CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 48 year old
female admitted to [**Hospital6 256**] on
[**2149-2-19**] from a rehabilitation facility.  The patient
had been healthy and in her usual state of health until late
in [**2148**] when she developed a case of Streptococcus pneumonia,
complicated by disseminated intravascular coagulation,
sepsis, acute renal failure, and two episodes of
pneumothorax.  During the course of the patient's sepsis the
patient required vasopressor support but as a result of the
low flow state, the patient developed ischemia and gangrene
of the distal end of both of her feet.  Following discharge
from [**Hospital 9464**] Hospital, the patient was transferred to a
rehabilitation facility for further management.  The patient
was transferred to [**Hospital6 256**] from
this rehabilitation facility for further management of her
gangrenous feet.

MEDICAL HISTORY: Streptococcus pneumonia complicated by
septic shock, DIC, bilateral lower extremity ulcers with
necrotic toes and feet, acute renal failure, pneumothorax.

MEDICATION ON ADMISSION: Tylenol prn; Colace 100 mg p.o.
b.i.d.; Heparin 5000 units b.i.d.; Protonix 40 mg p.o. q.d.;
Duragesic patch; Zyprexa.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Atherosclerosis of native arteries of the extremities with gangrene,Candidiasis of skin and nails,Anemia, unspecified
Ath ext ntv art gngrene,Cutaneous candidiasis,Anemia NOS
Admission Date:  [**2149-2-19**]       Discharge Date:  [**2149-3-12**]

Date of Birth:   [**2100-2-23**]       Sex:  F

Service:  Plastic Surgery

HISTORY OF PRESENT ILLNESS:  The patient is a 48 year old
female admitted to [**Hospital6 256**] on
[**2149-2-19**] from a rehabilitation facility.  The patient
had been healthy and in her usual state of health until late
in [**2148**] when she developed a case of Streptococcus pneumonia,
complicated by disseminated intravascular coagulation,
sepsis, acute renal failure, and two episodes of
pneumothorax.  During the course of the patient's sepsis the
patient required vasopressor support but as a result of the
low flow state, the patient developed ischemia and gangrene
of the distal end of both of her feet.  Following discharge
from [**Hospital 9464**] Hospital, the patient was transferred to a
rehabilitation facility for further management.  The patient
was transferred to [**Hospital6 256**] from
this rehabilitation facility for further management of her
gangrenous feet.

PAST MEDICAL HISTORY:  Streptococcus pneumonia complicated by
septic shock, DIC, bilateral lower extremity ulcers with
necrotic toes and feet, acute renal failure, pneumothorax.

MEDICATIONS ON ADMISSION:  Tylenol prn; Colace 100 mg p.o.
b.i.d.; Heparin 5000 units b.i.d.; Protonix 40 mg p.o. q.d.;
Duragesic patch; Zyprexa.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAMINATION:  On admission the patient was afebrile
with stable vital signs.  Her physical examination was
notable for dry gangrene of both feet from above the mid foot
distally.

HOSPITAL COURSE:  The patient was admitted to the [**Hospital6 1760**] as noted on [**2149-2-19**].
On [**2149-2-20**] the patient had bilateral lower extremity
doppler studies to evaluate the blood flow to her feet.  The
results of the study were essentially normal except for the
possibility of mild tibial artery occlusive disease.  On the
same day, the patient was taken to the Operating Room, had -

1.  Amputation of the right foot at the intermetatarsal level
2.  Amputation of the left foot at tarsometatarsal joint
level with radical debridement of soft tissues.

On the left a significant rectus flap was left and it
appeared the patient's foot on that side could be closed
primarily for longer on a vacuum-assisted closure dressing.
On the right it appeared that the patient would need a free
flap with possible split thickness skin graft.  Following
that, the patient's surgical sites were dressed with
vacuum-assisted closure dressings, and the patient thereafter
transferred out to the floor with an epidural for pain
control.  The patient was returned to the Operating Room on
[**2149-2-23**] for vacuum-assisted closure dressing change.
 At the time of the vacuum-assisted closure dressing change
the patient's wound bed looked excellent with good viable
tissue at both amputation stumps.  Minimal debridement was
required.  On [**2149-2-27**], the patient was taken to
surgery for definitive closure of her wounds.

Procedure performed on [**2149-2-27**] included -

1.  Free rectus abdominis muscle flap to the amputation stump
of the right foot.
2.  Local flap coverage of the left foot amputation stump.
3.  Split thickness skin graft to the vascularized muscle on
the right foot.
4.  Debridement of the soft tissue of both feet.

Following the procedure, the patient was transferred to the
Intensive Care Unit for further close monitoring of her free
flap.  The patient had an uneventful stay in the Intensive
Care Unit.  Her arterial doppler signal to the right foot,
free flap remained stable throughout.  Appropriate
adjustments to her pain medication were made as needed.  The
patient's hematocrit which had been noted to be 38.2 on
admission decreased to a low of 19.3 on [**2149-3-2**].
The patient was started on Epoetin, the patient was
transferred from the Intensive Care Unit to the regular
surgical floor on postoperative day #6.  The patient had been
placed on Dextran for anticoagulation following the surgery.
Dextran was discontinued on [**2149-3-4**].  The surgical
dressings for the patient's feet were taken down on
postoperative day #7 and the patient's flap and split
thickness skin graft was found to have thickened well and was
viable over greater than 95% of the area.  The patient was
seen by physical therapy following transfer to the floor and
training initiated on bed to wheelchair transfers.  The
patient continued to have activity restrictions and the feet
needed to be elevated at all times.  It was expected that
dangling would start approximately two weeks following the
procedure.  By postoperative day #12 which was [**2149-3-11**], the patient appeared stable and ready for discharge to
a rehabilitation facility.  The dressing changes of the feet
had been changed to simply dry gauze dressing on the right
foot with no dressing needed on the left foot.  The patient's
rectus flap harvest site was healing well.  The patient's
right thigh split thickness skin graft donor site was also
stable and healing well with Xeroform dressing was applied.
The patient continued to be seen by physical therapy.  The
patient remained on gentamicin and Ancef, but it was expected
that both of these antibiotics would be discontinued prior to
the patient's discharge.  The patient was to begin dangling
on postoperative day #13.  It is expected that the patient
will initially start by dangling her feet for a minute and a
half every hour during the day while awake and gradually
increasing by three to five minutes a day.  Further
instructions on the dangling protocol will be relayed to the
patient and to her rehabilitation facility.  It was expected
that the patient's Epoetin therapy will be discontinued prior
to discharge.

DISCHARGE CONDITION:  Stable.

DISCHARGE MEDICATIONS:
1.  Colace 100 mg p.o. b.i.d.
2.  Heparin 5000 units subcutaneously b.i.d.
3.  Ranitidine 150 mg p.o. b.i.d.
4.  Milk of magnesia prn
5.  Ambien 5 mg p.o. q.h.s. prn
6.  Elanzepine 5 mg p.o. q.d.
7.  Fentanyl patch 25 mcg per hour q. 3 days
8.  Gabapentin 300 mg p.o. t.i.d.
9.  Dilaudid 28 mg p.o. q. 4 hours prn
10. Aspirin 325 mg p.o. q.d.
11. Ferrous Sulfate 325 mg p.o. q.d.
12. Ascorbic acid 500 mg p.o. b.i.d.
13. Multivitamin tablets
14. Miconazole cream to perineum prn

FOLLOW UP:  The patient is to contact Dr.[**Name2 (NI) 23346**] office for
follow up appointment one to two weeks following discharge.

MISCELLANEOUS:  Regarding management of the patient's
surgical sites - The patient's abdominal incision is to be
left open to air and is expected to heal without
complications.  The patient's right side donor site is to
remain exposed to air with the Xeroform in place.  The
patient's left foot transmetatarsal amputation site is to
remain open to air and dressed only for protection and
comfort.  The sutures along her surgical incision will be
discontinued at an appropriate time by Dr. [**Last Name (STitle) 5385**].  The
patient's right foot transmetatarsal site is to be dressed
with a dry gauze dressing once or twice a day as needed.
Sutures and the small cotton plugs, ringing the patient's
surgical incision on the right should be left untouched.

Instructions on the patient's dangling protocol will be
relayed to care providers.

DISCHARGE DIAGNOSIS:
1.  Bilateral foot gangrene
2.  Anemia
3.  Yeast infection of skin



                            [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 7738**]

Dictated By:[**Name8 (MD) 997**]
MEDQUIST36

D:  [**2149-3-11**]  18:45
T:  [**2149-3-11**]  18:52
JOB#:  [**Job Number 46392**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Candidiasis of skin and nails,Anemia, unspecified'}


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 48 year old
female admitted to [**Hospital6 256**] on
[**2149-2-19**] from a rehabilitation facility.  The patient
had been healthy and in her usual state of health until late
in [**2148**] when she developed a case of Streptococcus pneumonia,
complicated by disseminated intravascular coagulation,
sepsis, acute renal failure, and two episodes of
pneumothorax.  During the course of the patient's sepsis the
patient required vasopressor support but as a result of the
low flow state, the patient developed ischemia and gangrene
of the distal end of both of her feet.  Following discharge
from [**Hospital 9464**] Hospital, the patient was transferred to a
rehabilitation facility for further management.  The patient
was transferred to [**Hospital6 256**] from
this rehabilitation facility for further management of her
gangrenous feet.

MEDICAL HISTORY: Streptococcus pneumonia complicated by
septic shock, DIC, bilateral lower extremity ulcers with
necrotic toes and feet, acute renal failure, pneumothorax.

MEDICATION ON ADMISSION: Tylenol prn; Colace 100 mg p.o.
b.i.d.; Heparin 5000 units b.i.d.; Protonix 40 mg p.o. q.d.;
Duragesic patch; Zyprexa.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Candidiasis of skin and nails,Anemia, unspecified'}
