CHIEF COMPLAINT: Gangrene right first toe.

PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old Asian
male with a past medical history significant for coronary
artery disease, diabetes mellitus and complete heart block
who was noted to have a right great toe ulcer several weeks
ago after a corn was trimmed.  The patient was seen by
cardiologist, Dr. [**Last Name (STitle) **] and referred to Dr. [**Last Name (STitle) **] for
surgical evaluation.  Apparently a need for the bypass graft
was discussed but patient was reluctant and requested a
second opinion.  He was then sent to Dr. [**Last Name (STitle) 1391**] who felt
that a bypass was also needed as well and he was then
admitted for further evaluation.

MEDICAL HISTORY: Significant for coronary artery
disease, status post coronary artery bypass grafting in [**2136**],
complete heart block leading to cardiac arrest, shock and
intubation in [**2140-2-2**].  Catheterization at that time
revealed non reconstructible disease.  Diabetes mellitus
since age 30, hypertension, hyperlipidemia, peptic ulcer
disease with a history of upper GI bleed while on IV Heparin
and pneumonia.

MEDICATION ON ADMISSION: 

ALLERGIES: Pramiracetam which leads to elevated LFT levels.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Congestive heart failure, unspecified,Hematoma complicating a procedure,Atrioventricular block, complete,Other specified cardiac dysrhythmias,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension
Ath ext ntv art gngrene,Ac osteomyelitis-ankle,DMII wo cmp nt st uncntr,CHF NOS,Hematoma complic proc,Atriovent block complete,Cardiac dysrhythmias NEC,Crnry athrscl natve vssl,Hypertension NOS
Admission Date:  [**2142-2-14**]       Discharge Date:  [**2142-3-5**]

Date of Birth:   [**2070-4-25**]       Sex:  M

Service:  VASCULAR

Addendum to last report dated [**2142-3-5**].

HOSPITAL COURSE:  The patient went into symptomatic
bradycardia with unresponsiveness.  He was given 2 mg of
Atropine without response and then was successfully
transcutaneously paced.  Shortly afterwards rhythm was
restored to normal sinus with rates in the approximately 80s
to 90s.  He was briefly hypotensive with a systolic blood
pressure in the 70s during the bradycardic episode, but was
never required to be intubated.  When his heart rate was
returned back to normal he remained hemodynamically stable
and was maintained down in the Medical Intensive Care Unit.
We were then instructed to hold all beta blockers as before
and he was subsequently suggested that he receive a permanent
pacemaker and AICD.  The patient had a second episode of
symptomatic bradycardia while in the Medical Intensive Care
Unit with similar symptoms of somewhat unresponsive, nausea,
vomiting and decreased blood pressure.  He responded to
dopamine and atropine.  Consultation by the electrophysiology
team was obtained during this time so that coordination of
permanent pacemaker and AICD could be inserted.

At this time consultation was sought by infectious disease
due to the fact that the patient had active infection in his
right foot with need for permanent pacemaker implantation.
They recommended Oxacillin 2 grams intravenous q 4 hours for
five weeks to be put on hold perioperatively and Vancomycin
to be started until after the implantation of the permanent
pacemaker.  The AICD and pacemaker were subsequently placed
on [**2142-2-19**].  The patient tolerated this quite well
and was maintained on the telemetry unit for approximately
five more days.  At this time vancomycin was continued for
five days as well as Levaquin and Flagyl.  The patient
continued to remain hemodynamically stable and had no issues.
He was then brought down to the Operating Room on [**2142-2-22**] for a right below knee popliteal to dorsalis pedis
bypass with nonreverse saphenous vein graft using the
contralateral greater saphenous vein.  Details of this
procedure are dictated in a separate operative note.

It should be noted that during this time frame the patient's
ejection fraction is noted to be of approximately 10%.  He
was considered to be at very high risk for surgery as he has
severe ischemic cardiomyopathy.  For the bypass procedure a
Swan-Ganz catheter was placed near the left groin.  This was
performed by the Electrophysiology Service down in the
cardiac catheterization laboratory as the patient did have a
brand new pacemaker and AICD wiring.  This was done under
fluoroscopy.  The patient tolerated the procedure quite well
and really had no hemodynamically significant events.  He had
blood pressures ranging from the low 80s to the 90s, which
was felt to be his baseline.  He continued to make good urine
throughout.  He needed one to two blood transfusions while he
had a stay in the Vascular Intensive Care Unit.  He responded
quite well with Lasix after the blood transfusion.

Currently he is doing quite well.  He did have an episode in
the Vascular Intensive Care Unit with which he dropped his
blood pressure and was noted to have quite a significant
bleed from his left groin.  He was evaluated by Dr. [**Last Name (STitle) **]
and felt that this was not a surgical emergency, but rather
he was having some oozing from the skin folds.  On
postoperative day number four he was taken back down to the
Operating Room for a right great toe ray amputation as the
previous amputation site had not healed and was quite
gangrenous.  At this point he was stable and had stopped
bleeding from the skin fold site.  The Vancomycin was then
subsequently discontinued and the patient was started back on
Oxacillin.  He was then transferred out to the floor on
postoperative day number five and advised to be strict
nonweight bearing on the right lower extremity.  He developed
a pressure ulceration on the left heel and a Multi-Podus boot
was placed.  This remains clean, dry and intact without
evidence of drainage or erythema.  His Is and Os remained
negative throughout his hospital stay.  He had no symptoms of
congestive heart failure or shortness of breath.

Physical therapy was consulted and felt that a rehab facility
might be adequate placement for him after hospitalization.
Currently he is waiting for a bed and will be discharged
shortly.  It should be noted that after the ray amputation of
the great toe that the patient had multiple bouts of watery
diarrhea.  These were sent numerous times for C-difficile
toxin and were all negative for C-difficile.  The patient was
remained on Flagyl and was started on Lomotil.  Once he was
started on Lomotil his number of diarrhea considerably
decreased.  He will be discharged from the hospital when a
bed is available.

At this time he is tolerating a diet and is able to get out
of bed with assistance.  His incisions are all clean, dry and
intact.  There is no evidence of active bleeding at this
time.  He has a small amount of ecchymosis on the right
anterior foreleg.  He has a palpable dorsalis pedis pulse.
The ulcer on the left heel is clean, dry and intact without
evidence of erythema.  Lungs are clear to auscultation
bilaterally.  Heart is regular rate and rhythm.  There is no
erythema or fluctuance around the pacemaker.  He is to follow
up with Dr. [**Last Name (STitle) 1391**] in approximately ten days for further
evaluation.  His toe amputation site is healing quite well at
this time and the sutures are to be removed by Dr. [**Last Name (STitle) 1391**].
He is to remain on strict nonweight bearing of the right
lower extremity.  He is to wear Multi-Podus boots on both
lower extremities while he is in bed.  An ace wrap is to be
applied from the toes to the knees on the right lower
extremity.  Infectious disease recommends that he stay on his
five weeks of Oxacillin and oral Levaquin.  He is to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22874**] on [**3-26**].  Any laboratory tests
performed in the rehab facility are to be sent to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 22874**].  The antibiotics are to end on [**3-26**].  An
appointment has been scheduled for him with Dr. [**Last Name (STitle) 22874**] who
is the infectious disease doctor [**First Name (Titles) **] [**3-26**] at 2:00 p.m. in
the [**Doctor Last Name 780**] Building on the sixth floor.  A call is to be
placed to Dr.[**Name (NI) 1392**] office for an appointment.

DISCHARGE DIAGNOSES:
1.  Nonhealing ulceration and gangrene of the right first toe
treated with distal bypass procedure and first toe
amputation.
2.  Insulin dependent diabetes mellitus.
3.  Severe ischemic cardiomyopathy with ejection fraction of
approximately 10%.
4.  Symptomatic bradycardia status post permanent pacemaker
and AICD placement.
5.  Diarrhea, currently resolved and being treated with
Lomotil.

DISCHARGE MEDICATIONS:  NPH 16 units q breakfast, 4 units q
bedtime.  Regular insulin sliding scale.  Digoxin 0.125 mg po
q.d., Aldactone 25 mg po b.i.d., Colchicine 0.6 mg po q.d.,
Accupril 20 mg po q.d., Lipitor 10 mg po q.d., aspirin 325 mg
po q.d., Protonix 40 mg po q.d., Colace 100 mg po b.i.d.,
Allopurinol 100 mg po q.d., heparin 5000 units subQ b.i.d.,
Levaquin 500 mg po q.d., Oxacillin 2 grams intravenous q 4
hours, Nystatin swish and swallow, Lasix 80 mg po q.a.m., 40
mg po q.p.m. and Percocet po q 4 hours prn.






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4417**]

Dictated By:[**Doctor First Name 22875**]
MEDQUIST36

D:  [**2142-3-5**]  14:22
T:  [**2142-3-5**]  14:35
JOB#:  [**Job Number 22876**]


Admission Date:  [**2142-2-14**]       Discharge Date:  [**2142-3-6**]

Date of Birth:   [**2070-4-25**]       Sex:  M

Service:  Vascular Surgery

CHIEF COMPLAINT:  Gangrene right first toe.

HISTORY OF PRESENT ILLNESS:  Mr. [**Known lastname **] is a 71-year-old Asian
male with a past medical history significant for coronary
artery disease, diabetes mellitus and complete heart block
who was noted to have a right great toe ulcer several weeks
ago after a corn was trimmed.  The patient was seen by
cardiologist, Dr. [**Last Name (STitle) **] and referred to Dr. [**Last Name (STitle) **] for
surgical evaluation.  Apparently a need for the bypass graft
was discussed but patient was reluctant and requested a
second opinion.  He was then sent to Dr. [**Last Name (STitle) 1391**] who felt
that a bypass was also needed as well and he was then
admitted for further evaluation.

PAST MEDICAL HISTORY:  Significant for coronary artery
disease, status post coronary artery bypass grafting in [**2136**],
complete heart block leading to cardiac arrest, shock and
intubation in [**2140-2-2**].  Catheterization at that time
revealed non reconstructible disease.  Diabetes mellitus
since age 30, hypertension, hyperlipidemia, peptic ulcer
disease with a history of upper GI bleed while on IV Heparin
and pneumonia.

PAST SURGICAL HISTORY:  Significant for coronary artery
bypass grafting times five in [**2136**], cataract extraction by
Dr. [**First Name (STitle) **] in [**2139**].

MEDICATIONS:  On admission were significant for Aspirin 325
mg q a.m., Allopurinol 100 mg q a.m., Colchicine 0.6 mg q 48
hours, Lasix 40 mg q a.m., Lasix 40 mg q p.m., Digoxin 0.125
mg q d, Accupril 20 mg po q d, Aldactone 25 mg po bid,
Prilosec 20 mg po bid, Lipitor 10 mg po q h.s., Multivitamin
one po q a.m., Insulin sliding scale 22 units NPH q a.m.,
Humalog sliding scale.

ALLERGIES:  Pramiracetam which leads to elevated LFT levels.

HOSPITAL COURSE:  The patient was admitted to [**Hospital1 346**] where he was started on Levofloxacin
and Flagyl.  He was planned for an angiogram and arm vein
mapping and later a right first toe amputation.  He underwent
a right first toe amputation on [**2142-2-15**].  Details of this
procedure are detailed in a separate operative note.  He was
then taken down to the angiography suite later that day for
an arteriogram which revealed mild bilateral renal artery
stenoses.  No significant aortoiliac disease.  Mild to
moderate right superficial femoral artery disease and
moderate to severe popliteal artery disease.  An occluded
right anterior tibial artery at the origin.  Right posterior
tibial artery with multiple stenoses, but constituting major
run-off to the foot.  Reconstruction to dorsalis pedis artery
at the foot and preserved plantar arches.  Based on these
findings, the patient was then sent for arm vein mapping as
he did have reconstructible peripheral vascular disease.  It
was decided by Dr. [**Last Name (STitle) 1391**] that the left greater saphenous
vein would be used.  It should be noted that the right
greater saphenous vein was used for his coronary artery
bypass graft.  The patient did have decent sized veins in the
right basilic vein, however, the rest of his arm veins were
somewhat inadequate and a longer vein would be needed for the
bypass.  Prior to the bypass procedure, cardiology
consultation was sought.  They felt that he was at a
significant risk secondary to his co-morbidities.  They
recommended not continuing Lopressor as the patient had
history of severe bradycardia going into cardiac arrest in
the past.  He was then scheduled for bypass grafting for the
following week.

The patient was doing quite well before his bypass when it
was noted that the patient was found to be unresponsive by
the nurses.  A code was called and ACLS was initiated.  When
the patient was hooked up to the monitor it was noted that he
had severe bradycardia with heart rates in the 30's to 40's.
Blood pressure was in the 80's to 90's.  He was then
subsequently given Atropine with good response.  Based on
these, it was felt he would subsequently need a permanent
pacemaker as well as an AICD placed.  Dictation to be
continued at supper time.




                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 4417**]

Dictated By:[**Doctor First Name 22875**]
MEDQUIST36

D:  [**2142-3-5**]  11:35
T:  [**2142-3-5**]  11:44
JOB#:  [**Job Number 22877**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Congestive heart failure, unspecified,Hematoma complicating a procedure,Atrioventricular block, complete,Other specified cardiac dysrhythmias,Coronary atherosclerosis of native coronary artery,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: Gangrene right first toe.

PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old Asian
male with a past medical history significant for coronary
artery disease, diabetes mellitus and complete heart block
who was noted to have a right great toe ulcer several weeks
ago after a corn was trimmed.  The patient was seen by
cardiologist, Dr. [**Last Name (STitle) **] and referred to Dr. [**Last Name (STitle) **] for
surgical evaluation.  Apparently a need for the bypass graft
was discussed but patient was reluctant and requested a
second opinion.  He was then sent to Dr. [**Last Name (STitle) 1391**] who felt
that a bypass was also needed as well and he was then
admitted for further evaluation.

MEDICAL HISTORY: Significant for coronary artery
disease, status post coronary artery bypass grafting in [**2136**],
complete heart block leading to cardiac arrest, shock and
intubation in [**2140-2-2**].  Catheterization at that time
revealed non reconstructible disease.  Diabetes mellitus
since age 30, hypertension, hyperlipidemia, peptic ulcer
disease with a history of upper GI bleed while on IV Heparin
and pneumonia.

MEDICATION ON ADMISSION: 

ALLERGIES: Pramiracetam which leads to elevated LFT levels.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Congestive heart failure, unspecified,Hematoma complicating a procedure,Atrioventricular block, complete,Other specified cardiac dysrhythmias,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension'}
