CHIEF COMPLAINT: Left lower extremity ischemia with
tissue loss

PRESENT ILLNESS: PT's CHART IS THINNED

MEDICAL HISTORY: DIABETES MELLITUS
HYPERTENSION
PERIPHERAL VASCULAR DISEASE
HYPERLIPIDEMIA
IMPAIRED VISION
OVERWEIGHT
POSITIVE PPD  [**2132**]
ANEMIA  [**2136**]
HEALTH MAINTENANCE
CORONARY ARTERY DISEASE  [**3-/2140**]
CVA
HYPERTENSION

MEDICATION ON ADMISSION: asa 325,
avandia 8',
cozaar 200',
humulin 36/15,
HCTZ 25',
lactulose 15',
Lipitor 20',
metformin 850",
nicardipine 30

ALLERGIES: Penicillins / Zestril

PHYSICAL EXAM: A/O X 2 NAD
NCAT, PERRL, EOMI
NEG LESIONS NARES, ORAL PHARNYX, AUDITORY
NEG SUPRACLAVICULAR NODES, SUPPLE, FAROM
LUNGS CTA B/L WITH SLIGHT CRACKLES AT BASES
RRR WITHOUT MURMERS
OBESE, NTTP, ND, POS BS, NEG CVA TENDERNESS
FOLEY TO GRAVITY
L AKA WOUND C/D/I GOOD FEM PULSE AT 2 PLUS
R 2 PLUS FEM / DP / PT

FAMILY HISTORY: Not known

SOCIAL HISTORY: Denies nicotine use, alcohol use, and drug use.
Unspecified septicemia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Primary pulmonary hypertension,Severe sepsis,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Septicemia NOS,Ath ext ntv art gngrene,Ac osteomyelitis-ankle,Surg compl-heart,Subendo infarct, initial,CHF NOS,Acute kidney failure NOS,Prim pulm hypertension,Severe sepsis,Crnry athrscl natve vssl,Anemia NOS,DMII wo cmp nt st uncntr,Hypertension NOS
Name:  [**Known lastname 4866**],[**Known firstname 3863**]               Unit No:   [**Numeric Identifier 4867**]

Admission Date:  [**2140-3-29**]              Discharge Date:   [**2140-4-19**]

Date of Birth:  [**2066-6-7**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Zestril

Attending:[**First Name3 (LF) 231**]
Addendum:
Pt hospital stay extended untill [**2140-4-19**]. Reason for hospital
sty increase is the avaialability of beds.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] - [**Location (un) 42**]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]

Completed by:[**2140-4-19**]

Admission Date:  [**2140-3-29**]              Discharge Date:   [**2140-4-19**]

Date of Birth:  [**2066-6-7**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Zestril

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Left lower extremity ischemia with
tissue loss


Major Surgical or Invasive Procedure:
Cardiac catherization with stent

Left femoral to peroneal bypass grafting with in-situ vein
graft, angioscopy, valve lysising

Left Abobove knee amputation

Bedside swallowing evaluation


History of Present Illness:
PT's CHART IS THINNED

78 y.o. female whom presented with an ischemic left foot

Past Medical History:
DIABETES MELLITUS
HYPERTENSION
PERIPHERAL VASCULAR DISEASE
HYPERLIPIDEMIA
IMPAIRED VISION
OVERWEIGHT
POSITIVE PPD  [**2132**]
ANEMIA  [**2136**]
HEALTH MAINTENANCE
CORONARY ARTERY DISEASE  [**3-/2140**]
CVA
HYPERTENSION



Social History:
Denies nicotine use, alcohol use, and drug use.

Family History:
Not known

Physical Exam:
A/O X 2 NAD
NCAT, PERRL, EOMI
NEG LESIONS NARES, ORAL PHARNYX, AUDITORY
NEG SUPRACLAVICULAR NODES, SUPPLE, FAROM
LUNGS CTA B/L WITH SLIGHT CRACKLES AT BASES
RRR WITHOUT MURMERS
OBESE, NTTP, ND, POS BS, NEG CVA TENDERNESS
FOLEY TO GRAVITY
L AKA WOUND C/D/I GOOD FEM PULSE AT 2 PLUS
R 2 PLUS FEM / DP / PT

Pertinent Results:
[**2140-4-18**]

WBC-14.8* RBC-3.53* Hgb-10.1* Hct-31.4* MCV-89 MCH-28.6
MCHC-32.2 RDW-14.5 Plt Ct-504*

[**2140-4-13**]

PT-13.6 PTT-35.6* INR(PT)-1.2
[**2140-4-18**]

Glucose-53* UreaN-21* Creat-0.8 Na-149* K-3.4 Cl-113* HCO3-32*
AnGap-7*
Calcium-8.8 Phos-4.0 Mg-2.1

ECG Study Date of [**2140-4-12**]

Sinus tachycardia and occasional ventricular ectopy. Lead V3 was
not obtained. Wandering baseline. Slight ST segment depressions
in leads V5-V6. In the context of poor quality ECG, repeat
tracing of diagnostic quality is suggested. The rate has
increased as compared to the previous tracing of [**2140-4-10**], and
except for ventricular ectopy, there is no diagnostic interim
change.


CHEST (PORTABLE AP)  [**2140-4-16**]

CHEST: The heart is enlarged and unwinding of the aorta is
present. Upper zone redistribution, suggesting some failure is
present. The tip of the right IJ line lies in the lower SVC. The
tip of the nasogastric tube lies within the stomach. Comparison
with the prior film shows some improvement in the degree of
failure.

IMPRESSION: Failure persists, but improved since [**2140-4-13**].
Line in satisfactory position

Cardiology Report ECHO Study Date of [**2140-3-30**]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.3 m/sec
Mitral Valve - E/A Ratio: 0.85
Mitral Valve - E Wave Deceleration Time: 235 msec
TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg)

INTERPRETATION:

Findings:

LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA.

LEFT VENTRICLE: Symmetric LVH. Normal LV cavity size. Mildly
depressed LVEF.

LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferolateral - hypo; mid inferolateral - hypo;

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild (1+) MR.

TRICUSPID VALVE: Moderate to severe [3+] TR. Moderate PA
systolic
hypertension.

PERICARDIUM: No pericardial effusion.

Conclusions:

The left atrium is elongated. There is symmetric left
ventricular hypertrophy.  The left ventricular cavity size is
normal. Overall left ventricular systolic  function is mildly
depressed. Resting regional wall motion abnormalities  include
inferolateral hypokinesis. Right ventricular chamber size and
free  wall motion are normal. The aortic valve leaflets are
mildly thickened. No  aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened.  Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic  hypertension. There is no pericardial effusion.

C.CATH [**2140-4-6**]

BRIEF HISTORY:   This is a 73 year old woman with a history of
diabetes
mellitus, hypertension, and dyslipedemia who was referred for a
heart
catheter because of a NSTEMI. She underwent left CFA-popliteal
bypass
[**2140-3-29**]. Postoperatively she developed respiratory failure and
required
intubation. Her cardiac markers became elevated with a CKMB of
34 and
troponin of 0.68. The echocardiogram showed hypokinesis of the
inferolateral wall. The ejection fraction was estimated to be
45-50%.
The resting EKG showed SR and non-spec. ST-T-wave changes
laterally.

INDICATIONS FOR CATHETERIZATION:

NSTEMI

**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA   DISCRETE 90
2) MID RCA   DISCRETE 90
2A) ACUTE MARGINAL   NORMAL
3) DISTAL RCA   DISCRETE 100
4) R-PDA   DIFFUSELY DISEASED
4A) R-POST-LAT   DIFFUSELY DISEASED

**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN   NORMAL
6) PROXIMAL LAD   DIFFUSELY DISEASED
6A) SEPTAL-1   NORMAL
7) MID-LAD   DIFFUSELY DISEASED 60
8) DISTAL LAD   DIFFUSELY DISEASED
9) DIAGONAL-1   DIFFUSELY DISEASED
10) DIAGONAL-2   DIFFUSELY DISEASED
12) PROXIMAL CX   NORMAL
13) MID CX   NORMAL
13A) DISTAL CX   NORMAL
14) OBTUSE MARGINAL-1   NORMAL
15) OBTUSE MARGINAL-2   DISCRETE 90
16) OBTUSE MARGINAL-3   DIFFUSELY DISEASED

PTCA COMMENTS:
We elected to treat the OM with PTCA/Stenting using heparin and
integrilin prophylactically.  The sheath was upsized to 7
French, and a
7 French XB 3.5 guide provided good support.  A PT [**Name (NI) 9165**]
Intermediate
wire crossed into the lower pole, and a Wizdom SS wire crossed
into the
upper pole.  A 2.0 x 15 mm Voyager was used to predilate the
lower pole
at 10 atm twice, and was also used to predilate the upper pole
at 12
atm.  The lower pole wire was removed, and the upper pole was
stented
with a 2.5 x 18 mm Hepacoat at 14 atm.  The stent was then
post-dilated
with a 2.75 x 13 mm Highsail at 18 atm twice.  Final angiography

demonsrated no dissection, no residual stenosis within the upper
pole
with a moderate residual in the lower pole, and TIMI-3 flow in
both
branches.

COMMENTS:
1. Selective coronary angiography showed aright dominant system
with
three vessel disease. The LMCA was without flow limiting
stenoses. The
LAD was diffusely diseased with up the 60% stenosis in the mid
segment.
The LCX filled a high OM1 which did not have flow limiting
stenoses. The
OM2 was a large vessel and had a 90% stenosis at the bifurcation
into a
large upper and a small lower branch. The RCA was diffusely
diseased
with 90% proximal, 90% mid and 100% mid occlusion. The diastal
RCA
filled via left to right collaterals.
2. Limited resting hemodynamics showed moderately elevated right
and
left sided filling pressures (RA mean 12 mmHg, RVEDP 20 mmHg,
PCW mean
22 mmHg). There was moderate pulmonary hypertension (PA mean 35
mmHg).
The cardiac output was normal (CO 6.1 l/min, CI 2.6 l/min/m2).
3. Successful PCI of the upper pole of the OM with a 2.5 x 18 mm

Hepacoat stent, post-dilated with a 2.75 mm balloon.  The lower
pole of
the OM was dilated with a 2.0 mm balloon.

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.
3. Moderate pulmonary hypertension.
4. Successful PCI of the OM.





Brief Hospital Course:
PT HAD A COMPLICATED HOSPITAL STAY

CHART IS THINNED

Pt admitted on [**2140-3-29**] for Left lower extremity ischemia with
tissue loss

Pt pre - op'd for procedure.

[**2140-3-30**]

Pt underwent a Left femoral to peroneal bypass grafting with in-
situ vein graft, angioscopy, valve lysis. Pt tolerated the
procedure well. There were no complications. Pt was transfered
to the PACU in stable condition.

[**2140-3-30**]

Because of the following listed below pt was transfered to the
SICU

#1 resp failure/intubated/CHF- likely 2ndary to HTN,
tachycardia, fluid resusc likely in setting of pulm HTN,
diast/syst dysfxn.

#2 hypotension- likely secondary to mixed cardiogenic and septic
physio. SVR low with NL CI but high filling pressures. Febrile
with high WBC. Since CI is not supra normal suspect some
mycoardial depression. Also has PHTN.

#3 NSVT- likely secondary to electrolyte changes, catechols,
stress of illness, and ischemia.

#4 NSTEMI- likely demand secondary to sepsis, tachy, CHF, HTN.

Pt recieved echo

TTE: with EF 45-50, basal inferior HK, 1+ TR, 3+TR, mod pulm
HTN.

[**2140-3-31**] - [**2140-4-3**]

Trop up but CK-MB rising. PA numbers very septic looking (high
CI, low SVR). On BB, getting diuresed. Sputum growing
GPC/GNR/GPR. Put on Antibiotics.

[**2140-4-4**]

Pt Extubated. Trop coming down. Heart rate still high and will
encourage BB PO. Still with fevers.

[**2140-4-5**]

Still febrile with leukocytosis. Trop less but still elevated.
HR still increased, Encouraged BB

[**2140-4-6**]

Pt for cardiac cath with PCW 22, TO RCA, 60% LAD, 90% OM s/p OM
hepacoat

[**2140-4-7**]

Still tachy and septic, volume overloaded with mental status
changes. NIVS showed BPG closed, this with pts sepsis warranted
L AKA>

[**2140-4-8**]

Pt undergoes Left AKA. Tolerated the procedure well. Recovered
from anesthesia without complications. Transfered back to the
SICU in stable condition.

[**2140-4-9**]

Pt status started to improve. Pt did recieve PRBC for low HCT
post op.
Cardiology feels that she is stable enough to sign off.  Pts
creat increase secondary to hypovolemia. Pt fluid replaced creat
improved.

[**2140-4-10**] - [**2140-4-15**]

Pt remained in SICU. Pt's staus improved. Pt started to take PO,
was able to get OOB to chair. Lines were changed

[**2140-4-16**]

Pt transfered to VICU. Here her diet was advanced as tolerated.
She is taking PO's. on discharge. Her foley was changed. Pt is
making urine, but foley will remain untill pt is mobile. She is
able to get OOB to chair with asst.

Pt to get REHAB screen

On discharge, central line is [**Name (NI) 1788**], pt has foley - making urine.
She is taking PO but needs encouragement. She is able to
mobilize with great help. Her mental status is appropriate.


Medications on Admission:
asa 325,
avandia 8',
cozaar 200',
humulin 36/15,
HCTZ 25',
lactulose 15',
Lipitor 20',
metformin 850",
nicardipine 30

Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) Elixir PO Q4-6H
(every 4 to 6 hours) as needed for fever.
5. Aspirin EC 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Gabapentin 250 mg/5 mL Solution Sig: One (1)  PO Q24H (every
24 hours).
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
11. Rosiglitazone Maleate 2 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
13. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. Insulin
Please see attached sheet for insulin dosing
16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
17. Cozaar 100 mg Tablet Sig: Two (2) Tablet PO once a day.
18. Nicardipine HCl 30 mg Capsule Sig: One (1) Capsule PO twice
a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Left lower extremity ischemia with tissue loss resulting - Left
femoral to peroneal bypass grafting with in-situ vein graft,
angioscopy, valve lysising then eventually  L AKA

POST OP
CHF
MI - cardiac cath - stentin of [**Female First Name (un) **]
ARF


Discharge Condition:
stable

Discharge Instructions:
Keep surgical wound clean, dry and intact. Check for signs of
infection, warmth over area, discharge from wound and redness or
swelling. Also check for signs od systemic infection. fever,
chills and sweats. If this happens Please call Dr. [**Last Name (STitle) 27977**]
office immediatly.

Pt also has stage 2 decubitus ulcer. Please see Wound care
instructions.

Followup Instructions:
Call Dr [**Last Name (STitle) 27978**] office at [**Telephone/Fax (1) 27979**] to make appointment
for two weeks.

Call Cardiology at [**Telephone/Fax (1) 27980**] to make appointment. Pt is post
operative from a stent

Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name12 (NameIs) 17452**] Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2140-5-23**] 8:40



Completed by:[**2140-4-18**]
{'Unspecified septicemia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Primary pulmonary hypertension,Severe sepsis,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified 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: Left lower extremity ischemia with
tissue loss

PRESENT ILLNESS: PT's CHART IS THINNED

MEDICAL HISTORY: DIABETES MELLITUS
HYPERTENSION
PERIPHERAL VASCULAR DISEASE
HYPERLIPIDEMIA
IMPAIRED VISION
OVERWEIGHT
POSITIVE PPD  [**2132**]
ANEMIA  [**2136**]
HEALTH MAINTENANCE
CORONARY ARTERY DISEASE  [**3-/2140**]
CVA
HYPERTENSION

MEDICATION ON ADMISSION: asa 325,
avandia 8',
cozaar 200',
humulin 36/15,
HCTZ 25',
lactulose 15',
Lipitor 20',
metformin 850",
nicardipine 30

ALLERGIES: Penicillins / Zestril

PHYSICAL EXAM: A/O X 2 NAD
NCAT, PERRL, EOMI
NEG LESIONS NARES, ORAL PHARNYX, AUDITORY
NEG SUPRACLAVICULAR NODES, SUPPLE, FAROM
LUNGS CTA B/L WITH SLIGHT CRACKLES AT BASES
RRR WITHOUT MURMERS
OBESE, NTTP, ND, POS BS, NEG CVA TENDERNESS
FOLEY TO GRAVITY
L AKA WOUND C/D/I GOOD FEM PULSE AT 2 PLUS
R 2 PLUS FEM / DP / PT

FAMILY HISTORY: Not known

SOCIAL HISTORY: Denies nicotine use, alcohol use, and drug use. 

### Response:
{'Unspecified septicemia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Cardiac complications, not elsewhere classified,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Acute kidney failure, unspecified,Primary pulmonary hypertension,Severe sepsis,Coronary atherosclerosis of native coronary artery,Anemia, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
