CHIEF COMPLAINT: Infected/bleeding L LE wound

PRESENT ILLNESS: This woman with previously ischemic left leg who
has developed multiple infections around her incision lines
and along fascial planes, presented with systemic infection
from her open left leg wounds. She was treated with IV
antibiotics and dressing changes but was noted to have
extensive necrotic and purulent material particularly from
her lateral calf wound and also extending posteriorly. These
were not amenable to bedside debridement.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: tylenol 650"", cinacalcet 60', Colace 100", heparin
5000''', gabapentin 300', Lantus 5U Q12pm, HISS, mirtazapine
15', oxycodone 10''', protonix 40", niferex 150', Renagel
2400''', simvastatin 20', tramadol 25", mvi, albuterol neb PRN,
lactulose 10''' PRN, milk of magnesia 30ml' PRN, ondansetrol
2''' PRN, senna 17.2" PRN, miconazole topical''' PRN, accuzyme"
topical

ALLERGIES: Lisinopril

PHYSICAL EXAM: AAOx3, VSS, Neuro intact.
Lungs: CTA
Cardiac: HR RRR
Abd: Obese, positive bowel sounds

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week.
Other postoperative infection,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Personal history of malignant neoplasm of kidney
Other postop infection,End stage renal disease,Ath ext ntv art gngrene,Comp-oth cardiac device,Hyp kid NOS w cr kid V,Aut neuropthy in oth dis,DMII circ nt st uncntrld,Gastroparesis,Hx of kidney malignancy
Admission Date:  [**2191-11-4**]              Discharge Date:   [**2191-12-24**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: SURGERY

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Infected/bleeding L LE wound

Major Surgical or Invasive Procedure:
L BKA, STSG [**2191-12-9**]
Debridement of necrotic left leg wound and change
of a wound VAC dressing [**2191-11-16**]
Resection of pseudoaneurysm and ligation of
fistula [**2191-11-17**]
Exchange of vac under conscious sedation [**11-23**]
Debridement of necrotic left leg wound [**2191-11-8**]


History of Present Illness:
This woman with previously ischemic left leg who
has developed multiple infections around her incision lines
and along fascial planes, presented with systemic infection
from her open left leg wounds. She was treated with IV
antibiotics and dressing changes but was noted to have
extensive necrotic and purulent material particularly from
her lateral calf wound and also extending posteriorly. These
were not amenable to bedside debridement.


Past Medical History:
renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

Social History:
Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week.


Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
AAOx3, VSS, Neuro intact.
Lungs: CTA
Cardiac: HR RRR
Abd: Obese, positive bowel sounds

Extremities: LLE-BKA

Pulses: Fem [**Doctor Last Name **] graft
Rt 2+ None palp
Lt 2+ None palp


Pertinent Results:
RADIOLOGY  Final Report

PICC W/O PORT  [**2191-11-7**] 8:03 AM

IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French double lumen PICC line placement via the right brachial
venous approach. Final internal length is 36 cm, with the tip
positioned in SVC. The line is ready to use.

[**2191-11-7**] 1:57 PM

ART DUP EXT LO UNI;F/U

FINDINGS: Duplex evaluation was performed of left lower
extremity bypass. Peak velocities in cm/sec are 52 in the native
proximal vessel, 38 at the proximal anastomosis, 53 at the
distal anastomosis and 144 in the native distal vessel. From
proximal to distal, velocities are 230, 85, 70, 80, 77, 72 and
76 cm/sec within the vein graft.

IMPRESSION: Patent left leg bypass with elevated velocities in
the proximal graft suggestive of significant stenosis greater
than 75%

[**2191-11-7**] 10:44 AM

CHEST (PORTABLE AP)

Left infrahilar opacification has improved. Pulmonary vascular
congestion and mild cardiomegaly have also decreased. No pleural
effusion or pneumothorax. Upper lungs entirely clear.

[**2191-11-5**] 3:08 PM

FINDINGS:

There is extensive reticular edema in the subcutaneous fat.
Evaluation for the presence of a subtle abscess is limited in
the absence of contrast; however, no large fluid collections are
seen within the subcutaneous fat or muscle. A small subtle
collection, however, cannot adequately be excluded.
Additionally, extensive vascular calcific atherosclerosis is
noted. There is extensive subcutaneous edema.

Evaluation of the osseous structures demonstrates
demineralization of the bones with periosteal thickening which
can be seen in the setting of renal insufficiency and chronic
venous stasis. No fractures are present.

IMPRESSION:
1. Limited examination for the detection of an abscess without
the use of contrast; however, no large abscess is identified.
Extensive edema and subcutaneous edema is present.
2. Extensive calcific atherosclerosis and evidence of chronic
venous stasis.
3. Extensive demineralization of the bones.

[**2191-11-5**] 2:55 pm SWAB     Site: LEG      Source: Right leg
ulcer.

STAPH AUREUS COAG +.    MODERATE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    MODERATE GROWTH.
_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S


Brief Hospital Course:
This is a 53 y.o woman with previously ischemic left leg who
developed multiple infections around her incision lines and
along fascial planes, presented with systemic infection from her
open left leg wounds. She was treated with IV
antibiotics and dressing changes but was noted to have extensive
necrotic and purulent material particularly from her lateral
calf wound and also extending posteriorly. These were not
amenable to bedside debridement. Patient was admitted on
[**2191-11-8**], was taken to the OR for debridement of necrotic left
leg wound. Post-operatively, was recovered then transfered to
the ICU. Successfully extubated the next day, recovered and
transfered to [**Hospital Ward Name 121**] 5. For details, please see operative note.
The patient remained on IV antiobiotics, and received daily
wound care and dressing changes.  On [**11-16**], the patient returned
to the operating room for another wound debridement after which
a VAC was placed to the wound; please see operative note for
details.  The patient recovered in the PACU initially, and then
on [**Hospital Ward Name 121**] 5.
 On [**2104-11-16**], a large ulcerated lesion on an AV graft was noted
to be bleeding despite compression, and the patient was taken to
the operating room on [**11-17**] for a resection of a pseudoaneurysm
and ligation of her AV fistula.
On [**11-23**], the patient was brought to the operating room for a
change of the VAC dressing.  DEspite repeated debridements,
continued wound care and intravenous antibiotics, it was felt
that a left below the knee amputation would be the best
intervention; this surgery along with a split thickness skin
graft and a VAC dressing placement was performed on [**12-9**].

Neuro:  A pain consult was called initially for help controlling
the patient's chronic pain.  Her medications were altered with
good results.  Prior to dressing changes, VAC changes, and other
procedures, the patient received adequate pain control.
Psychiatry was also consulted during this admission for
depression, who recommmended Seroquel and Haldol which were used
with good effect.
CV:  The patient received metoprolol during her hospitalization,
and her vital signs were routintely monitored.
Pulmonary:  The patient was extubated from her multiple
surgeries when appropriate, and recovered well.  She required
good pulmonary toilet, and was encouraged to get up and out of
bed.  She remained on supplemental oxygen throughout her stay,
and was unable to be weaned.
GI/GU: The patient's diet was advanced post operatively as
tolerated; she was put on a diabetic diet during her stay.  Her
urine output was monitored closely, and her intravenous fluids
were managed accordingly for post op hypovolemia.
Heme:  The patient's hematocrit was monitored frequently, and
when appropriate, the patient was transfused for post operative
blood loss/anemia.
Endo: Managed with Glargine and regular insulin sliding scale.
renal was consulted for further management and the patient was
dialysed per routine.  Her antibiotics and other medications
were renally dosed.

Wound/ID: [**12-5**] AVfistula site found to be infected-she received
routine wound care, cultured grew 1+ GNRs-klebsiella, resistant
to cipro, treated with Ceftazidime, which will end on [**12-21**].
[**2191-11-16**]- stool positive C-diff, ID recommended PO Metronidazole
and vancomycin x 4wks (slated to end on [**1-4**]).
The amputation/skin graft wound was dressed daily with Adaptic
and the AV fistula site had wet to dry dressing changes
QDay-[**Hospital1 **].  Granulation tissue did form under the skin graft.
The superior edge of the skin graft was the slowest to take.

Prophylaxis: The patient received aspirin and subcutaneous
heparin throughout her stay for DVT prophylaxis.

Medications on Admission:
[**Last Name (un) 1724**]: tylenol 650"", cinacalcet 60', Colace 100", heparin
5000''', gabapentin 300', Lantus 5U Q12pm, HISS, mirtazapine
15', oxycodone 10''', protonix 40", niferex 150', Renagel
2400''', simvastatin 20', tramadol 25", mvi, albuterol neb PRN,
lactulose 10''' PRN, milk of magnesia 30ml' PRN, ondansetrol
2''' PRN, senna 17.2" PRN, miconazole topical''' PRN, accuzyme"
topical

Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HD PROTOCOL
(HD Protochol).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
12. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO QOD ().
13. Insulin Regular Human 100 unit/mL Solution Sig: per scale sc
as directed Injection breakfast lunch dinner and bedtime: SC
Sliding Scale
Humalog Insulin Dose
0-70   mg/dL 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers 4 oz. Juice
and 15 gm crackers
71-120   mg/dL 0   Units 0   Units 0   Units 0   Units
121-160   mg/dL 2   Units 2   Units 2   Units 2   Units
161-200   mg/dL 4   Units 4   Units 4   Units 4   Units
201-240   mg/dL 6   Units 6   Units 6   Units 6   Units
241-280   mg/dL 8   Units 8   Units 8   Units 8   Units
> 280   mg/dL Notify M.D. .
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Nursing care

Discharge Diagnosis:
S/p LLE debridement of wound
S/p LBKA, STSG ([**12-9**])
history of DM2
history of ESRD on HD
history of depression
history of PVD
history of PUD
history of OSA
history of osteoporosis
history of HTN
history of RCC
history of diabetic gastroparesis


Discharge Condition:
stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION

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 restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.

You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.

No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:

Redness in or drainage from your leg wound(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 6 weeks.

Do not drive a car unless cleared by your Surgeon.

Try to keep leg elevated when able.

BATHING/SHOWERING:

You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.

WOUND CARE:

Sutures / 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 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
four weeks after surgery.

MEDICATIONS:

Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can 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 pressure to your amputation site.

No strenuous activity for 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:
Provider: [**Last Name (NamePattern4) **].[**Name (NI) 24947**] Phone: [**Telephone/Fax (1) 2625**] Date/Time -----



Completed by:[**2191-12-24**]
{'Other postoperative infection,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Personal history of malignant neoplasm of kidney'}


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: Infected/bleeding L LE wound

PRESENT ILLNESS: This woman with previously ischemic left leg who
has developed multiple infections around her incision lines
and along fascial planes, presented with systemic infection
from her open left leg wounds. She was treated with IV
antibiotics and dressing changes but was noted to have
extensive necrotic and purulent material particularly from
her lateral calf wound and also extending posteriorly. These
were not amenable to bedside debridement.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: tylenol 650"", cinacalcet 60', Colace 100", heparin
5000''', gabapentin 300', Lantus 5U Q12pm, HISS, mirtazapine
15', oxycodone 10''', protonix 40", niferex 150', Renagel
2400''', simvastatin 20', tramadol 25", mvi, albuterol neb PRN,
lactulose 10''' PRN, milk of magnesia 30ml' PRN, ondansetrol
2''' PRN, senna 17.2" PRN, miconazole topical''' PRN, accuzyme"
topical

ALLERGIES: Lisinopril

PHYSICAL EXAM: AAOx3, VSS, Neuro intact.
Lungs: CTA
Cardiac: HR RRR
Abd: Obese, positive bowel sounds

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week. 

### Response:
{'Other postoperative infection,End stage renal disease,Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to other cardiac device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Peripheral autonomic neuropathy in disorders classified elsewhere,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Gastroparesis,Personal history of malignant neoplasm of kidney'}
