CHIEF COMPLAINT: painful foot

PRESENT ILLNESS: 59 year old male with h/o HTN and dyslipidemia who was referred
for urgent peripheral catherization for presumed limb ischemia.
Five days prior to admission, he developed sudden onset acute
pain in his left foot. He reports it was worse when laying in
bed. He did not seek medical attention until this weekend, when
he was found not to have a palpable pulse in his left foot. He
described a cold painful foot worse at night while lying flat
but present with ambulation.  Denies a previous history of
claudication like symptoms.  No history of chest pain, SOB or
DOE. No history of palpitations. No history of trauma. Later
evaluated by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**], who described a diminished
DP/PT compared to 2+ on the right and subsequently referred for
urgent cath by Dr. [**Last Name (STitle) 911**].
.
On catherization was found to have an occluded PT and AT filled
slowly by collateral flow. Peroneal origin stump occluded with
proximal clot.  PTA, laser atherectomy and thrombectomy
attempted without success. A Unifuse catheter for overnight
lysis was placed and Pt transferred to CCU. Currently patient
complaining of intermittent Left foot pain. Otherwise w/o
complaint.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain.  All of the other
review of systems were negative.

MEDICAL HISTORY: left hernia repair
hypertension
hyperlipidemia

MEDICATION ON ADMISSION: Aspirin 81mg daily
Lipitor 40mg daily (increased on [**4-1**])
Zestoretic 10-12.5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: well appearing NAD
HEENT: conjunctiva were pink with no pallor or cyanosis of the
oral mucosa.
Neck: supple without JVD. No CB's. 2+ carotids
Chest: The respirations were not labored and there were no use
of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs anteriorly
CVS: RRR. normal S1 and the S2 was normal. There were no rubs,
murmurs, clicks or gallops. PMI non-displaced
ABD: abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended.
EXT: no pallor, cyanosis, clubbing or edema. There were no
abdominal, femoral or carotid bruits
Skin: no lesions
Neuro: AO3, CNs intact, sensation to light touch intact.

FAMILY HISTORY: Father died at age 78 of CAD/diabetes complications

SOCIAL HISTORY: Married. Dentist. Social history is significant for the absence
of current tobacco use. There is no history of alcohol abuse.
Atherosclerosis of native arteries of the extremities with rest pain,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Ath ext ntv at w rst pn,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2137-4-2**]              Discharge Date:   [**2137-4-6**]

Date of Birth:  [**2077-4-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
painful foot


Major Surgical or Invasive Procedure:
1. Limb catheterization x 2


History of Present Illness:
59 year old male with h/o HTN and dyslipidemia who was referred
for urgent peripheral catherization for presumed limb ischemia.
Five days prior to admission, he developed sudden onset acute
pain in his left foot. He reports it was worse when laying in
bed. He did not seek medical attention until this weekend, when
he was found not to have a palpable pulse in his left foot. He
described a cold painful foot worse at night while lying flat
but present with ambulation.  Denies a previous history of
claudication like symptoms.  No history of chest pain, SOB or
DOE. No history of palpitations. No history of trauma. Later
evaluated by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**], who described a diminished
DP/PT compared to 2+ on the right and subsequently referred for
urgent cath by Dr. [**Last Name (STitle) 911**].
.
On catherization was found to have an occluded PT and AT filled
slowly by collateral flow. Peroneal origin stump occluded with
proximal clot.  PTA, laser atherectomy and thrombectomy
attempted without success. A Unifuse catheter for overnight
lysis was placed and Pt transferred to CCU. Currently patient
complaining of intermittent Left foot pain. Otherwise w/o
complaint.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain.  All of the other
review of systems were negative.

Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations. Reports dyspnea on heavy exertion. Of note was
seen at NWH last week for vasovagal syncope in setting of
gastroenteritis with dehydration.

Past Medical History:
left hernia repair
hypertension
hyperlipidemia


Social History:
Married. Dentist. Social history is significant for the absence
of current tobacco use. There is no history of alcohol abuse.

Family History:
Father died at age 78 of CAD/diabetes complications

Physical Exam:
General: well appearing NAD
HEENT: conjunctiva were pink with no pallor or cyanosis of the
oral mucosa.
Neck: supple without JVD. No CB's. 2+ carotids
Chest: The respirations were not labored and there were no use
of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs anteriorly
CVS: RRR. normal S1 and the S2 was normal. There were no rubs,
murmurs, clicks or gallops. PMI non-displaced
ABD: abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended.
EXT: no pallor, cyanosis, clubbing or edema. There were no
abdominal, femoral or carotid bruits
Skin: no lesions
Neuro: AO3, CNs intact, sensation to light touch intact.


Pertinent Results:
[**2137-4-2**] 07:30AM   estGFR-Using this
[**2137-4-2**] 07:30AM   GLUCOSE-130* UREA N-29* CREAT-1.2 SODIUM-140
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
[**2137-4-2**] 09:30AM   FIBRINOGE-345
[**2137-4-2**] 09:30AM   PT-12.9 PTT-23.8 INR(PT)-1.1
[**2137-4-2**] 11:17PM   PLT COUNT-288
[**2137-4-2**] 11:17PM   POTASSIUM-4.1
[**2137-4-4**] 05:00AM BLOOD WBC-6.6 RBC-3.51*# Hgb-10.9*# Hct-29.7*
MCV-84 MCH-30.9 MCHC-36.6* RDW-12.9 Plt Ct-213
[**2137-4-4**] 05:00AM BLOOD Calcium-8.3* Phos-3.5 Mg-2.3
.
Peripheral Cath [**2137-4-2**]:
1) Peripheral angiography revealed an angiographically normal
appearing
abdominal aorta, bilateral renal arteries, left CIA, EIA, IIA,
CFA, PFA,
SFA, and popliteal arteries.  The left peroneal artery had an
abrupt
proximal thrombotic occlusion, the left posterior tibial artery
was
occluded, and the left anterior tibial artery was patent but had
a
distal filling defect.  The foot filled via multiple
collaterals.
2) Unsuccessful attempts at PTCA, laser atherectomy, rheolytic
thrombectomy, and stenting was performed in the left peroneal
artery.
Continuous lytic therapy with alteplase was performed via a
Unifuse
catheter and left overnight in the left anterior tibial artery
with
intention to return to the cath lab in 24 hrs to take relook
angiograms.

FINAL DIAGNOSIS:
1. Acute critical limb ischemia with occlusion of the left
posterior
tibial, peroneal, and distal anterior tibial artery.
2. Viable left foot with filling via multiple collaterals.
3. Angiographically normal abdominal aorta and left lower
extremity to
the level of the popliteal artery.
4. [**Name (NI) 16445**] PTCA, laser atherectomy, rheolytic thrombectomy,
and
stenting of the left peroneal artery.
5. Overnight continuous lytic therapy of the left anterior
tibial
artery
.
Venous mapping b/l: The greater saphenous veins are patent
bilaterally. Please see digitized image on PACS for formal
sequential venous measurements
.
Echo [**2137-4-3**]:
Conclusions:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen  ovale is seen by 2D, color Doppler or saline
contrast with maneuvers (cannot  definitively exclude). Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.

* No intracardiac mass/ thrombus identified (cannot definitively
exclude

.
Periph cath [**2137-4-3**]:
1) Sterile 6F sheath exchange for a 6F [**Last Name (un) 12297**] sheath.  Repeat
lower
extremity angiography revealed improved flow in the left
anterior tibial
artery with a persistent distal occlusion with now
reconstitution of the
dorsalis pedis artery.  The plantar and peroneal arteries were
reconstituting via collaterals.  The peroneal and posterior
tibial
arteries were proximally occluded.
2) Intervention on the distal left anterior tibial artery was
attempted.
The lesion was crossed with a Whisper wire.  Distal wire
position in a
robust dorsalis pedis was confirmed by distal contrast
injection.  A
Spider filter was deployed in the DP.  Thrombectomy was
performed with a
ThrombCat thrombectomy catheter.  There was no improved flow
noted and
there was continued collateral filling of the DP and peroneal
arteries.
Given the heavy thrombus burden in the peroneal, posterior
tibial, and
anterior tibial artery that had been unable to be cleared
despite
multiple techniques over 2 days, the foot appeared to still be
viable
due to collateral filling.  After discussion with vascular
surgery, the
decision to follow the patient with clinical exams was made and
if foot
became more ischemic then probable surgical embolectomy or
bypass would
be needed.

FINAL DIAGNOSIS:
1. Improved L anterior tibial artery flow noted with persistent
distal
occlusion, continued occlusion of the left peroneal and
posterior
tibial artery despite overnight infusion of lytic therapy.
2. Left foot viable due to collateral filling.
3. Unsuccessful thrombectomy of the distal left anterior tibial
artery
with essentially unchanged angiography
.
CTA torso [**2137-4-4**]:
1. No evidence of aortic dissection or aneurysm. Mild calcified
atherosclerosis involving the abdominal aorta and common iliac
arteries bilaterally.
2. Sigmoid diverticulosis

Brief Hospital Course:
60 yo with HTN and dyslipidemia presenting with an acute left
limb ischemia.
.
# Left Limb Ischemia: The patient presented with signs/symptoms
of limb ischemia, and peripheral catheterization revealed an
occluded left posterior tibial artery. Attempts at thrombectomy,
angioplasty, and stenting were unsuccessful in restoring flow.
Therefore, a peripheral catheter was left in place and he was
administered heparin and TPa directly to the clot.  Repeat
catheterization the following day revealed minimal improvement
in clot burden, but collateral flow noted in the plantar and
peroneal arteries.  After consulting with vascular surgery, the
patient was started on anticoaggulation systemically and
followed with serial exams.  CTA torso and echocardiogram were
performed and unrevealing of cause of the clot.  His foot pain
and function improved slightly, and he was discharged on
anticoaggulation (lovenox bridge to coumadin) along with an
aspirin daily.  He will follow up with Dr. [**Last Name (STitle) 3060**] from Hematology
for a full work up of hypercoaggulability.  He will also follow
up with his primary care physician.
.
# Dyslipidemia- He was continued on a statin.
.
# HTN- His outpt lisinopril/hctz were  held initially but
restarted upon discharge.
.
# FEN: cardiac/heart healthy diet
.
# PPx: heparin/coumadin, diet
.
# Full Code


Medications on Admission:
Aspirin 81mg daily
Lipitor 40mg daily (increased on [**4-1**])
Zestoretic 10-12.5mg daily


Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
4. Zestoretic 10-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours) for 7 days.
Disp:*1120 mg* Refills:*0*
6. Outpatient Lab Work
Please check PT/PTT INR
Tuesday [**2137-4-9**]
Please fax results to Dr [**First Name11 (Name Pattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 410**] : ([**Telephone/Fax (1) 16446**]


Discharge Disposition:
Home

Discharge Diagnosis:
1. Left limb ischemia


Discharge Condition:
Good


Discharge Instructions:
You were treated for ischemia of your left foot.
You should continue all your medications as prescribed.
You will be on lovenox until your warfarin level is on the
appropiate range INR [**3-9**]
You should have blood drawn on Tuesday [**4-9**] to check your
INR.
If you have worsening pain, fevers, chills or any other symptoms
that may concern you call your PCP or come to the Emergency
department

Followup Instructions:
You should follow up with Dr [**Last Name (STitle) 410**] in [**2-5**] weeks.
You should call Dr [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3060**] (hematology division) to make
an appointment in the next 4 weeks. Phone: ([**Telephone/Fax (1) 16447**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

Completed by:[**2137-4-8**]
{'Atherosclerosis of native arteries of the extremities with rest pain,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: painful foot

PRESENT ILLNESS: 59 year old male with h/o HTN and dyslipidemia who was referred
for urgent peripheral catherization for presumed limb ischemia.
Five days prior to admission, he developed sudden onset acute
pain in his left foot. He reports it was worse when laying in
bed. He did not seek medical attention until this weekend, when
he was found not to have a palpable pulse in his left foot. He
described a cold painful foot worse at night while lying flat
but present with ambulation.  Denies a previous history of
claudication like symptoms.  No history of chest pain, SOB or
DOE. No history of palpitations. No history of trauma. Later
evaluated by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**], who described a diminished
DP/PT compared to 2+ on the right and subsequently referred for
urgent cath by Dr. [**Last Name (STitle) 911**].
.
On catherization was found to have an occluded PT and AT filled
slowly by collateral flow. Peroneal origin stump occluded with
proximal clot.  PTA, laser atherectomy and thrombectomy
attempted without success. A Unifuse catheter for overnight
lysis was placed and Pt transferred to CCU. Currently patient
complaining of intermittent Left foot pain. Otherwise w/o
complaint.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain.  All of the other
review of systems were negative.

MEDICAL HISTORY: left hernia repair
hypertension
hyperlipidemia

MEDICATION ON ADMISSION: Aspirin 81mg daily
Lipitor 40mg daily (increased on [**4-1**])
Zestoretic 10-12.5mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: well appearing NAD
HEENT: conjunctiva were pink with no pallor or cyanosis of the
oral mucosa.
Neck: supple without JVD. No CB's. 2+ carotids
Chest: The respirations were not labored and there were no use
of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs anteriorly
CVS: RRR. normal S1 and the S2 was normal. There were no rubs,
murmurs, clicks or gallops. PMI non-displaced
ABD: abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended.
EXT: no pallor, cyanosis, clubbing or edema. There were no
abdominal, femoral or carotid bruits
Skin: no lesions
Neuro: AO3, CNs intact, sensation to light touch intact.

FAMILY HISTORY: Father died at age 78 of CAD/diabetes complications

SOCIAL HISTORY: Married. Dentist. Social history is significant for the absence
of current tobacco use. There is no history of alcohol abuse. 

### Response:
{'Atherosclerosis of native arteries of the extremities with rest pain,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
