CHIEF COMPLAINT: Incidental asymptomatic left subclavian artery aneurysm

PRESENT ILLNESS: Ms. [**Known lastname **] is an 86-year-old woman referred by Dr. [**Last Name (STitle) 29111**]
[**Name (STitle) 11302**] for evaluation of a newly detected asymptomatic left
subclavian artery aneurysm.  She had not been seen by doctor in
many years, but was noticing difficulty with vision. She saw an
ophthalmologist in preparation for cataract surgery.  Her
preoperative evaluation detected hypertension and significant
hyperlipidemia. A
chest x-ray, as part of the preoperative evaluation, noted a
mass in the upper left chest prompting a CT scan, which
demonstrates a 4-cm pseudoaneurysm originating at the inferior
aspect of the origin left subclavian artery.  She denies any
history of major trauma, specifically she does not recall any
motor vehicle accidents or major falls.  She is a long-term
smoker and ongoing smoker smoking three quarters of a pack per
day.  She does have newly diagnosed hypertension and
hyperlipidemia.  She does not have diabetes.

MEDICAL HISTORY: PMH: HTN, Chol

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: Zocor 20'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: a/o x 3
supple
farom
neg lymphandopathy
cta
rrr
pos bs
surgical incision c/d/i
Pulses: Fem DP PT [**Name (NI) 1035**] [**Name (NI) **] Uln
     Rt 2+  D  D  2+    2+  mono
     Lt 2+  D  D  2+    2+  mono

FAMILY HISTORY: non-contrubutory. She has no family history of aneurysms

SOCIAL HISTORY: She is a homemaker.  She does not drink alcohol
Thoracic aneurysm without mention of rupture,Unspecified essential hypertension,Pure hypercholesterolemia,Aneurysm of subclavian artery,Other complications due to other vascular device, implant, and graft
Thoracic aortic aneurysm,Hypertension NOS,Pure hypercholesterolem,Subclavian aneurysm,Comp-oth vasc dev/graft
Admission Date:  [**2164-10-22**]              Discharge Date:   [**2164-10-31**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Incidental asymptomatic left subclavian artery aneurysm

Major Surgical or Invasive Procedure:
[**2164-10-22**] - PROCEDURE:  Right carotid to left carotid bypass with
6 mm
PTFE, left carotid to left subclavian transposition

[**2164-10-23**] - PROCEDURES: 1. Stent graft repair of aortic arch/left
subclavian artery aneurysm with a [**Doctor Last Name 4726**] TAG endograft. The
endograft data is the following: It is a [**Doctor Last Name 4726**] TAG graft,
reference#[**Serial Number 80235**], lot #[**Serial Number 80236**]. 2. Thoracic aortography. 3.
Placement of an aortic conduit for delivery of the stentgraft.

[**2164-10-23**] - PROCEDURE:  Thoracic aortic stent graft placement.


History of Present Illness:
Ms. [**Known lastname **] is an 86-year-old woman referred by Dr. [**Last Name (STitle) 29111**]
[**Name (STitle) 11302**] for evaluation of a newly detected asymptomatic left
subclavian artery aneurysm.  She had not been seen by doctor in
many years, but was noticing difficulty with vision. She saw an
ophthalmologist in preparation for cataract surgery.  Her
preoperative evaluation detected hypertension and significant
hyperlipidemia. A
chest x-ray, as part of the preoperative evaluation, noted a
mass in the upper left chest prompting a CT scan, which
demonstrates a 4-cm pseudoaneurysm originating at the inferior
aspect of the origin left subclavian artery.  She denies any
history of major trauma, specifically she does not recall any
motor vehicle accidents or major falls.  She is a long-term
smoker and ongoing smoker smoking three quarters of a pack per
day.  She does have newly diagnosed hypertension and
hyperlipidemia.  She does not have diabetes.

She has no family history of aneurysms.  She has not had any
stroke or left arm ischemia or embolization and is not having
any chest pain or arm swelling.


Past Medical History:
PMH: HTN, Chol

PSH: neg


Social History:
She is a homemaker.  She does not drink alcohol

Family History:
non-contrubutory. She has no family history of aneurysms

Physical Exam:
a/o x 3
supple
farom
neg lymphandopathy
cta
rrr
pos bs
surgical incision c/d/i
Pulses: Fem DP PT [**Name (NI) 1035**] [**Name (NI) **] Uln
     Rt 2+  D  D  2+    2+  mono
     Lt 2+  D  D  2+    2+  mono


Pertinent Results:
[**2164-10-25**] - [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT - The left atrium is
normal in size. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is asymmetric left ventricular hypertrophy in the basal septum.
Mid to apical septum wall thickness appears to be normal. No
mid-cavitary gradient is identified. Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. The mitral valve leaflets are
structurally normal. Moderate to severe eccentric jet (3+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is mild pulmonary artery systolic
hypertension with estimated pulmonary [**Last Name (un) **] systolic pressure
around 40 mm Hg. There is no pericardial effusion.

Radiology Report CTA NECK W&W/OC & RECONS Study Date of [**2164-10-25**]
5:39 AM The CT scan does not reveal a discrete area of change of
density of the brain to suggest that there has been a new
stroke. IMPRESSION: Extensive postoperative changes and other
findings as noted above.

Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2164-10-25**] 5:40 AM IMPRESSION: 1. No pulmonary embolism is
noted. 2. Moderate bilateral pleural effusion and bibasilar
atelectasis. 3. Status post stent grafting of aortic arch for
exclusion of the pseudoaneurysm of aortic arch and status post
tying off of the origin of the left common carotid artery. 4.
Pathologically enlarged anterior precarinal node. Since this
node was not as prominent on the prior study of [**2164-10-9**], an infectious etiology is suggested as a cause. 5. Small
amount of high-density fluid in the abdomen. 6. possible splenic
infarct.

Radiology Report CHEST (PORTABLE AP) Study Date of [**2164-10-25**]
11:55 AM IMPRESSION: 1. ET tube in satisfactory position
approximately 6.1 cm above carina. 2. Aortic stent with density
related to known pseudoaneurysm stable compared with earlier the
same day. 3. Small bilateral effusions.
4. Review of recent CT for correlation revealed a mass in right
breast,
possibly a seroma, dense cyst or dilated duct, but not fully
characterized on this exam. A similar smaller left breast mass
is also present. Clinical
correlation and, if clinically indicated, further assessment
with mammography or ultrasound should be considered, to
conclusively exclude a neoplasm.

[**2164-10-30**] 06:25AM BLOOD

WBC-9.4 RBC-3.37* Hgb-10.1* Hct-30.9* MCV-92 MCH-30.0 MCHC-32.7
RDW-14.2 Plt Ct-313

[**2164-10-29**] 04:11AM BLOOD

PT-11.9 PTT-24.7 INR(PT)-1.0

[**2164-10-30**] 06:25AM BLOOD

Glucose-112* UreaN-17 Creat-0.6 Na-144 K-4.0 Cl-105 HCO3-30
AnGap-13

[**2164-10-29**] 04:11AM BLOOD

Calcium-8.7 Mg-1.7

[**2164-10-25**] 06:31PM

URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

[**2164-10-30**] 4:41 am STOOL     CONSISTENCY: WATERY

CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2164-10-30**]):

Feces negative for C.difficile toxin A & B by EIA.

Brief Hospital Course:
This is a 86F admitted for a Lt subclavian aneurysm

She agreed to have an elective surgery. Pre-operatively, she was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained,  all other preperations were made.

This was a staged procedure.

[**10-22**] PROCEDURE:

Right carotid to left carotid bypass with 6 mm PTFE, left
carotid to left subclavian transposition

She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She/ tolerated the procedure
well without any difficulty or complication.

Post-operatively, she was extubated and transferred to the CVICU
for further stabilization and monitoring. She was kept NPO for
the next part of her procedure.

[**10-23**]: PROCEDURES:

1. Stent graft repair of aortic arch/left subclavian artery
   aneurysm with a [**Doctor Last Name 4726**] TAG endograft. The endograft data
   is the following: It is a [**Doctor Last Name 4726**] TAG graft,  reference
   #[**Serial Number 80235**], lot #[**Serial Number 80236**].
2. Thoracic aortography.
3. Placement of an aortic conduit for delivery of the stent
   graft which was performed Dr. [**Last Name (STitle) **].

She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She/ tolerated the procedure
well without any difficulty or complication.

Post-operatively, she transferred to the CVICU for further
stabilization and monitoring. She was intubated.

She had a epidural for pain control. Pain Service was following
her.

[**10-24**]:

Nitro drip for pressure suport, pain control with Epidural,
foley to gravity, intubated.

[**10-25**]:

Pressors remain, pain control with Epidural, foley, NGT and OGT
for feeding, had increase in 02 requirements. CXR obtained. SQ
hep, MPB's.

Found to have pulmonary edema, Lasix drip to keep negative (cr
stable)

Pt experienced Right arm weakness, Neurology consult obtained.
Epidural removed, Heparin IV started, Lasix drip for diuresis.
CT scan negative. Resolution of arm weakness in the same day
(thought to be peripheral not central).

TPN for feeding.

Remained intubated

[**10-26**]:

Pressors, heparin drip remained, foley gravity, lasix drip to
keep negative (cr stable). TPN remained.

Cardiolgy consulted for new MR found on echo intra - op.
Recommended BB.

Pt extubated without difficulty.

[**10-27**]:

Neurologically intact after extubation, remained on neo for
pressure support, lasix DC'd, TF remained. diet advanced,
heparin drip remained. foley to gravity.

[**10-28**]:

Changed to PO meds from IV, Heparin drip DC'd, OOB to chair, Neo
weaned, foley to gravity. Pt much improved, OGT and NGT removed.

[**10-29**] - [**10-31**]

She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status.

Tele DC'd.

On the floor she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. Shewas discharged to a rehabilitation
facility in stable condition.

To note she did have an increase in her WBC. Also had looses
stool. C-Diff negative.

Stable for DC to rehab.

creatinine at baseline.


Medications on Admission:
[**Last Name (un) 1724**]: Zocor 20'

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 599**] of [**Location (un) 55**]

Discharge Diagnosis:
Left Subclavian Artery Aneurysm


Discharge Condition:
Good


Discharge Instructions:
Post Surgery Wound Care

Overview

Your doctor has placed sutures (stitches) to keep the incision
closed for proper wound healing. Sometimes, sutures need to be
removed in a few weeks. Sometimes, the sutures are all under the
skin and will eventual dissolve on their own and do not need to
be removed.

In either case, please follow these routine wound care
instructions.

Leave the original bandage that was applied at the time of your
surgery in place for 48 hours. If the bandage should become
loose, reinforce the dressing with surgical tape.

After approximately 48 hours, you can gently remove the bandage.

If you have steri-strips on your incision (little white paper
tapes), keep them in place until they begin to fall off on their
own. Do not pull the steri-strips off as this could put stress
on the incision line. When the steri-strips start to peel off,
they can be gently washed off.

Please try to keep the incision line clean and dry. You can
shower and gently wash the incision line with soap and water.
Dry the incision area and keep the incision line open to air.

It is not necessary to apply antibiotic ointment, alcohol,
hydrogen peroxide, or a new bandage to the incision line. If
your sutures get caught on your clothing or there is a small
amount of drainage from the incision, you may want to cover it
with small gauze for your own comfort. If so, please use as
little tape as possible to hold the gauze in place as tape can
irritate the skin.

A small amount of drainage from the incision in the first few
days after surgery is not unusual and it will probably resolve
on its own. However, if you should notice bleeding from the
surgical site, apply firm direct pressure for ten minutes. If
the bleeding persists, reapply firm direct pressure for an
additional ten minutes. If the bleeding does not stop after 20
minutes, call our contact phone numbers or go to the nearest
emergency room for assistance.

What to Avoid

Please avoid the following:

Do not submerge the incision line under water for a prolonged
period of time with activities like taking a bath, swimming, or
sitting in a hot tub.

Do not participate in any vigorous activities or exercises that
may put stress on the incision.

Do not take aspirin, ibuprofen, or any other nonsteroidal
anti-inflammatory medication that may cause problems with
bleeding unless instructed by your doctor.

Do not apply perfumes or scented lotions to the sutures as this
may cause irritation.

When to Call the Doctor

Please contact us immediately if you develop:

Fevers, chills, or night sweats

Increasing redness, pain, or pus at the incision

Bleeding that does not stop with firm pressure

Followup Care

If your sutures need to be removed, this is usually done [**12-1**]
weeks after surgery. Even if your sutures will dissolve, the
doctor usually likes to examine the incision while it is
healing. Therefore, you should have been scheduled for a
follow-up appointment in clinic at the time of your discharge
from surgery. As this appointment is very important, please
contact the clinic if you do not have one scheduled or you need
to change the date and/or time.

Followup Instructions:
An breast cyst/mass was seen on your CT scan from [**10-25**] and on
subsequent x-rays. You should schedule a mammography with your
primary care physician to [**Name9 (PRE) 702**] on this breast mass.

You should also schedule a follow-up appointment with your
Dentist in reference to your tooth which was chipped during the
process of intubation.



Completed by:[**2164-10-31**]
{'Thoracic aneurysm without mention of rupture,Unspecified essential hypertension,Pure hypercholesterolemia,Aneurysm of subclavian artery,Other complications due to other vascular device, implant, and graft'}


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: Incidental asymptomatic left subclavian artery aneurysm

PRESENT ILLNESS: Ms. [**Known lastname **] is an 86-year-old woman referred by Dr. [**Last Name (STitle) 29111**]
[**Name (STitle) 11302**] for evaluation of a newly detected asymptomatic left
subclavian artery aneurysm.  She had not been seen by doctor in
many years, but was noticing difficulty with vision. She saw an
ophthalmologist in preparation for cataract surgery.  Her
preoperative evaluation detected hypertension and significant
hyperlipidemia. A
chest x-ray, as part of the preoperative evaluation, noted a
mass in the upper left chest prompting a CT scan, which
demonstrates a 4-cm pseudoaneurysm originating at the inferior
aspect of the origin left subclavian artery.  She denies any
history of major trauma, specifically she does not recall any
motor vehicle accidents or major falls.  She is a long-term
smoker and ongoing smoker smoking three quarters of a pack per
day.  She does have newly diagnosed hypertension and
hyperlipidemia.  She does not have diabetes.

MEDICAL HISTORY: PMH: HTN, Chol

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: Zocor 20'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: a/o x 3
supple
farom
neg lymphandopathy
cta
rrr
pos bs
surgical incision c/d/i
Pulses: Fem DP PT [**Name (NI) 1035**] [**Name (NI) **] Uln
     Rt 2+  D  D  2+    2+  mono
     Lt 2+  D  D  2+    2+  mono

FAMILY HISTORY: non-contrubutory. She has no family history of aneurysms

SOCIAL HISTORY: She is a homemaker.  She does not drink alcohol 

### Response:
{'Thoracic aneurysm without mention of rupture,Unspecified essential hypertension,Pure hypercholesterolemia,Aneurysm of subclavian artery,Other complications due to other vascular device, implant, and graft'}
