CHIEF COMPLAINT: necrotic toes

PRESENT ILLNESS: The patient is an 82 yo M with ESRD (HD M,W,F), HTN, AFib, PVD,
Hyperlipidemia and CAD s/p ACS and recent stenting presents to
vascular clinic c/o "necrotic toes".  He was seen as an
inpatient about a month ago and found to have ischemic
toes on both feet.  At that time he had cardiac/medical issues
which were treated first.  He presented from rehab today with
complaints of drainage from a necrotic toe on the right foot. He
says that over the past week he has had a lot more pain in his
feet and walking has become more difficult. He denies any
fevers, chills, chest pain, sob. Of note, he was recently
restarted on coumadin.  Per rehab records he received 2.5mg of
coumadin on the 17th, 18th and 20th and his INR at rehab today
was 8.4 .

MEDICAL HISTORY: ESRD - ? [**1-30**] interstitial nephritis from anti-hypertensives per
Atrius PCP note, [**Name Initial (PRE) **] arm fistula
Afib
Hyperparathyroidism [**1-30**] ESRD
CAD
HTN
HLD
Cholecystectomy

MEDICATION ON ADMISSION: coumadin 2.5mg'; plavix 75, dronedarone 400'', lactulose,
bisacodyl, lasix 100', lopressor 50'', nitro tab prn,
calcitriol0.25', renagel 800'''; crestor 40', asa 81';
nephrocaps'; prilosec 20'; tylenol; oxycodone

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Skin: No atypical lesions.
Heart: Irreg rhythm(afib).
Lungs: Clear to auscultation bilat; Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Extremities: Feet are cool to the touch bilat. No RLE edema, No
LLE Edema, abnormal: 2nd toe amps on the right and left feet.
Right 3rd toe is necrotic with a small ulcer at the base, and a
small amt of drainage. Right 4th toe is necrotic and dry. Left
3rd toe is necrotic and dry.
Pulses:
DP/PT dopplerable bilat

FAMILY HISTORY: Unknown

SOCIAL HISTORY: He is a retired anesthesiologist and was working part-time as a
laboratory technician. He does not smoke. Denies EtOH. No
recreational drug use. He has 4 children and a wife and is from
the [**Country 31115**] and there is no heart disease in his family.
Living with daughter near HD site.
Atherosclerosis of native arteries of the extremities with gangrene,Cerebral embolism with cerebral infarction,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Other dysphagia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Chronic airway obstruction, not elsewhere classified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Other persistent mental disorders due to conditions classified elsewhere,Renal dialysis status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants
Ath ext ntv art gngrene,Crbl emblsm w infrct,End stage renal disease,Food/vomit pneumonitis,Acute respiratry failure,Hyp kid NOS w cr kid V,Sec hyperparathyrd-renal,Atrial fibrillation,Dysphagia NEC,Crnry athrscl natve vssl,Iatrogenc hypotnsion NEC,Chr airway obstruct NEC,Hyperlipidemia NEC/NOS,Anemia in chr kidney dis,Mental disor NEC oth dis,Renal dialysis status,Status-post ptca,Long-term use anticoagul
Admission Date:  [**2159-12-18**]              Discharge Date:   [**2160-1-10**]

Date of Birth:  [**2077-5-9**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
necrotic toes

Major Surgical or Invasive Procedure:
Right lower extremity angiography with percutaneous angioplasty
of right peroneal artery x2

History of Present Illness:
The patient is an 82 yo M with ESRD (HD M,W,F), HTN, AFib, PVD,
Hyperlipidemia and CAD s/p ACS and recent stenting presents to
vascular clinic c/o "necrotic toes".  He was seen as an
inpatient about a month ago and found to have ischemic
toes on both feet.  At that time he had cardiac/medical issues
which were treated first.  He presented from rehab today with
complaints of drainage from a necrotic toe on the right foot. He
says that over the past week he has had a lot more pain in his
feet and walking has become more difficult. He denies any
fevers, chills, chest pain, sob. Of note, he was recently
restarted on coumadin.  Per rehab records he received 2.5mg of
coumadin on the 17th, 18th and 20th and his INR at rehab today
was 8.4 .

Past Medical History:
ESRD - ? [**1-30**] interstitial nephritis from anti-hypertensives per
Atrius PCP note, [**Name Initial (PRE) **] arm fistula
Afib
Hyperparathyroidism [**1-30**] ESRD
CAD
HTN
HLD
Cholecystectomy


Social History:
He is a retired anesthesiologist and was working part-time as a
laboratory technician. He does not smoke. Denies EtOH. No
recreational drug use. He has 4 children and a wife and is from
the [**Country 31115**] and there is no heart disease in his family.
Living with daughter near HD site.


Family History:
Unknown

Physical Exam:
ADMISSION PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Skin: No atypical lesions.
Heart: Irreg rhythm(afib).
Lungs: Clear to auscultation bilat; Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Extremities: Feet are cool to the touch bilat. No RLE edema, No
LLE Edema, abnormal: 2nd toe amps on the right and left feet.
Right 3rd toe is necrotic with a small ulcer at the base, and a
small amt of drainage. Right 4th toe is necrotic and dry. Left
3rd toe is necrotic and dry.
Pulses:
DP/PT dopplerable bilat

DISCHARGE PHYSICAL EXAM
Vitals: Tm 99.4, Tc98.2, BP 100s-140s/50s-60s, 70s-80s, RR20,
95/RA
General: oriented to self, [**Hospital1 **], year, interactive,
following commands
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: S1, S2 regular rhythm, normal rate
Abdomen: soft, ntnd, no guarding, no rebound
Ext: right 3-5th amputation side c/d/i, great toe necrotic,
motor is [**1-2**] in LE, [**2-2**] in UE bilaterally


Pertinent Results:
Admission Labs:
WBC-9.7 RBC-3.68* Hgb-11.2* Hct-34.5* MCV-94 MCH-30.5 MCHC-32.5
RDW-19.3* Plt Ct-285
PT-106.0* PTT-49.7* INR(PT)-13.4*
Glucose-117* UreaN-46* Creat-6.6*# Na-141 K-4.5 Cl-95* HCO3-31
AnGap-20
Calcium-8.5 Phos-5.9* Mg-3.0*

FOOT FILMS [**12-17**]
IMPRESSION: No radiographic evidence of osteomyelitis.

PRE-OP CXR [**12-17**]
IMPRESSION: Slight interstitial pulmonary edema with
cardiomegaly. No
superimposed acute process.

CT SINUS/MANDIBLE [**12-18**]
IMPRESSION:
1. No evidence for facial or orbital fracture.
2. Severe degenerative disease involving both temporomandibular
joints and the included upper cervical spine.
3. Chronic inflammatory sinus disease.

CT HEAD [**12-18**]
IMPRESSION: No evidence for intracranial hemorrhage.
Wedge-shaped
hypodensities in the left cerebellum, suggestive or prior
infarcts.

ART EXT [**12-24**]
IMPRESSION: Evidence of bilateral tibial disease at rest, which
appears
similar in comparison to the prior examination from one month
ago.

PATHOLOGY LEFT 2ND/4TH TOES [**12-25**]
Left 2nd and 4th toes and right 3rd and 4th toes (A-H):
1.  Gangrene, all toes.
2.  Atheroemboli are seen in multiple vessels.

CARDIAC CATH REPORT [**12-27**]
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease, with a known totally
occluded RCA
and patent OM stent.

CXR [**2159-12-29**]
There is again seen a hazy opacity within the lung bases
bilaterally which are
stable and may represent early infiltrate. Aspiration is also a
consideration. There is unchanged cardiomegaly and calcification
and
tortuosity of thoracic aorta. There is some mild prominence of
the pulmonary inteRstitial markings. The right-sided central
venous catheter has the lead tip in the distal SVC, stable.

CHANGE OF G-GJ TUBE
IMPRESSION: Successful exchange of a percutaneous endoscopically
placed
gastrostomy tube for an 18 French MIC gastrojejunostomy tube.
The tube is
ready for use.

CHEST XRAY [**2159-12-31**]
There is no change in the cardiomediastinal silhouette
appearance including
cardiomegaly and tortuous and most likely dilated aortic arch.
Lungs are
unchanged in appearance including left retrocardiac atelectasis
and to a
lesser degree right retrocardiac atelectasis. There is no
interval
development of pneumothorax. No appreciable pleural effusion is
noted,
although a small amount of fluid cannot be excluded. PEG is
projecting over
the upper abdomen. If the bibasilar atelectasis reflects
aspiration, there
has been no significant change since the prior study, thus
aspiration
pneumonia should be considered.


Brief Hospital Course:
Dr [**Known lastname **] is an 82 M with PVD, CKD on HD MWF, progressive
dementia, who was admitted to the vascular surgery service for
evaluation and treatment of his bilateral toe gangrene.  He was
transferred to the Medicine service for continued management of
his aspiration PNA, A-fib with RVR, and CVA found on CT imaging.

#Gangrene of toes:  Dr. [**Known lastname **] was initially admitted with
gangrenous toes and was admitted to the vascular service for
evaluation and treatment of his bilateral toe gangrene.  He
underwent right lower extremity angiography, which showed
single-vessel run-off into the lower leg through his peroneal
artery, which was angioplastied in 2 places.  He later underwent
left lower extremity angiography, which also showed
single-vessel run-off and a long segment of the peroneal artery
was angioplastied and stented.  He was taken to the OR on [**12-25**]
for amputations of his right 3rd and 4th toes, and his left 3rd
and 5th toes.  He was then transferred to the Medicine service
for further management of his MMP.  The vascular service
continued to follow the patient while he was under the care of
the Medicine service both on the floor and in the ICU and
recommended eventual amputation when the patient is more stable
(as he was noted to have a necrotic great toe on the right foot
c/w dry gangrene).  As such, he was discharged with outpatient
follow up appointments with the Vascular service for further
work up.  The pt will need to have dry dressing changes
continued as per vascular recs.
.
# Respiratory/PNA/Excess Secretions:  Dr.[**Name (NI) 93718**] breathing was
labored on admission, with evidence of fluid overload on his
CXR.  He has COPD and was using accessory muscles for breathing,
though his family reports this is his baseline.  His oxygen
requirement increased over a few days, and he began having a wet
[**Last Name (LF) **], [**First Name3 (LF) **] a CXR was obtained on [**12-26**] which showed a likely
aspiration pneumonia.  Pt was started on vanc/cipro/flagyl by
Vascular Surgery with white count and CXR indicative of possible
PNA.  Febrile to 100.4 two days prior to transfer to medicine.
The medicine team continued same abx and changed to vanc/zosyn
on day of transfer to MICU (on [**2159-12-29**]).  Of note, became acutely
tachypneic on morning of [**2159-12-29**]. While volume overload was
certainly possible given the 2 units of pRBCs received o/n (see
below under anemia), it was thought more likely [**1-30**] mucus
plugging as the RN noted increased suction requirement Q15
minutes.  As such, a repeat CXR was done and an ABG showed that
the pt did seem to be retaining CO2.  Due to increased RN needs
and respiratory decompensation, pt was transferred to MICU-7. In
the MICU, over 300mL of TFs were suctioned from his G tube
suggesting that the patient may have been chronically aspirating
while on the floor. his TFs were held and antibiotics
(Vanc/zosyn) were continued for aspiration PNA. He was noted to
have trouble clearing his own secretions but with suctioning was
able to maintain his airway and hypoxia resolved. Trach was
considered but given his ability to [**Month/Day (2) **] up secretions this was
deferred. Vanc/zosyn was continued for an 8 day course and
completed on [**2160-1-4**].  After transfer back to the floor, he was
continued to be seen with respiratory c/s for deep suction and
chest PT.  Upon discharge, he was on room air and would
occasionally be placed on face mask or NC for comfort.  Also,
the pt was kept on his prn nebs and guaifenesin for comfort.
.
#CVA: His speech was quite garbled on admission, though he was
generally alert and oriented.  His family reports that his
speech has been declining over the past few months, and that his
primary physician has been evaluating him for this problem.  A
head CT obtained this admission did not show any evidence of
acute hemorrhage, though did show wedge-shaped hypodensities in
the left cerebellum, suggestive of prior infarcts.  Upon
transfer to Medicine, notified family of finding.  Of note, pt
has very poor cerebellar exam, and possibly contributing to the
dysphagia which led to the aspiration event (see below for
dysphagia management).  As the CVA seems to be 10 days old at
least, neuro was not contact[**Name (NI) **] as not much to do and out of time
where herniation is an imminent possibility.  He was set up with
neuro f/u as an outpatient.  PT/OT consults were called and the
dysphagia managed as below. His neurologic exam on discharge was
alert, oriented X 2, able to answer questions with one word
answers appropriately, tremor worse on left than right, with
poor motor function throughout ([**1-2**]).  As such, our suspicion
for further stroke was high, however we held off on further
imaging as it would not change our acute management and as per
further discussion with the family, would not be in line with
goals of care.  Of note, he was started on heparin gtt
transiently while INR was subtherapeutic given CVA, A-fib, and
PVD.  We d/c'ed heparin gtt on [**2160-1-7**] given high risk of
hemorrhagic event on multiple antiplatelet/anticoagulant
medications.  He was discharged on ASA/plavix/coumadin (INR of
2.5).  He will have his INR checked as an outpatient and faxed
to his PCP's office for titration.  Coumadin dose at time of d/c
was 2 mg.
.
# A-fib: Pt has h/o of afib and was on dronadarone prior to
admission.  Upon admission, his INR was 13.4 thought to be [**1-30**]
dronadarone and coumadin. He was reversed with Vitamin K. He was
nted to go into rapid A-fib with HD.  Was amio loaded which
brought pt back into sinus.  Was then maintained on dronadarone.
 Unfortunately, he continued to have RVR recurrence with HD, so,
the patient was fully loaded with amio and then transitioned to
PO amiodarone. Dronedarone was discontinued. INR was
supratherapeutic on admission to the MICU and coumadin was held.
once the INR came down coumadin was restarted and uptitrated.
INR on d/c was 2.5.  Of note, he remained in sinus rhythm during
HD sessions after the proper amio load.  (Coumadin dose at d/c
was 2 mg daily).  He will require INR checks as an outpatient in
the next few days regarding titration of his coumadin.
.
# ST changes on EKG/transient hypotension: As per the vascular
team, he became somewhat hypotensive during his angiography,
requiring fluid boluses and a small amount of neosynephrine.
His blood pressure stabilized overnight, and the neo was weaned
off.  He had one additional episode of hypotension to the 70's
after taking his pain medication and beta-blocker, which
resolved after a small fluid bolus.    He was again transiently
hypotensive during his amputations with some ST segment
depressions.  EKGs taken post-operatively were unchanged from
previous.  He had a slight troponin leak, which was stable.
However, upon transfer to the medicine service, ST changes noted
on tele and ST elevations noted on EKG ([**12-27**]).  ST elevations
were noticed in V2 V3, concerning given that there was ST
depression in the same leads previously immediately post-op.
Multiple EKGs done showed ST elevation were transient and would
change leads.   Atrius Cardiology (who was following) asked for
bedside echo and decided to cath pt.  Cath done showed
(unchanged from [**10-6**]) 50% occlusion of the LAD, complete
occlusion of the RCA, and patent stents and LCx.  Of note,
cardiac enzymes were sent and trended and CK rose to 600s,
however peaked and started trending down again.  As per
cardiology, would continue aspirin, warfarin, plavix.  Of note,
pt through all of this did not have any CP, however did have one
episode immediately after the cardiac cath, thought [**1-30**]
vasospasm.  After the initial episode of CP, he no longer had
episodes, and as per Atrius cards, would consider [**12-30**] inch of
nitro paste for CP likely [**1-30**] vasospasm.  Finally, given that
new anemia may have been contributing to demand ischemia, pt was
transfused two units of pRBCs with appropriate hct bump.  Of
note, he was continued on ASA/plavix (in addition to coumadin at
time of discharge).
.
# Dysphagia: Thought [**1-30**] cerebellar strokes.  Due to his garbled
speech and concern for aspiration, a formal speech/swallow
evaluation was obtained, which showed [**Month/Day (2) **] aspiration and he
was made strict NPO.  A PEG tube was placed on [**12-25**] and used
for tube feeds and medications.  He was thought to continue to
aspirate contributing to his respiratory distress thought
partially due to aspiration given the large amounts of TFs
suctioned from his airways during the event. He had his G tube
transitioned to a GJ tube on [**2160-1-3**]. He will benefit from speech
and swallow therapy on discharge and for now is dependent on the
feeding tube for nutritional needs. He was started on Q4H oral
care on the floor.
.
His TFs currently are: Isosource 1.5 Cal Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q12h Goal rate:
40 ml/hr
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 150 ml water q6h .
.
# CKD on HD:  He has end-stage renal disease, on hemodialysis 3x
weekly.  He still makes some urine, though his baseline
creatinine is [**5-2**].  Renal was consulted and gave recommendations
regarding his dialysis regimen while admitted.  He was
maintained on MWF dialysis schedule.  Dialysis was complicated
with Afib with RVR (see above) which resolved after amio load.
He was continued on his regimen while here, and will continue to
be dialyzed as an outpatient at his dialysis center:
Chronic Unit-[**Location (un) **] ph [**Telephone/Fax (1) 33567**] f [**Telephone/Fax (1) 93719**]
Nephrologist- Dr. [**Last Name (STitle) **]
[**Name (STitle) 57321**]/W/F
** Of note, pt's family will have further discussion regarding
whether dialysis is within his goals of care**
.
# Anemia: Pt's Hct dropped from 35 at time of admission to 24.8
on day of transfer to Medicine.  Iron studies were sent which
indicate ACD, and hemolysis labs were negative (hapto normal).
Pt was transfused out of concern that anemia was contributing to
possible demand ischemia.  His Hct was then stable around 28-30
and checked daily to QOD.  He was guaiac negative, and anemia
thought likely [**1-30**] ACD and also [**1-30**] CKD.  Will defer EPO
treatment to nephrology team at dialysis.
.
# Code Status: Was Full Code for much of hospitalization,
however given prognosis, further discussion was made with family
by both inhouse team as well as pt's PCP.  [**Last Name (NamePattern4) **]'s family decided
to move toward DNR/DNI, and current discussion regarding
possible hospice care in the future if clinical situation
deteriorates.  Also to be discussed is whether dialysis is
within his goals of care.  We will defer this discussion to his
outpt palliative care team (as per [**Location (un) 2274**]) and his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **].

Medications on Admission:
coumadin 2.5mg'; plavix 75, dronedarone 400'', lactulose,
bisacodyl, lasix 100', lopressor 50'', nitro tab prn,
calcitriol0.25', renagel 800'''; crestor 40', asa 81';
nephrocaps'; prilosec 20'; tylenol; oxycodone

Discharge Medications:
1. clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every
eight (8) hours.
3. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. amiodarone 400 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
6. rosuvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. sevelamer carbonate 800 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. B complex-vitamin C-folic acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
9. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: 325-650 mg PO Q6H
(every 6 hours) as needed for pain/ fever.
10. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ccs PO BID
(2 times a day): hold for diarrhea.
11. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: hold for diarrhea.
12. warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette [**Last Name (STitle) **]: [**12-30**]
Drops Ophthalmic PRN (as needed) as needed for dry eye.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb treatment Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
15. ipratropium bromide 0.02 % Solution [**Month/Day (2) **]: One (1) neb
treatment Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
16. guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: 5-10 MLs PO Q6H (every 6
hours) as needed for sore throat, expectorant.
17. calcitriol 1 mcg/mL Solution [**Month/Day (2) **]: 0.25 mcg PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] nursing and Therapy Center

Discharge Diagnosis:
Primary Diagnosis
- Gangrene, s/p amputation

Secondary Diagnoses
- CVA
- Dysphagia requiring PEG tube
- Aspiration pneumonia
- Atrial Fibrillation


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization.  You were admitted to [**Hospital1 18**] with gangrene of
the toes underwent an amputation.  You were transferred to the
medicine service for continued management of your medical
issues.  You required a stay in the ICU because of worsening
secretions we thought was from a pneumonia.  You were treated
with IV antibiotics.  As for your A-fib, you were started on
amiodarone and continued on your coumadin.
.
You were noted to have had a stroke on CT scan, so you will be
continued on coumadin for that.  You had a PEG tube placed given
the difficulty swallowing, and you were treated with antibiotics
for possible aspiration pneumonia.  Your EKG showed some
concerning changes so you also had a cardiac cath which showed
similar coronary disease as your last cath.  Finally, you were
dialyzed by our renal team because of your kidney disease.
.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
- STOP taking DRONEDARONE
- STOP taking OMEPRAZOLE
- STOP taking CIALIS
- STOP taking PERCOCET
- STOP taking LACTULOSE
- STOP taking FUROSEMIDE
- START taking AMIODARONE 400 mg daily
- START taking LANSOPRAZOLE 30 mg daily
- START taking WARFARIN 2 mg daily
- START using ALBUTEROL NEBS every 6 hours as needed for
shortness of breath or wheezing
- START using IPRATROPIUM NEBS every 6 hours as needed for
shortness of breath or wheezing
- START taking DOCUSATE 100 mg twice daily as needed for
constipation
- START taking SENNA 1 tab twice daily as needed for
constipation
- START taking GUAIFENESIN as needed for [**Hospital1 **] or throat
irritation
- START using ARTIFICIAL TEARS as needed for dry eyes
- CHANGE your ASPIRIN to 81 mg daily
- CHANGE your CALCITRIOL to the liquid form
- INCREASE YOUR METOPROLOL TARTRATE 50 MG to Three times daily
- DECREASE your ROSUVASTATIN to 20 mg daily
.
Because of the difficulty swallowing, please do not take
anything (not even pills) by mouth.  Continue taking the rest of
your medications as previous prescribed
.
Please follow up with your physicians as indicated below

Followup Instructions:
Department: VASCULAR SURGERY
When: MONDAY [**2160-1-28**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2160-1-10**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Cerebral embolism with cerebral infarction,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Other dysphagia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Chronic airway obstruction, not elsewhere classified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Other persistent mental disorders due to conditions classified elsewhere,Renal dialysis status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants'}


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: necrotic toes

PRESENT ILLNESS: The patient is an 82 yo M with ESRD (HD M,W,F), HTN, AFib, PVD,
Hyperlipidemia and CAD s/p ACS and recent stenting presents to
vascular clinic c/o "necrotic toes".  He was seen as an
inpatient about a month ago and found to have ischemic
toes on both feet.  At that time he had cardiac/medical issues
which were treated first.  He presented from rehab today with
complaints of drainage from a necrotic toe on the right foot. He
says that over the past week he has had a lot more pain in his
feet and walking has become more difficult. He denies any
fevers, chills, chest pain, sob. Of note, he was recently
restarted on coumadin.  Per rehab records he received 2.5mg of
coumadin on the 17th, 18th and 20th and his INR at rehab today
was 8.4 .

MEDICAL HISTORY: ESRD - ? [**1-30**] interstitial nephritis from anti-hypertensives per
Atrius PCP note, [**Name Initial (PRE) **] arm fistula
Afib
Hyperparathyroidism [**1-30**] ESRD
CAD
HTN
HLD
Cholecystectomy

MEDICATION ON ADMISSION: coumadin 2.5mg'; plavix 75, dronedarone 400'', lactulose,
bisacodyl, lasix 100', lopressor 50'', nitro tab prn,
calcitriol0.25', renagel 800'''; crestor 40', asa 81';
nephrocaps'; prilosec 20'; tylenol; oxycodone

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Skin: No atypical lesions.
Heart: Irreg rhythm(afib).
Lungs: Clear to auscultation bilat; Normal respiratory effort.
Gastrointestinal: Non distended, No masses.
Extremities: Feet are cool to the touch bilat. No RLE edema, No
LLE Edema, abnormal: 2nd toe amps on the right and left feet.
Right 3rd toe is necrotic with a small ulcer at the base, and a
small amt of drainage. Right 4th toe is necrotic and dry. Left
3rd toe is necrotic and dry.
Pulses:
DP/PT dopplerable bilat

FAMILY HISTORY: Unknown

SOCIAL HISTORY: He is a retired anesthesiologist and was working part-time as a
laboratory technician. He does not smoke. Denies EtOH. No
recreational drug use. He has 4 children and a wife and is from
the [**Country 31115**] and there is no heart disease in his family.
Living with daughter near HD site. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Cerebral embolism with cerebral infarction,End stage renal disease,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Other dysphagia,Coronary atherosclerosis of native coronary artery,Other iatrogenic hypotension,Chronic airway obstruction, not elsewhere classified,Other and unspecified hyperlipidemia,Anemia in chronic kidney disease,Other persistent mental disorders due to conditions classified elsewhere,Renal dialysis status,Percutaneous transluminal coronary angioplasty status,Long-term (current) use of anticoagulants'}
