CHIEF COMPLAINT: left lower extremity ischemia, dyspnea/chest pain

PRESENT ILLNESS: VASCULAR SERVICE: 70M s/p left SFA-PT with NRSVG on [**2118-3-22**]
for a non-healing left toe ulcer presents for bilateral lower
extremity angiogram and angioplasty for bilateral great toe
ulcers with dry gangrene.  He reports having had rest pain in
the left forefoot x 1 year in the same distribution as the
duskiness in that foot.  He reports rest pain in the right foot
as well to a lesser extent.
.
CARDIOLOGY SERVICE: 70 y/o male with severe aortic stenosis,
diabetes, peripheral vascular disease, hyperlipidemia, carotid
disease, recent peripheral bypass surgery, remote tobacco abuse,
mild coronary disease, who is POD 3 from a left superficial
femoral artery/bypass graft Dacron patch angioplasty (preveious
bypass SFA--PT, origin of graft had become occluded. Vascular
surgery unable to harvest a [**Last Name (LF) 5703**], [**First Name3 (LF) **] did a patch angioplasty of
bypass, with restored flow and palpable pulse). His course has
been complicated by acute respiratory distress and intubation
(currently s/p extubation) who developed chest pain in the
setting of his respiratory distress. The patient reportedly
tolerated the procedure without difficulty, but in the
post-operative period, after receiving about 2-3 L of IVF, he
developed SOB and crushing chest pressure (says like an
"elephant on my chest"), and was intubated for a brief period.
He was aggressively diuresed, and post-extubation, he was
feeling better, with more comfortable breathing and no chest
pain.
.
On transfer, the patient resports being slightly SOB this AM,
though currently he feels fine. He reports baseline orthopnea.
Denies any chest pain or lightheadedness.
.
On cardiac review of symptoms, the patient endorses orthopnea,
lower extremity edema, presyncope with exertion, and lower
extremity claudication.

MEDICAL HISTORY: -Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

MEDICATION ON ADMISSION: Furosemide 60 mg DAILY
Gabapentin 800 mg TID
Glimepiride 4 mg DAILY
Metolazone 5 mg WEEKLY
Metoprolol Tartrate 50 mg [**Hospital1 **]
Oxazepam 10 mg TID PRN anxiety/tremors
Rosuvastatin 5 mg DAILY
Aspirin 325 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Potassium Chloride 10 mEq DAILY
NPH Insulin and Novalog SS
Epinephrine [EpiPen] PRN emergency
Nitroglycerine PRN emergency

ALLERGIES: Unasyn

PHYSICAL EXAM: Vitals: Tm: 99.1, BP: 124/60, HR: 97, O2 sat: 99% 2L
CONSTITUTIONAL: No acute distress. Patient able to relay
history.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM.
THYROID: No thyromegaly or thyroid nodules.
CV: Tachycardic Regular rhythm. nl S1, S2. No extra heart
sounds. Harsh, 3/6 systolic ejection murmur, radiating to neck.
JVP difficult to assess due to size, but does not appear
elevated.
LUNGS: Good air entry bilaterally with crackles at bases. No
rhonchi or wheezing.
GI: Soft, NT, ND. +bowel sounds No HSM. No abdominal bruits.
HEME/LYMPH: 2+ peripheral edema in LE bilaterally  DP/PT:
difficult to assess due to edema, but dopplerable.
SKIN: Right lower extremity is cool. LLE has venous stasis
changes. Healing incision without erythema or pus near medial
malleolus. Healing, staped wound on anterior aspect of left
thigh. Well-demarcated ulcers at the tips of his toes.

FAMILY HISTORY: Mother died at age [**Age over 90 **] years with Alzheimers. Father died at 69
of diabetes and coronary artery disease. He has three healthy
children.
.
There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: Pt lives with his sister. [**Name (NI) **] quit smoking but reports h/o 3 ppd
x 20 years. He denies EtOH consumption.
.
He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.
Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Atherosclerosis of native arteries of the extremities with gangrene,Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes,Background diabetic retinopathy,Ulcer of other part of foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Obesity, unspecified,Other chronic pulmonary heart diseases,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution
DMII neuro nt st uncntrl,Subendo infarct, initial,Acute respiratry failure,Ac systolic hrt failure,Ath ext ntv art gngrene,Surg compl-heart,Neuropathy in diabetes,Diabetic retinopathy NOS,Ulcer other part of foot,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Aortic valve disorder,Obesity NOS,Chr pulmon heart dis NEC,Atrial fibrillation,Abn react-surg proc NEC,Accid in resident instit
Admission Date:  [**2119-5-3**]              Discharge Date:   [**2119-5-17**]

Date of Birth:  [**2049-3-15**]             Sex:   M

Service: MEDICINE

Allergies:
Unasyn

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
left lower extremity ischemia, dyspnea/chest pain

Major Surgical or Invasive Procedure:
1. Diagnostic angiogram
2. Left superficial femoral artery/bypass graft, Dacron patch
angioplasty
3. Aortic valvuloplasty

History of Present Illness:
VASCULAR SERVICE: 70M s/p left SFA-PT with NRSVG on [**2118-3-22**]
for a non-healing left toe ulcer presents for bilateral lower
extremity angiogram and angioplasty for bilateral great toe
ulcers with dry gangrene.  He reports having had rest pain in
the left forefoot x 1 year in the same distribution as the
duskiness in that foot.  He reports rest pain in the right foot
as well to a lesser extent.
.
CARDIOLOGY SERVICE: 70 y/o male with severe aortic stenosis,
diabetes, peripheral vascular disease, hyperlipidemia, carotid
disease, recent peripheral bypass surgery, remote tobacco abuse,
mild coronary disease, who is POD 3 from a left superficial
femoral artery/bypass graft Dacron patch angioplasty (preveious
bypass SFA--PT, origin of graft had become occluded. Vascular
surgery unable to harvest a [**Last Name (LF) 5703**], [**First Name3 (LF) **] did a patch angioplasty of
bypass, with restored flow and palpable pulse). His course has
been complicated by acute respiratory distress and intubation
(currently s/p extubation) who developed chest pain in the
setting of his respiratory distress. The patient reportedly
tolerated the procedure without difficulty, but in the
post-operative period, after receiving about 2-3 L of IVF, he
developed SOB and crushing chest pressure (says like an
"elephant on my chest"), and was intubated for a brief period.
He was aggressively diuresed, and post-extubation, he was
feeling better, with more comfortable breathing and no chest
pain.
.
On transfer, the patient resports being slightly SOB this AM,
though currently he feels fine. He reports baseline orthopnea.
Denies any chest pain or lightheadedness.
.
On cardiac review of symptoms, the patient endorses orthopnea,
lower extremity edema, presyncope with exertion, and lower
extremity claudication.

Past Medical History:
-Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

Social History:
Pt lives with his sister. [**Name (NI) **] quit smoking but reports h/o 3 ppd
x 20 years. He denies EtOH consumption.
.
He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol.

Family History:
Mother died at age [**Age over 90 **] years with Alzheimers. Father died at 69
of diabetes and coronary artery disease. He has three healthy
children.
.
There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

Physical Exam:
Vitals: Tm: 99.1, BP: 124/60, HR: 97, O2 sat: 99% 2L
CONSTITUTIONAL: No acute distress. Patient able to relay
history.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM.
THYROID: No thyromegaly or thyroid nodules.
CV: Tachycardic Regular rhythm. nl S1, S2. No extra heart
sounds. Harsh, 3/6 systolic ejection murmur, radiating to neck.
JVP difficult to assess due to size, but does not appear
elevated.
LUNGS: Good air entry bilaterally with crackles at bases. No
rhonchi or wheezing.
GI: Soft, NT, ND. +bowel sounds No HSM. No abdominal bruits.
HEME/LYMPH: 2+ peripheral edema in LE bilaterally  DP/PT:
difficult to assess due to edema, but dopplerable.
SKIN: Right lower extremity is cool. LLE has venous stasis
changes. Healing incision without erythema or pus near medial
malleolus. Healing, staped wound on anterior aspect of left
thigh. Well-demarcated ulcers at the tips of his toes.

Pertinent Results:
LABS ON ADMISSION:
[**2119-5-3**] 09:00PM BLOOD WBC-4.8 RBC-4.20* Hgb-12.2* Hct-34.9*
MCV-83 MCH-29.0 MCHC-34.9 RDW-14.0 Plt Ct-214
[**2119-5-3**] 09:00PM BLOOD PT-12.1 PTT-25.5 INR(PT)-1.0
[**2119-5-3**] 09:00PM BLOOD Glucose-229* UreaN-35* Creat-1.4* Na-143
K-3.3 Cl-102 HCO3-30 AnGap-14
[**2119-5-9**] 09:05PM BLOOD CK(CPK)-69
[**2119-5-8**] 01:06PM BLOOD CK-MB-2 cTropnT-<0.01
[**2119-5-9**] 09:05PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2119-5-3**] 09:00PM BLOOD Calcium-9.5 Phos-3.6 Mg-1.7
[**2119-5-9**] 07:45PM BLOOD Type-ART Temp-37.6 Rates-/30 FiO2-92
pO2-87 pCO2-59* pH-7.25* calTCO2-27 Base XS--2 AADO2-523 REQ
O2-86 Intubat-NOT INTUBA Comment-NON-REBREA
[**2119-5-9**] 09:17PM BLOOD Lactate-1.2
.
LABS ON DISCHARGE:
[**2119-5-17**] 05:30AM BLOOD WBC-5.3 RBC-3.35* Hgb-9.5* Hct-28.0*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.3 Plt Ct-323
[**2119-5-17**] 05:30AM BLOOD Plt Ct-323
[**2119-5-17**] 05:30AM BLOOD Glucose-119* UreaN-23* Creat-1.1 Na-137
K-3.9 Cl-101 HCO3-24 AnGap-16
[**2119-5-16**] 05:35AM BLOOD CK(CPK)-35*
[**2119-5-17**] 05:30AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
[**2119-5-10**] 08:16AM BLOOD Type-ART pO2-107* pCO2-38 pH-7.44
calTCO2-27 Base XS-1
.
ECHO [**2119-5-15**]
.
There is symmetric left ventricular hypertrophy. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened.
.
Compared with the prior study (images reviewed) of [**2119-5-10**],
the peak gradient across the aortic valve has decreased from
95mm Hg (mean 64mm Hg) to 69mm Hg (mean 40mm Hg).
.
CATH [**2119-5-15**]
.
COMMENTS:
1. Resting hemodynamics revealed critical aortic stenosis with a

calculated valve area of 0.53mm2. There were elevated left and
right
sided filling pressures with a PCWP of 25mmHg and an RVEDP of
18mmHg.
The central aortic pressure was normal at 133/65 with a mean of
94mmHg.
2. Successful aortic balloon valvuloplasty using a 20mm x 5cm,
22mm x
6cm, and 25mm x 6cm Tyshak II balloon.
3. Following aortic balloon valvuloplasty, the calculated valve
area
improved to 0.83mm2.
4. Supravalvular aortography demonstrated trace aortic
regurgitation.
5. Abdominal aortography demonstrated vessel diameter > 6mm from
the
aorta to the femoral arteries.
.
FINAL DIAGNOSIS:
1. Critical aortic stenosis.
2. Elevated left and right sided filling pressures.
3. Successful aortic balloon valvuloplasty.
.
CXR PA and lateral [**2119-5-11**]:
.
FINDINGS: As compared to the previous examination, the patient
has been
extubated. The lung volumes are normal. However, on today's
examination,
bilateral pleural effusions of moderate extent are seen. This
leads to
bilateral basal areas of hypoventilation.
.
No other focal parenchymal opacities. Persistent minimal
pulmonary edema.
Unchanged normal size of the cardiac silhouette.
.
LENI [**2119-5-10**]:
IMPRESSION:
.
1. Limited evaluation of the left superficial femoral [**Month/Day/Year 5703**];
however, no
definite deep venous thrombosis identified.
2. Bilateral subcutaneous edema.
.
ECHO [**2119-5-10**]
.
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Severe calcific aortic stenosis.
.
Compared with the prior study (images reviewed) of [**2119-3-6**],
the degree of aortic stenosis was probably OVERmeasured on the
prior. However, both studies show severe aortic stenosis.

Brief Hospital Course:
70 y/o male with severe aortic stenosis ([**Location (un) 109**] ~ 0.8), diabetes,
PVD, HLD, carotid disease, multiple peripheral bypass surgeries,
remote tobacco abuse, and minimal coronary disease with 30% RCA
on cath from [**7-19**], who is POD 2 from Left superficial femoral
artery/bypass graft Dacron patch angioplasty, complicated by
post-operative volume overload and presents with chest pain at
rest.
.
# VASCULAR: the patient was admitted to Dr. [**Last Name (STitle) 1391**] service for
left lower extremity ischemia and bilateral lower extremity
ulcers. Started on broad spectrum antibiotics and Heparin drip.
Patient was hydrated with bicarb and given mucomyst pre-angio.
On [**2119-5-4**], the patient was taken to the angio suite, underwent
bilateral lower extremity angiograms. He was determined to need
left SFA-bypass graft jump graft, and right femoral-PT or
peroneal bypass. On [**5-3**], patient had [**Date Range 5703**] mapping to
determine bypass conduits in preparation for his up coming lower
extremity bypass surgery. Left SFA-bypass graft jump graft, and
right femoral-PT or peroneal bypass was booked for Monday
[**2119-5-8**]. On [**2119-5-8**], the patient underwent Left superficial
femoral artery/bypass graft Dacron patch angioplasty, and
tolerated procedure well. Palpable pulse in graft.
.
In the afternoon of [**2119-5-9**], the patient developed progressive
dyspnea and was transferred to the CVICU where he was intubated
and briefly maintained on neo. Symptoms were thought to be
secondary to fluid overload and diuresis was started. He had a
troponin = 0.03. Repeat CXR showed pulmonary edema. Echo was
performed which showed a gradient accross aortic valve of 95
mmHg, improved from previous echo on [**2119-3-9**], otherwise stable.
LENIs were negative. On [**2119-5-11**], Patient complained of chest
pain. ECG showed new ST depressions across precordial leads.
Serial troponins were 0.84 (11:05), 1.03 (19:45). Patient was
transferred to cardiology service and accepted for transfer for
planned aortic valvuloplasty.
.
# Non ST elevation myocardial infarction: In the setting of
respiratory distress and fluid overload, the patient had
ischemic EKG changes consistent with global involvement of his
LV. Troponins showing rise: 0.8--1--1.45. Currently chest pain
free. Etiology not felt to be plaque rupture. Patient was
treated for exacerbation of heart failure and diuresed. He was
monitored on telemetry without events. On discharge, patient was
oxygenating well on RA. He was continued on aspirin, statin,
metoprolol. There are no new medication changes from a cardiac
perspective.
.
# Acute exacerbation of heart failure: The patient was given
fluids in the setting of surgery and has severe aortic stenosis
which likely precipitated his heart failure. He had acute
respiratory distress and chest pain. He has been aggressively
diuresed. Admission weight: 105.2 kg. Initial goal fluid
balance: negative [**Telephone/Fax (1) 1999**] mL per day for several days. Since
has aortic stenosis, runs the risk of becoming too hypotensive
if diuresed too aggressively. Patient was continued on lasix,
metoprolol and on discharge there were no changes to home
regimen.
.
# Severe aortic stenosis: Not a surgical candidate for aortic
valve replacement due to calcification. Echo on [**2119-5-10**] showed
severe aortic stenosis with a valve area of 0.8-1 cm2. Patient
underwent percutaneous valvuloplasty for temporary improvement
in symptoms. The peak gradient across the aortic valve has
decreased from 95mm Hg (mean 64mm Hg) to 69mm Hg (mean 40mm Hg).
On formal cath report, resting hemodynamics revealed critical
aortic stenosis with a calculated valve area of 0.53mm2. There
were elevated left and right sided filling pressures with a PCWP
of 25mmHg and an RVEDP of 18mmHg. Following aortic balloon
valvuloplasty, the calculated valve area improved to 0.83mm2.
Final diagnosis: Successful aortic balloon valvuloplasty without
complications.
.
# Peripheral vascular disease: The patient had a AAA in [**4-/2116**]
and extensive wounds in the tips on his toes on the lower
extremities. Has a history of poor wound healing. Now s/p left
superficial femoral artery/bypass graft Dacron patch
angioplasty. Continued on vancomycin, metronidazole, and cipro
while in house. Discharged with 2 weeks of bactrim, per ID recs.
.
# Diabetes Mellitus Type II: Controlled. Last hemoglobin A1C in
[**7-/2118**] was 6.0. Continued home NPH and HISS. Home glimepiride
held in setting of cath, resumed on discharge.
.
# Hypertension: Goal SBP<130/90. Evidence of mild symmetric LVH
on Echo. Continued on metoprolol, furosemide
.
# Hyperlipidemia: No fasting lipid panel in system. Continued
atorvastatin; discharged on home dose of rosuvastatin.
.
# Chronic renal insufficiency: Cr=1.1, at baseline. Received
pre-cath hydration.
.
# Dispo: discharged to rehab, PCP [**Name9 (PRE) 702**] arranged, outpatient
follow-up with Dr. [**Last Name (STitle) 1391**] in [**2-11**] weeks

Medications on Admission:
Furosemide 60 mg DAILY
Gabapentin 800 mg TID
Glimepiride 4 mg DAILY
Metolazone 5 mg WEEKLY
Metoprolol Tartrate 50 mg [**Hospital1 **]
Oxazepam 10 mg TID PRN anxiety/tremors
Rosuvastatin 5 mg DAILY
Aspirin 325 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Potassium Chloride 10 mEq DAILY
NPH Insulin and Novalog SS
Epinephrine [EpiPen] PRN emergency
Nitroglycerine PRN emergency

Discharge Medications:
1. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO twice a day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
4. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
5. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
6. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a week.
8. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a
day) as needed for anxiety/tremors.
9. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: 28
units qAM, 24 units qPM units Subcutaneous DAILY.
14. Humalog 100 unit/mL Solution Sig: PER SLIDING SCALE units
Subcutaneous DAILY.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 25576**]

Discharge Diagnosis:
PRIMARY:
1. left superficial femoral artery/bypass graft Dacron patch
angioplasty
2. severe aortic stenosis
3. aortic valvuloplasty
.
SECONDARY:
1. peripheral vascular disease
2. hypertension
3. hyperlipidemia
4. chronic kidney disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted to the hospital and underwent left superficial
femoral artery/bypass grafting. You developed some chest pain
and shortness of breath subsequently, likely in the setting of
receiving too much intravenous fluids. You also underwent aortic
valve valvuloplasty for your aortic stenosis.
.
NEW MEDICATIONS/MEDICATION CHANGES:
- START bactrim 800-160 mg tablet: one tablet by mouth twice a
day for 2 weeks
.
Otherwise, please continue your prior medications.
.
Please seek medical attention for chest pain, shortness of
breath, difficulty breathing, fevers, abdominal pain, or any
other concerning symptoms. Please weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.

Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office for follow-up in 2 weeks.
Phone: [**Telephone/Fax (1) 1393**]. Staples will be removed on this visit.
.
You already have an appointment with your primary care doctor,
Dr. [**Last Name (STitle) 28949**], on [**5-25**] at 1:15 pm.



Completed by:[**2119-5-17**]
{'Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Atherosclerosis of native arteries of the extremities with gangrene,Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes,Background diabetic retinopathy,Ulcer of other part of foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Obesity, unspecified,Other chronic pulmonary heart diseases,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}


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 lower extremity ischemia, dyspnea/chest pain

PRESENT ILLNESS: VASCULAR SERVICE: 70M s/p left SFA-PT with NRSVG on [**2118-3-22**]
for a non-healing left toe ulcer presents for bilateral lower
extremity angiogram and angioplasty for bilateral great toe
ulcers with dry gangrene.  He reports having had rest pain in
the left forefoot x 1 year in the same distribution as the
duskiness in that foot.  He reports rest pain in the right foot
as well to a lesser extent.
.
CARDIOLOGY SERVICE: 70 y/o male with severe aortic stenosis,
diabetes, peripheral vascular disease, hyperlipidemia, carotid
disease, recent peripheral bypass surgery, remote tobacco abuse,
mild coronary disease, who is POD 3 from a left superficial
femoral artery/bypass graft Dacron patch angioplasty (preveious
bypass SFA--PT, origin of graft had become occluded. Vascular
surgery unable to harvest a [**Last Name (LF) 5703**], [**First Name3 (LF) **] did a patch angioplasty of
bypass, with restored flow and palpable pulse). His course has
been complicated by acute respiratory distress and intubation
(currently s/p extubation) who developed chest pain in the
setting of his respiratory distress. The patient reportedly
tolerated the procedure without difficulty, but in the
post-operative period, after receiving about 2-3 L of IVF, he
developed SOB and crushing chest pressure (says like an
"elephant on my chest"), and was intubated for a brief period.
He was aggressively diuresed, and post-extubation, he was
feeling better, with more comfortable breathing and no chest
pain.
.
On transfer, the patient resports being slightly SOB this AM,
though currently he feels fine. He reports baseline orthopnea.
Denies any chest pain or lightheadedness.
.
On cardiac review of symptoms, the patient endorses orthopnea,
lower extremity edema, presyncope with exertion, and lower
extremity claudication.

MEDICAL HISTORY: -Peripheral vascular disease: s/p endovascular AAA repair with a
[**Doctor Last Name **] EXCLUDER device on [**2116-5-4**]. 23 x 160 mm main body
device and a 12 x 100 mm right iliac contralateral limb device
CTA post implantation have failed to show any evidence of
endoleak. Non healing ulcer [**2118-3-22**].  He underwent
left femoral to posterior tibial bypass graft with nonreversed
saphenous [**Year (4 digits) 5703**] graft and angioscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
Following surgery, his left leg ulcer had improved.
-s/p right carotid endarterectomy with patch angioplasty [**2116-5-18**].
-Hypertension, essential
-Hyperlipidemia
-Right eye cataract last year; left cataract is pending.
-Chronic renal insufficiency
-History of osteomyelitis
-OSA
-History of GI bleed [**12/2115**]
-Chronic back pain
-Chronic tremor

MEDICATION ON ADMISSION: Furosemide 60 mg DAILY
Gabapentin 800 mg TID
Glimepiride 4 mg DAILY
Metolazone 5 mg WEEKLY
Metoprolol Tartrate 50 mg [**Hospital1 **]
Oxazepam 10 mg TID PRN anxiety/tremors
Rosuvastatin 5 mg DAILY
Aspirin 325 mg DAILY
Docusate Sodium 100 mg [**Hospital1 **]
Potassium Chloride 10 mEq DAILY
NPH Insulin and Novalog SS
Epinephrine [EpiPen] PRN emergency
Nitroglycerine PRN emergency

ALLERGIES: Unasyn

PHYSICAL EXAM: Vitals: Tm: 99.1, BP: 124/60, HR: 97, O2 sat: 99% 2L
CONSTITUTIONAL: No acute distress. Patient able to relay
history.
EYES: No conjunctival pallor. No icterus.
ENT/Mouth: MMM.
THYROID: No thyromegaly or thyroid nodules.
CV: Tachycardic Regular rhythm. nl S1, S2. No extra heart
sounds. Harsh, 3/6 systolic ejection murmur, radiating to neck.
JVP difficult to assess due to size, but does not appear
elevated.
LUNGS: Good air entry bilaterally with crackles at bases. No
rhonchi or wheezing.
GI: Soft, NT, ND. +bowel sounds No HSM. No abdominal bruits.
HEME/LYMPH: 2+ peripheral edema in LE bilaterally  DP/PT:
difficult to assess due to edema, but dopplerable.
SKIN: Right lower extremity is cool. LLE has venous stasis
changes. Healing incision without erythema or pus near medial
malleolus. Healing, staped wound on anterior aspect of left
thigh. Well-demarcated ulcers at the tips of his toes.

FAMILY HISTORY: Mother died at age [**Age over 90 **] years with Alzheimers. Father died at 69
of diabetes and coronary artery disease. He has three healthy
children.
.
There is a family history of diabetes and heart disease.  There
is no history of hypertension or strokes.  His mother died at
age [**Age over 90 **] years of Alzheimers and his father died at 69 of diabetes
and coronary artery disease. He has three healthy children.

SOCIAL HISTORY: Pt lives with his sister. [**Name (NI) **] quit smoking but reports h/o 3 ppd
x 20 years. He denies EtOH consumption.
.
He has been living with his sister since [**2115**] with his medical
disability.  He does not currenly smoke but did smoke 3 packs
per day for 20 years.  He does not drink alcohol. 

### Response:
{'Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Acute respiratory failure,Acute systolic heart failure,Atherosclerosis of native arteries of the extremities with gangrene,Cardiac complications, not elsewhere classified,Polyneuropathy in diabetes,Background diabetic retinopathy,Ulcer of other part of foot,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Aortic valve disorders,Obesity, unspecified,Other chronic pulmonary heart diseases,Atrial fibrillation,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}
