft data is the following:  Reference number
    [**Serial Number 31948**], serial number [**Serial Number 31949**]. The Dacron tube
    graft data is the following:  Vascutek Gelweave graft
    catalog number [**Numeric Identifier 31950**], lot number [**Serial Number 31951**], serial
    number [**Serial Number 31952**]


History of Present Illness:
64 y/o male with h/o hypertension, ETOHISM, colon CA, GERD,
depression pressent to ER c/o aching all over and back pain.  CT
scan at [**Hospital **] Hospital showed Type A dissection originating at
level of aortic root and extending to level of left renal
artery.
Dissections extends into both innominate artery and LCCA.  CT of
head does not show evidence of CVA. Required nipride and esmolol
in flight.


Past Medical History:
Type A Aortic Dissection, s/p Bentall [**2112-2-13**]
Post-op A-fib
Intracranial Bleed
Left Lower Lobe Infiltrate
Respiratory Failure

PMH:
colon cancer, EtOH dependence, hypertension, ?liver disease, s/p
partial colectomy, TURP


Social History:
divorced Caucasian man, father of one son.


Family History:
non-contributory

Physical Exam:
PE: BP 118/56  HR 81 (SR)  RR 22 Sats 92%
General - trembling, appears anxious
HEENT - EOMI, PERRLA
Neck - Full ROM
Lungs - CTA
Cardio - Nl S1 and S2, no S3, S4, murmur
Abdomen - soft, nontender, well-healed lower abdominal incisions
Ext- no edema, warm


Pertinent Results:
ECHO [**2-17**]
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45-50%). The right ventricular cavity is
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The appearance of the
ascending aorta is consistent with a normal tube graft measuring
31 mm in diameter. The aortic arch is mildly dilated. The
descending thoracic aorta is mildly dilated. A mobile density is
seen in the aortic arch and descending aorta consistent with an
intimal flap/aortic dissection. There is flow in the true lumen
with a small communication with the false lumen just distal to
the aortic arch. A bileaflet mechanical aortic valve prosthesis
is present. The aortic valve prosthesis leaflets appear to move
normally. The transaortic gradient is normal for this
prosthesis. (Peak/mean gradients are 8/4 mmHg at a CO of 5
L/min). There is no aortic valve stenosis. Washing jets typical
for a mechanical prosthesis are seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results at the time of the study.
ECHO [**2112-2-26**]
No spontaneous echo contrast or mass/thrombus are seen in the
body of the left atrium or left atrial appendage. Mild
spontaneous echo contrast without thrombus is seen in the body
of the right atrium. The interatrial septum is aneurysmal.
Overall left ventricular systolic function is normal (LVEF>55%).
There are simple atheroma in the descending thoracic aorta. A
mobile density is seen in the aortic arch extending to at least
50 cm in the descending aorta consistent with an intimal
flap/aortic dissection. There is flow in both lumens. A
bileaflet aortic valve prosthesis is present which is
well-seated with normal leaflet motion and washing jets (normal
for mechanical prosthesis). The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.

IMPRESSION: No thrombus in the atria or atrial appendages.
Aortic dissection from the arch to the descending aorta (at
least 50 cm from the incisors). Well-seated bileaflet aortic
valve with normal leaflet motion.

Head CT [**2112-2-24**]
IMPRESSION:

1. Tiny focus of left acute subarachnoid hemorrhage.

2. A 2.1 x 2.3 cm left basal ganglia acute intraparenchymal
hematoma with
mild surrounding edema and mass effect on the left lateral
ventricle, with a
few hypodense foci which may relate to ongoing hemorrhage.
Correlate
clinically to decide on further work up for underlying
vascular/neopalstic
cause. Follwo up as clinically indicated.

Head CT [**2112-2-25**]
IMPRESSION:

Interval slight increase in the size of a left basal ganglia
intraparenchymal
hemorrhage, which measures 2.2 x 3.2 cm today.
Head CT [**2112-2-26**]
IMPRESSION:

Slight increase in size of left basal ganglia hemorrhage
compared to [**2-25**].





Brief Hospital Course:
Mr [**Known lastname 31469**] was taken emergently to the OR of repair of type A
dissection on [**2112-2-14**] Mr. [**Known lastname 31469**] [**Last Name (Titles) 1834**] a Bentall procedure
(#27 st. [**Male First Name (un) **] mechanical valve)/ascending aorta and hemiarch
replacement (#28 Dacron); re-exploration for bleeding on [**2112-2-14**]
and chest left open; Chest ultimately closed on [**2112-2-17**]. He
required multiple blood products throughout his surgical course.
Remained intubated until [**2112-2-21**]. Upon extubation was awake,
confused and moving all extremities. He developed upper
extremity swelling and an ultrasound was performed. This
revealed a partially occlusive thrombus in the left internal
jugular, left
subclavian, left axillary and left brachial veins. A partially
occlusive thrombus within the right internal jugular vein and
near total occlusion of the left basilic vein was also noted.
There were also partially occlusive thrombus in the right
basilic and cephalic veins as well. A Heparin induced
thrombocytopenia assay was sent and was negative. He continued
on coumadin and heparin for anticoagulation for his mechanical
aortic valve and upper extremity deep vein thrombosis. On [**2-24**]
he had worsening mental status and stopped moving the RUE and
only responded to pain stimuli. Head CT showed approx 2x1.5cm
Left basal ganglia intraparenchymal hemorrhage. He was never
hypertensive. Neurosurgery was called but no neurosurgical
intervention was indicated, they advised the team to reverse him
with protamine and FFP, and keep BPs controlled, although per
report they were already under control.  He was re-intubated.
Echo on [**2-26**] revealed no thrombus in the atria.  He was
successfully cardioverted on [**2112-2-26**] for atrial flutter.  He was
cardio-verted again on [**2112-2-28**] for a-flutter and amiodarone was
increased.  White blood cell count continued to rise.  He was
pan-cultured and empiric antibiotics were initiated for
persistent LLL infiltrate/suspected ventilator associated
pneumonia(VAP).  He was ultimately treated with vancomycin and
cefepime for VAP with resolution. Head CT [**3-1**] revealed enlarging
bleed- anti-coagulation was held.
Psychiatry consulted for delirium and medication adjustments
were recommended.  He received a Dob Hoff tube and tolerated
tube feeds at goal. EEG showed abnormalities due to slowing of
the background rhythm suggestive of a moderate to severe
encephalopathy. He [**Month/Day (1) 1834**] bronchoscopy on [**2-28**] for copious
secretions with good results. He received a trach and PEG on
[**2112-3-4**] for long term feeding and respiratory care. Repeat CT of
the brain revealed the bleed to be stable.  Coumadin was resumed
on [**2112-3-4**] for the mechanical valve (7 days post bleed per
neurology recommendation). His goal INR is 2.5 for his
mechanical aortic valve with no heparin bridge per neurology. He
was weaned to trach collar which he tolerated well. Tube feeds
were continued without significant residuals. Mr. [**Known lastname 31469**] remained
stable however vegetative and was transferred to [**Hospital **]
Rehabilitation on [**2112-3-9**] for further care. Follow-up has been
scheduled.

Medications on Admission:
amiodipine 5 mg Q am, Effexor XR 75 mg Zqm, Lisinoprim 10 mg Q
am, Mirrazapine 30 mg Qhs, MVI 1 tab Q am, Neurontin 400 mg TID,
Prilosec 20 mg Q am, Seroquel 100 mg TID, Dulcolax 5 mg Q 6 hr
prn, Ibuprofen 600 mg Q 6 hr prn, Maglox 30 cc Q 4 hours prn,
MOM 30 cc QD prn

Discharge Medications:
1. Insulin Sliding Scale
Insulin SC  (per Insulin Flowsheet)
      Sliding Scale
2. amiodarone 200 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
Tablet(s)
3. metoprolol tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO TID
(3 times a day).
4. atorvastatin 10 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at
bedtime).
5. thiamine HCl 100 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
8. folic acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

9. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1)  PO BID (2
times a day).
10. therapeutic multivitamin     Liquid [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
11. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
[**Last Name (STitle) **]: 4-6 Puffs Inhalation Q4H (every 4 hours).
12. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
13. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) Solution
PO Q4H (every 4 hours) as needed for temperature >38.0.
14. warfarin 2.5 mg Tablet [**Hospital1 **]: Dose for goal INR of 2.5 Tablet
PO ONCE (Once): Mechanical AVR. Monitor daily PT/INR.
15. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. HydrALAzine 10-20 mg IV Q4H:PRN SBP>140
17. magnesium hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Location (un) 86**]

Discharge Diagnosis:
Type A Aortic Dissection, s/p Bentall [**2112-2-13**]
Post-op A-fib
Intracranial Bleed
Upper extremity deep vein thrombosis
Left Lower Lobe Infiltrate
Respiratory Failure
PMH:
colon cancer, EtOH dependence, hypertension, ?liver disease, s/p
partial colectomy, TURP


Discharge Condition:
Vegetative state
Mobility: Assisted range of motion. Right side grimaces to pain,
left side withdraws to pain.
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema


Discharge Instructions:
1) Please shower/bath daily including washing incisions gently
with mild soap, no baths or swimming until cleared by surgeon.
Evaluate incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart
4) No driving.
5) No lifting more than 10 pounds for 10 weeks
6) Coumadin for mechanical AVR. Goal INR is 2.5. Monitor daily
INR and dose accordingly. No heparin bridge recommended per the
neurology service.
7) Daily tracheostomy care
8) Goal systolic blood pressure 120-130mmHg.
9) Please call with any questions or concerns [**Telephone/Fax (1) 170**]

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**


Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] Tuesday [**2112-4-5**] 1:15PM
Cardiologist: Will need referral to cardiologist via primary
care physician as an outpatient.

Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10508**] in [**3-1**] weeks
Neurologist [**Doctor First Name **] [**Doctor Last Name **] as needed [**Telephone/Fax (1) 2574**]. Please
call for appointment.

**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**

Labs: PT/INR for Coumadin ?????? indication - mechanical AVR
Goal INR 2.5
First draw [**2112-3-10**]
Will need coumadin follow-up arranged through Dr. [**Last Name (STitle) **] when
discharged from rehab.



Completed by:[**2112-3-9**]
{'Dissection of aorta, thoracic,Intracerebral hemorrhage,Toxic encephalopathy,Cardiac arrest,Hematoma complicating a procedure,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Major depressive affective disorder, recurrent episode, unspecified,Acute venous embolism and thrombosis of deep veins of upper extremity,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified alcohol dependence, in remission,Fever, unspecified,Anxiety state, unspecified,Leukocytosis, unspecified,Thrombocytopenia, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Acquired absence of intestine (large) (small),Do not resuscitate status,Personal history of malignant neoplasm of large intestine,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use'}


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: 64 year old male w/ type A dissection

PRESENT ILLNESS: 64 y/o male with h/o hypertension, ETOHISM, colon CA, GERD,
depression pressent to ER c/o aching all over and back pain.  CT
scan at [**Hospital **] Hospital showed Type A dissection originating at
level of aortic root and extending to level of left renal
artery.
Dissections extends into both innominate artery and LCCA.  CT of
head does not show evidence of CVA. Required nipride and esmolol
in flight.

MEDICAL HISTORY: Type A Aortic Dissection, s/p Bentall [**2112-2-13**]
Post-op A-fib
Intracranial Bleed
Left Lower Lobe Infiltrate
Respiratory Failure

MEDICATION ON ADMISSION: amiodipine 5 mg Q am, Effexor XR 75 mg Zqm, Lisinoprim 10 mg Q
am, Mirrazapine 30 mg Qhs, MVI 1 tab Q am, Neurontin 400 mg TID,
Prilosec 20 mg Q am, Seroquel 100 mg TID, Dulcolax 5 mg Q 6 hr
prn, Ibuprofen 600 mg Q 6 hr prn, Maglox 30 cc Q 4 hours prn,
MOM 30 cc QD prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PE: BP 118/56  HR 81 (SR)  RR 22 Sats 92%
General - trembling, appears anxious
HEENT - EOMI, PERRLA
Neck - Full ROM
Lungs - CTA
Cardio - Nl S1 and S2, no S3, S4, murmur
Abdomen - soft, nontender, well-healed lower abdominal incisions
Ext- no edema, warm

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: divorced Caucasian man, father of one son. 

### Response:
{'Dissection of aorta, thoracic,Intracerebral hemorrhage,Toxic encephalopathy,Cardiac arrest,Hematoma complicating a procedure,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Acute posthemorrhagic anemia,Major depressive affective disorder, recurrent episode, unspecified,Acute venous embolism and thrombosis of deep veins of upper extremity,Peripheral vascular complications, not elsewhere classified,Hyperosmolality and/or hypernatremia,Unspecified essential hypertension,Other and unspecified alcohol dependence, in remission,Fever, unspecified,Anxiety state, unspecified,Leukocytosis, unspecified,Thrombocytopenia, unspecified,Esophageal reflux,Personal history of malignant neoplasm of prostate,Acquired absence of intestine (large) (small),Do not resuscitate status,Personal history of malignant neoplasm of large intestine,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anticoagulants causing adverse effects in therapeutic use'}
