CHIEF COMPLAINT: Claudication

PRESENT ILLNESS: 75 year old female with a history of coronary artery disease
status post RCA stenting in [**2116**] and cath in [**1-24**] with occluded
LAD and minimal RCA ISR, presumed infarct related cardiomyopathy
with recent PMIBI showing LVEF of 30% and fixed anterior defect
presents for bilateral lower extremity angiography and stenting
because of cluadication and postive ABIs.

MEDICAL HISTORY: -Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis

MEDICATION ON ADMISSION: ASA, plavix, metoprolol 25', atorvastatin 80', losartan 25',
Lasix 20', Amlodipine 5 mg', prednisone 5', Keppra 750'',
celecoxib 100', benzonatate 100', omeprazole 20', Brimonidine
(0.2 % 1 in L eye'''), timolol maleate (0.255 each eye'), B12 IM
(1x/mo), Vit D 400U'

ALLERGIES: Tape [**12-14**]"X10YD / Morphine

PHYSICAL EXAM: Pt expired.

FAMILY HISTORY: No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

SOCIAL HISTORY: - Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.
Atherosclerosis of native arteries of the extremities with ulceration,Dissection of iliac artery,Acidosis,Acute on chronic systolic heart failure,Other chronic pulmonary heart diseases,Acute posthemorrhagic anemia,Tricuspid valve disorders, specified as nonrheumatic,Other emphysema,Accidental puncture or laceration during a procedure, not elsewhere classified,Ulcer of other part of foot,Other iatrogenic hypotension,Old myocardial infarction,Leukocytosis, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of steroids,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Do not resuscitate status,Epilepsy, unspecified, without mention of intractable epilepsy,Rheumatoid arthritis,Pernicious anemia
Ath ext ntv art ulcrtion,Dissection iliac artery,Acidosis,Ac on chr syst hrt fail,Chr pulmon heart dis NEC,Ac posthemorrhag anemia,Nonrheum tricusp val dis,Emphysema NEC,Accidental op laceration,Ulcer other part of foot,Iatrogenc hypotnsion NEC,Old myocardial infarct,Leukocytosis NOS,Crnry athrscl natve vssl,Status-post ptca,Long-term use steroids,Acc cut/hem in surgery,Hypertension NOS,Do not resusctate status,Epilep NOS w/o intr epil,Rheumatoid arthritis,Pernicious anemia
Admission Date:  [**2123-6-11**]              Discharge Date:   [**2123-6-14**]

Date of Birth:  [**2047-9-27**]             Sex:   F

Service: SURGERY

Allergies:
Tape [**12-14**]"X10YD / Morphine

Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Claudication

Major Surgical or Invasive Procedure:
[**2123-6-11**]  Iliac artery stent grafts x2.


History of Present Illness:
75 year old female with a history of coronary artery disease
status post RCA stenting in [**2116**] and cath in [**1-24**] with occluded
LAD and minimal RCA ISR, presumed infarct related cardiomyopathy
with recent PMIBI showing LVEF of 30% and fixed anterior defect
presents for bilateral lower extremity angiography and stenting
because of cluadication and postive ABIs.

Past Medical History:
-Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis


Social History:
- Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits.


Family History:
No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

Physical Exam:
Pt expired.

Pertinent Results:
[**2123-6-11**] C. cath  INTERVENTIONAL COMMENTS:
Initial angiography demonstrated right common and external iliac
artery
stenosis that on careful hemodynamic assessment (slow pullback
of MPA-1
catheter from common femoral artery to distal aorta) revealed a
significant 40 mmHg peak-to-peak gradient at this location with
normalization of the pressure to the central aorta beyond. After

discussion and review of the images with Vascular Surgery, Dr.
[**Last Name (STitle) 3407**],
we planned to treat this inflow disease with PTA and stenting
followed
by inpatient admission for further planning of lower extremity
revascularization with surgical bypass grafting.
Prior to the intervention, heparin was given prophylactically
and a
therapeutic ACT was confirmed. The short 5F right brachial
artery sheath
was exchanged over a wire for a 90cm long 5F Shuttle Sheath
placed in
the proximal right common iliac artery immediately prior to the
lesion.
The lesion was crossed easily with a V-18 wire and then
pre-dilated with
a 6.0x40mm Submarine Plus balloon for prolonged inflations at
low
pressure. A 7.0x60mm Zilver self-expanding stent was then
deployed and
the lesion was post-dilated with a 7.0x40mm Submarine Plus
balloon at 10
atm for 60 sec and then again at 10 atm for 70 sec. Repeat
pullback
across the lesion with a 5F MPA-1 catheter revealed improved
peak-to-peak pressure gradient of 20 mmHg, with interim
angiography
demonstrating a residual 30% stenosis in the mid-stent.
Following a final post-dilatation inflation with a 7.0x40mm
Submarine
Plus balloon at 10 atm for 40 sec to treat the mid-stent
residual
stenosis, angiography demonstrated active contrast extravasation

(perforation) of the external and common iliac artery within the
stented
segment. The patient rapidly became hypotensive with SBP 70s and
was
given wide-open IV fluids and started on dopamine IV and
neosynepherine
IV vasopressor support with improvement of SBP 90s. A 7.0x80mm
Submarine
Plus balloon was advanced across the perforation site and
inflated with
successful tamponade of the bleeding evidenced by resolution of
contrast
extravasation on angiography. Protamine was administered for
reversal of
heparinzation given active bleeding. The patient was intubated
by
anesthesia for airway protection. 7.5F right internal jugular
and 7F
right femoral venous access sheaths were inserted and 3 units
packed
RBCs were rapidly administered with eventual weaning off off
dopamine
and neosynepherine and stabilization of SBP 110-120s.
For definitive treatment of the perforation, retrograde right
femoral
arterial access was obtained with micropuncture technique under
fluoroscopic guidance and a 7F sheath was inserted. A Magic
Torque wire
was advanced across the perforation site to the ascending aorta
and
after deflation and withdrawal of the antegrade 7.0x80mm
Submarine Plus
balloon a 7.0x59mm ICAST covered stent was deployed across the
right
external and common iliac artery. Interim angiography
demonstrated a
small area of dissection/extravastion at the proximal end of the
covered
stent, and therefore an additional overlapping 7.0x38mm ICAST
covered
stent was deployed proximally. Final angiography demonstrated no

residual perforation, no angiographically apparent dissection,
no
residual stenosis in the stented segment, and normal flow.
Right heart catheterization was then performed via the RIJ with
a 7.5F
Swan-Ganz VIP catheter notable for normal right and left heart
filling
pressures with RVEDP 9 mmHg and PCWP 14 mmHg (see above for
complete
hemodynamics), and was then sutured in place for ongoing
hemodynamic
monitoring with the catheter tip located in the central
pulmonary
artery. The right brachial and right femoral arterial sheaths
were
removed manually with adequate hemostasis. The patient remained
hemodynamically stable off vasopressors in the catheterization
lab and
was transferred to the CVICU for further care.

[**2123-6-13**] CXR
FINDINGS:  Interval extubation and removal of nasogastric tube.
Slight
advancement of Swan-Ganz catheter, now in the right main
pulmonary artery.  Cardiac silhouette remains enlarged, and is
accompanied by new pulmonary vascular congestion and bilateral
dependent alveolar opacities.  Bilateral small-to-moderate
pleural effusions are also new.

IMPRESSION:
1.  Development of bilateral lower lobe airspace opacities,
which may reflect dependent pulmonary edema. Coexisting
aspiration is an additional
consideration given the clinical concern for aspiration event.

2.  New bilateral pleural effusions.


[**2123-6-14**] 04:05AM BLOOD WBC-13.0* RBC-3.54* Hgb-10.8* Hct-33.0*
MCV-93 MCH-30.5 MCHC-32.8 RDW-15.7* Plt Ct-121*
[**2123-6-11**] 03:39PM BLOOD Neuts-81.8* Lymphs-14.4* Monos-3.2
Eos-0.4 Baso-0.2
[**2123-6-14**] 04:05AM BLOOD Plt Ct-121*
[**2123-6-14**] 04:05AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-149*
K-4.3 Cl-115* HCO3-20* AnGap-18
[**2123-6-14**] 04:05AM BLOOD ALT-58* AST-112* LD(LDH)-307*
AlkPhos-256* Amylase-25 TotBili-1.2
[**2123-6-14**] 04:05AM BLOOD Lipase-9
[**2123-6-12**] 08:41AM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.07*
[**2123-6-14**] 04:05AM BLOOD Albumin-3.1* Calcium-8.7 Phos-4.4 Mg-2.6
[**2123-6-13**] 12:15AM BLOOD Type-CENTRAL VE pO2-57* pCO2-41 pH-7.23*
calTCO2-18* Base XS--9
[**2123-6-12**] 11:11PM BLOOD Glucose-71 Lactate-1.4 K-3.5
[**2123-6-12**] 11:11PM BLOOD freeCa-1.17

Brief Hospital Course:
Pt was admitted for the proposed procedure through the
cardiology service.  During the procedure of stenting her right
external iliac the vessel ruptured.  Vascualr surgery was
consulted during the case.  She underwent s/p stent graft repair
with 2X covered stents. During the procedure she had a transient
episode of hypotension
that was treated with neosynephrine in the cath lab initially
but resolved prior to transfer to the CVICU.  Cardiology was
consulted for their input on her coronary disease and
infarct-related cardiomyopathy in the post-procedural setting.
Her family was contact[**Name (NI) **] and her situation discussed.

She was diuresed overnight and the plan was for extubation in
the morning.  She self extubated overnight on the [**2123-6-12**] ->
[**2123-6-13**].  She was made DNR DNI and was supported.  She expired
the following afternoon with her family at her side.


Medications on Admission:
 ASA, plavix, metoprolol 25', atorvastatin 80', losartan 25',
Lasix 20', Amlodipine 5 mg', prednisone 5', Keppra 750'',
celecoxib 100', benzonatate 100', omeprazole 20', Brimonidine
(0.2 % 1 in L eye'''), timolol maleate (0.255 each eye'), B12 IM
(1x/mo), Vit D 400U'

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Right iliac artery rupture
Heart Failure


Discharge Condition:
expired


Discharge Instructions:
none

Followup Instructions:
none



Completed by:[**2123-6-14**]
{'Atherosclerosis of native arteries of the extremities with ulceration,Dissection of iliac artery,Acidosis,Acute on chronic systolic heart failure,Other chronic pulmonary heart diseases,Acute posthemorrhagic anemia,Tricuspid valve disorders, specified as nonrheumatic,Other emphysema,Accidental puncture or laceration during a procedure, not elsewhere classified,Ulcer of other part of foot,Other iatrogenic hypotension,Old myocardial infarction,Leukocytosis, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of steroids,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Do not resuscitate status,Epilepsy, unspecified, without mention of intractable epilepsy,Rheumatoid arthritis,Pernicious anemia'}


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: Claudication

PRESENT ILLNESS: 75 year old female with a history of coronary artery disease
status post RCA stenting in [**2116**] and cath in [**1-24**] with occluded
LAD and minimal RCA ISR, presumed infarct related cardiomyopathy
with recent PMIBI showing LVEF of 30% and fixed anterior defect
presents for bilateral lower extremity angiography and stenting
because of cluadication and postive ABIs.

MEDICAL HISTORY: -Hypertension
-CAD s/p RCA stenting in [**2117-9-12**]
-COPD/emphysema
-PVD/LE claudication
---> Fem-fem bypass graft
---> Left fem-SFA profunda bypass
-Carotid artery disease
-Prior head trauma
--->Fractured skull at age 14 months after falling out of a
second story window
--->Age 9: hit in the head with an axe by brother
-History of fainting spells since childhood
-Seizure disorder diagnosed in [**2112**] - last seizure [**12/2120**]
-Rheumatoid arthritis on chronic steroids
-Osteopenia
-Glaucoma
-Macular degeneration
-Cataract surgery, left eye
-Raynaud's phenomenon
-s/p cholecystectomy
-s/p Appendectomy
-Pernicious anemia-Vit B 12 injections monthly
-Diverticulosis

MEDICATION ON ADMISSION: ASA, plavix, metoprolol 25', atorvastatin 80', losartan 25',
Lasix 20', Amlodipine 5 mg', prednisone 5', Keppra 750'',
celecoxib 100', benzonatate 100', omeprazole 20', Brimonidine
(0.2 % 1 in L eye'''), timolol maleate (0.255 each eye'), B12 IM
(1x/mo), Vit D 400U'

ALLERGIES: Tape [**12-14**]"X10YD / Morphine

PHYSICAL EXAM: Pt expired.

FAMILY HISTORY: No family history of early MI, arrhythmias, cardiomyopathies, or
sudden cardiac death. Mother had angina.

SOCIAL HISTORY: - Lives with daughter.
- Previous 40-50 year smoking history; quit [**2109**].
- No EtOH or illicits. 

### Response:
{'Atherosclerosis of native arteries of the extremities with ulceration,Dissection of iliac artery,Acidosis,Acute on chronic systolic heart failure,Other chronic pulmonary heart diseases,Acute posthemorrhagic anemia,Tricuspid valve disorders, specified as nonrheumatic,Other emphysema,Accidental puncture or laceration during a procedure, not elsewhere classified,Ulcer of other part of foot,Other iatrogenic hypotension,Old myocardial infarction,Leukocytosis, unspecified,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of steroids,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Do not resuscitate status,Epilepsy, unspecified, without mention of intractable epilepsy,Rheumatoid arthritis,Pernicious anemia'}
