CHIEF COMPLAINT: Right leg ulceration.

PRESENT ILLNESS: This 77 year-old white male with
known hypertension, type 2 diabetes with a right intra-tibial
ulcer, which developed post trauma in [**Month (only) 205**] of this year.  He
has been followed by a wound care center and has undergone
multiple debridements without resolution of the ulcer or
improvement.  He had onset of foot pain with leg at heart
level and must sleep in chair with legs dependent resulting
in chronic lower extremity edema bilaterally.  The patient
was admitted to [**Doctor Last Name 1728**] [**Hospital 107**] Hospital from [**9-14**] to [**9-27**].
Workup included cultures of the right leg, which were staph
aureus positive, sensitive to Cephazolin, Chloramphenicol,
Clindamycin, Erythromycin, Gentamycin, Levofloxacin,
Oxacillin, Bactrim, Tetracycline and Vancomycin.  The patient
was treated with Kefzol 1 gram with multiple intravenous
restarts now on Keflex 500 mg q.i.d.

MEDICAL HISTORY: Type 2 diabetes with neuropathy,
hypertension, right Charcot foot, cerebrovascular accident in
[**2112**], degenerative back and hand changes.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a 77 year-old white male,
married, lives with his wife.  [**Name (NI) **] is retired postal worker.
He is a former smoker, thirty pack years, occasional coffee
and alcohol.
Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of ankle,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Universal ulcerative (chronic) colitis,Intestinal infection due to Clostridium difficile,Unspecified essential hypertension
Ath ext ntv art ulcrtion,Ulcer of ankle,DMII neuro nt st uncntrl,Neuropathy in diabetes,Univrsl ulcertve colitis,Int inf clstrdium dfcile,Hypertension NOS
Admission Date:  [**2114-9-27**]       Discharge Date:  [**2114-10-22**]


Service:  VASCULAR

CHIEF COMPLAINT:  Right leg ulceration.

Information was obtained from the transfer records and the
patient who was a reliable historian.

HISTORY OF PRESENT ILLNESS:  This 77 year-old white male with
known hypertension, type 2 diabetes with a right intra-tibial
ulcer, which developed post trauma in [**Month (only) 205**] of this year.  He
has been followed by a wound care center and has undergone
multiple debridements without resolution of the ulcer or
improvement.  He had onset of foot pain with leg at heart
level and must sleep in chair with legs dependent resulting
in chronic lower extremity edema bilaterally.  The patient
was admitted to [**Doctor Last Name 1728**] [**Hospital 107**] Hospital from [**9-14**] to [**9-27**].
Workup included cultures of the right leg, which were staph
aureus positive, sensitive to Cephazolin, Chloramphenicol,
Clindamycin, Erythromycin, Gentamycin, Levofloxacin,
Oxacillin, Bactrim, Tetracycline and Vancomycin.  The patient
was treated with Kefzol 1 gram with multiple intravenous
restarts now on Keflex 500 mg q.i.d.

An MRI of the lumbosacral spine was done, which showed
degenerative changes with narrowing of the L4 and L5 and L3
and L4 and narrowing of the intervertebral foramina narrowing
of L4 and S1.  An MRA of his extremity was completed, which
showed bilateral tibial disease.  Noninvasive studies showed
atherosclerosis of the right external vessels, patent to the
level of the popliteal artery.  The tibial vessels were
occluded.  There was diminished flow in the dorsalis pedis
and posterior tibial pulse.  The ankle brachial index on the
left was 1.17.  Noninvasive venous showed negative for deep
venous thrombosis.  Bone scan was negative for osteomyelitis.
Foot films were unremarkable.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON TRANSFER:  Keflex 500 mg q.i.d., Imodium 2 mg
q 6 hours, Ditropan XL 5 mg q.d., Oxycontin 20 mg b.i.d.,
Neurontin 300 mg b.i.d., Zoloft 50 mg q.d., Percocet 5/325
one to two q 3 hours prn for pain, Glyburide 5 mg q.a.m.,
Lisinopril 40 mg q.d., Imipramine 25 mg b.i.d., Actos 15 mg
q.d., Zantac 150 mg b.i.d.

PAST MEDICAL HISTORY:  Type 2 diabetes with neuropathy,
hypertension, right Charcot foot, cerebrovascular accident in
[**2112**], degenerative back and hand changes.

PAST SURGICAL HISTORY:  Bilateral cataracts.

SOCIAL HISTORY:  The patient is a 77 year-old white male,
married, lives with his wife.  [**Name (NI) **] is retired postal worker.
He is a former smoker, thirty pack years, occasional coffee
and alcohol.

REVIEW OF SYSTEMS:  Negative for constitutional symptoms,
dyspnea, wheezing, shortness of breath, cough, pneumonia or
asthma, myocardial infarction, chest pain, palpitations,
paroxysmal nocturnal dyspnea, orthopnea.  He denies
claudication, deep venous thrombosis, thrombosed phlebitis.
He does admit to loose green stools since starting his
antibiotic therapy.

History of stroke was found on MRI.  The patient was not
aware he had a cerebrovascular accident until four days later
when he had trouble stepping up to the curb.  He has had no
further symptoms or residual.  He denies syncope, seizures or
amaurosis.  He checks his glucoses at least two times per
week.

PHYSICAL EXAMINATION:  Vital signs temperature 98.6.  86.
20.  Blood pressure 132/50.  97% O2 sat on room air, 93.4
kilograms.  He is alert white male in no acute distress.
HEENT examination shows bilateral lens implants.  Pulse
examination shows intact carotids, brachial, radial, femoral
pulses bilaterally with bilateral carotid bruits.  There were
no femoral bruits.  Popliteal pulses were difficult to assess
secondary to edema.  Dorsalis pedis pulses bilaterally were
dopplerable.  Posterior tibial pulses were dopplerable
bilaterally.  Lungs were clear to auscultation.  Heart is
regular rate and rhythm with a normal S1 and S2.  There were
no murmurs, rubs or gallops or extra heart sounds.  Abdomen
was benign.  There was no tenderness.  The right anterior
tibial aspect of the lower extremity was with multiple full
thickness ulcerations with fibrinous areas and granulation
tissue.  There was no erythema or exudate or odor.  There was
significant amount of serous fluid.  Bone joint examination
showed right Charcot foot deformity with degenerative changes
of the hands.  Lower extremity bilaterally from foot to knees
showed 4+ edema.  The neurological examination was
unremarkable.

ADMISSION LABORATORY:  CBC with a white count of 14.5,
hematocrit 34.5, platelets 352, PT/INR, PTT was normal.  BUN
34, creatinine 1.5, potassium 4.7.  Electrocardiogram, normal
sinus rhythm with a V rate of 81 with left axis deviation,
bifascicular block, right bundle branch and left anterior
vesicular block.  Probably old anterior septal infarct.  No
acute ischemic changes were noted.  Chest x-ray was
unremarkable.

HOSPITAL COURSE:  The patient was admitted to the Vascular
Service.  He was placed on bed rest.  He was allowed to sleep
in a chair.  Cultures of the right leg were obtained.  He was
continued on his transfer medications.  He was begun on IV
Kefzol 1 gram q 8 hours, Flagyl 500 mg q 8 hours.  SubQ
heparin for patient's deep venous thrombosis prophylaxis.
Ultrasound of the carotids were obtained, which showed
minimal disease, 40 to 59% on the right and less then 40% on
the left.  Cardiology was requested to see the patient for
perioperative risk assessment.  The patient's stress was
negative for ischemic changes.  The echocardiogram on the
dobutamine demonstrated left ventricular wall thickness.
Cavity size and systolic function were normal.  Regional left
ventricular wall motion was normal.  Dobutamine stress was
dynamic wall motion and increased left ventricular function
are present.  There are no signs of inducible ischemia.

The patient was begun on Lopressor 12.5 mg for beta blockade
perioperatively.  This was increased as tolerated. The
patient underwent an arteriogram on [**9-28**], which demonstrated
aorta and iliacs were patent, but were tortuous.  The common
femoral, superficial femoral artery, popliteal were patent
without disease.  There was severe tibial disease with
occlusion of the proximal AT PT, peroneal with single vessel
run off was diffusely disease, reconstituted and distal
posterior tibial and plantars and dorsalis pedis and arch.

The patient was transferred to the VICU for epidural
placement so we could allow the patient the  patient to rest
with his legs elevated and diminish his significant amount of
peripheral edema.  Infectious disease was requested to see
the patient on [**2114-10-2**], because of onset of chills, rigors
and rising total white count.  On admission it was 14.5 and
it peaked at 23.0.  Recommendations were that the patient
could possibly have C-diff colitis given the history of
antibiotics.  Recommendations were Vancomycin 1 gram IV q 24
hours, Levofloxacin 500 mg IV q 24 hours, Flagyl 500 mg q 8
hours and Flagyl po 500 mg q 8 hours.  They also recommended
a general surgery consult.  Abdominal CT was obtained, which
showed thickening of the bowel walls consistent with an
inflammatory colitis.  His surgery was deferred.  He remained
in the Intensive Care Unit monitored and continued
antibiotics.  Cultures obtained to initial onset of sepsis
were urine, which were negative.  Blood cultures were
negative and wound cultures showed diphtheroids.  TPN was
begun on [**2114-10-4**].  The patient's white count peaked at 28.3.
His stool for C-diff was positive.  He was continued on
treatment with eventual resolution of his symptoms and
defervescence of his temperature curve.  His PA catheter was
changed on [**10-16**] to a CVL.

His diet was advanced as tolerated.  The patient's white
count continued to show improvement and on [**2114-10-9**] his white
count was down to 26.7 with 68% PMNs and 5% bands.  The
patient was prepared for surgery and on [**10-10**] underwent a BK
popliteal to posterior tibial bypass with reverses saphenous
vein graft.  He tolerated the procedure well and was
transferred to the PACU in stable condition.
Postoperatively, he remained stable.  His wounds were clean,
dry and intact and he had a functioning graft pulse.  The
patient was continued on his antibiotics for his C-diff.  He
required transfusion of 2 units of packed red blood cells for
a hematocrit of 25.5.  Diet was advanced as tolerated and he
remained in the VICU.  Vancomycin was discontinued on
[**2114-10-13**] and he was converted to oral Flagyl at that time.
Physical therapy was requested to see the patient.  They
began mobility exercises and strengthening exercises.

The patient underwent on [**10-18**] a split thickness skin graft
to the right leg from the left thigh.  He tolerated the
procedure well and was transferred to the PACU.  He continued
to do well and was returned to the regular nursing floor.
Multi ______ boots were applied to the right lower extremity.
Physical therapy was requested to see the patient and begin
ambulation.  The dressing from the graft site was removed on
[**10-22**].  There was 100% take of the graft.  Dressing changes
were done by the physicians.  It was with Adaptic, fluff, dry
sterile dressing and Ace wrap.  Case management was
requested to see the patient and begin screening for rehab
potentially for Thursday or Friday of that week.  His
proximal staples on the right leg were discontinued without
difficulty.

DISCHARGE CONDITION:  The patient was discharged in stable
condition to rehab for continued rehabilitation.  The left
thigh showed serous oozing through Xeroform.  The right leg
dressing was clean, dry and intact with a warm foot.

MEDICATIONS ON DISCHARGE:  Oxycontin 10 mg b.i.d.,
Levofloxacin 500 mg q.d., heparin 5000 units subQ b.i.d.,
Tylenol 650 mg q 6 hours around the clock, Ditropan 2.5 mg
b.i.d., Glyburide 2.5 mg q.a.m., Neurontin 300 mg b.i.d.,
Lopressor 25 mg b.i.d. hold for systolic blood pressure less
then 120 heart rate less then 50.  Hydrochlorothiazide 25 mg
daily.  Lisinopril 40 mg q day.  Zoloft 50 mg b.i.d.  Regular
insulin sliding scale, glucoses less then 200 no insulin, 200
to 250 2 units, 251 to 300 4 units , 301 to 350 6 units, 351
to 400 8 units, 401 to 450 10 units.  Zantac 150 mg b.i.d.
Flagyl IV 500 mg q 8 hours.

DISCHARGE DIAGNOSES:
1.  Ischemic right leg ulcer status post right popliteal
dorsalis pedis bypass graft, split thickness skin graft.
2.  Diabetes type 2 controlled.
3.  C-difficile colitis resolved.






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

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

D:  [**2114-10-22**]  09:53
T:  [**2114-10-22**]  09:59
JOB#:  [**Job Number 35988**]


Admission Date:  [**2114-9-27**]       Discharge Date:  [**2114-10-25**]


Service:  VASCULAR SURGERY


This is an addendum to the discharge summary dated [**2114-10-22**].


HOSPITAL COURSE:  The patient continued to do well with his
split thickness skin graft to his right lower leg while
awaiting a bed at a short term rehab facility.  The right
lower leg skin graft was almost a 100% take.  The left thigh
donor site was dry and healing well.  The staples from the
STSG was removed on [**2114-10-24**].  The patient was offered a bed
at [**Hospital3 36034**] on [**2114-10-25**].  The patient accepted
this bed and was transferred there on the same day.





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

Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36

D:  [**2114-11-26**]  10:33
T:  [**2114-11-26**]  10:35
JOB#:  [**Job Number 36035**]
{'Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of ankle,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Universal ulcerative (chronic) colitis,Intestinal infection due to Clostridium difficile,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: Right leg ulceration.

PRESENT ILLNESS: This 77 year-old white male with
known hypertension, type 2 diabetes with a right intra-tibial
ulcer, which developed post trauma in [**Month (only) 205**] of this year.  He
has been followed by a wound care center and has undergone
multiple debridements without resolution of the ulcer or
improvement.  He had onset of foot pain with leg at heart
level and must sleep in chair with legs dependent resulting
in chronic lower extremity edema bilaterally.  The patient
was admitted to [**Doctor Last Name 1728**] [**Hospital 107**] Hospital from [**9-14**] to [**9-27**].
Workup included cultures of the right leg, which were staph
aureus positive, sensitive to Cephazolin, Chloramphenicol,
Clindamycin, Erythromycin, Gentamycin, Levofloxacin,
Oxacillin, Bactrim, Tetracycline and Vancomycin.  The patient
was treated with Kefzol 1 gram with multiple intravenous
restarts now on Keflex 500 mg q.i.d.

MEDICAL HISTORY: Type 2 diabetes with neuropathy,
hypertension, right Charcot foot, cerebrovascular accident in
[**2112**], degenerative back and hand changes.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a 77 year-old white male,
married, lives with his wife.  [**Name (NI) **] is retired postal worker.
He is a former smoker, thirty pack years, occasional coffee
and alcohol. 

### Response:
{'Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of ankle,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Universal ulcerative (chronic) colitis,Intestinal infection due to Clostridium difficile,Unspecified essential hypertension'}
