CHIEF COMPLAINT: Juxta-renal abdominal aortic aneurysm.

PRESENT ILLNESS: Pt is a 78 year old man currently admitted for AAA repair who is
recently s/p intraventricular hemorrhage

MEDICAL HISTORY: PMHx:
* Seizure disorder (details not available at this time)
* Abdominal aortic aneurysm
* Atrial fibrillation
* Hypertension
* COPD
* CHF
* Pulmonary hypertension
* Benign prostatic hypertrophy
* T2 compression fracture found [**2199-1-7**]
* s/p MRSA baceremia [**2199-1-7**]
* s/p heparin induced thrombocytopenia
* s/p cholecystectomy [**2198-1-7**]

MEDICATION ON ADMISSION: keppra 1000', toprol 75", albuterol, enalapril 5', megace 400',
NTG prn, prevacid 30', ultram 50 prn, colace 100", senna 1",
warfarin 3 to 5'(for AF)

ALLERGIES: Dilantin / Heparin Agents

PHYSICAL EXAM: Physical exam:
T Afeb  HR 88  BP 150/87  RR 14  Sat 96% on RA )
GEN 	sitting in chair, leaning to the right side, asleep
HEENT 	NCAT, MMM, OP clear, +~1.5cm skin-colored fleshy,
irregular lesion beneath right eye
Chest 	CTAB
CVS 	irregular rhythm, no m/r/g
ABD 	soft, NT, ND, +BS
EXT 	no rash, weak distal pulses

FAMILY HISTORY: Family history: Mother - deceased, stroke. Father - deceased,
MI.

SOCIAL HISTORY: Retired from [**Company 2676**], lives in rehab, has son and
daughter-in-law.
Quit smoking 10 years ago, ?4 packs per day for
20 years. No EtOH.
Abdominal aneurysm without mention of rupture,Atrial fibrillation,Congestive heart failure, unspecified,Other emphysema,Toxic encephalopathy,Acidosis,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Nonspecific abnormal findings in stool contents,Other specified disorders resulting from impaired renal function,Personal history of other diseases of circulatory system
Abdom aortic aneurysm,Atrial fibrillation,CHF NOS,Emphysema NEC,Toxic encephalopathy,Acidosis,Adv eff anticoagulants,Hypertension NOS,Hypotension NOS,Chr pulmon heart dis NEC,Abn find-stool contents,Impair ren funct dis NEC,Hx-circulatory dis NEC
Admission Date:  [**2199-5-1**]              Discharge Date:   [**2199-5-8**]

Date of Birth:  [**2121-4-19**]             Sex:   M

Service: SURGERY

Allergies:
Dilantin / Heparin Agents

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Juxta-renal abdominal aortic aneurysm.

Major Surgical or Invasive Procedure:
1. Infrarenal tube graft repair of abdominal aortic aneurysm via
retroperitoneal approach.


History of Present Illness:
Pt is a 78 year old man currently admitted for AAA repair who is
recently s/p intraventricular hemorrhage

Past Medical History:
PMHx:
* Seizure disorder (details not available at this time)
* Abdominal aortic aneurysm
* Atrial fibrillation
* Hypertension
* COPD
* CHF
* Pulmonary hypertension
* Benign prostatic hypertrophy
* T2 compression fracture found [**2199-1-7**]
* s/p MRSA baceremia [**2199-1-7**]
* s/p heparin induced thrombocytopenia
* s/p cholecystectomy [**2198-1-7**]



Social History:
Retired from [**Company 2676**], lives in rehab, has son and
daughter-in-law.
Quit smoking 10 years ago, ?4 packs per day for
20 years. No EtOH.


Family History:
Family history: Mother - deceased, stroke. Father - deceased,
MI.

Physical Exam:
Physical exam:
T Afeb  HR 88  BP 150/87  RR 14  Sat 96% on RA )
GEN 	sitting in chair, leaning to the right side, asleep
HEENT 	NCAT, MMM, OP clear, +~1.5cm skin-colored fleshy,
irregular lesion beneath right eye
Chest 	CTAB
CVS 	irregular rhythm, no m/r/g
ABD 	soft, NT, ND, +BS
EXT 	no rash, weak distal pulses


Pertinent Results:
[**2199-5-8**] INR 2.6

[**2199-5-7**] 02:20AM BLOOD

WBC-6.2 RBC-3.15* Hgb-9.5* Hct-28.0* MCV-89 MCH-30.3 MCHC-34.1
RDW-16.1* Plt Ct-167

[**2199-5-7**] 02:20AM BLOOD

PT-23.5* PTT-36.1* INR(PT)-2.3*

[**2199-5-7**] 02:20AM BLOOD

Glucose-136* UreaN-25* Creat-1.2 Na-138 K-4.3 Cl-108 HCO3-25
AnGap-9

[**2199-5-7**] 02:20AM BLOOD

Calcium-8.0* Phos-2.0* Mg-2.0

[**2199-5-4**] 08:22AM BLOOD

Lactate-1.0

[**2199-5-2**] 10:22PM BLOOD

Glucose-100 Lactate-2.3* K-3.4* Cl-125*

EVALUATION:
The examination was performed while the patient was seated
upright in the bed on VICU 11.
Cognition, language, speech, voice: Awake, alert, but slow to
respond, limited verbal output, appearing fatigued. He did
follow
one step commands, though inconsistently, with a delay and with
visual cues/modeling.  Pt's speech was intelligible and fluent,
but responses were very limited. Vocal quality was breathy,
though the pt could generate adequate voicing with effort.

Teeth: Edentulous
Secretions: Mild amount of thick, clear, sputum was stranding
from the hard palate to the tongue. This was removed with the
Yankauer catheter.

ORAL MOTOR EXAM:
WFL for labial and lingual symmetry and ROM. However, both
labial/buccal tone and tongue strength were diminished. Palatal
elevation was symmetrical. Gag was absent.

SWALLOWING ASSESSMENT:
PO swallowing assessment was completed at bedside with ice
chips,
thin liquids (tsp, cup), purees ( tsp x2), and nectar thick
liquid (tsp, cup). Oral transit was minimally slowed though no
residue was noted. Pt had a difficult time initiating taking any
po's, so feeding was required however he would not open his
mouth
sufficiently to actually allow adequate boluses into his mouth.
Laryngeal elevation appeared adequate to palpation, though he
swallowed multiple times per bolus. He did c/o sensation of
puree
sticking in his throat. Overt coughing was noted with thin
liquids and pt confirmed sensation of aspiration. No further
po's
could be assessed as pt refused any more boluses.

SUMMARY / IMPRESSION:
Pt is demonstrating overt signs of aspiration with thin liquids,
but more significantly is refusing all po's, despite maximal
encouragement. As such, beyond thin liquids the examination was
limited by the pt's fatigue, delayed response time and refusal.
Notes from discharge facility indicate poor po intake has been
an
issue, but the pt was on a full po diet so it appears that he
was
able to advance off of tube feedings. Unclear whether this
decline is related to post op somnolence or possible
toxic-metabolic issues noted per neurology. However, at this
time, I would recommend the pt remain NPO with enteral nutrition
and medications via the PEG. We will plan to re-evaluate pt
later
this week, either [**2199-5-8**] or [**2199-5-9**].

RECOMMENDATIONS:
1. Remain NPO with enteral nutrition and medications via the
PEG.

MR HEAD W/O CONTRAST  [**2199-5-4**] 9:13 PM

Interpretation: There are several areas of hyperintensity on the
diffusion weighted images. These are located in the right
frontal and left occipital lobes with questionable involvement
of the left frontal lobe. These areas are hyperintense on FLAIR,
raising the possibility that they may represent T2 shine
through. However, these diffusion findings are new since the
prior MR examination. Therefore, these likely reflect relatively
new ischemia, although they may not be truly acute. There is no
evidence of hemorrhage, edema, masses, or mass effect. The
vessels appear unchanged, with a large right A1, and no
detectable left A1 branch of the anterior cerebral artery.

Impression: Several areas of diffusion abnormality suggesting
recent infarction. No evidence of hemorrhage.

CT HEAD W/O CONTRAST  [**2199-5-4**] 2:36 PM

FINDINGS: There is no evidence of hemorrhage, mass effect, or
shift of normally midline structures. Chronic right frontal and
parietal lobe infarctions are again noted. Marked
periventricular white matter hypodensity is again seen most
consistent with chronic microvascular infarctions. The
ventricles are prominent and similar in size and symmetry.

The paranasal sinuses and mastoid air cells are well aerated.

IMPRESSION: No evidence of hemorrhage. Stable prominent
ventricles.

NOTE ADDED AT ATTENDING REVIEW: I agree with the above
interpretation. However, I am concerned that the CTA may suggest
an arteriovenous malformation. There were numerous prominent
vessels, arterial and venous, and no explanation for the
hemorrhage. I discussed this concern with Dr. [**Last Name (STitle) 71522**] at 9:25
pm on [**2199-5-4**].

[**2199-5-1**]

EKG

Atrial fibrillation, mean ventricular rate, 80. Compared to the
previous
tracing of [**2199-4-25**] no major change.

Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 72 [**Telephone/Fax (2) 71523**]7 55



Brief Hospital Course:
[**5-1**], Pt admitted had a Infrarenal tube graft repair of
abdominal aortic aneurysm via retroperitoneal approach.

Tolerated the procedure well. Had epidural placed for pain
control .L renal cross
clamp time 25 minutes. Argatroban was administered
intra-operatively

Prolong intubation in SICU / requiring pressure support /
metabolic acidosis

On [**5-2**], there was a period of hypotension to 90s/50s requiring
pressor support, but this was transient.

Pt was extubated on [**5-3**].

Pain is currently being managed with Dilaudid PCA and
Bupivacaine epidural. The last morphine dose was at 4:50pm on
[**5-2**]. Epidural DC by pain service

Pt has been somewhat difficult to arouse with limited speech
output and eye rolling during morning rounds [**5-4**], prompting
consult for seizure evaluation from Neurology

CT scan / MRI done - no acute process. Possible AVM. To be
followed as an outpt. Medications adjusted.

Final neurological - toxic-metabolic encephalopathy related to
post-surgical state and sedative medications (Dilaudid) being
used for pain control

Pt received fundaperinox from transition to coumadin for Afib.
Hx of HIT pos. When INR at goal, Fundaperinox was DC'd.

Pt with difficulty swallowing / G tube / pt on TF. Speech and
swallow consult obtained:

BEDSIDE SWALLOWING EVALUATION:

HISTORY: Thank you for referring this 78 year old male admitted
from [**Hospital1 1501**] on [**2199-5-1**] for AAA repair. AAA was diagnosed when pt
was
admitted [**12-12**] s/p right parietal subacute infarction as well as
right intraventricular hemorrhage. Post op, neurology was
consulted as the pt was somnolent with decreased speech output.
Neurology consult reported that the pt may have toxic-metabolic
encephalopathy related to post-surgical state and sedative
medications being used for pain control. PMH includes:
s/p right parietal subacute infarction and right
intraventricular
hemorrhage,  Seizure disorder, Abdominal aortic aneurysm, Atrial
fibrillation, Hypertension, COPD, CHF, Pulmonary
hypertension,Benign prostatic hypertrophy, T2 compression
fracture found [**2199-1-7**], s/p MRSA bacteremia [**1-13**], s/p
heparin induced thrombocytopenia, s/p cholecystectomy [**1-12**],(+)
UTI.

We were consulted this admission to evaluate whether pt was able
to swallow safely. We evaluated the pt multiple times last
admission with the last examination being a video swallow study
completed on [**2199-2-7**]. That study revealed a mild-moderate
oropharyngeal dysphagia that worsened over time.  After fatigue,
he demonstrated reduced A-P tongue movement, moderate oral
cavity
residue, moderately reduced hyolaryngeal excursion and laryngeal
valve closure, moderate vallecular residue and mild pyriform
sinus residue.  Pt was observed to penetrate both thin and
nectar
thick liquids with eventual aspiration of residue of thin
liquids.

Because pt's oral and pharyngeal muscles fatigued so quickly, he
was at risk to aspirate any texture of solid or liquid over the
course of an entire meal.  As such, we recommended that  the pt
remain primarily NPO at this time with nutrition, hydration, and
medication via PEG.

Per discharge summary from rehab facility, the pt participated
in
speech therapy, had a repeat video swallow study and progressed
to a ground solid, thin liquid po diet while at rehab. However,
his po intake remained poor despite stopping tube feedings and
starting the pt on Megace. However, notes from rehab facility
and
extended care facility indicate the pt was solely on a po diet,
not on tube feedings prior to admission here for AAA repair.

EVALUATION:
The examination was performed while the patient was seated
upright in the bed on VICU 11.
Cognition, language, speech, voice: Awake, alert, but slow to
respond, limited verbal output, appearing fatigued. He did
follow
one step commands, though inconsistently, with a delay and with
visual cues/modeling.  Pt's speech was intelligible and fluent,
but responses were very limited. Vocal quality was breathy,
though the pt could generate adequate voicing with effort.

Teeth: Edentulous
Secretions: Mild amount of thick, clear, sputum was stranding
from the hard palate to the tongue. This was removed with the
Yankauer catheter.

ORAL MOTOR EXAM:
WFL for labial and lingual symmetry and ROM. However, both
labial/buccal tone and tongue strength were diminished. Palatal
elevation was symmetrical. Gag was absent.

SWALLOWING ASSESSMENT:
PO swallowing assessment was completed at bedside with ice
chips,
thin liquids (tsp, cup), purees ( tsp x2), and nectar thick
liquid (tsp, cup). Oral transit was minimally slowed though no
residue was noted. Pt had a difficult time initiating taking any
po's, so feeding was required however he would not open his
mouth
sufficiently to actually allow adequate boluses into his mouth.
Laryngeal elevation appeared adequate to palpation, though he
swallowed multiple times per bolus. He did c/o sensation of
puree
sticking in his throat. Overt coughing was noted with thin
liquids and pt confirmed sensation of aspiration. No further
po's
could be assessed as pt refused any more boluses.

SUMMARY / IMPRESSION:
Pt is demonstrating overt signs of aspiration with thin liquids,
but more significantly is refusing all po's, despite maximal
encouragement. As such, beyond thin liquids the examination was
limited by the pt's fatigue, delayed response time and refusal.
Notes from discharge facility indicate poor po intake has been
an
issue, but the pt was on a full po diet so it appears that he
was
able to advance off of tube feedings. Unclear whether this
decline is related to post op somnolence or possible
toxic-metabolic issues noted per neurology. However, at this
time, I would recommend the pt remain NPO with enteral nutrition
and medications via the PEG.

RECOMMENDATIONS:
1. Remain NPO with enteral nutrition and medications via the
PEG.

[**2199-5-7**] No overnight events, neurology signed off- will see as
outpatient. PT/OT continued. REhab screen in process.
[**2199-5-8**]: VSS. No overnight events. Will discharge to rehab with
tubefeeds via Gtube. Patient will follow up with Dr.
[**Last Name (STitle) **] as scheduled. Remains on Coumadin for afib (goal
INR 2.0-3.0)

Medications on Admission:
keppra 1000', toprol 75", albuterol, enalapril 5', megace 400',
NTG prn, prevacid 30', ultram 50 prn, colace 100", senna 1",
warfarin 3 to 5'(for AF)

Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1)  Inhalation
Q6H (every 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed. ML(s)
3. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: One (1)  PO BID (2
times a day).
9. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime):
goal [**2-9**] / INR.
10. Tubefeeding orders
Tubefeeding: Start After 12:01AM; Probalance Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 55
ml/hr
Residual Check: q4h Hold feeding for residual >= : 150 ml
Flush w/ 200 ml water q8h
11. Regular Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-65   mg/dL [**1-8**] amp D50
66-120   mg/dL 0   Units 0   Units 0   Units 0   Units
121-160   mg/dL 2   Units 2   Units 2   Units 2   Units
161-200   mg/dL 4   Units 4   Units 4   Units 4   Units


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] Manor - [**Location (un) **]

Discharge Diagnosis:
PRIMARY
.
AAA
post operative pro long intubation - hypoxia
hyotension requiring pressure support
hyperchloremic metabolic acidosis 2nd to NS infusion
guiac positive stools
hypokalemia / hypomagnesium
Heparin induced thrombocytopenia
.
SECONDARY
.
AF
seizure disorder
HTN
R. intraventricular bleed
emphysema
T2 compression fx
Post operative transfusion
decrease platelets
post op confusion


Discharge Condition:
stable
Plt 167
Creat 1.2
INR(PT)-2.6


Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-14**]
weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	You may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

2. It is normal to have incisional and leg swelling:
??????	Wear loose fitting pants/clothing (this will be less
irritating to incision)
??????	Elevate your legs above the level of your heart (use [**2-9**]
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

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	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:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	You should get up every day, get dressed and walk, gradually
increasing your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????	You may shower (let the soapy water run over 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
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 101.5F for 24 hours
??????	Bleeding from incision
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions

Followup Instructions:
Call Neurology and schedule an appointment, They can be reached
at 617

Provider:

[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-23**]
11:15



Completed by:[**2199-5-8**]
{'Abdominal aneurysm without mention of rupture,Atrial fibrillation,Congestive heart failure, unspecified,Other emphysema,Toxic encephalopathy,Acidosis,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Nonspecific abnormal findings in stool contents,Other specified disorders resulting from impaired renal function,Personal history of other diseases of circulatory system'}


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: Juxta-renal abdominal aortic aneurysm.

PRESENT ILLNESS: Pt is a 78 year old man currently admitted for AAA repair who is
recently s/p intraventricular hemorrhage

MEDICAL HISTORY: PMHx:
* Seizure disorder (details not available at this time)
* Abdominal aortic aneurysm
* Atrial fibrillation
* Hypertension
* COPD
* CHF
* Pulmonary hypertension
* Benign prostatic hypertrophy
* T2 compression fracture found [**2199-1-7**]
* s/p MRSA baceremia [**2199-1-7**]
* s/p heparin induced thrombocytopenia
* s/p cholecystectomy [**2198-1-7**]

MEDICATION ON ADMISSION: keppra 1000', toprol 75", albuterol, enalapril 5', megace 400',
NTG prn, prevacid 30', ultram 50 prn, colace 100", senna 1",
warfarin 3 to 5'(for AF)

ALLERGIES: Dilantin / Heparin Agents

PHYSICAL EXAM: Physical exam:
T Afeb  HR 88  BP 150/87  RR 14  Sat 96% on RA )
GEN 	sitting in chair, leaning to the right side, asleep
HEENT 	NCAT, MMM, OP clear, +~1.5cm skin-colored fleshy,
irregular lesion beneath right eye
Chest 	CTAB
CVS 	irregular rhythm, no m/r/g
ABD 	soft, NT, ND, +BS
EXT 	no rash, weak distal pulses

FAMILY HISTORY: Family history: Mother - deceased, stroke. Father - deceased,
MI.

SOCIAL HISTORY: Retired from [**Company 2676**], lives in rehab, has son and
daughter-in-law.
Quit smoking 10 years ago, ?4 packs per day for
20 years. No EtOH. 

### Response:
{'Abdominal aneurysm without mention of rupture,Atrial fibrillation,Congestive heart failure, unspecified,Other emphysema,Toxic encephalopathy,Acidosis,Anticoagulants causing adverse effects in therapeutic use,Unspecified essential hypertension,Hypotension, unspecified,Other chronic pulmonary heart diseases,Nonspecific abnormal findings in stool contents,Other specified disorders resulting from impaired renal function,Personal history of other diseases of circulatory system'}
