CHIEF COMPLAINT: Abdominal aortic aneurysm.

PRESENT ILLNESS: The patient is a male with history of aortic aneurysms had
progressive increase in size; now has an aortic aneurysm greater
than 5.5 cm. Due to his young age and his family history, the
decision was made to repair. Due to his anatomy, it was felt
that he would not be a good stent graft candidate.

MEDICAL HISTORY: PMH: 5.7cm infra-renal/juxta-renal AAA, COPD, obesity, asthma,
hypercholesterolemia, BPH, lumbosacral radiculopathy, colonic
adenoma
.
PSH: multiple skin grafts on left ankle after burn ([**2159**]),
multiple knee surgeries on L. and arthroscopic on R. ([**2159**]), R.
rotator cuff repair ([**2168**])

MEDICATION ON ADMISSION: Fluticasone (FLOVENT HFA) 220 mcg 1 puff [**Hospital1 **], albuterol sulfate
(Proair) 90 mcg 2 puffs q4-6 hrs, lipitor 80 mg po qd,

ALLERGIES: Anspor / Wellbutrin

PHYSICAL EXAM: Physical Exam on Discharge:
AVSS
Abdomen, soft, non-distended, non-tender
Vertical midline incision with small eschar patches, without
induration or signs of infection
Pulses:
R: p/p/p/p
L: p/p/weakly palp/p

FAMILY HISTORY: Familial history of AAA.

SOCIAL HISTORY: Current smoker.
Abdominal aneurysm without mention of rupture,Acute respiratory failure following trauma and surgery,Acute gastric ulcer with perforation, without mention of obstruction,Other candidiasis of other specified sites,Acquired coagulation factor deficiency,Postoperative shock, other,Chronic obstructive asthma with (acute) exacerbation,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Obesity, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Tobacco use disorder,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Abdom aortic aneurysm,Ac resp flr fol trma/srg,Ac stomach ulcer w perf,Candidiasis site NEC,Acq coagul factor defic,Postop shock, other,Ch obst asth w (ac) exac,Ac posthemorrhag anemia,DMII wo cmp nt st uncntr,Acc cut/hem in surgery,Obesity NOS,Hypertension NOS,Pure hypercholesterolem,BPH w/o urinary obs/LUTS,Tobacco use disorder,Abn react-anastom/graft
Admission Date:  [**2199-12-30**]              Discharge Date:   [**2200-1-20**]

Date of Birth:  [**2141-3-16**]             Sex:   M

Service: SURGERY

Allergies:
Anspor / Wellbutrin

Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal aortic aneurysm.

Major Surgical or Invasive Procedure:
[**2199-12-30**]: 1. Repair of juxtarenal abdominal aortic aneurysm with
14 mm tube graft. 2. Splenectomy for bleeding.
.
[**2200-1-8**]: Over the scope clip to gastric perforation by endoscopy


History of Present Illness:
The patient is a male with history of aortic aneurysms had
progressive increase in size; now has an aortic aneurysm greater
than 5.5 cm. Due to his young age and his family history, the
decision was made to repair. Due to his anatomy, it was felt
that he would not be a good stent graft candidate.

Past Medical History:
PMH: 5.7cm infra-renal/juxta-renal AAA, COPD, obesity, asthma,
hypercholesterolemia, BPH, lumbosacral radiculopathy, colonic
adenoma
.
PSH: multiple skin grafts on left ankle after burn ([**2159**]),
multiple knee surgeries on L. and arthroscopic on R. ([**2159**]), R.
rotator cuff repair ([**2168**])


Social History:
Current smoker.

Family History:
Familial history of AAA.

Physical Exam:
Physical Exam on Discharge:
AVSS
Abdomen, soft, non-distended, non-tender
Vertical midline incision with small eschar patches, without
induration or signs of infection
Pulses:
R: p/p/p/p
L: p/p/weakly palp/p


Pertinent Results:
[**2199-12-30**] 02:35PM BLOOD WBC-12.7* RBC-3.36*# Hgb-10.7*#
Hct-30.2*# MCV-90 MCH-31.9 MCHC-35.5* RDW-13.8 Plt Ct-188
[**2200-1-8**] 04:29AM BLOOD WBC-22.4* RBC-3.93* Hgb-11.7* Hct-34.4*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.0 Plt Ct-855*
[**2199-12-30**] 02:35PM BLOOD PT-15.7* PTT-46.9* INR(PT)-1.5*
[**2200-1-8**] 04:29AM BLOOD PT-19.2* PTT-28.1 INR(PT)-1.8*
[**2199-12-30**] 06:21PM BLOOD Glucose-134* UreaN-13 Creat-1.0 Na-139
K-4.6 Cl-109* HCO3-26 AnGap-9
[**2199-12-30**] 06:21PM BLOOD ALT-48* AST-59* LD(LDH)-301*
CK(CPK)-1703* AlkPhos-43 TotBili-2.2*
[**2199-12-30**] 06:21PM BLOOD CK-MB-21* MB Indx-1.2 cTropnT-<0.01
[**2199-12-31**] 02:40AM BLOOD CK-MB-102* cTropnT-<0.01
[**2199-12-31**] 12:04PM BLOOD CK-MB-145* MB Indx-1.3 cTropnT-<0.01
[**2199-12-31**] 08:30PM BLOOD CK-MB-188* MB Indx-1.1 cTropnT-<0.01
[**2200-1-1**] 12:00PM BLOOD HEPARIN DEPENDENT ANTIBODIES- NEGATIVE

[**2200-1-19**] 07:02AM BLOOD WBC-15.0* RBC-3.65* Hgb-11.2* Hct-32.9*
MCV-90 MCH-30.7 MCHC-34.1 RDW-14.0 Plt Ct-792*
[**2200-1-20**] 06:45AM BLOOD WBC-14.7* RBC-3.74* Hgb-11.1* Hct-33.0*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-697*
[**2200-1-9**] 08:59AM BLOOD PT-15.2* PTT-25.3 INR(PT)-1.4*
[**2199-12-30**] 02:35PM BLOOD Fibrino-120*
[**2200-1-20**] 06:45AM BLOOD Glucose-113* UreaN-14 Creat-1.0 Na-135
K-4.8 Cl-99 HCO3-27 AnGap-14
[**2200-1-14**] 06:06AM BLOOD ALT-30 AST-19 AlkPhos-71 TotBili-0.2
[**2200-1-20**] 06:45AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.3
[**2200-1-9**] 06:34AM BLOOD Triglyc-146
[**2200-1-15**] 06:07AM BLOOD Vanco-22.8*
[**2200-1-6**] 07:56AM BLOOD K-3.3
.
[**2200-1-7**] CT Torso with NGT and IV contrast:
IMPRESSION:
1. Leakage of contrast from the posterosuperior aspect of the
gastric fundus with oral contrast present within the left upper
quadrant and splenectomy bed.
2. Satisfactory postoperative appearance of open abdominal
aortic aneurysm  repair.
3. Scattered colonic diverticulosis.
4. Moderate prostatic enlargement.
5. Left sided varicocele.
.
[**2200-1-8**] Endoscopy/Over the Scope Clipping by GI service:
Findings: Esophagus: Normal esophagus. Stomach:  Mucosa: A few
areas of erythema and erosions were noted in the antrum
consistent with NG tube induced injury. Other A small 8 mm
opening was noted at the fundus surrounded by an area of
erythema and mucosal edema s/o site of the perforation.  Turbid
fluid could be aspirated through the opening.  An over the scope
clip (12mm, T-type, OTSC) was loaded over the scope and the
scope advanced to the region of the perforation.  The opposing
ends of the defect were suctioned into the clip cap.  The OTSC
was then successfully deployed at the perforation.  The clip
appeared in good position.  No fluid could be suctioned through
this region. Duodenum: Normal duodenum. Other findings: After
the OTSC placement, an NG tube was placed under endoscopic
vision successfully into gastric antrum.  Impression: A few
areas of erythema and erosions were noted in the antrum
consistent with NG tube trauma. A small opening was noted at the
fundus surrounded by an area of erythema and mucosal edema c/w
the site of the perforation. An over the scope clip (OTSC) was
successfully deployed to close the perforation. Another NG tube
was then placed in the antrum. Otherwise normal EGD to third
part of the duodenum
.
[**2200-1-9**] CT a/p:
IMPRESSION:
1. No oral contrast extravasation on today's exam. No evidence
of leak.
2. Residual about 9 x 2.7 x 3.4 cm low to intermediate density
fluid in the subphrenics space with drain in place.
3. Moderate left pleural effusion and left basilar atelectasis.
.
[**2200-1-14**] UGI:
IMPRESSION: No extraluminal oral contrast. No fluoroscopic
evidence of
gastric perforation.
.
[**2200-1-15**] CT a/p:
IMPRESSION:
1. No evidence of extraluminal oral contrast.
2. Small, 3.6 cm peripherally enhancing collection abutting the
posterior
aspect of the fundus as described above.
3. Two perigastric surgical drains as described above.
4. Post-surgical appearance following abdominal aortic aneurysm
repair.
5. Right lower lobe lung nodule. This likely represents
inflected or inflamed lung, though recommend followup to
resolution to exclude an underlying nodule.
6. Diverticulosis.

Brief Hospital Course:
SUMMARY: 58M with 5.7cm infra-renal/juxta-renal AAA who
presented for open AAA resection-suprarenal cross clamp, with
intraoperative course complicated splenic laceration requiring
splenectomy, and post-operative course complicated by small
gastric fundal perforation requiring endoclipping.
.
BRIEF HOSPITAL COURSE:
The patient was brought to the OR on [**2199-12-30**] for open repair of
juxtarenal abdominal aortic aneurysm with 14 mm tube graft. A
perioperative epidural was placed. Reader referred to operative
note for full details. Intraoperative bleeding with splenic
laceration was noted, for which the ACS service was consulted,
and ultimately performed a splenectomy during the same procedure
(attending surgeon, Dr. [**Last Name (STitle) **]. 2 [**Doctor Last Name **] drains were placed post
operatively in the left flank, and the patient was transferred
to the PACU and the ICU intubated, with an NGT, in stable
condition.
.
ICU Course:  The patient had an uneventful ICU course. He was
appropriately diuresed with a lasix drip, and transfused as
necessary. Tube feeds were begun on POD 4, and HIT panel
returned negative. His epidural was removed, and he was weaned
off the ventilator, extubated on POD5. On POD5 erythema
surrounding his midline vertical abdominal incision was noted
and he was begun on cefazolin given concern for a superficial
skin infection. He was transferred to the floor (VICU) on
[**2200-1-6**] in stable condition, tolerating clears which were begun
on [**2200-1-6**] (POD 7).
.
VICU and floor course: Prior to initiating clears on HD8, the
patient had serosanguineous output from his 2 flank JP drains in
the splenic bed. Following initiation of clears on POD7,
however, JP output markedly increased to over a liter per day
from each drain. The color of the drains also became bilious.
Given the change in JP output and a persistently uptrending WBC
count, the patient underwent a CTA torso on POD 8, [**2200-1-7**],
which showed a small gastric perforation along the greater
curvature of the stomach. In discussion between the ACS service
and the gastroenterology service, the patient underwent an
endocscopy-guided clipping (over the scope clipping, OTSC) of
the gastric fundus perforation on [**2200-1-8**] by the GI service,
without complication. JP output markedly decreased post
procedure. Day 1 of TPN was initiated thereafter on [**2200-1-9**] (POD
10), and the patient underwent 7 days total of TPN.  CT a/p on
[**2200-1-9**] (POD 10) with contrast via NGT showed no active
extravasation, UGI series on [**2200-1-14**] confirmed no extravasation,
and the NGT was removed on [**2200-1-14**] (POD 15). He received
post-splenectomy vaccinations on [**2200-1-10**] (POD 11). Fluconazole
was added to his emperic vancomycin/ciprofloxacin/flagyl on
[**2200-1-14**] when budding yeast returned from one of his JP drains.
He completed a total 2 week course of v/c/f, and 5 days of
fluconazole. Repeat CT a/p on [**2200-1-15**] again showed no active
extravasation, and demonstrated a small residual peri-splenic
bed collection (residual 9 x 2.7 x 3.4 cm subphrenic
collection). The collection was thought not ammenable to
additional drainage at that time given potential injury to
pancreas/lung. It will be monitored in the future with repeat CT
as necessary as an outpatient to evaluate
progression/resolution. The patient was again started on clears
[**2200-1-15**], which he tolerated, and his diet was advanced slowly.
JP output remained stable during this time. One flank JP was
removed on [**2200-1-17**], and the second and final JP on [**2200-1-19**]. His
central line was removed, and tip culture returned negative. On
discharge he was tolerating a regular diet, ambulating
independently, with pain well controlled on oral medications.
Regarding his pulse-exam post operatively, he had palpable
distal pulses throughout his post-operative period. Vertical
midline staples were removed prior to discharge. He was
discharged home on HD22 with instructions to follow up with Dr.
[**Last Name (STitle) **] of vascular surgery and the ACS service.

Medications on Admission:
Fluticasone (FLOVENT HFA) 220 mcg 1 puff [**Hospital1 **], albuterol sulfate
(Proair) 90 mcg 2 puffs q4-6 hrs, lipitor 80 mg po qd,


Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. pantoprazole 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. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: 1
tab twice daily for 7 days then increase to 2 tabs twice daily.
.
Disp:*98 Tablet(s)* Refills:*2*
5. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation every 4-6 hours as needed for wheeze:
shortness of breath, wheezes.
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Nicoderm CQ 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal once a day: wean to 14mg/hr patches when tolerable.



Discharge Disposition:
Home

Discharge Diagnosis:
Abdominal aortic aneurysm, status post open repair
Splenectomy
Gastric Perforation, status post endoscopic repair
Dyslipidemia
COPD


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital after a repair of your
abdominal aortic aneurysm on [**2199-12-30**]. Your spleen was also
removed, and a small perforation in your stomach was repaired
with an endoclip.
.
We have started you on several new medications, metoprolol
(lopressor) for high blood pressure, pantoprazole (protonix) for
stomach acid, aspirin for your blood vessels and metformin for
high blood sugars.  Additionally, please continue all your
regular home medications.
.
It is imperative than you remain smoke free!  While you were in
the hospital we gave you nicotine patches at 21mg/day.  Please
continue to use the patches if needed and wean the dosage as
tolerable.
.
Division of Vascular 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 [**5-2**]
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 [**12-27**]
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:
??????	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.
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed.

Followup Instructions:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**First Name9 (NamePattern2) 2287**] [**Location (un) **], his office will
call you to arrange.
.
Please call and make an appointment to be seen by your PCP for
monitoring of the new medications we started you on in the
hospital.
.
Please follow up with the acute care surgeons (who removed your
spleen) in [**12-28**] weeks. Please call [**Telephone/Fax (1) 1864**] to make an
appointment.



Completed by:[**2200-1-20**]
{'Abdominal aneurysm without mention of rupture,Acute respiratory failure following trauma and surgery,Acute gastric ulcer with perforation, without mention of obstruction,Other candidiasis of other specified sites,Acquired coagulation factor deficiency,Postoperative shock, other,Chronic obstructive asthma with (acute) exacerbation,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Obesity, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Tobacco use disorder,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: The patient is a male with history of aortic aneurysms had
progressive increase in size; now has an aortic aneurysm greater
than 5.5 cm. Due to his young age and his family history, the
decision was made to repair. Due to his anatomy, it was felt
that he would not be a good stent graft candidate.

MEDICAL HISTORY: PMH: 5.7cm infra-renal/juxta-renal AAA, COPD, obesity, asthma,
hypercholesterolemia, BPH, lumbosacral radiculopathy, colonic
adenoma
.
PSH: multiple skin grafts on left ankle after burn ([**2159**]),
multiple knee surgeries on L. and arthroscopic on R. ([**2159**]), R.
rotator cuff repair ([**2168**])

MEDICATION ON ADMISSION: Fluticasone (FLOVENT HFA) 220 mcg 1 puff [**Hospital1 **], albuterol sulfate
(Proair) 90 mcg 2 puffs q4-6 hrs, lipitor 80 mg po qd,

ALLERGIES: Anspor / Wellbutrin

PHYSICAL EXAM: Physical Exam on Discharge:
AVSS
Abdomen, soft, non-distended, non-tender
Vertical midline incision with small eschar patches, without
induration or signs of infection
Pulses:
R: p/p/p/p
L: p/p/weakly palp/p

FAMILY HISTORY: Familial history of AAA.

SOCIAL HISTORY: Current smoker. 

### Response:
{'Abdominal aneurysm without mention of rupture,Acute respiratory failure following trauma and surgery,Acute gastric ulcer with perforation, without mention of obstruction,Other candidiasis of other specified sites,Acquired coagulation factor deficiency,Postoperative shock, other,Chronic obstructive asthma with (acute) exacerbation,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Obesity, unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Tobacco use disorder,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
