CHIEF COMPLAINT: ruptured AAA

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old woman with a history of CAD s/p
pacemaker placement, atrial fibrillation, and known AAA who
presented to an OSH today with abdominal and back pain, and was
scanned demonstrating an 8.4 X 7.5 cm AAA with evidence of leak.
 She was therefore transferred to [**Hospital1 18**]
urgently for vascular surgery evaluation.

MEDICAL HISTORY: PMH:
HTN
hypothyroidism
s/p pacemaker
Atrial fibrillation
CHF
h/o MRSA cellulitis in legs
history of falls

MEDICATION ON ADMISSION: potassium 20 meq daily
lasix 40 mg po qd
digoxin .125 mg daily
cardizem ER 240 mg po qd
ASA 81 mg po qd
miralax
clonidine 0.1 mg po bid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
PE:
HR 61  BP 170/75  94% RA
NAD, awake/alert, responsive; poor historian
RRR
lungs clear
abdomen soft, moderately distended, pulsatile mass with deep
palpation
bilateral lower extremities warm, no ulceration
Pulses:
R femoral palpable, R DP palpable
L femoral palpable, L DP palpable
\
On Discharge:
VSS Afebrile
WDWN in NAD
Lungs - cta bilat
Card - RRR, paced at 60, strong PMI felt in the distal,external
thoracic cavity, due to pts habitus can feel PMI in the extreme
LUQ of the abd
Abd- soft +bs, no m/t/o
Ext- warm and dry, Fem/DP/PT pulses all palpable bilat

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone with daughter nearby
Abdominal aneurysm, ruptured,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Cardiac arrest,Dissection of iliac artery,Urinary tract infection, site not specified,Mechanical complication of other vascular device, implant, and graft,Fitting and adjustment of cardiac pacemaker,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Rupt abd aortic aneurysm,Ac on chr diast hrt fail,Pneumonia, organism NOS,Cardiac arrest,Dissection iliac artery,Urin tract infection NOS,Malfunc vasc device/graf,Ftng cardiac pacemaker,Pseudomonas infect NOS,Anemia NOS,Hypothyroidism NOS,Hypertension NOS,Meth resis Staph carrier,Abn react-procedure NEC
Admission Date:  [**2122-6-13**]              Discharge Date:   [**2122-6-23**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
ruptured AAA

Major Surgical or Invasive Procedure:
[**2122-6-13**]:
Endovascular stent graft exclusion of ruptured abdominal aortic
aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body endo prosthesis
and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and [**Doctor Last Name 4726**] 14-1/2 x 7 left
iliac extension limb

[**2122-6-22**]:
[**Company 1543**] Permanent Pacemaker generator exchange [**2122-6-22**]


History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a history of CAD s/p
pacemaker placement, atrial fibrillation, and known AAA who
presented to an OSH today with abdominal and back pain, and was
scanned demonstrating an 8.4 X 7.5 cm AAA with evidence of leak.
 She was therefore transferred to [**Hospital1 18**]
urgently for vascular surgery evaluation.


Past Medical History:
PMH:
HTN
hypothyroidism
s/p pacemaker
Atrial fibrillation
CHF
h/o MRSA cellulitis in legs
history of falls

PSH:
s/p cholecystectomy
s/p L CEA


Social History:
lives alone with daughter nearby


Family History:
NC

Physical Exam:
On Admission:
PE:
HR 61  BP 170/75  94% RA
NAD, awake/alert, responsive; poor historian
RRR
lungs clear
abdomen soft, moderately distended, pulsatile mass with deep
palpation
bilateral lower extremities warm, no ulceration
Pulses:
R femoral palpable, R DP palpable
L femoral palpable, L DP palpable
\
On Discharge:
VSS Afebrile
WDWN in NAD
Lungs - cta bilat
Card - RRR, paced at 60, strong PMI felt in the distal,external
thoracic cavity, due to pts habitus can feel PMI in the extreme
LUQ of the abd
Abd- soft +bs, no m/t/o
Ext- warm and dry, Fem/DP/PT pulses all palpable bilat

Pertinent Results:
[**2122-6-13**] 11:31 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2122-6-16**]**

   MRSA SCREEN (Final [**2122-6-16**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.

[**2122-6-16**] 12:17 am BLOOD CULTURE      Source: Line-arterial.

                            **FINAL REPORT [**2122-6-22**]**

   Blood Culture, Routine (Final [**2122-6-22**]):    NO GROWTH.
[**2122-6-16**] 12:17 am BLOOD CULTURE      2ND.

                            **FINAL REPORT [**2122-6-22**]**

   Blood Culture, Routine (Final [**2122-6-22**]):    NO GROWTH.

[**2122-6-16**] 12:17 am URINE      Source: Catheter.

                            **FINAL REPORT [**2122-6-18**]**

   URINE CULTURE (Final [**2122-6-18**]):
      PSEUDOMONAS AERUGINOSA.    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------     8 S
CEFTAZIDIME-----------     2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------     4 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------   <=1 S

Radiology Report CT CHEST W/O CONTRAST Study Date of [**2122-6-14**]
1:12 PM
IMPRESSION:
Extremely limited examination due to lack of intravenous
contrast.

1. Cardiomegaly. Small bibasal effusions and pulmonary
ground-glass
opacities. The lung findings may represent infection, fluid
overload or ARDS.

2. AAA with an aortofemoral bypass graft in situ. The
appearances are
suggestive of an endoleak as described above.

3. Extensive atherosclerosis in the vasculature of the abdomen
and pelvis
including the coronary arteries.

4. Striated appearance of both kidneys, most marked on the
right. The
appearances may represent acute tubular necrosis from prior
contrast
administration.

Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2122-6-16**] 10:34 AM
Reason: PE PROTOCOL. Please eval for PE.
 IMPRESSION:
1. Unchanged multifocal bilateral ground-glass opacities
consistent with
multifocal pneumonia.
2. Compared to [**2122-6-14**] increase of now large bilateral
simple pleural
effusion and partial atelectasis of the superior segments of the
lower lobes
bilaterally.
3. Unchanged ascending aorta and aortic arch dilatation with
focal aortic
arch aneurysm.
4. Unchanged cardiomegaly without significant pulmonary edema.
5. A central line ends in the distal left brachiocephalic vein.


UNILAT UP EXT VEINS US RIGHT Study Date of [**2122-6-18**] 1:36 PM
Reason: r/o dvt in rue
Occlusive thrombus involving the right cephalic vein. No DVT in
the right upper extremity.

[**2122-6-19**] 4:13 PM
UNILAT LOWER EXT VEINS RIGHT
Reason: CALF PAIN, PLEASE EVAL FOR DVT
IMPRESSION: No evidence of DVT in right lower extremity.

[**2122-6-23**] 03:56AM BLOOD WBC-8.8 RBC-3.09* Hgb-10.6* Hct-31.9*
MCV-103* MCH-34.3* MCHC-33.2 RDW-18.6* Plt Ct-249
[**2122-6-23**] 03:56AM BLOOD Glucose-81 UreaN-31* Creat-1.3* Na-137
K-3.2* Cl-95* HCO3-33* AnGap-12
[**2122-6-23**] 03:56AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
[**2122-6-16**] 12:17AM URINE RBC-[**3-13**]* WBC-21-50* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2122-6-22**] 05:46AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-FEW
Epi-0-2
[**2122-6-16**] 12:17AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2122-6-22**] 05:46AM URINE Blood-MOD Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2122-6-16**] 12:17AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2122-6-22**] 05:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.016

Brief Hospital Course:
Patient was admitted from an OSH with leaking AAA seen on OSH
imaging.  She was emergently taken to the angio suite and her
images were uploaded and reviewed.  She underwent:
1. Ultrasound-guided puncture of bilateral common femoral
    arteries.
2. Bilateral introduction of catheter into aorta.
3. Abdominal aortogram and selective iliac arteriogram.
4. Endovascular stent graft exclusion of ruptured abdominal
    aortic aneurysm with a [**Doctor Last Name 4726**] 31 x 14-1/2 x 130 main body
    endo prosthesis and right [**Doctor Last Name 4726**] 20 x 9.5 iliac limb and
    [**Doctor Last Name 4726**] 14-1/2 x 7 left iliac extension limb.
5. Perclose closure of bilateral common femoral
    arteriotomies.
6. Left common femoral endarterectomy with vein patch
    angioplasty.

The patient tolerated the procedure well.  Of note, she was not
intubated for the procedure given her age and co-morbidities.

Neuro: no active issues, patient is alert and interactive

Cardiopulmonary: Post-operatively she was closely monitored in
the CVICU. Initally her PPM was pacing her appropriately,
however, overnight she had an episode of asystole, lasting less
than 30 seconds. Compression were started, and the pt almost
immediately began pacing appropriately again. These episodes
recurred a few more times the evening of POD 0 and
electrophysiology was urgently consulted.  The EP fellow
interrogated the device and found the RV lead to be dislodged.
He adjusted the settings, and the pacer functioned properly.  He
recommended repleting electrolytes and discontinuing digoxin as
well.  These interventions resolved her arrythmias.  On [**6-16**]
the patient went into atrial fibrillation with rapid ventricular
response and required IV lopressor and then a diltiazem drip for
rate control.  EP and cardiology were asked to advise on
treatment.  Soltalol 80mg [**Hospital1 **] and diltiazem 30mg qid were
started and the diltiazem gtt weaned off. The pt returned to a
paced sinus rhythm within 24hrs of the atrial fibrillation and
had no further episodes throughout her stay.  Anticoagulation
was initally recommended, however given the pts age and
comorbidities it was decided that heparin/coumadin benefit would
not outway the risk, and thus asprin 325mg was initiated. On the
morning of [**6-16**] the patient began to c/o SOB, required increased
O2 and was hypoxemic on her ABG. There was concern for CHF
exacerbation as well as PE.  She urgently underwent CTA which
ruled out pulmonary embolism.  The CT did reveal pulmonary edema
and bilateral pleural effusions.  Interventional pulmonology was
consulted and felt these effusions were not large enough to
drain. There was some concern the pt may have developed
pneumonia as well given her previous emesis and immobility.  The
patient was put on broad spectrum antibiotic coverage and put on
a fluid restriction and aggressively diuresed with lasix over
the next several days with close monitoring and repletion of her
electrolytes.  The diureses significantly improved her symptoms
and her O2 requirements were subsequently minimal. On [**6-22**] she
was thought to be quite stable from a medical and surgical
standpoint and EP took her to the procedure lab where they
exchanged her PPM for a new device.  She tolerated the procedure
well and her.

GI/Nutrition:  The patient vomitted twice on POD 0 during chest
compressions, after which an  NG tube placed.  The tube was
removed a few days later when her bowel function returned.
Speech and swallow was consulted to evaluate for aspiration risk
prior to advancing the patients diet.  On preliminary
examination she passed her swallow evaluation and she was
started on a ground puree diet which was later advanced to
regular diet with thin liquids which she tolerated well.

GU: patient was found to have a UTI on Urinalysis and she was
started on antibiotics.  The culture grew moderate amt of
pseudomonas and she was started on cirpo. Her foley was
exchanged.  It was not removed as she was being aggressively
diuresed and her I/O's required close monitoring. A second UA/Cx
was sent on [**6-22**] and was negative with no bacterial growth. At
the time of discharge her foley was removed and she was voiding
without difficulty.

ID: Post-operatively patient received 3 days of kefzol for
perioperative coverage.  Given her UTI, she was started on
ciprofloxacin on [**2122-6-16**], but this was switched to ceftriaxone
and doxyclycline given concern for PNA after episodes of
vomitting and consolidation seen on CXR and CT.

Heme: patient received SQH throughout her stay for dvt
prophylaxis. There was concern for a DVT in her RUE and RLE
during her stay, however both were ruled out. She did work with
physical therapy but given her deconditioned state only
ambulated minimally. She is discharged on SQH to continue at
rehabilitation facility until she is ambulating at her baseline
state.

Medications on Admission:
potassium 20 meq daily
lasix 40 mg po qd
digoxin .125 mg daily
cardizem ER 240 mg po qd
ASA 81 mg po qd
miralax
clonidine 0.1 mg po bid


Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until pt fully
ambulatory and low risk for dvt.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb INH Inhalation Q6H (every 6 hours)
as needed for wheezing.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb inh
Inhalation Q6H (every 6 hours) as needed for SOB.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day: when
on lasix.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]

Discharge Diagnosis:
8.4 X 7.5cm ruptured AAA


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


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,
except for the following changes: we have stopped your digoxin
and diltiazem and you are now on sotalol. You should take
aspirin [**Street Address(2) 42488**] of your previous 81mg.
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go to rehab:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-11**]
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
??????	Do not shower x 1 week, you may have sponge baths. After 1
week you may shoewer, but no soaking tubs
??????	Your right chest/shoulder dressing covering the incision from
the pacemaker exchange should stay on for three days, it may be
removed on thursday [**6-25**]. The groin and leg 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
??????	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
??????	Keep your f/u appointment to be seen 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.

Followup Instructions:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2122-6-30**]
1:00
(pacemaker follow up and wound check)

Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2122-7-16**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2122-7-16**] 12:00
(vascular surgery f/u, imaging of aorta and see surgeon)



Completed by:[**2122-6-23**]
{'Abdominal aneurysm, ruptured,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Cardiac arrest,Dissection of iliac artery,Urinary tract infection, site not specified,Mechanical complication of other vascular device, implant, and graft,Fitting and adjustment of cardiac pacemaker,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: ruptured AAA

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old woman with a history of CAD s/p
pacemaker placement, atrial fibrillation, and known AAA who
presented to an OSH today with abdominal and back pain, and was
scanned demonstrating an 8.4 X 7.5 cm AAA with evidence of leak.
 She was therefore transferred to [**Hospital1 18**]
urgently for vascular surgery evaluation.

MEDICAL HISTORY: PMH:
HTN
hypothyroidism
s/p pacemaker
Atrial fibrillation
CHF
h/o MRSA cellulitis in legs
history of falls

MEDICATION ON ADMISSION: potassium 20 meq daily
lasix 40 mg po qd
digoxin .125 mg daily
cardizem ER 240 mg po qd
ASA 81 mg po qd
miralax
clonidine 0.1 mg po bid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
PE:
HR 61  BP 170/75  94% RA
NAD, awake/alert, responsive; poor historian
RRR
lungs clear
abdomen soft, moderately distended, pulsatile mass with deep
palpation
bilateral lower extremities warm, no ulceration
Pulses:
R femoral palpable, R DP palpable
L femoral palpable, L DP palpable
\
On Discharge:
VSS Afebrile
WDWN in NAD
Lungs - cta bilat
Card - RRR, paced at 60, strong PMI felt in the distal,external
thoracic cavity, due to pts habitus can feel PMI in the extreme
LUQ of the abd
Abd- soft +bs, no m/t/o
Ext- warm and dry, Fem/DP/PT pulses all palpable bilat

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone with daughter nearby 

### Response:
{'Abdominal aneurysm, ruptured,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Cardiac arrest,Dissection of iliac artery,Urinary tract infection, site not specified,Mechanical complication of other vascular device, implant, and graft,Fitting and adjustment of cardiac pacemaker,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Unspecified acquired hypothyroidism,Unspecified essential hypertension,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
