CHIEF COMPLAINT: ischemic gangrenous right 3rd toe

PRESENT ILLNESS: patient was refered to Dr. [**Last Name (STitle) 1391**] for nonhealing rt. toe
ulceration evaluation and underwent a diagnostic angiogram on
[**2146-5-19**]. Returns [**2146-5-23**] for perioperative antibiotics and rt. leg
vascular revascularzation. No interval changes since d/c [**2146-5-20**].

MEDICAL HISTORY: history of DM2, uncontrolled, insulin-dependant with
hyperglycemia requiring IV insulin gtt. on admission
[**Date range (2) 94001**].
history of ischemic heart disease, MI [**2135**], s/p PCI/stenting RCA
[**2139**], s/p 4V CABG's w mitral annulus ring [**2138**], occluded graftx3
w/patient LIMA/LAD graft by cath [**2-22**] (Lima-LAD,SVG-dg,OM,RCA)
history of chronic systolic and diastolic CHF, compensated
history of progressive aortic valve stenosis by TEE [**5-24**]
history of hyperlipdemia-statins
history of chronic obstructive pulmonary disease-inhalers
history of Bell's Palsey
history of tobacco use 30pk-yrs d/c'd [**2144**]
history of hypertension
history of tonsillectomy

MEDICATION ON ADMISSION: humalog 50-50 (35U), plavix 75', toprol XL 100 (1.5 tab daily),
lisinopril 20', amlodipine 2.5', digoxin 50mcg ([**11-17**] cap daily),
tramadol 50''', ibuprofen 800 (1 tab q6-8h prn), nitroquick 0.4
SL ([**11-18**] tab prn), Niaspan 500'' qhs, crestor 20', spiriva
w/handihaler 18mcg and inhalation cap', combivent 18mcg-103mcg
(3 aerosols prn), spironolactone', loperamide 2mg', protonix
40', tricor 48'', gabapentin 100''', lantus (25 cartridge),
amoxicillin 500'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VSS
NAD
RRR, systolic murmur
CTAB, no crackles
Abd soft, NT/ND, +BS
R leg with staples in place, c/d/i
R 3rd toe amputation site with sutures in place, c/d/i
DP/PT [**Name (NI) **] bilaterally

FAMILY HISTORY: positive for CAD father @ age 40
positive for MI mother @  age 64 w/b CHF

SOCIAL HISTORY: habits smoking d/c since [**2144**]
Denies ETOH
Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Acute kidney failure with lesion of tubular necrosis,Atherosclerosis of native arteries of the extremities with gangrene,Rheumatic heart failure (congestive),Ulcer of other part of foot,Long-term (current) use of insulin,Polyneuropathy in diabetes,Mitral valve insufficiency and aortic valve stenosis,Carrier or suspected carrier of other specified bacterial diseases,Infection with microorganisms resistant to penicillins,Iron deficiency anemia secondary to blood loss (chronic),Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Other and unspecified hyperlipidemia,Other emphysema,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use
DMII circ uncntrld,Ac kidny fail, tubr necr,Ath ext ntv art gngrene,Rheumatic heart failure,Ulcer other part of foot,Long-term use of insulin,Neuropathy in diabetes,Mitral insuf/aort stenos,Bacteria dis carrier NEC,Inf mcrg rstn pncllins,Chr blood loss anemia,Cor ath unsp vsl ntv/gft,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Dysthymic disorder,Hyperlipidemia NEC/NOS,Emphysema NEC,Old myocardial infarct,Status-post ptca,History of tobacco use
Admission Date:  [**2146-5-23**]              Discharge Date:   [**2146-6-1**]

Date of Birth:  [**2093-9-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ischemic gangrenous right 3rd toe

Major Surgical or Invasive Procedure:
Right fem-PT [**Name (NI) **] [**Name (NI) 94000**] and right 3rd toe amputation [**2146-5-24**]


History of Present Illness:
patient was refered to Dr. [**Last Name (STitle) 1391**] for nonhealing rt. toe
ulceration evaluation and underwent a diagnostic angiogram on
[**2146-5-19**]. Returns [**2146-5-23**] for perioperative antibiotics and rt. leg
vascular revascularzation. No interval changes since d/c [**2146-5-20**].

Past Medical History:
history of DM2, uncontrolled, insulin-dependant with
hyperglycemia requiring IV insulin gtt. on admission
[**Date range (2) 94001**].
history of ischemic heart disease, MI [**2135**], s/p PCI/stenting RCA
[**2139**], s/p 4V CABG's w mitral annulus ring [**2138**], occluded graftx3
w/patient LIMA/LAD graft by cath [**2-22**] (Lima-LAD,SVG-dg,OM,RCA)
history of chronic systolic and diastolic CHF, compensated
history of progressive aortic valve stenosis by TEE [**5-24**]
history of hyperlipdemia-statins
history of chronic obstructive pulmonary disease-inhalers
history of Bell's Palsey
history of tobacco use 30pk-yrs d/c'd [**2144**]
history of hypertension
history of tonsillectomy


Social History:
habits smoking d/c since [**2144**]
Denies ETOH

Family History:
positive for CAD father @ age 40
positive for MI mother @  age 64 w/b CHF

Physical Exam:
VSS
NAD
RRR, systolic murmur
CTAB, no crackles
Abd soft, NT/ND, +BS
R leg with staples in place, c/d/i
R 3rd toe amputation site with sutures in place, c/d/i
DP/PT [**Name (NI) **] bilaterally


Pertinent Results:
[**2146-5-28**] 03:55AM BLOOD WBC-6.2 RBC-3.51* Hgb-10.1* Hct-29.2*
MCV-83 MCH-28.9 MCHC-34.8 RDW-13.9 Plt Ct-226
[**2146-5-27**] 08:22PM BLOOD Hct-30.3*
[**2146-5-27**] 04:50AM BLOOD WBC-8.3 RBC-3.20* Hgb-9.4* Hct-26.7*
MCV-83 MCH-29.2 MCHC-35.1* RDW-13.9 Plt Ct-225
[**2146-5-26**] 02:08PM BLOOD Hct-26.7*
[**2146-5-26**] 04:36AM BLOOD WBC-9.4 RBC-3.15* Hgb-9.1* Hct-26.4*
MCV-84 MCH-28.9 MCHC-34.4 RDW-14.0 Plt Ct-209
[**2146-5-25**] 02:49PM BLOOD Hct-25.6*
[**2146-5-25**] 04:07AM BLOOD WBC-7.2 RBC-2.99* Hgb-8.5* Hct-25.4*
MCV-85 MCH-28.5 MCHC-33.6 RDW-13.8 Plt Ct-248
[**2146-5-24**] 08:27PM BLOOD WBC-7.2 RBC-3.14* Hgb-9.1* Hct-27.0*
MCV-86 MCH-28.8 MCHC-33.6 RDW-13.8 Plt Ct-273
[**2146-5-24**] 10:20AM BLOOD WBC-6.8 RBC-2.79* Hgb-8.0* Hct-23.6*
MCV-85 MCH-28.5 MCHC-33.8 RDW-13.4 Plt Ct-291
[**2146-5-24**] 08:27PM BLOOD PT-14.6* PTT-29.7 INR(PT)-1.3*
[**2146-5-24**] 10:20AM BLOOD PT-13.7* PTT-29.3 INR(PT)-1.2*
[**2146-5-28**] 03:55AM BLOOD Glucose-156* UreaN-31* Creat-1.5* Na-138
K-4.2 Cl-102 HCO3-27 AnGap-13
[**2146-5-27**] 04:50AM BLOOD Glucose-170* UreaN-32* Creat-1.5* Na-136
K-4.4 Cl-102 HCO3-26 AnGap-12
[**2146-5-26**] 04:36AM BLOOD Glucose-120* UreaN-31* Creat-1.6* Na-137
K-4.2 Cl-103 HCO3-28 AnGap-10
[**2146-5-25**] 04:07AM BLOOD Glucose-183* UreaN-38* Creat-1.8* Na-139
K-5.0 Cl-106 HCO3-26 AnGap-12
[**2146-5-24**] 08:27PM BLOOD Glucose-158* UreaN-40* Creat-1.8* Na-139
K-4.9 Cl-105 HCO3-26 AnGap-13
[**2146-5-24**] 10:20AM BLOOD Glucose-104 UreaN-40* Creat-1.7* Na-140
K-4.7 Cl-105 HCO3-28 AnGap-12
[**2146-5-26**] 04:36AM BLOOD CK(CPK)-301*
[**2146-5-25**] 09:45PM BLOOD CK(CPK)-206*
[**2146-5-25**] 07:42AM BLOOD CK(CPK)-144
[**2146-5-25**] 04:07AM BLOOD CK(CPK)-126
[**2146-5-24**] 08:27PM BLOOD ALT-41* AST-56* CK(CPK)-66
[**2146-5-26**] 04:36AM BLOOD CK-MB-2 cTropnT-0.05*
[**2146-5-25**] 09:45PM BLOOD CK-MB-2 cTropnT-0.06*
[**2146-5-25**] 02:49PM BLOOD CK-MB-2 cTropnT-0.06*
[**2146-5-25**] 07:42AM BLOOD CK-MB-3 cTropnT-0.08*
[**2146-5-28**] 03:55AM BLOOD Calcium-8.8 Phos-4.5
[**2146-5-27**] 04:50AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
[**2146-5-26**] 04:36AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.2
[**2146-5-25**] 04:07AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9
[**2146-5-24**] 08:27PM BLOOD Calcium-8.4 Phos-3.7 Mg-2.1
[**2146-5-24**] 10:20AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2

Brief Hospital Course:
[**2146-5-23**] Admitted. antibiotics began. Preop'd for surgery
[**2146-5-24**] right fem-PT [**Name (NI) 45029**]. transferd to PACU IV NTG gtt for
systolic HTN and elevated pulmonary aryery pressures. Stable and
tansfered to VICU.
[**2146-5-25**] POD #1 Temperature max 100.6 Vanco/Zosyn continued. diet
advanced. Remain on bedrest. cardiac enzymes cycled. transfused
1 unit PRBCs Hct. 25.6. Swan remains in place. Remains in VICU
[**2146-5-26**] POD#2 Temperature 102, blood cultures and urine cultures
obtained. post transfusion HCT (2 units PRBC) 26.5. IV Ngtt
continued. Insulin adjusted. Diuresed.
[**2146-5-27**] POD#3 Transfused for Hct 26. NTG patch started and IV
ntg weaned. Swan converted to CVL. lasix, spirolactone and ACE-I
restarted. OOB to chair. PT to evaluate.
[**2146-5-28**] POD#4 Stable. Afebrile.
[**2146-5-29**] POD#5 Worked with PT with crutches and weight-bearing on
right. Removed arterial line.
[**2146-5-30**] POD#6 Removed central line. Worked with PT with walking
and stairs. [**Hospital **] rehab today.

Medications on Admission:
humalog 50-50 (35U), plavix 75', toprol XL 100 (1.5 tab daily),
lisinopril 20', amlodipine 2.5', digoxin 50mcg ([**11-17**] cap daily),
tramadol 50''', ibuprofen 800 (1 tab q6-8h prn), nitroquick 0.4
SL ([**11-18**] tab prn), Niaspan 500'' qhs, crestor 20', spiriva
w/handihaler 18mcg and inhalation cap', combivent 18mcg-103mcg
(3 aerosols prn), spironolactone', loperamide 2mg', protonix
40', tricor 48'', gabapentin 100''', lantus (25 cartridge),
amoxicillin 500'

Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
9. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

11. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO BID (2 times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-17**]
Puffs Inhalation Q4H (every 4 hours) as needed.
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal Q24H (every 24 hours).
16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 5 days.
22. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
23. insulin
please see attached insulin sliding scale
24. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
s/p right fem-PT bypass graft and right 3rd toe amputation
DM2 insulin dependant, uncontrolled
history of ischemic heart diseases/p MI s/p PTCI/stents [**2135**],
s/p 4V-CABG's, [**2138**] with occluded grafts x3 with patent LiMA-lad
graft by cardiac cath [**1-22**]
history of hyperlipdemia
history of chronic obstructive pulmonary disease
history of depression and anxiety
history of Bell's palsey
history of tobacco use,d/c x 1 yr prior 30pkyrs
history of acute diastolic and systolic congestive heart
failure-compensated
history of tonsillectomy
postoperative blood loss anemia, transfused
postoperative CHF excerbation, diuresed
postop TEE-progressive AS
history of mitral valve disease(MR) s/p mitral annulus ring
placement w/CABG's


Discharge Condition:
stable


Discharge Instructions:
Incision Care:  Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-Your staples will be removed during at your follow up
appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5(F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication.  You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**8-31**]  lbs) until your follow up appointment.
* Adhere to 2 gm sodium diet


Followup Instructions:
Follow-up with your cardiologist after discharge.
Follow-up with your [**Last Name (un) **] physician after discharge for any
changes to your insulin regimen.
Follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks to have staples removed,
call for an appointment [**Telephone/Fax (1) 1393**].



Completed by:[**2146-5-30**]

Name:  [**Known lastname **],[**Known firstname 126**] R.             Unit No:   [**Numeric Identifier 14706**]

Admission Date:  [**2146-5-23**]              Discharge Date:   [**2146-6-1**]

Date of Birth:  [**2093-9-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 231**]
Addendum:
addtitional d/c dx
: acute on chronic renal failure

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
postoperative acute renal failure on chronic renal failure

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]

Completed by:[**2146-6-1**]

Name:  [**Known lastname **],[**Known firstname 126**] R.             Unit No:   [**Numeric Identifier 14706**]

Admission Date:  [**2146-5-23**]              Discharge Date:   [**2146-6-1**]

Date of Birth:  [**2093-9-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 231**]
Addendum:
[**2146-5-31**]
Just prior to discharge to rehab yesterday, patient began to
experience some lightheadedness. SBP was measured to be in the
80-90s, so patient was kept overnight for monitoring. PM Lasix
and metoprolol doses were held for low BP.
[**2146-6-1**] b/p improved. d/c to rehab

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 5025**] & Rehab Center - [**Location (un) **]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]

Completed by:[**2146-6-1**]
{'Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Acute kidney failure with lesion of tubular necrosis,Atherosclerosis of native arteries of the extremities with gangrene,Rheumatic heart failure (congestive),Ulcer of other part of foot,Long-term (current) use of insulin,Polyneuropathy in diabetes,Mitral valve insufficiency and aortic valve stenosis,Carrier or suspected carrier of other specified bacterial diseases,Infection with microorganisms resistant to penicillins,Iron deficiency anemia secondary to blood loss (chronic),Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Other and unspecified hyperlipidemia,Other emphysema,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use'}


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: ischemic gangrenous right 3rd toe

PRESENT ILLNESS: patient was refered to Dr. [**Last Name (STitle) 1391**] for nonhealing rt. toe
ulceration evaluation and underwent a diagnostic angiogram on
[**2146-5-19**]. Returns [**2146-5-23**] for perioperative antibiotics and rt. leg
vascular revascularzation. No interval changes since d/c [**2146-5-20**].

MEDICAL HISTORY: history of DM2, uncontrolled, insulin-dependant with
hyperglycemia requiring IV insulin gtt. on admission
[**Date range (2) 94001**].
history of ischemic heart disease, MI [**2135**], s/p PCI/stenting RCA
[**2139**], s/p 4V CABG's w mitral annulus ring [**2138**], occluded graftx3
w/patient LIMA/LAD graft by cath [**2-22**] (Lima-LAD,SVG-dg,OM,RCA)
history of chronic systolic and diastolic CHF, compensated
history of progressive aortic valve stenosis by TEE [**5-24**]
history of hyperlipdemia-statins
history of chronic obstructive pulmonary disease-inhalers
history of Bell's Palsey
history of tobacco use 30pk-yrs d/c'd [**2144**]
history of hypertension
history of tonsillectomy

MEDICATION ON ADMISSION: humalog 50-50 (35U), plavix 75', toprol XL 100 (1.5 tab daily),
lisinopril 20', amlodipine 2.5', digoxin 50mcg ([**11-17**] cap daily),
tramadol 50''', ibuprofen 800 (1 tab q6-8h prn), nitroquick 0.4
SL ([**11-18**] tab prn), Niaspan 500'' qhs, crestor 20', spiriva
w/handihaler 18mcg and inhalation cap', combivent 18mcg-103mcg
(3 aerosols prn), spironolactone', loperamide 2mg', protonix
40', tricor 48'', gabapentin 100''', lantus (25 cartridge),
amoxicillin 500'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VSS
NAD
RRR, systolic murmur
CTAB, no crackles
Abd soft, NT/ND, +BS
R leg with staples in place, c/d/i
R 3rd toe amputation site with sutures in place, c/d/i
DP/PT [**Name (NI) **] bilaterally

FAMILY HISTORY: positive for CAD father @ age 40
positive for MI mother @  age 64 w/b CHF

SOCIAL HISTORY: habits smoking d/c since [**2144**]
Denies ETOH 

### Response:
{'Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled,Acute kidney failure with lesion of tubular necrosis,Atherosclerosis of native arteries of the extremities with gangrene,Rheumatic heart failure (congestive),Ulcer of other part of foot,Long-term (current) use of insulin,Polyneuropathy in diabetes,Mitral valve insufficiency and aortic valve stenosis,Carrier or suspected carrier of other specified bacterial diseases,Infection with microorganisms resistant to penicillins,Iron deficiency anemia secondary to blood loss (chronic),Coronary atherosclerosis of unspecified type of vessel, native or graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Dysthymic disorder,Other and unspecified hyperlipidemia,Other emphysema,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Personal history of tobacco use'}
