CHIEF COMPLAINT: Left lower extremity nonhealing ulcers

PRESENT ILLNESS: Mr. [**Known lastname 5721**] is a 71 year old male with an extensive past
medical history s/p L SFA-PT [**Name (NI) **] who presented to clinic today
from [**Hospital6 **] with complaints of worsening LLE ulcers
and left 5th toe gangrene.  His sister reports that he first
developed LLE wounds approximately 2 months ago prior to his
transfer to rehab, and that she feels they are related to
dressings being too tight.  She reports they have been growing
continually worse over the past several weeks prompting Mr.
[**Known lastname 71725**] clinic visit today.

MEDICAL HISTORY: PMH: DM, HTN, HLD, Carotid stenosis, PVD, severe AS, CRI,
cataracts, OSA, neuropathy

MEDICATION ON ADMISSION: coumadin 6' (held), Prilosec 20', Lovemir 42u SQ', Humalog ISS,
minocin 100'', lasix 40', amiodarone 200', ASA 81', neurontin
800'', levemir 40u qHS, lidoderm 5% TD q12h, metoprolol 50'',
MVI', serax 10''', pravastatin 40', senna' prn, colace 100'',
lactulose 30 q6h prn, oxycodone 5 q4h prn, zinc sulfate 220'

ALLERGIES: Unasyn

PHYSICAL EXAM: PE on admission:
Neuro/Psych: NAD, abnormal: Anxious, aphasic but oriented x3.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy.
Skin: Abnormal: LLE wounds; sacral pressure wound. .
Heart: Regular rate and rhythm, abnormal: Loud, high pitched
systolic ejection murmur.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, No hernia, abnormal: Obese.
Rectal: Not Examined.
Extremities: No femoral bruit/thrill, abnormal: 2+ pitting edema
of LE bilaterally.  Chronic skin changes, L>R.  LLE wounds x7.

FAMILY HISTORY: There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.
Atherosclerosis of native arteries of the extremities with gangrene,Aphasia,Chronic ulcer of other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Ath ext ntv art gngrene,Aphasia,Chronic skin ulcer NEC,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2120-10-9**]              Discharge Date:   [**2120-10-22**]

Date of Birth:  [**2049-3-15**]             Sex:   M

Service: SURGERY

Allergies:
Unasyn

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Left lower extremity nonhealing ulcers

Major Surgical or Invasive Procedure:
Left lower extremity angiogram [**2120-10-15**] with Dr. [**Last Name (STitle) 1391**]
[**Name (STitle) 2325**] femoral to femoral-posterior tibial graft bypass graft with
PTFE and left fifth toe amputation [**2120-10-17**] with Dr. [**Last Name (STitle) 1391**]


History of Present Illness:
Mr. [**Known lastname 5721**] is a 71 year old male with an extensive past
medical history s/p L SFA-PT [**Name (NI) **] who presented to clinic today
from [**Hospital6 **] with complaints of worsening LLE ulcers
and left 5th toe gangrene.  His sister reports that he first
developed LLE wounds approximately 2 months ago prior to his
transfer to rehab, and that she feels they are related to
dressings being too tight.  She reports they have been growing
continually worse over the past several weeks prompting Mr.
[**Known lastname 71725**] clinic visit today.

Past Medical History:
PMH: DM, HTN, HLD, Carotid stenosis, PVD, severe AS, CRI,
cataracts, OSA, neuropathy

PSH: R CEA, L SFA-PT [**Name (NI) **] w NRSVG 09 and Dacron patch angioplasty
09, 10, EVAR, aortic balloon valvuloplasty 10, trach, PEG

Social History:
He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.


Family History:
There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

Physical Exam:
PE on admission:
Neuro/Psych: NAD, abnormal: Anxious, aphasic but oriented x3.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy.
Skin: Abnormal: LLE wounds; sacral pressure wound. .
Heart: Regular rate and rhythm, abnormal: Loud, high pitched
systolic ejection murmur.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, No hernia, abnormal: Obese.
Rectal: Not Examined.
Extremities: No femoral bruit/thrill, abnormal: 2+ pitting edema
of LE bilaterally.  Chronic skin changes, L>R.  LLE wounds x7.

Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. DP: D. PT: D.
LLE Femoral: P. DP: D. PT: D.

DESCRIPTION OF WOUND: 1. Left dorsal foot: 4cm irregular wound
with eschar, surrounding erythema and induration.
2. L 5th toe gangrenous, no evident purulence, dry
3. L lateral MTP wound 2x1cm with eschar, no drainage
4. L great toenail with onycomycosis, surrounding eschar, no
purulence
5. L medial heel wound: 2x2cm with eschar, no surrounding
erythema
6. L posterior heel wound: 3x3cm with eschar, depressed, no
surrounding erythema or purulence. Tender to palpation.
7. L posterior calf: 1x-.5cm eschar, irregular, no surrounding
erythema, no purulence.

PE on discharge:
Gen: AAOx4, conversant with expressive aphasia, NAD
CVS: Regular, grade IV systolic murmur
Pulm: clear bilaterally
Abd: soft, nontender, nondistended
Ext: left lower extremity wounds stable with eschars, adaptic
dressings applied.  Left leg  incisions clean, dry and intact -
no erythema, no drainage, no induration.
Pulses: Fem: Palp b/l, DP/PT Dop b/l
Neuro:  CN II-XII grossly intact


Brief Hospital Course:
Mr. [**Known lastname 5721**] was admitted on [**10-9**] for evaluation of his left
lower extremity vasculature, and he underwent non-invasive
arterial studies on [**10-10**] which revealed occlusion of his left
SFA-PT graft.  On [**10-11**], he underwent upper extremity vein mapping
in preparation for a possible bypass graft, which revealed
patent upper extremity veins, R>L, and his right arm was
subsequently protected from any needlesticks or IVs.  His IV
antibiotics were continued, and wound care with adaptic
dressings was performed daily.

On [**10-15**], he underwent left lower extremity angiography after
being pre-medicated with IV bicarbonate.  His left SFA to PT
bypass was found to be patent, but the proximal left SFA was
occluded on angiogram.  He was thus offered a left femoral to
graft bypass to circumvent the occluded SFA segment proximal to
the patent graft.  After discussion with the patient and his
sister, [**Name2 (NI) 3548**], and discussion of the risks and benefits of
surgery, Mr. [**Known lastname 5721**] agreed to undergo bypass on [**2120-10-17**].

After appropriate preparation and informed consent, Mr. [**Known lastname 5721**] [**Last Name (Titles) 8783**]t left femoral to existing (femoral-posterior tibial
bypass) bypass graft with PTFE and left 5th toe amputation with
primary closure.  He tolerated the procedure well.  After
initial recovery in the PACU, Mr. [**Known lastname 5721**] was transferred to
the vascular surgery floor for further monitoring and recovery.
He was placed on the lower extremity bypass pathway, and his
activity and diet were advanced accordingly, to full ambulation
with physical therapy and regular diet by [**10-20**].  His pain was
controlled with oral pain medication, and a heparin drip was
maintained post-operatively until his usual coumadin dosing
became therapeutic on [**10-22**].  His IV antibiotics were continued
throughout his hospital stay, and transitioned to oral bactrim
at the time of discharge.  He remained hemodynamically stable,
and received 3 units of pRBCs for falling hematocrit
post-operatively in light of his critical aortic stenosis.  His
blood pressure remained within the target range throughout his
post-operative course.

On [**10-22**], Mr. [**Known lastname 5721**] was found to be ambulating with assistance
(at his baseline), tolerating a regular diet, therapeutic on his
coumadin, and reporting good pain control with oral pain
medication.  He was deemed stable for discharge back to [**Hospital **] with instruction to follow up with Dr. [**Last Name (STitle) 1391**] in
clinic in 2 weeks for wound check and graft evaluation.  He will
continue his coumadin and a 10 day course of bactrim.  He will
need physical therapy and speech therapy, as well as wound care
(adaptic and kerlex) for his left lower extremity wounds.  Mr.
[**Known lastname 5721**] understood and agreed with the plan and was transferred
to [**Location (un) 25576**] on [**2120-10-22**].

Medications on Admission:
coumadin 6' (held), Prilosec 20', Lovemir 42u SQ', Humalog ISS,
minocin 100'', lasix 40', amiodarone 200', ASA 81', neurontin
800'', levemir 40u qHS, lidoderm 5% TD q12h, metoprolol 50'',
MVI', serax 10''', pravastatin 40', senna' prn, colace 100'',
lactulose 30 q6h prn, oxycodone 5 q4h prn, zinc sulfate 220'

Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for Pain for 5 days.
Disp:*24 Tablet(s)* Refills:*0*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. oxazepam 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day).
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for Pain.
13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
14. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
15. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: *Please continue regular INR checks and adjust coumadin
dosing accordingly for INR goal [**3-14**]*.
17. minocycline 50 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
18. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
19. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
20. Humalog 100 unit/mL Solution Sig: per sliding scale
Subcutaneous per sliding scale: Please see insulin sliding
scale.
21. Insulin sliding scale
Insulin SC Sliding Scale (Humalog)
          Breakfast Lunch     Dinner    Bedtime
Glucose Insulin Dose
0-70      mg/dL Proceed with hypoglycemia protocol
71-150    mg/dL 0   Units 0   Units 0   Units 0   Units
151-200   mg/dL 3   Units 3   Units 3   Units 3   Units
201-250   mg/dL 6   Units 6   Units 6   Units 6   Units
251-300   mg/dL 9   Units 9   Units 9   Units 9   Units
301-350   mg/dL 12  Units 12   Units 12   Units 12   Units
351-400   mg/dL 15  Units 15   Units 15   Units 15   Units
> 400   mg/dL Notify M.D.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
Left lower extremity ulcers
left 5th toe dry gangrene
Occlusion of left superficial femoral artery to posterior tibial
artery bypass graft


Discharge Condition:
Mental Status: Clear and coherent, severe expressive aphasia.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

2. It is normal to have swelling of the leg you were operated
on:
??????	Elevate your leg above the level of your heart (use [**3-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	Eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	Unless you were told not to bear any weight on operative foot:

??????	You should get up every day, get dressed and walk
??????	You should gradually increase your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????	You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Please call [**Telephone/Fax (1) 1393**] to schedule a follow up appointment
with Dr. [**Last Name (STitle) 1391**] in clinic in 2 weeks.
Please follow up with your PCP for INR checks and coumadin dose
adjustments.
{'Atherosclerosis of native arteries of the extremities with gangrene,Aphasia,Chronic ulcer of other specified sites,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 nonhealing ulcers

PRESENT ILLNESS: Mr. [**Known lastname 5721**] is a 71 year old male with an extensive past
medical history s/p L SFA-PT [**Name (NI) **] who presented to clinic today
from [**Hospital6 **] with complaints of worsening LLE ulcers
and left 5th toe gangrene.  His sister reports that he first
developed LLE wounds approximately 2 months ago prior to his
transfer to rehab, and that she feels they are related to
dressings being too tight.  She reports they have been growing
continually worse over the past several weeks prompting Mr.
[**Known lastname 71725**] clinic visit today.

MEDICAL HISTORY: PMH: DM, HTN, HLD, Carotid stenosis, PVD, severe AS, CRI,
cataracts, OSA, neuropathy

MEDICATION ON ADMISSION: coumadin 6' (held), Prilosec 20', Lovemir 42u SQ', Humalog ISS,
minocin 100'', lasix 40', amiodarone 200', ASA 81', neurontin
800'', levemir 40u qHS, lidoderm 5% TD q12h, metoprolol 50'',
MVI', serax 10''', pravastatin 40', senna' prn, colace 100'',
lactulose 30 q6h prn, oxycodone 5 q4h prn, zinc sulfate 220'

ALLERGIES: Unasyn

PHYSICAL EXAM: PE on admission:
Neuro/Psych: NAD, abnormal: Anxious, aphasic but oriented x3.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy.
Skin: Abnormal: LLE wounds; sacral pressure wound. .
Heart: Regular rate and rhythm, abnormal: Loud, high pitched
systolic ejection murmur.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: No masses, No hernia, abnormal: Obese.
Rectal: Not Examined.
Extremities: No femoral bruit/thrill, abnormal: 2+ pitting edema
of LE bilaterally.  Chronic skin changes, L>R.  LLE wounds x7.

FAMILY HISTORY: There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Aphasia,Chronic ulcer of other specified sites,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
