CHIEF COMPLAINT: Acute ischemia of the left lower extremity, left lower extremity
ischemia and rest pain

PRESENT ILLNESS: This unfortunate 75-year-old lady was transferred from [**Hospital1 10151**] Center. She is ventilatory-dependent and had a
stroke and is noncommunicative, but was noted to have a cool
pale left lower extremity prior to admission. She was
heparinized. A CT angiogram was done which suggested embolus and
some thrombosis of her superficial femoral artery. She was
admitted and underwent emergent Left femoral thromboembolectomy
with vein patch angioplasty on [**2163-6-11**]. Her superficial femoral
artery was occluded all the way down to the above-knee popliteal
artery where it reconstituted through collaterals in the
profunda femoris artery. After undergoing embolectomy she did
not improve, and her foot continued to be threatened. She was
take to the OR for left lower extremity arteriogram on [**2163-6-12**]
with primary stenting of the left superficial femoral and
above-knee popliteal artery with balloon angioplasty of the left
peroneal artery.

MEDICAL HISTORY: PMH: diabetes mellitus (type 2), COPD s/p ruptured diverticulum
with prolonged resp failure and trach in rehab for approximately
1 year and removed in [**11-5**], developed COPD exacerbation one
month ago and has been ventilator dependent since then, HTN, CHF
[**3-2**] diastolic dysfunction, prior CVA, s/p MI, depression,
anxiety, multiple hernia repairs, colostomy, h/o MRSA, C.diff,
Pseudomonas, VRE

MEDICATION ON ADMISSION: combivent INH 6 puffs Q6H, ASA 325 mg', citalopram 10 mg',
colace 100 mg'', erapenem 1 gm', methadone 5 mg'', metoprolol 25
mg''', omeprazole 40 mg', senna 8.6 mg'

ALLERGIES: Penicillins / Levaquin in D5W

PHYSICAL EXAM: VITALS:  Afebrile, vital signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2. No evidence of carotid bruits. Trach tube in place
for chronic ventilatory needs.
RESP: decreased breath sounds to auscultation bilaterally
without adventitious sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: The right lower extremity is warm well-perfused and is
without erythema, drainage or edema. The left lower extremity is
warm well-perfused and is with mild reperfusion changes that are
stable, mild erythema, but without mottling or changes in pulse
exam (below).
PULSE EXAM: Left PT dopplerable, R DP/PT dopplerable signals
(monophasic)

FAMILY HISTORY: Per records, positive for CAD.

SOCIAL HISTORY: The patient is a nursing home resident, a former smoker.
Arterial embolism and thrombosis of lower extremity,Chronic respiratory failure,Dependence on respirator, status,Atherosclerosis of native arteries of the extremities with rest pain,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, other speech and language deficits,Unspecified essential hypertension,Tracheostomy status
Lower extremity embolism,Chronic respiratory fail,Respirator depend status,Ath ext ntv at w rst pn,Chr airway obstruct NEC,DMII wo cmp nt st uncntr,Late ef-spch/lang df NEC,Hypertension NOS,Tracheostomy status
Admission Date:  [**2163-6-11**]              Discharge Date:   [**2163-6-15**]

Date of Birth:  [**2088-12-23**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Levaquin in D5W

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Acute ischemia of the left lower extremity, left lower extremity
ischemia and rest pain


Major Surgical or Invasive Procedure:
[**2163-6-11**] - left femoral thromboembolectomy, vein patch
angioplasty

[**2163-6-12**] - Arteriogram of the left lower extremity, Primary
stenting of the left superficial femoral and above-knee
popliteal artery, Balloon angioplasty of the left peroneal
artery, Perclose closure of the right common femoral
arteriotomy.


History of Present Illness:
This unfortunate 75-year-old lady was transferred from [**Hospital1 10151**] Center. She is ventilatory-dependent and had a
stroke and is noncommunicative, but was noted to have a cool
pale left lower extremity prior to admission. She was
heparinized. A CT angiogram was done which suggested embolus and
some thrombosis of her superficial femoral artery. She was
admitted and underwent emergent Left femoral thromboembolectomy
with vein patch angioplasty on [**2163-6-11**]. Her superficial femoral
artery was occluded all the way down to the above-knee popliteal
artery where it reconstituted through collaterals in the
profunda femoris artery. After undergoing embolectomy she did
not improve, and her foot continued to be threatened. She was
take to the OR for left lower extremity arteriogram on [**2163-6-12**]
with primary stenting of the left superficial femoral and
above-knee popliteal artery with balloon angioplasty of the left
peroneal artery.


Past Medical History:
PMH: diabetes mellitus (type 2), COPD s/p ruptured diverticulum
with prolonged resp failure and trach in rehab for approximately
1 year and removed in [**11-5**], developed COPD exacerbation one
month ago and has been ventilator dependent since then, HTN, CHF
[**3-2**] diastolic dysfunction, prior CVA, s/p MI, depression,
anxiety, multiple hernia repairs, colostomy, h/o MRSA, C.diff,
Pseudomonas, VRE

PSH: Rigid bronchoscopy, flexible bronchoscopy, BAL,
tracheostomy revision and dilation ([**2163-5-24**])


Social History:
The patient is a nursing home resident, a former smoker.


Family History:
Per records, positive for CAD.


Physical Exam:
VITALS:  Afebrile, vital signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2. No evidence of carotid bruits. Trach tube in place
for chronic ventilatory needs.
RESP: decreased breath sounds to auscultation bilaterally
without adventitious sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: The right lower extremity is warm well-perfused and is
without erythema, drainage or edema. The left lower extremity is
warm well-perfused and is with mild reperfusion changes that are
stable, mild erythema, but without mottling or changes in pulse
exam (below).
PULSE EXAM: Left PT dopplerable, R DP/PT dopplerable signals
(monophasic)


Pertinent Results:
[**2163-6-15**] 03:13AM BLOOD WBC-11.9* RBC-2.97* Hgb-7.4* Hct-23.8*
MCV-80* MCH-24.9* MCHC-31.0 RDW-17.7* Plt Ct-596*

[**2163-6-10**] 09:55PM BLOOD Neuts-72.6* Lymphs-19.0 Monos-3.9 Eos-3.6
Baso-1.0

[**2163-6-15**] 07:18AM BLOOD PT-14.8* PTT-48.4* INR(PT)-1.3*

[**2163-6-15**] 03:13AM BLOOD Glucose-144* UreaN-13 Creat-0.5 Na-139
K-5.3* Cl-97 HCO3-35* AnGap-12

[**2163-6-14**] 12:32AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9

[**2163-6-11**] CTA AORTA/BIFEM/ILIAC RUNOFF W: Widespread severe
atherosclerotic disease as outlined above including occlusion of
most of the left superficial artery. Abdominal aortic aneurysm,
stable in size and measuring up to 41 mm. Mixed sclerotic and
lytic appearance of bones without discrete lesions, possibly
reflecting a metabolic abnormality; correlation with laboratory
testing and consideration of bone mineral density screening are
suggested when clinically appropriate. Irregular appearance of
each femoral head, potentially related to avascular necrosis.
Large ventral hernia containing most of the solid organs and
bowel.


Brief Hospital Course:
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative period and transitioned to PO
narcotic medication with adequate pain control on POD#[**1-30**]. The
patient remained neurologically stable from previous exams; of
note she is non-communicative and withdraws to pain, on exam.
She is without change from baseline.

CARDIOVASCULAR: The patient remained hemodynamically stable
intra-op and in the immediate post-operative period. Their
vitals signs were closely monitored with telemetry in the
cardiovascular ICU.

The patient did well following their vascular procedures. The
patient was closely monitored with serial pulse exams in the
post-op period. If appropriate, doppler signaling was frequently
assessed in the involved extremity. Their post-op pulse exam
demonstrated dopplerable signals of the left lower extremity
DP/PT. The patient was placed on a heparin gtt for
anticoagulation once she was admitted, given the concern for
acute ischemia, and was bridged to oral Coumadin. Their PTT was
assessed every 6 hours (PTT goal 60 - 80). The patient was
started on Coumadin 3 mg PO daily on [**2163-6-13**] and this was
increased to 5 mg PO daily, which was her dosing on discharge.
She continues to bridge from heparin gtt to Coumadin. She needs
INR monitoring.

RESPIRATORY: The patient remained chronically vented with
respiratory support and intermittent episodes of CPAP were
maintained. The patient had no episodes of desaturation or
pulmonary concerns. The patient denied cough or respiratory
symptoms. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation.

GASTROINTESTINAL: The patient was NPO following their procedure.
The patient experienced no nausea or vomiting. The patient was
transitioned to her regular tube feeding regimen of Novasource
at 60 cc/hr continuous, following her procedures, after a
Dobhoff tube was replaced. IV fluids were discontinued once
adequate Dobhoff tube feeds were established.

GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter
remained in place on admission, and the patient was able to
successfully void without issue. The patient's intake and output
was closely monitored for UOP > 30 mL per hour output. The
patient's creatinine was stable.

HEME: The patient's post-op hematocrit was stable and trended
closely. The patient remained hemodynamically stable and
received transfusion of 4 units of packed red cells with
favorable response. The patient's coagulation profile remained
normal and was monitoring given her Coumadin dosing. The patient
had no evidence of bleeding from their incision.

ID: The patient showed no signs of infection and remained
afebrile in the post-op period. Their white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. The patient received only
standard peri-operative antibiotics, and did not require further
antibiotics post-op.

ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.

PROPHYLAXIS: The patient also had sequential compression boot
devices in place during immobilization to promote circulation.
GI prophylaxis was sustained with Protonix/Famotidine when
necessary. The patient was discharged in stable condition to her
acute ventilatory rehabilitation facility.


Medications on Admission:
combivent INH 6 puffs Q6H, ASA 325 mg', citalopram 10 mg',
colace 100 mg'', erapenem 1 gm', methadone 5 mg'', metoprolol 25
mg''', omeprazole 40 mg', senna 8.6 mg'

Discharge Medications:
1. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**1-30**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB.
2. aspirin 325 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
3. citalopram 20 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY (Daily).
4. methadone 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day).
5. metoprolol tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice
a day: hold for hr<55 sbp<100.
6. clopidogrel 75 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
7. docusate sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Five (5) mL PO TID (3
times a day).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. chlorhexidine gluconate 0.12 % Mouthwash [**Month/Day (2) **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day): while on mechanical
ventilation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Acute ischemia of the left lower extremity with rest pain


Discharge Condition:
Mental Status: Non-verbal, opens eyes to stimuli, does not
follow
commands
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	Take Plavix (Clopidogrel) 75mg once daily
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**3-3**]
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
??????	It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and 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:
??????	When you go home, you may walk and go up and down stairs
??????	You may shower (let the soapy water run over groin 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 or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	Call and schedule an appointment to be seen in [**4-1**] weeks for
post procedure check and ultrasound

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.

Followup Instructions:
Please call Dr.[**Name (NI) 5695**] office for a follow up in 4 weeks
for office visit and ultrasound.

Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 3121**]





Name:  [**Known lastname **],[**Known firstname **]                    Unit No:   [**Numeric Identifier 12979**]

Admission Date:  [**2163-6-11**]              Discharge Date:   [**2163-6-15**]

Date of Birth:  [**2088-12-23**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Levaquin in D5W

Attending:[**First Name3 (LF) 1546**]
Addendum:
Pt was discharged on a heparin gtt at 1700units/hr. She was
mechanically ventilated. She has a non-heparin dependent PICC in
the Right Basilic,inserted: [**2163-6-14**].   She has a dubhoff tube,
foley catheter and colostomy bag in place at time of discharge.
Her left leg wounds have staples intact and are clean, dry and
intact. Her right groin puncture site is c/d/i.  All wounds
should be covered with dry gauze.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 609**] for the Aged - MACU

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]

Completed by:[**2163-6-15**]
{'Arterial embolism and thrombosis of lower extremity,Chronic respiratory failure,Dependence on respirator, status,Atherosclerosis of native arteries of the extremities with rest pain,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, other speech and language deficits,Unspecified essential hypertension,Tracheostomy status'}


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: Acute ischemia of the left lower extremity, left lower extremity
ischemia and rest pain

PRESENT ILLNESS: This unfortunate 75-year-old lady was transferred from [**Hospital1 10151**] Center. She is ventilatory-dependent and had a
stroke and is noncommunicative, but was noted to have a cool
pale left lower extremity prior to admission. She was
heparinized. A CT angiogram was done which suggested embolus and
some thrombosis of her superficial femoral artery. She was
admitted and underwent emergent Left femoral thromboembolectomy
with vein patch angioplasty on [**2163-6-11**]. Her superficial femoral
artery was occluded all the way down to the above-knee popliteal
artery where it reconstituted through collaterals in the
profunda femoris artery. After undergoing embolectomy she did
not improve, and her foot continued to be threatened. She was
take to the OR for left lower extremity arteriogram on [**2163-6-12**]
with primary stenting of the left superficial femoral and
above-knee popliteal artery with balloon angioplasty of the left
peroneal artery.

MEDICAL HISTORY: PMH: diabetes mellitus (type 2), COPD s/p ruptured diverticulum
with prolonged resp failure and trach in rehab for approximately
1 year and removed in [**11-5**], developed COPD exacerbation one
month ago and has been ventilator dependent since then, HTN, CHF
[**3-2**] diastolic dysfunction, prior CVA, s/p MI, depression,
anxiety, multiple hernia repairs, colostomy, h/o MRSA, C.diff,
Pseudomonas, VRE

MEDICATION ON ADMISSION: combivent INH 6 puffs Q6H, ASA 325 mg', citalopram 10 mg',
colace 100 mg'', erapenem 1 gm', methadone 5 mg'', metoprolol 25
mg''', omeprazole 40 mg', senna 8.6 mg'

ALLERGIES: Penicillins / Levaquin in D5W

PHYSICAL EXAM: VITALS:  Afebrile, vital signs stable.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2. No evidence of carotid bruits. Trach tube in place
for chronic ventilatory needs.
RESP: decreased breath sounds to auscultation bilaterally
without adventitious sounds. No wheezing, rhonchi or crackles.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No masses or peritoneal signs.
EXTR: The right lower extremity is warm well-perfused and is
without erythema, drainage or edema. The left lower extremity is
warm well-perfused and is with mild reperfusion changes that are
stable, mild erythema, but without mottling or changes in pulse
exam (below).
PULSE EXAM: Left PT dopplerable, R DP/PT dopplerable signals
(monophasic)

FAMILY HISTORY: Per records, positive for CAD.

SOCIAL HISTORY: The patient is a nursing home resident, a former smoker. 

### Response:
{'Arterial embolism and thrombosis of lower extremity,Chronic respiratory failure,Dependence on respirator, status,Atherosclerosis of native arteries of the extremities with rest pain,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, other speech and language deficits,Unspecified essential hypertension,Tracheostomy status'}
