CHIEF COMPLAINT: Type A dissection with chest pain

PRESENT ILLNESS: This 48 year old white male presented chest pain starting this
morning at 5am, of gradual onset with progressively increasing
severity.  He was evaluated
at [**Hospital **] Hospital ED where a CTA of the chest/abdomen showed
Type A aortic dissection.  He was transferred to [**Hospital1 18**] for
cardiac surgery consult.

MEDICAL HISTORY: Tobacco abuse, EtOH abuse, h/o MVC 28 years ago with bilateral
leg fractures s/p surgical fixation, chronic dermatitis left
lower leg, gout.

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: 71  Resp: 18  O2 sat: 98% on 3L
B/P  Right: 138/68   Left:
Height: 68 in.    Weight: 245 lbs. (estimated)

FAMILY HISTORY: None Noted

SOCIAL HISTORY: Lives with: girlfriend [**Doctor First Name **]
Contact: girlfriend [**Name2 (NI) **] [**Telephone/Fax (1) 92019**]
Occupation: diesel mechanic
Cigarettes: Smoked no [] yes [x] last cigarette _this AM_ Hx: 1
ppd x 40 years
Other Tobacco use:
ETOH: < 1 drink/week []  [**1-10**] drinks/week [] >8 drinks/week [x]
(8
beers/night)
Illicit drug use: none
Dissection of aorta, thoracic,Acute respiratory failure,Rhabdomyolysis,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Cellulitis and abscess of leg, except foot,Other complications due to other cardiac device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Other specified complications of procedures not elsewhere classified,Nontraumatic compartment syndrome of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Oliguria and anuria,Abnormal coagulation profile,Iron deficiency anemia, unspecified
Dsct of thoracic aorta,Acute respiratry failure,Rhabdomyolysis,Acute kidney failure NOS,Iatrogenic pneumothorax,Cellulitis of leg,Comp-oth cardiac device,Gastrointest hemorr NOS,Oth spcf cmplc procd NEC,Nontraum comp syn-low ex,Abn react-surg proc NEC,Accid in resident instit,Oliguria & anuria,Abnrml coagultion prfile,Iron defic anemia NOS
Admission Date:  [**2158-1-9**]              Discharge Date:   [**2158-2-3**]

Date of Birth:  [**2109-12-27**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Type A dissection with chest pain

Major Surgical or Invasive Procedure:
[**2158-1-9**] - Bentall procedure (31-mm St. [**Male First Name (un) 923**] conduit mechanical
valve graft and replacement of the ascending and hemiarch aorta
with a 28-mm Gelweave tube graft under circulatory arrest with
selective antegrade cerebral perfusion).
[**2158-1-9**] - Mediastinal re-exploration with control of left and
right coronary button anastomotic bleeders, chest closure.
[**2158-1-10**] - Right leg four-compartment fasciotomy with debridement.

[**2158-1-12**] - Debridement lateral compartment, proximal.
[**2158-1-16**] - Irrigation and debridement of medial fasciotomy and
delayed primary closure. 2. Irrigation and debridement of the
lateral compartment with debridement of necrotic muscle and
delayed primary closure.


History of Present Illness:
This 48 year old white male presented chest pain starting this
morning at 5am, of gradual onset with progressively increasing
severity.  He was evaluated
at [**Hospital **] Hospital ED where a CTA of the chest/abdomen showed
Type A aortic dissection.  He was transferred to [**Hospital1 18**] for
cardiac surgery consult.


Past Medical History:
Tobacco abuse, EtOH abuse, h/o MVC 28 years ago with bilateral
leg fractures s/p surgical fixation, chronic dermatitis left
lower leg, gout.


Social History:
Lives with: girlfriend [**Doctor First Name **]
Contact: girlfriend [**Name2 (NI) **] [**Telephone/Fax (1) 92019**]
Occupation: diesel mechanic
Cigarettes: Smoked no [] yes [x] last cigarette _this AM_ Hx: 1
ppd x 40 years
Other Tobacco use:
ETOH: < 1 drink/week []  [**1-10**] drinks/week [] >8 drinks/week [x]
(8
beers/night)
Illicit drug use: none


Family History:
None Noted

Physical Exam:
Pulse: 71  Resp: 18  O2 sat: 98% on 3L
B/P  Right: 138/68   Left:
Height: 68 in.    Weight: 245 lbs. (estimated)

Five Meter Walk Test #1_______ #2 _________  #3_________

General:
Skin: Dry [x] intact [x]  chronic cellulitis left lower leg
HEENT: PERRLA [x] EOMI [x]
Neck:  Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x]  Irregular []  Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]  bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]  Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral      Right: palp   Left: palp
DP           Right: non-palp   Left: non-palp
PT           [**Name (NI) 167**]: non-palp   Left: non-palp
Radial       Right: palp   Left: palp

Carotid Bruit        Right:    Left:


Pertinent Results:
[**2158-1-9**] ECHO
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.

There is a small PFO.

Overall left ventricular systolic function is normal (LVEF>55%),
although unable to obtain transgastric midpapillary view.

The aortic root is severely dilated at the sinus level. A mobile
density is seen in the ascending aorta consistent with an
intimal flap/aortic dissection. A mobile density is seen in the
descending aorta consistent with an intimal flap/aortic
dissection. The views of the upper descending aorta and aortic
arch were unable to be obtained.

The number of aortic valve leaflets cannot be determined due to
the presence of the mobile echodensity but is suggestive of
bicuspid anatomy. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet.

The mitral valve appears structurally normal with trivial mitral
regurgitation.

There is no pericardial effusion.

Dr. [**Last Name (STitle) **] was notified in person of the results on in the
operating room.

POSTBYPASS:
The patient is av paced on phenylephrine infusion. Later A paced
on phenylephrine and epinephrine infusions. There is a well
seated mechanical valve in the aortic position. Characteristic
washing jets are appreciated. Bileaflet motion is appreciated.
There is dropout of the ascending aorta consistent with a tube
graft. Peak and mean gradients across the valve are 7mmHg &
4mmHg, respectively with a cardiac output of 3L/m. The remaining
valves are unchanged. Biventricular function is maintained. The
dissection flap can still be seen in the descending aorta. All
findings discussed with surgeons at the time of the exam.
.
CT Chest [**2158-1-19**]
1. Mild hemopericardium, small amount of mediastinal fluid
surrounding the
ascending aortic graft and soft tissue density posterior to the
sternum are likely postsurgical and within normal 8 days after
surgery; however,
superimposed infection cannot be excluded.
2. Bibasilar opacities are likely due to atelectasis; however,
superimposed infection cannot be excluded.
3. No abdominal or pelvic findings that might explain the
patient's rising
white blood count.
.
LE ultrasound [**2158-1-19**]
No evidence of DVT in right or left lower extremity.
.
[**2158-1-12**] PICC Line Placement
IMPRESSION: Successful uncomplicated placement of a 26 cm
tip-to-cuff 15.4
French tunneled hemodialysis line with the tip in the right
atrium. The
catheter is ready to use.

[**2158-2-1**] 04:01AM BLOOD Hct-25.4*
[**2158-1-31**] 04:53AM BLOOD WBC-4.3 RBC-3.02* Hgb-9.2* Hct-25.2*
MCV-84 MCH-30.5 MCHC-36.5* RDW-15.3 Plt Ct-198
[**2158-1-9**] 08:30AM BLOOD WBC-10.5 RBC-3.74* Hgb-12.6* Hct-35.4*
MCV-95 MCH-33.7* MCHC-35.6* RDW-12.5 Plt Ct-175
[**2158-2-1**] 04:01AM BLOOD PT-16.2* PTT-63.8* INR(PT)-1.5*
[**2158-1-31**] 04:53AM BLOOD PT-17.0* PTT-58.9* INR(PT)-1.6*
[**2158-1-30**] 09:48AM BLOOD PT-16.5* PTT-41.4* INR(PT)-1.6*
[**2158-1-29**] 05:20PM BLOOD PT-18.5* PTT-42.1* INR(PT)-1.7*
[**2158-2-1**] 04:01AM BLOOD Glucose-103* UreaN-54* Creat-1.0 Na-136
K-3.7 Cl-100 HCO3-27 AnGap-13
[**2158-1-31**] 04:53AM BLOOD Glucose-94 UreaN-71* Creat-1.2 Na-134
K-3.5 Cl-98 HCO3-27 AnGap-13
[**2158-1-30**] 09:48AM BLOOD Glucose-95 UreaN-78* Creat-1.7* Na-132*
K-3.5 Cl-95* HCO3-27 AnGap-14
[**2158-1-26**] 06:31AM BLOOD Glucose-115* UreaN-149* Creat-4.8*
Na-129* K-5.2* Cl-94* HCO3-18* AnGap-22*
[**2158-1-20**] 03:01AM BLOOD Glucose-87 UreaN-60* Creat-3.3* Na-129*
K-4.1 Cl-93* HCO3-24 AnGap-16
[**2158-1-10**] 11:12PM BLOOD UreaN-31* Creat-3.4* Na-143 K-5.1 Cl-104
[**2158-1-9**] 08:30AM BLOOD Glucose-132* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-107 HCO3-21* AnGap-17

Brief Hospital Course:
He was admitted to the [**Hospital1 18**] on [**2158-1-9**] for surgical management
of his Type A aortic dissection. He was taken directly to the
Operating Room where he underwent repair of his dissection with
a Bentall procedure using a 31-mm St. [**Male First Name (un) 923**] conduit
mechanical valve graft and replacement of the ascending and
hemiarch aorta with a 28-mm Gelweave tube graft under
circulatory arrest with selective antegrade cerebral
perfusion. Please see operative note for details.

Postoperatively he was taken to the intensive care unit with an
open chest. He required multiple blood products and red blood
cells for significant postoperative bleeding. He was later
returned to the Operating Room where he underwent re-exploration
for bleeding, found to be from the coronary buttons. Hemostasis
was achieved and his chest was closed. He was then returned to
the intensive care unit for monitoring.

The orthopedic service was consulted for compartment
syndrome/rhabdomyolysis of the right . On [**2158-1-10**] at the bedside
due to hemodynamic instability, he underwent right lower
extremity fasciotomies and placement of a VAC dressing. This was
debrided on [**2158-1-12**] and again on [**2158-1-16**] when it was ultimately
washed out and closed.

His myoglobins peaked at 60,000 and he became oliguiric.  The
Nephrology Service was consulted and  CVVHD was started and the
renal service continued to follow him closely. Heparin was
started for anticoagulation given his mechanical aortic valve.
He was treated aggressively for hypertension. Tube feeds were
started for nutritional support.

He developed thick secretions which smelled foul with fever and
leukocytosis. Vancomycin was started and a bronchoscopy was
performed. Cultures were positive for coagulase positive staph
aureas and vancomycin was continued. A chest tube was placed for
a right pneumothorax. He continued with significant leukocytosis
and the Infectious Disease service was consulted. A lower
extremity ultrasound was negative for deep vein thrombosis or
abscess. An initial surface echo did not show any evidence of
endocarditis. Cefepime and ciprofloxacin were started but later
changed to Meropenum. Flagyl was started for presumed c. diff,
however, cultures remained negative and the Flagyl was stopped.

A CT scan showed a small amount of fluid surrounding the aortic
graft but no frank infectious process. He was again transfused
for postoperative anemia. He continued on hemodialysis on a
Tuesday, Thursday and Saturday schedule. On [**2158-1-21**] he was
successfully extubated. Nystain was started for oral
candidiasis. Phenylephrine was slowly weaned off. CVVH was
switched to hemodialysis on [**2158-1-21**].

Coumadin was started for his mechanical valve. Physical Therapy
began to work with him to help with his postoperative strength
and mobility. On [**2158-1-23**], he was transferred to [**Hospital Ward Name 121**] 6 for
further recovery. Heparin was stopped when his INR was
therapeutic. While recovering on the floor he dropped his
hematocrit again which prompted a TTE that revealed a possible
vegetations on the aortic and mitral valves. He therefore
underwent TEE on POD #21 which showed no signs of any
vegetations.

His dialysis tunnelled line was accidently discontinued during a
dialysis run, but his kidney function improved to the point
where a trial off dialysis was given and he continued to make
adequate urine.  The renal function slowly improved and he
autodiuresed.  He made steady progress and was discharged to
[**Hospital3 **] of [**Location (un) 1121**] in [**Hospital1 3597**],  on [**2158-2-3**].

 Antibiotics were all discontinued on [**1-31**]. He will follow-up
with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 1005**] (orthopedics) and the renal service
as directed. Staples from the fasciotomy sites were removed and
the wound was healing well.

BUN/creatinine the day of discharge were 20/0.6 rerspectively.


Medications on Admission:
None

Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three
times a day: hold HR<60,sbp<100.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
6. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(two tablets) twice daily for two weeks, then
200mg (one tablet) twice daily for two weeks, then 200mg(one
tablet) daily until instructed to discontinue. Tablet(s)
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-5**]
Puffs Inhalation Q6H (every 6 hours).
10. warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a
day: INR goal [**1-6**].
Should receive 5mg on [**2158-2-3**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)

Discharge Diagnosis:
Type A aortic dissection
s/p Bentall(31mm mechanical valved conduit), open chest
s/p reoperaton for bleeding and chest closure
s/p right lower extremity two compartment fasciotomies
s/p closure of fasciotomies
post operative myoglobin induced renal failure
gastrointestinal bleed


Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Fasciotomy - healing well, no erythema or drainage. Staples in
place.
1+ Edema


Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your 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 provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Hemodialysis is on a Tuesday, Thursday and Saturday schedule.
7) Leg staples to remain in place until orthopedics removes.
8) 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) **] ([**Telephone/Fax (1) 170**]) on [**2158-2-21**] at 1:45pm
Cardiologist: Dr. [**Last Name (STitle) 72502**] [**Name (STitle) **] at 9:00a [**Telephone/Fax (1) 92020**]
Orthopedics: Dr. [**Last Name (STitle) 1005**] Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2158-2-2**]
10:00
ORTHO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2158-2-2**] 9:40

Please call to schedule appointments with:
Primary Care: Dr. [**Last Name (STitle) 8964**] ([**Telephone/Fax (1) 45950**]) in 2 weeks

**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 Aortic Valve
Goal INR 2.0-3.0
First draw [**2158-1-27**]
Please arrange for outpatient coumadin management upon discharge
from rehab.



Completed by:[**2158-2-3**]
{'Dissection of aorta, thoracic,Acute respiratory failure,Rhabdomyolysis,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Cellulitis and abscess of leg, except foot,Other complications due to other cardiac device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Other specified complications of procedures not elsewhere classified,Nontraumatic compartment syndrome of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Oliguria and anuria,Abnormal coagulation profile,Iron deficiency anemia, 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: Type A dissection with chest pain

PRESENT ILLNESS: This 48 year old white male presented chest pain starting this
morning at 5am, of gradual onset with progressively increasing
severity.  He was evaluated
at [**Hospital **] Hospital ED where a CTA of the chest/abdomen showed
Type A aortic dissection.  He was transferred to [**Hospital1 18**] for
cardiac surgery consult.

MEDICAL HISTORY: Tobacco abuse, EtOH abuse, h/o MVC 28 years ago with bilateral
leg fractures s/p surgical fixation, chronic dermatitis left
lower leg, gout.

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Pulse: 71  Resp: 18  O2 sat: 98% on 3L
B/P  Right: 138/68   Left:
Height: 68 in.    Weight: 245 lbs. (estimated)

FAMILY HISTORY: None Noted

SOCIAL HISTORY: Lives with: girlfriend [**Doctor First Name **]
Contact: girlfriend [**Name2 (NI) **] [**Telephone/Fax (1) 92019**]
Occupation: diesel mechanic
Cigarettes: Smoked no [] yes [x] last cigarette _this AM_ Hx: 1
ppd x 40 years
Other Tobacco use:
ETOH: < 1 drink/week []  [**1-10**] drinks/week [] >8 drinks/week [x]
(8
beers/night)
Illicit drug use: none 

### Response:
{'Dissection of aorta, thoracic,Acute respiratory failure,Rhabdomyolysis,Acute kidney failure, unspecified,Iatrogenic pneumothorax,Cellulitis and abscess of leg, except foot,Other complications due to other cardiac device, implant, and graft,Hemorrhage of gastrointestinal tract, unspecified,Other specified complications of procedures not elsewhere classified,Nontraumatic compartment syndrome of lower extremity,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution,Oliguria and anuria,Abnormal coagulation profile,Iron deficiency anemia, unspecified'}
