CHIEF COMPLAINT: bilateral lower extremities arterial ulcers

PRESENT ILLNESS: 52 yof with extensive [**First Name3 (LF) 1106**] history presents to clinic with
concern for infected bilateral lower extremity ulcers. Ms.
[**Known lastname 13257**] is well known to our team and presented today for eval
of her LE ulcers. She recently saw her
pcp who put her on oral steroids. She reports the uclers
worsened and are draining.

MEDICAL HISTORY: Type I Diabetes Mellitus
Peripoheral neuropathy
Diabetic Nephropathy (failed transplant)
- pt was scheduled for repeat transplant on [**2174-8-23**] but was
cancelled because of her PVD historybilateral retinopathy s/p
retinal detachment.
Benign Hypertension
significant PVD history with multiple prior LE bypass surgeries
Prior GI bleeding on ASA and plavix
CAD s/p MIx2, s/p LAD stents
s/p CABG [**8-19**]
Meningitis
chronic anemia
- likely multifactorial due to renal failure, hx of antral
erosions and mild esophagitis on EGD
CVA x 2
hyperlipidemia

MEDICATION ON ADMISSION: lipitor 40mg once daily, nephrocaps 1 tab daily, calcium acetate
667 2tabs [**Hospital1 **], plavix 75mg daily, tricor 145mg daily, lantus 12u
am , humalog ss, lisinopril 20 mg daily, lorazepam 1mg qhs,
metop succinate 100mg daily, faroxetine 10mg daily, tylenol prn,
vit c 500mg daily, asa, zinc 50 mg daily

ALLERGIES: Darvon

PHYSICAL EXAM: On admission:
Vitals: T 94.5-97.2, BP 119-152/40-46, P 58-70, RR 14, O2sat 94%
2L NC
General: lying in bed, no acute distress, appears stated age
HEENT: NCAT, PERLL, anicteric, OP clear
Neck: supple, no LAD
Pulm: poor inspiratory effort, mildly reduced BS at bases,
occasional rhonchi at left base
CV: irreg, appears to have PVCs on A-line [**Location (un) 1131**], nl S1 S2, no
m/r/g
Abd: ecchymoses, soft, overweight, non-tender, +BS
Extrem: both lower extremities wrapped, poor and faint DP/PT
pulses bilaterally, right extremity prior digit amputation
Neuro: CN 2-12 intact, non-focal

FAMILY HISTORY: Her mother is alive at age 77 without significant medical
problems.  [**Name (NI) **] father died at age 76 of sepsis.  He also had
type 2 diabetes and prostate cancer.  She has a sister age 51
and another sister age 41 who has type 1 diabetes.  There is no
family history of blood disorders or colon cancer.

SOCIAL HISTORY: Two children in their 20s.  She lives with her boyfriend and has
24-hour support at home from him and from her daughter.  She
formerly worked at the post-office.  She has a 30-pack-year
history of smoking and quit in [**2165**].  She does not drink
alcohol.
Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,End stage renal disease,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Unspecified pleural effusion,Ulcer of heel and midfoot,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Systolic heart failure, unspecified,Blood in stool,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Cardiac arrest,Leukocytosis, unspecified,Malnutrition of moderate degree
DMI neuro nt st uncntrld,Acute respiratry failure,End stage renal disease,Subendo infarct, initial,Acute kidney failure NOS,Compl kidney transplant,Pleural effusion NOS,Ulcer of heel & midfoot,Ben hyp kid w cr kid V,Systolic hrt failure NOS,Blood in stool,Nephritis NOS in oth dis,Abn react-org transplant,Accident in place NEC,Neuropathy in diabetes,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Hyperlipidemia NEC/NOS,Ath ext ntv art ulcrtion,Diabetic retinopathy NOS,Anemia in chr kidney dis,Chr airway obstruct NEC,Cardiac arrest,Leukocytosis NOS,Malnutrition mod degree
Admission Date:  [**2177-1-16**]              Discharge Date:   [**2177-2-6**]

Date of Birth:  [**2125-1-14**]             Sex:   F

Service: MEDICINE

Allergies:
Darvon

Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
bilateral lower extremities arterial ulcers

Major Surgical or Invasive Procedure:
left femoral-popliteal bypass graft angioplasty

History of Present Illness:
52 yof with extensive [**First Name3 (LF) 1106**] history presents to clinic with
concern for infected bilateral lower extremity ulcers. Ms.
[**Known lastname 13257**] is well known to our team and presented today for eval
of her LE ulcers. She recently saw her
pcp who put her on oral steroids. She reports the uclers
worsened and are draining.

Past Medical History:
Type I Diabetes Mellitus
Peripoheral neuropathy
Diabetic Nephropathy (failed transplant)
- pt was scheduled for repeat transplant on [**2174-8-23**] but was
cancelled because of her PVD historybilateral retinopathy s/p
retinal detachment.
Benign Hypertension
significant PVD history with multiple prior LE bypass surgeries
Prior GI bleeding on ASA and plavix
CAD s/p MIx2, s/p LAD stents
s/p CABG [**8-19**]
Meningitis
chronic anemia
- likely multifactorial due to renal failure, hx of antral
erosions and mild esophagitis on EGD
CVA x 2
hyperlipidemia

Social History:
Two children in their 20s.  She lives with her boyfriend and has
24-hour support at home from him and from her daughter.  She
formerly worked at the post-office.  She has a 30-pack-year
history of smoking and quit in [**2165**].  She does not drink
alcohol.


Family History:
Her mother is alive at age 77 without significant medical
problems.  [**Name (NI) **] father died at age 76 of sepsis.  He also had
type 2 diabetes and prostate cancer.  She has a sister age 51
and another sister age 41 who has type 1 diabetes.  There is no
family history of blood disorders or colon cancer.

Physical Exam:
On admission:
Vitals: T 94.5-97.2, BP 119-152/40-46, P 58-70, RR 14, O2sat 94%
2L NC
General: lying in bed, no acute distress, appears stated age
HEENT: NCAT, PERLL, anicteric, OP clear
Neck: supple, no LAD
Pulm: poor inspiratory effort, mildly reduced BS at bases,
occasional rhonchi at left base
CV: irreg, appears to have PVCs on A-line [**Location (un) 1131**], nl S1 S2, no
m/r/g
Abd: ecchymoses, soft, overweight, non-tender, +BS
Extrem: both lower extremities wrapped, poor and faint DP/PT
pulses bilaterally, right extremity prior digit amputation
Neuro: CN 2-12 intact, non-focal


Pertinent Results:
admission labs:
[**2177-1-16**] 10:00PM   GLUCOSE-219* UREA N-86* CREAT-6.3*#
SODIUM-139 POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-23 ANION GAP-25*
[**2177-1-16**] 10:00PM   WBC-17.4* RBC-5.51*# HGB-13.8 HCT-48.5*
MCV-88# MCH-25.1*# MCHC-28.5* RDW-20.0*
[**2177-1-16**] 10:00PM   PLT COUNT-424


Brief Hospital Course:
The patient was admitted to the [**Year/Month/Day **] Surgical Service for
evaluation and treatment of the ulceration of bilateral lower
extremities. Patient was hemodynamically stable at the time of
admission.

Neuro: The patient received oral and intravenous pain control
with good effect. During the periods when she was mildly
confused or lethargic, the pain medications were used with care.
Patient was alert and oriented until the HD 11 when she was
found to be confused and obtunded in respiratory distress and
subsequently transferred to the ICU. Her mental status has been
fluctuating since.

Psych: Patient has been depressed throughout the entire stay.
She experienced hoplessness and helplessness with her current
situation. She was also voiced wishes to die. Patient has been
seen on by a social work services.

CV: At the time of admission patient was stable from a
cardiovascular standpoint. Few days after the admission she
experienced episodes of nausea. She was rulled out for
myocardial ischemia. Her troponin was elevated in 0.4 range and
in the days to follow, it rose as high as 1.2. Cardiology was
consulted and felt that the etiology was the stress ischemia.
They recommended trending troponins, serial EKGs were done. No
intervention was recommended. There was no acute ischemia.
Recommendation was to stop lisinopril as patient was in
worsening renal failure, beta blocker was recommended, but
currently held, as patient blood pressure has been quite low.
Further follow up was not necessary, perhaps catheterization in
the future. Patient was cleared for the angiogram by cardiology.
Patient had an echocardiogram which showed right ventricular
strain.

Patient had an angiogram done which showed stenosis in the left
femoral to popliteal bypass graft, which was angioplastied.
Patient tolearted the procedure well and was stable
post-procedure. Her signals dopelarable monophasic - posterior
tibialis and dorsalis pedis bilaterally.

Pulmonary: Patient has an underlying COPD. She was initially
stable from the respiratory standpoint. Her oxygen requirement
increased over the course of the week of hodpitalization from
one liter to three liters on nasal canula. As her renal function
worsened she developed bilateral pleural effusion, worse on the
right. She was found with altered mental status on HD 11. Her ph
at that time was 7. She was emergently intubated and transferred
to the ICU. She remained intubated for a day and extubated
easily. She underwent diagnostic/therapeutic thoracocentesis on
HD 12 while in ICU. She also recieved more agressive
hemodialysis to optimaize her respiratory status. After transfer
from the ICU to floor her repiratory status remained stable,
sating over 92% on 3L NC.

GI/GU/FEN: Patient's intake and output were closely monitored.
She is on hemodialysis and continued to be hemodialysed on MWF
per her schedule. However, she was also hemodilaysed on three
consecutive days following the respiratory distress which was
most likely attributable to right heart failure and fluid
overload. Electrolytes were routinely followed, and were not
replaced as patient is on hemodialysis. Patient was on regular
diet, however has had a poor intake. No supplemental nutrition
was provided.

ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Her WBC remoned high
despite the treatment with levofloxacin and unasyn. Levofloxacin
was stopped on HD 12, the dose of unasyn was decreased on HD14.
Patient has remained afebrile. Patient has blood cultures
pending.

Wound care was provided twice daily to lower extremitied
bilaterally. The wounds are significantly improved bilaterally.
The culture grew beta streptococcus.

Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. Patient was
followed by [**Last Name (un) **].

Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.

Prophylaxis: The patient received subcutaneous heparin, aspirin
and plavix. She was unable to umbulate secondary to her painful
feet. She ambulated to chair.

At the time of transfer, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, yet had poor intake. She was stable from respiratory and
cardiovascular standpoint. Her code status was not addressed,
she is full code at the time of transfer.
.
.
ICU course:  The patient was transferred to the MICU for GI
bleed.  This stabilized shortly after ICU admission, with no
further signs of bleeding per rectum.   However, she developed a
supraventricular arrhythma with HR 130-140, similar to episodes
of junctional tachycardia documented during prior admissions.
EKG while tachycardic also demonstrated ischemic ST elevations
in the inferior leads with reciprocal depressions in the
precordium.  Goals of care were clarified with the patient and
her family, and the decision was made not to pursue aggressive
cardiac interventions including cathetherization, CPR, shocks,
or intubation.  Shortly thereafter, the patient's blood pressure
became unstable, requiring >8L of fluid as well as
neosynephrine.  She then spontaneously converted to NSR and her
BP stabilized, although pressors continued to be required.
Goals of care were again addressed with the patient and her
family.  The decision was made to move toward making the patient
comfortable.  Appropriate medication changes were made, and the
patient died the following day.


Medications on Admission:
lipitor 40mg once daily, nephrocaps 1 tab daily, calcium acetate
667 2tabs [**Hospital1 **], plavix 75mg daily, tricor 145mg daily, lantus 12u
am , humalog ss, lisinopril 20 mg daily, lorazepam 1mg qhs,
metop succinate 100mg daily, faroxetine 10mg daily, tylenol prn,
vit c 500mg daily, asa, zinc 50 mg daily

Discharge Disposition:
Expired

Discharge Diagnosis:
deceased

Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased


Completed by:[**2177-2-6**]
{'Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,End stage renal disease,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Unspecified pleural effusion,Ulcer of heel and midfoot,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Systolic heart failure, unspecified,Blood in stool,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Cardiac arrest,Leukocytosis, unspecified,Malnutrition of moderate degree'}


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: bilateral lower extremities arterial ulcers

PRESENT ILLNESS: 52 yof with extensive [**First Name3 (LF) 1106**] history presents to clinic with
concern for infected bilateral lower extremity ulcers. Ms.
[**Known lastname 13257**] is well known to our team and presented today for eval
of her LE ulcers. She recently saw her
pcp who put her on oral steroids. She reports the uclers
worsened and are draining.

MEDICAL HISTORY: Type I Diabetes Mellitus
Peripoheral neuropathy
Diabetic Nephropathy (failed transplant)
- pt was scheduled for repeat transplant on [**2174-8-23**] but was
cancelled because of her PVD historybilateral retinopathy s/p
retinal detachment.
Benign Hypertension
significant PVD history with multiple prior LE bypass surgeries
Prior GI bleeding on ASA and plavix
CAD s/p MIx2, s/p LAD stents
s/p CABG [**8-19**]
Meningitis
chronic anemia
- likely multifactorial due to renal failure, hx of antral
erosions and mild esophagitis on EGD
CVA x 2
hyperlipidemia

MEDICATION ON ADMISSION: lipitor 40mg once daily, nephrocaps 1 tab daily, calcium acetate
667 2tabs [**Hospital1 **], plavix 75mg daily, tricor 145mg daily, lantus 12u
am , humalog ss, lisinopril 20 mg daily, lorazepam 1mg qhs,
metop succinate 100mg daily, faroxetine 10mg daily, tylenol prn,
vit c 500mg daily, asa, zinc 50 mg daily

ALLERGIES: Darvon

PHYSICAL EXAM: On admission:
Vitals: T 94.5-97.2, BP 119-152/40-46, P 58-70, RR 14, O2sat 94%
2L NC
General: lying in bed, no acute distress, appears stated age
HEENT: NCAT, PERLL, anicteric, OP clear
Neck: supple, no LAD
Pulm: poor inspiratory effort, mildly reduced BS at bases,
occasional rhonchi at left base
CV: irreg, appears to have PVCs on A-line [**Location (un) 1131**], nl S1 S2, no
m/r/g
Abd: ecchymoses, soft, overweight, non-tender, +BS
Extrem: both lower extremities wrapped, poor and faint DP/PT
pulses bilaterally, right extremity prior digit amputation
Neuro: CN 2-12 intact, non-focal

FAMILY HISTORY: Her mother is alive at age 77 without significant medical
problems.  [**Name (NI) **] father died at age 76 of sepsis.  He also had
type 2 diabetes and prostate cancer.  She has a sister age 51
and another sister age 41 who has type 1 diabetes.  There is no
family history of blood disorders or colon cancer.

SOCIAL HISTORY: Two children in their 20s.  She lives with her boyfriend and has
24-hour support at home from him and from her daughter.  She
formerly worked at the post-office.  She has a 30-pack-year
history of smoking and quit in [**2165**].  She does not drink
alcohol. 

### Response:
{'Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled,Acute respiratory failure,End stage renal disease,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Unspecified pleural effusion,Ulcer of heel and midfoot,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage V or end stage renal disease,Systolic heart failure, unspecified,Blood in stool,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Polyneuropathy in diabetes,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Other and unspecified hyperlipidemia,Atherosclerosis of native arteries of the extremities with ulceration,Background diabetic retinopathy,Anemia in chronic kidney disease,Chronic airway obstruction, not elsewhere classified,Cardiac arrest,Leukocytosis, unspecified,Malnutrition of moderate degree'}
