CHIEF COMPLAINT: heel ulcer

PRESENT ILLNESS: This [**Age over 90 **]-year-old gentleman has had a non- healing ulcer of his
right posterior heel with exposed Achilles tendon. This is quite
painful. He underwent
arteriography in an attempt at a catheter-based intervention by
cardiology without success. He is open to the level of the below
knee popliteal occluded anterior tibial artery and has distal
anterior tibial and dorsalis pedis artery as the only runoff
vessel to his foot

MEDICAL HISTORY: 1. TIA (daughter is not sure about this)
2. Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
3. CAD s/p PCI x 2
4. Severe PVD
5. Hypercholesterolemia
6. Hypothyroidism
7. Chronic low back pain
8. AFib s/p ablation
9. s/p cholecystectomy
[**48**]. s/p bilateral carotid endartectomies
11. s/p left popliteal graft
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

MEDICATION ON ADMISSION: ASA 81', Plavix 75', Imdur 60', Toprol 50', Lasix 60', Synthroid
122', Lipitor 80', Coumadin 2.5 Tu/Th/Sa, 5 M/W/F/[**Doctor First Name **], Colace

ALLERGIES: Levaquin

PHYSICAL EXAM: a/o
elderly male
nad
crackles at bases
ireg / irreg with holosytolic murmer
Abd S, NT, ND
Tattoo marks in the lower midline of the pelvis
Uncirc phallus with tight phimosis
Desc testes bilaterally
R leg inc c/d/i
achillies tndomn area with vac r heel

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Lived with daughter x 4 [**Name2 (NI) 1686**]. Walks with a cane. Lives in the
basement of his daughter's house. Just had one VNA visit
yesterday (they sent him here).
Achilles bursitis or tendinitis,Retention of urine, unspecified,Anemia, unspecified,Redundant prepuce and phimosis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Atrial fibrillation,Mitral valve insufficiency and aortic valve stenosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Personal history of malignant neoplasm of prostate,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of heel and midfoot
Achilles tendinitis,Retention urine NOS,Anemia NOS,Redun prepuce & phimosis,Mth sus Stph aur els/NOS,Chr airway obstruct NEC,Ocl crtd art wo infrct,Crnry athrscl natve vssl,Status-post ptca,Pure hypercholesterolem,Hypothyroidism NOS,Atrial fibrillation,Mitral insuf/aort stenos,BPH w urinary obs/LUTS,Hx-prostatic malignancy,Ath ext ntv art ulcrtion,Ulcer of heel & midfoot
Admission Date:  [**2146-9-9**]              Discharge Date:   [**2146-9-15**]


Service: SURGERY

Allergies:
Levaquin

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
heel ulcer

Major Surgical or Invasive Procedure:
[**9-9**]: R BKPO-DP bypass w/RSVG
[**9-13**]: achilles excision and VAC placement


History of Present Illness:
This [**Age over 90 **]-year-old gentleman has had a non- healing ulcer of his
right posterior heel with exposed Achilles tendon. This is quite
painful. He underwent
arteriography in an attempt at a catheter-based intervention by
cardiology without success. He is open to the level of the below
knee popliteal occluded anterior tibial artery and has distal
anterior tibial and dorsalis pedis artery as the only runoff
vessel to his foot

Past Medical History:
1. TIA (daughter is not sure about this)
2. Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
3. CAD s/p PCI x 2
4. Severe PVD
5. Hypercholesterolemia
6. Hypothyroidism
7. Chronic low back pain
8. AFib s/p ablation
9. s/p cholecystectomy
[**48**]. s/p bilateral carotid endartectomies
11. s/p left popliteal graft
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

Social History:
Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Lived with daughter x 4 [**Name2 (NI) 1686**]. Walks with a cane. Lives in the
basement of his daughter's house. Just had one VNA visit
yesterday (they sent him here).

Family History:
Non-contributory

Physical Exam:
a/o
elderly male
nad
crackles at bases
ireg / irreg with holosytolic murmer
Abd S, NT, ND
Tattoo marks in the lower midline of the pelvis
Uncirc phallus with tight phimosis
Desc testes bilaterally
R leg inc c/d/i
achillies tndomn area with vac r heel

Pertinent Results:
[**2146-9-15**] 05:30AM BLOOD

WBC-8.2 RBC-3.81* Hgb-11.4* Hct-33.7* MCV-88 MCH-29.9 MCHC-33.8
RDW-15.4 Plt Ct-184

[**2146-9-15**] 05:30AM BLOOD

PT-14.7* PTT-32.7 INR(PT)-1.3*

[**2146-9-15**] 05:30AM BLOOD

Glucose-102 UreaN-18 Creat-1.0 Na-137 K-3.8 Cl-103 HCO3-29
AnGap-9

[**2146-9-15**] 05:30AM BLOOD

Calcium-8.0* Phos-2.7 Mg-2.0
[**2146-9-12**] 11:09AM

URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
URINE RBC-0-2 WBC-[**2-14**] Bacteri-OCC Yeast-NONE Epi-0-2

[**2146-9-9**] 12:58 pm SWAB      RIGHT HEEL.

GRAM STAIN (Final [**2146-9-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.

WOUND CULTURE (Final [**2146-9-12**]):
STAPH AUREUS COAG +.    MODERATE GROWTH.
PROBABLE ENTEROCOCCUS.    SPARSE GROWTH.
GRAM NEGATIVE ROD(S).    SPARSE GROWTH.

                             STAPH AUREUS COAG +
                             |
CIPROFLOXACIN---------   =>8 R
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

[**2146-9-13**] 8:07 AM

HEEL (AXIAL & LATERAL) RIGHT

Reason: evaluate heel ulcer/exposed achilles tendon

HISTORY: Patient with heel ulcer and exposed Achilles tendon.

FINDINGS: Comparison is made to previous study from [**2146-8-19**].

Since the prior study, the soft tissue ulcer along the posterior
medial aspect of the ankle has increased significantly in size.
There is increased lucency and loss of the cortical white line
involving the margin of the medial malleolus. These findings are
highly suggestive for osteomyelitis. There is no soft tissue
gas. There is prominent swelling medially greater than lateral.
[**Year (4 digits) **] calcifications are seen. There is a plantar spur. The
tibiotalar joint is within normal limits.

IMPRESSION: Findings consistent with osteomyelitis involving the
medial malleolus with increase in the soft tissue ulcer and bony
destruction since the previous study

[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT

Echocardiographic Measurements
Results  Measurements  Normal Range
Aortic Valve - Peak Gradient:  *55 mm Hg  < 20 mm Hg
Aortic Valve - Valve Area:  *0.8 cm2  >= 3.0 cm2

Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.

LEFT VENTRICLE: Normal LV wall thickness and cavity size.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the ascending aorta. Normal descending aorta diameter.
Complex (>4mm) atheroma in the descending thoracic aorta.

AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate-severe AS
(area 0.8-1.0cm2). Mild (1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. Mild to moderate ([**12-14**]+) MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.

PERICARDIUM: Moderate pericardial effusion. No echocardiographic
signs of tamponade.

Conclusions
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses and cavity size are normal. Right
ventricular chamber size and free wall motion are normal. There
are complex (>4mm) atheroma in the ascending aorta. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is moderate to severe aortic
valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-14**]+) mitral regurgitation is seen. There is a
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.


Brief Hospital Course:
pt admitted

pre-opd for lower extremity BPG

Podiatry consult for heel ulcer

Broad spectrum AB / Cx's taken

Urology consult for Foley placement. Pt with history of
difficult foley placements

Swan placed prior to surgery.

Pt taken to the OR underwent a Right below knee popliteal to
dorsalis pedis
artery bypass with reverse saphenous vein.

POD #1 In the PACU / no sequele from BPG. Pt extubated. Pt
bedrest.

POD # 2 Palp graft / HCT stable. Gentle diuresis. OOB to chair.
Diet advanced.

POD # 3 Pt c/o right shoulder pain, Ortho consult - Bursitis. Py
injected with Depo medrol. NSAIDS started.

POD # 4 Stable / Swan changed over wire to TLC. Podiatry
consulted for heel ulcer. Seen by Dr [**Last Name (STitle) **]. this was for the
exposed tendon.

POD #5 Pt brought  OR foe debridement of achilles tendon / Vac
Placement. MP boots placed

POD # 5 cardiology sees pt / followed closely, Pt with main
artery stent. Plavix restarted / asa to continue.

POD # 6 PT consult / Recommend rehab.

Pt stable for rehab.

Medications on Admission:
ASA 81', Plavix 75', Imdur 60', Toprol 50', Lasix 60', Synthroid
122', Lipitor 80', Coumadin 2.5 Tu/Th/Sa, 5 M/W/F/[**Doctor First Name **], Colace

Discharge Medications:
 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO every other day:
follow INR / goal is [**1-15**]. alternating with 5 /2.5 / 5 / 2.5 -
etc.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 21 days.
13. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for shoulder pain.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 21 days.
15. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day
for 21 days: monite cbc and chem 7 [**Hospital1 **] weekly / if nuetropenic
and or creatinine increases / please call Dr [**Last Name (STitle) **] office.

17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO every other
day: alternating with 5 /2.5 / 5 / 2.5 - etc.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]

Discharge Diagnosis:
non-healing R heel ulcer
urinary retention requiring foley and leg Bag

HTN, Hchol, CAD, Afib, prostate CA/BPH, hypothyroid, COPD


Discharge Condition:
Good


Discharge Instructions:
Open Wound: VAC DRESSING  Patient's Discharge Instructions

Introduction:

This will provide helpful information in caring for your wound.
If you have any questions or concerns please talk with your
doctor or nurse. You have an open wound, as opposed to a closed
(sutured or stapled) wound. The skin over the wound is left open
so the deep tissues may heal before the skin is allowed to heal.
Premature closure or healing of the skin can result in
infection. Your wound was left open to allow new tissue growth
within the wound itself. The wound is covered with a VAC
dressing. This will be changed around every three days.

The VAC:

_ helps keep the wound tissue clean

_ absorbs drainage

_ prevents premature healing of skin

- promotes healing

When to Call the Doctor:

Watch for the following signs and symptoms and notify your
doctor if these occur:

Temperature over 101.5 F or chills

Foul-smelling drainage or fluid from the wound

Increased redness or swelling of the wound or skin around it

Increasing tenderness or pain in or around the wound.

Division of [**Location (un) **] and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

2. It is normal to have swelling of the leg you were operated
on:
??????	Elevate your leg above the level of your heart (use [**1-15**]
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

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	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:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	Unless you were told not to bear any weight on operative foot:

??????	You should get up every day, get dressed and walk
??????	You should gradually increase your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????	You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over 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
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Follow up Dr. [**Last Name (STitle) 11679**] [**Telephone/Fax (1) 2394**] in [**1-15**] weeks. Call to make
patient appointment prior to discharge

Per Urology: Current foley (placed [**9-9**]) not to stay in more
than 1 month, needs F/U with [**Hospital 159**] Clinic [**Telephone/Fax (1) 164**] by
[**10-9**] if foley still in, if he passes void trial at rehab then
f/u 2-3 months (needs circumsicion).

Call Dr [**Last Name (STitle) 45762**] office at [**Telephone/Fax (1) 3121**]. Schedule an
appointment for 2 weeks

Call Dr [**Last Name (STitle) **] office at ([**Telephone/Fax (1) 4335**]. scheduel an appontment
for 2 weeks



Completed by:[**2146-9-15**]
{'Achilles bursitis or tendinitis,Retention of urine, unspecified,Anemia, unspecified,Redundant prepuce and phimosis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Atrial fibrillation,Mitral valve insufficiency and aortic valve stenosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Personal history of malignant neoplasm of prostate,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of heel and midfoot'}


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: heel ulcer

PRESENT ILLNESS: This [**Age over 90 **]-year-old gentleman has had a non- healing ulcer of his
right posterior heel with exposed Achilles tendon. This is quite
painful. He underwent
arteriography in an attempt at a catheter-based intervention by
cardiology without success. He is open to the level of the below
knee popliteal occluded anterior tibial artery and has distal
anterior tibial and dorsalis pedis artery as the only runoff
vessel to his foot

MEDICAL HISTORY: 1. TIA (daughter is not sure about this)
2. Carotid artery stenosis: Chronically occluded right internal
carotid artery. Left, with 40-59% carotid stenosis.
3. CAD s/p PCI x 2
4. Severe PVD
5. Hypercholesterolemia
6. Hypothyroidism
7. Chronic low back pain
8. AFib s/p ablation
9. s/p cholecystectomy
[**48**]. s/p bilateral carotid endartectomies
11. s/p left popliteal graft
12. s/p left knee arthroscopy
13. s/p lumbar decompression '[**34**]
14. s/p left leg thrombectomy

MEDICATION ON ADMISSION: ASA 81', Plavix 75', Imdur 60', Toprol 50', Lasix 60', Synthroid
122', Lipitor 80', Coumadin 2.5 Tu/Th/Sa, 5 M/W/F/[**Doctor First Name **], Colace

ALLERGIES: Levaquin

PHYSICAL EXAM: a/o
elderly male
nad
crackles at bases
ireg / irreg with holosytolic murmer
Abd S, NT, ND
Tattoo marks in the lower midline of the pelvis
Uncirc phallus with tight phimosis
Desc testes bilaterally
R leg inc c/d/i
achillies tndomn area with vac r heel

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Previous 30 pack-year tobacco, quit 40 [**Year (2 digits) 1686**] ago. Occasional EtOH.
Lived with daughter x 4 [**Name2 (NI) 1686**]. Walks with a cane. Lives in the
basement of his daughter's house. Just had one VNA visit
yesterday (they sent him here). 

### Response:
{'Achilles bursitis or tendinitis,Retention of urine, unspecified,Anemia, unspecified,Redundant prepuce and phimosis,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Chronic airway obstruction, not elsewhere classified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Pure hypercholesterolemia,Unspecified acquired hypothyroidism,Atrial fibrillation,Mitral valve insufficiency and aortic valve stenosis,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Personal history of malignant neoplasm of prostate,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of heel and midfoot'}
