CHIEF COMPLAINT: Vein graft stenosis of the right lower extremity.

PRESENT ILLNESS: This is a 57-year-old woman who previously had an ischemic ulcer
of her right lower extremity. She underwent a femoral to
anterior tibial bypass. Surveillance studies had shown vein
graft stenosis of the proximal anastomosis, which was
successfully dilated. She subsequently developed a distal
anastomotic stenosis. An attempt was made at angioplasty, which
gave some temporary improvement, but the improvement was limited
and soon re-stenosed. She presents now for surgical revision.

MEDICAL HISTORY: 1.  Prior CVA s/p right CEA - treated at [**Hospital1 2025**], presented with
right sided numbness, which is the only residual symptom
2.  Type II Diabetes
3.  Hypertension
4.  Peripheral vascular disease, for right fem-[**Doctor Last Name **] bypass

MEDICATION ON ADMISSION: Plavix 75 QD, Toprol 50, cardizem 240 QD, Lyrica50', Zocor 40,
Metformin 500 QD, ASA81, Lisinopril 10', Prilosec 10, Glyburide
5mg'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE:

FAMILY HISTORY: Father: CVA in 50s, malignancy?

SOCIAL HISTORY: Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies
Atherosclerosis of autologous vein bypass graft of the extremities,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension
Ath ext autologs bps gft,Ac posthemorrhag anemia,DMII wo cmp nt st uncntr,Hypertension NOS
Admission Date:  [**2174-2-4**]              Discharge Date:   [**2174-2-10**]

Date of Birth:  [**2116-2-19**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Vein graft stenosis of the right lower extremity.

Major Surgical or Invasive Procedure:
Jump graft from right femoral to anterior tibial bypass to the
distal anterior tibial artery using left cephalic vein,
angioplasty of pre-existing femoral to anterior tibial bypass,
angioscopy.


History of Present Illness:
This is a 57-year-old woman who previously had an ischemic ulcer
of her right lower extremity. She underwent a femoral to
anterior tibial bypass. Surveillance studies had shown vein
graft stenosis of the proximal anastomosis, which was
successfully dilated. She subsequently developed a distal
anastomotic stenosis. An attempt was made at angioplasty, which
gave some temporary improvement, but the improvement was limited
and soon re-stenosed. She presents now for surgical revision.

Past Medical History:
1.  Prior CVA s/p right CEA - treated at [**Hospital1 2025**], presented with
right sided numbness, which is the only residual symptom
2.  Type II Diabetes
3.  Hypertension
4.  Peripheral vascular disease, for right fem-[**Doctor Last Name **] bypass

Social History:
Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies


Family History:
Father: CVA in 50s, malignancy?

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:

rle - palp fem, [**Doctor Last Name **], Doppl DP / graft palp

lle - palp fem, [**Doctor Last Name **], pt, dp


Pertinent Results:
[**2174-2-9**] 05:50AM BLOOD

WBC-8.5 RBC-3.66* Hgb-10.5* Hct-31.9* MCV-87 MCH-28.8 MCHC-32.9
RDW-15.9* Plt Ct-245

[**2174-2-10**] 05:55AM BLOOD

PT-16.6* PTT-81.0* INR(PT)-1.5*

[**2174-2-8**] 01:03AM BLOOD

BLOOD Calcium-8.9 Phos-4.3 Mg-2.2

[**2174-2-5**]  10:02:16 AM

Sinus rhythm. Short P-R interval. ST-T wave abnormalities. Since
the previous tracing of [**2174-1-27**] the ST-T wave abnormalities are
more prominent.

Intervals Axes
Rate PR QRS QT/QTc P QRS T
88 152 92 374/419.57 41 31 79

[**2174-2-5**] 12:24 AM

CHEST PORT. LINE PLACEMENT

Endotracheal tube is in place, terminating 4 cm above the
carina. Right subclavian vascular catheter terminates within the
lower superior vena cava, with no pneumothorax evident on the
supine radiograph. Cardiac silhouette is upper limits of normal
in size. There is new mild vascular engorgement and perihilar
haziness, likely reflecting mild volume overload. Minor discoid
atelectasis is present at the left lung base, and there is a
questionable small left pleural effusion.



Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2173-2-4**] for an elective Jump graft
from right femoral to anterior tibial bypass to the distal
anterior tibial artery using left cephalic vein, angioplasty of
pre-existing femoral to anterior tibial bypass, angioscopy.
Pre-operatively, she was consented, prepped, and brought down to
the operating room for surgery. Intra-operatively, she was
closely monitored and remained hemodynamically stable. She
tolerated the procedure well without any difficulty or
complication. Post-operatively, she was extubated and
transferred to the PACU for further stabilization and
monitoring. She was then transferred to the floor for further
recovery. On the floor, she remained hemodynamically stable with
her pain controlled. She progressed with physical therapy to
improve her strength and mobility. She continues to make steady
progress without any incidents. She was home with services.

To not pt had transfusion with PRBC for blood loss in the OR

Pt was started on coumadin post operatively. On DC her INR is
1.5. She will go home on lovenox bridge. Her PCP will follow her
INR.

Medications on Admission:
Plavix 75 QD, Toprol 50, cardizem 240 QD, Lyrica50', Zocor 40,
Metformin 500 QD, ASA81, Lisinopril 10', Prilosec 10, Glyburide
5mg'

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q3H (every 3 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Lovenox 80 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
twice a day for 10 days.
Disp:*20  Lovenox (Subcutaneous) 80 mg/0.8 mL Syringe*
Refills:*0*
14. Outpatient Lab Work
Daily INR.
Please fax the results to Dr[**Name (NI) 29792**] office.
FAX: [**Telephone/Fax (1) 66506**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 3894**] Health VNA

Discharge Diagnosis:
Vein graft stenosis of the right lower extremity
HTN
DM2
post operative anemia - blood tranfusion


Discharge Condition:
stable


Discharge Instructions:
You are [**Doctor First Name **] put on coumadin for Revision R fem-AT w/jump graft
fem AK-[**Doctor Last Name **] -->distal AT w/left arm v., angioplasty, angioscopy
w/vein lysis

How will I be treated for this condition ?

You will receive two daily subcutaneous (underneath the skin)
injections of enoxaparin (Lovenox) for 5-7 days along with a
longer course of an oral medication called warfarin (Coumadin).
Both medications belong to a class of drugs known as
anticoagulants. Anticoagulants prevent clots.

How is enoxaparin (Lovenox) given?

Enoxaparin is given subcutaneously twice daily. Many patients
can give the injections to themselves at home, and you can be
given instructions to learn how to give yourself these
injections if this is an appropriate plan for you. It is
important to give the medication exactly as directed.

When to stop enoxaparin (Lovenox)?

Your PCP will tell you when to stop enoxaparin. This is stopped
when your INR is above 2 (this is a reflection of coumadin).
When your INR is at 2, this means that you blood is thin enough
to be on coumadin alone. The level of INR when you are on
coumadin is 2-2.5.

How is warfarin (Coumadin) given?

Warfarin is given orally once daily. You will be getting regular
blood tests to measure how well this medication is working. The
dose of warfarin may be adjusted according to the results of the
blood tests.

What should I do if I miss a dose of enoxaparin or warfarin?
You should contact [**Name (NI) **],[**First Name3 (LF) **] A [**Telephone/Fax (1) 66507**] as soon as
you notice that you have missed a dose.

What are some of the side effects of enoxaparin?

Approximately 2% of patients may experience bleeding. Please
notify PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 41186**] immediately if you
experience any of the following symptoms:

unusual bleeding or bruising (e.g., bleeding gums, red spots on
the skin, nose bleeds)

heavy menstrual bleeding

blood in urine or stool; black tarry stools

back pain or stomach pain

cold, blue, or painful feet

Other minor side effects include skin irritation, pain, and
bruises at the injection site.

What are some of the side effects of warfarin?

Like enoxaparin the major complication of warfarin is bleeding.
Therefore, you should notify PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 41186**]
if you experience any of the symptoms listed in the previous
answer. Please check with your doctor for more information on
warfarin.

Should I be aware of other signs and symptoms?
You should notify PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 41186**]
immediately if you experience chest pain, shortness of breath, a
feeling of passing out, or palpitation (heart racing).

What medications do I need to avoid while on these medications?

You should avoid taking medications that contain aspirin,
medications such as ibuprofen (Advil, Motrin, Nuprin), naproxen
(Aleve), ketoprofen (Orudis KT, Actron Caplets), or any other
non-steroidal anti-inflammatory drugs (NSAIDs). You should
always check with your doctor before starting any new
prescription or over-the-counter medication. Moreover, alcohol
and various food may also interact with warfarin. Please check
with your doctor, nurse [**First Name (Titles) **] [**Last Name (Titles) 57**] for more information.

What other precautions do I need to take while on these
medications?

Monitor signs and symptoms of bleeding.

Be careful while brushing or flossing your teeth.

Avoid injuries.

Keep enoxaparin syringes at room temperature. Do not refrigerate
or freeze enoxaparin. Store away from heat and direct light.

Keep all medications out of the reach of children

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 [**3-5**]
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:
You are set up for three ways to track your INR. One through
VNA. They will draw your INR and fax the results to Dr [**Last Name (STitle) 13959**]
office. His fax number is [**Telephone/Fax (1) 66506**].

If VNA does not come to your house to draw tour INR, you are to
either got to Dr[**Name (NI) 29792**] office or to [**Location (un) **] - [**Hospital 1459**]
Hospital. If you go to Dr[**Name (NI) 29792**] office, please call before
you go. You also have a prescription to have your INR drawwn, If
you go to [**Location (un) **] - [**Hospital 1459**] Hospital, you must present the
prescription.

Dr [**Last Name (STitle) 13959**] is aware hthat he has to follow your INR.



Completed by:[**2174-2-10**]
{'Atherosclerosis of autologous vein bypass graft of the extremities,Acute posthemorrhagic anemia,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: Vein graft stenosis of the right lower extremity.

PRESENT ILLNESS: This is a 57-year-old woman who previously had an ischemic ulcer
of her right lower extremity. She underwent a femoral to
anterior tibial bypass. Surveillance studies had shown vein
graft stenosis of the proximal anastomosis, which was
successfully dilated. She subsequently developed a distal
anastomotic stenosis. An attempt was made at angioplasty, which
gave some temporary improvement, but the improvement was limited
and soon re-stenosed. She presents now for surgical revision.

MEDICAL HISTORY: 1.  Prior CVA s/p right CEA - treated at [**Hospital1 2025**], presented with
right sided numbness, which is the only residual symptom
2.  Type II Diabetes
3.  Hypertension
4.  Peripheral vascular disease, for right fem-[**Doctor Last Name **] bypass

MEDICATION ON ADMISSION: Plavix 75 QD, Toprol 50, cardizem 240 QD, Lyrica50', Zocor 40,
Metformin 500 QD, ASA81, Lisinopril 10', Prilosec 10, Glyburide
5mg'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE:

FAMILY HISTORY: Father: CVA in 50s, malignancy?

SOCIAL HISTORY: Pt livers with two daughters at home.
Tob: 0.5ppd x40years (since age 17)
EtOH: social - 2 beers every 2 weeks
Illicit drug use: denies 

### Response:
{'Atherosclerosis of autologous vein bypass graft of the extremities,Acute posthemorrhagic anemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension'}
