CHIEF COMPLAINT: Abdominal aortic aneurysm.

PRESENT ILLNESS: This 81-year-old lady has a 6.4 cm infrarenal abdominal aortic
aneurysm. She had a 7 cm thoracic aneurysm which was treated
with an [**First Name3 (LF) 96989**] about 3 months ago. She is now having repair
of her second aneurysm

MEDICAL HISTORY: Thoracic and Abdominal Aortic Aneurysms
Hypertension
Diverticulosis
Chronic Back Pain(L1 collapse)
Arthritis
s/p Cataract Surgery
s/p Appendectomy
s/p Cholecystectomy
s/p Mole removals
s/p D&C

MEDICATION ON ADMISSION: crestor 10', ASA 81', toprol 25'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: Tm 101.1, Tc 100.0, BP 107/50(106-151/46-68), MAPs
67-99,
RR 24-40, SaO2 96%/FT
Genl: appears to be in some distress, moving around in bed
frequently, tachypneic
HEENT: NCAT, eyes closed, sl dry MM
CV: RRR, nl S1, S2
Chest: tachypneic, some resp distress, but lungs clear
anteriorly
Abd: soft, retroperitoneal C/D/I
Ext:  all distal pulses palp

FAMILY HISTORY: Denies history of premature coronary disease.

SOCIAL HISTORY: Active smoker, 50 pack year history. Denies ETOH. She is
widowed, currently lives with her 22 year old granddaughter. She
is retired.
Abdominal aneurysm without mention of rupture,Acidosis,Alcohol withdrawal,Acute kidney failure, unspecified,Drug-induced psychotic disorder with delusions,Urinary tract infection, site not specified,Other iatrogenic hypotension,Metabolic encephalopathy,Other specified anemias,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Other and unspecified disc disorder, lumbar region,Arthropathy, unspecified, site unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Examination of participant in clinical trial
Abdom aortic aneurysm,Acidosis,Alcohol withdrawal,Acute kidney failure NOS,Drug psych disor w delus,Urin tract infection NOS,Iatrogenc hypotnsion NEC,Metabolic encephalopathy,Anemia NEC,Hypertension NOS,Dvrtclo colon w/o hmrhg,Disc dis NEC/NOS-lumbar,Arthropathy NOS-unspec,Adv eff benzodiaz tranq,Exam-clincal trial
Admission Date:  [**2196-11-2**]              Discharge Date:   [**2196-11-10**]

Date of Birth:  [**2115-2-9**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Abdominal aortic aneurysm.


Major Surgical or Invasive Procedure:
Resection and repair of abdominal aortic aneurysm with 18 mm
Dacron tube graft


History of Present Illness:
This 81-year-old lady has a 6.4 cm infrarenal abdominal aortic
aneurysm. She had a 7 cm thoracic aneurysm which was treated
with an [**First Name3 (LF) 96989**] about 3 months ago. She is now having repair
of her second aneurysm

Past Medical History:
Thoracic and Abdominal Aortic Aneurysms
Hypertension
Diverticulosis
Chronic Back Pain(L1 collapse)
Arthritis
s/p Cataract Surgery
s/p Appendectomy
s/p Cholecystectomy
s/p Mole removals
s/p D&C

Social History:
Active smoker, 50 pack year history. Denies ETOH. She is
widowed, currently lives with her 22 year old granddaughter. She
is retired.


Family History:
Denies history of premature coronary disease.

Physical Exam:
PE: VS: Tm 101.1, Tc 100.0, BP 107/50(106-151/46-68), MAPs
67-99,
RR 24-40, SaO2 96%/FT
Genl: appears to be in some distress, moving around in bed
frequently, tachypneic
HEENT: NCAT, eyes closed, sl dry MM
CV: RRR, nl S1, S2
Chest: tachypneic, some resp distress, but lungs clear
anteriorly
Abd: soft, retroperitoneal C/D/I
Ext:  all distal pulses palp

Neurologic examination:
Mental status: eyes closed, tries to open them to command,
follows command to open eyes or stick out tongue to daughter's
command, can also squeeze and release intermittently to
daughter's command. Minimal vocalizations to questions - "what"
or "[**Last Name (un) 46536**]", seems somewhat appropriate but not very interactive.

Cranial nerves: pupils equal and reactive, blinks to visual
threat b/l, L>R, +corneal reflexes. ?mild facial droop at rest
on
right, but no real NLF flattening and definite full excursion
bilaterally with grimace. Tongue midline.

Motor: moves all extremities spontaneously, symmetrically.
Strong
when resisting (not tested by command).

Sensory: withdraws to noxious stim in all extremities

DTRs: reflexes normal and symmetric throughout BUE, decreased in
BLE but symmetric. R toe mute, L toe upgoing.

Pertinent Results:
[**2196-11-10**] 06:00AM BLOOD

WBC-10.8 RBC-3.31* Hgb-9.5* Hct-28.4* MCV-86 MCH-28.6 MCHC-33.5
RDW-16.3* Plt Ct-289#

[**2196-11-9**] 02:11AM BLOOD

PT-12.7 PTT-29.4 INR(PT)-1.1

[**2196-11-10**] 06:00AM BLOOD

Glucose-81 UreaN-38* Creat-1.6* Na-141 K-4.4 Cl-105 HCO3-26
AnGap-14

[**2196-11-9**] 02:11AM BLOOD

Calcium-8.0* Phos-3.6 Mg-2.2

[**2196-11-4**] 01:24AM

URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR
Bilirub-NEG URINE RBC-[**3-13**]* WBC-[**6-18**]* Bacteri-NONE Yeast-NONE
Epi-0

[**2196-11-7**] 8:59 am MRSA SCREEN     Site: RECTAL

MRSA SCREEN (Final [**2196-11-9**]):    NO STAPHYLOCOCCUS AUREUS
ISOLATED.

[**2196-11-6**] 10:10 AM

CHEST PORT. LINE PLACEMENT

One portable view. Comparison with the previous study done
[**2196-11-5**]. There is interval improvement in bilateral pleural
effusions. The heart and mediastinal structures are unchanged. A
vascular stent is in place in the descending aorta as before. An
endotracheal tube and nasogastric tube remain in place. A
Swan-Ganz catheter has been withdrawn. A right internal jugular
catheter has been inserted and terminates in the superior vena
cava.

IMPRESSION: Interval improvement and bilateral pleural
effusions. Line placement as described.

[**2196-11-4**] 2:10 PM

CT HEAD W/O CONTRAST

FINDINGS: There is no acute intracranial hemorrhage, shift of
normally midline structures, or hydrocephalus. [**Doctor Last Name **]-white matter
differentiation is preserved. Soft tissues and osseous
structures are normal. The visualized paranasal sinuses and
mastoid air cells are clear.

IMPRESSION: No acute intracranial hemorrhage

[**2196-11-4**] 4:00 PM

RENAL U.S.

FINDINGS: The study is recent postop with extensive surgical
dressings, particularly over the left flank. The patient was
intubated and not able to comply with technologist's directions.

Limited imaging of the right kidney demonstrates a length of
approximately 10 cm. The echotexture is grossly unremarkable.
There is no hydronephrosis or stone identified. Visualization of
the left kidney was moderately compromised. The length is
approximately 9 cm. Again no gross hydronephrosis is seen. The
echotexture cannot be adequately evaluated. No stone is seen.
The patient was catheterized prior to arrival at Radiology. No
fluid is identified in the bladder. Despite multiple attempts,
visualization of the Foley catheter balloon was also not
possible.

IMPRESSION: Markedly limited study. Renal sizes are grossly
within normal limits and symmetric. No gross hydronephrosis is
identified. No stones are seen.

Cardiology Report ECHO Study Date of [**2196-11-2**]

MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: 0.7 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Diastolic Dimension: 5.6 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: 0.29 (nl >= 0.29)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aortic Valve - Valve Area: *2.7 cm2 (nl >= 3.0 cm2)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Pericardium - Effusion Size: 0.7 cm

INTERPRETATION:

Findings:

Rotated heart secondary to COPD, limited and suboptimal
transesophageal and  transgastric views.  Normal LV systolic
function without any focal abnormalities. LV circumflex  area
during diastole started with 14cmsq and was same after the cross
clamp  came off.  No wall motion abnormalities detected at the
time of cross clamping of the  aorta that was suprarenal for
22min and then for another 40 minutes for  infrarenal clamp.
Echodense shadow seen in the descending thoracic aorta
consistent with aortic  stent no endoleak seen at the graft
sight. Mild to slightly moderate TR  The PA systolic pressure
estimated from TR equal to 40 mm of Hg that  correlates with the
PA systolic pressure tracing from the PA cath.  Propagation
velocity remained within the normal range before the cross clamp
 and after the cross clamp.

LEFT ATRIUM: Normal LA size. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
All four
pulmonary veins identified and enter the left atrium.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. The IVC is
normal in diameter  with appropriate phasic respirator
variation.

LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D  images. Normal LV wall thicknesses and cavity
size. Overall normal LVEF  (>55%). TVI E/e' >15, suggesting
PCWP>18mmHg. No resting LVOT gradient.

LV WALL MOTION: basal anterior - normal; mid anterior - normal;
basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal;  mid inferoseptal - normal; basal
inferior - normal; mid inferior - normal;  basal inferolateral -
normal; mid inferolateral - normal; basal anterolateral  -
normal; mid anterolateral - normal; anterior apex - normal;
septal apex -  normal; inferior apex - normal; lateral apex -
normal; apex - normal;

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

AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal  descending aorta diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
Three aortic  valve leaflets.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**1-11**]+] TR.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.

PERICARDIUM: Small pericardial effusion.

Conclusions:

The left atrium is normal in size. No mass/thrombus is seen in
the left atrium  or left atrial appendage. Left ventricular wall
thicknesses and cavity size  are normal. Overall left
ventricular systolic function is normal (LVEF>55%).  The
calculated myocardial performance index was 0.34 (MPI A =528 ms;
MPI B = 394ms). Tissue velocity imaging E/e' is elevated (>15)
suggesting increased  left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber  size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.  There are three aortic valve leaflets. The
mitral valve appears structurally  normal with trivial mitral
regurgitation. The transmitral flow propagation  velocity is 47c
m/s (nl <=0.45m/s) There is a small pericardial effusion.





Brief Hospital Course:
Pt admitted on [**2196-11-2**]

Underwent a Resection and repair of abdominal aortic aneurysm
with 18 mm Dacron tube graft. There were no complications. Pt
was extubated in the OR.

Transfered to the VICU in stable condition

Pt had increase in creat / ARF / responded to gentle hydration.
On admission creat was 1.0 / On DC 1.6 / Pt high creat 2.3. Pt
also recieve an US of kidneys / limited study / essentially
negative.

In the above workup pt was found to have UTI / treated with
levofloxacin.

Pt became agitated post operative - CIWA scale. Pt recieved
ativan, became hypercarbic. STAT code called. Pt intubated on
the floor.  Found to be acidotic with increase lactate.
Transfered to the TICU.

Also during this time questionable facial droop / nuerology
consulted / head CT negative

Pt remaind intubated for 3 days. Pt extubated.

Post extubation pt transfered to the rehular floor.

PT cleared for home with vna

pt anmbulkating / taking po / urinating / pos bm

Medications on Admission:
crestor 10', ASA 81', toprol 25'

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed: prn for pain.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
retroperitoneal AAA
hypercarbia secondary to ativan - requiring intubation
Alcohol Withdrawal
UTI
ARF postoperative with normalization befor DC
Post operative hypovolemia
Right facial droop  - sedating medications
Metabolic acidosis


Discharge Condition:
Stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING AORTIC SURGERY

This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.

ACTIVITY:

There are no specific restrictions on activity other than no
lifting an object heavier than twenty-five (25) pounds for the
first three (3) months. Gradually increase your level of
activity back to normal depending on how you feel. Fatigue is
normal, especially for the first month postoperative. Resume
driving when you feel strong enough and comfortable enough
without needing pain medication.

PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:

Severe and worsening abdominal pain .

Pain or swelling in one of your legs.

Increasing pain, redness or drainage related to your incision(s)

Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.

Exercise:

Limit strenuous activity for 8 weeks.

Resume driving when you feel strong enough and comfortable
enough without needing pain medication .

No heavy lifting greater than 20 pounds for 8 weeks.

Avoid excessive bending at the hips and stooping for 4 weeks.

BATHING/SHOWERING:

You may shower immediately if the incision is dry upon coming
home. No baths until sutures / staples are removed. Dissolving
sutures may have been used. In either case, you can wash your
incision gently with soap and water.

WOUND CARE:

Suture / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.

When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.

Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.

MEDICATIONS:

You may resume taking medication you were on prior to your
surgery unless specifically instructed otherwise by your
physician [**Name9 (PRE) **] will be given a new prescription for pain
medication, which should be taken every three (3) to four (4)
hours only if necessary.

Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.

CAUTIONS:

NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.

Avoid heavy lifting (over 20 pounds) for 8 weeks after surgery.

No strenuous activity for 4-6 weeks after surgery.

DIET:

There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.

For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.

If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.

If you have diabetes and would like additional guidance, you may
request a referral from your doctor.

FOLLOW-UP APPOINTMENT:

Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!

Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.

PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.


Followup Instructions:
Calll Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an
apppointment for 2 weeks



Completed by:[**2196-11-10**]
{'Abdominal aneurysm without mention of rupture,Acidosis,Alcohol withdrawal,Acute kidney failure, unspecified,Drug-induced psychotic disorder with delusions,Urinary tract infection, site not specified,Other iatrogenic hypotension,Metabolic encephalopathy,Other specified anemias,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Other and unspecified disc disorder, lumbar region,Arthropathy, unspecified, site unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Examination of participant in clinical trial'}


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: Abdominal aortic aneurysm.

PRESENT ILLNESS: This 81-year-old lady has a 6.4 cm infrarenal abdominal aortic
aneurysm. She had a 7 cm thoracic aneurysm which was treated
with an [**First Name3 (LF) 96989**] about 3 months ago. She is now having repair
of her second aneurysm

MEDICAL HISTORY: Thoracic and Abdominal Aortic Aneurysms
Hypertension
Diverticulosis
Chronic Back Pain(L1 collapse)
Arthritis
s/p Cataract Surgery
s/p Appendectomy
s/p Cholecystectomy
s/p Mole removals
s/p D&C

MEDICATION ON ADMISSION: crestor 10', ASA 81', toprol 25'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: Tm 101.1, Tc 100.0, BP 107/50(106-151/46-68), MAPs
67-99,
RR 24-40, SaO2 96%/FT
Genl: appears to be in some distress, moving around in bed
frequently, tachypneic
HEENT: NCAT, eyes closed, sl dry MM
CV: RRR, nl S1, S2
Chest: tachypneic, some resp distress, but lungs clear
anteriorly
Abd: soft, retroperitoneal C/D/I
Ext:  all distal pulses palp

FAMILY HISTORY: Denies history of premature coronary disease.

SOCIAL HISTORY: Active smoker, 50 pack year history. Denies ETOH. She is
widowed, currently lives with her 22 year old granddaughter. She
is retired. 

### Response:
{'Abdominal aneurysm without mention of rupture,Acidosis,Alcohol withdrawal,Acute kidney failure, unspecified,Drug-induced psychotic disorder with delusions,Urinary tract infection, site not specified,Other iatrogenic hypotension,Metabolic encephalopathy,Other specified anemias,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Other and unspecified disc disorder, lumbar region,Arthropathy, unspecified, site unspecified,Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use,Examination of participant in clinical trial'}
