CHIEF COMPLAINT: Cold Left Lower Extremity

PRESENT ILLNESS: 73y/o female admitted to [**First Name9 (NamePattern2) 81456**] [**Doctor First Name **] [**2-16**] for 6 month history
of intermittent abdominal distention and flatus associated with
diminished appetite. Denies post pranial abdominal pain.
Admitting physical abdominal acities and distention. Patient was
to under go expl lab today but develope acute left
foot ischemia. The patient was evaluated by Dr. [**Last Name (STitle) 1391**] and
patient was transfered here for further evaluation. When she
arrived, her IV heparin was running at 850U/hr. Patient denies
any history of cardiac problems, asthma, stroke, arrythmia's,
PUD, bowel changes, melena or bloody stools.

MEDICAL HISTORY: no acute illness or surgical history

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: At admission:
VS: T 98.0  HR 124  B/P 117/81  RR 22  O2sat 95% @4L
Gen: no acute distress, anxious mild dyspena with speech
HEENT: no JVD, no carotid bruits, pulses 1+
Lungs: diffuse wheezing
Heart: irregular, irregular no mumur, gallop or rub.
ABD: mid distention with diminshed bowel sounds and mild RLQ
tenderness. No bruits
PV: left foot pale, cold, nonsensate, can not wiggle toes of
dorsiflex foot. temperature change extends to below left knee.
Rt. foot cool with good capillary rfill and motor/sensory
intact.
Pulse exam: 1+ femorals bilaterally with bruits, [**Doctor Last Name **] absent
bilaterally, rt. DP/PT dopperable monophasic .lt. pedal pulses
absent.
Neuro: oriented to time,place and person. non focal exam except
for left foot findings.

FAMILY HISTORY: not assessed

SOCIAL HISTORY: Married, lives at home w/husband and daughter. [**Name (NI) 4906**]
recovering from recent hospitalization for perforated bowel. +
Tobacco use, 1ppd, though recently cut down 1 month ago. + ETOH,
approx 1 drink/day.
Arterial embolism and thrombosis of lower extremity,Cerebral artery occlusion, unspecified with cerebral infarction,Malignant ascites,Nontraumatic compartment syndrome of lower extremity,Acute systolic heart failure,Rhabdomyolysis,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Unspecified intestinal obstruction,Secondary malignant neoplasm of pleura,Malignant neoplasm of ovary,Urinary tract infection, site not specified,Alcohol withdrawal,Acute kidney failure, unspecified,Acute respiratory failure,Atrial fibrillation,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Chronic airway obstruction, not elsewhere classified,Benign essential hypertension
Lower extremity embolism,Crbl art ocl NOS w infrc,Malignant ascites,Nontraum comp syn-low ex,Ac systolic hrt failure,Rhabdomyolysis,Hemorrhage complic proc,Effusion NEC exc tb,Intestinal obstruct NOS,Second malig neo pleura,Malign neopl ovary,Urin tract infection NOS,Alcohol withdrawal,Acute kidney failure NOS,Acute respiratry failure,Atrial fibrillation,Ocl crtd art wo infrct,Chr airway obstruct NEC,Benign hypertension
Admission Date:  [**2160-2-22**]              Discharge Date:   [**2160-3-5**]

Date of Birth:  [**2088-12-5**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Cold Left Lower Extremity

Major Surgical or Invasive Procedure:
Left iliac, femoral, superficial femoral artery, profunda
embolectomy, 4-compartment fasciotomy.

History of Present Illness:
73y/o female admitted to [**First Name9 (NamePattern2) 81456**] [**Doctor First Name **] [**2-16**] for 6 month history
of intermittent abdominal distention and flatus associated with
diminished appetite. Denies post pranial abdominal pain.
Admitting physical abdominal acities and distention. Patient was
to under go expl lab today but develope acute left
foot ischemia. The patient was evaluated by Dr. [**Last Name (STitle) 1391**] and
patient was transfered here for further evaluation. When she
arrived, her IV heparin was running at 850U/hr. Patient denies
any history of cardiac problems, asthma, stroke, arrythmia's,
PUD, bowel changes, melena or bloody stools.


Past Medical History:
no acute illness or surgical history

Social History:
Married, lives at home w/husband and daughter. [**Name (NI) 4906**]
recovering from recent hospitalization for perforated bowel. +
Tobacco use, 1ppd, though recently cut down 1 month ago. + ETOH,
approx 1 drink/day.


Family History:
not assessed

Physical Exam:
At admission:
VS: T 98.0  HR 124  B/P 117/81  RR 22  O2sat 95% @4L
Gen: no acute distress, anxious mild dyspena with speech
HEENT: no JVD, no carotid bruits, pulses 1+
Lungs: diffuse wheezing
Heart: irregular, irregular no mumur, gallop or rub.
ABD: mid distention with diminshed bowel sounds and mild RLQ
tenderness. No bruits
PV: left foot pale, cold, nonsensate, can not wiggle toes of
dorsiflex foot. temperature change extends to below left knee.
Rt. foot cool with good capillary rfill and motor/sensory
intact.
Pulse exam: 1+ femorals bilaterally with bruits, [**Doctor Last Name **] absent
bilaterally, rt. DP/PT dopperable monophasic .lt. pedal pulses
absent.
Neuro: oriented to time,place and person. non focal exam except
for left foot findings.

At discharge:
expired

Pertinent Results:
[**2160-2-22**] 05:53PM BLOOD WBC-21.6* RBC-4.26 Hgb-13.3 Hct-37.4
MCV-88 MCH-31.4 MCHC-35.6* RDW-13.1 Plt Ct-272
[**2160-2-23**] 04:50AM BLOOD WBC-18.5* RBC-3.75* Hgb-11.9* Hct-32.7*
MCV-87 MCH-31.8 MCHC-36.5* RDW-13.3 Plt Ct-256
[**2160-2-24**] 03:11AM BLOOD WBC-12.7* RBC-3.86* Hgb-11.9* Hct-34.2*
MCV-89 MCH-30.9 MCHC-34.9 RDW-13.3 Plt Ct-250
[**2160-3-3**] 12:51AM BLOOD WBC-7.1 RBC-2.45* Hgb-7.5* Hct-21.4*
MCV-87 MCH-30.7 MCHC-35.3* RDW-15.7* Plt Ct-364
[**2160-3-4**] 02:53AM BLOOD WBC-10.9# RBC-2.67* Hgb-8.2* Hct-23.2*
MCV-87 MCH-30.6 MCHC-35.1* RDW-15.4 Plt Ct-506*
[**2160-3-5**] 12:12AM BLOOD WBC-10.6 RBC-3.63*# Hgb-11.0*# Hct-31.3*#
MCV-86 MCH-30.4 MCHC-35.2* RDW-15.0 Plt Ct-250#
[**2160-2-22**] 05:53PM BLOOD PT-15.5* PTT-53.8* INR(PT)-1.4*
[**2160-2-22**] 10:29PM BLOOD PT-17.1* PTT->150 INR(PT)-1.5*
[**2160-2-23**] 04:50AM BLOOD PT-15.0* PTT-71.0* INR(PT)-1.3*
[**2160-3-3**] 12:51AM BLOOD PT-15.8* PTT-101.1* INR(PT)-1.4*
[**2160-3-4**] 11:04PM BLOOD PT-15.6* PTT-62.8* INR(PT)-1.4*
[**2160-2-22**] 05:53PM BLOOD Glucose-80 UreaN-23* Creat-0.9 Na-131*
K-5.2* Cl-97 HCO3-23 AnGap-16
[**2160-2-22**] 10:29PM BLOOD Glucose-83 UreaN-22* Creat-0.8 Na-140
K-4.8 Cl-105 HCO3-27 AnGap-13
[**2160-2-23**] 04:50AM BLOOD Glucose-92 UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-104 HCO3-24 AnGap-12
[**2160-3-2**] 12:59AM BLOOD Glucose-84 UreaN-34* Creat-2.1* Na-137
K-3.8 Cl-102 HCO3-25 AnGap-14
[**2160-3-3**] 12:51AM BLOOD Glucose-145* UreaN-41* Creat-2.2* Na-136
K-3.9 Cl-101 HCO3-27 AnGap-12
[**2160-3-4**] 02:53AM BLOOD Glucose-120* UreaN-53* Creat-2.1* Na-138
K-4.5 Cl-103 HCO3-26 AnGap-14
[**2160-2-22**] 05:53PM BLOOD ALT-133* AST-196* AlkPhos-134*
TotBili-0.5
[**2160-2-23**] 04:50AM BLOOD ALT-132* AST-297* CK(CPK)-[**Numeric Identifier 81457**]*
AlkPhos-108 TotBili-0.4
[**2160-2-25**] 01:30AM BLOOD ALT-129* AST-147* CK(CPK)-1632*
AlkPhos-119* TotBili-0.2
[**2160-3-3**] 12:51AM BLOOD ALT-32 AST-17 AlkPhos-127* TotBili-0.4
[**2160-2-25**] 03:00PM BLOOD CK-MB-26* MB Indx-2.1
[**2160-2-26**] 02:41AM BLOOD CK-MB-21* MB Indx-2.0
[**2160-2-27**] 11:29AM BLOOD CK-MB-16* MB Indx-2.8
[**2160-2-22**] 10:29PM BLOOD Calcium-5.6* Phos-4.1 Mg-1.3*
[**2160-2-23**] 04:50AM BLOOD Albumin-1.7* Calcium-6.6* Phos-3.5
Mg-1.3*
[**2160-3-3**] 12:51AM BLOOD Albumin-2.1* Phos-5.4* Mg-2.5
[**2160-3-4**] 02:53AM BLOOD Calcium-8.6 Phos-5.1* Mg-2.4
[**2160-2-24**] 03:11AM BLOOD calTIBC-66* Ferritn-469* TRF-51*
[**2160-3-3**] 09:37AM BLOOD calTIBC-100* TRF-77*
[**2160-2-24**] 07:13PM BLOOD %HbA1c-5.9
[**2160-2-24**] 07:13PM BLOOD Triglyc-152* HDL-9 CHOL/HD-9.9 LDLcalc-50
[**2160-2-24**] 07:20PM BLOOD Ammonia-27
[**2160-2-24**] 07:13PM BLOOD TSH-2.6

[**2-22**] ECG: Sinus tachycardia (119). Diffuse ST-T wave abnormality.
Cannot rule out myocardial ischemia. Low QRS voltage in the limb
leads. No previous tracing available for comparison.

[**2-23**] TTE: The left atrium is normal in size. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is severe regional left ventricular systolic
dysfunction with basal to mid septal and anterior
hypokinesis/akinesis and mid inferior akinesis. No masses or
thrombi are seen in the left ventricle. Overall left ventricular
systolic function is severely depressed (LVEF= 20-30 %). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.

IMPRESSION: Severe regional left ventricular systolic
dysfunction consistent with multivessel coronary artery disease.
Mild (1+) mitral regurgitation. Moderate to severe [3+]
tricuspid regurgitation with moderate pulmonary artery systolic
hypertension.

[**2-23**] CT abd/pelvis: 1. Findings poorly evaluated without
intravenous contrast but potentially suspicious for peritoneal
carcinomatosis, including ascites and probable peritoneal and
serosal thickening. If there is an outside hospital CT with
intravenous contrast, then this can be scanned into the system
for comparison. 2. Partial small-bowel obstruction, with
transition point in the distal ileum. Contrast does pass into
the colon. 3. Moderate ascites. 4. Moderate bilateral pleural
effusions and adjacent atelectasis. 5. Small hiatal hernia. 6.
Tiny non-obstructing left nephrolithiasis. 7. Anasarca.

[**2-23**] CT Head: FINDINGS: There is a moderate-sized area of
hypodensity in the watershed territory between the right MCA and
PCA territory, consistent with reported history of subacute
infarction. There is no sign of hemorrhagic transformation
within this area. There is no other intracranial hemorrhage.
There is no mass, mass effect, or evidence of other area of
infarction.

There is moderate sulcal prominence in the bilateral frontal
lobes, most
consistent with atrophy, slightly out of proportion to
ventricular size. Basal cisterns are normal. There is mild
mucosal thickening in the ethmoid air cells, and nasal passages.
Paranasal sinuses and mastoid air cells are
otherwise normally aerated.

IMPRESSION: Evolving area of infarction in the watershed
territory between
the right MCA and PCA distributions. No sign of intracranial
hemorrhage, or hemorrhagic transformation of this infarct.

[**3-1**] cytology: Pleural fluid: ATYPICAL. Atypical epithelioid
cells present: Rare clusters of atypical epithelioid cells are
present, but degeneration precludes definitive classification.

[**3-5**] TTE: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality, however, [**Hospital1 **]-ventricular
systolic function appears to be preserved.


Brief Hospital Course:
The patient was admitted on [**2160-2-22**]. After initial evaluation,
she was taken to the OR emergently for LLE thrombectomy. She
underwent a left iliac, femoral, superficial femoral artery,
profunda embolectomy, 4-compartment fasciotomy.
Post-operatively, her pulses were pulses (DP and PT) were
monophasic. She was taken to the CVICU, intubated and sedated
and on pressors, and on a heparin drip. She remained on pressor
support, as her pressures could not tolerate her pain/sedation
drips.
She had new onset atrial fibrillation which was rate controlled.
She was aggressively treated for rhabdomyolysis and ARF with
hydration. She had a bedside ECHO which showed: severe regional
LV systolic dysfunction (EF 20-30%) consistent with multivessel
CAD. Mild (1+) MR. Moderate to severe [3+] TR with moderate PA
systolic hypertension. She had a head CT which showed right
parieto-occipital infarct. The patient remained intubated. She
could not be weaned off the ventilator - she would thrash about
in the bed, and was unresponsive to commands. She would move her
upper extremities, and right lower extremity; muscle twitches
were noted in her left lower extremity. Attempts to extubate
were not successful - she would hypertensive and very highly
aggitated when these attempts were made. She was switched to TPN
and made NPO when she vomitted tube feeds - this may have been
due to extensive carcinomatosis causing pSBO.

She was seen by gyn/onc for her ascites and distension, as well
as CT scan, which were concerning for ovarian cancer. She had a
CT scan of her abdomen and pelvis on [**2-23**]; this was concerning
for peritoneal carcinomatous, including ascites and probable;
pSBO; moderate bilateral pleural effusions and adjacent
atelectasis; small hiatal hernia; tiny non-obstructing left
nephrolithiasis; anasarca. Peritoneal ascites came back positive
for adenocarcinoma, suspicious for ovarian cancer. Pleural fluid
cytology, from a right thoracentesis on [**3-1**], came back positive
for malignant cells. She was not deemed to be a surgical
candidate, though may be a chemotherapy candidate; however,
discussing these options were deffered as the patient could not
be extubated to participate in these discussions.

The patient was made DNR/DNI [**2-26**]. On the morning of [**3-5**], the
patient became acutely hypotensive and was treated with blood
(for postoperative blood loss and intravascular depletion),
fluids and pressors. Her heparin drip was discontinued. A
femoral artery line was placed when the radial line stopped
working. The patient's lower extremity and abdomen became
mottled, her abdomen tense, and it became more difficult to
ventilate her; she became increasingly acidotic. Her family was
made aware. The decision was made to make her CMO. Time of death
was 0528 on [**2160-3-5**].

Medications on Admission:
none

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
none

Followup Instructions:
none


Completed by:[**2160-3-14**]
{'Arterial embolism and thrombosis of lower extremity,Cerebral artery occlusion, unspecified with cerebral infarction,Malignant ascites,Nontraumatic compartment syndrome of lower extremity,Acute systolic heart failure,Rhabdomyolysis,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Unspecified intestinal obstruction,Secondary malignant neoplasm of pleura,Malignant neoplasm of ovary,Urinary tract infection, site not specified,Alcohol withdrawal,Acute kidney failure, unspecified,Acute respiratory failure,Atrial fibrillation,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Chronic airway obstruction, not elsewhere classified,Benign essential hypertension'}


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: Cold Left Lower Extremity

PRESENT ILLNESS: 73y/o female admitted to [**First Name9 (NamePattern2) 81456**] [**Doctor First Name **] [**2-16**] for 6 month history
of intermittent abdominal distention and flatus associated with
diminished appetite. Denies post pranial abdominal pain.
Admitting physical abdominal acities and distention. Patient was
to under go expl lab today but develope acute left
foot ischemia. The patient was evaluated by Dr. [**Last Name (STitle) 1391**] and
patient was transfered here for further evaluation. When she
arrived, her IV heparin was running at 850U/hr. Patient denies
any history of cardiac problems, asthma, stroke, arrythmia's,
PUD, bowel changes, melena or bloody stools.

MEDICAL HISTORY: no acute illness or surgical history

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: At admission:
VS: T 98.0  HR 124  B/P 117/81  RR 22  O2sat 95% @4L
Gen: no acute distress, anxious mild dyspena with speech
HEENT: no JVD, no carotid bruits, pulses 1+
Lungs: diffuse wheezing
Heart: irregular, irregular no mumur, gallop or rub.
ABD: mid distention with diminshed bowel sounds and mild RLQ
tenderness. No bruits
PV: left foot pale, cold, nonsensate, can not wiggle toes of
dorsiflex foot. temperature change extends to below left knee.
Rt. foot cool with good capillary rfill and motor/sensory
intact.
Pulse exam: 1+ femorals bilaterally with bruits, [**Doctor Last Name **] absent
bilaterally, rt. DP/PT dopperable monophasic .lt. pedal pulses
absent.
Neuro: oriented to time,place and person. non focal exam except
for left foot findings.

FAMILY HISTORY: not assessed

SOCIAL HISTORY: Married, lives at home w/husband and daughter. [**Name (NI) 4906**]
recovering from recent hospitalization for perforated bowel. +
Tobacco use, 1ppd, though recently cut down 1 month ago. + ETOH,
approx 1 drink/day. 

### Response:
{'Arterial embolism and thrombosis of lower extremity,Cerebral artery occlusion, unspecified with cerebral infarction,Malignant ascites,Nontraumatic compartment syndrome of lower extremity,Acute systolic heart failure,Rhabdomyolysis,Hemorrhage complicating a procedure,Other specified forms of effusion, except tuberculous,Unspecified intestinal obstruction,Secondary malignant neoplasm of pleura,Malignant neoplasm of ovary,Urinary tract infection, site not specified,Alcohol withdrawal,Acute kidney failure, unspecified,Acute respiratory failure,Atrial fibrillation,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Chronic airway obstruction, not elsewhere classified,Benign essential hypertension'}
