CHIEF COMPLAINT: Chief Complaint: L 4th toe gangrene
.
Reason for ICU Transfer: Hypoxemic Respiratory Failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 53yo female with IDDM, HTN, CAD s/p prior stents
to OM, CKD with baseline creatinine of 1.9, and COPD who
presented to OSH with foot pain, now s/p amputation of the L 4th
toe for gangrene and transferred to the MICU post-op for
hypoxemic respiratory failure.
.
The pt cut herself on the bottom of her foot 2 weeks ago. She
had pain on the dorsum of her foot for three days prior to
admission with redness and bluish discoloration of that region.
She received unasyn and vancomycin at an OSH and transferred to
[**Hospital1 18**] ED for further evaluation. Her SpO2 was noted to be 92% on
RA upon transfer. Podiatry was consulted who performed beside
debridement of left fourth toe gangrene and planned for
amputation in OR on [**2186-6-24**]. Her labs were notable for a WBC of
16.4, glucose of 435 with UA showing no ketones, and creatinine
of 1.4 with sodium of 132. She was given cipro (vanc and unasyn
given at OSH). She was admitted to medicine overnight and kept
NPO and continued on vanc/cipro/flagyl.
.
She was tachypnic prior to intubation this morning with
desaturations to the 80s on RA. She was intubated and throughout
the case had desaturations to the 80s which took 10-15min to
come back up to the 90s. During weaning of sedation, she began
to cough and desaturate, and further weaning was not attempted.
Her ABG was 7.23/62/74 and temp was 38 intraoperatively. She
received a total of 600mL crystalloid during the case and was on
phenylephrine at 0.6 at time of transfer to the PACU. Her SBPs
ranged 80s-200s during the case.  Estimated blood loss was
<30cc. There was less bleeding than expected and the plan was to
consult vascular for possible further interventions. Her
Propofol was kept at 100. She received Vanc and Flagyl intra-op
and is still receiving Cipro as well. FS was in the 300s in the
PACU, and she was given 3 units of Humalog. Her last vent
settings in the PACU were AC 500/100/10/7, with overbreathing of
the vent. Last PACU vitals were 99.1, 118/48, 98, 19, 100%.
.
Of note, per her husband, in [**2185-12-17**], she was treated for
PNA, CHF, and an MI. She was in a medically-induced coma for 2
weeks at [**Hospital6 15083**] in [**Hospital1 1559**], and required HD [**1-18**]
volume overload. She is on nocturnal O2 but per report had a
negative sleep study at some point.
.
In the ICU, she is intubated and sedated.

MEDICAL HISTORY: 1. CAD s/p PCI in [**2179**]/[**2176**] (Please see cath report for anatomy)

MEDICATION ON ADMISSION: Gabapentin 600 mg po TID
Metoprolol XL 100 mg po qdaily
Lantus 80 units qhs
Zestril 10 mg po qdaily
Lipitor 80 mg po qdaily
Lasix 40 mg po qdaily
Advair 50/500 inh [**Hospital1 **]
Spiriva 18 mcg inh qdaily
Nitro 0.2 mg/hr patch daily 12 hrs on/12 hrs off
Nitro 0.4 mg SL q4 prn chest pain
Fluticasone 50 mcg inh [**Hospital1 **]
Oxycodone 5 mg po q4 prn pain
Albuterol 90 mcg inh [**Hospital1 **]
Senna 8.6 mg po BID
Colace 100 mg po BID
Thiamine 100 mg po qdaily
MVA po qdaily
Aspirin 325 mg po qdaily
Tylenol 500 mg po BID
Fish oil

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
Vitals: T: 98.2 BP: 151/70 P: 83 R: 18 O2: 89%
General: Intubated, sedated, not following commands
HEENT: Sclera anicteric, ETT in place, pupils constricted and
minimally reactive but equal
Neck: supple, JVP not seen [**1-18**] habitus, Mallampati [**2-17**].
Lungs: Diffuse rhonchi, no rales or wheeze.
CV: Regular rhythm, slightly fast, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: slightly cool distal LE, somewhat sluggish cap refill,
non-palpable distal pulses, palpable femoral b/l, L foot with
drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **]
[**Name5 (PTitle) **]: Streaky erythema over medial LLE, border marked

FAMILY HISTORY: Father with MI in 50s, CABGx2, paternal grandmother with CVA,
DM. Otherwise non-contributory.

SOCIAL HISTORY: - Tobacco:   1ppd x 33 yrs, current
- Alcohol:   denies
- Illicits:  denies
Lives with husband and teenage son. Homemaker.
Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Polyneuropathy in diabetes,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Cellulitis and abscess of toe, unspecified,Other bone involvement in diseases classified elsewhere,Open wound of foot except toe(s) alone, complicated,Accidents caused by unspecified cutting and piercing instrument or object,Accidents occurring in unspecified place,Tobacco use disorder,Obesity, unspecified,Body Mass Index 34.0-34.9, adult,Peripheral angiopathy in diseases classified elsewhere,Dysthymic disorder
DMI oth uncntrld,Hyposmolality,Ath ext ntv art gngrene,Ac osteomyelitis-ankle,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,MRSA elsewhere/NOS,Cellulitis of leg,Chr airway obstruct NEC,Neuropathy in diabetes,Long-term use of insulin,Crnry athrscl natve vssl,Pure hypercholesterolem,Cellulitis, toe NOS,Bone involv in oth dis,Open wound foot-compl,Acc-cutting instrum NOS,Accident in place NOS,Tobacco use disorder,Obesity NOS,BMI 34.0-34.9,adult,Angiopathy in other dis,Dysthymic disorder
Admission Date:  [**2186-6-24**]              Discharge Date:   [**2186-7-4**]

Date of Birth:  [**2131-12-23**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Chief Complaint: L 4th toe gangrene
.
Reason for ICU Transfer: Hypoxemic Respiratory Failure


Major Surgical or Invasive Procedure:
[**2186-6-27**]:
1. Ultrasound-guided puncture of right common femoral
    artery.
2. Contralateral second-order catheterization of left
    external iliac artery.
3. Abdominal aortogram.
4. Serial arteriogram of left lower extremity.
5. Balloon angioplasty of left superficial femoral artery
    x3, one in the proximal superficial femoral artery, one
    in the mid superficial femoral artery, one in the very
    distal superficial femoral artery.
6. Stent placement along the superficial femoral artery x4.

[**2186-6-29**]:
1. Radical debridement of left foot down to [**Month/Day/Year 500**].
2. Application of negative pressure wound therapy.


History of Present Illness:
Ms. [**Known lastname **] is a 53yo female with IDDM, HTN, CAD s/p prior stents
to OM, CKD with baseline creatinine of 1.9, and COPD who
presented to OSH with foot pain, now s/p amputation of the L 4th
toe for gangrene and transferred to the MICU post-op for
hypoxemic respiratory failure.
.
The pt cut herself on the bottom of her foot 2 weeks ago. She
had pain on the dorsum of her foot for three days prior to
admission with redness and bluish discoloration of that region.
She received unasyn and vancomycin at an OSH and transferred to
[**Hospital1 18**] ED for further evaluation. Her SpO2 was noted to be 92% on
RA upon transfer. Podiatry was consulted who performed beside
debridement of left fourth toe gangrene and planned for
amputation in OR on [**2186-6-24**]. Her labs were notable for a WBC of
16.4, glucose of 435 with UA showing no ketones, and creatinine
of 1.4 with sodium of 132. She was given cipro (vanc and unasyn
given at OSH). She was admitted to medicine overnight and kept
NPO and continued on vanc/cipro/flagyl.
.
She was tachypnic prior to intubation this morning with
desaturations to the 80s on RA. She was intubated and throughout
the case had desaturations to the 80s which took 10-15min to
come back up to the 90s. During weaning of sedation, she began
to cough and desaturate, and further weaning was not attempted.
Her ABG was 7.23/62/74 and temp was 38 intraoperatively. She
received a total of 600mL crystalloid during the case and was on
phenylephrine at 0.6 at time of transfer to the PACU. Her SBPs
ranged 80s-200s during the case.  Estimated blood loss was
<30cc. There was less bleeding than expected and the plan was to
consult vascular for possible further interventions. Her
Propofol was kept at 100. She received Vanc and Flagyl intra-op
and is still receiving Cipro as well. FS was in the 300s in the
PACU, and she was given 3 units of Humalog. Her last vent
settings in the PACU were AC 500/100/10/7, with overbreathing of
the vent. Last PACU vitals were 99.1, 118/48, 98, 19, 100%.
.
Of note, per her husband, in [**2185-12-17**], she was treated for
PNA, CHF, and an MI. She was in a medically-induced coma for 2
weeks at [**Hospital6 15083**] in [**Hospital1 1559**], and required HD [**1-18**]
volume overload. She is on nocturnal O2 but per report had a
negative sleep study at some point.
.
In the ICU, she is intubated and sedated.

Past Medical History:
1. CAD s/p PCI in [**2179**]/[**2176**] (Please see cath report for anatomy)

2. IDDM complicated by neuropathy
3. Hypertension
4. COPD
5. HTN
6. HL
7. CKD
8. Anxiety
9. Depression
10. OA
11. Thoracic radiculopathy
12. Chronic pain
13. Chronic sinusitis
14. h/o of R toe cellulitis
15. h/o PNA
16. s/p R breast cyst exicision [**2179**]


Social History:
- Tobacco:   1ppd x 33 yrs, current
- Alcohol:   denies
- Illicits:  denies
Lives with husband and teenage son. Homemaker.


Family History:
Father with MI in 50s, CABGx2, paternal grandmother with CVA,
DM. Otherwise non-contributory.

Physical Exam:
ON ADMISSION:
Vitals: T: 98.2 BP: 151/70 P: 83 R: 18 O2: 89%
General: Intubated, sedated, not following commands
HEENT: Sclera anicteric, ETT in place, pupils constricted and
minimally reactive but equal
Neck: supple, JVP not seen [**1-18**] habitus, Mallampati [**2-17**].
Lungs: Diffuse rhonchi, no rales or wheeze.
CV: Regular rhythm, slightly fast, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: slightly cool distal LE, somewhat sluggish cap refill,
non-palpable distal pulses, palpable femoral b/l, L foot with
drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **]
[**Name5 (PTitle) **]: Streaky erythema over medial LLE, border marked

On Discharge:
Gen: Obese female in nad, alert and oriented x 3, normal affect
Heent: PERRLA, oropharynx pink and moist
Neck: Supple, no jvd
Lungs: CTA bilat
CV: RRR
Abd: Obese, soft, +bs, no m/t/o
Ext: Warm, well perfused. Left 4th digit is amputated with open
wound from met head resection. Wound is pink without drainage or
surrounding erythema.
Pulses: DP/PT - dopplerable bilat


Pertinent Results:
ADMISSION LABS:

[**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409
[**2186-6-24**] 12:50AM BLOOD Neuts-85.6* Lymphs-8.9* Monos-3.5 Eos-1.0
Baso-1.0
[**2186-6-24**] 12:50AM BLOOD PT-12.1 PTT-24.4 INR(PT)-1.0
[**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*#
Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19
[**2186-6-24**] 03:45PM BLOOD ALT-20 AST-29 CK(CPK)-68 AlkPhos-107*
TotBili-0.3
[**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
[**2186-6-24**] 12:50AM BLOOD CRP-264.4*
[**2186-6-24**] 11:43AM BLOOD Type-ART Rates-/12 Tidal V-600 FiO2-100
O2 Flow-6 pO2-74* pCO2-62* pH-7.23* calTCO2-27 Base XS--2
AADO2-587 REQ O2-95 Intubat-INTUBATED Vent-CONTROLLED
[**2186-6-24**] 11:43AM BLOOD Glucose-311* Lactate-1.6 Na-133* K-4.7
Cl-99* calHCO3-27

MICROBIOLOGY:
[**6-24**] Foot wound Cx: Staph aureus coag positive, moderate growth.

IMAGING:
- [**6-24**] foot XR: Soft tissue defect about the base of the fourth
toe, but no
radiographic evidence for osteomyelitis. If clinical concern for

osteomyelitis persists, MR [**First Name (Titles) **] [**Last Name (Titles) 500**] scan may be considered.
- [**6-24**] BL LE US: No evidence DVT in either lower extremity. Only
one posterior tibial vein seen bilaterally and one peroneal vein
seen on the right, calf vein thrombosis can therefore not be
entirely excluded
-[**6-25**] CXR: CHF with interstitial edema, probably slightly better
compared with [**2186-6-24**]. Bibasilar collapse and/or consolidation,
slightly worse compared with [**2186-6-24**].

[**2186-6-24**] 12:50AM BLOOD WBC-16.4*# RBC-4.59 Hgb-14.5# Hct-41.2
MCV-90 MCH-31.5 MCHC-35.2* RDW-13.8 Plt Ct-409
[**2186-6-24**] 03:45PM BLOOD WBC-18.0* RBC-4.28 Hgb-13.2 Hct-38.0
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.7 Plt Ct-427
[**2186-6-24**] 11:03PM BLOOD Hct-35.6*
[**2186-6-25**] 04:03AM BLOOD WBC-13.1* RBC-3.95* Hgb-12.5 Hct-35.2*
MCV-89 MCH-31.6 MCHC-35.5* RDW-13.9 Plt Ct-354
[**2186-6-26**] 08:00AM BLOOD WBC-14.0* RBC-4.24 Hgb-13.1 Hct-39.1
MCV-92 MCH-31.0 MCHC-33.6 RDW-13.6 Plt Ct-404
[**2186-6-27**] 07:40AM BLOOD WBC-10.3 RBC-4.04* Hgb-12.6 Hct-36.9
MCV-91 MCH-31.1 MCHC-34.1 RDW-13.5 Plt Ct-416
[**2186-6-28**] 07:05AM BLOOD WBC-11.9* RBC-4.24 Hgb-13.1 Hct-37.2
MCV-88 MCH-30.8 MCHC-35.1* RDW-13.8 Plt Ct-428
[**2186-6-29**] 06:25AM BLOOD WBC-12.7* RBC-4.03* Hgb-12.1 Hct-36.6
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.8 Plt Ct-454*
[**2186-6-30**] 06:55AM BLOOD WBC-13.3* RBC-4.08* Hgb-12.5 Hct-37.1
MCV-91 MCH-30.8 MCHC-33.8 RDW-13.5 Plt Ct-451*
[**2186-7-1**] 07:45AM BLOOD WBC-14.1* RBC-4.07* Hgb-12.4 Hct-35.9*
MCV-88 MCH-30.4 MCHC-34.6 RDW-13.9 Plt Ct-533*
[**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509*
[**2186-7-2**] 05:45AM BLOOD WBC-12.5* RBC-3.84* Hgb-11.9* Hct-34.7*
MCV-90 MCH-31.0 MCHC-34.4 RDW-13.8 Plt Ct-509*
[**2186-7-4**] 05:55AM BLOOD WBC-11.5* RBC-3.87* Hgb-12.1 Hct-35.1*
MCV-91 MCH-31.4 MCHC-34.6 RDW-13.9 Plt Ct-658*
[**2186-6-24**] 12:50AM BLOOD Glucose-435* UreaN-34* Creat-1.4*#
Na-132* K-4.4 Cl-96 HCO3-21* AnGap-19
[**2186-6-24**] 03:45PM BLOOD Glucose-311* UreaN-30* Creat-1.3* Na-134
K-4.9 Cl-101 HCO3-21* AnGap-17
[**2186-6-25**] 04:03AM BLOOD Glucose-112* UreaN-29* Creat-1.3* Na-137
K-3.8 Cl-103 HCO3-22 AnGap-16
[**2186-6-26**] 08:00AM BLOOD Glucose-180* UreaN-30* Creat-1.3* Na-143
K-3.9 Cl-103 HCO3-24 AnGap-20
[**2186-6-27**] 07:40AM BLOOD Glucose-373* UreaN-27* Creat-1.3* Na-141
K-4.0 Cl-106 HCO3-22 AnGap-17
[**2186-6-28**] 07:05AM BLOOD Glucose-186* UreaN-23* Creat-1.1 Na-140
K-4.6 Cl-104 HCO3-24 AnGap-17
[**2186-6-29**] 06:25AM BLOOD Glucose-223* UreaN-22* Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-21* AnGap-17
[**2186-6-30**] 06:55AM BLOOD Glucose-396* UreaN-21* Creat-1.1 Na-134
K-4.2 Cl-101 HCO3-23 AnGap-14
[**2186-7-1**] 07:45AM BLOOD Glucose-262* UreaN-24* Creat-1.1 Na-134
K-4.4 Cl-103 HCO3-22 AnGap-13
[**2186-7-2**] 05:45AM BLOOD Glucose-297* UreaN-25* Creat-1.1 Na-135
K-4.7 Cl-105 HCO3-22 AnGap-13
[**2186-7-3**] 06:30AM BLOOD Glucose-205* UreaN-21* Creat-1.1 Na-140
K-4.5 Cl-108 HCO3-21* AnGap-16
[**2186-6-24**] 03:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2186-6-24**] 11:03PM BLOOD CK-MB-2 cTropnT-0.01
[**2186-6-25**] 04:03AM BLOOD CK-MB-2 cTropnT-0.01
[**2186-6-24**] 03:45PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
[**2186-6-25**] 04:03AM BLOOD Calcium-8.2* Phos-2.9 Mg-2.0
[**2186-6-26**] 08:00AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.1
[**2186-6-27**] 07:40AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9
[**2186-6-28**] 07:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.8
[**2186-6-29**] 06:25AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.7
[**2186-6-30**] 06:55AM BLOOD Calcium-9.1 Phos-3.3 Mg-1.8
[**2186-7-1**] 07:45AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.8
[**2186-7-2**] 05:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.7
[**2186-7-3**] 06:30AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2186-6-24**] 12:50AM BLOOD CRP-264.4*
[**2186-6-27**] 07:40AM BLOOD Vanco-23.4*
[**2186-6-29**] 11:15AM BLOOD Vanco-22.2*
[**2186-6-30**] 06:55AM BLOOD Vanco-8.4*
[**2186-7-1**] 07:45AM BLOOD Vanco-7.8*
[**2186-7-2**] 07:20PM BLOOD Vanco-15.5

[**2186-6-24**] 12:20 am BLOOD CULTURE

                            **FINAL REPORT [**2186-6-30**]**

   Blood Culture, Routine (Final [**2186-6-30**]):    NO GROWTH.
[**2186-6-24**] 12:50 am BLOOD CULTURE

                            **FINAL REPORT [**2186-6-30**]**

   Blood Culture, Routine (Final [**2186-6-30**]):    NO GROWTH.

[**2186-6-24**] 11:00 am FOOT CULTURE      LEFT FOOT - 4TH TOE CULTURE.


                            **FINAL REPORT [**2186-6-26**]**

   GRAM STAIN (Final [**2186-6-24**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   WOUND CULTURE (Final [**2186-6-26**]):
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

[**2186-6-24**] 3:45 pm MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2186-6-26**]**

   MRSA SCREEN (Final [**2186-6-26**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.

[**2186-6-24**] 5:28 pm SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2186-6-26**]**

   GRAM STAIN (Final [**2186-6-24**]):
      [**10-10**] PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2186-6-26**]):    NO GROWTH.

[**2186-6-29**] 9:00 am TISSUE     Site: FOOT      4TH LEFT METATARSAL
HEAD.

   GRAM STAIN (Final [**2186-6-29**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2186-7-2**]):
      STAPH AUREUS COAG +.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 326-0163L [**2186-6-24**].
      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).    SPARSE GROWTH.

   ANAEROBIC CULTURE (Final [**2186-7-3**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

[**2186-6-24**] 02:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2186-6-24**] 02:30AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2186-6-24**] 02:30AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
[**2186-6-24**] 02:30AM URINE Mucous-RARE
[**2186-6-24**] 02:30AM URINE Hours-RANDOM
[**2186-6-24**] 02:30AM URINE Uhold-HOLD

Radiology Report FOOT AP,LAT & OBL LEFT Study Date of [**2186-6-24**]
12:25 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-24**] 12:25 PM
FOOT AP,LAT & OBL LEFT; -76 BY SAME PHYSICIAN   [**Name Initial (PRE) 7417**] # [**Clip Number (Radiology) 15084**]

Reason: s/p debridement



[**Hospital 93**] MEDICAL CONDITION:
   54 year old woman s/p partial amp 4th left toe
REASON FOR THIS EXAMINATION:
   s/p debridement



Final Report
LEFT FOOT, THREE VIEWS

REASON FOR EXAM: Status post partial amputation of fourth left
toe and
debridement.

Comparison is made with prior study performed 11 hours earlier.

In the interim, there has been partial amputation distal to the
metatarsophalangeal joint of the fourth toe. There are no other
interval
changes.


Radiology Report ART EXT (REST ONLY) Study Date of [**2186-6-27**]
10:11 AM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] FA2 [**2186-6-27**] 10:11 AM
ART EXT (REST ONLY)   Clip # [**Clip Number (Radiology) 15085**]
Reason: evaluate peripheral arterial disease



[**Hospital 93**] MEDICAL CONDITION:
   54 year old woman with ? PVD
REASON FOR THIS EXAMINATION:
   evaluate peripheral arterial disease



Final Report
BILATERAL ARTERIAL DOPPLER

CLINICAL INFORMATION: 54-year-old female with 20 years of
diabetes mellitus.
The patient has neuropathy in both feet and the hands. Recent
amputation of
the left fourth toe performed.

ABIs, Doppler waveforms and PVRs were obtained bilaterally at
rest.

ABIs, right PT 0.50, DP 0.51, left PT 0.66, left DP 0.51.
Segmental
pressures, Doppler waveforms, and PVRs are significantly
decreased bilaterally
from the thighs down, left greater than right. In addition, on
the left side,
there is additional infrapopliteal disease.

IMPRESSION: Findings suggest bilateral inflow disease with
moderate
depression of the ABIs at rest on both sides. It was confirmed
by the
waveforms, pressures and Doppler. In addition, there appears to
be a
superimposed disease in the infrapopliteal region on the left.


Radiology Report FOOT AP,LAT & OBL LEFT PORT Study Date of
[**2186-6-29**] 9:50 AM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-6-29**] 9:50 AM
FOOT AP,LAT & OBL LEFT PORT   Clip # [**Clip Number (Radiology) 15086**]
Reason: L 4th met head resection cut



[**Hospital 93**] MEDICAL CONDITION:
   54 year old woman s/p removal of L 4th residual proximal
phalanx & met head.
REASON FOR THIS EXAMINATION:
   L 4th met head resection cut



Final Report
INDICATION: Status post removal of the fourth proximal phalanx.

COMPARISON: [**2186-6-24**].

THREE VIEWS LEFT FOOT: Patient is status post amputation at the
level of the
fourth metatarsal neck with an overlying VAC and soft tissue
changes.
Remainder of the digits are grossly unremarkable. There is no
acute fracture
appreciated. Small plantar calcaneal spur is noted.


Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2186-7-3**] 2:14 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6889**] FA5 [**2186-7-3**] 2:14 PM
CHEST PORT. LINE PLACEMENT   Clip # [**Clip Number (Radiology) 15087**]
Reason: 46cm right picc. tip?



[**Hospital 93**] MEDICAL CONDITION:
   54 year old woman with new picc
REASON FOR THIS EXAMINATION:
   46cm right picc. tip?



Final Report
INDICATION: A 54-year-old woman with new PICC line.

COMPARISON: Chest radiograph from [**2186-6-25**].

ONE VIEW OF THE CHEST:

The lungs are well expanded and clear. The cardiac silhouette is
top normal.
The mediastinal silhouette and hilar contours are normal. No
pleural effusion
or pneumothorax is present. A right-sided PICC line terminates
with its tip
in the distal SVC.



Brief Hospital Course:
Ms. [**Known lastname **] is a 53-year-old female with IDDM, HTN, CAD s/p prior
stents to OM, CKD with baseline creatinine of 1.9 and COPD who
is admitted with left fourth toe gangrene and ascending
lymphangitis, now intubated s/p amputation for hypoxemic
respiratory failure and with hypotension.
.
# Hypoxemic Respiratory Failure: The etiology of her respiratory
failure is unclear; the DDx includes COPD exacerbation vs CHF vs
pneumonia. Her CXR post-op appears suggests volume overload. The
patient is an active smoker as well, and likely has some
component of OSA which may also be contributing. Leukocytosis
and fever suggest infectious component contributing, nothing to
suggest aspiration. ACS also possible given cardiac hx, and P.E.
was also on the differential. She was given standing ipratropium
and albuterol MDIs and broad spectrum antibiotics with
Vanc/Cefepime/Flagyl for HCAP. Sputum and blood cultures were
sent. Tidal volumes of 6mg/kg were given because of the risk of
ARDS. No diuresis was induced given her tenuous BP, and IVF were
minimized. An ACS workup was done as below. Respiratory status
improved on the floor and she was satting well without oxygen at
the time of discharge
.
# Hypotension: Her BPs very labile during her toe amputation
procedure, and in the MICU she was requiring phenylephrine to
maintain MAP >65. This could be a medication effect from
propofol in the setting of positive intrathoracic pressure. It
could also possibly be related to ARDS and sepsis given toe
infection and leukocytosis, fever. ACS is also possible given
CAD history causing cardiogenic shock. Her  sedation was changed
from propofol to fentanyl/midazolam, and she was weaned from
phenylephrine to keep MAP>60. Over her hospital stay she
remained off pressors and was placed back on her home
antihypertensive regimen which she tolerated well.
.
# Left fourth toe gangrene/ascending lymphangitis: She is now
s/p amputation of 4th toe by podiatry, s/p LLE angio showng SFA
occlusion s/p balloon PTA SFA and stent x 4, and L 4th met head
resection. A wound VAC was attempted after met head resection
but given the location of the wound was not working effectively.
Wet to dry dressings were initiated and her wound showed
appropriate progress. She is discharged with daily wet to dry
dressings. Given her mrsa wound culture data, a PICC line was
placed and she was discharged on vancomycin.  Her insurance was
only active through the end of [**Month (only) 205**], and thus she will get IV
vanco through [**7-15**]. At that time she will transition to PO
bactrim [**Hospital1 **] x 4 weeks.

# CAD: She is at risk for MI, which could be contributing to
hypoxemia and hypotension. She had 3 sets of negative cardiac
enzymes. We continued her ASA 325mg PO daily, atorvastatin 80mg
PO daily, and held metoprolol and nitro patch in the setting of
hypotension.  Once BPs were stable, her antihypertensives were
restarted. Nitro patch was not restarted in house, but it is
recommended she follow up with her PCP and cardiologist within
10 days of discharge.
.
# Hypertension: She was initially hypotensive, so we held
zestril and metoprolol and lasix.   As she improved metoprolol
was resumed. AT the time of discharge her BP's were consistently
>130 and her lasix and lisinopril were resumed.

# IDDM: She was hyperglycemic in house and [**Last Name (un) **] diabetes team
was consulted. Her Lantus was increased to 90 units QHS and an
agressive humalog sliding scale was titrated. At the time of
discharge her glucose was stable.
.
# Hyponatremia: This was mild at 132 on admission, and it is
improving now. Her Na returned to [**Location 213**].
.
# COPD: Her COPD likely contributed to her resp. failure. We
held her home Advair and tiotripium and gave her MDIs as above.
Once respiratory status improved back to  baseline home meds
were resumed.
.
#. CKD: Her creatinine was at 1.4 and trended down to 1.1 , and
remained there for most of her hospitalization
.
#. Chronic pain: Pain was well controlled with oral and iv
narcotics while in house. She is stable on an oral regimen at
the time of discahrge
.
#. Chronic sinusitis: stable; she was given Flonase nasal spray.

She is discharged in stable condition, home with VNA services.
She is touch down heel weight bearing on her LLE and maintains
this without difficulty. She will follow up with vascular and
podiatry in 1 week. She is instructed to follow up with her PCP
and cardiologist in the next 1-2 weeks.


Medications on Admission:
Gabapentin 600 mg po TID
Metoprolol XL 100 mg po qdaily
Lantus 80 units qhs
Zestril 10 mg po qdaily
Lipitor 80 mg po qdaily
Lasix 40 mg po qdaily
Advair 50/500 inh [**Hospital1 **]
Spiriva 18 mcg inh qdaily
Nitro 0.2 mg/hr patch daily 12 hrs on/12 hrs off
Nitro 0.4 mg SL q4 prn chest pain
Fluticasone 50 mcg inh [**Hospital1 **]
Oxycodone 5 mg po q4 prn pain
Albuterol 90 mcg inh [**Hospital1 **]
Senna 8.6 mg po BID
Colace 100 mg po BID
Thiamine 100 mg po qdaily
MVA po qdaily
Aspirin 325 mg po qdaily
Tylenol 500 mg po BID
Fish oil

Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750)
Recon Soln Intravenous Q 12H (Every 12 Hours) for 2 weeks: until
[**7-15**].
Disp:*qs Recon Soln(s)* Refills:*0*
2. Outpatient Lab Work
Please draw Chem 7, Vanc trough q week
3. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
4. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
5. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
6. Lantus 100 unit/mL Solution Sig: Ninety (90) units
Subcutaneous at bedtime: this is a higher dose than you were
previously on.
7. Humalog 100 unit/mL Solution Sig: sliding scale  Subcutaneous
four times a day.
8. sliding scale
Insulin SC Sliding Scale
            Breakfast     Lunch      Dinner      Bedtime
            Humalog       Humalog    Humalog      Humalog
 Glucose          Insulin Dose
0-70mg/dL -----Proceed with hypoglycemia protocol----
71-150mg/dL  0Units       0Units     0Units      0Units
151-200mg/dL 8Units       8Units     10Units     0Units
201-250mg/dL 10Units     10Units     12Units     2Units
251-300mg/dL 12Units     12Units     14Units     3Units
301-350mg/dL 14Units     14Units     16Units     4Units
351-400mg/dL 16Units     16Units     18Units     5Units
> 400mg/dL   [**Name8 (MD) 15088**] M.D.-------------------
9. Zestril 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
13. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
14. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

16. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
17. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): call pcp for refills.
Disp:*30 Tablet(s)* Refills:*2*
18. multivitamin,tx-minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. omega-3 fatty acids     Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
22. senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: while on narcotics
.
23. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): while on narcotics.
24. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
25. Nitro
if your cardiologist recocmmended that you be on a nitro patch
or take sub lingual nitro prn for chest pain, please resume
those meds as prescribed
26. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 weeks: you should start this medication when your
vancomycin has completed .
Disp:*56 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Ovrelook VNA

Discharge Diagnosis:
Left lower extremity ischemia with gangrene, and osteomyelitis
left foot.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	If instructed, take Plavix (Clopidogrel) 75mg once daily
??????	You will be on IV vancomycin for 2 weeks. After you complete
that course you will start oral bactrim ds twice daily for 4
weeks. Please continue all other medications you were taking
before surgery. We have increased your lantus dose and adjusted
your sliding scale regimen.
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**1-19**]
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
??????	It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and 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:
??????	When you go home, you may walk and go up and down stairs.
??????	You may only touch down weight bear on your left heel. DO NOT
bear weight through your left foot!
??????	Your groin incision may be left uncovered, unless you have
small amounts of drainage from the wound, then place a dry
dressing or band aid over the area that is draining.  Your left
foot wound should be packed with wet to dry dressing daily by
the VNA.
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until cleared by surgeon, and no longer on pain
meds.
??????	Call and schedule an appointment to be seen in [**2-17**] weeks for
post procedure check and ultrasound

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.

Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2186-7-10**] 8:05
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2186-7-12**] 11:45



Completed by:[**2186-7-4**]

Name:  [**Known lastname 2471**],[**Known firstname 2472**]                    Unit No:   [**Numeric Identifier 2473**]

Admission Date:  [**2186-6-24**]              Discharge Date:   [**2186-7-4**]

Date of Birth:  [**2131-12-23**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 726**]
Addendum:
Final pathology from [**6-29**] did show acute osteomyelitis as below.


Pertinent Results:
Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 8**] [**Known lastname 2474**],[**Known firstname 2472**]       [**2131-12-23**]    54 Female      [**-1/2907**]
[**Numeric Identifier 2473**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 455**]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 2475**]/mtd



SPECIMEN SUBMITTED: basic 4th proximal phalanx, 4th metatarsal
head left.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2186-6-29**] [**2186-6-29**] [**2186-7-4**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2476**]/ttl
Previous biopsies:    [**-1/2833**]  LEFT FOOT 4TH TOE.

DIAGNOSIS:



I.  "Basic 4th proximal phalanx" (A):

Bone and articular cartilage with acute osteomyelitis.

II.  "4th metatarsal head left" (B):

Bone and articular cartilage with focal osteomyelitis.


Discharge Disposition:
Home With Service

Facility:
Ovrelook VNA

Discharge Diagnosis:
Left lower extremity ischemia with gangrene, and acute
osteomyelitis left foot.


                             [**First Name11 (Name Pattern1) 168**] [**Last Name (NamePattern4) 730**] MD [**MD Number(2) 731**]

Completed by:[**2186-7-19**]
{'Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Polyneuropathy in diabetes,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Cellulitis and abscess of toe, unspecified,Other bone involvement in diseases classified elsewhere,Open wound of foot except toe(s) alone, complicated,Accidents caused by unspecified cutting and piercing instrument or object,Accidents occurring in unspecified place,Tobacco use disorder,Obesity, unspecified,Body Mass Index 34.0-34.9, adult,Peripheral angiopathy in diseases classified elsewhere,Dysthymic disorder'}


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: Chief Complaint: L 4th toe gangrene
.
Reason for ICU Transfer: Hypoxemic Respiratory Failure

PRESENT ILLNESS: Ms. [**Known lastname **] is a 53yo female with IDDM, HTN, CAD s/p prior stents
to OM, CKD with baseline creatinine of 1.9, and COPD who
presented to OSH with foot pain, now s/p amputation of the L 4th
toe for gangrene and transferred to the MICU post-op for
hypoxemic respiratory failure.
.
The pt cut herself on the bottom of her foot 2 weeks ago. She
had pain on the dorsum of her foot for three days prior to
admission with redness and bluish discoloration of that region.
She received unasyn and vancomycin at an OSH and transferred to
[**Hospital1 18**] ED for further evaluation. Her SpO2 was noted to be 92% on
RA upon transfer. Podiatry was consulted who performed beside
debridement of left fourth toe gangrene and planned for
amputation in OR on [**2186-6-24**]. Her labs were notable for a WBC of
16.4, glucose of 435 with UA showing no ketones, and creatinine
of 1.4 with sodium of 132. She was given cipro (vanc and unasyn
given at OSH). She was admitted to medicine overnight and kept
NPO and continued on vanc/cipro/flagyl.
.
She was tachypnic prior to intubation this morning with
desaturations to the 80s on RA. She was intubated and throughout
the case had desaturations to the 80s which took 10-15min to
come back up to the 90s. During weaning of sedation, she began
to cough and desaturate, and further weaning was not attempted.
Her ABG was 7.23/62/74 and temp was 38 intraoperatively. She
received a total of 600mL crystalloid during the case and was on
phenylephrine at 0.6 at time of transfer to the PACU. Her SBPs
ranged 80s-200s during the case.  Estimated blood loss was
<30cc. There was less bleeding than expected and the plan was to
consult vascular for possible further interventions. Her
Propofol was kept at 100. She received Vanc and Flagyl intra-op
and is still receiving Cipro as well. FS was in the 300s in the
PACU, and she was given 3 units of Humalog. Her last vent
settings in the PACU were AC 500/100/10/7, with overbreathing of
the vent. Last PACU vitals were 99.1, 118/48, 98, 19, 100%.
.
Of note, per her husband, in [**2185-12-17**], she was treated for
PNA, CHF, and an MI. She was in a medically-induced coma for 2
weeks at [**Hospital6 15083**] in [**Hospital1 1559**], and required HD [**1-18**]
volume overload. She is on nocturnal O2 but per report had a
negative sleep study at some point.
.
In the ICU, she is intubated and sedated.

MEDICAL HISTORY: 1. CAD s/p PCI in [**2179**]/[**2176**] (Please see cath report for anatomy)

MEDICATION ON ADMISSION: Gabapentin 600 mg po TID
Metoprolol XL 100 mg po qdaily
Lantus 80 units qhs
Zestril 10 mg po qdaily
Lipitor 80 mg po qdaily
Lasix 40 mg po qdaily
Advair 50/500 inh [**Hospital1 **]
Spiriva 18 mcg inh qdaily
Nitro 0.2 mg/hr patch daily 12 hrs on/12 hrs off
Nitro 0.4 mg SL q4 prn chest pain
Fluticasone 50 mcg inh [**Hospital1 **]
Oxycodone 5 mg po q4 prn pain
Albuterol 90 mcg inh [**Hospital1 **]
Senna 8.6 mg po BID
Colace 100 mg po BID
Thiamine 100 mg po qdaily
MVA po qdaily
Aspirin 325 mg po qdaily
Tylenol 500 mg po BID
Fish oil

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
Vitals: T: 98.2 BP: 151/70 P: 83 R: 18 O2: 89%
General: Intubated, sedated, not following commands
HEENT: Sclera anicteric, ETT in place, pupils constricted and
minimally reactive but equal
Neck: supple, JVP not seen [**1-18**] habitus, Mallampati [**2-17**].
Lungs: Diffuse rhonchi, no rales or wheeze.
CV: Regular rhythm, slightly fast, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: slightly cool distal LE, somewhat sluggish cap refill,
non-palpable distal pulses, palpable femoral b/l, L foot with
drsg [**Name5 (PTitle) **] [**Name5 (PTitle) **]
[**Name5 (PTitle) **]: Streaky erythema over medial LLE, border marked

FAMILY HISTORY: Father with MI in 50s, CABGx2, paternal grandmother with CVA,
DM. Otherwise non-contributory.

SOCIAL HISTORY: - Tobacco:   1ppd x 33 yrs, current
- Alcohol:   denies
- Illicits:  denies
Lives with husband and teenage son. Homemaker. 

### Response:
{'Diabetes with other specified manifestations, type I [juvenile type], uncontrolled,Hyposmolality and/or hyponatremia,Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Cellulitis and abscess of leg, except foot,Chronic airway obstruction, not elsewhere classified,Polyneuropathy in diabetes,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Pure hypercholesterolemia,Cellulitis and abscess of toe, unspecified,Other bone involvement in diseases classified elsewhere,Open wound of foot except toe(s) alone, complicated,Accidents caused by unspecified cutting and piercing instrument or object,Accidents occurring in unspecified place,Tobacco use disorder,Obesity, unspecified,Body Mass Index 34.0-34.9, adult,Peripheral angiopathy in diseases classified elsewhere,Dysthymic disorder'}
