CHIEF COMPLAINT: hypoxia, hemodynamic instability

PRESENT ILLNESS: 41 yo M with h/o L4 burst fracture s/p L3-L5 fusion, complicated
by psoas abscess and formation of chronic sinus tract,
presenting with bleeding from sinus tract, fever, and hypoxia.

MEDICAL HISTORY: ulcerative colitis
L4 burst fracture s/p L3-L5 fusion [**2196**]
chronic sinus tract, as above
IVC filter placed via right groin
previous ureteric stent, now removed

MEDICATION ON ADMISSION: Lialda 1.2 grams, 2 tabs daily

ALLERGIES: Percocet

PHYSICAL EXAM: ADMISSION
T 98.9, HR 93, BP 115/64, RR 19, O2 Sat 96%/6L NC (was on NRB on
transfer to MICU)
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. Mild basilar rales.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Back: Sinus tract in left flank with wick in place and large
amount of blood on dressing but no active bleeding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. Face symmetric. Strength 5/5 throughout upper and
lower extremities.

FAMILY HISTORY: hyperlipidemia

SOCIAL HISTORY: Works as [**Doctor Last Name 3456**]. Married. Lives with wife.
-Tob: [**1-26**] cig/month
-EtOH: none
-Drugs: none
Peripheral vascular complications, not elsewhere classified,Unspecified septicemia,Sepsis,Psoas muscle abscess,Persistent postoperative fistula,Aneurysm of iliac artery,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Nontraumatic hematoma of soft tissue,Personal history of other diseases of digestive system,Unspecified local infection of skin and subcutaneous tissue,Hypoxemia
Surg comp-peri vasc syst,Septicemia NOS,Sepsis,Psoas muscle abscess,Persist postop fistula,Iliac artery aneurysm,Abn react-artif implant,Nontrauma hema soft tiss,Prsnl hst ot spf dgst ds,Local skin infection NOS,Hypoxemia
Admission Date:  [**2200-9-2**]              Discharge Date:   [**2200-9-11**]

Date of Birth:  [**2159-4-2**]             Sex:   M

Service: SURGERY

Allergies:
Percocet

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
hypoxia, hemodynamic instability


Major Surgical or Invasive Procedure:
1. Ultrasound-guided puncture of left common femoral
    artery.
2. Ipsilateral second-order catheterization of left
    external iliac artery.
3. Pelvic arteriogram.
4. Stent placement in common iliac artery.
5. Perclose closure of the left common femoral arteriotomy.


History of Present Illness:
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion, complicated
by psoas abscess and formation of chronic sinus tract,
presenting with bleeding from sinus tract, fever, and hypoxia.

The patient had an L4 burst fracture in [**2195**], fused with cage in
[**State 108**]. He later developed a fluid collection in that area, and
has a drain put in [**2200-8-25**]. 1 month later, the drain was
pulled, and the patient developed a draining sinus tract. The
patient was taken to the OR for debridement in 12/[**2197**]. This was
complicated by ureter injury. Since then, the patient had
persistent yellow/green drainage from the sinus tract.

On Sunday, the patient developed profuse bleeding from sinus
tract, which resolved before he reached [**Hospital3 417**] Medical
Center. At [**Hospital3 417**], the patient had a abd/pelvis CT
showing post-surgical changes in the left psoas muscle extending
into the left lateral abdominal wall, with no discrete fluid
collection or hematoma.  Labs were notable for WBC 14.9, 51%
bands.  The [**Hospital 228**] hospital course was complicated by fever
to as high as 103, hypotension to 89/43 which was
fluid-responsive, and further bleeding from the sinus tract in
the setting of fever and vomiting. Surgery consulted at the [**Hospital 6451**] hospital, who packed the sinus tract but did not
pursue more aggressive debridement. Pt was directly transferred
to the internal medicine
team at the [**Hospital1 18**] for further management of sinus tract
infection.

Upon arrival to the floor, patient was noted to have active,
profuse bleeding of bright red blood from the sinus tract. He
was hypotensive to low 100's/60's, with HR in low 100's. He was
bolused 3L NS, and transfusion of 2 units of PRBCs and FFP was
begun. He was given Vanc + Zosyn for broad coverage, and
admitted
to the ICU. His hemodynamics stabilized with BP's 120s/60's, and
HR 80's. The pressure dressing was removed, and sinus tract
examined, which did not appear to be actively bleeding any
longer. A CTA of abdomen/pelvis demonstrated active
extravasation of blood from a lumbar artery to L psoas muscle.
Vascular surgery
was consulted for further management.

Review of systems:
-Constitutional: +fevers, chills. Lost 10 pounds in past year.
-Resp: No cough. No shortness of breath.
-CV: No chest pain. No dizziness or lightheadedness.
-GI: No abdominal pain. +non-bloody emesis on Sunday. Chronic
diarrhea/BRBPR. No melena. No bowel or bladder incontinence.
-GU: No difficulty urinating or pain with urination.
-Neuro: No focal weakness, tingling, or numbness.

Past Medical History:
ulcerative colitis
L4 burst fracture s/p L3-L5 fusion [**2196**]
chronic sinus tract, as above
IVC filter placed via right groin
previous ureteric stent, now removed

PAST SURGICAL HISTORY:
s/p L ankle ORIF with hardware placement
s/p lumbar fusion with hardware placement
s/p OR washout/debridement [**12/2198**]


Social History:
Works as [**Doctor Last Name 3456**]. Married. Lives with wife.
-Tob: [**1-26**] cig/month
-EtOH: none
-Drugs: none


Family History:
hyperlipidemia

Physical Exam:
ADMISSION
T 98.9, HR 93, BP 115/64, RR 19, O2 Sat 96%/6L NC (was on NRB on
transfer to MICU)
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. Mild basilar rales.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Back: Sinus tract in left flank with wick in place and large
amount of blood on dressing but no active bleeding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. Face symmetric. Strength 5/5 throughout upper and
lower extremities.

DISHCARGE
T 99.7  HR 72  BP 132/78 RR 16 97%RA
Gen: No acute distress.
Neuro: A+Ox3.
Resp: Normal respiratory effort. No resp distress.
CV: RRR. Normal s1 and s2.
Abd: +BS. Soft. NT/ND.
Ext: Warm and well-perfused.
Pulses: Radial pulses palp bilaterally. DP/PT palp bilat


Pertinent Results:
CTA Abd/Pelvis
1. Psoas phlegmonous changes are again visualized with a chronic
sinus tract. However, the left psoas appears enlarged with
hyperdense foci consistent with intramuscular hemorrhage with
evidence of foci of active arterial extravasation. Evaluation of
the left psoas is somewhat obscured by streak artifact from
adjacent metallic structures. However, multiple dilated tortuous
structures are visualized and may represent mycotic aneurysms
involving the iliolumbar artery versus foci of hemorrhage.
2. Relatively stable appearance of mild left hydronephrosis
tapering to the level of the left psoas collection.
3. Mild wall thickening and hyperemia involving the descending
colon, sigmoid colon, and rectum. Although these findings may
represent proctocolitis, evaluation is somewhat limited due to
lack of distention of the bowel.  Correlation with symptoms is
recommended.
4. New mild ascites as well as new bilateral small pleural
effusions with
adjacent airspace atelectasis.
5. Right fat-containing inguinal hernia descending into the
scrotal sac with a right hydrocele.
6. IVC filter in place.
7. L4 burst fracture with L3-L5 cage.
.
MRA Abd w and w/o Contrast
Pseudoaneurysm from the left common iliac artery arising
adjacent to lumbar orthopedic hardware within the left psoas
muscle. This arises roughly 2 cm from the origin of the left
common iliac artery and 1 cm proximal to the origin of the left
internal iliac artery. Large multilobulated pseudoaneurysm
occupying the left psoas muscle with large surrounding thrombus
and hemorrhage. Report was urgently communicated to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] at 5:57 p.m. on [**2200-9-5**], and with the
interventional radiology fellow on call at pager [**Numeric Identifier 5603**] at the
time of scan.

Blood cultures negative.

[**2200-9-10**] 07:40PM BLOOD Hct-31.5*
[**2200-9-10**] 03:51AM BLOOD WBC-9.8 RBC-3.49* Hgb-9.9* Hct-28.3*
MCV-81* MCH-28.4 MCHC-35.0 RDW-16.0* Plt Ct-631*

Brief Hospital Course:
HOSPITAL COURSE
41 yo M with h/o L4 burst fracture s/p L3-L5 fusion complicated
chronic sinus tract, presenting with active bleeding from sinus
tract, fever, hypoxia and hemodynamic instability, found to have
pseudoaneurysm of left common iliac artery communicating w sinus
tract, now s/p endovascular stenting. Patient admitted to MICU.

Course in MICU [**Date range (1) 40895**]:
#Pseudoaneurysm of left common iliac artery:  Patient initially
presented to [**Hospital1 18**] in setting of profuse bleeding from sinus
tract.  Patient received 6 units pRBCs, 2 units FFP, 1 bag
platelets.  CTA abd/pelvis demonstrated intramuscular hemorrhage
at area of ileopsoas with a mycotic psuedoaneurysm w evidence
active arterial extravasation. IR attempted embolization of the
psuedoaneurysm, but were unable to locate the artery feeding it.
 Subsequent MRA demonstrated pseudoaneurysm from the left common
iliac artery with large surrounding thrombus and hemorrhage.
Patient was transferred to Vascular Service and underwent
endovascular stenting.
.
#Hypoxemia: Following transfer, patient w worsening oxygen
requirement, fluffy infilatrate on CXR.  Initial concern was for
CHF vs ARDS [**2-26**] unknown infectious process.  Timeline not
consistent w TRALI.  TTE demonstrated low-normal systolic
ejection function w possible hypokinesis of basal inferoseptal
segment.  Patient received 10mg IV lasix w good effect, although
patient remained w 2L O2 requirement at time of transfer.

#Fever: Patient initially w fever and bandemia at OSH w/o
localizing symptoms or culture data.  Patient has a long history
of signs of infection w/o positive culture data.  Patient
remained w intermittent fevers through the ICU stay.  Likely
source of infection is known sinus tract.  Patient treated w
vanco/zosyn.  No culture data at time of transfer.
.
#Ulcerative colitis - No known flare.  Held lialda given ongoing
other issues.

Patient was transferred to VICU on [**2200-9-6**]. He underwent angio
and endovascular stent placement x2 in the common iliac artery
on the left with perclosure of left common femoral artery on
[**9-6**]. Bleeding continued and patient was transfused 2 units of
blood and patient underwent repeat angio with another stent
placed on [**9-8**]. Crit was still low so additional 2 units of
blood were given. Patient did well postoperatively. Crits were
closely followed and stable. Pt was switch from vanco/zosyn to
bactrim. Patient was tolerating a regular diet, pain well
managed and ambulating on his own. Discussed operation to remove
hardware in a few weeks, patient seems amenable. Discussed
operation with Dr. [**Last Name (STitle) 1391**] and Dr. [**Last Name (STitle) 363**]. Patient will go home
on Bactrim. On discharge, pt was ambulating, tolerating regular
diet, pain controlled, hematocrit stable.


Medications on Admission:
Lialda 1.2 grams, 2 tabs daily


Discharge Medications:
1. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): Take until you come back to
hospital for reoperation.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Left common iliac pseudoaneurysm.


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


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 when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-27**]
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
??????	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 and schedule an appointment to be seen in [**4-30**] weeks for
post procedure check and CTA


Followup Instructions:
If you have questions call Dr.[**Name (NI) 1392**] office [**Telephone/Fax (1) 1393**].
{'Peripheral vascular complications, not elsewhere classified,Unspecified septicemia,Sepsis,Psoas muscle abscess,Persistent postoperative fistula,Aneurysm of iliac artery,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Nontraumatic hematoma of soft tissue,Personal history of other diseases of digestive system,Unspecified local infection of skin and subcutaneous tissue,Hypoxemia'}


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: hypoxia, hemodynamic instability

PRESENT ILLNESS: 41 yo M with h/o L4 burst fracture s/p L3-L5 fusion, complicated
by psoas abscess and formation of chronic sinus tract,
presenting with bleeding from sinus tract, fever, and hypoxia.

MEDICAL HISTORY: ulcerative colitis
L4 burst fracture s/p L3-L5 fusion [**2196**]
chronic sinus tract, as above
IVC filter placed via right groin
previous ureteric stent, now removed

MEDICATION ON ADMISSION: Lialda 1.2 grams, 2 tabs daily

ALLERGIES: Percocet

PHYSICAL EXAM: ADMISSION
T 98.9, HR 93, BP 115/64, RR 19, O2 Sat 96%/6L NC (was on NRB on
transfer to MICU)
Gen: No acute distress.
HEENT: NC/AT. Anicteric sclerae. Moist mucous membranes. OP
clear.
Neck: Supple.
Resp: Normal respiratory effort. Mild basilar rales.
CV: RRR. Normal s1 and s2. No M/G/R.
Abd: +BS. Soft. NT/ND. No rebound or guarding.
Back: Sinus tract in left flank with wick in place and large
amount of blood on dressing but no active bleeding.
Ext: Warm and well-perfused. Radial and DP pulses 2+
bilaterally.
Neuro: A+Ox3. Face symmetric. Strength 5/5 throughout upper and
lower extremities.

FAMILY HISTORY: hyperlipidemia

SOCIAL HISTORY: Works as [**Doctor Last Name 3456**]. Married. Lives with wife.
-Tob: [**1-26**] cig/month
-EtOH: none
-Drugs: none 

### Response:
{'Peripheral vascular complications, not elsewhere classified,Unspecified septicemia,Sepsis,Psoas muscle abscess,Persistent postoperative fistula,Aneurysm of iliac artery,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Nontraumatic hematoma of soft tissue,Personal history of other diseases of digestive system,Unspecified local infection of skin and subcutaneous tissue,Hypoxemia'}
