CHIEF COMPLAINT: AAA

PRESENT ILLNESS: 69 y.o female with AAA, which has grown from 4 cm to 6.5 cm.

MEDICAL HISTORY: 1. CAD s/p CABG [**2138**] LIMA-->LAD, VG-->OM, VG--->RCA. Exercise
MIBI ([**3-3**]): Interval development of moderate, reversible distal
anterior wall and apical perfusion defect, involving the
expected LAD territory. Stable, moderate, predominantly fixed
perfusion defect involving the lateral wall and lateral portion
of the inferior wall. Normal left ventricular cavity size.Mildly
depressed left ventricular function with hypokinesis ofthe apex
and septal akinesis, the latter being consistent with prior
CABG. EF 46%.
[**4-30**] Echo: mild LAE, mild LV sys fcn, focal hypokinesis w/ basal
inf/lat wall

MEDICATION ON ADMISSION: ASA 81', Lipitor 20', Iron 325'' Imdur 90', Lasix 40'', Protonix
40', Univasc 15', nadolol 60', Norvasc 10', Lantus 31HS, Humulin
SS, Epogen

ALLERGIES: Cardizem / Codeine / Optiray 300

PHYSICAL EXAM: Elderly female, NAD
NCAT, PERRL, EOMI
neg lesions nares, oral pharnyx, auditory
supple, farom
neg lymphandopathy or supraclavicular nodes
[**Hospital1 **]-basilar crackles at bases
rrr without murmers
Right groin  / JP drain / neg erythema noted
palpable pulse b/l le

FAMILY HISTORY: Her mother had non-alcoholic liver cirrhosis.
Her father had diabetes.

SOCIAL HISTORY: Patient denies any significant etoh history.  She used to smoke
cigarettes but quit 18 years ago.  No tattoos.  No IVDU.  She is
Irish/Lebanese.lives with son.  2 Daughters work at [**Hospital1 18**] in
PACU.
Abdominal aneurysm without mention of rupture,Infection and inflammatory reaction due to other vascular device, implant, and graft,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Cirrhosis of liver without mention of alcohol,Congestive heart failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Pneumonia, organism unspecified,Acquired coagulation factor deficiency,Thrombocytopenia, unspecified,Unspecified essential hypertension,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Long-term (current) use of insulin,Aortocoronary bypass status,Legal blindness, as defined in U.S.A.
Abdom aortic aneurysm,React-oth vasc dev/graft,Hemorrhage complic proc,Ac posthemorrhag anemia,Cirrhosis of liver NOS,CHF NOS,Chr blood loss anemia,DMII ophth nt st uncntrl,Pneumonia, organism NOS,Acq coagul factor defic,Thrombocytopenia NOS,Hypertension NOS,Portal hypertension,Esoph varice oth dis NOS,Long-term use of insulin,Aortocoronary bypass,Legal blindness-usa def
Admission Date:  [**2142-7-6**]              Discharge Date:   [**2142-7-31**]

Date of Birth:  [**2072-12-5**]             Sex:   F

Service: SURGERY

Allergies:
Cardizem / Codeine / Optiray 300

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA

Major Surgical or Invasive Procedure:
[**2142-7-6**]- Endovascular repair of abdominal aortic aneurysm with
bilateral femoral endarterectomies complicated by left external
iliac artery avulsion s/p left iliac stent graft to left CFA,
bilateral femoral endartectomies and rt.

CFA patch angioplasty [**2142-7-7**]

RT. groin washout [**2142-7-8**]


History of Present Illness:
69 y.o female with AAA, which has grown from 4 cm to 6.5 cm.

Past Medical History:
1. CAD s/p CABG [**2138**] LIMA-->LAD, VG-->OM, VG--->RCA. Exercise
MIBI ([**3-3**]): Interval development of moderate, reversible distal
anterior wall and apical perfusion defect, involving the
expected LAD territory. Stable, moderate, predominantly fixed
perfusion defect involving the lateral wall and lateral portion
of the inferior wall. Normal left ventricular cavity size.Mildly
depressed left ventricular function with hypokinesis ofthe apex
and septal akinesis, the latter being consistent with prior
CABG. EF 46%.
[**4-30**] Echo: mild LAE, mild LV sys fcn, focal hypokinesis w/ basal
inf/lat wall

2. DM2
3. cryptogenic cirrhosis (?NASH) c/b esophgeal varicies
4. pancytopenia
5. CRI (1.9)
6. h/o PUD
7. h/o LGIB (AVM)
8. AAA: [**3-3**] Abd MRI- infrarenal AAA 5 x 6 cm with diffuse
atherosclerotic change
9. MI [**2122**]
10. s/p R cataract surgery


Social History:
Patient denies any significant etoh history.  She used to smoke
cigarettes but quit 18 years ago.  No tattoos.  No IVDU.  She is
Irish/Lebanese.lives with son.  2 Daughters work at [**Hospital1 18**] in
PACU.


Family History:
Her mother had non-alcoholic liver cirrhosis.
Her father had diabetes.

Physical Exam:
Elderly female, NAD
NCAT, PERRL, EOMI
neg lesions nares, oral pharnyx, auditory
supple, farom
neg lymphandopathy or supraclavicular nodes
[**Hospital1 **]-basilar crackles at bases
rrr without murmers
Right groin  / JP drain / neg erythema noted
palpable pulse b/l le


Pertinent Results:
[**2142-7-31**]

WBC-2.8* RBC-3.57* Hgb-10.4* Hct-31.1* MCV-87 MCH-29.2 MCHC-33.5
RDW-18.2* Plt Ct-70*

[**2142-7-27**]

PT-14.4* PTT-32.5 INR(PT)-1.4

[**2142-7-31**]

Glucose-116* UreaN-13 Creat-1.3* Na-136 K-4.0 Cl-102 HCO3-28
AnGap-10

[**2142-7-31**]

Calcium-7.6* Phos-2.8 Mg-1.7

[**2142-7-11**]

freeCa-1.03*

[**Month/Day/Year 706**]  Final Report

CHEST (PA & LAT)  [**2142-7-28**] 5:52 PM

CHEST (PA & LAT)

Reason: please eval tip of picc. thanks

[**Hospital 93**] MEDICAL CONDITION:
69 year old woman with AAA, recurrent CHF,CAD with baslar
crackles and JVD.
REASON FOR THIS EXAMINATION:
please eval tip of picc. thanks
This is a two view chest dated [**2142-7-28**].

INDICATION: PICC line placement.

Comparison is made to previous study of [**2142-7-23**].

A left PICC line is present, terminating within the superior
vena cava. The cardiac silhouette is mildly enlarged. There is
upper zone [**Year (4 digits) 1106**] redistribution, mild perihilar haziness, and
subtle interstitial opacities in the perihilar and basilar
regions. Small pleural effusions are noted as well as a small
amount of fluid within the fissures.

IMPRESSION:
1. Left PICC line in satisfactory position.

2. Congestive heart failure, which has worsened compared to the
recent radiograph.
Cardiology Report ECG Study Date of [**2142-7-26**]  10:11:22 AM


Sinus bradycardia, rate 57. Left anterior hemiblock. T wave
inversion in
lead VI suggestive of ischemia. Non-specific repolarization
changes in the
lateral standard and precordial leads. Possible old inferior
wall myocardial
infarction. Cannot exclude anterior myocardial infarction of
indeterminate age.
Compared to the previous tracing of [**2142-7-25**] T waves are more
deeply inverted in
leads V2 and aVL suggesting an ongoing acute ischemic process.


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
57 132 104 486/478.58 24 -44 100
Cardiology Report ECHO Study Date of [**2142-7-18**]



PATIENT/TEST INFORMATION:
Indication: Left ventricular function.  H/O cardiac surgery.
Height: (in) 66
Weight (lb): 164
BSA (m2): 1.84 m2
BP (mm Hg): 144/43
HR (bpm): 77
Status: Inpatient
Date/Time: [**2142-7-18**] at 16:30
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W272-1:13
Test Location: West SICU/CTIC/VICU
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1111**]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.0 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 3.2 cm
Left Ventricle - Fractional Shortening: 0.35 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 1.27
Mitral Valve - E Wave Deceleration Time: 170 msec
TR Gradient (+ RA = PASP): *52 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

This study was compared to the prior study of [**2141-5-23**].


LEFT ATRIUM: Moderate LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mild
regional LV
systolic dysfunction. Mildly depressed LVEF.

LV WALL MOTION: Regional LV wall motion abnormalities include:
basal inferior
- hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo;

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+]
TR. Moderate
PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.


PERICARDIUM: No pericardial effusion.

Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. There is mild regional left ventricular
systolic
dysfunction. Overall left ventricular systolic function is
mildly depressed.
Resting regional wall motion abnormalities include inferolateral
hypokinesis.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation
is seen. There is moderate pulmonary artery systolic
hypertension. There is no
pericardial effusion.

Compared with the prior study (tape reviewed) of [**2141-5-23**], the
estimated
pulmonary artery ysystolic pressure is now higher. Left
ventricualr systolic
function appears similar.

Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2142-7-18**] 18:58.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]
[**Name Initial (NameIs) 706**]  Final Report

CTA ABD W&W/O C & RECONS  [**2142-7-16**] 3:41 PM

CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS

Reason: ENDOVASCULAR REPAIR AAA
Field of view: 40 Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
69 year old woman s/p endovascular AAA repair
REASON FOR THIS EXAMINATION:
We need CTA of Abdomen
CONTRAINDICATIONS for IV CONTRAST: None.

HISTORY: 69-year-old woman status post endovascular abdominal
aortic aneurysm repair.

COMPARISON: [**2142-5-16**].

TECHNIQUE: Multiple axial images of the abdomen and pelvis were
obtained both prior to and following the administration of 150
cc of Optiray. In addition, reconstructed images in the coronal
and sagittal planes were obtained.

CT OF THE ABDOMEN WITHOUT AND WITH IV CONTRAST: Few images
through the lung bases demonstrate small bilateral pleural
effusions with associated bibasilar atelectasis, left greater
than right. There are small paracardial lymph nodes measuring up
to 7 mm in diameter.

There is a large amount of ascites, surrounding the liver and
spleen. The spleen is enlarged. There are splenic artery
calcifications seen. No focal liver lesions are identified. Both
kidneys are slightly atrophic. There are bilateral symmetric
nephrograms . The adrenal glands are unremarkable. There are
calcified gallstones in the gallbladder.

The free fluid surrounding the liver and spleen tracks into the
pelvis, surrounding the bladder.

The celiac, superior mesenteric, and renal arteries are patent.
There is an infrarenal aortic aneurysm, unchanged in size
compared to [**2142-5-24**]. However, in the interim, there has
been a placement of aorto- bilateral iliac stent grafts.

Within the left posterior pararenal space, there is a large
collection with attenuation values ranging between 40-29
Hounsfield units measuring approximately 9.8 (transverse)x 4.9
(anterior-posterior) x 10.3 cm in the craniocaudad dimension.
This displaces the left kidney anteriorly. These are best
visualized on the coronal reconstructed images, and the inferior
aspect of this hematoma abuts the left limb of the stent graft.
However, no active extravasation is identified.

CT PELVIS WITH IV CONTRAST: There is diverticulosis without
diverticulitis. There is a large amount of free fluid in the
pelvis. There is air in the bladder presumably from recent
instrumentation. There are bilateral groin skin staples. There
is slight asymmetry of the left groin musculature with small low
attenuation fluid, which could be secondary to postoperative
procedures.

RECONSTRUCTED IMAGES: Reformatted images in the coronal and
sagittal planes confirmed the presence of the left posterior
pararenal space hematoma, which displaces the left kidney
anteriorly. The value grade of these images is 4.

Findings were communicated to Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] on [**2142-7-16**].

IMPRESSION:
1. Left posterior pararenal space hematoma displacing the left
kidney anteriorly. No active extravasation is identified.
2. Marked amount of ascites.
3. Bilateral pleural effusions and bibasilar atelectasis.
4. Splenomegaly.
[**2142-7-26**] 12:40 am STOOL     CONSISTENCY: SOFT      Source:
Stool.

                            **FINAL REPORT [**2142-7-26**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2142-7-26**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
      Reference Range:  Negative.
 [**2142-7-18**] 7:30 pm BLOOD CULTURE

                            **FINAL REPORT [**2142-7-24**]**

   AEROBIC BOTTLE (Final [**2142-7-24**]):    NO GROWTH.

   ANAEROBIC BOTTLE (Final [**2142-7-24**]):    NO GROWTH.
[**2142-7-9**] 9:06 am SWAB     Site: RECTAL      RECTAL.

                            **FINAL REPORT [**2142-7-13**]**

   MRSA SCREEN (Final [**2142-7-11**]):    NO STAPHYLOCOCCUS AUREUS
ISOLATED.

   R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2142-7-13**]):
      No VRE isolated.
      ENTEROCOCCUS SP..    MODERATE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
LEVOFLOXACIN----------     1 S
PENICILLIN------------     2 S
VANCOMYCIN------------     2 S







Brief Hospital Course:
Pt admitted [**2142-7-6**] AAA

Pt underwent a endovascular abdominal aortic aneurysm repair,
repair of left external iliac artery avulsion, bypass from left
iliac stent graft to left common femoral artery, and bilateral
femoral endarterectomy and patch angioplasty of
right common femoral artery. Pt remained intubated post
procedure. She was transfered to SICU in fair condition.

Pt experienced a iliac artery rupture intra - op.

[**2142-7-7**] - [**2142-7-15**] - SICU status

Pt experience blood loss intra procedure. Pt had multiple blood
transfusions / BP / HR / HCT were followed.

Pt was on and off IV blood pressure medications for BP support.

Pt also experienced high grade temps Vanco / Zosyn started

Pt extubated [**2142-7-13**]

[**Last Name (un) **] consult put in for the patient.

[**2142-7-16**] - [**2142-7-18**]

Pt transfered to the floor in stable condition. Pt diet advanced
as tolerated. PT consult is obtained.

Pt still has significant drainage from groin incision. Pt gets
CTA ( no endo leak ). Zosyn is DC'd. Pt remains on Vancomycin.
Cefazolin started.

Pt experiences chest pain. Pt ruled out for MI by CK, but pt had
inrease in troponin level. Given the patients difficult hospital
course to date a cardiology consult was obtained. They suggested
that the pt recently had MI, but probable not related to this
hospital course.

Pt beta blocker increases / asa continued

[**2142-7-19**] - [**2142-7-24**]

Pt recieves surface echo. EF 45% / found to have mild chf, pt
recieves lasix. Lytes replenished.

Cx show e-coli / staph coag neg. from groin, Cefazolin dc'd. Pt
put on Zosyn. C/W Vancomycin.

Groin continues to drain.

Epogen restarted

[**2142-7-25**] - [**2142-7-26**]

Pt goes back to the OR for lymphatic leak from right groin. She
undergoes an excision and debridement of right groin wound and
secondary primary closure. Pt recieves a JP drain. She tolerates
the procedure well. There are no complications. This is done by
MAC. She is transfered to the PACU in stable condition.

After recovery from anesthesia transfered to the floor in stable
condition.

[**2142-7-27**] - [**2142-7-30**]

Pt recieves PICC line. Case management is involved for home VNA
services. Pt consult is obtained.

[**2142-7-31**]

Pt is stable on DC. She is urinating / taking PO / pos BM.

She leaves with VNA services for:
1. IV antibiotics
2. daily weights
3. lytes / vanco dosing - labs
4. JP drain monitering

She is to follow-up with Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **] in one week


Medications on Admission:
ASA 81', Lipitor 20', Iron 325'' Imdur 90', Lasix 40'', Protonix
40', Univasc 15', nadolol 60', Norvasc 10', Lantus 31HS, Humulin
SS, Epogen

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed.
Disp:*100 cc* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
7. Epoetin Alfa 4,000 unit/mL Solution Sig: as directed
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*1 vial* Refills:*2*
8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Moexipril 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Nadolol 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
13. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for for loose bowel
movements.
Disp:*30 Tablet(s)* Refills:*0*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
15. glargine  Sig: Ten (10) units  at bedtime.
16. Vancomycin HCl 1000 mg IV Q 24H
please check trough at 3rd dose
HOLD FOR VANCO TROUGH >15
17. Outpatient Lab Work
[**Hospital1 **], bun/cr and trough weekly. call results to Dr.[**Name (NI) 5695**]
office [**Telephone/Fax (1) 3121**]
18. Humalog 100 unit/mL Solution Sig: as directed  Subcutaneous
four times a day: AC scale:
glucoses <100 no insulin
glucoses 101-150/4u
glucoses 151-200/5u
glucoses 201-250/6u
glucoses 251-300/7u
glucoses 301-350/8u
glucoses 351-400/9u
glucoses >400 [**Name8 (MD) 138**] md
Bedtime scale:
glucoses <150,no insulin
glucoses 151-200/2u
glucoses 201-250/3u
glucoses 251-300/4u
glucoses 301-350/5u
glucoses 351-400/5u
glucoses >400 [**Name8 (MD) 138**] Md.
19. ampicillan  Sig: One (1) 500 mg  four times a day for 6
weeks.
Disp:*60 500mg* Refills:*3*
20. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
Status post abdominal aortic aneurysm repair, postoperative
blood loss anemia ,transfused

DM2 insulin dependant,uncontrolled

Postoperative CHF, compensated

HX CAD w angina, controlled


Discharge Condition:
stable

Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Also
call if you loose more then 5 lbs.

Adhere to 2 gm sodium diet

Moniter cbc,bun,cr, vanco trough weekly.

Continue antibiotics for total of 6 weeks started [**7-9**]-continue
thru [**8-19**]

You have a JP drain, please moniter the output and empty daily.

Call if your surgical wound becomes red, drains, or has
discharge. Also call if you experience fever and or chills.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-8-2**] 11:30

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2142-9-11**] 1:30

Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2143-1-23**] 9:00

Provider: [**Name10 (NameIs) 1111**],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 3121**]  Follow-up
appointment should be in 1 weeks.

You have an appointment already with Dr [**Last Name (STitle) **]. Please schedule
another appointment when you leave. Schedule the appointment for
one week. He can be reached at [**Telephone/Fax (1) 5003**]



Completed by:[**2142-7-31**]

Unit No:  [**Numeric Identifier 22375**]
Admission Date: [**2142-7-6**]
Discharge Date: [**2142-7-31**]
Date of Birth:  [**2072-12-5**]
Sex:  F
Service:  VSU


CHIEF COMPLAINT:  Abdominal aortic aneurysm.

HISTORY OF PRESENT ILLNESS:  This is a 69-year-old female who
was initially evaluated by Dr. [**Last Name (STitle) **] in an office visit
on [**2142-4-30**] for a known abdominal aortic aneurysm.
Patient was encouraged by her daughter to seek followup and
evaluation. The aneurysm was 1st noted 4 years ago at the
time of her coronary artery bypass by Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **].
It was found to be in a 4 cm range. This is progressively
enlarged and it is now at 6.5 cm in maximal diameter. She
does admit to having intermittent episodes of chest pain and
had a nuclear medicine scan which showed a small area of
reversible ischemia and larger fixed defect with a mildly
reduced ejection fraction. Patient has had episodes of
congestive failure in the past.

Patient is known to have a chronic anemia related to GI
bleeds of uncertain origin. Hematocrit usually ranges between
25 and 32. Patient also is known to have hepatic cirrhosis of
undetermined etiology, and she has been followed by Dr. [**First Name (STitle) **]
[**Name (STitle) **] in the past. Her albumin is 3. Her PT is approximately
14. Her platelet count is 70-80 range. She has not undergone
a repeat coronary angiography because of her inability to
tolerate Plavix secondary to her GI bleeding. Patient does
admit to chronic low back pain and denies any other specific
symptoms.

PAST MEDICAL HISTORY:  Past medical history is significant
for hypertension, type 2 diabetes x18 years and insulin
dependent, does admit to history of gallstones, asymptomatic,
history of spinal canal stenosis, history of angina, coronary
artery disease.

PAST SURGICAL HISTORY:  Past surgical history includes CABG
and tonsillectomy.

ALLERGIES:  Cardizem - manifestations not documented. Plavix
- GI bleed.

PHYSICAL EXAMINATION:  She is a well appearing, elderly lady
in no acute distress. Blood pressure is 150/80, pulse 58.
HEENT exam was unremarkable. Chest was clear to auscultation.
Heart is regular rate and rhythm. Abdominal exam is soft.
There is no shifting dullness or fluid wave. Her aneurysm is
faintly palpable. Her abdomen is slightly protuberant and is
nontender. Pulse exam: She has palpable femorals bilaterally.
Popliteal pulses are nonpalpable. She has strongly palpable
right DP and a very diminished left DP.

Patient now was admitted for elective abdominal aortic
repair.

HOSPITAL COURSE:  Patient was admitted to the preoperative
holding area on [**2142-7-6**]. She underwent an endovascular
abdominal aortic aneurysm repair with repair of the left
external iliac avulsion with a bypass from the left iliac
stent graft to the common femoral artery. She had bilateral
femoral endarterectomies and a patch angioplasty to the right
common femoral. Patient tolerated the procedure well and was
transferred to the PACU in stable condition.

Patient was transferred to the SICU for continued care.
Patient returned on [**2142-7-8**] to the OR for a right groin
washout. She remained in the SICU for vasopressor support and
ventilation. Patient was transferred to regular nursing floor
on [**7-12**].

On [**7-23**], patient had an episode of shortness of breath.
This was very consistent with congestive heart failure.
Patient was diuresed with improvement in her symptoms.
Patient was followed by [**Last Name (un) **] during her hospitalization for
glycemic management. Patient returned to the OR on [**2142-7-25**] for a right groin wound washout and primary closure.
PICC line was placed on [**2142-7-26**] for long-term
antibiotics.

Patient's wound culture grew E. coli and Staph-coag negative
MRSA. Patient was continued on vancomycin and levofloxacin.
The patient's wound showed continued improvement. Patient
will be discharged to home with IV antibiotics for a total of
6 weeks. Antibiotics were started on [**7-9**], will continue
through [**8-20**]. Patient should follow up with Dr. [**Last Name (STitle) **]
as directed.

DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm status post endovascular repair,
   iliac avulsion left status post bypass graft from iliac
   stent to common left femoral artery, status post bilateral
   femoral endarterectomies with a right femoral artery
   angioplasty.
2. Blood loss anemia corrected.
3. Type 2 diabetes, insulin dependent controlled.
4. Coronary artery disease with congestive failure
   postoperatively compensated.
5. Right groin seroma with infection treated.
6. Hypertension controlled.


DISCHARGE MEDICATIONS:  Acetaminophen 325 mg tablets [**1-28**] q.4-
6h. p.r.n., Protonix 40 mg daily, Sarna lotion to effected
areas daily, aspirin 81 mg daily, oxycodone/acetaminophen
5/325 tablets [**1-28**] q.4-6h. p.r.n., nitroglycerin sublingual
0.3 mg tablets p.r.n., Epogen 4000 units subcutaneously every
Monday, Wednesday, and Friday, isosorbide mononitrate 90 mg
daily, atorvastatin 20 mg daily, ferrous sulfate 325 mg
daily, moexipril 7.5 mg daily, nadolol 60 mg daily,
diphenoxy/atropine 2.5/0.25 mg tablets 2 q.6h. p.r.n. for
bowel movements, calcium carbonate 500 mg q.i.d. p.r.n., and
Bicillin 500 mg q.6h. times a total of 1 week, glargine 10
units at bedtime, Humalog insulin before meals and at bedtime
as directed, vancomycin 1 gram q.24h. for a total of 6 weeks.
This will be continued through [**2142-8-20**].

DISCHARGE INSTRUCTIONS:  Patient should follow up with Dr.
[**Last Name (STitle) **] as directed. The wound should continue with dry
sterile dressings. If there is increasing drainage, erythema,
or if patient develops fever, they should call the office
sooner. Outpatient lab work includes a CBC, BUN, creatinine,
and vancomycin trough weekly. These results should be called
to Dr.[**Name (NI) 5695**] office.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]

Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D:  [**2142-7-31**] 10:28:05
T:  [**2142-7-31**] 11:01:22
Job#:  [**Job Number 22376**]
{'Abdominal aneurysm without mention of rupture,Infection and inflammatory reaction due to other vascular device, implant, and graft,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Cirrhosis of liver without mention of alcohol,Congestive heart failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Pneumonia, organism unspecified,Acquired coagulation factor deficiency,Thrombocytopenia, unspecified,Unspecified essential hypertension,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Long-term (current) use of insulin,Aortocoronary bypass status,Legal blindness, as defined in U.S.A.'}


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: AAA

PRESENT ILLNESS: 69 y.o female with AAA, which has grown from 4 cm to 6.5 cm.

MEDICAL HISTORY: 1. CAD s/p CABG [**2138**] LIMA-->LAD, VG-->OM, VG--->RCA. Exercise
MIBI ([**3-3**]): Interval development of moderate, reversible distal
anterior wall and apical perfusion defect, involving the
expected LAD territory. Stable, moderate, predominantly fixed
perfusion defect involving the lateral wall and lateral portion
of the inferior wall. Normal left ventricular cavity size.Mildly
depressed left ventricular function with hypokinesis ofthe apex
and septal akinesis, the latter being consistent with prior
CABG. EF 46%.
[**4-30**] Echo: mild LAE, mild LV sys fcn, focal hypokinesis w/ basal
inf/lat wall

MEDICATION ON ADMISSION: ASA 81', Lipitor 20', Iron 325'' Imdur 90', Lasix 40'', Protonix
40', Univasc 15', nadolol 60', Norvasc 10', Lantus 31HS, Humulin
SS, Epogen

ALLERGIES: Cardizem / Codeine / Optiray 300

PHYSICAL EXAM: Elderly female, NAD
NCAT, PERRL, EOMI
neg lesions nares, oral pharnyx, auditory
supple, farom
neg lymphandopathy or supraclavicular nodes
[**Hospital1 **]-basilar crackles at bases
rrr without murmers
Right groin  / JP drain / neg erythema noted
palpable pulse b/l le

FAMILY HISTORY: Her mother had non-alcoholic liver cirrhosis.
Her father had diabetes.

SOCIAL HISTORY: Patient denies any significant etoh history.  She used to smoke
cigarettes but quit 18 years ago.  No tattoos.  No IVDU.  She is
Irish/Lebanese.lives with son.  2 Daughters work at [**Hospital1 18**] in
PACU. 

### Response:
{'Abdominal aneurysm without mention of rupture,Infection and inflammatory reaction due to other vascular device, implant, and graft,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Cirrhosis of liver without mention of alcohol,Congestive heart failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Pneumonia, organism unspecified,Acquired coagulation factor deficiency,Thrombocytopenia, unspecified,Unspecified essential hypertension,Portal hypertension,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Long-term (current) use of insulin,Aortocoronary bypass status,Legal blindness, as defined in U.S.A.'}
