CHIEF COMPLAINT: Abdominal Pain

PRESENT ILLNESS: HPI: 57F heavy smoker with recent admission [**2112-10-1**] - [**2112-10-3**]
with
chest and abdominal pain and odynophagia who was found to have
circumferential mural thrombus in the supra-renal aorta on cross
sectional imaging. At that time the aortic pathology was though
to be chronic. Ultimately, her pain resolved with the initiation
of a PPI and GI cocktail, and was discharged home after a 3 day
hospital stay. On [**10-6**] she again presented to an OSH with
abdominal pain where a CT abdomen was done which showed an
aortic
dissection. She was emergently transferred to [**Hospital1 18**] where a CTA
of the torso confirmed an aortic dissection of the descending
thoracic aorta (at the level of the left pulmonary vein) to just
below the takeoff of the celiac. At the time of presentation to
[**Hospital1 18**] she was not complaining of any abdominal pain and her
vascular exam was unchanged (palpable bilateral upper and lower
extremity pulses).
.

MEDICAL HISTORY: Sinusitis

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  last discharge.
1. Omeprazole 40 mg PO DAILY
2. Donnatol 10 mL PO BID:PRN abdominal pain
3. Atorvastatin 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. DiCYCLOmine 10 mg PO QID

ALLERGIES: Ativan

PHYSICAL EXAM: Physical Exam:
Alert and oriented x 3
VS:BP 110' 70's         HR  70-80's       RR stable / AF
Carotids: 2+, no bruits or JVD
COR; S1 S2
Resp: Lungs clear
Abd: Soft, non tender / obese / (+ BM)
Ext: Pulses:  palpable DP /PT bilaterally /Feet warm,  well
perfused.  No open areas
Incisions: CDI
Wounds: Left Right groin puncture site: Dressing clean dry and
intact. Soft, no hematoma or ecchymosis
Lumbar drian site intact / no drainage / no fluctuance

FAMILY HISTORY: 89yo father with CHF

SOCIAL HISTORY: Married to retired police officer, 5 children. Current [**1-25**] PPD
smoker with > 30 yr smoking history. No alcohol or IVDA.
Dissection of aorta, thoracoabdominal,Embolism and thrombosis of thoracic aorta,Urinary tract infection, site not specified,Drug-induced delirium,Tobacco use disorder,Obesity, unspecified,Headache,Body Mass Index 37.0-37.9, adult,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Examination of participant in clinical trial
Dsct of thoracoabd aorta,Thoracic aortic embolism,Urin tract infection NOS,Drug-induced delirium,Tobacco use disorder,Obesity NOS,Headache,BMI 37.0-37.9,adult,Adv eff analgesics NEC,Exam-clincal trial
Admission Date:  [**2112-10-6**]              Discharge Date:   [**2112-10-14**]

Date of Birth:  [**2055-4-7**]             Sex:   F

Service: SURGERY

Allergies:
Ativan

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Abdominal Pain

Major Surgical or Invasive Procedure:
[**2112-10-10**] Thoracic Endovascular Aortic Aneurysm Repair


History of Present Illness:
HPI: 57F heavy smoker with recent admission [**2112-10-1**] - [**2112-10-3**]
with
chest and abdominal pain and odynophagia who was found to have
circumferential mural thrombus in the supra-renal aorta on cross
sectional imaging. At that time the aortic pathology was though
to be chronic. Ultimately, her pain resolved with the initiation
of a PPI and GI cocktail, and was discharged home after a 3 day
hospital stay. On [**10-6**] she again presented to an OSH with
abdominal pain where a CT abdomen was done which showed an
aortic
dissection. She was emergently transferred to [**Hospital1 18**] where a CTA
of the torso confirmed an aortic dissection of the descending
thoracic aorta (at the level of the left pulmonary vein) to just
below the takeoff of the celiac. At the time of presentation to
[**Hospital1 18**] she was not complaining of any abdominal pain and her
vascular exam was unchanged (palpable bilateral upper and lower
extremity pulses).
.


Past Medical History:
Sinusitis

Past Surgical History:
Lap CCY, Tubal Ligation

Social History:
Married to retired police officer, 5 children. Current [**1-25**] PPD
smoker with > 30 yr smoking history. No alcohol or IVDA.


Family History:
89yo father with CHF

Physical Exam:
Physical Exam:
Alert and oriented x 3
VS:BP 110' 70's         HR  70-80's       RR stable / AF
Carotids: 2+, no bruits or JVD
COR; S1 S2
Resp: Lungs clear
Abd: Soft, non tender / obese / (+ BM)
Ext: Pulses:  palpable DP /PT bilaterally /Feet warm,  well
perfused.  No open areas
Incisions: CDI
Wounds: Left Right groin puncture site: Dressing clean dry and
intact. Soft, no hematoma or ecchymosis
Lumbar drian site intact / no drainage / no fluctuance


Pertinent Results:
[**2112-10-6**] PORTABLE CHEST
FINDINGS:  The heart size is within normal limits.  The
mediastinal contours are prominent.  The lungs are clear of
consolidation, although there is minimal bibasilar atelectasis.
There is prominence of the central pulmonary vasculature as
well.  There is no large pleural effusion or pneumothorax.

IMPRESSION:  Mediastinal prominence may represent an unfolded
aorta, although correlation with subsequent torso CTA performed
on the same date is recommended; minimal pulmonary vascular
congestion and bibasilar atelectasis.

[**2112-10-6**] ct chest
CT OF THE CHEST WITH CONTRAST:  The thyroid gland is normal and
symmetric in appearance.  The trachea and central airways are
patent to the segmental level.

Extensive emphysema is seen throughout the upper lungs.
Bibasilar atelectasis is noted.

The esophagus is normal.  There is no axillary, mediastinal, or
hilar
lymphadenopathy.

A small amount of pericardial fluid in the superior recess is of
relative low attenuation but slightly above that of simple fluid
(20-25 [**Doctor Last Name **]). Coronary calcification is noted.

CT OF THE ABDOMEN WITH CONTRAST:  The liver is normal in
attenuation without focal lesion or intra- or extra-hepatic
biliary ductal dilatation.  The gallbladder is surgically
absent.  The CBD is mildly prominent, compatible with
post-cholecystectomy state, measuring 11 mm, probably due to
prior cholecystectomy.  The pancreas, spleen, and right adrenal
gland are normal.

A 9 mm hypodensity in the left adrenal gland (2:99) is
indeterminate on this study but unchanged.  A 6 mm hypodense
focus in the interpolar region of the right kidney is too small
to characterize.  There is no hydronephrosis.

The stomach, small and large bowel appear unremarkable with the
exception of sigmoid diverticula without active inflammatory
changes.  A fat-containing ventral hernia is noted.  There is no
mesenteric or retroperitoneal adenopathy.  There is no free air
or free fluid in the abdomen.

CT OF THE PELVIS WITH CONTRAST:  The bladder is densely filled
with contrast.  From the prior study, the uterus and ovaries are
unremarkable.  The rectum is normal.  There is no pelvic or
inguinal adenopathy.  There is no free pelvic fluid.

OSSEOUS STRUCTURES:  There is no lytic or sclerotic bony lesion
concerning for osseous malignancy.  Minimal multilevel
degenerative changes are seen in the spine.

CTA:  Extensive high density thickening of the aortic wall
involving the
descending aorta, beginning at the level of the left subclavian
artery and
extending to the level just below the renal arteries is similar
or slightly progressed from the previous examination of [**9-30**] and
compatible with intramural hematoma.  A new frank type B
dissection flap across the lumen begins at the level of the left
pulmonary vein (2:47) and extends just to the level just beyond
the celiac artery.  The celiac artery appears to fill off the
false lumen, with the remainder of the intra-abdominal arteries
filling off the true lumen.  Minimal intramural hematoma
involves the proximal superior mesenteric artery.  Multiple
areas of intramural contrast extravasation and/or ulceration are
new along the upper descending aorta within the intramural
hematoma, but above formation of the flap (2:25, 2:39, 2:38 and
2:101).  There are ulcerating Atherosclerotic plaques and patchy
calcification along the lower
descending thoracic aorta.

Just beyond the origin of the left common carotid and left
subclavian there is focal irregularity (2:6 and 2:5), which are
likely related to plaque at a site of vessel tortuosity.

Axial measurements of the aortic lumen measure up to 35 x 31 mm
in axial
dimensions along the proximal descending aorta. Along the upper
ascending
aorta measurements up to 37 x 34 mm correspond to slight
ectasia.

An aortic aneurysm is seen (2:139) at the level of the inferior
mesenteric
artery takeoff, measuring 2.7 cm, distinct from the dissection
and consistent with an incidental finding.

BONES: There are no suspicious lytic or blastic lesions.

IMPRESSION:

1.  Type B aortic dissection extending from the level of the
left pulmonary vein to just beyond the celiac artery with the
celiac artery filling off the false lumen.  Minimal fluid in the
superior pericardial recess is mildly hyperdense, so a
hemorrhagic component is possible although apparent measured
increase in attenuation may be technical in etiology.

2.  Distal infrarenal aortic aneurysm just above the [**Female First Name (un) 899**] takeoff
measuring 2.7 cm; attention in follow-up imaging is recommended
for surveillance.

3.  Indeterminate 9 mm hypodense left adrenal lesion, but most
likely benign, although not fully characterized.  Attention in
follow-up imaging surveillance is recommended; alternatively if
further characterization is desired at this time or before
follow-up imaging of the dissection, dedicated CT or MR protocol
could be considered.

4.  Diverticulosis without evidence of active inflammation.

5.  Coronary artery calcifications.

Preliminary findings were discussed with Dr. [**Last Name (STitle) **] by Dr.
[**First Name (STitle) **] in person at 2231 at the time of discovery on [**2112-10-6**].

[**2112-10-7**] CT HEAD
FINDINGS:  There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction.  The ventricles and sulci are normal in
size and configuration.  The basal cisterns appear patent and
there is preservation of [**Doctor Last Name 352**]-white matter differentiation.

No fracture is identified.  The visualized paranasal sinuses,
mastoid air
cells and middle ear cavities are clear.  The globes are
unremarkable.

CONCLUSION:  No evidence of hemorrhage, mass, mass effect, or
acute
infarction.

[**2112-10-10**]:  CT CHEST/ ABD/ PELVIS :
FINDINGS:

CT CHEST:  The visualized portion of the thyroid is unremarkable
in
appearance. There are multiple subcentimeter nodules in
bilateral breasts.  The trachea is midline.  The airways are
patent to the subsegmental level.

There is severe centrilobular emphysema throughout the lungs
with apical
predilection.  There is bibasilar atelectasis.  There are no
effusions,
nodules or pneumothorax.

There is no supraclavicular, axillary, mediastinal or hilar
lymphadenopathy.

Pericardial fluid is again noted, but is slightly decreased in
amount from previous examination.  Coronary artery calcification
is noted.  The heart and great vessels are otherwise
unremarkable in appearance.

CT ABDOMEN:  The liver is homogeneous in appearance with no
focal lesions
without intrahepatic biliary duct dilatation.  The gallbladder
is surgically absent and the CBD is prominent measuring 1.2 cm
in diameter compatible with post-cholecystectomy.  The pancreas
and spleen are unremarkable in appearance. The right adrenal
gland is unremarkable in appearance.  There is a stable 9-mm
hypodensity in the left adrenal gland, likely representing
adenoma.  There is a stable 6-mm hypodensity in the interpolar
region of the right kidney that is too small to fully
characterize by CT examination, but likely representing a simple
cyst.  Otherwise, bilateral kidneys present symmetric uptake and
excretion of contrast without hydronephrosis, stones, worrisome
lesions or perinephric abnormalities.

The stomach, duodenum and small bowel are unremarkable in
appearance with no focal wall thickening or obstruction noted.
There are scattered diverticula throughout the large intestine,
predominantly located in the sigmoid colon.  There is no
mesenteric or retroperitoneal lymphadenopathy.  There is no free
air or ascites within the abdomen.  There is a fat-containing
ventral hernia as well as a small umbilical hernia.

CT PELVIS:  The uterus and bilateral ovaries are unremarkable in
appearance.  There is a small amount of air within the bladder,
compatible with recent instrumentation.  There is no pelvic or
inguinal lymphadenopathy.  There is no free pelvic fluid.

OSSEOUS STRUCTURES:  Degenerative changes are noted throughout
the spine.  There are no focal lesions in the visualized osseous
structures concerning for malignancy.

CTA:  Again noted is extensive high-density thickening of the
aortic wall
beginning proximally at the level of the left subclavian artery
and extending to just inferior of the renal arteries as well as
dissection flap, beginning at the level of the left pulmonary
vein and extending just beyond the celiac artery.  The extent of
dissection is stable; however, there is increased amount of
hematoma within the false lumen at the level of the celiac
artery which is narrowing the false lumen and presenting mass
effect on the true lumen.  Despite the increased mass effect,
the celiac artery has preserved flow and is filling off of the
false lumen.  The SMA and [**Female First Name (un) 899**] are patent, receiving flow from
the true lumen.  There are multiple areas of descending aorta
ulceration as well as atherosclerotic plaques, which are stable
from previous examination.  Maximum dimensions of the aortic
lumen within the ascending aorta measures 4.0 x 3.7 cm and in
the descending aorta 3.5 x 3.5 cm, representing slight ectasia.
Again noted is a focal aortic aneurysm at
the level of the [**Female First Name (un) 899**] measuring 2.7 cm.

IMPRESSION:
1.  Type B aortic dissection extending from the level of the
left pulmonary vein to just beyond the celiac artery with the
celiac artery filling from the false lumen.  Extent of
dissection is unchanged; however, there is increased amount of
clot in the false lumen, narrowing the false lumen, presenting
greater mass effect on the true lumen.  However, flow is
preserved.
2.  Distal infrarenal aortic aneurysm at the level of the [**Female First Name (un) 899**].
3.  9 mm hypodense lesion in the left adrenal gland, most likely
representing an adenoma.  Attention on followup imaging is
recommended.
4.  Diverticulosis.
5.  Coronary artery calcifications as well as multiple
ulcerative
atherosclerotic plaques within the aorta.
6.  Fat-containing umbilical as well as ventral hernia.
7.  Small right interpolar renal hypodensity too small to fully
characterize by CT, but likely representing a simple cyst.
8.  Extensive emphysema.
9.  Small focus of air within the bladder that could represent
recent
instrumentation or infection.  Clinical correlation is
recommended.

 [**2112-10-11**] CT Chest abd pelvis
Final Report INDICATION:  57-year-old woman with known type B
dissection status post repair presents with epigastric pain,
evaluate for flow within the SMA and celiac.

COMPARISON:  CTA torso [**2112-10-10**].

TECHNIQUE:  Helical axial MDCT images were obtained from the
chest, abdomen and pelvis after the administration of IV
contrast in the arterial phase.  Multiplanar reformatted images
were obtained in the sagittal and coronal planes.

DOSE REPORT:  Total DLP [**2074**].98 mGy-cm.

FINDINGS:

CT OF THE CHEST:  The visualized portion of the thyroid is
unremarkable. The trachea is midline.  The airways are patent to
the subsegmental levels.  Severe emphysematic changes are noted
in bilateral lungs.  Bilateral pleural effusions are new since
most recent prior examination.  There is adjacent opacification
which most likely represents compressive atelectasis; however,
infectious process cannot be completely excluded.

There is atherosclerotic calcification involving the coronary
vessels.  There is no evidence of pericardial effusion.
Mediastinal, axillary and hilar lymph nodes do not meet CT size
criteria for pathology.

The heart and great vessels are otherwise unremarkable in
appearance.

CT OF THE ABDOMEN:  The liver is homogenous in appearance
without evidence of focal liver lesions.  There is no evidence
of intrahepatic biliary dilation.  The patient is status post
cholecystectomy.  The spleen, pancreas and right adrenal gland
are unremarkable. 9 mm left adrenal nodule is unchanged from the
prior examination.  Bilateral kidneys show no evidence of
hydronephrosis.

Retroperitoneal and mesenteric lymph nodes do not meet CT size
criteria for pathology.  There is no free air or free fluid
within the abdomen.

CT OF THE PELVIS:  The bladder contains a Foley.  Air within the
bladder
likely represents instrumentation.  The uterus appears
unremarkable.  There is evidence of sigmoid and descending colon
diverticulosis without evidence of diverticulitis.

Bilateral pelvic side wall lymph nodes do not meet CT size
criteria for
pathology.  Small fat-containing ventral hernia is noted.

CTA:  Patient is status post repair of type B dissection with
EVAR stent graft extending from the level of the left subclavian
artery and to just inferior to the origin of the renal arteries.
 The dissection appears to extend into the celiac
trunk(301:104); it is difficult to say if this was present on
the prior study. Both sides of the dissection flap, however
appear perfused homogenously with patent celiac trunk.  The SMA
and [**Female First Name (un) 899**] are patent.  Again noted are areas of aortic ulcerations
as well as atherosclerotic plaques stable from the prior
examination.  Maximum dimension of the aortic lumen within the
ascending aorta measures 2.8 x 3.6 cm and the 3.1 x 3.1 cm
within the descending aorta.  Again
noted is a focal aortic aneurysmal morphology at the level of
the [**Female First Name (un) 899**]
measuring 2.7 cm (3:140 and 602b:47).

3D reformations generated in the imaging lab of the aorta and
endovascular stent include 3D MIP and VR rotations, curved
reformatted images, and 3D measurements (below). These were
reviewed in the interpretation of this examination.

Measurements:
Aortic valve: 3.8 cm
Aortic cusps: 4.4 cm
Ascending aorta/[**MD Number(3) 26547**]: 4.0 cm
Ascending aorta/Proximal arch: 3.6 cm
Proximal descending thoracic aorta/Distal arch (stent lumen +
aorta wall): 2.8 cm Maximum, descending thoracic aorta (stent
lumen + aorta wall): 5.0 cm Abdominal aorta, celiac trunk (stent
lumen + aorta wall): 2.8 cm Abdominal aorta, SMA (stent lumen +
aorta wall): 2.8 cm

IMPRESSION:

1.  Status post repair of type B aortic dissection with EVAR
stent graft
extending from the level of the left subclavian artery to just
below the
origin of the renal arteries.
2.  Distal infrarenal aortic aneurysm at the level of the [**Female First Name (un) 899**],
unchanged.
3.  Dissection appears to extend into the celiac trunk. Both
sides of the
dissection flap demonstrate homogenous perfusion with patency of
celiac trunk SMA and [**Female First Name (un) 899**].
4. Unchanged 9 mm right adrenal nodule.
5. Bilateral pleural effusions with adjacent compressive
atelectasis new from the prior exam.
6. Ventral fat containing hernia.

[**2112-10-13**] CXR
Final Report
CHEST RADIOGRAPH

INDICATION:  Fever, evaluation for pneumothorax and line
position.

FINDINGS:  As compared to the previous radiograph from [**10-12**], [**2112**], the venous introduction sheath on the right has been
changed to a right internal jugular vein catheter.  The signs
indicative of bilateral parenchymal opacities at the lung bases,
most likely fluid overload, have decreased in severity.  The
size of the cardiac silhouette, including the aortic stent
graft, is unchanged.





Brief Hospital Course:
On [**10-6**] the pt presented to an OSH with abdominal pain where a
CT abdomen was done which showed an aortic dissection. She was
transferred to [**Hospital1 18**] and had a confirmatory CTA.  She was
admitted to the ICU for blood pressure control and serial
abdominal exams.

At the time of presentation to [**Hospital1 18**] she was not complaining of
any abdominal pain and her vascular exam was unchanged (palpable
bilateral upper and lower extremity pulses).  She was agitated
while in the ICU and received Ativan to which she became
delerious.  She was seen by psychiatry for acute delerium and
they asked to hold ativan and to use Hadol for any agitation.

She remained stable and the plan was to manage her medially.
She was transferred to the VICU.  On the morning of [**2112-10-10**] she
was complaining of upper abdominal pain and retro sternal pain.
Her VS were stable at that pt as was her EKG.  On exam she
looked slightly pale without diaphoresis.  Her distal pulses
were all palpable at that time. She was sent for stat CTA and
then sent to prep and hold where she was consented for TEVAR.
It was noted on the CT that she had extension of her dissection
with possible compressive thrombus.

She underwent the procedure without complication. She was
recovered in the VICU and did well.  Her diet and activity were
advanced. She was voiding freely and tolerating an oral diet.
She ambulated without assistance.  Her follow up appts were
scheduled.  She was councelled to follow up with her PCP within
two weeks.


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from  last discharge.
1. Omeprazole 40 mg PO DAILY
2. Donnatol 10 mL PO BID:PRN abdominal pain
3. Atorvastatin 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. DiCYCLOmine 10 mg PO QID


Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. DiCYCLOmine 10 mg PO QID
4. Omeprazole 40 mg PO DAILY
5. Acetaminophen-Caff-Butalbital [**1-25**] TAB PO Q6H:PRN headache
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg [**1-25**]
tablet(s) by mouth q 4 hours Disp #*30 Tablet Refills:*0
6. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
7. Metoprolol Tartrate 12.5 mg PO BID
hold for SBP < 100, HR < 60
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
8. Donnatol 10 mL PO BID:PRN abdominal pain


Discharge Disposition:
Home

Discharge Diagnosis:
Aortic Dissection / Type B
Intramural Aortic Thrombus
complicated urinary tract infection
delerium / acute / medication reaction
headache


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital with a Type B Aortic
Dissection
You underwent a Envovascular repair of this aneurysm without
complication. You were found to have a urinary tract infection
and were started on antibiotics for this.  You also had a
reaction to ATIVAN that caused you to be very confused - This is
now listed in our system as an allergy to avoid this reaction
again.

Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions

MEDICATIONS:
??????	Take Aspirin 325mg (enteric coated) 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 AT HOME:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-26**]
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

ACTIVITIES:
??????	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 THE OFFICE FOR: [**Telephone/Fax (1) 90383**]
??????	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

FOR 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:
Dr. [**Last Name (STitle) **] would like to see you in the office in one
months time - an appointment has been made for you - if you need
to change the date/time, please call the office at [**Telephone/Fax (1) **]
thank you

Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2112-11-14**] 1:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2112-11-14**] 2:45

As always, please call your primary care physician for an
appointment to be seen in the next two weeks to inform and
update them of your care. I attempted to make an appointment for
you but the office was closed.  This is very improtant that you
follow up.
Name: ATTAR,[**Female First Name (un) **]
Address: [**Last Name (un) 28705**], [**Location (un) 28706**],[**Numeric Identifier 28707**]
Phone: [**Telephone/Fax (1) 24306**]
Fax: [**Telephone/Fax (1) 75010**]



Completed by:[**2112-10-14**]
{'Dissection of aorta, thoracoabdominal,Embolism and thrombosis of thoracic aorta,Urinary tract infection, site not specified,Drug-induced delirium,Tobacco use disorder,Obesity, unspecified,Headache,Body Mass Index 37.0-37.9, adult,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Examination of participant in clinical trial'}


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: Abdominal Pain

PRESENT ILLNESS: HPI: 57F heavy smoker with recent admission [**2112-10-1**] - [**2112-10-3**]
with
chest and abdominal pain and odynophagia who was found to have
circumferential mural thrombus in the supra-renal aorta on cross
sectional imaging. At that time the aortic pathology was though
to be chronic. Ultimately, her pain resolved with the initiation
of a PPI and GI cocktail, and was discharged home after a 3 day
hospital stay. On [**10-6**] she again presented to an OSH with
abdominal pain where a CT abdomen was done which showed an
aortic
dissection. She was emergently transferred to [**Hospital1 18**] where a CTA
of the torso confirmed an aortic dissection of the descending
thoracic aorta (at the level of the left pulmonary vein) to just
below the takeoff of the celiac. At the time of presentation to
[**Hospital1 18**] she was not complaining of any abdominal pain and her
vascular exam was unchanged (palpable bilateral upper and lower
extremity pulses).
.

MEDICAL HISTORY: Sinusitis

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from  last discharge.
1. Omeprazole 40 mg PO DAILY
2. Donnatol 10 mL PO BID:PRN abdominal pain
3. Atorvastatin 20 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. DiCYCLOmine 10 mg PO QID

ALLERGIES: Ativan

PHYSICAL EXAM: Physical Exam:
Alert and oriented x 3
VS:BP 110' 70's         HR  70-80's       RR stable / AF
Carotids: 2+, no bruits or JVD
COR; S1 S2
Resp: Lungs clear
Abd: Soft, non tender / obese / (+ BM)
Ext: Pulses:  palpable DP /PT bilaterally /Feet warm,  well
perfused.  No open areas
Incisions: CDI
Wounds: Left Right groin puncture site: Dressing clean dry and
intact. Soft, no hematoma or ecchymosis
Lumbar drian site intact / no drainage / no fluctuance

FAMILY HISTORY: 89yo father with CHF

SOCIAL HISTORY: Married to retired police officer, 5 children. Current [**1-25**] PPD
smoker with > 30 yr smoking history. No alcohol or IVDA. 

### Response:
{'Dissection of aorta, thoracoabdominal,Embolism and thrombosis of thoracic aorta,Urinary tract infection, site not specified,Drug-induced delirium,Tobacco use disorder,Obesity, unspecified,Headache,Body Mass Index 37.0-37.9, adult,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Examination of participant in clinical trial'}
