CHIEF COMPLAINT: She is a 78-year-old woman with an infrarenal abdominal aneurysm
and bilateral leg claudication left worse than right at 10 feet
distance.

PRESENT ILLNESS: 78-year-old woman with a history of non-insulin dependent
diabetes and ex-75 pack year smoker who presents to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] service, with a history of bilateral lower extremity
claudication, left greater than right as stated previously
associated with no clear ischemic rest pain however, this is now
debilitating in nature.

MEDICAL HISTORY: PMH:

MEDICATION ON ADMISSION: 1. Metformin 500 TID
2. Atenolol 75 QD
3. Ranitidine
4. Fosamax
5. Lipitor 20 QD
6. ASA QD
7. Nifedipine SR 90 QD
8. Levoxyl 725 mcg QD

ALLERGIES: Percocet / Naprosyn / Darvocet A500

PHYSICAL EXAM: PE:

FAMILY HISTORY: Non contributary

SOCIAL HISTORY: She is an ex-smoker of 75 pack years,
she does not smoke currently,
she does not drink outside of socially.
She uses no recreational drugs.
She is a country music singer.
Abdominal aneurysm without mention of rupture,Unspecified pleural effusion,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with intermittent claudication,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension,Unspecified acquired hypothyroidism,Esophageal reflux,Pure hypercholesterolemia
Abdom aortic aneurysm,Pleural effusion NOS,Urin tract infection NOS,Ath ext ntv at w claudct,DMII wo cmp nt st uncntr,Hypertension NOS,Iatrogenc hypotnsion NEC,Hypothyroidism NOS,Esophageal reflux,Pure hypercholesterolem
Admission Date:  [**2164-10-9**]              Discharge Date:   [**2164-10-18**]

Date of Birth:  [**2086-2-24**]             Sex:   F

Service: SURGERY

Allergies:
Percocet / Naprosyn / Darvocet A500

Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
She is a 78-year-old woman with an infrarenal abdominal aneurysm
and bilateral leg claudication left worse than right at 10 feet
distance.


Major Surgical or Invasive Procedure:
Retroperitoneal tube graft repair of abdominal aortic aneurysm


History of Present Illness:
78-year-old woman with a history of non-insulin dependent
diabetes and ex-75 pack year smoker who presents to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] service, with a history of bilateral lower extremity
claudication, left greater than right as stated previously
associated with no clear ischemic rest pain however, this is now
debilitating in nature.

Also on workup of CT was found to have an infrarenal abdominal
aneurysm as well as extensive aortoiliac atherosclerotic
disease. The aneurysm at its
maximum diameter was 5x3x5x4 cm.

Past Medical History:
PMH:

DM,
HTN,
GERD,
AAA,
Hyperchol,
HyopTH

PSH:

appendectomy,
TAH,
R-breast bx


Social History:
She is an ex-smoker of 75 pack years,
she does not smoke currently,
she does not drink outside of socially.
She uses no recreational drugs.
She is a country music singer.

Family History:
Non contributary

Physical Exam:
PE:

AFVSS

NEURO:

PERRL / EOMI

MAE equally

Answers simple commands

Neg pronator drift

Sensation intact to ST

2 plus DTR

Neg Babinski

HEENT:

NCAT

Neg lesions nares, oral pharnyx, auditory

Supple / FAROM

neg lyphandopathy, supra clavicular nodes

LUNGS: CTA b/l

CARDIAC: RRR without murmers

ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness,

INC: c/d/i

EXT:

rle - palp fem, [**Doctor Last Name **], / dop pt, dp

lle - palp fem, [**Doctor Last Name **], / dop pt, dp


Pertinent Results:
[**2164-10-17**]

WBC-18.6* RBC-4.24 Hgb-12.5 Hct-36.8 MCV-87 MCH-29.4 MCHC-33.9
RDW-15.6* Plt Ct-394

[**2164-10-13**]

Neuts-85.5* Bands-0 Lymphs-9.5* Monos-2.6 Eos-2.3 Baso-0.1

[**2164-10-14**]

PT-13.6* PTT-29.5 INR(PT)-1.2

[**2164-10-17**]

Glucose-118* UreaN-18 Creat-0.8 Na-136 K-3.9 Cl-98 HCO3-25
AnGap-17

[**2164-10-17**]

Calcium-7.6* Phos-2.5* Mg-1.9

[**2164-10-13**]

freeCa-1.12

[**2164-10-9**] 2:52 PM

CHEST PORT

COMMENTS: A single supine AP view of the chest was reviewed and
compared with PA and lateral chest radiographs from [**2164-8-29**].

Tip of an endotracheal tube is located 5 cm above the level of
the carina. A right-sided Swan-Ganz catheter is seen with its
tip projecting over the right main pulmonary artery. The heart
size is normal. The mediastinal and hilar contours are
unchanged. The lungs are clear. No pleural effusions or
pneumothoraces are identified. The pulmonary vasculature is
within normal limits.

IMPRESSION:
1. Tip of right Swan-Ganz catheter located in the right main
pulmonary artery.
2. No pneumothorax.

[**2164-10-9**]

ECHO

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%)
Aorta - Valve Level: 3.5 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.5 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 0.83
Mitral Valve - E Wave Deceleration Time: 294 msec

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA  and extending into the RV.

LEFT VENTRICLE: Normal LV wall thicknesses and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.

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

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

AORTA: Normal aortic root diameter.

AORTIC VALVE: Aortic valve not well seen. No AS. No AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR.

TRICUSPID VALVE: Indeterminate PA systolic pressure.

PERICARDIUM: There is an anterior space which most likely
represents a fat  pad, though a loculated anterior pericardial
effusion cannot be excluded.

GENERAL COMMENTS: Suboptimal image quality - poor apical views.
Suboptimal  image quality as the patient was difficult to
position. Suboptimal image  quality - ventilator. Based on [**2156**]
AHA endocarditis prophylaxis  recommendations, the echo findings
indicate a low risk (prophylaxis not  recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal hypokinesis of the anterolateral wall.
The remaining  segments contract well. Right ventricular chamber
size and free wall motion  are normal. The aortic valve is not
well seen. There is no aortic valve  stenosis. No aortic
regurgitation is seen. The mitral valve appears  structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which  most likely represents a fat pad, though a
loculated anterior pericardial  effusion cannot be excluded.

IMPRESSION: Mild regional left ventricular systolic dysfunction
c/w CAD.

Based on [**2156**] AHA endocarditis prophylaxis recommendations, the
echo findings  indicate a low risk (prophylaxis not
recommended). Clinical decisions  regarding the need for
prophylaxis should be based on clinical and  echocardiographic
data.

[**2164-10-9**]  1:27:06 PM

ECG

Sinus rhythm. Non-specific ST-T wave changes. Compared to the
previous tracing of [**2164-8-29**].
TRACING #1

Intervals Axes
Rate PR  QRS QT/QTc  P  QRS T
67   132 80  [**Telephone/Fax (2) 12458**]  85

[**2164-10-16**] 10:26 am

STOOL     CONSISTENCY: WATERY      Source: Stool.

FINAL REPORT [**2164-10-17**]

CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2164-10-17**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range:  Negative.

[**2164-10-15**] 12:19 pm

URINE - CATHETER

FINAL REPORT 09/13/0

URINE CULTURE (Final [**2164-10-16**]):    NO GROWTH

GENERAL URINE INFORMATION
Color     Appear  Sp [**Last Name (un) **]
Yellow    Clear   1.007

DIPSTICK URINALYSIS

Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH  Leuks
NEG   NEG     NEG     NEG     NEG    NEG     NEG     7.0 NEG


Brief Hospital Course:
Pt admitted [**2164-10-9**]

Pt undergoes a Retroperitoneal tube graft repair of abdominal
aortic aneurysm. She tolerates the procedure well. There are no
complications. Pt is intubated. Transfered to the PACU in stable
condition.

She did require post operaritive drips for hemodynamics.

Once recovered from anesthesia. Pt is transfered to the SICU in
stable condition.She is still intubated

[**2164-10-10**] - [**2164-10-14**]

Pt emained in the SICU

She required IV drips for BP control / and gentle diuresis.

Pt extubated [**2164-10-12**]

After extubation, pt still required gentlee diuresis.

Pt did experience some confusion, Narcotics DC'd. Pt mental
status did improve.

Diet was advanced as tolerated.

[**2164-10-15**]

Pt transfered to the VICU

Case management and PT were consulted.

Pt diet was advanced

Foley removed, PT delined.

Pt with slight increase in WBC, low grade temp - UTI, tx with
antibiotics.

[**2164-10-16**] - [**2164-10-18**]

Pt transfered to the floor.

Pt stable

On discharge pt is taking PO, ambulating, pos BM, urinating.

Pt did have multiple stools. C- Diff neg.

Medications on Admission:
1. Metformin 500 TID
2. Atenolol 75 QD
3. Ranitidine
4. Fosamax
5. Lipitor 20 QD
6. ASA QD
7. Nifedipine SR 90 QD
8. Levoxyl 725 mcg QD

Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4-6H (every 4 to 6 hours) as needed.
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-5**]
Puffs Inhalation Q4H (every 4 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
13. Insulin
Insulin SC  (per Insulin Flowsheet)
Sliding Scale

QACHS, QPC2H, HS, QAM
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50   mg/dL 4 oz. Juice
51-150    mg/dL 0
151-200   mg/dL 2   Units
201-250   mg/dL 4   Units
251-300   mg/dL 6   Units
301-350   mg/dL 8   Units
351-400   mg/dL 10  Units
> 400   mg/dL Notify M.D.

14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Abdominal aortic aneurysm


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:
Follopw up with Dr [**Last Name (STitle) **] in two weeks. She can be reached at
[**Telephone/Fax (1) 2395**].



Completed by:[**2164-10-18**]
{'Abdominal aneurysm without mention of rupture,Unspecified pleural effusion,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with intermittent claudication,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension,Unspecified acquired hypothyroidism,Esophageal reflux,Pure hypercholesterolemia'}


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: She is a 78-year-old woman with an infrarenal abdominal aneurysm
and bilateral leg claudication left worse than right at 10 feet
distance.

PRESENT ILLNESS: 78-year-old woman with a history of non-insulin dependent
diabetes and ex-75 pack year smoker who presents to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] service, with a history of bilateral lower extremity
claudication, left greater than right as stated previously
associated with no clear ischemic rest pain however, this is now
debilitating in nature.

MEDICAL HISTORY: PMH:

MEDICATION ON ADMISSION: 1. Metformin 500 TID
2. Atenolol 75 QD
3. Ranitidine
4. Fosamax
5. Lipitor 20 QD
6. ASA QD
7. Nifedipine SR 90 QD
8. Levoxyl 725 mcg QD

ALLERGIES: Percocet / Naprosyn / Darvocet A500

PHYSICAL EXAM: PE:

FAMILY HISTORY: Non contributary

SOCIAL HISTORY: She is an ex-smoker of 75 pack years,
she does not smoke currently,
she does not drink outside of socially.
She uses no recreational drugs.
She is a country music singer. 

### Response:
{'Abdominal aneurysm without mention of rupture,Unspecified pleural effusion,Urinary tract infection, site not specified,Atherosclerosis of native arteries of the extremities with intermittent claudication,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other iatrogenic hypotension,Unspecified acquired hypothyroidism,Esophageal reflux,Pure hypercholesterolemia'}
