CHIEF COMPLAINT: cool and painful right lower extremity

PRESENT ILLNESS: 65 year old M with a PMH of left AKA and CAD s/p 4V CABG
presents with a 6 hour history of a cool and painful RLE.  The
patient notes that at 1pm, his right foot acutely became more
pale and started hurting.  He was taken to a local ED, where he
was given a bolus of heparin.  His pain resolved, but the foot
remained cold and the OSH was unable to doppler any distal
pulses.  Therefore, the patient was transfered to [**Hospital1 18**] ED for
further care.  At time of presentation, he denied any
pain/parasthesias or difficulty moving his foot.  He did state
that it felt cold, however.  He denies any trauma to that area.
He is able to ambulate with a prosthesis on his left foot and a
cane.  Of note, the patient is on coumadin for history of PE/DVT
and INR was 1.4 at the OSH.

MEDICAL HISTORY: HTN
CAD s/p CABG [**2129**]
L AKA [**2119**]
hypercholesterolemia
PE/DVT on Coumadin
PVD s/p aortobifem [**2119**]'s

MEDICATION ON ADMISSION: ASA 81 mg qd
lisinopril 10 mg qd
HCTZ 12.5 mg qd
Omeprazole 20 mg qd
Metoprolol 50 mg qd
Lovastatin 20 mg qd
Coumadin 7 mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: xx

FAMILY HISTORY: n/c

SOCIAL HISTORY: n/c
Unspecified essential hypertension,Other complications due to other vascular device, implant, and graft,Candidiasis of lung,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Acidosis,Acute myocardial infarction of unspecified site, initial episode of care,Acute respiratory failure,Acute vascular insufficiency of intestine,Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Above knee amputation status,Aortocoronary bypass status,Pure hypercholesterolemia
Hypertension NOS,Comp-oth vasc dev/graft,Candidiasis of lung,Hemorrhage complic proc,Ac posthemorrhag anemia,Acidosis,AMI NOS, initial,Acute respiratry failure,Ac vasc insuff intestine,Renal vascular disorder,Abn react-anastom/graft,Long-term use anticoagul,Hx-ven thrombosis/embols,Status amput above knee,Aortocoronary bypass,Pure hypercholesterolem
Admission Date:  [**2148-11-23**]              Discharge Date:   [**2148-12-18**]

Date of Birth:  [**2083-3-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
cool and painful right lower extremity

Major Surgical or Invasive Procedure:
[**2148-11-24**]  Aorto-Bifem thrombectomy
[**2148-11-25**] Flexible sigmoidoscopy


History of Present Illness:
65 year old M with a PMH of left AKA and CAD s/p 4V CABG
presents with a 6 hour history of a cool and painful RLE.  The
patient notes that at 1pm, his right foot acutely became more
pale and started hurting.  He was taken to a local ED, where he
was given a bolus of heparin.  His pain resolved, but the foot
remained cold and the OSH was unable to doppler any distal
pulses.  Therefore, the patient was transfered to [**Hospital1 18**] ED for
further care.  At time of presentation, he denied any
pain/parasthesias or difficulty moving his foot.  He did state
that it felt cold, however.  He denies any trauma to that area.
He is able to ambulate with a prosthesis on his left foot and a
cane.  Of note, the patient is on coumadin for history of PE/DVT
and INR was 1.4 at the OSH.


Past Medical History:
HTN
CAD s/p CABG [**2129**]
L AKA [**2119**]
hypercholesterolemia
PE/DVT on Coumadin
PVD s/p aortobifem [**2119**]'s


Social History:
n/c

Family History:
n/c

Physical Exam:
xx

Pertinent Results:
[**2148-12-10**] 04:15AM BLOOD WBC-15.7* RBC-3.25* Hgb-9.3* Hct-28.2*
MCV-87 MCH-28.7 MCHC-33.1 RDW-15.6* Plt Ct-1353*

[**2148-12-10**] 04:15AM BLOOD Plt Ct-1353*

[**2148-12-10**] 04:15AM BLOOD PT-14.5* PTT-59.1* INR(PT)-1.3*

[**2148-12-10**] 04:15AM BLOOD Glucose-117* UreaN-17 Creat-0.7 Na-135
K-3.5 Cl-107 HCO3-24 AnGap-8

[**2148-12-9**] 03:35AM BLOOD Glucose-193* UreaN-16 Creat-0.7 Na-134
K-3.8 Cl-102 HCO3-20* AnGap-16

[**2148-12-7**] 02:52AM BLOOD ALT-37 AST-46* AlkPhos-187* Amylase-146*
TotBili-1.6*

[**2148-12-7**] 02:52AM BLOOD Lipase-279*

[**2148-12-10**] 04:15AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.0

MRCP (MR ABD W&W/OC) Study Date of [**2148-12-9**] 1:18 PM
There is no evidence of cholecystitis, although there is sludge
in
the gallbladder. There is no biliary dilatation. There are
bilateral pleural effusions. There is evidence of previous
retroperitoneal hemorrhage. There is ischemic abnormality of the
spleen.

CHEST (PORTABLE AP) Study Date of [**2148-12-5**] 7:39 AM
FINDINGS: As compared to the previous examination, there is no
relevant
overall change. Minimal areas of hypoventilation at both lung
bases, minimal right-sided pleural effusion limited to the very
area of the costophrenic sinus. No newly appeared focal
parenchymal opacity suggestive of pneumonia, normal size of the
cardiac silhouette.

LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2148-12-3**]
8:09 AM IMPRESSION:
1. No intra- or extra-hepatic bile duct dilatation.
2. Gallbladder sludge but no son[**Name (NI) 493**] evidence for acute
cholecystitis.
3. Small right pleural effusion.
4. Mild splenomegaly.

CT GUIDANCE DRAINAGE Study Date of [**2148-11-29**] 1:31 PM
IMPRESSION: Successful CT-guided placement of an 8 French
pigtail catheter in the pelvic fluid collection. 90 mL of clear
brown fluid was aspirated. A sample was sent to the laboratory
for Gram stain, fungal smear and bacterial and fungal cultures.

CT ABDOMEN W/CONTRAST Study Date of [**2148-11-28**] 1:16 PM
Impression:
1) Markedly abnormal segment of sigmoid colon as described above
suggestive of infarcted bowel. The portions of the sigmoid
immediately proximal as well as the rectum appear re-perfused.
2) Interval decrease in the right retroperitoneal hemorrhage
with surgical
drain in place.
3) Unorganized intraperitoneal fluid in the deep pelvis adjacent
to the
sigmoid with thin peritoneal enhancement.
4) Persistent abnormal perfusion pattern of the spleen
suggestive of ischemic injury.
5) Moderate bilateral pleural effusions with associated
atelectasis.
6) This study was not tailored as an arterial phase study to
evaluate the
bypass graft, though there remains persisting high-grade
stenosis of the
distal aorta. The right SFA does appear re-perfused and there is
some re-
perfusion of the proximal portion of the left iliac graft.

US ABD LIMIT, SINGLE ORGAN PORT Study Date of [**2148-11-25**] 9:28 AM
IMPRESSION:
1. Unremarkable gallbladder containing an echogenic structure
which may be a small polyp or adherent gallstone. Otherwise, no
signs of cholecystitis
identified. No biliary dilatation.
2. Ascites identified in the perihepatic space.

Portable TTE (Complete) Done [**2148-11-25**] at 9:44:56 AM      FINAL

Conclusions
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No significant valvular abnormality seen. Moderate
pulmonary artery systolic hypertension.

CTA ABD W&W/O C & RECONS Study Date of [**2148-11-24**] 10:42 AM

IMPRESSION:
1. High-grade distal aortic stenosis appears secondary to acute
thrombosis
in the proximal graft. Clot begins just below the origin of the
renal
arteries, and extends inferiorly towards the bifurcation. Right
iliac graft
is patent, but the left is completely occluded.

2. Very large right retroperitoneal hemorrhage, with areas of
active
extravasation of contrast in right groin. Foci of active
extravasation in the right groin cannot be directly connected to
the external iliac graft, and may be arising from a bleeding
superficial or subcutaneous muscular branch vessel in the right
groin deep to the staple line.

3. Multiple wedge-shaped perfusion defects in the left kidney,
most
consistent with infarcts, acuity uncertain.

4. Findings consistent with hypoperfusion complex in the
visceral organs,
including splenic hypoperfusion, adrenal hyperenhancement, and
heterogeneous perfusion of the liver.

5. Relative hypoperfusion of the sigmoid colon may be secondary
to shock as the sigmoid and superior rectal arteries are patent
but clamped down in
appearance.

6. Occluded right superficial femoral artery.

ECG Study Date of [**2148-11-24**]  7:43:22 PM
Sinus tachycardia with a decrease in voltage as compared with
prior
tracing of [**2148-11-23**]. There are new downsloping ST segment
depressions
and T wave inversions in leads I and aVL with ST-T wave
flattening
in the inferior leads and new ST segment depression and T wave
inversion
in leads V5-V6. These findings are consistent with active
inferolateral
ischemia. Followup and clinical correlation are suggested.

 ECG Study Date of [**2148-11-23**]  8:31:38 PM
Sinus rhythm with intraventricular conduction delay. Left
bundle-branch block pattern. Peaking of the T waves is present
in leads V2-V6 which is consisent with hyperkalemia or anterior
myocardial infarction. A Q wave is also present in lead V1
consistent with anteroseptal myocardial infarction, age
undetermined. No previous tracing available for comparison.




Brief Hospital Course:
[**2148-11-23**] Transferred from OSH for threatened RLE. Started
Heparin drip.

[**2148-11-24**] Patient had a CTA abdomen-Very large right
retroperitoneal hemorrhage, with areas of active extravasation
of contrast in right groin.  High-grade distal aortic stenosis
appears secondary to acute thrombosis in the proximal graft.
Clot begins just below the origin of the renal arteries, and
extends inferiorly towards the bifurcation. Right iliac graft is
patent, but the left is completely occluded. Taken to OR for
Thrombectomy of right limb of aortobifemoral, resection of
pseudoaneurysm with interposition graft. Patient tolerated
procedure, intubated, L bracila arterial line, foley, NGT, and R
IJ central line placed. Patient remained intubated and sedate
post-operatively, transferred to the CVICU. On heparin drip.
Pulses of RLE w/ [**Last Name (un) **] signals popletieal, and PT, absent DP.
RISS for glycemic control. Fluid resuscitation and pressors for
hypotention. Transfused with 2 units packed red blood cells.
Follow up CTA done-with persistent right groin bleeding and
retroperitoneal hematoma. Taken back to OR for Exploration of
right groin with ligation of bleeding vessel, evacuation of
retroperitoneal hematoma. JP drians placed. Postoperatively-
fluid resuscitated. Remains on pressors, heparin drip and
intubated.

12/29-31/08 CVICU days # 2, 3. Intubated on pressors, and
heparin gtt. Continue RISS. Hct stable. WBC rising- started on
Levaquin emperically. Pan cultured. Cardiach ECHO done- LVEF >55
%.

[**2148-11-28**] CVICU day # 4, intubated-weaning to CPAP, sedate, RISS,
Vanco an Metronidazole added to ABX. Off pressors. WBC
peristently elevated with low grade temp. Abdominal CT
done-Unorganized intraperitoneal fluid in the deep pelvis
adjacent to the sigmoid with thin peritoneal enhancement.

[**2148-11-29**]  CVICU day # 5. Now w/ generalized anasarca. Still
febrile. Remain intubated. Hypertensive managed w/ metoprolol
and Hydralazine IV. Underwent successful CT-guided placement of
an 8 French pigtail catheter in the pelvic fluid collection. 90
mL of clear brown fluid was aspirated. Sample was sent to the
laboratory for Gram stain, fungal smear and bacterial and fungal
cultures. Continue ABX. Added Fluconazole-prelin Cx came back w/
yeast. Started TPN.

[**2148-11-30**] CVICU day # 6. Still febrile T maxed 101.8. Remain
intubated-CPAPing. Axillary arterial line placed at bedside.
Hydralazine and Metoprolol for hypertension. Remains on Vanco,
Zosyn, Flagyl and Fluconazole. Levaquin d/c'd. ID consulted-
recs to continue w/ current ABX. Started Lasix [**Hospital1 **]. Patient
started having diarrhea negative C-diff, abdomenn also
distended. General surgery consulted-will follow.

[**2148-12-1**] CVICU day # 7 Remains febrile (T amx 101.6)-became
confused. Weaned and extubated. Remains on ABX
(Vanc/Zosyn/Fluconazole). Tube feeds started, stooling bloody.
General surgery following- no scope for now. Getting diuresed. R
IJ changed to L subclavian CL.

[**2148-12-2**] CVICU day # 8 Afebrile. WBC continue to rise. ID
following-Continue w/ ABX (Vanc/Zosyn/Fluc). Tube feeds on
hold-speech and swallow eval-swallowing OK. Rechecking C-diff
cultures. Continue to diurese.

[**2148-12-3**] CVICU day # 9 Spiked temp 101.7-pan cultured. Elevated
LFT's. Abdomenal US was done-negative extra-hepatic bile duct
dilatation, or acute cholecystitis. Has Gallbladder sludge.
Continue ABX (Vanc/Zosyn/Fluc). NGT replaced to Dobhoff. Tube
feeds resumed after abdominal US.

[**Date range (1) 81630**] HD [**11-9**] CVICU day # [**9-7**] Afebrile. Peritoneal pigtail
d/c'd. ABX continue(Zosyn/Fluconazole), Vanco dicontinued.
Continue to diurese. LFT's remain elevated- d/c'd statin.
Patient continue to have diarrhea.

[**2148-12-6**] HD 14 CVICU day # 12 Low grade temp, still confused. LFTs
still elevated-continued to monitor. Transferred to [**Hospital Ward Name 121**] 5 VICU.
Still stooling- flexiseal in rectum. Taking po meds.

[**Date range (1) 81631**] HD 15-16 (VICU) VSS, afebrile. WBC down, LFTS's
normalized. Diffuse tenderness of mid abdomen. Gen Surgery resc-
MRCP. A-line d/c'd. Continues on TPN and heparin gtt. Continues
w/ Zosyn.

1/12-13/09 HD 16-17 (VICU) VSS, low grade temps. MRCP
done-negative. Continues on TPN and heparin drip. Started
regular diet. Still having diarrhea. Thigh drain d/c'd. Started
Coumadin. Continue Zosyn. Physical therapy consult for out of
bed.

[**2148-12-11**] HD 18 VICU VSS, afebrile. Continue w/ Zosyn, TPN,
heparin gtt. TPN d/c'd after bag is finished. Coumadin dosed.
Groin staples removed. Stool for C-diff sent again. Continue to
work w/ physical therapy. Calorie count.

[**2148-12-12**] HD# 19 VICU - episode of rectal bleeding noted in rectal
bag. Heparin dose decreased. repeat HCT. stable @ 28.1. Rectal
tube removed and bleeding stopped. anticoagulation
continued.patient not thearpeutic on coumadin INR 1.3 IV heparin
bridge continued and coumadin dosed.
[**2148-12-13**] HD#20 Transfered to floor.INR 1.7 today will continue
with IV heparin bridge.
will dose with 7mg coumadin tonight. IF INR on [**12-14**] 2.0 or >
will d/c heaprin and d/c to rehab. Discharge dose should be
7.0mgm daily. Will D/C Iv antibiotics at discharge and continue
a  two week course of augmentin 875mg [**Hospital1 **] until seen in f/up
with Dr. [**Last Name (STitle) 1391**].


Medications on Admission:
ASA 81 mg qd
lisinopril 10 mg qd
HCTZ 12.5 mg qd
Omeprazole 20 mg qd
Metoprolol 50 mg qd
Lovastatin 20 mg qd
Coumadin 7 mg qd

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Outpatient Lab Work
INR weekly
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
9. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
10. Warfarin 1 mg Tablet Sig: Seven (7) Tablet PO Once Daily at
4 PM.
11. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.


Discharge Disposition:
Extended Care

Facility:
Country [**Hospital 731**] Rehabilitation & Nursing Center - [**Location (un) 5028**]

Discharge Diagnosis:
Thrombosed psuedoaneurysm
Right retroperitoneal hematoma with bleeding collateral vessel
history of HTN
history of hyperlipedemia
history of PE/DVT
postoperative acute anemia secondary to blood loss -requiring
blood transfusion
postoperative pneumonia-yeast
reactive thrombocytosis,annticoagulated

PSH:
PVD s/p aortobifem [**2119**]'s
history of CAD s/p CABG [**2129**]
history of L AKA [**2119**]


Discharge Condition:
Stable


Discharge Instructions:
- ambulate as tolerated FU with Dr. [**Last Name (STitle) 1391**]
- Elevate leg when sitting
- no driving till FU
- may shower, no tub baths
- Keep wound dry and clean, call if noted to have redness,
draining, swelling, or if temp is greater than 101.5
- Continue all medications as directed
- Diet as tolerated
- Keep all FU appointments
- Call Dr.[**Name (NI) 1392**] office for FU appointment in 2 weeks
- you will be on live long coumdain, take as directed, f/.up
with your PCP for [**Name9 (PRE) 1783**] of your INR-goal 2.0-3.0

Followup Instructions:
 Dr. [**Last Name (STitle) 1391**] Phone:[**Telephone/Fax (1) 1393**] 2 weeks f/up, call for
appointment.



Completed by:[**2148-12-13**]

Name:  [**Known lastname 13097**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 13098**]

Admission Date:  [**2148-11-23**]              Discharge Date:   [**2148-12-18**]

Date of Birth:  [**2083-3-6**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 231**]
Addendum:
1/17-19/09 No acute events, discharge did not push through,
still awaiting rehab bed (insurance approval). INR therapeutic,
heparin drip stopped. Started PO Augmentin in prepation for
discharge.

[**12-17**] Still awaiting rehab bed. INR [**Last Name (LF) 13099**], [**First Name3 (LF) **] dose
Coumadin accordingly.
[**2148-12-18**] INR 3.9 today, dose tonight to 2.5mg to maintain INR
2.0-3.0. INr should be monitered daily while adjusting coumadin
dose and while on antibiotics and until stablized off
antibitics. Coumadin dose not given today.Please administer @
1600. Continue antibiotics for another five days to complete his
course. Followup with Dr. [**Last Name (STitle) **] in 2 weeks. please call for
an appointment.

Brief Hospital Course:

Discharge Disposition:
Extended Care

Facility:
Country [**Hospital **] Rehabilitation & Nursing Center - [**Location (un) 6451**]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]

Completed by:[**2148-12-18**]
{'Unspecified essential hypertension,Other complications due to other vascular device, implant, and graft,Candidiasis of lung,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Acidosis,Acute myocardial infarction of unspecified site, initial episode of care,Acute respiratory failure,Acute vascular insufficiency of intestine,Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Above knee amputation status,Aortocoronary bypass status,Pure hypercholesterolemia'}


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: cool and painful right lower extremity

PRESENT ILLNESS: 65 year old M with a PMH of left AKA and CAD s/p 4V CABG
presents with a 6 hour history of a cool and painful RLE.  The
patient notes that at 1pm, his right foot acutely became more
pale and started hurting.  He was taken to a local ED, where he
was given a bolus of heparin.  His pain resolved, but the foot
remained cold and the OSH was unable to doppler any distal
pulses.  Therefore, the patient was transfered to [**Hospital1 18**] ED for
further care.  At time of presentation, he denied any
pain/parasthesias or difficulty moving his foot.  He did state
that it felt cold, however.  He denies any trauma to that area.
He is able to ambulate with a prosthesis on his left foot and a
cane.  Of note, the patient is on coumadin for history of PE/DVT
and INR was 1.4 at the OSH.

MEDICAL HISTORY: HTN
CAD s/p CABG [**2129**]
L AKA [**2119**]
hypercholesterolemia
PE/DVT on Coumadin
PVD s/p aortobifem [**2119**]'s

MEDICATION ON ADMISSION: ASA 81 mg qd
lisinopril 10 mg qd
HCTZ 12.5 mg qd
Omeprazole 20 mg qd
Metoprolol 50 mg qd
Lovastatin 20 mg qd
Coumadin 7 mg qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: xx

FAMILY HISTORY: n/c

SOCIAL HISTORY: n/c 

### Response:
{'Unspecified essential hypertension,Other complications due to other vascular device, implant, and graft,Candidiasis of lung,Hemorrhage complicating a procedure,Acute posthemorrhagic anemia,Acidosis,Acute myocardial infarction of unspecified site, initial episode of care,Acute respiratory failure,Acute vascular insufficiency of intestine,Vascular disorders of kidney,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Above knee amputation status,Aortocoronary bypass status,Pure hypercholesterolemia'}
