CHIEF COMPLAINT: Ischemic right plantar ulcer with occluded
right bypass graft.

PRESENT ILLNESS: Was obtained from the patient
and transfer data from [**Hospital3 **].  This is a 57-year-old
white male with diabetes, who had a "blister" on the right
plantar fifth met head which was debrided by his podiatrist
seven weeks ago.  After several office debridements, there
was no improvement or healing, the patient was referred to a
Vascular surgeon.

MEDICAL HISTORY: 1. Diabetic type 2 insulin dependent with retinopathy.
2. Bilateral mature cataracts.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is single.  He is an electrician
technologist.  He is a former smoker.  He has not smoked for
35 years.  He denies alcohol use.  He lives with a
significant other.  [**Name (NI) **] ambulates independently.
Other complications due to other vascular device, implant, and graft,Ulcer of heel and midfoot,Other combinations of endocrine dysfunction,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified osteomyelitis, ankle and foot,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Unspecified essential hypertension
Comp-oth vasc dev/graft,Ulcer of heel & midfoot,Comb endocr dysfunct NEC,Abn react-anastom/graft,Osteomyelitis NOS-ankle,DMII ophth nt st uncntrl,Diabetic retinopathy NOS,Hypertension NOS
Admission Date:  [**2170-1-23**]       Discharge Date:  [**2170-1-31**]

Date of Birth:   [**2112-4-3**]       Sex:  M

Service:  Vascular

CHIEF COMPLAINT:  Ischemic right plantar ulcer with occluded
right bypass graft.

HISTORY OF PRESENT ILLNESS:  Was obtained from the patient
and transfer data from [**Hospital3 **].  This is a 57-year-old
white male with diabetes, who had a "blister" on the right
plantar fifth met head which was debrided by his podiatrist
seven weeks ago.  After several office debridements, there
was no improvement or healing, the patient was referred to a
Vascular surgeon.

The patient underwent a right BK [**Doctor Last Name **] to tarsal bypass graft
nonreverse saphenous vein on [**2170-1-17**] at [**Hospital6 **], which failed.  Patient had a thrombectomy of the
bypass graft on [**1-21**], but the graft was occluded.  A right
below the knee amputation was recommended, but the patient
sought a second opinion.  He was seen in the office by Dr.
[**Last Name (STitle) **] on [**2170-1-23**].  He is now admitted for further
evaluation and treatment.

The right foot x-ray at [**Hospital3 **] showed osteomyelitis of
the right fifth met head.  Cultures grew skin flora including
beta hemolytic Strep group B and heavy beta B fragilis group.
Patient was begun on Flagyl and Zithromax 250 mg q.d.  Also
was treated with Silvadene dressings.  Patient was also
admitted for further evaluation and treatment.

ALLERGIES:  No known drug allergies.

MEDICATIONS:
1. Insulin NPH 54 units q.a.m. with 2-8 regular at lunch, and
54 units of NPH presupper with a regular insulin-sliding
scale.
2. Lopressor 25 mg b.i.d.
3. Zantac 150 mg b.i.d.
4. Ativan 0.5 mg t.i.d. prn.
5. Flagyl 500 mg t.i.d.
6. Zithromax 250 mg q.d.
7. Heparin subQ b.i.d.

PAST MEDICAL HISTORY:
1. Diabetic type 2 insulin dependent with retinopathy.
2. Bilateral mature cataracts.

PAST SURGICAL HISTORY:
1. Left thumb surgery.
2. Right BK [**Doctor Last Name **] tarsal artery with nonreverse saphenous vein
on [**2170-1-17**].
3. Thrombectomy of right [**Doctor Last Name **]-PT bypass graft on [**2170-1-21**].
4. Bilateral laser treatments.

SOCIAL HISTORY:  Patient is single.  He is an electrician
technologist.  He is a former smoker.  He has not smoked for
35 years.  He denies alcohol use.  He lives with a
significant other.  [**Name (NI) **] ambulates independently.

PHYSICAL EXAMINATION:  Vital signs:  98.3, 76, 18, blood
pressure 126/52, O2 saturation 98% on room air.  General
appearance:  Alert and cooperative white male in no acute
distress.  HEENT examination is unremarkable.  Carotids are
palpable without bruits.  Pulse examination:  Radials are 2+
bilaterally.  Femorals are 2+ bilaterally.  The right
popliteal is absent at the dorsalis pedis and PT on the right
Doppler signal.  The popliteal on the left is 2+ with a
dopplerable dorsalis pedis on the left and a palpable PT on
the left.  Chest examination:  Lungs are clear to
auscultation.  Heart is regular, rate, and rhythm without
murmur, but distant.  Abdominal examination was benign.
Right lower extremity shows [**Doctor Last Name **]-tarsal bypass sutures intact
with erythema along the entire length.  There is a Penrose
drain at the distal incision.  The plantar fifth met head
ulcer is 2.5 cm, which probes to bone.  There is no odor.
There is minimal drainage.

ADMITTING LABORATORIES:  White count of 11.3, hematocrit
32.5, platelets 397 K.  BUN 16, creatinine 0.8.  PT and INR
were normal.

EKG was in normal sinus rhythm with a rate of 79, there are
no acute ischemic changes.

Chest x-ray was unremarkable.

HOSPITAL COURSE:  Patient was admitted to the Vascular
service.  He was continued on antibiotics.  [**Last Name (un) **] was
requested to evaluate and manage the patient's diabetes.  The
patient was preoped and underwent on [**2170-1-26**], patient had a
right [**Doctor Last Name **] to plantar bypass with left arm vein angioscopy and
intraoperative arteriogram.  Patient tolerated the procedure
well.  Was extubated and transferred to the PACU in stable
condition.

Postoperatively, immediately the patient was hemodynamically
stable.  His postoperative hematocrit was 29.7, BUN 17,
creatinine 0.8, K of 4.4.  Patient continued to remain stable
and was transferred to the VICU for continued monitoring and
care.

On postoperative day one, there were no overnight events.
Patient's diet was advanced as tolerated.  He was restarted
on is preoperative oral medications.  He was transfused 1
unit of packed red blood cells.

Postoperative day two the patient remained in the VICU.
There were no overnight events.  On postoperative day three,
patient's Foley was discontinued.  Central line was
discontinued.  Vancomycin was discontinued.  His
post-transfusion hematocrit was 27.9.  Antibiotics were
continued, and patient was transferred to the regular nursing
floor.

Patient required multiple adjustments in his insulin dosing.
He was begun on NPH insulin with adjustments.  Patient should
follow up with [**Last Name (un) **], Dr. [**Last Name (STitle) 54300**] for evaluation and
long-term management of his diabetes.  Patient should call
for an appointment.  Considerations of Lantus will be decided
at that time.  Patient will also require patient education
regarding injections.  Weightbearing status at the time of
discharge was partial weightbearing, heel touchdown only,
essential distances.  Patient should elevate the leg when
sitting in a chair in bed.

The patient had PVRs of the right transmetatarsal done prior
to discharge.  Depending on what the PVR shows, what further
intervention will or will not be needed for the ulceration.
Patient will continue on antibiotics for two weeks post
discharge.  Wounds at the time of discharge were clean, dry,
and intact.  The right foot wound was with minimal erythema
with normal saline wet-to-dry dressings t.i.d.

DISCHARGE MEDICATIONS:
1. Flagyl 500 mg t.i.d. for a total of 14 days.
2. Acetaminophen 325-650 mg q.4-6h. prn for pain.
3. Colace 100 mg b.i.d.
4. Senna two q.d. prn.
5. Metoprolol 25 mg b.i.d., hold for systolic blood pressure
less than 110, heart rate less than 55.
6. Ranitidine 150 mg b.i.d.
7. Levofloxacin 500 mg q.24h. for a total of 14 days.
8. Insulin-sliding scale as follows:  NPH insulin 54 units at
breakfasttime and 28 units at bedtime.  Humalog sliding scale
breakfast, lunch, dinner and at bedtime.  Breakfast sliding
scale and dinner sliding scale are as follows:  Glucoses less
than 120, no insulin; 121-160, 2 units; 161-200, 4 units;
201-240, 6 units; 241-280, 8 units; 281-320 10 units; 321-360
12 units; 361-400 14 units.  Lunchtime Humalog sliding scale:
glucoses less than 240, no insulin; 241-280 4 units; 281-320
6 units; 321-360 8 units; 361-400 10 units.  Bedtime sliding
scale is as follows:  Glucoses less than 240 no insulin;
241-280 2 units; 281-320 4 units; 321-360 6 units; 361-400 8
units.

DISCHARGE DIAGNOSES:
1. Ischemic foot ulcer status post right popliteal-pedal
bypass with arm vein and intraoperative angiogram.
2. Insulin dependent diabetes type 2.
3. Blood loss anemia corrected.
4. Hypertension controlled.



                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 19472**]

Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36

D:  [**2170-1-30**]  12:11
T:  [**2170-1-30**]  12:45
JOB#:  [**Job Number 54301**]
{'Other complications due to other vascular device, implant, and graft,Ulcer of heel and midfoot,Other combinations of endocrine dysfunction,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified osteomyelitis, ankle and foot,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,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: Ischemic right plantar ulcer with occluded
right bypass graft.

PRESENT ILLNESS: Was obtained from the patient
and transfer data from [**Hospital3 **].  This is a 57-year-old
white male with diabetes, who had a "blister" on the right
plantar fifth met head which was debrided by his podiatrist
seven weeks ago.  After several office debridements, there
was no improvement or healing, the patient was referred to a
Vascular surgeon.

MEDICAL HISTORY: 1. Diabetic type 2 insulin dependent with retinopathy.
2. Bilateral mature cataracts.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: Patient is single.  He is an electrician
technologist.  He is a former smoker.  He has not smoked for
35 years.  He denies alcohol use.  He lives with a
significant other.  [**Name (NI) **] ambulates independently. 

### Response:
{'Other complications due to other vascular device, implant, and graft,Ulcer of heel and midfoot,Other combinations of endocrine dysfunction,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified osteomyelitis, ankle and foot,Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled,Background diabetic retinopathy,Unspecified essential hypertension'}
