CHIEF COMPLAINT: Pain and ischemia bilateral lower extremities

PRESENT ILLNESS: 65 yo M significant PMH refered by Dr. [**Last Name (STitle) 74514**] with ischemic lower
extremities bilaterally form [**Last Name (un) 11560**] Gen. Hospital.  Pt states
pain and coolness for several months, progressive in bilateral
lower extremities, right more than left.

MEDICAL HISTORY: PMH: HTN, ESRD on hemodialysis, h/o congestive heart failure,
COPD, anemia secondary to ESRD, CAD h/o MI, h/o angioplasty 30
yrs ago, hyperlipidemia, severe PVD
.
PSH: Left BKA [**2123**] secondary to trauma/osteo, ?bladder surgery,
appendectomy, rotator cuff surgery, right forearm fistula failed

MEDICATION ON ADMISSION: Albuterol, Aspirin, Atenolol, BusPIRone, Carvedilol, Calcium
Acetate, Docusate Sodium, Ipratropium Bromide MDI, Isosorbide
Mononitrate (Extended Release), Lisinopril, Mesalamine,
Nephrocaps, Nicotine Patch, Nitroglycerin SL,
Oxycodone-Acetaminophen, Pantoprazole, seroquel, Sevelamer,
Senna, Simvastatin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: 98.9  96  124/52  18  99% 2L NC
Gen: NAD
Chest: decreased breath sounds bilaterally, o/w clear
CV: RRR, no murmurs
Abd: S/ND/NT, +BS
Ext: cool stump on left, ischemic [**Year (4 digits) **]
Pulses:
     Fem   [**Doctor Last Name **]   DP   PT
[**Name (NI) **]  NP    NP    [**Name8 (MD) 74515**]  NP    palp

FAMILY HISTORY: unknown

SOCIAL HISTORY: see previous d/c summeries
Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nontraumatic compartment syndrome of lower extremity,Pulmonary collapse,Drug-induced delirium,Pressure ulcer, lower back,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other acute postoperative pain,Other iatrogenic hypotension,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Atrial fibrillation,Long-term (current) use of anticoagulants,Tobacco use disorder,Below knee amputation status,Mitral valve disorders,Other opiates and related narcotics causing adverse effects in therapeutic use,Insomnia, unspecified
Ath ext ntv art gngrene,End stage renal disease,Comp-ren dialys dev/grft,Hyp kid NOS w cr kid V,Nontraum comp syn-low ex,Pulmonary collapse,Drug-induced delirium,Pressure ulcer, low back,Hematoma complic proc,Subendo infarct, initial,CHF NOS,Chr airway obstruct NEC,Acute postop pain NEC,Iatrogenc hypotnsion NEC,Anemia in chr kidney dis,Crnry athrscl natve vssl,Status-post ptca,Atrial fibrillation,Long-term use anticoagul,Tobacco use disorder,Status amput below knee,Mitral valve disorder,Adv eff opiates,Insomnia NOS
Admission Date:  [**2135-8-11**]              Discharge Date:   [**2135-9-6**]

Date of Birth:  [**2069-9-8**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Pain and ischemia bilateral lower extremities

Major Surgical or Invasive Procedure:
Left axillary-bifemoral bypass
left fem-[**Doctor Last Name **] bypass


History of Present Illness:
65 yo M significant PMH refered by Dr. [**Last Name (STitle) 74514**] with ischemic lower
extremities bilaterally form [**Last Name (un) 11560**] Gen. Hospital.  Pt states
pain and coolness for several months, progressive in bilateral
lower extremities, right more than left.


Past Medical History:
PMH: HTN, ESRD on hemodialysis, h/o congestive heart failure,
COPD, anemia secondary to ESRD, CAD h/o MI, h/o angioplasty 30
yrs ago, hyperlipidemia, severe PVD
.
PSH: Left BKA [**2123**] secondary to trauma/osteo, ?bladder surgery,
appendectomy, rotator cuff surgery, right forearm fistula failed


Social History:
see previous d/c summeries

Family History:
unknown

Physical Exam:
PE: VS: 98.9  96  124/52  18  99% 2L NC
Gen: NAD
Chest: decreased breath sounds bilaterally, o/w clear
CV: RRR, no murmurs
Abd: S/ND/NT, +BS
Ext: cool stump on left, ischemic [**Year (4 digits) **]
Pulses:
     Fem   [**Doctor Last Name **]   DP   PT
[**Name (NI) **]  NP    NP    [**Name8 (MD) 74515**]  NP    palp


Pertinent Results:
[**2135-8-11**] 07:10PM   GLUCOSE-141* UREA N-21* CREAT-5.3* SODIUM-141
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-26 ANION GAP-18
[**2135-8-11**] 07:10PM   estGFR-Using this
[**2135-8-11**] 07:10PM   ALT(SGPT)-4 AST(SGOT)-23 LD(LDH)-153 ALK
PHOS-83 AMYLASE-94 TOT BILI-0.2
[**2135-8-11**] 07:10PM   LIPASE-19
[**2135-8-11**] 07:10PM   CALCIUM-9.9 PHOSPHATE-4.6* MAGNESIUM-1.6
[**2135-8-11**] 07:10PM   WBC-12.5* RBC-4.05* HGB-11.2* HCT-33.6*
MCV-83 MCH-27.8 MCHC-33.5 RDW-18.5*
[**2135-8-11**] 07:10PM   PLT COUNT-272
[**2135-8-11**] 07:10PM   PT-17.4* PTT-35.5* INR(PT)-1.6*

Brief Hospital Course:
[**2135-8-11**] admitted to Vascular service. Vanco/cipro and flagyl
began. Home meds continued.Transplant /hemodialysis acces team
consulted for failed AVf secondary to stenosis.Renal dialysis
team followed patient for his hemodialysis needs.
[**2135-8-16**] thrombectomy RUE fistula, revision of fisutla with AVRUE
graft.
[**2135-8-16**] left ax-bifemoral bpg
[**2135-8-17**] left cavicular hematoma, Iv heparin d/c'd,wound
evacuation of hematoma. transfered to ICU requiring neo gtt for
b/p support.Chronic pain consulted. PCA diludied effective. in
addition to percocet tabs [**11-23**] q4h prn.Neurotin added to regment
after discussion with renal.
[**2135-8-18**] extubated. Pain meds adjusted for optium relief.
[**2135-8-19**] Code "purple" for extreme agitatioon and hallucinations
. Required haldol 5mgm IV with schedualed 2.5mgm tid and 5mgm IV
prn for his agitation.Episode probable secondary to increased
opate regment.
[**2135-8-20**] delerium slowly improving. AF controlled with beta
blockade.hypotension requiring vasopressor support.Right
fem-bkpop with NRSVG for ischemic rt. foot.
[**2135-8-21**] cardology for persistant af managment.Required amidarone
gtt to convert.
periop Mi, small.
[**2135-8-22**] postop delerium controlled with haldol. wean to
extubate began. tube feed
began.
10/02/07Extubated.CVVHD.
[**2135-8-24**] Neo gtt weaning. coumadin began.
[**2135-8-25**] right leg sutured for bleeding @ incisiional
site.Transfered to VICU.
[**2135-8-26**] patient evaluated by physical thearphy-will require
rehab.
[**Date range (1) 74516**] persistant leukocytosis. stool for cdiff sent. AF
with HD converted with 10mg lopressor Iv.
[**8-31**] /07 pain meds adjusted
Over the next week medications were reduced and PT was involved.
The foot was warm and good doppler signals. He required HD per
the renal service.
His coumadin was titrated for a goal of [**12-25**].
He was screened for rehab with plans to return to clinic for
evaluation of his toes and possible amputation. He will be
continued on his antibiotic till follow-up
Of note on [**2135-9-6**] his coumadin was held for an INR of 4.5.
He was discharged to rehab on [**2135-9-6**]

Medications on Admission:
Albuterol, Aspirin, Atenolol, BusPIRone, Carvedilol, Calcium
Acetate, Docusate Sodium, Ipratropium Bromide MDI, Isosorbide
Mononitrate (Extended Release), Lisinopril, Mesalamine,
Nephrocaps, Nicotine Patch, Nitroglycerin SL,
Oxycodone-Acetaminophen, Pantoprazole, seroquel, Sevelamer,
Senna, Simvastatin

Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*240 Capsule, Sustained Release(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*60 Cap(s)* Refills:*2*
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*60 Tablet, Sublingual(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Capsule(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*60 neb* Refills:*3*
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours) as needed.
Disp:*60 neb* Refills:*0*
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
Disp:*60 * Refills:*2*
12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*60 Tablet(s)* Refills:*0*
16. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
17. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*2*
18. Vancomycin 1,000 mg Recon Soln Sig: One (1)  Intravenous
QHD.
Disp:*60 * Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) **]

Discharge Diagnosis:
right lower extremity ischemia


Discharge Condition:
Stable to rehab


Discharge Instructions:
Discharge Instructions:  Please call your doctor or return to
the ER for any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered. Continue on antibiotics for ... days.
* Continue to amubulate several times per day.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1391**].  Please call to make an
appointment: [**Telephone/Fax (1) 1393**]
{'Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nontraumatic compartment syndrome of lower extremity,Pulmonary collapse,Drug-induced delirium,Pressure ulcer, lower back,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other acute postoperative pain,Other iatrogenic hypotension,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Atrial fibrillation,Long-term (current) use of anticoagulants,Tobacco use disorder,Below knee amputation status,Mitral valve disorders,Other opiates and related narcotics causing adverse effects in therapeutic use,Insomnia, 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: Pain and ischemia bilateral lower extremities

PRESENT ILLNESS: 65 yo M significant PMH refered by Dr. [**Last Name (STitle) 74514**] with ischemic lower
extremities bilaterally form [**Last Name (un) 11560**] Gen. Hospital.  Pt states
pain and coolness for several months, progressive in bilateral
lower extremities, right more than left.

MEDICAL HISTORY: PMH: HTN, ESRD on hemodialysis, h/o congestive heart failure,
COPD, anemia secondary to ESRD, CAD h/o MI, h/o angioplasty 30
yrs ago, hyperlipidemia, severe PVD
.
PSH: Left BKA [**2123**] secondary to trauma/osteo, ?bladder surgery,
appendectomy, rotator cuff surgery, right forearm fistula failed

MEDICATION ON ADMISSION: Albuterol, Aspirin, Atenolol, BusPIRone, Carvedilol, Calcium
Acetate, Docusate Sodium, Ipratropium Bromide MDI, Isosorbide
Mononitrate (Extended Release), Lisinopril, Mesalamine,
Nephrocaps, Nicotine Patch, Nitroglycerin SL,
Oxycodone-Acetaminophen, Pantoprazole, seroquel, Sevelamer,
Senna, Simvastatin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: VS: 98.9  96  124/52  18  99% 2L NC
Gen: NAD
Chest: decreased breath sounds bilaterally, o/w clear
CV: RRR, no murmurs
Abd: S/ND/NT, +BS
Ext: cool stump on left, ischemic [**Year (4 digits) **]
Pulses:
     Fem   [**Doctor Last Name **]   DP   PT
[**Name (NI) **]  NP    NP    [**Name8 (MD) 74515**]  NP    palp

FAMILY HISTORY: unknown

SOCIAL HISTORY: see previous d/c summeries 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Nontraumatic compartment syndrome of lower extremity,Pulmonary collapse,Drug-induced delirium,Pressure ulcer, lower back,Hematoma complicating a procedure,Subendocardial infarction, initial episode of care,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other acute postoperative pain,Other iatrogenic hypotension,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Atrial fibrillation,Long-term (current) use of anticoagulants,Tobacco use disorder,Below knee amputation status,Mitral valve disorders,Other opiates and related narcotics causing adverse effects in therapeutic use,Insomnia, unspecified'}
