CHIEF COMPLAINT: iscemic leg

PRESENT ILLNESS: The patient is a 76 year-old male with past medical history of
peripheral [**First Name3 (LF) 1106**] disease as well as multiple strokes,
hypercholesterolemia, status post
carotid endarterectomy who presented with acute left lower
extremity ischemia.

MEDICAL HISTORY: 1. DMII, last HgA1c 5.9%
2. CAD s/p CABG x3+x2 last [**2136**]
3. h/o embolic CVA, source not identified
4. mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 50-55% in [**4-/2144**]
5. HTN
6. COPD
7. Hypercholesteroemia
8. GOUT
9. Amarousis Fugax.
10. PVD s/p L CEA in [**2143**], now with R carotid stenosis 80%
11. 3 prior CVA thought d/t L carotid stenosis
12. h/o GIB

MEDICATION ON ADMISSION: protonix,
metformin 850",
70/30 28 U qAM, 20 U qPM,
lasix 40',
lisinopril 10',
feSO4,
lipitor 20',
ASA 81',
allopurinol 300', atenolol 50'
.

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: PE:

FAMILY HISTORY: No strokes or seizures. Multiple family members with MI.

SOCIAL HISTORY: Cab driver
Lives alone
Occassional ETOH (drinks [**11-30**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago
Atherosclerosis of native arteries of the extremities with intermittent claudication,Congestive heart failure, unspecified,Embolism and thrombosis of iliac artery,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Pure hypercholesterolemia,Gout, unspecified,Old myocardial infarction,Personal history of other diseases of circulatory system
Ath ext ntv at w claudct,CHF NOS,Iliac artery embolism,Chr airway obstruct NEC,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hypertension NOS,DMII wo cmp nt st uncntr,Anemia NOS,Pure hypercholesterolem,Gout NOS,Old myocardial infarct,Hx-circulatory dis NEC
Admission Date:  [**2145-4-7**]              Discharge Date:   [**2145-4-14**]

Date of Birth:  [**2069-3-6**]             Sex:   M

Service: SURGERY

Allergies:
Nitroglycerin

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
iscemic leg

Major Surgical or Invasive Procedure:
1.  Abdominopelvic arteriogram.

2.  PROCEDURE:
a. Bilateral groin explorations.
b. Left superficial femoral artery and profunda
thrombectomy.
c. Thrombectomy of femoral-femoral graft.
d. Patch angioplasty of left common femoral artery.


History of Present Illness:
The patient is a 76 year-old male with past medical history of
peripheral [**First Name3 (LF) 1106**] disease as well as multiple strokes,
hypercholesterolemia, status post
carotid endarterectomy who presented with acute left lower
extremity ischemia.

Past Medical History:
1. DMII, last HgA1c 5.9%
2. CAD s/p CABG x3+x2 last [**2136**]
3. h/o embolic CVA, source not identified
4. mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 50-55% in [**4-/2144**]
5. HTN
6. COPD
7. Hypercholesteroemia
8. GOUT
9. Amarousis Fugax.
10. PVD s/p L CEA in [**2143**], now with R carotid stenosis 80%
11. 3 prior CVA thought d/t L carotid stenosis
12. h/o GIB


Social History:
Cab driver
Lives alone
Occassional ETOH (drinks [**11-30**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago


Family History:
No strokes or seizures. Multiple family members with MI.

Physical Exam:
PE:

AFVSS

NEURO:

PERRL / EOMI

MAE equally

Answers simple commands

Neg pronator drift

Sensation intact to ST

2 plus DTR

Neg Babinski

HEENT:

NCAT

Neg lesions nares, oral pharnyx, auditory

Supple / FAROM

neg lyphandopathy, supra clavicular nodes

LUNGS: CTA b/l

CARDIAC: RRR without murmers

ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness

EXT:

Pulses: L palp PT, dop DP. R dop PT/DP.

Groin C/D/I

Pertinent Results:
[**2145-4-13**]

WBC-8.0 RBC-3.47* Hgb-10.1* Hct-30.7* MCV-88 MCH-29.0 MCHC-32.7
RDW-16.6* Plt Ct-316

[**2145-4-13**]

Plt Ct-316

[**2145-4-10**]

Glucose-130* UreaN-24* Creat-1.0 Na-137 K-4.2 Cl-107 HCO3-22
AnGap-12

[**2145-4-10**]

CK(CPK)-53

[**2145-4-10**]

Calcium-7.7* Phos-3.4 Mg-1.6

[**2145-4-8**]

Glucose-122* Lactate-1.4 Na-138 K-4.6 Cl-110

[**2145-4-8**]

Hgb-9.3* calcHCT-28

[**2145-4-8**]

Cardiology Report ECG


Sinus bradycardia with first degree A-V block. Left atrial
abnormality.
Intraventricular conduction defect. Inferior myocardial
infarction, age
undetermined. Lateral ST-T wave changes may be due to myocardial
ischemia.
Low QRS voltages in the precordial leads. Since the previous
tracing the rate is slower.


Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 [**Telephone/Fax (2) 19875**] 6 101

Cardiology Report ECHO Study Date of [**2145-4-8**]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.5 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Pressure Half Time: 704 ms
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 1.30
Mitral Valve - E Wave Deceleration Time: 189 msec
TR Gradient (+ RA = PASP): *35 mm Hg (nl <= 25 mm Hg)


LEFT ATRIUM: Mild LA enlargement.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Normal LV cavity size. Moderately depressed
LVEF.

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

AORTA: Normal aortic root diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace
AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
thickening of  mitral valve chordae. Calcified tips of papillary
muscles. Moderate to severe  (3+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild PA
systolic hypertension.

PERICARDIUM: No pericardial effusion.

Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Posterior and apical
akinesis with  lateral hypokinesis is present.
3. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
4. The mitral valve leaflets are mildly thickened. There is
moderate
thickening of the mitral valve chordae. Moderate to severe (3+)
mitral
regurgitation is seen.
5. There is mild pulmonary artery systolic hypertension.
6. Compared with the report of the prior study (images
unavailable for review)  of [**2144-4-22**], LV function has
deteriorated.

[**2145-4-7**] 8:31 PM

CHEST (PRE-OP PA & LAT)

COMPARISON: [**2144-11-7**].

PA AND LATERAL CHEST RADIOGRAPHS:

Cardiomediastinal and hilar contours appear unchanged. Again
noted is calcification within the aorta. Again seen are median
sternotomy wires. Pulmonary vascularity appears within normal
limits. No focal consolidations are seen within the lungs. There
is no evidence of pleural effusions.

IMPRESSION: No evidence of acute cardiopulmonary disease.









Brief Hospital Course:
The patient as placed on heparin drip and underwent angiogram
which showed occlusion of his common femoral artery on the left.
 A proposed fem-fem bypass was recommended.  The patient,
however, has had previous [**Year (4 digits) 1106**] surgery with bilateral groin
explorations and it was unclear whether he has had a previous
fem-fem bypass or peripheral distal bypass. Therefore, groin
exploration and possible fem- fem bypass is recommended.  The
patient agreed to proceed to
surgery.  Risks and benefits were explained and he consented.

The patient agreed to the below procedure:

PROCEDURE:
1.  Bilateral groin explorations.
2.  Left superficial femoral artery and profunda
    thrombectomy.
3.  Thrombectomy of femoral-femoral graft.
4.  Patch angioplasty of left common femoral artery.

Pt tolerated the procedure well, there were no complications. Pt
extubated in the OR. Transfered to the PACU in stable condition.
Once recovered from anesthesia. Pt transfered to the VICU in
stable condition.

Pt had normal post operative recovery.

On DC, pt is stable. taking PO / ambulating / urinating / pos BM

Medications on Admission:
protonix,
metformin 850",
70/30 28 U qAM, 20 U qPM,
lasix 40',
lisinopril 10',
feSO4,
lipitor 20',
ASA 81',
allopurinol 300', atenolol 50'
.


Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: Two (2) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Insulin
Fingerstick QACHS

Insulin SC Fixed Dose Orders

Breakfast                Dinner
70 / 30      14  Units   70 / 30      10  Units
Insulin SC Sliding Scale

Breakfast Lunch Dinner Bedtime

Regular

Glucose Insulin Dose

0-75      4 oz OJ
76-110    mg/dL 0   Units 0   Units 0   Units 0   Units
111-160   mg/dL 2   Units 2   Units 2   Units 2   Units
161-200   mg/dL 4   Units 4   Units 4   Units 4   Units
201-240   mg/dL 6   Units 6   Units 6   Units 6   Units
241-280   mg/dL 8   Units 8   Units 8   Units 8   Units
> 280   mg/dL Notify M.D.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 2203**] VNA

Discharge Diagnosis:
Left leg ischemia.


Discharge Condition:
Stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING LEG BYPASS SURGERY

This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.

ACTIVITY:

There are no specific restrictions on activity. You should be as
active as is comfortable. Some fatigue is expected for the first
several weeks. Leg swelling is typical following this type of
surgery and can be controlled by elevating your leg above the
level of your heart when you are not walking.

PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:

Redness in or drainage from your leg wound(s).

New pain, numbness or discoloration of your foot or toes.

Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.

Exercise:

Limit strenuous activity for 4 weeks.

No heavy lifting greater than 20 pounds for the next 7 days.

No Driving.

BATHING/SHOWERING:

You shower immediately upon coming home. No bathing. A clear
dressing may cover your leg incision and this should be left in
place for three (3) days. Remove it after this time and wash
your incision(s) gently with soap and water. Dissolving sutures,
which do not have to be removed, were probably used.

If you have staples these will be removed on your follow-up
appointment.

WOUND CARE:

Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for removal.

When the sutures / staples are removed the doctor may or may not
place pieces of tape called steri-strips over the incision.
These will stay on about a week and you may shower with them on.
If these do not fall off after 10 days, you may peel them off
with warm water and soap in the shower.

Avoid taking a tub bath, swimming, or soaking in a hot tub for
two weeks after surgery.

MEDICATIONS:

Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.

Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.

CAUTIONS:

NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.

Avoid bending for 4-6 weeks.

No strenuous activity for 4-6 weeks after surgery.

DIET :

There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.

For people with [**Location (un) 1106**] problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.

If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.

If you have diabetes and would like additional guidance, you may
request a referral from your doctor.

FOLLOW-UP APPOINTMENT:

Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!

Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:00 Monday
through Friday.

PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE.


Followup Instructions:
Call dr[**Initials (NamePattern4) 1720**] [**Last Name (NamePattern4) 19876**] at [**Telephone/Fax (1) 1241**]. Schedule an
appointment for 2 weeks.

Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] (NHB)
Date/Time:[**2145-8-26**] 1:30

Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2145-8-26**] 2:00



Completed by:[**2145-4-14**]
{'Atherosclerosis of native arteries of the extremities with intermittent claudication,Congestive heart failure, unspecified,Embolism and thrombosis of iliac artery,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Pure hypercholesterolemia,Gout, unspecified,Old myocardial infarction,Personal history of other diseases of circulatory system'}


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: iscemic leg

PRESENT ILLNESS: The patient is a 76 year-old male with past medical history of
peripheral [**First Name3 (LF) 1106**] disease as well as multiple strokes,
hypercholesterolemia, status post
carotid endarterectomy who presented with acute left lower
extremity ischemia.

MEDICAL HISTORY: 1. DMII, last HgA1c 5.9%
2. CAD s/p CABG x3+x2 last [**2136**]
3. h/o embolic CVA, source not identified
4. mild [**Last Name (LF) 19874**], [**First Name3 (LF) **] 50-55% in [**4-/2144**]
5. HTN
6. COPD
7. Hypercholesteroemia
8. GOUT
9. Amarousis Fugax.
10. PVD s/p L CEA in [**2143**], now with R carotid stenosis 80%
11. 3 prior CVA thought d/t L carotid stenosis
12. h/o GIB

MEDICATION ON ADMISSION: protonix,
metformin 850",
70/30 28 U qAM, 20 U qPM,
lasix 40',
lisinopril 10',
feSO4,
lipitor 20',
ASA 81',
allopurinol 300', atenolol 50'
.

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: PE:

FAMILY HISTORY: No strokes or seizures. Multiple family members with MI.

SOCIAL HISTORY: Cab driver
Lives alone
Occassional ETOH (drinks [**11-30**] scotch every few months)
Hx of 50 pack year smoking, quit several years ago 

### Response:
{'Atherosclerosis of native arteries of the extremities with intermittent claudication,Congestive heart failure, unspecified,Embolism and thrombosis of iliac artery,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Pure hypercholesterolemia,Gout, unspecified,Old myocardial infarction,Personal history of other diseases of circulatory system'}
