CHIEF COMPLAINT: Left foot gangrene.  The information was
obtained from hospital records and the daughter.  The patient
is Portugese speaking.

PRESENT ILLNESS: This is a 72-year-old Portugese
speaking male with a history of left foot ulceration and
cellulitis.  Cultures have grown out MRSA and Morganella
which was treated without changes.  Noninvasive studies
demonstrated severe femoral-tibial disease and left forefoot
flow deficit.  Right ABI was 0.4, resting, and left ABI was
not measured.

MEDICAL HISTORY: Daily Insulin dependent.  Atrial
fibrillation.  Sick sinus syndrome.  Hypercholesterolemia.
History of alcohol abuse.  History of congestive heart
failure.  History of dehydration with orthostasis.  History
of mild chronic renal insufficiency, 3.5-2.0.  Chronic
anemia.  Negative upper GI on barium enema.  Hematocrit was
24, transferrin 17, total IBC 206, ferratin 4.5.  Obstructive
sleep apnea, blood gases on room air of 7.48, 42, 93, 97%.
T12 compression fracture.  Left foot infection of MRSA
Morganella morganii which was sensitive to Gentamicin,
Bactrim, Unasyn, Ceftriaxone, Ceftazidime, ................,
and Cipro, and ................  Gallstones by ultrasound,
asymptomatic.  Cataract, left eye.

MEDICATION ON ADMISSION: Atenolol 25 mg q.d., Avandia 4 mg
b.i.d., .................. 2.5 mg q.Thursday, Potassium
Chloride 20 mEq q.d., Ativan 4 mg b.i.d., Protonix 40 mg
bedtime, Spironolactone 50 mg t.i.d., Flomax 0.4 mg h.s.,
Lasix 80 mg q.a.m. and 40 mg q.p.m., Neurontin 100 mg t.i.d.,
................... 5 mg t.i.d., Nephrocaps 1 daily,
Simethicone 80 mg t.i.d., Insulin 75/25 20 U q.a.m.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is retired, barely inactive.  He is a
non-smoker.  He drinks 3-4 glasses of wine; he previously
drank 1 gallon per day.  He has not any alcohol over the last
two months.
Atherosclerosis of native arteries of the extremities with gangrene,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Atrial fibrillation,Alcohol abuse, unspecified,Bipolar I disorder, most recent episode (or current) unspecified,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified
Ath ext ntv art gngrene,Cellulitis of leg,DMI wo cmp nt st uncntrl,Atrial fibrillation,Alcohol abuse-unspec,Bipolor I current NOS,Chr blood loss anemia,CHF NOS
Admission Date:  [**2178-7-9**]       Discharge Date:  [**2178-7-27**]

Date of Birth:   [**2106-1-8**]       Sex:  M

Service:  VASCULAR

CHIEF COMPLAINT:  Left foot gangrene.  The information was
obtained from hospital records and the daughter.  The patient
is Portugese speaking.

HISTORY OF PRESENT ILLNESS:  This is a 72-year-old Portugese
speaking male with a history of left foot ulceration and
cellulitis.  Cultures have grown out MRSA and Morganella
which was treated without changes.  Noninvasive studies
demonstrated severe femoral-tibial disease and left forefoot
flow deficit.  Right ABI was 0.4, resting, and left ABI was
not measured.

The patient was evaluated at [**Hospital6 **] from [**2178-5-12**], to [**2178-6-7**], by Vascular Surgery, and felt that the
patient was not a viable candidate for revascularization, and
the patient's daughter referred the patient to Dr. [**Last Name (STitle) **],
who was seen in the office on the day of admission.  He is
now admitted for intravenous antibiotics, open TMA, then with
potential bypassing graft depending on wound response.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

PAST MEDICAL HISTORY:  Daily Insulin dependent.  Atrial
fibrillation.  Sick sinus syndrome.  Hypercholesterolemia.
History of alcohol abuse.  History of congestive heart
failure.  History of dehydration with orthostasis.  History
of mild chronic renal insufficiency, 3.5-2.0.  Chronic
anemia.  Negative upper GI on barium enema.  Hematocrit was
24, transferrin 17, total IBC 206, ferratin 4.5.  Obstructive
sleep apnea, blood gases on room air of 7.48, 42, 93, 97%.
T12 compression fracture.  Left foot infection of MRSA
Morganella morganii which was sensitive to Gentamicin,
Bactrim, Unasyn, Ceftriaxone, Ceftazidime, ................,
and Cipro, and ................  Gallstones by ultrasound,
asymptomatic.  Cataract, left eye.

PAST SURGICAL HISTORY:  Pacemaker on [**2176-7-7**], VVI mode.
Echocardiogram in [**2175**] showed normal left ventricular
function, trivial aortic stenosis.  Echocardiogram on [**2178-6-7**] showed normal left ventricular function, dilated
hypertrophy left ventricle, right ventricle dilated, right
atrium, dilated, left atrium dilated, aortic stenosis without
significant changes from previous echocardiogram.  O.S.
laser.

MEDICATIONS ON ADMISSION:  Atenolol 25 mg q.d., Avandia 4 mg
b.i.d., .................. 2.5 mg q.Thursday, Potassium
Chloride 20 mEq q.d., Ativan 4 mg b.i.d., Protonix 40 mg
bedtime, Spironolactone 50 mg t.i.d., Flomax 0.4 mg h.s.,
Lasix 80 mg q.a.m. and 40 mg q.p.m., Neurontin 100 mg t.i.d.,
................... 5 mg t.i.d., Nephrocaps 1 daily,
Simethicone 80 mg t.i.d., Insulin 75/25 20 U q.a.m.

SOCIAL HISTORY:  He is retired, barely inactive.  He is a
non-smoker.  He drinks 3-4 glasses of wine; he previously
drank 1 gallon per day.  He has not any alcohol over the last
two months.

REVIEW OF SYSTEMS:  Positive for difficulty in hearing.
Ankle edema.  Hip claudication bilaterally with no rest pain.
No history of stroke or myocardial infarction.

PHYSICAL EXAMINATION:  Vitals signs:  Afebrile, pulse rate
72, blood pressure 120/60 in the right arm, 116/60 sitting,
118/60 lying.  General:  The patient was a drowsy, obese,
Portugese speaking male.  HEENT:  Unremarkable.  Tongue was
midline but fissured.  Pulses:  Carotids were palpable
without bruits.  Brachial and radial pulses were palpable
bilaterally.  Abdominal aorta was non-prominent.  Femoral
pulses were palpable bilaterally.  No bruits.  Absent
popliteal, dorsalis pedis, and posterior tibial spot
palpation bilaterally.  Chest:  Diminished base sounds
bilaterally with crackles two-thirds up on the right side.
Heart:  Irregularly, regular rhythm with diminished S1 and
S2.  There were no murmurs, rubs or gallops.  Pacemaker
battery implant in the pectoral area on the right.  Abdomen:
Distended and dull to percussion.  Bowel sounds were
diminished.  Could not assess for organomegaly or masses.
There were no bruits.  Extremities:  Right hand was deformed
with 3+ edema.  The right and lower extremities from knee to
foot were with 3+ edema with severe chronic edematous
changes, cellulitis, and bullous lesions, and venous
insufficiency skin changes.  The left foot was with dry
gangrene of the hallux and first toe.  The drainage was
without odor.  There was erythema present in the first toe
joint; capsule was exposed.

LABORATORY DATA:  Admission labs included a white count of
8.0, hematocrit 29.9, platelet count 411,000; BUN 34,
creatinine 1.5, potassium 3.3, supplemented and rechecked at
3.5; PT and INR were normal.

Chest x-ray showed single lead, pacemaker in the right
ventricle with moderate cardiomegaly.  There were no
infiltrates or effusion.  There was a 6 mm left upper lobe
nodule.

Electrocardiogram was paced rhythm.
HOSPITAL COURSE:  KUB done on admission showed probable
ascites, and large loops of small bowel, air in the
descending colon.

HOSPITAL COURSE:  The patient was continued on his
preadmission medications.  He was begun on intravenous
antibiotics of Vancomycin and Bactrim.  Right IJ was placed
on the day of admission secondary to lack of peripheral
venous access.  Chest x-ray was negative for pneumothorax.
The patient underwent a right first metatarsal amputation on
[**2178-7-9**], without complication and was transferred to
the Recovery Room.

He remained stable.  Chest x-ray showed line in appropriate
placement.  The patient was in congestive heart failure.
Cardiology was requested to the see the patient and help with
management of his congestive heart failure.  Recommendations
to continue with beta-blockers, ACE inhibitors, and Lasix as
needed.  [**Last Name (un) **] was consulted to manage the patient's
diabetes.

Other recommendations made included avoiding Avandia because
of fluid retention and non-steroidals because of diminished
renal function and fluid retention, and to monitor I&Os and
daily weights, consider Demadex if weight increases or
congestive heart failure symptoms increase, and hold
Spironolactone.

On postoperative day #1 there were overnight events.
Postoperative hematocrit was 23.8.  BUN and creatinine
remained stable.  Lasix was continued.  They felt that the
low hematocrit was secondary to volume overload.  The patient
underwent an arteriogram on [**7-13**] which demonstrated
patent aorta, the renals were patent.  There was bilateral
plaque disease in the iliacs, and commons were satisfactory.
Left external iliac had no gradient, and common femoral and
bilateral femorals were satisfactory.  There was minimal SFA
disease.  The short segment of the AK-BK popliteal which was
occluded.  There was diseased BK popliteal with patent tibial
.................. trunk.  The PT, peroneal and AT all
occluded at the origin.  The PT and peroneal were with
moderate diffuse disease.  The BT reconstructed at the ankle
and perfused arch.  The AT reconstructed at the ankle and
perfused to DP.

An attempt was made on [**2178-7-17**], to recannulate the
popliteal occlusion without success.  The patient's volume
status margin was very narrow, and he continued to have
intermittent episodes exacerbation of congestive heart
failure requiring continual adjustment in his medications.
He received a unit of packed cells on [**2178-7-14**], for his
continuing anemia.  His posttransfusion hematocrit was 25.9,
up from 24.3.  The patient was continued to be diuresed.
Physical Therapy began to work with the patient with
non-weightbearing ambulation.  Recommendations were to
consider anticoagulation for chronic atrial fibrillation and
maintain an INR of [**1-10**].

On [**7-18**], the patient was transferred to the SICU for
sepsis observation secondary to increasing ischemia of the
left extremity and postoperative fevers, agitation, and
hypotension, and decreased SVR, with increased cardiac
output.  A white count at the time of transfer was 9.0, with
a hematocrit of 25.4, BUN 19, creatinine 1.5, potassium 4.1,
calcium 1.14, phosphorus 3.6, magnesium 2.2.  Cultures of the
foot were obtained on admission which grew  .................
Bacterium, gram-negative rods, anaerobes,
..................., ..................., and
..................

The patient went to surgery on [**7-18**] for a left femoral
BK popliteal bypass with non-reversed saphenous vein graft.
He tolerate the procedure well and transferred to the PACU
with a Dopplerable dorsalis pedis and posterior tibial.

Postoperatively he remained with a low-grade temperature of
38.8??????.  His SVR was 618.  His index was 3.9.  His
postoperative hematocrit was 25.9.  His BUN and creatinine
remained stable.  Diuresis was continued.  Because of the
patient's persistent temperature elevation and increasing
cardiac output and diminishing SVR, the patient was
pancultured, and Levaquin was added to his intravenous
antibiotics.

Over the next 48 hours, the patient's SVR and index improved.
His white count remained stable at 8.9.  He was transfused a
unit of packed red blood cells for a hematocrit of 24.7.  His
posttransfusion hematocrit was unchanged.  His blood cultures
grew gram-positive rods.  Clindamycin was added to his
antibiotic regimen at this point.  He continued to show
improvement in his temperature curve and his hemodynamics.

On [**7-22**], the patient underwent a left TMA without
complication.  Postoperatively he continued to remain
afebrile.  He was transferred to the VICU for continued
monitoring and care.  His blood cultures were with
questionable Lactobacillus, and his wound cultures from the
operating room were with no growth.  He continued to remain
afebrile.  His hematocrit stabilized at 25.3.  His renal
function remained stable.  He was transfused a unit of packed
red blood cells on [**7-24**] followed by intravenous Lasix.
He was transferred to the regular nursing floor.  Physical
Therapy began to work with the patient, and a rehabilitation
screening was begun.


GI was consulted to see the patient regarding his ascites.
They felt that the patient had underlying liver disease
secondary to his chronic alcohol abuse, and this was
exacerbated the stresses of surgery.  Ultrasound of the
abdomen and liver were obtained to determined the presence of
ascites and evaluate the haptic portal vein system.  This
result was pending at the time of dictation.  He also
underwent a diagnostic paracentesis.  These results were
pending at the time of dictation.

At the time of discharge, the patient was afebrile.
Hematocrit was 26.2, white count 7.3.  Electrolytes were with
a BUN of 20, creatinine 1.4, potassium 4.0.  His wound
cultures were no growth.  The patient was started on
Aldactone 50 mg q.d., as per GI recommendations.  The
remaining GI evaluation and follow-up will be done on an
outpatient basis.  The patient should follow-up with Dr.
[**Last Name (STitle) **] in two weeks to assess his left foot wound.  He will
remain strict non-weightbearing.

DISCHARGE MEDICATIONS:  NPH Insulin 4 U q.a.m., Aldactone 50
mg q.d., Flagyl 500 mg b.i.d., Levofloxacin 500 mg q.d.,
Lasix 80 mg b.i.d., Percocet [**12-9**] 5/325 q.4-6 hours p.r.n.
pain, Atenolol 25 mg daily, Simethicone 80 mg t.i.d.,
Captopril 6.25 mg t.i.d., Tylenol 650 mg q.4-6 hours p.r.n.,
Dulcolax tab [**12-9**] p.r.n., Colace 100 mg b.i.d., Vancomycin 1 g
IV q.18 hours, Clindamycin 600 mg q.8 hours,
................... 1.5 mg q.Thursday, Flomax 0.4 mg q.h.s.,
Nephrocaps 1 q.d., Neurontin 100 mg q.d., Bactrim DS 1 b.i.d.

DISCHARGE INSTRUCTIONS:  Dressings with normal saline,
wet-to-dry dressing packed in the plantar surface of the
wound with dry sterile dressings and Ace bandage daily.  The
patient is non-weightbearing.  Foot should be elevated when
the patient is in chair.

DISCHARGE DIAGNOSIS:
1.  Ischemic left foot changes status post hallectomy and toe
amputation status post left femoral below-knee popliteal
bypass graft, status post left TMA.
2.  Diabetes type 2, controlled.
3.  History of alcohol abuse with abdominal ascites, etiology
quarried.
4.  Biventricular failure.
5.  Chronic blood loss anemia, corrected.
6.  Septicemia, treated.





                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 19472**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D:  [**2178-7-27**]  10:47
T:  [**2178-7-27**]  11:49
JOB#:  [**Job Number 35810**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Atrial fibrillation,Alcohol abuse, unspecified,Bipolar I disorder, most recent episode (or current) unspecified,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified'}


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: Left foot gangrene.  The information was
obtained from hospital records and the daughter.  The patient
is Portugese speaking.

PRESENT ILLNESS: This is a 72-year-old Portugese
speaking male with a history of left foot ulceration and
cellulitis.  Cultures have grown out MRSA and Morganella
which was treated without changes.  Noninvasive studies
demonstrated severe femoral-tibial disease and left forefoot
flow deficit.  Right ABI was 0.4, resting, and left ABI was
not measured.

MEDICAL HISTORY: Daily Insulin dependent.  Atrial
fibrillation.  Sick sinus syndrome.  Hypercholesterolemia.
History of alcohol abuse.  History of congestive heart
failure.  History of dehydration with orthostasis.  History
of mild chronic renal insufficiency, 3.5-2.0.  Chronic
anemia.  Negative upper GI on barium enema.  Hematocrit was
24, transferrin 17, total IBC 206, ferratin 4.5.  Obstructive
sleep apnea, blood gases on room air of 7.48, 42, 93, 97%.
T12 compression fracture.  Left foot infection of MRSA
Morganella morganii which was sensitive to Gentamicin,
Bactrim, Unasyn, Ceftriaxone, Ceftazidime, ................,
and Cipro, and ................  Gallstones by ultrasound,
asymptomatic.  Cataract, left eye.

MEDICATION ON ADMISSION: Atenolol 25 mg q.d., Avandia 4 mg
b.i.d., .................. 2.5 mg q.Thursday, Potassium
Chloride 20 mEq q.d., Ativan 4 mg b.i.d., Protonix 40 mg
bedtime, Spironolactone 50 mg t.i.d., Flomax 0.4 mg h.s.,
Lasix 80 mg q.a.m. and 40 mg q.p.m., Neurontin 100 mg t.i.d.,
................... 5 mg t.i.d., Nephrocaps 1 daily,
Simethicone 80 mg t.i.d., Insulin 75/25 20 U q.a.m.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: He is retired, barely inactive.  He is a
non-smoker.  He drinks 3-4 glasses of wine; he previously
drank 1 gallon per day.  He has not any alcohol over the last
two months. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Cellulitis and abscess of leg, except foot,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Atrial fibrillation,Alcohol abuse, unspecified,Bipolar I disorder, most recent episode (or current) unspecified,Iron deficiency anemia secondary to blood loss (chronic),Congestive heart failure, unspecified'}
