CHIEF COMPLAINT: transfer from outside hospital for R leg thrombectomy

PRESENT ILLNESS: Ms. [**Known lastname 64059**] is an 85 year old woman with history of hypertension,
PVD presents as tranfer from [**Hospital3 **] for superficial
femoral artery thrombectomy. She reported that she was about to
take a shower the day of her admission to the outside hospital
when she experienced dizziness and also pain from her Right
ankle to her Right knee associated with some numbness of her
Right big toe as well as the 2nd and 3rd digits.  She lied down
on a bath mat, denied any loss of consciousness or head trauma.
The dizziness resolved but then recurred, so her daughters took
her to [**Hospital3 5365**] where she was admitted in complete heart
block and noted to have an ischemic Right foot with cyanosis
extending to midfoot.  She was noted at that time to have 2
episodes of near syncope from near asystole.  At [**Hospital1 10551**], she had emergent placement of temporary pacer wire in
her Right IJ with restoration of heart rate.  She was then taken
to the OR with thrombectomy of R leg and started on a Heparin
drip. Later, a permanent pacer was placed.  She had an
echocardiogram that showed normal EF, mildly dilated RA, mild
MR, and moderate TR.  She was noted to have elevated troponin-T
which trended 0.03, 0.037, 0.03 and was felt to have an NSTEMI.
The Right foot was noted to still be cold compared to the Left,
so she was referred to [**Hospital1 18**] for RLE angiogram [**2183-2-19**] with Dr.
[**Last Name (STitle) **].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Hypertension, tobacco use
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: DDD Pacer placed recently at [**Hospital1 392**]
3. OTHER PAST MEDICAL HISTORY:
Hypertension
left cheek basal cell carcinoma
left eyelid basal cell carcinoma s/p resection
s/p appendectomy
PVD with arteriogram [**6-7**] of left leg, followed by Dr. [**Last Name (STitle) **]

MEDICATION ON ADMISSION: Norvasc
Lasix
Potassium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Significant for a father with COPD and cancer.

SOCIAL HISTORY: She lives alone.  She has smoked for 60 years, had cut down to 5
cigarettes per day then quit [**2182**].  Restarted smoking socially
recently.  Has a daughter that lives nearby.
Arterial embolism and thrombosis of lower extremity,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Atrioventricular block, complete,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Tobacco use disorder,Cardiac pacemaker in situ,Atherosclerosis of native arteries of the extremities with rest pain,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Lower extremity embolism,Subendo infarct, initial,Urin tract infection NOS,Atriovent block complete,Accidental op laceration,Hypertension NOS,Crnry athrscl natve vssl,Tobacco use disorder,Status cardiac pacemaker,Ath ext ntv at w rst pn,Abn react-surg proc NEC
Admission Date:  [**2183-2-19**]              Discharge Date:   [**2183-2-24**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
transfer from outside hospital for R leg thrombectomy

Major Surgical or Invasive Procedure:
Angiogram of Right Superficial Femoral Artery and Right Peroneal
Arteries with Partial Thrombectomy


History of Present Illness:
Ms. [**Known lastname 64059**] is an 85 year old woman with history of hypertension,
PVD presents as tranfer from [**Hospital3 **] for superficial
femoral artery thrombectomy. She reported that she was about to
take a shower the day of her admission to the outside hospital
when she experienced dizziness and also pain from her Right
ankle to her Right knee associated with some numbness of her
Right big toe as well as the 2nd and 3rd digits.  She lied down
on a bath mat, denied any loss of consciousness or head trauma.
The dizziness resolved but then recurred, so her daughters took
her to [**Hospital3 5365**] where she was admitted in complete heart
block and noted to have an ischemic Right foot with cyanosis
extending to midfoot.  She was noted at that time to have 2
episodes of near syncope from near asystole.  At [**Hospital1 10551**], she had emergent placement of temporary pacer wire in
her Right IJ with restoration of heart rate.  She was then taken
to the OR with thrombectomy of R leg and started on a Heparin
drip. Later, a permanent pacer was placed.  She had an
echocardiogram that showed normal EF, mildly dilated RA, mild
MR, and moderate TR.  She was noted to have elevated troponin-T
which trended 0.03, 0.037, 0.03 and was felt to have an NSTEMI.
The Right foot was noted to still be cold compared to the Left,
so she was referred to [**Hospital1 18**] for RLE angiogram [**2183-2-19**] with Dr.
[**Last Name (STitle) **].

On presentation, pt was resting comfortably, reporting no pain
or dizziness. She had a low grade temperature and had the
following vitals: T 100.0  BP 164/62  HR 82  RR 22.

Review of Systems as above, negative for fevers/chills/nausea,
vision changes, has occasional headaches, no neurological signs.
Occasional dizziness at baseline, weakness attributed to age. No
orthopnea, PND, palpitations, or chest pain. No cough, SOB. No
nausea, vomiting, diarrhea, constipation, abdominal pain. No
dysuria. No skin/joint changes other than above.

Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, tobacco use
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: DDD Pacer placed recently at [**Hospital1 392**]
3. OTHER PAST MEDICAL HISTORY:
Hypertension
left cheek basal cell carcinoma
left eyelid basal cell carcinoma s/p resection
s/p appendectomy
PVD with arteriogram [**6-7**] of left leg, followed by Dr. [**Last Name (STitle) **]

Social History:
She lives alone.  She has smoked for 60 years, had cut down to 5
cigarettes per day then quit [**2182**].  Restarted smoking socially
recently.  Has a daughter that lives nearby.

Family History:
Significant for a father with COPD and cancer.

Physical Exam:
Admission Exam:

100.0 164/62 82 22
GEN: Elderly pleasant lady in no distress, rambling tangential
conversation but answering appropriately, alert
Neck: No jugular venous distention noted, some external jugular
pulsations noted around 5cm at 30 degrees. Carotid pulsations
palpable.
Lungs:  Scattered wheezes, light crackles and adventitious
sounds are appreciated.
CV: S1 and S2 are very faint but regular and no appeciable
murmurs are heard
ABd: Soft NT ND obese abdomen
SKIN: Diffuse senile ecchymoses on bilateral arms
EXT: No BLE edema is noted. R foot is cold compared to very warm
and well perfused L foot. Tips of all toes bilaterally with some
pinkness, but no cyanosis noted. DP's and PT's are not palpable
bilaterally.

Prior to discharge,
the feet were both warm and well perfused with only the Right
sided toes feeling cool to touch.  The 2nd and 3rd digits on the
right foot had decreased sensation.  Right posterior tibial
pulse was dopplerable, but right dorsalis pedis pulse was not
dopplerable.

Pertinent Results:
[**2183-2-20**] 12:30AM BLOOD WBC-9.2 RBC-4.19* Hgb-10.3* Hct-32.3*
MCV-77* MCH-24.7* MCHC-32.0 RDW-16.8* Plt Ct-252
[**2183-2-24**] 03:47AM BLOOD WBC-8.2 RBC-3.93* Hgb-9.7* Hct-30.7*
MCV-78* MCH-24.7* MCHC-31.6 RDW-16.9* Plt Ct-307
[**2183-2-24**] 03:47AM BLOOD PT-12.8 PTT-23.0 INR(PT)-1.1
[**2183-2-20**] 12:30AM BLOOD Glucose-141* UreaN-19 Creat-0.9 Na-141
K-3.9 Cl-106 HCO3-27 AnGap-12
[**2183-2-24**] 03:47AM BLOOD Glucose-102* UreaN-24* Creat-1.0 Na-141
K-4.3 Cl-107 HCO3-27 AnGap-11
[**2183-2-20**] 12:30AM BLOOD CK(CPK)-146
[**2183-2-20**] 12:30AM BLOOD CK-MB-3 cTropnT-0.03*
[**2183-2-20**] 06:05AM BLOOD %HbA1c-5.5 eAG-111
[**2183-2-20**] 06:05AM BLOOD Triglyc-69 HDL-41 CHOL/HD-3.4 LDLcalc-85

Cardiology Report	Cardiac Cath	Study Date of [**2183-2-21**]

COMMENTS:
1. Access was obtained in retrograde fashion through the left
common
femoral artery.
2. A 4F Omniflush catheter was advanced into the lower abdominal
aorta.
Non selective angiography revealed:
    - Abodminal aorta: minimal disease
    - Single patent renal artery bilaterally
    - Left: patent CIA, IIA, EIA and CFA.
    - right: patent CIA, IIA, EIA and CFA.
3. An angled glide wire was then crossed over and advanced into
the
right SFA over which the Omni flush catheter was exchanged for a
straight glide catheter that was advanced to the CFA level and
selective
angiography was performed which demonstrated:
    - 90% SFA lesion proximally,
    - patent popliteal artery
    - patent TPT.
    - occluded anterior tibial artery
    - occluded posterial tibial artery
    - single peroneal artery run off with 100% occlusion at
distal calf.
4. Successful PTA and stenting of the right sfa stenosis with a
5.0x40mm
Everflex Protege stent that was 5.0mm. Final angiography
revealed no
residual stenosis, localized perforation and good distal flow
(see PTA
comments).
5. Unsuccessful PTA of the peroneal artery with 2.0mm and 3.0mm
balloons. Final angiography revealed localized perforation and
unchanged
flow status.


FINAL DIAGNOSIS:
1. Peripheral artery disease.
2. [**Name (NI) 64060**] PTA and stenting of the right SFA.
3. Unsuccessful intervention of the right peroneal artery.
4. Stable localized perforation at the right SFA level as well
as the
right peroneal artery level.

Radiology Report	ART EXT (REST ONLY)	Study Date of [**2183-2-20**] 3:47
PM

FINDINGS: Doppler waveform analysis, pulse volume recording, and
ankle-
brachial index were calculated at rest.

On the right, there is triphasic waveform within the femoral,
superficial
femoral, and popliteal distributions with monophasic waveforms
in the
posterior tibial and dorsalis pedis distribution. Additionally,
there is
marked loss of amplitude at the level of the ankle and
metatarsal on pulse
volume recordings. The ankle brachial index is 0.43.

On the left, there is a triphasic waveform at the level of the
femoral artery,
with loss of phasicity at the superficial femoral, popliteal,
and posterior
tibial and dorsalis pedis distributions, with monophasic
waveform seen at
levels. The ankle-brachial index measures 0.45. There is
significant loss of
amplitude at the level of the calf, ankle, and metatarsal
levels.

IMPRESSION: Findings are consistent with significant right
tibial disease,
and left disease at the SFA and tibial levels.

Brief Hospital Course:
Ms [**Known lastname 64059**] is a 85 year-old female with hypertension, PVD,
complete block s/p pacemaker placement, and an ischemic right
leg s/p thrombectomy and RLE angiogram complicated by a small
perforation transferred to the CCU for monitoring of hematoma
formation.
.
# Ischemic R foot s/p thrombectomy and RLE angiogram with small
perforation:
Patient had partial thrombectomy at outside hospital and was
transferred to [**Hospital1 18**] for further thrombectomy. During the
catheterization, the superficial femoral artery was underwent
successful percutaneous transluminal angioplasty.  There was
diffuse peripheral arterial disease but no intervention was made
at the level of the right peroneal artery.  The procedure was
complicated by localized perforation of the right superficial
femoral artery as well as the right peroneal artery.  Her
anticoagulation with heparin was reversed with protamine.
Vascular surgery was consulted with no intervention.  Her right
foot did become warm and of normal color after the procedure
with just the toes feeling cooler to touch.  Posterior tibial
pulses on both feet were dopplerable; dorsalis pedis pulse was
dopplerable on the left foot but not the right foot.

The patient was transferred to the CCU for monitoring but was
not found to have any signs of compartment syndrome.  She had a
large anterior hematoma and ecchymoses.  Her groin site was
tender and continues to have staples upon discharge, which
should be removed during her followup appointment with Dr. [**Last Name (STitle) **].
She did have one episode of sudden throbbing leg pain which
resolved after tylenol and one dose of oxycodone.  Ms. [**Known lastname 64059**]
may require another procedure in the near future for her
peripheral arterial disease and should follow up with Dr. [**Last Name (STitle) **] in
two weeks to confirm.  She was started on plavix during this
hospitalization after placement of the stent.

# Coronary Artery Disease:
Patient is a current smoker with significant peripheral arterial
disease, so she likely has coronary artery disease as well,
though she reports no history.  She was reported to have
elevated cardiac enzymes at the outside hospital; however, her
CK here was normal and her trop was stable at 0.03.  She has no
history of angina, though her peripheral vascular disease puts
her at risk for CAD as well.  She was started on a beta blocker
and aspirin which should be continued as an outpatient.  She may
require further workup for coronary artery disease as an
outpatient. She was counseled on the importance of smoking
cessation.

# Hypertension:
The patient was continued on her home dose of amlodipine during
hospitalization and should restart her home lasix upon
discharge.

# Complete Heart Block:
Patient was noted to be in complete heart block at the outside
hospital and had a pacemaker placed. EKG showed V-paced rhythm.
She was monitored on telemetry.  Upon discharge, the visiting
nurse will monitor her site of pacemaker placement.

# Urinary Tract Infection:
Patient was started on Ciprofloxacin 500mg twice daily on [**2-24**]
and should be continued for three days total.

# Tobacco Use:
Patietn was counseled on smoking cessation.

Medications on Admission:
Norvasc
Lasix
Potassium

Meds on transfer: Nexium, Morphine, Tylenol, Zofran

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 doses.
Disp:*5 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Lasix - dosage unknown
7. Potassium - dosage unknown

Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Right Superficial Femoral Artery Thrombosis

Secondary Diagnoses:
Urinary Tract Infection
Hypertension
Peripheral Vascular Disease
Tobacco Abuse


Discharge Condition:
Stable.
Alert and Oriented x3.
Ambulatory.


Discharge Instructions:
Dear Ms. [**Known lastname 64059**],
You were transferred to [**Hospital1 18**] from another hospital because you
were having right leg pain and needed to have an angiogram and
removal of the blood clot in your leg. At the other hospital,
you had a pacemaker placed because you had passed out from an
abnormal heart rhythm. It also appears that you may have had a
small heart attack at the other hospital. It appears that a clot
had blocked off an artery in your right leg, so you had a
procedure here at [**Hospital1 18**] to remove the clot. Most of the clot was
removed, though you may need to have another procedure to remove
the rest at a later time.  During the procedure, you experienced
a complication in which part of your artery was perforated and
blood leaked into your leg. You were monitored for this
complication and found to be stable, though you should seek
medical attention if you are experiencing increasing leg pain at
home.  You will need to follow up with Dr. [**Last Name (STitle) **] as scheduled
below.

Please be sure to quit smoking, as it can contribute to heart
disease and the Peripheral Vascular Disease in your legs.

Because you may have had a small heart attack that caused the
abnormal rhythm in your heart at the other hospital, you should
be evaluated for Coronary Artery Disease by your primary care
physician or cardiologist. You have high risk of heart disease
because you have smoked for many years and because you have
peripheral vascular disease.  You were started on daily aspirin
for this reason.

The following changes have been made to your medications.
- Please start taking aspirin 325mg daily
- Please start taking Metoprolol Succinate (or Toprol XL) 50mg
daily
- Please start taking Clopidogrel (Plavix) 75mg daily until you
are told by Dr. [**Last Name (STitle) **] that you no longer need it
- Please start taking Ciprofloxacin 500mg twice daily for 3 days
total for a urinary tract infection

Please be sure to keep all of your followup appointments.

Please seek medical attention if you begin to experience
worsening leg pain, chest pain, sudden shortness of breath,
lightheadedness or any other symptoms concerning to you.

Followup Instructions:
Please be sure to keep all of your followup appointments.

Dr. [**Location (un) 64061**] Office
[**3-10**], at 2pm
- At this visit, please be sure to discuss your new medications,
including how much longer you should be taking Plavix, and your
risk for cardiac disease. You may need a stress test in the
future. Also, please be sure to discuss whether or not you will
need a followup procedure to remove the rest of the clot in your
leg.

Please set up an appointment with your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] at [**Telephone/Fax (1) 5457**].
{'Arterial embolism and thrombosis of lower extremity,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Atrioventricular block, complete,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Tobacco use disorder,Cardiac pacemaker in situ,Atherosclerosis of native arteries of the extremities with rest pain,Other specified surgical operations and procedures 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: transfer from outside hospital for R leg thrombectomy

PRESENT ILLNESS: Ms. [**Known lastname 64059**] is an 85 year old woman with history of hypertension,
PVD presents as tranfer from [**Hospital3 **] for superficial
femoral artery thrombectomy. She reported that she was about to
take a shower the day of her admission to the outside hospital
when she experienced dizziness and also pain from her Right
ankle to her Right knee associated with some numbness of her
Right big toe as well as the 2nd and 3rd digits.  She lied down
on a bath mat, denied any loss of consciousness or head trauma.
The dizziness resolved but then recurred, so her daughters took
her to [**Hospital3 5365**] where she was admitted in complete heart
block and noted to have an ischemic Right foot with cyanosis
extending to midfoot.  She was noted at that time to have 2
episodes of near syncope from near asystole.  At [**Hospital1 10551**], she had emergent placement of temporary pacer wire in
her Right IJ with restoration of heart rate.  She was then taken
to the OR with thrombectomy of R leg and started on a Heparin
drip. Later, a permanent pacer was placed.  She had an
echocardiogram that showed normal EF, mildly dilated RA, mild
MR, and moderate TR.  She was noted to have elevated troponin-T
which trended 0.03, 0.037, 0.03 and was felt to have an NSTEMI.
The Right foot was noted to still be cold compared to the Left,
so she was referred to [**Hospital1 18**] for RLE angiogram [**2183-2-19**] with Dr.
[**Last Name (STitle) **].

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Hypertension, tobacco use
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: DDD Pacer placed recently at [**Hospital1 392**]
3. OTHER PAST MEDICAL HISTORY:
Hypertension
left cheek basal cell carcinoma
left eyelid basal cell carcinoma s/p resection
s/p appendectomy
PVD with arteriogram [**6-7**] of left leg, followed by Dr. [**Last Name (STitle) **]

MEDICATION ON ADMISSION: Norvasc
Lasix
Potassium

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission Exam:

FAMILY HISTORY: Significant for a father with COPD and cancer.

SOCIAL HISTORY: She lives alone.  She has smoked for 60 years, had cut down to 5
cigarettes per day then quit [**2182**].  Restarted smoking socially
recently.  Has a daughter that lives nearby. 

### Response:
{'Arterial embolism and thrombosis of lower extremity,Subendocardial infarction, initial episode of care,Urinary tract infection, site not specified,Atrioventricular block, complete,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Tobacco use disorder,Cardiac pacemaker in situ,Atherosclerosis of native arteries of the extremities with rest pain,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
