CHIEF COMPLAINT: Left foot ulcer.

PRESENT ILLNESS: The patient is a 56-year-old
woman with a history of diabetes with a left foot ulcer for
the past two years.  She has had multiple debridements and
the wound has failed to heal.  The patient was admitted for
further evaluation of the left foot wound and debridement and
reconstruction with flap closure.

MEDICAL HISTORY: 1.  Coronary artery disease with
myocardial infarction in [**2130**], status post percutaneous
transluminal coronary angioplasty.  2.  Ejection fraction of
30%.  3.  Noninsulin-dependent diabetes mellitus.  4.
Diabetic neuropathy.  5.  Charcot joint of the foot.

MEDICATION ON ADMISSION: Imdur 120 p.o. q.d., Digoxin 0.125
mg p.o. q.d., Lasix 20 mg p.o. q.d., Avapro 150 mg p.o. q.d.,
Glucotrol XL 10 mg p.o. b.i.d., Folate 1 p.o. q.d., Celexa 20
mg p.o. q.d., Percocet [**11-23**] tab p.o. q.4-6 hours p.r.n.,
Restoril p.r.n., Nitroglycerin sublingual tab p.r.n.,
Coumadin 4 mg p.o. q.d., Aspirin 1 a day.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient denied alcohol and smoking.
Ulcer of other part of foot,Other postoperative infection,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Old myocardial infarction
Ulcer other part of foot,Other postop infection,CHF NOS,Surg compl-heart,Atrial fibrillation,Crnry athrscl natve vssl,DMII neuro nt st uncntrl,Neuropathy in diabetes,Old myocardial infarct
Admission Date:  [**2135-7-19**]       Discharge Date:  [**2135-8-8**]

Date of Birth:   [**2078-10-14**]       Sex:  F

Service:  PLASTICS SERVICE

CHIEF COMPLAINT:  Left foot ulcer.

HISTORY OF PRESENT ILLNESS:  The patient is a 56-year-old
woman with a history of diabetes with a left foot ulcer for
the past two years.  She has had multiple debridements and
the wound has failed to heal.  The patient was admitted for
further evaluation of the left foot wound and debridement and
reconstruction with flap closure.

PAST MEDICAL HISTORY:  1.  Coronary artery disease with
myocardial infarction in [**2130**], status post percutaneous
transluminal coronary angioplasty.  2.  Ejection fraction of
30%.  3.  Noninsulin-dependent diabetes mellitus.  4.
Diabetic neuropathy.  5.  Charcot joint of the foot.

MEDICATIONS ON ADMISSION:  Imdur 120 p.o. q.d., Digoxin 0.125
mg p.o. q.d., Lasix 20 mg p.o. q.d., Avapro 150 mg p.o. q.d.,
Glucotrol XL 10 mg p.o. b.i.d., Folate 1 p.o. q.d., Celexa 20
mg p.o. q.d., Percocet [**11-23**] tab p.o. q.4-6 hours p.r.n.,
Restoril p.r.n., Nitroglycerin sublingual tab p.r.n.,
Coumadin 4 mg p.o. q.d., Aspirin 1 a day.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient denied alcohol and smoking.

PHYSICAL EXAMINATION:  General:  The patient was a
comfortable-appearing woman.  Vital signs:  Temperature
98.1??????, heart rate 88, blood pressure 112/70, respirations 20,
97% on room air.  HEENT:  Pupils equal and reactive to light.
Neck:  Supple.  Chest:  Clear bilaterally.  Heart:  Regular,
rate and rhythm.  There was a 2 out of 6 systolic ejection
murmur.  Abdomen:  Soft and nontender.  No masses.
Extremities:  The left foot was edematous, and painful to
palpation.  There was a large 10 cm x 6 cm ulceration on the
medial arch where the tissue is pink with some granulation.
The right leg had no edema.  She had 1+ dorsalis pedis pulses
bilaterally.  Neurological:  She was alert and oriented times
three.

LABORATORY DATA:  On admission the patient's white blood cell
count was 6.5, hematocrit 31.1, platelet count 290,000; CHEM7
was with a sodium of 137, potassium 4.7, chloride 101,
bicarbonate 22, BUN 24, creatinine 1.1, glucose 197.

Lower extremity arteriogram basically showed occlusion of the
left dorsalis pedis artery of the metatarsal base with
collaterals filling the digits in the distal foot.  Note was
made of an ulcerative plaque of the dorsalis pedis over the
talus.

Chest x-ray was normal.

Digoxin was 0.7 on admission.

HOSPITAL COURSE:  The patient was admitted and placed on
intravenous Vancomycin.  The patient underwent a lower
extremity arteriogram on the day of admission which showed
the results as above.  After speaking with Cardiology and the
patient being cleared for surgery, the patient was taken to
the Operating Room on hospital day #3 where she underwent a
left foot debridement, rectus free flap to the left foot and
a split-thickness skin graft from the right thigh.  The
patient tolerated the procedure well without any complication
and was taken to the PACU in stable condition.

The patient was then admitted to the SICU for close
monitoring of the flap and the patient's hemodynamic status.
The patient was kept on intravenous Vancomycin empirically.
On postoperative day #1, the patient had a T-max of 102??????F
with a white blood count of 11.7.  Infectious Disease consult
was obtained.  The patient was placed intravenous Zosyn in
addition to the Vancomycin.  The wound cultures taken in the
Operating Room grew out coagulation negative staphylococcus,
................ bacterium species diphtheroids, and some
rare growth of gram-negative rods.  In addition, a urine
culture was taken which showed no growth to date, and blood
cultures were taken which showed no growth to date.  Chest
x-ray was also shown to be normal.

On postoperative day #2, the patient continued to spike a
temperature to 102.6??????, and white blood cell count increased
to 14.6.  The patient remained hemodynamically stable and
nontoxic.  She was continued on the intravenous Vancomycin
and intravenous Zosyn.  On postoperative day #3, her white
blood cell count had come to 10.5, and subsequently she only
had a few days of low-grade fever.  During this time, there
were no signs of superficial infections on inspection of her
wounds.  She did have increasing abdominal pain which was
well controlled with pain medication.

On postoperative day #4, the patient was transferred to the
floor for the subsequent care and recovery.  On the floor on
postoperative day #6, the patient awoke in the morning with
abdominal pain and was found to have a rapid heart rate in
the 120s to 130s.  Electrocardiogram established that the
patient was in atrial fibrillation.  The patient was rate
controlled using intravenous Amiodarone and Lopressor.  The
patient converted back to sinus rhythm that morning.  The
patient was then changed to p.o. Amiodarone 400 mg p.o.
b.i.d. and Lopressor 12.5 mg p.o. b.i.d.  Cardiology consult
was obtained and recommended the treatment.

On that evening, the patient was noted by the staff to have
some drainage from the abdominal site.  The dressing was
taken down, and pus was expressed from the abdominal wound.
The wound was opened, cultures taken, and the wound was
packed with wet gauze.  The wound culture grew out
Enterobacter sensitive to Levofloxacin on which she was
started in addition to Ancef for empiric coverage of
gram-positive skin flora.  During this time, she remained
afebrile and hemodynamically stable.  The wound was placed on
a Vac dressing on postoperative day #14.  The wound had
remained clean and dry.  The patient's flap remained viable
throughout her recovery with strong Doppler signals.  The
patient was started on dangle protocol once transferred to
the floor, which has been increased every day. The flap has
tolerated the dangle procedure.  She is currently dangling
for 7 min t.i.d. off the bedside.  The patient has otherwise
been stable and is now ready for rehabilitation.

Of note, the intravenous Zosyn and Vancomycin were
discontinued on postoperative day #6.  She has continued on
the intravenous Ancef and p.o. Levofloxacin for coverage of
the abdominal wound species.

DISCHARGE DIAGNOSIS:
1.  Status post rectus free flap to left foot with
split-thickness skin graft.
2.  New onset atrial fibrillation, spontaneous conversion to
sinus rhythm.
3.  Diabetes type 2.
4.  Charcot joint.
5.  Myocardial infarction in [**2130**] status post percutaneous
transluminal coronary angioplasty.
6.  Cardiomegaly with an ejection fraction of 30%.
7.  Diabetic neuropathy.

DISCHARGE MEDICATIONS:  Digoxin 0.125 mg p.o. q.d., Glucotrol
XL 10 mg p.o. b.i.d., Zantac 150 mg p.o. b.i.d., Amiodarone
400 mg p.o. q.d. until [**2135-9-4**], then change to
Amiodarone 200 p.o. q.d., Lopressor 12.5 mg p.o. b.i.d.,
Restoril 50 mg p.o. q.h.s., Lasix 20 mg p.o. q.d., Imdur 120
mg p.o. q.d., holding for systolic blood pressure less than
100, heart rate less than 55, Celexa 20 mg p.o. q.d., Aspirin
325 mg p.o. q.d., Heparin 5000 U subcue b.i.d.

DISCHARGE INSTRUCTIONS:  1.  The Vac dressing should be
changed on Tuesdays and Fridays.  2.  Left foot flap should
have Adaptic with dry gauze dressing twice a day.  3.  Dangle
left foot protocol should be increased 1 min a day as
tolerated, and once the patient has reached up to 15 min/day
t.i.d., the patient can receive physical therapy with
non-weightbearing on left foot.

FOLLOW-UP:  The patient is to follow-up with Dr. [**Last Name (STitle) 13797**] and
will call the office for an appointment.

CONDITION ON DISCHARGE:  Stable.





                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19095**], M.D.  [**MD Number(1) 19096**]

Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36

D:  [**2135-8-8**]  10:59
T:  [**2135-8-8**]  11:23
JOB#:  [**Job Number 39429**]

TRANSITIONAL CARE UNIT, [**Hospital **] HOSPITAL, [**Street Address(2) 39430**],
[**Location (un) **], [**Telephone/Fax (1) 39431**](cclist)
{'Ulcer of other part of foot,Other postoperative infection,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Old myocardial infarction'}


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 foot ulcer.

PRESENT ILLNESS: The patient is a 56-year-old
woman with a history of diabetes with a left foot ulcer for
the past two years.  She has had multiple debridements and
the wound has failed to heal.  The patient was admitted for
further evaluation of the left foot wound and debridement and
reconstruction with flap closure.

MEDICAL HISTORY: 1.  Coronary artery disease with
myocardial infarction in [**2130**], status post percutaneous
transluminal coronary angioplasty.  2.  Ejection fraction of
30%.  3.  Noninsulin-dependent diabetes mellitus.  4.
Diabetic neuropathy.  5.  Charcot joint of the foot.

MEDICATION ON ADMISSION: Imdur 120 p.o. q.d., Digoxin 0.125
mg p.o. q.d., Lasix 20 mg p.o. q.d., Avapro 150 mg p.o. q.d.,
Glucotrol XL 10 mg p.o. b.i.d., Folate 1 p.o. q.d., Celexa 20
mg p.o. q.d., Percocet [**11-23**] tab p.o. q.4-6 hours p.r.n.,
Restoril p.r.n., Nitroglycerin sublingual tab p.r.n.,
Coumadin 4 mg p.o. q.d., Aspirin 1 a day.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient denied alcohol and smoking. 

### Response:
{'Ulcer of other part of foot,Other postoperative infection,Congestive heart failure, unspecified,Cardiac complications, not elsewhere classified,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Old myocardial infarction'}
