CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for long
standing diabetes mellitus, hypertension, coronary artery
disease.  He is status post myocardial infarction and
extensive peripheral vascular disease, and is status post
multiple peripheral bypasses.  The patient had been recently
admitted to [**Hospital6 34976**] in [**Location (un) 5503**] for five
days due to bacteremia and was discharged on Augmentin.  He
was seen in clinic on the day of admission for bilateral leg
ulcers and referred to the hospital for admission.  He denies
any history of nausea, vomiting, fevers or chills, but does
report having diarrhea four to five days prior to admission.
No chest pain or shortness of breath.

MEDICAL HISTORY: Past medical history is significant
for diabetes mellitus, coronary artery disease, history of
myocardial infarction, congestive heart failure, atrial
fibrillation and chronic renal insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: He had no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Atherosclerosis of native arteries of the extremities with gangrene,Ulcer of calf,Cellulitis and abscess of leg, except foot,Infection (chronic) of amputation stump,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Pneumonia due to other gram-negative bacteria,Acute osteomyelitis, ankle and foot,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Morbid obesity
Ath ext ntv art gngrene,Ulcer of calf,Cellulitis of leg,Infection amputat stump,Acute & chronc resp fail,Food/vomit pneumonitis,CHF NOS,Pneumo oth grm-neg bact,Ac osteomyelitis-ankle,DMII circ nt st uncntrld,Long-term use of insulin,Bone involv in oth dis,Morbid obesity
Admission Date: [**2181-9-5**]        Discharge Date: [**2181-10-11**]

Date of Birth:  [**2106-1-8**]        Sex:  M

Service:  VSU


HISTORY OF PRESENT ILLNESS:  The patient is a 75 year old
male with a past medical history significant for long
standing diabetes mellitus, hypertension, coronary artery
disease.  He is status post myocardial infarction and
extensive peripheral vascular disease, and is status post
multiple peripheral bypasses.  The patient had been recently
admitted to [**Hospital6 34976**] in [**Location (un) 5503**] for five
days due to bacteremia and was discharged on Augmentin.  He
was seen in clinic on the day of admission for bilateral leg
ulcers and referred to the hospital for admission.  He denies
any history of nausea, vomiting, fevers or chills, but does
report having diarrhea four to five days prior to admission.
No chest pain or shortness of breath.

PAST MEDICAL HISTORY:  Past medical history is significant
for diabetes mellitus, coronary artery disease, history of
myocardial infarction, congestive heart failure, atrial
fibrillation and chronic renal insufficiency.

PAST SURGICAL HISTORY:  Past surgical history is significant
for a right TMA, a right STSG of the right ankle, venous
bypass graft from previous right popliteal to dorsalis pedis
and cephalic vein bypass; another STSG for the right foot;
right dorsalis pedis to distal bypass graft, a left TMA, a
left superficial femoral artery to popliteal bypass graft.

MEDICATIONS:  Medications on admission included Megace,
Prozac, insulin, Darvocet, Neurontin, Protonix, Reglan,
aspirin and Duragesic patch.

ALLERGIES:  He had no known drug allergies.

PHYSICAL EXAMINATION:  On examination on admission, the
patient's vital signs included a temperature of 96.2 F.;
pulse of 95; blood pressure 129/63; O2 saturation is 96
percent and his respiratory rate was 18.  He was in no acute
distress.  His pupils were equally round and reactive.
Extraocular movements intact.  Sclerae were white, no
conjunctival injection.  His neck was supple; no carotid
bruits.  His heart rate was irregularly irregular.  His lungs
were clear to auscultation bilaterally.  His abdomen was
soft, nontender, nondistended.  Extremities:  He had an ulcer
at the lateral aspect of the left lower extremity.  He was
status post TMA.  He had an ulcer on the lateral aspect of
the leg and also on the anterior aspect of the TMA.  He had
Doppler able posterior tibial and dorsalis pedis pulses.
Right lower extremity revealed multiple ulcers on the calf
and Doppler able dorsalis pedis and posterior tibialis
pulses.

LABORATORY DATA:  His labs on admission included a white
blood cell count of 9.8, hematocrit of 36.8, platelets of
737.  His chemistry revealed a sodium of 137, potassium 5.7,
chloride 102, bicarbonate 23, BUN and creatinine 9 and 0.9.
Glucose was 62.

He had an EKG which showed no change from his examination in
[**Month (only) 205**] but irregular rhythm.  Chest x-ray showed a mild
pulmonary edema with a right pleural effusion.

HOSPITAL COURSE:  He was admitted to the Vascular Surgery
Service and placed on intravenous antibiotics and was preoped
for a bilateral lower extremity debridement of ulcers.  The
patient tolerated the procedure well.  He was placed on
antibiotics, Vancomycin, Levofloxacin and Flagyl.  He was
given a Fentanyl patch for pain control and was treated with
intravenous fluids.  Nutrition was involved in his care
postoperatively.  He also received a cardiac evaluation and
the [**Last Name (un) **] Diabetes Center was involved.  On the [**9-14**], he underwent a right above the knee amputation.  He
tolerated the procedure well.  His blood sugars were
monitored closely throughout his stay.  He was treated
primarily in the Surgical Intensive Care Unit and in the
Vascular Intensive Care Unit throughout his stay.

On the [**9-18**], the patient was found to be
increasingly somnolent and it was determined that he was in
respiratory failure with acidosis.  He was intubated at this
time and his vital signs were monitored closely.  It was
thought that he had aspirated during a meal.  He was
transferred from the Vascular Intensive Care Unit to the
Medical Intensive Care Unit at that time.  He was sedated
appropriately with Propofol and a Swan-Ganz catheter was
placed.  He was started on a Dopamine drip.  A Dobhoff
feeding tube was placed and he was initiated on tube feeds.
His Infectious Disease issues were dealt with by the
Infectious Disease Service.  Multiple cultures were obtained
which showed gram negative rods consistent with enterococcus
from his left heel wound along with Pseudomonas.  A lavage
revealed Citrobacter which is resistant to multiple agents
and his right stump revealed a Citrobacter also resistant to
multiple agents along with Methicillin resistant
Staphylococcus aureus.  He was on Meropenem and Vancomycin
for his pneumonia and these agents covered his stump
infection as well.

A Dermatology consultation was also obtained due to a rash
which had been noted for the last few days by the primary
team, that began at his right forearm and appeared
morbilliform in character and non itchy.  Dermatology
recommended Triamcinolone ointment to the arms and
Dermatology Service also followed him throughout the
remainder of his course at the hospital.

The patient had a tracheostomy during his stay; this was done
on [**10-9**] when a percutaneous tracheostomy was placed
due to chronic respiratory failure.  The patient was
discharged to a rehabilitation facility on [**10-11**].  At
that time, he was receiving tube feeds at 85 cc an hour.
Tube feeds were ProMod with fiber.  He had a trache in place.
He was on Vancomycin, Levofloxacin and Flagyl and his
diabetes mellitus was being managed by the [**Hospital **] [**Hospital 982**]
Clinic.  His Lantus was at 26 units and he had a regular
insulin sliding scale as well.

DISCHARGE DIAGNOSES:
1. Status post incision and drainage of leg ulcers.
2. Status post right above the knee amputation.
3. Citrobacter pneumonia.
4. Status post PEG tube placement.
5. Status post percutaneous tracheostomy tube placement.


DISCHARGE MEDICATIONS:
1. Lorazepam 0.5 to 1 mg intravenously q. Four hours p.r.n.
2. Furosemide 20 mg intravenously three times a day.
3. Lactulose 30 cc p.o. or NG tube twice a day p.r.n.
4. Insulin sliding scale.
5. Non-formulary Lantus 20 units subcutaneously daily.
6. Fluoxetine hydrochloride 20 mg p.o. q. Day.
7. Gabapentin 200 mg p.o. twice a day.
8. Methadone 20 mg p.o. or NG twice a day.
9. Famotidine 20 mg p.o. q. 12 hours.
10.      Albuterol nebulizers, one nebulizer inhaled q. Six
   hours p.r.n.
11.      Vancomycin 1000 mg intravenously q. 24.
12.      Meropenem 1000 mg intravenously q. Eight.
13.      Metoprolol 12.5 mg p.o. or NG twice a day.
14.      Milk of Magnesia 30 cc p.o. or NG q. Six hours
   p.r.n.
15.      Bisacodyl 10 mg p.o. or p.r. q. Day.
16.      Colace 100 mg p.o. twice a day.
17.      Aquaphor Ointment, one application topically twice a
   day to arms and trunk.
18.      Triamcinolone acetonide 0.1 percent cream, one
   application topically twice a day to be placed on arms and
   trunk of affected area, avoiding the face, groin and
   axillae.
19.      Dakens quarter strength, one application topically
   as directed.
20.      Miconazole powder, two percent, one application
   topically four times a day p.r.n.
21.      Heparin flushes to his lines, subcutaneous heparin
   5000 units three times a day.

Other medications will have to be added in a Discharge
Addendum.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7258**], [**MD Number(1) 7263**]

Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D:  [**2181-10-11**] 17:15:45
T:  [**2181-10-11**] 18:14:51
Job#:  [**Job Number 34977**]


Name:  [**Known lastname 6215**],[**Known firstname 6216**]              Unit No:   [**Numeric Identifier 6217**]

Admission Date:  [**2181-9-5**]              Discharge Date:   [**2181-10-22**]

Date of Birth:  [**2106-1-8**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3717**]
Addendum:
please see remainig addendum

Major Surgical or Invasive Procedure:
Debridement bilateral heels
Right AKA
Percutaneous tracheostomy
Percutaneous G-J tube placement (tube now in 2nd portion of
duodenum)


Brief Hospital Course:
Mr. [**Name14 (STitle) 6218**] was maintained on meropenem and vancomycin to
cover multi-resistant citrobacter koseri and MRSA that grew from
both BAL and the right AKA stump.  He has a VAC dressing in
place that is changed every 3 days.  He is currently still
ventilator dependent, tolerating trach collar trials on a daily
basis, but needing venitlator assistance at night.  He is
tolerating enteral feeding via a percutaneously placed
transgastric jejunostomy tube.  On [**10-18**] his feeding tube was
pulled out 5cm.  An x-ray performed with contrast via the tube
revealed the tip in the 2nd portion of the duodenum.  HE IS AT
RISK FOR PULLING THE TUBE OUT! On [**2181-10-21**] the antibiotics were
discontinued as he had been afebrile and completed a 30 day
course.  He lasted on trach collar for longer periods, and on
the day of discharge had been on trach collar for 30 hours.

Discharge Medications:
1. Triamcinolone acetonide 0.1%, apply TP [**Hospital1 **]
2. Milk of magnesia 30cc NG q6h prn
3. Miconazole powder 2% to groin folds
4. Methadone 10mg NG [**Hospital1 **]
5. Lopressor 25mg NG [**Hospital1 **]
6. Ativan 0.5-1mg IV q4h prn
7. Lactulose 30ml PO/NG, [**Hospital1 **] prn
8. Lantus 20u SC qhs
9. Regular insulin sliding scale
10. Heparin 5000u SC tid
11. Neurontin 200mg PO/NG [**Hospital1 **]
12. Prozac 20mg PO/NG qd
13. Colace (liquid) 100mg PO/NG [**Hospital1 **]
14. Dulcolax 10mg PO/PR qd prn
15. Aquaphor ointment TP [**Hospital1 **] to arms, trunk
16. Albuterol 1-2 puffs q4h prn


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 6219**] - [**Location (un) 2653**]

Discharge Diagnosis:
Gangarenous ulcers bilateral legs/heels
Aspiration pneumonia
Respiratory failure with ventilator dependence
Status post placement percutaneous transgastric jejunostomy tube

Discharge Condition:
Good

Discharge Instructions:
VAC dressing to right AKA stump with 125 mmHg suction.  Change
every 72hours (last changed [**10-19**])
Tracheostomy care
Ventilator support with weaning as tolerated
GJ-tube feedings: respalor at goal rate 60/hour

Followup Instructions:
With Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 162**] two weeks after discharge ([**Telephone/Fax (1) 6220**]

                             [**First Name11 (Name Pattern1) 798**] [**Last Name (NamePattern4) 3683**] MD [**MD Number(1) 3724**]

Completed by:[**2182-1-1**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Ulcer of calf,Cellulitis and abscess of leg, except foot,Infection (chronic) of amputation stump,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Pneumonia due to other gram-negative bacteria,Acute osteomyelitis, ankle and foot,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Morbid obesity'}


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: 

PRESENT ILLNESS: The patient is a 75 year old
male with a past medical history significant for long
standing diabetes mellitus, hypertension, coronary artery
disease.  He is status post myocardial infarction and
extensive peripheral vascular disease, and is status post
multiple peripheral bypasses.  The patient had been recently
admitted to [**Hospital6 34976**] in [**Location (un) 5503**] for five
days due to bacteremia and was discharged on Augmentin.  He
was seen in clinic on the day of admission for bilateral leg
ulcers and referred to the hospital for admission.  He denies
any history of nausea, vomiting, fevers or chills, but does
report having diarrhea four to five days prior to admission.
No chest pain or shortness of breath.

MEDICAL HISTORY: Past medical history is significant
for diabetes mellitus, coronary artery disease, history of
myocardial infarction, congestive heart failure, atrial
fibrillation and chronic renal insufficiency.

MEDICATION ON ADMISSION: 

ALLERGIES: He had no known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Ulcer of calf,Cellulitis and abscess of leg, except foot,Infection (chronic) of amputation stump,Acute and chronic respiratory failure,Pneumonitis due to inhalation of food or vomitus,Congestive heart failure, unspecified,Pneumonia due to other gram-negative bacteria,Acute osteomyelitis, ankle and foot,Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Other bone involvement in diseases classified elsewhere,Morbid obesity'}
