CHIEF COMPLAINT: Left inner thigh pain and swelling.

PRESENT ILLNESS: This is an 88 year old white
female status post left femoral-DP bypass graft in [**2121-5-12**] with vein patch angioplasty in [**2121-8-12**], who
presented to [**Hospital6 33**] on [**2123-1-14**], with pain at
the site of a bone marrow biopsy for aplastic anemia.  She
developed temperatures with a temperature maximum of 102.0 F.
with increasing left thigh erythema, swelling and tenderness.
Ultrasound was done which was negative for fluid collection.
A repeat ultrasound was done on the 8th which showed a
pseudo-aneurysm, query graft infection.  The patient is known
to have a Pseudomonas urinary tract infection which is
treated with Ceftazidine.

MEDICAL HISTORY: 1.  Peripheral vascular disease status post fem-DP bypass
    graft in [**2121-4-12**].
2.  Bilateral hip replacements in [**2112**] and [**2113**].
3.  Coronary artery disease status post coronary artery
    bypass graft times four in [**2117**].
4.  History of myocardial infarction prior to coronary artery
    bypass graft.
5.  Hypertension.
6.  History of gout.
7.  History of creatinine renal insufficiency with a baseline
    creatinine of 2.0.

MEDICATION ON ADMISSION: 

ALLERGIES: Include Percocet, shellfish, Prozac and Ativan;
reactions unknown.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in a retirement home;
non-smoker, non-drinker.
Other complications due to other vascular device, implant, and graft,Aneurysm of artery of lower extremity,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aplastic anemia, unspecified,Cellulitis and abscess of toe, unspecified
Comp-oth vasc dev/graft,Lower extremity aneurysm,Lower extremity embolism,Urin tract infection NOS,Cellulitis of leg,Hyp kid NOS w cr kid V,Aplastic anemia NOS,Cellulitis, toe NOS
Admission Date:  [**2123-1-19**]       Discharge Date:


Service:  VASCULAR S

This is an 88 year old female transferred from [**Hospital6 3426**] to our Emergency Room.

CHIEF COMPLAINT:  Left inner thigh pain and swelling.

HISTORY OF PRESENT ILLNESS:  This is an 88 year old white
female status post left femoral-DP bypass graft in [**2121-5-12**] with vein patch angioplasty in [**2121-8-12**], who
presented to [**Hospital6 33**] on [**2123-1-14**], with pain at
the site of a bone marrow biopsy for aplastic anemia.  She
developed temperatures with a temperature maximum of 102.0 F.
with increasing left thigh erythema, swelling and tenderness.
Ultrasound was done which was negative for fluid collection.
A repeat ultrasound was done on the 8th which showed a
pseudo-aneurysm, query graft infection.  The patient is known
to have a Pseudomonas urinary tract infection which is
treated with Ceftazidine.

PAST MEDICAL HISTORY:
1.  Peripheral vascular disease status post fem-DP bypass
    graft in [**2121-4-12**].
2.  Bilateral hip replacements in [**2112**] and [**2113**].
3.  Coronary artery disease status post coronary artery
    bypass graft times four in [**2117**].
4.  History of myocardial infarction prior to coronary artery
    bypass graft.
5.  Hypertension.
6.  History of gout.
7.  History of creatinine renal insufficiency with a baseline
    creatinine of 2.0.

PAST SURGICAL HISTORY:
1.  Cesarean section.
2.  Ovarian cystectomy.
3.  Appendectomy.
4.  Left fourth toe amputation.

ALLERGIES:  Include Percocet, shellfish, Prozac and Ativan;
reactions unknown.

MEDICATIONS ON TRANSFER:
1.  Aspirin 325 mg q. day.

SOCIAL HISTORY:  The patient lives in a retirement home;
non-smoker, non-drinker.

PHYSICAL EXAMINATION:  Vital signs 98.6 F.; 72; 193/55; 28;
O2 saturation on room air is 99%.  The patient is alert and
oriented times three.  HEENT is unremarkable.  There is no
jugular venous distention.  Lungs are clear to auscultation
bilaterally.  Cardiac is II/VI systolic ejection murmur.
Abdominal examination is unremarkable.  Musculoskeletal
examination shows a left inner thigh erythema, swelling and
redness.  Neurological examination was unremarkable.

LABORATORY:  In the Emergency Room included white count of
1.4, hematocrit 31.2, platelets 47,000.  Electrolytes:
Sodium 132, potassium 3.2, chloride 100, CO2 29.1, BUN 44,
creatinine 2.8.  INR and PTT were normal.

Chest x-ray showed a cardiomegaly with upper zone
re-distribution.

Ultrasound of the thigh was negative for deep venous
thrombosis and echocardiogram was obtained which showed an
ejection fraction of 60% with two to three plus mitral
regurgitation.  Abdominal ultrasound showed a normal spleen.

The patient was then admitted to the hospital for further
evaluation and treatment.

HOSPITAL COURSE:   The patient was admitted to the Vascular
Service.  She was placed on bed rest with bathroom
privileges.  Her routine labs were monitored.  She had
bilateral vein mapping, upper and lower extremities,
completed and an ultrasound, arterial, done on the thigh.
Ultrasound of the affected leg was inconclusive regarding a
pseudo-aneurysm.  The patient was placed on neutropenic
precautions secondary to her low white count of 1.4.
Cardiology was notified of her admission.
Hematology/Oncology was consulted.  She was begun on Zosyn
2.25 grams q. eight hours, Flagyl 500 q. 12 and Vancomycin 1
gram.

The Hematology/Oncology consultation recommended beginning
Epogen of 30,000 units and continue weekly until hematocrit
is 30 or greater; start Neupogen 300 mcg subcutaneously q.
day and skip if white count is greater than 10,000, restart
folic acid 1 mg q. day; transfuse for hematocrit to be
maintained between 28 and 30.  Transfuse postoperatively to
maintain platelet count greater than 50,000 if bleeding.
Follow serial counts.

Rheumatology felt that the patient did have active gout by
clinical examination.  Their recommendations were to
adequately hydrate and give Mucomyst prior to any
radiological interventional diagnostic procedure and to
consider starting Prednisone.

Renal also was requested to see the patient and recommended
to dose all medications for a creatinine clearance of 15 to
25.  Avoid non-steroidal anti-inflammatory agents and ACE
inhibitors at this time.  The patient underwent, on
[**2123-1-21**], a left extra-acomic bypass with thrombectomy of
the femoral-DP bypass graft of left less saphenous vein,
ligation and drainage of an infected pseudo-aneurysm.  The
patient tolerated the procedure well and was transferred to
the PACU in stable condition and then was transferred to the
SICU for continued monitoring care secondary to coagulopathy
and neutropenia.  The patient required two units of packed
red blood cells and two units of fresh frozen plasma
postoperatively and interoperatively.

Postoperative day one, there were no overnight events.  She
remained on SIMV.  Her extremity examination showed dressings
were clean, dry and intact with a palpable graft pulse and a
warm foot.  Plans were to wean sedation and then wean as
tolerated towards extubation.  Antibiotics were continued and
cultures were monitored and choice narrowed according to
culture results.

Ultimate recommendations of Rheumatology were Prednisone
course and tapered as they felt that she would be at high
risk for use of Colchicine secondary to her bone marrow
suppression.  She was begun on steroids with improvement in
her clinical symptomatology of her left toe, but as
infectious process could not be ruled out, the patient
remained on antibiotics.

Postoperative day two, there were no overnight events.  The
patient was extubated.  She did have a temperature elevation
of 101.7 F., that defervesced to 100.7 F.  Blood and urine
cultures were obtained.  The white blood cell count was 1.4.
Incentive spirometry and chest PT was begun.  A chest x-ray
was obtained without evidence of focal consolidation.

During the postoperative period, the patient had acceleration
of her renal dysfunction with a peak creatinine of 3.4
post-fever.  It was secondary to a yeast urinary tract
infection.  She was begun on a course of Fluconazole.  She
also was growing Pseudomonas from her wound and her
antibiotics were converted to Ciprofloxacin.  Zosyn was
discontinued on [**2123-1-24**], after initiating Ciprofloxacin.

The patient was transferred to the Regular Nursing Floor on
postoperative day number four.  Ambulation was begun.  There
was continued improvement in her creatinine to show a fall
from 3.4 to 2.7 over the next 48 hours after beginning
treatment for the urinary tract infection.  The etiology of
the patient's acute deterioration of renal function was
unclear.  [**Name2 (NI) **] SMA glomerular dilatation rate was less than
20.  Possible consideration of the membranous glomerular
nephritis and amyloidosis.  This should be worked up on an
outpatient basis once the patient has recovered from her
current hospitalization.

The patient required multiple medication adjustments for her
systolic and diastolic hypertension.  On postoperative day
her blood pressure remained elevated and required adjustments
in her Norvasc and was converted to Cardura.  The patient
continued to show clinical improvement both in her erythema
and pain in the left toe and renal function.

She underwent, on [**2123-2-4**], a left first toe amputation
without complications and tolerated the procedure well.  The
wound was primarily closed.  The patient continued to
progress clinically.  The patient was evaluated by Physical
Therapy and recommendations were that she would need
[**Hospital 3058**] rehabilitation placement.

The patient was discharged in stable condition.  Her groin
wound on the left side showed some base residual necrosis but
was granulating at the edges.  The toe amputation site was
clean, dry and intact.  The graft was palpable and the foot
was warm.  The patient should follow-up with Dr. [**Last Name (STitle) 1476**] in
one to two weeks' time.

The patient will continue on intravenous antibiotics,
Ciprofloxacin and Ceftazidime until seen by him at that time.


DISCHARGE MEDICATIONS:
1.  Lopressor 75 mg twice a day.
2.  Epogen 15,000 units two times per week.
3.  Lasix 20 mg q. day.
4.  Accupril 10 mg twice a day.
5.  Prednisone 20 mg q. day until [**2-4**], and then begin 10 mg
    of Prednisone [**2-5**] until [**2-6**]; Prednisone 5 mg q. day
    from [**2-7**] until [**2-8**], then discontinue.
6.  Ciprofloxacin 400 mg intravenous q. 24 hours.
7.  Ceftazidine 1 gram q. 24 hours.
8.  Protonix 40 mg q. day.
9.  Darvocet one to two tablets p.r.n. q. four to six hours.
10. Nitropaste 1 inch q. four hours p.r.n. for systolic blood
    pressure greater than 180.
11. Albuterol and Atrovent Metered-Dose Inhaler, puffs two q.
    four hours p.r.n.
12. Neupogen 300 mcg subcutaneously q. day.
13. Cardura 1 mg at h.s.
14. Diovan 150 mg q. day.
15. Cardizem was discontinued.
16. Folic acid 1 mg q. day.
17. Subcutaneous heparin 5000 units twice a day until patient
    is ambulating in a consistent basis.

DISCHARGE DIAGNOSES:
1.  Infected pseudo-aneurysm status post excision.
2.  Left toe infection, gout, status post amputation and
    Prednisone therapy.
3.  Hypertension, improved.
4.  Chronic renal insufficiency, etiology undetermined.
5.  Aplastic anemia, stable.



                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D.  [**MD Number(1) 1478**]

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

D:  [**2123-2-8**]  10:05
T:  [**2123-2-8**]  10:08
JOB#:  [**Job Number 11981**]


Name:  [**Known lastname **], [**Known firstname **]                       Unit No:  [**Numeric Identifier 1760**]

Admission Date:  [**2123-1-19**]     Discharge Date:  [**2123-2-13**]

Date of Birth:   [**2034-3-6**]     Sex:  F

Service:

ADDENDUM COVERS [**Date range (1) 1761**] - HISTORY AS FOLLOWS:  Ms.
[**Known lastname 734**] who is an 88-year-old woman required an additional
few days of hospitalization between the dates listed above in
order to obtain and place in a rehabilitation hospital.  Her
discharge summary, I believe, fills in the appropriate
details regarding her admission and medications.




                          [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D.  [**MD Number(1) 144**]

Dictated By:[**Dictator Info **]

MEDQUIST36

D:  [**2123-3-4**]  15:26
T:  [**2123-3-9**]  09:13
JOB#:  [**Job Number 1762**]
{'Other complications due to other vascular device, implant, and graft,Aneurysm of artery of lower extremity,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aplastic anemia, unspecified,Cellulitis and abscess of toe, unspecified'}


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: Left inner thigh pain and swelling.

PRESENT ILLNESS: This is an 88 year old white
female status post left femoral-DP bypass graft in [**2121-5-12**] with vein patch angioplasty in [**2121-8-12**], who
presented to [**Hospital6 33**] on [**2123-1-14**], with pain at
the site of a bone marrow biopsy for aplastic anemia.  She
developed temperatures with a temperature maximum of 102.0 F.
with increasing left thigh erythema, swelling and tenderness.
Ultrasound was done which was negative for fluid collection.
A repeat ultrasound was done on the 8th which showed a
pseudo-aneurysm, query graft infection.  The patient is known
to have a Pseudomonas urinary tract infection which is
treated with Ceftazidine.

MEDICAL HISTORY: 1.  Peripheral vascular disease status post fem-DP bypass
    graft in [**2121-4-12**].
2.  Bilateral hip replacements in [**2112**] and [**2113**].
3.  Coronary artery disease status post coronary artery
    bypass graft times four in [**2117**].
4.  History of myocardial infarction prior to coronary artery
    bypass graft.
5.  Hypertension.
6.  History of gout.
7.  History of creatinine renal insufficiency with a baseline
    creatinine of 2.0.

MEDICATION ON ADMISSION: 

ALLERGIES: Include Percocet, shellfish, Prozac and Ativan;
reactions unknown.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient lives in a retirement home;
non-smoker, non-drinker. 

### Response:
{'Other complications due to other vascular device, implant, and graft,Aneurysm of artery of lower extremity,Arterial embolism and thrombosis of lower extremity,Urinary tract infection, site not specified,Cellulitis and abscess of leg, except foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Aplastic anemia, unspecified,Cellulitis and abscess of toe, unspecified'}
