CHIEF COMPLAINT: This 57 y/o Patient is c/o an new open wound on her right  knee
after recent BKA. She has a history of extensive Peripheral
artey disease and sustained a stroke about 5 weeks ago, no
residual deficits. She presented to  with new ulcer and redness
over her R
knee. She denies any trauma. To note she had a right ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision in [**2-22**]

PRESENT ILLNESS: This 57 year old F has an extensive history of peripheral ertery
disease. Most recently with right belwo knee amputation. She is
now c/o a new open wound on her right knee. She denies any
trauma. She also denies nausea, emesis or abdominal pain.

MEDICAL HISTORY: The patient has had a couple of recent admissions to other
hospitals and suffered a stroke about 5 weeks ago. No residual
deficits.
[**6-25**] s/p right below the knee amputation
[**8-22**] s/p transmetatarsal amputation of right foot
[**2-22**] right ileofemoral bypass with 8mm ringed PTFE, s/p
subsequent revision
Multiple right and left lower extremity percutaneous
interventions/stents, including left external iliac stenting
[**2167**], pta [**2168**], right external iliac, common femoral and
porfunda
femoris thromboendarterectomy, Dacron patch angioplasty 2093
[**1-19**] s/p Left femoral popliteal bypass, left great toe
amputation
Lacunar infarts x 2
hypercholesterolemia
CAD s/p MI, [**2169**] occluded RCA on angiography
Peripheral neuropathy
CHF, EF 25%
DM type I
DKA [**2170**]
Hypothyroidism
Acute renal failure [**12-19**] after peripheral angiography
Cervical spondylosis/nerve entrapment s/p c4-C6 discectomy and
fusion as well as L4-L5 laminectomy
CRF Stage III

MEDICATION ON ADMISSION: atorvastatin 80', plavix 75', digoxin 250mcg', lasix 60',
ibuprofen 800", insulin pump, levothyroxine 200mcg', lisinopril
5', protonix 40', accuzyme to LLE ulcer daily, ASA 325'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.0   P:86    BP: 144/80   RR:18   Spo2:96%
General: NAD. A&Ox3.
Pulm: Lungs clear bilaterally. Good excursion. No crackles or
wheezes.
Cardiac: RRR.
Abd: Soft. NT. ND. No palpable masses.
LLE: Palpable popliteal pulse, palpable posterior tibial pulse,
palpable dorsalis pedis pulse. TMA site C/D/I
RLE: palp fem, no palp graft, area of erythema noted on knee,
warm to touch, open wound shallow.

FAMILY HISTORY: Father died at age 50 of an MI

SOCIAL HISTORY: Lives at home with her 84 year old mother.  Does not work.
Patient??????s friend [**Name (NI) **] will bring her to the procedure, 617 328
Other complications due to other vascular device, implant, and graft,Infection (chronic) of amputation stump,Ulcer of other part of lower limb,Chronic diastolic heart failure,Embolism and thrombosis of iliac artery,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,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Old myocardial infarction,Tobacco use disorder,Long-term (current) use of insulin,Chronic kidney disease, Stage III (moderate),Other toe(s) amputation status
Comp-oth vasc dev/graft,Infection amputat stump,Ulcer oth part low limb,Chr diastolic hrt fail,Iliac artery embolism,Abn react-anastom/graft,Mth sus Stph aur els/NOS,DMI neuro nt st uncntrld,Neuropathy in diabetes,Cor ath unsp vsl ntv/gft,Hypothyroidism NOS,Pure hypercholesterolem,Hx TIA/stroke w/o resid,Old myocardial infarct,Tobacco use disorder,Long-term use of insulin,Chr kidney dis stage III,Status amput othr toe(s)
Admission Date:  [**2175-8-3**]              Discharge Date:   [**2175-8-9**]

Date of Birth:  [**2118-5-29**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
This 57 y/o Patient is c/o an new open wound on her right  knee
after recent BKA. She has a history of extensive Peripheral
artey disease and sustained a stroke about 5 weeks ago, no
residual deficits. She presented to  with new ulcer and redness
over her R
knee. She denies any trauma. To note she had a right ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision in [**2-22**]


Major Surgical or Invasive Procedure:
1. Right iliofemoral graft thrombectomy.
2. Iliofemoral bypass graft to profunda femoris artery
   bypass graft with PTFE.


History of Present Illness:
This 57 year old F has an extensive history of peripheral ertery
disease. Most recently with right belwo knee amputation. She is
now c/o a new open wound on her right knee. She denies any
trauma. She also denies nausea, emesis or abdominal pain.

Past Medical History:
The patient has had a couple of recent admissions to other
hospitals and suffered a stroke about 5 weeks ago. No residual
deficits.
[**6-25**] s/p right below the knee amputation
[**8-22**] s/p transmetatarsal amputation of right foot
[**2-22**] right ileofemoral bypass with 8mm ringed PTFE, s/p
subsequent revision
Multiple right and left lower extremity percutaneous
interventions/stents, including left external iliac stenting
[**2167**], pta [**2168**], right external iliac, common femoral and
porfunda
femoris thromboendarterectomy, Dacron patch angioplasty 2093
[**1-19**] s/p Left femoral popliteal bypass, left great toe
amputation
Lacunar infarts x 2
hypercholesterolemia
CAD s/p MI, [**2169**] occluded RCA on angiography
Peripheral neuropathy
CHF, EF 25%
DM type I
DKA [**2170**]
Hypothyroidism
Acute renal failure [**12-19**] after peripheral angiography
Cervical spondylosis/nerve entrapment s/p c4-C6 discectomy and
fusion as well as L4-L5 laminectomy
CRF Stage III


Social History:
Lives at home with her 84 year old mother.  Does not work.
Patient??????s friend [**Name (NI) **] will bring her to the procedure, 617 328

8137. Previously worked as a researcher at [**Hospital1 18**].


Family History:
Father died at age 50 of an MI

Physical Exam:
VS: 99.0   P:86    BP: 144/80   RR:18   Spo2:96%
General: NAD. A&Ox3.
Pulm: Lungs clear bilaterally. Good excursion. No crackles or
wheezes.
Cardiac: RRR.
Abd: Soft. NT. ND. No palpable masses.
LLE: Palpable popliteal pulse, palpable posterior tibial pulse,
palpable dorsalis pedis pulse. TMA site C/D/I
RLE: palp fem, no palp graft, area of erythema noted on knee,
warm to touch, open wound shallow.


Pertinent Results:
[**2175-8-8**] 06:20AM BLOOD WBC-7.2 RBC-3.38* Hgb-10.2* Hct-30.6*
MCV-91 MCH-30.1 MCHC-33.3 RDW-12.7 Plt Ct-303
[**2175-8-8**] 06:20AM BLOOD Plt Ct-303
[**2175-8-8**] 06:20AM BLOOD Creat-1.4* K-3.6

[**2175-8-3**]
HISTORY: A 57-year-old woman with PNH of stroke, evaluate for
acute CVA.

HEAD CT: Axial imaging was performed through the brain without
IV contrast.

COMPARISON: MRI brain [**2169-5-4**].

FINDINGS: In the medial aspect of the right cerebellar
hemisphere is a region
of hypodensity (2:12), but has not yet reached CSF density and
likely
represents an evolving subacute infarct. There are no areas
suspicious for
acute vascular infarct. Ventricles and sulci display minimal
prominence
likely age- related atrophy. There is no shift of normally
midline
structures. [**Doctor Last Name **]- white matter differentiation remains well
preserved. There
is no edema. The osseous structures appear intact. Paranasal
sinuses,
ethmoid and mastoid air cells are clear, which is an improvement
from [**2169**]
where the maxillary sinuses were partially opacified.

IMPRESSION:
1. Area of hypodensity in the medial aspect of the right
cerebellar
hemisphere, corresponding to the site of subacute infarct. No
regions
concerning for acute vascular territorial infarction. If there
is a
persistent concern, MRI is more sensitive for evaluation.
2. No hemorrhage.
3. Improvement in aeration of the maxillary sinuses.

NOTE ADDED AT ATTENDING REVIEW: The right cerebellar lesion
appears to
represent atrophy, suggesting an old infarct, rather than a
subacute lesion.

[**2175-8-3**] CTA
Final Report
HISTORY: 57-year-old woman with infection of BK [**Doctor Last Name **] bypass
graft. Please
assess infrarenal to right lower extremity stump for arterial
blood flow.

CTA AORTA RUNOFF: Helical imaging was performed from the level
of the kidneys
through or below the level of the right below-knee amputation
prior without IV
contrast. Subsequently, after uneventful administration of
intravenous
contrast, helical imaging was again performed from the level of
the kidneys to
below the level of the right below-knee amputation. Coronal and
sagittal
reformats were prepared. Repeat imaging was performed in the
venous phase.

COMPARISON: CT pelvis from [**2173-8-25**].

FINDINGS: The partially visualized kidneys enhance symmetrically
with small
bilateral hypodensities too small to fully characterize. At the
origin of the
bilateral renal arteries are moderate-severe narrowing with
adjacent calcific
atherosclerotic plaque. There is hypoenhancement of the left
kidney, which is
slightly atrophic compared to the right.Tiny accessory left
renal artery
perfuses the upper pole. Small wedge-shaped peripheral areas of
hypoenhancement are likely infarcts. The hepatic vasculature
appears
conventional and the liver and gallbladder are unremarkable. The
partially
visualized spleen appears unremarkable. Abdominal loops of bowel
are normal in
their appearance.

Approximately 6 cm below the aortic bifurcation on the right is
a bypass graft
which demonstrates complete occlusive thrombus along its entire
length
extending into the right mid thigh. There are small collateral
arterial
vessels which flow into the right proximal thigh (5a:157). Right
popliteal
artery recionstitutes and is patent but diminuitive. Proximal
right AT and PT
are patent but not well assessed. Right peroneal appears
occluded In
addition, there is a bypass graft catheter from the left common
femoral artery
to the left above knee popliteal artery, which demonstrates
normal arterial
flow. The left popliteal artery is patent. The left anterior
tibial artery is
widely patent proximally. The left PT and peroneal arteries are
diminuitive
with significant disease not well assessed on this study.

The bladder, rectum, sigmoid colon and pelvic loops of small and
large bowel
appear normal. The bladder wall is mildly thickened but may be
due to
underdistension of the bladder. The uterus appears atrophic.
Adnexal
structures are not visualized. There is no free air in the
abdomen or pelvis.

BONE WINDOWS: There are no suspicious sclerotic or lytic
lesions. There are
mild degenerative changes of the lower lumbar spine. Patient is
status post
L4/L5 laminectomy.

IMPRESSION:
1. Complete occlusive thrombus along the length of the right
femoral bypass
graft. The left femoral bypass graft demonstrates normal
arterial flow. There
are small collateral arterial vessels which perfuses the right
lower extremity
with reconstitution of a diminutive politeal artery. there may
be occlusion of
the right peroneal artery and there is disease in the proximal
left PT and
peroneal arteries incompletely assessed on this study.

2. Moderate-severe bilateral renal artery stenosis with adjacent
calcific
plaque. Mild left renal atrophy and hypoenhancement indicates
worse stenosis
on the left. Possible small bilateral renal infarcts.

3. Status post L4/L5 laminectomy.

[**2175-8-4**]
HISTORY: Possible prior stroke.

FINDINGS: Calcific plaque involving the internal carotid
arteries
bilaterally. The peak systolic velocities on the right are 186,
145, 128, 108
and 133 cm/sec for the proximal, mid and distal ICA and CCA and
ECA
respectively. Similar values on the left are 73, 119, 77, 71,
and 80 cm/sec.
The ICA to CCA ratio is 1.7 on the right and 1.6 on the left.
There is
antegrade flow involving both vertebral arteries.

IMPRESSION:

1. Approximately 60% right ICA stenosis.

2. Approximately 40% left ICA stenosis.






Brief Hospital Course:
The  patient was taken to the operating room on [**2175-8-4**] and
underwent a right iliofemoral graft thrombectomy and an
iliofemoral bypass graft to the profunda femoris artery bypass
graft with PTFE.  She was hemodynamically stable throughout the
entire case and continued to be so after awaking from
anesthesia.  The patient was taken to the recovery room in
stable condition.
[**8-5**] VSS, no events. Transfered from PACU to VICU. Home
medications reviewed. Diet resumed. Resumed Lasix for STABLE,
CHRONIC DIASTOLIC CHF. Placed on Vanco/Cipro/Flagyl
[**Date range (1) 107524**] VSS, no events. Tolerating diet. Cleared for discharge
to home. IV ABX changed to po ABX on [**8-8**] (Diclox/cipro/flagyl).
Neurology following for recent stroke.
[**8-9**] VSS, no events. Discharged to home on Augmentin. F/U
scheduled with Dr. [**Last Name (STitle) **].

Medications on Admission:
atorvastatin 80', plavix 75', digoxin 250mcg', lasix 60',
ibuprofen 800", insulin pump, levothyroxine 200mcg', lisinopril
5', protonix 40', accuzyme to LLE ulcer daily, ASA 325'

Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): refills from PCP [**Name9 (PRE) **],[**Name9 (PRE) 275**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 107525**].
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
12. Insulin pump
Insulin  Pump SC (Self Administering Medication)
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
Disp:*1 1* Refills:*0*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.


Discharge Disposition:
Home

Discharge Diagnosis:
57F with painful and infected R BKA Stump, had stroke 5 weeks
ago with no residual affects, now s/p ilio-PFA bypass
PMH: [**4-26**] s/p L 4th toe amp and angio, [**6-25**] s/p R BKA, [**8-22**] s/p
transmetatarsal amputation of right foot, [**2-22**] R ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision, Mult R and
LLE percutaneous interventions/stents, including L external
iliac stenting, [**2167**], pta [**2168**], R external iliac, CFA and
profunda, femoris thromboendarterectomy, Dacron patch
angioplasty [**2169**] [**1-19**] s/p L femoral popliteal bypass, L great
toe amputation Lacunar infarts x 2, ^chol, CAD s/p MI, [**2169**]
occluded RCA on angiography, Peripheral neuropathy, CHF (EF
25%), IDDM on insulin pump, DKA [**2170**], Hypothyroidism, ARF [**12-19**]
after peripheral angiography, Cervical spondylosis/nerve
entrapment s/p c4-C6 discectomy and fusion as well as L4-L5
laminectomy


Discharge Condition:
stable


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Unless you were told not to bear any weight on operative foot:
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 swelling of the leg you were operated
on:
??????	Elevate your leg above the level of your heart (use [**2-21**]
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:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	Unless you were told not to bear any weight on operative foot:

??????	You should get up every day, get dressed and walk
??????	You should gradually increase 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 (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2175-8-31**] 11:15



Completed by:[**2175-8-9**]
{'Other complications due to other vascular device, implant, and graft,Infection (chronic) of amputation stump,Ulcer of other part of lower limb,Chronic diastolic heart failure,Embolism and thrombosis of iliac artery,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,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Old myocardial infarction,Tobacco use disorder,Long-term (current) use of insulin,Chronic kidney disease, Stage III (moderate),Other toe(s) amputation status'}


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: This 57 y/o Patient is c/o an new open wound on her right  knee
after recent BKA. She has a history of extensive Peripheral
artey disease and sustained a stroke about 5 weeks ago, no
residual deficits. She presented to  with new ulcer and redness
over her R
knee. She denies any trauma. To note she had a right ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision in [**2-22**]

PRESENT ILLNESS: This 57 year old F has an extensive history of peripheral ertery
disease. Most recently with right belwo knee amputation. She is
now c/o a new open wound on her right knee. She denies any
trauma. She also denies nausea, emesis or abdominal pain.

MEDICAL HISTORY: The patient has had a couple of recent admissions to other
hospitals and suffered a stroke about 5 weeks ago. No residual
deficits.
[**6-25**] s/p right below the knee amputation
[**8-22**] s/p transmetatarsal amputation of right foot
[**2-22**] right ileofemoral bypass with 8mm ringed PTFE, s/p
subsequent revision
Multiple right and left lower extremity percutaneous
interventions/stents, including left external iliac stenting
[**2167**], pta [**2168**], right external iliac, common femoral and
porfunda
femoris thromboendarterectomy, Dacron patch angioplasty 2093
[**1-19**] s/p Left femoral popliteal bypass, left great toe
amputation
Lacunar infarts x 2
hypercholesterolemia
CAD s/p MI, [**2169**] occluded RCA on angiography
Peripheral neuropathy
CHF, EF 25%
DM type I
DKA [**2170**]
Hypothyroidism
Acute renal failure [**12-19**] after peripheral angiography
Cervical spondylosis/nerve entrapment s/p c4-C6 discectomy and
fusion as well as L4-L5 laminectomy
CRF Stage III

MEDICATION ON ADMISSION: atorvastatin 80', plavix 75', digoxin 250mcg', lasix 60',
ibuprofen 800", insulin pump, levothyroxine 200mcg', lisinopril
5', protonix 40', accuzyme to LLE ulcer daily, ASA 325'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 99.0   P:86    BP: 144/80   RR:18   Spo2:96%
General: NAD. A&Ox3.
Pulm: Lungs clear bilaterally. Good excursion. No crackles or
wheezes.
Cardiac: RRR.
Abd: Soft. NT. ND. No palpable masses.
LLE: Palpable popliteal pulse, palpable posterior tibial pulse,
palpable dorsalis pedis pulse. TMA site C/D/I
RLE: palp fem, no palp graft, area of erythema noted on knee,
warm to touch, open wound shallow.

FAMILY HISTORY: Father died at age 50 of an MI

SOCIAL HISTORY: Lives at home with her 84 year old mother.  Does not work.
Patient??????s friend [**Name (NI) **] will bring her to the procedure, 617 328 

### Response:
{'Other complications due to other vascular device, implant, and graft,Infection (chronic) of amputation stump,Ulcer of other part of lower limb,Chronic diastolic heart failure,Embolism and thrombosis of iliac artery,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,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Old myocardial infarction,Tobacco use disorder,Long-term (current) use of insulin,Chronic kidney disease, Stage III (moderate),Other toe(s) amputation status'}
