CHIEF COMPLAINT: Right leg gangrene.

PRESENT ILLNESS: This is an 80 year-old gentleman
with right first toe ischemic gangrenous changes post trauma
for duration of 5 to 6 months. Initially saw his podiatrist
who did a nail clipping and since then the wound has
progressed. The patient has been on antibiotics po regimen.
Medication and length of therapy he does not remember.
Patient denies right calf hip claudication. He does admit to
right first toe pain with walking. Patient underwent an
arteriogram at [**Hospital6 3105**] where they felt that
the patient was not a surgical candidate. Patient was
referred to Dr. [**Last Name (STitle) 1391**] for a second opinion. Patient now is
admitted for elective surgery. Last dose of Coumadin was
[**2155-7-20**].

MEDICAL HISTORY: Coronary artery disease with history
of myocardial infarction in [**2148**]. Denies any congestive heart
failure, type 2 diabetes with neuropathy and nephropathy
insulin dependent for the last 10 to 12 years, history of
hypercholesterolemia, history of aortic valvular disease,
history of carotid disease, history of C diff in [**Month (only) 958**] of 99,
pneumonia in [**Month (only) 216**] of 99. Echo [**7-/2149**] showed an AVR prosthesis
with ejection fraction of 45%, left ventricular hypertrophy
and MR with mitral valve prolapse. Patient has a history of
hematochezia, which was worked up at [**Hospital3 **], which was
negative.

MEDICATION ON ADMISSION: Lantus 20 units every a.m., renal
vit every day, Lopid 600 mg b.i.d., Coreg 25 mg b.i.d.,
Prevacid 30 mg every day, Diovan 320 mg every day, Lasix 80
mg every day hold on dialysis days. Renagel 2400 mg t.i.d.,
Zoloft 50 mg every day, lisinopril 20 mg b.i.d., aspirin 81
mg every day, albuterol puffs multidose inhaler 2 q.i.d.,
Spiriva puff 1 every day, Advair discus 100/50 puff 1 b.i.d.,
Digitek 0.125 mg every day, Norvasc 5 mg every p.m., Coumadin
2 mg every p.m., Procrit at dialysis, Lasix 160 mg every a.m.
Wednesday, Thursday, Saturday, Sunday and 80 mg of Lasix
every p.m., which is to be held on hemodialysis days.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is widowed for the last 5 years.
Lives with his daughter. [**Name (NI) **] is retired. Had been self
employed. He is a former 3 pack per day smoker for 20 years.
Has not smoked for 10 years. Does admit to alcohol use, but
has discontinued alcohol for the last 15 years.
Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to renal dialysis device, implant, and graft,Mitral valve insufficiency and aortic valve insufficiency,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aortocoronary bypass status,Pure hypercholesterolemia,Heart valve replaced by other means,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes
Ath ext ntv art gngrene,Comp-ren dialys dev/grft,Mitral/aortic val insuff,Ac posthemorrhag anemia,Hyp kid NOS w cr kid V,Aortocoronary bypass,Pure hypercholesterolem,Heart valve replac NEC,DMII neuro nt st uncntrl,Neuropathy in diabetes
Unit No:  [**Numeric Identifier 28016**]
Admission Date: [**2155-7-22**]
Discharge Date: [**2155-8-7**]
Date of Birth:  [**2075-5-5**]
Sex:  M
Service:  VSU


CHIEF COMPLAINT:  Right leg gangrene.

HISTORY OF PRESENT ILLNESS:  This is an 80 year-old gentleman
with right first toe ischemic gangrenous changes post trauma
for duration of 5 to 6 months. Initially saw his podiatrist
who did a nail clipping and since then the wound has
progressed. The patient has been on antibiotics po regimen.
Medication and length of therapy he does not remember.
Patient denies right calf hip claudication. He does admit to
right first toe pain with walking. Patient underwent an
arteriogram at [**Hospital6 3105**] where they felt that
the patient was not a surgical candidate. Patient was
referred to Dr. [**Last Name (STitle) 1391**] for a second opinion. Patient now is
admitted for elective surgery. Last dose of Coumadin was
[**2155-7-20**].

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:  Lantus 20 units every a.m., renal
vit every day, Lopid 600 mg b.i.d., Coreg 25 mg b.i.d.,
Prevacid 30 mg every day, Diovan 320 mg every day, Lasix 80
mg every day hold on dialysis days. Renagel 2400 mg t.i.d.,
Zoloft 50 mg every day, lisinopril 20 mg b.i.d., aspirin 81
mg every day, albuterol puffs multidose inhaler 2 q.i.d.,
Spiriva puff 1 every day, Advair discus 100/50 puff 1 b.i.d.,
Digitek 0.125 mg every day, Norvasc 5 mg every p.m., Coumadin
2 mg every p.m., Procrit at dialysis, Lasix 160 mg every a.m.
Wednesday, Thursday, Saturday, Sunday and 80 mg of Lasix
every p.m., which is to be held on hemodialysis days.

SOCIAL HISTORY:  Patient is widowed for the last 5 years.
Lives with his daughter. [**Name (NI) **] is retired. Had been self
employed. He is a former 3 pack per day smoker for 20 years.
Has not smoked for 10 years. Does admit to alcohol use, but
has discontinued alcohol for the last 15 years.

PAST MEDICAL HISTORY:  Coronary artery disease with history
of myocardial infarction in [**2148**]. Denies any congestive heart
failure, type 2 diabetes with neuropathy and nephropathy
insulin dependent for the last 10 to 12 years, history of
hypercholesterolemia, history of aortic valvular disease,
history of carotid disease, history of C diff in [**Month (only) 958**] of 99,
pneumonia in [**Month (only) 216**] of 99. Echo [**7-/2149**] showed an AVR prosthesis
with ejection fraction of 45%, left ventricular hypertrophy
and MR with mitral valve prolapse. Patient has a history of
hematochezia, which was worked up at [**Hospital3 **], which was
negative.

PAST SURGICAL HISTORY:  He is status post AVR and CABG in
[**2139**] in [**Location (un) 5450**], [**Location (un) 3844**]. Left AV fistula in [**2151**].
Bilateral carotid endarterectomies in 97. Hemodialysis is at
Marymac Dialysis Center [**Telephone/Fax (1) 28017**].

PHYSICAL EXAMINATION:  General appearance, alert white male
in no acute distress. HEENT exam shows bilateral transmitted
murmurs versus bruits. Carotid pulses are 1+ bilaterally.
There is no JVD. There is no thyromegaly. Lungs are clear to
auscultation. Heart is a regular rate and rhythm with 2/6
systolic ejection murmur at the base, which radiates to the
apex and carotids. Abdominal exam is soft, nontender,
nondistended. Bowel sounds x 4. No masses. Epigastric and
iliac bruits. Peripheral vascular exam shows right first toe
with ischemic color changes and the nail tip gangrene.
Patient has bilateral femoral bruits. He has underwent a left
greater saphenous vein harvest. Pulses are on the right
radial 2+, femoral 1+, popliteal, DP and PT absent. On the
left the radial pulse is 1+, femoral 1+, absent popliteal,
dopplerable DP and absent PT. Left AV fistula in the upper
arm has a thrill and neurological exam patient is oriented x
3, nonfocal.

HOSPITAL COURSE:  Patient was admitted to the vascular
service. Renal was consulted for hemodialysis needs. The
patient was continued on Augmentin renal dosing and he was
placed on bed rest in the vascular position. IV
heparinization was instituted once the patient's INR was less
then 2.0. Patient's echocardiogram demonstrated moderate left
atrial enlargement, right atrium and interatrial septum was
moderately dilated and with an aneurysmal interatrial septum.
The left ventricular showed symmetrical left ventricular
hypertrophy mild, the left ventricular cavity size was
normal. The suboptimal technical quality of focal wall motion
abnormality could not be fully excluded. Overall ejection was
greater then 55%. There is a false LV tendon, which is
(normal variant). The aortic valve was by a prosthetic aortic
valve. There is thickened AVR leaflets and increased AVR
gradient with a mild aortic insufficiency of 1+. The mitral
valve showed moderate mitral anular calcification with mild
thickening of the mitral valve cordae and calcifications at
the tips of the papillary muscles. There was no mitral
stenosis. The mitral regurg is 1+. Due to the acoustic
shadowing the severity of the mitral regurg may be
significantly underestimated. The tricuspid valve was not
well visualized. It was indeterminate PA systolic pressure.
The pulmonic valve was not well seen. There was no
pericardial effusion. Admitting chest x-ray showed
cardiomegaly without acute cardiopulmonary process and left
pleural thickening. Ultrasounds of the carotids were obtained
for a history of carotid endarterectomy, which demonstrated
less then 40% right internal and left internal carotid artery
stenosis.

Patient was evaluated by renal who felt that patient would
require more then just twice a week hemodialysis. He was
begun on a Monday, Tuesday, Thursday, Saturday schedule.
[**Last Name (un) **] also followed the patient for his diabetes care. The
patient underwent on [**2155-7-24**] a right axillary bifemoral
bypass. He tolerated the procedure well. He was transferred
to the PACU in stable condition. Postoperatively he remained
hemodynamically stable and was transferred to the VICU for
continued monitoring and care. Postoperative day one he did
require fluid boluses overnight for low urinary output.
Heparin drip was begun. He complained of right shoulder pain.
An ultrasound was obtained, which showed a right subclavian
DVT. His feet were warm and well perfuse. His medications
were converted to po pain medications. He was restarted on
his preoperative medications. Ambulation to chair was begun.
Patient was transferred to the ICU, required a need for neo-
synephrine support. Postoperative day 2 his neo was slowly
weaned. He remained afebrile. Blood gas 7.31, 38, 126, 21, -
6. The graft was dopplerable. Anticipated to transfer patient
to the VICU once weaned off of his neo. Postoperative day 3
the patient continued on triple antibiotic therapy. He
continued on neo-synephrine. He was extubated and the neo was
weaned and he was transferred to the VICU for continued care.
Because the patient remained on the neo-synephrine the
patient required to be transferred to the SICU for continued
care. Dialysis was continued by the renal service.

By postoperative day 5 the neo was weaned. Hematocrit was
stable at 29.4. BUN 40, creatinine 2.5. Patient was adequate
control with Dilaudid for pain. He continued on his
preoperative medications. His Swan was discontinued.
Ambulation was begun. His diet was advanced as tolerated.
Patient was transferred to the VICU for continued monitoring
and care. Patient continued to do well and was transferred to
the regular floor on [**2155-7-30**]. Heparin drip was continued with
a goal PTT of 60 to 70. Vancomycin was continued. MRSA screen
was negative. VRE screen was negative. Patient had blood
cultures done, which were negative. His hematocrit drifted to
26.9. They felt this was related to volume and he required
aggressive hemodialysis over the next 72 hours on a daily
basis for volume overload.
Vancomycin was discontinued on [**2155-7-31**]. His central line was
converted to a peripheral line. He is beginning screening and
physical therapy assessed the patient for discharge planning.
Patient was dialyzed on [**2155-8-5**]. There was difficulty with
accessing the AV fistula. It was noted on physical exam only
the proximal 1 mm of the AV fistula had a good thrill. An AV
fistulogram was recommended. At the time of dictation this
was ordered and pending scheduling.

The remaining hospital course prior to discharge will be
dictated at the time of patient's discharge.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]

Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D:  [**2155-8-5**] 14:05:27
T:  [**2155-8-5**] 14:56:26
Job#:  [**Job Number 28018**]





Name:  [**Known lastname 4895**],[**Known firstname 4896**] J.              Unit No:   [**Numeric Identifier 4897**]

Admission Date:  [**2155-7-22**]              Discharge Date:   [**2155-8-7**]

Date of Birth:  [**2075-5-5**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 231**]
Addendum:
[**2155-8-6**] s/p a-v fistulogram and dilitation.Will hemodialize
[**2155-8-7**]  before sending to rehab.

Major Surgical or Invasive Procedure:

Brief Hospital Course:
.

Medications on Admission:
see d/c summary part 1

Discharge Disposition:
Extended Care

Facility:
[**Location (un) 2785**] House Nursing Home - [**Location 2786**]

Discharge Diagnosis:
Ischemic right leg gangrene
postoperative blood loss anemia,corrected
arterio-venous fistula stenosis
postoperative hypotension, requiring vasopressor
support,resolved
End stage renal disease on hemodialysis Tue/Fri@home, Monday
wed. fri in hospital
diabetes type 2, insulin dependant with neuropathy and
nephropathy
history of hypercholestremia
history of coronary artery disease, MI [**2139**], S/p CABG's [**2139**] @
[**Location (un) 4898**] N.H.
history of aortic valvular disease s/p AVR
history of carotid disease s/p bilateral carotid endartectomies
history of pneumonia [**7-/2149**]
history of c. difficle [**2-/2149**]
s/p Arterio-venous fistula


Discharge Condition:
stable


Discharge Instructions:
Please take medications as prescribed. please return to
emergency room if signs of infections occur such as temperatures
greater than 100.4, increasing pain, redness or drainage from
incision site. Patient recieved last dialysis Thursday [**2155-8-7**].
Please have patient dialyzed Monday [**2155-8-11**] then Friday
[**8-15**]. From that point please have patient resume normal
Tuesday, Friday dialysis schedule

Followup Instructions:
2 weeks Dr. [**Last Name (STitle) **]. call for appointment [**Telephone/Fax (1) 236**]


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

Completed by:[**2155-8-7**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to renal dialysis device, implant, and graft,Mitral valve insufficiency and aortic valve insufficiency,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aortocoronary bypass status,Pure hypercholesterolemia,Heart valve replaced by other means,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes'}


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 gangrene.

PRESENT ILLNESS: This is an 80 year-old gentleman
with right first toe ischemic gangrenous changes post trauma
for duration of 5 to 6 months. Initially saw his podiatrist
who did a nail clipping and since then the wound has
progressed. The patient has been on antibiotics po regimen.
Medication and length of therapy he does not remember.
Patient denies right calf hip claudication. He does admit to
right first toe pain with walking. Patient underwent an
arteriogram at [**Hospital6 3105**] where they felt that
the patient was not a surgical candidate. Patient was
referred to Dr. [**Last Name (STitle) 1391**] for a second opinion. Patient now is
admitted for elective surgery. Last dose of Coumadin was
[**2155-7-20**].

MEDICAL HISTORY: Coronary artery disease with history
of myocardial infarction in [**2148**]. Denies any congestive heart
failure, type 2 diabetes with neuropathy and nephropathy
insulin dependent for the last 10 to 12 years, history of
hypercholesterolemia, history of aortic valvular disease,
history of carotid disease, history of C diff in [**Month (only) 958**] of 99,
pneumonia in [**Month (only) 216**] of 99. Echo [**7-/2149**] showed an AVR prosthesis
with ejection fraction of 45%, left ventricular hypertrophy
and MR with mitral valve prolapse. Patient has a history of
hematochezia, which was worked up at [**Hospital3 **], which was
negative.

MEDICATION ON ADMISSION: Lantus 20 units every a.m., renal
vit every day, Lopid 600 mg b.i.d., Coreg 25 mg b.i.d.,
Prevacid 30 mg every day, Diovan 320 mg every day, Lasix 80
mg every day hold on dialysis days. Renagel 2400 mg t.i.d.,
Zoloft 50 mg every day, lisinopril 20 mg b.i.d., aspirin 81
mg every day, albuterol puffs multidose inhaler 2 q.i.d.,
Spiriva puff 1 every day, Advair discus 100/50 puff 1 b.i.d.,
Digitek 0.125 mg every day, Norvasc 5 mg every p.m., Coumadin
2 mg every p.m., Procrit at dialysis, Lasix 160 mg every a.m.
Wednesday, Thursday, Saturday, Sunday and 80 mg of Lasix
every p.m., which is to be held on hemodialysis days.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is widowed for the last 5 years.
Lives with his daughter. [**Name (NI) **] is retired. Had been self
employed. He is a former 3 pack per day smoker for 20 years.
Has not smoked for 10 years. Does admit to alcohol use, but
has discontinued alcohol for the last 15 years. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Other complications due to renal dialysis device, implant, and graft,Mitral valve insufficiency and aortic valve insufficiency,Acute posthemorrhagic anemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aortocoronary bypass status,Pure hypercholesterolemia,Heart valve replaced by other means,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes'}
