CHIEF COMPLAINT: Ischemic right foot.

PRESENT ILLNESS: This is a 74-year-old male, with
multiple medical problems and known peripheral vascular
disease, who underwent a left fem-[**Doctor Last Name **] and right [**Doctor Last Name **]-PT
bypass, now admitted for nonhealing right second toe ulcer.
The patient's family admits that the patient is not
maintaining leg elevation when resting.  He denies fevers,
chills, nausea or vomiting, abdominal pain.  He is now
admitted for further evaluation and treatment.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: Vital signs are stable, afebrile.  The
patient is an alert, white male in no acute distress.  HEENT
exam is unremarkable.  Chest is clear to auscultation.  Heart
has a regular rate and rhythm.  Abdomen is soft, nontender,
nondistended, no palpable masses.  Pulse exam - 2+ femorals
bilaterally.  The right lower extremity is with edema, right
greater than left.  The left TMA site is clean, dry and
intact.  He has dopplerable DP and PT bilaterally.  Left heel
is with Duoderm.  The right graft is palpable.  There is a
small ulcer on the medial malleolus.  There is a larger 3x3
cm ulcer on the lateral malleolus.  Neurological exam is
unremarkable.

FAMILY HISTORY: 

SOCIAL HISTORY: 
Other complications due to other vascular device, implant, and graft,Gangrene,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of leg, except foot,Ulcer of heel and midfoot,Atrial fibrillation,Congestive heart failure, unspecified,Pure hypercholesterolemia
Comp-oth vasc dev/graft,Gangrene,Ac osteomyelitis-ankle,Cellulitis of leg,Ulcer of heel & midfoot,Atrial fibrillation,CHF NOS,Pure hypercholesterolem
Admission Date:  [**2180-4-29**]       Discharge Date:  [**2180-5-16**]

Date of Birth:   [**2106-1-8**]       Sex:  M

Service:  VASCULAR

CHIEF COMPLAINT:  Ischemic right foot.

HISTORY OF PRESENT ILLNESS:  This is a 74-year-old male, with
multiple medical problems and known peripheral vascular
disease, who underwent a left fem-[**Doctor Last Name **] and right [**Doctor Last Name **]-PT
bypass, now admitted for nonhealing right second toe ulcer.
The patient's family admits that the patient is not
maintaining leg elevation when resting.  He denies fevers,
chills, nausea or vomiting, abdominal pain.  He is now
admitted for further evaluation and treatment.

PAST MEDICAL HISTORY - ILLNESSES:  1) Atrial fibrillation, 2)
Congestive heart failure, 3) Diabetes, 4) Coronary artery
disease, status post myocardial infarction in [**2175**], 5)
Chronic renal insufficiency, 6) Hypercholesterolemia.

PAST SURGICAL HISTORY:  1) Left fem-[**Doctor Last Name **] in [**7-7**]) Left TMA
in [**7-7**]) Right [**Doctor Last Name **]-PT with nonreversed saphenous vein in
[**6-/2177**], 4) Right fifth toe amputation, 5) Left first toe
amputation, 6) Right foot split-thickness skin graft on
[**2179-7-15**], 7) Pacemaker in [**2175**], VVI.

MEDICATIONS:  1) NPH Insulin 20 U q am and 15 U q hs, 2)
lactulose 30 mg qd, 3) lasix 80 mg [**Hospital1 **], 4) potassium chloride
40 mEq [**Hospital1 **], 5) milk of magnesia 30 cc prn, 6) neurontin 300
mg tid, 7) Lopressor 25 mg [**Hospital1 **], 8) colace 100 mg [**Hospital1 **], 9)
metolazone 2.5 mg qd.

ALLERGIES:  No known drug allergies.

PHYSICAL EXAM:  Vital signs are stable, afebrile.  The
patient is an alert, white male in no acute distress.  HEENT
exam is unremarkable.  Chest is clear to auscultation.  Heart
has a regular rate and rhythm.  Abdomen is soft, nontender,
nondistended, no palpable masses.  Pulse exam - 2+ femorals
bilaterally.  The right lower extremity is with edema, right
greater than left.  The left TMA site is clean, dry and
intact.  He has dopplerable DP and PT bilaterally.  Left heel
is with Duoderm.  The right graft is palpable.  There is a
small ulcer on the medial malleolus.  There is a larger 3x3
cm ulcer on the lateral malleolus.  Neurological exam is
unremarkable.

HOSPITAL COURSE:  The patient was admitted to the vascular
service.  He was placed on bed rest with the leg elevated.
Noninvasive studies were obtained which demonstrated
significant bilateral SFA tibial disease with noncompressible
vessels.  The femoral dopplerable signal was triphasic
bilaterally.  The popliteal, PT and DP signals were
monophasic bilaterally.  The metatarsal forefoot pressure was
10 mm on the right and 11 mm on the left.  Ankle brachial
index was calculated at 0.71 on the right and 0.78 on the
left, but this was elevated secondary to his noncompressible
vessels.

The patient underwent an arteriogram with Dr. [**Last Name (STitle) **] in the
Catheterization Lab on [**2180-5-2**], after being hydrated and
Mucomyst protocol.  The findings demonstrated abdominal aorta
mildly diseased with single renal arteries bilaterally
without evidence of stenosis.  There were patent bilateral
common iliac, external iliac, hypogastric arteries.  The
right lower extremity had patent common femoral, profunda and
SFA.  Popliteal was patent.  There was an occluded previously
placed BK to PT bypass graft.  The AT occludes just distal to
its origin.  The TP trunk is patent.  The PT and peroneal
occlude just at their origins.  The AT reconstitutes in the
distal calf.  The PT is occluded.  The AT runoff is to the DP
and tarsal.  The arch is incomplete.  The patient tolerated
the arteriogram without complication.

Cardiology was consulted regarding perioperative risk
assessment.  They felt that he had a normal P-thallium last
[**Month (only) 205**], is asymptomatic, and recommended a repeat study.  If
the study is negative, he can proceed to surgery.  The stress
portion of the study was the patient had no angina, but the
EKG was uninterpretable secondary to pace being a paced
rhythm.  The nuclear study demonstrated no perfusion defects.
Left ventricular cavity size was normal.  There was normal
wall motion.  The ejection fraction was calculated at 69%.
In comparison with patient's previous exam of [**2179-6-21**], there
has been no significant change.  The patient's admitting foot
cultures grew gram-negative rods, moderate growth of
three-colony morphologies.  Sensitivities were not performed.
The patient was continued on vanco and Zosyn.

The patient underwent, on [**2180-5-10**], a right popliteal-pedal
bypass with right arm vein.  He tolerated the procedure well
and was transferred to the PACU in stable condition.  He
remained hemodynamically stable.  His postoperative crit was
36.5, BUN 34, creatinine 0.4, K 3.6 which was repleted.
Chest x-ray was unremarkable.  EKG was without ischemic
changes, but it was a paced rhythm.

The patient continued to do well and was transferred to the
VICU for continued monitoring and care.  On postoperative day
#1, there were no overnight events.  He had adequate pain
control.  Incentive spirometry was instituted.  Beta blockers
were continued.  The patient was allowed up out of bed.  PT
and OT were requested to see the patient.  He remained in the
VICU.  Postoperative day #2, he continued to do well and was
transferred to the regular nursing floor after being delined.
He had a palpable graft pulse with dopplerable DP and PT.

On [**5-12**], it was noted that the patient had bumped his
creatinine from 1.4 to 1.9.  His vanco was held.  His lasix
was held.  His potassium was held.  His Zosyn was renal
dosed.  Over the following 48 hours it was continued to be
monitored, and the offending medications held with
improvement in his creatinine to 1.6 on [**2180-5-15**].  His
remaining hospital course was unremarkable.

He was seen by physical therapy who felt that he would do
well and benefit from rehab when he was medically stable for
discharge.  The patient was discharged in stable condition.
Wounds were clean, dry and intact.  He had a functioning
graft pulse.

DISCHARGE MEDICATIONS:  1) gabapentin 300 mg tid, 2)
metolazone 2.5 mg qd, 3) Dulcolax 10 mg PR prn, 4) miconazole
powder 2% [**Hospital1 **] to groin, 5) oxycodone/acetaminophen 1-2
tablets q 4-6 h prn, 6) metoprolol 25 mg [**Hospital1 **]--hold for
systolic blood pressure less than 120, heart rate less than
60, 7) colace 100 mg [**Hospital1 **], 8) senna tabs 1 [**Hospital1 **], 9) lasix
dosing will be adjusted and reinstituted once patient's
creatinine is to baseline, 10) continue on vancomycin 750 mg
q 48 h and 11) Zosyn 2.5 mg q 8 h until discharge, and then
will be converted to Augmentin for a total of 2 more weeks.
These will be dosed according to his creatinine clearance,
12) NPH Insulin 20 U q breakfast and NPH 15 U at bedtime, qid
sliding scales.  Gluc qid or q 6 h as follows:  Glucoses less
than 120 - 0 Insulin, 121-140 - 2 U, 141-160 - 4 U, 161-180 -
6 U, 181-200 - 8 U, 201-220 - 10 U, 221-240 - 12 U, 241-260 -
14 U, 261-280 - 16 U, 281-300 - 18 U, greater than 300 - 20
U.

DISCHARGE DIAGNOSES:  1) Right foot ischemia, status post
right popliteal-pedal bypass with right arm vein.  2) Status
post arteriogram with right leg runoff.  3) Diabetes, insulin
dependent, controlled.  4) History of pacemaker implantation,
remote, functioning.  5) Chronic renal insufficiency with
elevated creatinine secondary to medications, improved.  6)
History of Methicillin resistant Staphylococcus aureus.

DISCHARGE INSTRUCTIONS:  1) The patient should follow-up with
Dr. [**Last Name (STitle) **] in [**12-9**] weeks for skin clip removal.  2) He can be
full weightbearing essential distances only.  3) Fingersticks
ac and at hs.  4) Follow-up with Doctors [**Name5 (PTitle) **] and [**Name5 (PTitle) **]
in two week's time.




                       DR.[**Last Name (STitle) **],[**First Name3 (LF) 1112**] 02-285

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

D:  [**2180-5-15**]  09:46
T:  [**2180-5-15**]  08:46
JOB#:  [**Job Number 34949**]
{'Other complications due to other vascular device, implant, and graft,Gangrene,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of leg, except foot,Ulcer of heel and midfoot,Atrial fibrillation,Congestive heart failure, unspecified,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: Ischemic right foot.

PRESENT ILLNESS: This is a 74-year-old male, with
multiple medical problems and known peripheral vascular
disease, who underwent a left fem-[**Doctor Last Name **] and right [**Doctor Last Name **]-PT
bypass, now admitted for nonhealing right second toe ulcer.
The patient's family admits that the patient is not
maintaining leg elevation when resting.  He denies fevers,
chills, nausea or vomiting, abdominal pain.  He is now
admitted for further evaluation and treatment.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: Vital signs are stable, afebrile.  The
patient is an alert, white male in no acute distress.  HEENT
exam is unremarkable.  Chest is clear to auscultation.  Heart
has a regular rate and rhythm.  Abdomen is soft, nontender,
nondistended, no palpable masses.  Pulse exam - 2+ femorals
bilaterally.  The right lower extremity is with edema, right
greater than left.  The left TMA site is clean, dry and
intact.  He has dopplerable DP and PT bilaterally.  Left heel
is with Duoderm.  The right graft is palpable.  There is a
small ulcer on the medial malleolus.  There is a larger 3x3
cm ulcer on the lateral malleolus.  Neurological exam is
unremarkable.

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Other complications due to other vascular device, implant, and graft,Gangrene,Acute osteomyelitis, ankle and foot,Cellulitis and abscess of leg, except foot,Ulcer of heel and midfoot,Atrial fibrillation,Congestive heart failure, unspecified,Pure hypercholesterolemia'}
