CHIEF COMPLAINT: Nonhealing ulceration of the right lower
extremity for approximately six months.

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.  Insulin dependent diabetes mellitus for the last 34 years
with triopathy and gastroparesis.
2.  Coronary artery disease status post myocardial infarction
in [**2114**].
3.  Hypertension.
4.  70 pack per year history of nicotine use, which continues
today.  She admits to 2?????? pack per day for the last 34 years.
5.  Hyperlipidemia.
6.  The patient admits to having two cerebrovascular
accidents with residual defect on the left, both occurring in
[**2116**], as well as anemia, and end-stage renal disease status
post kidney transplant in 9/[**2117**].

MEDICATION ON ADMISSION: 1.  Insulin pump with a basal rate of 0.7 units, 12 midnight
to 12 noon, 0.9 units 12 noon to 6 p.m. and 0.7 units 6 p.m.
to 12 midnight.
2.  Aspirin 325 mg p.o.q.d.
3.  Lasix 80 mg p.o.q.d.
4.  Neurontin 200 mg p.o.q.d.
5.  Lopressor 25 mg p.o.b.i.d.
6.  Prograf 2 mg b.i.d.
7.  CellCept [**Pager number **] mg p.o.b.i.d.
8.  Prednisone 7.5 mg p.o.q.d.
9.  Bactrim single strength p.o.b.i.d. for PCP [**Name Initial (PRE) 1102**].
10. MS Contin 60 mg p.o.q.d.
11. Dilaudid 2 mg p.o.t.i.d.
12. Moban 50 mg p.o.q.h.s.
13. Dulcolax.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a 70 pack per year history
of nicotine use, which continues today.  She admits to 2??????
pack per day for the last 34 years.  She denies any history
of alcohol abuse.
Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled,Peripheral angiopathy in diseases classified elsewhere,Ulcer of heel and midfoot,Polyneuropathy in diabetes,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Kidney replaced by transplant,Unspecified essential hypertension
DMI circ uncntrld,Angiopathy in other dis,Ulcer of heel & midfoot,Neuropathy in diabetes,CHF NOS,Chr airway obstruct NEC,Kidney transplant status,Hypertension NOS
Admission Date:  [**2118-11-30**]       Discharge Date:  [**2118-12-14**]

Date of Birth:   [**2074-6-22**]       Sex:  F

Service:  VASCULAR SURGERY

CHIEF COMPLAINT:  Nonhealing ulceration of the right lower
extremity for approximately six months.

HISTORY:  Mrs. [**Known lastname **] is a 54-year-old white female with the
past medical history significant for diabetes mellitus,
insulin dependent for the last 34 years, as well as coronary
artery disease, congestive heart failure, and end-stage renal
disease status post renal transplant times one year ago.  The
patient presents with a nonhealing ulceration of her right
lower extremity on the plantar surface of her right foot for
approximately the last six months.  She has a severe history
of neuropathy.  It is felt that this is most likely a
neuropathic ulcer, as she does not admit to any trauma to the
area.  The ulcer is approximately 3-mm x 3-mm in size with a
hyperkeratotic lesion on the plantar aspect of the right
first phalangeal joint.  She is status post multiple bypass
surgeries, which ultimately resulted in a left lower
extremity below-the-knee amputation, times two years ago with
a right femoral-popliteal bypass in [**2112**].

She was admitted to the Vascular Surgery Service for further
evaluation, as well as angiography and surgical correction.

PAST MEDICAL HISTORY:
1.  Insulin dependent diabetes mellitus for the last 34 years
with triopathy and gastroparesis.
2.  Coronary artery disease status post myocardial infarction
in [**2114**].
3.  Hypertension.
4.  70 pack per year history of nicotine use, which continues
today.  She admits to 2?????? pack per day for the last 34 years.
5.  Hyperlipidemia.
6.  The patient admits to having two cerebrovascular
accidents with residual defect on the left, both occurring in
[**2116**], as well as anemia, and end-stage renal disease status
post kidney transplant in 9/[**2117**].

SOCIAL HISTORY:  The patient has a 70 pack per year history
of nicotine use, which continues today.  She admits to 2??????
pack per day for the last 34 years.  She denies any history
of alcohol abuse.




PAST SURGICAL HISTORY:  History is significant for multiple
bypass procedures of the lower extremities; left below knee
amputation in [**2117**]; kidney transplant 9/[**2117**].

MEDICATIONS ON ADMISSION:
1.  Insulin pump with a basal rate of 0.7 units, 12 midnight
to 12 noon, 0.9 units 12 noon to 6 p.m. and 0.7 units 6 p.m.
to 12 midnight.
2.  Aspirin 325 mg p.o.q.d.
3.  Lasix 80 mg p.o.q.d.
4.  Neurontin 200 mg p.o.q.d.
5.  Lopressor 25 mg p.o.b.i.d.
6.  Prograf 2 mg b.i.d.
7.  CellCept [**Pager number **] mg p.o.b.i.d.
8.  Prednisone 7.5 mg p.o.q.d.
9.  Bactrim single strength p.o.b.i.d. for PCP [**Name Initial (PRE) 1102**].
10. MS Contin 60 mg p.o.q.d.
11. Dilaudid 2 mg p.o.t.i.d.
12. Moban 50 mg p.o.q.h.s.
13. Dulcolax.

PHYSICAL EXAMINATION:  Examination revealed a well-developed,
somewhat cachectic white female appearing in no apparent
distress, but appearing older than her stated age of 54.
NECK:  Neck was supple without evidence of carotid bruits.
HEART:  HEART:  Heart revealed regular rate and rhythm, 2/6
systolic ejection murmur.  LUNGS:  Lungs were clear to
auscultation bilaterally.  ABDOMEN:  Abdomen was soft,
nontender, and nondistended with positive bowel sounds and a
palpable kidney transplant in the right lower quadrant.
EXTREMITIES:  Examination revealed positive femoral pulses
bilaterally with only Dopplerable popliteal and pedal pulses
on the right.  There is a below the knee amputation present
on the left.  The ulcer was very superficial on the plantar
aspect of the right lower extremity approximately
3 -mm x 3-mm in size.

HOSPITAL COURSE:  The patient was admitted to [**Hospital1 346**], where she was evaluated by
Dr.[**Last Name (STitle) **], who felt that she would need an angiogram to
assess her lower extremity vasculature as she was not healing
the ulcer and it was felt that the bypass, which was
performed in the past, was either closed or severely
diseased.  This was performed on [**12-1**] and revealed a
narrowed distal aorta without significant focal stenoses;
normal iliac system; and right transplanted kidney.  The
right femoral popliteal bypass was not visualized and the
native artery was severely diseased and diffusely narrowed.
There was a very high-grade stenosis in the above knee
popliteal arteries as described.  A single vessel anterior
tibial runoff to the foot supplies a patent dorsalis pedis
artery, which reconstitutes to the plantar arch.  Based on
these findings, it was decided that she would need a distal
revascularization and a vein mapping of her arms, which were
performed.  This revealed that she had a patent left basilic
and cephalic vein and this was used for her bypass procedure.
Prior to the operation she was evaluated by the Renal
Transplant Service who recommended switching her Prograf and
CellCept over to IV, while she remained NPO.

[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultation was also sought, as she is a very
brittled diabetic, and she was managed on the insulin pump.
She was subsequently taken down the operating room on
[**12-2**], where a right common femoral to
popliteal-anterior tibial bypass performed with left arm vein
graft.  Details of this procedure are dictated in a separate
operative note.

The patient was transferred up to the Vascular Intensive Care
Unit.  She was maintained with a CVP catheter.  She did
fairly well.  However, she did have a slightly low urine
output for which she was given maintenance IV fluids with
lactated Ringer at 125 an hour.  She was started on an
insulin drip for sugars well into the 300s.  It was managed
by the [**Last Name (un) **] Unit.  She was doing quite well from a
hemodynamic standpoint until postoperative day #3, when she
went into congestive heart failure and became shortness of
breath with desaturations down into the 80s.  She was closely
managed by the Vascular Team.  She was given IV Lasix 20 mg
times three doses.  She had a very minimal response to this
and she diuresed approximately one liter.  The electrolytes
were evaluated and subsequently repleted appropriately.  A
Swan-Ganz catheter was introduced and did reveal that she had
high filling pressures.  It was noted that her weight was
approximately 7-kg over her baseline.  She continued to
respond slowly to the Lasix and she was stable.  However, it
was noted that she did desaturate and had a period of
confusion.  It was felt that she may be intubated.  So, she
was subsequently transferred to the Surgical Intensive Care
Unit.  At this point, the aggressive diuresis kicked in and
she continued to diurese quite well.  Intubation of the
patient was avoided and she remained stable with evidence of
decreased shortness of breath and improving O2 saturations.
She was maintained in the Intensive Care Unit for three days,
at which time she was continued on her insulin drip.  She was
then subsequently transferred back up to Re-vascular
Intensive Care Unit where she was monitored.  She was started
back on her insulin pump on postoperative day #10.  It should
be noted that while she was in the Intensive Care Unit
consultation was sought by the Department of Cardiology to
facilitate her healing.  They recommended aggressive diuresis
with loop diuretics, as well as continuing the Lopressor to
decrease the heart rate with a successful treatment plan.
She eventually began to take off some of the fluid, which was
present.

At this time she is up on the floor.  She is doing quite
well.  Chest x-ray has improved.  However, there is still
evidence of some mild congestive heart failure present.  The
patient is essentially asymptomatic and is without any
problems at this time.  She denies any symptoms of shortness
of breath, chest pain, or dyspnea.  She is afebrile.  She is
back on her insulin pump.  She did have an increase in her
basal rate to 1.8 units.  She has been shown, by the learning
center, how to bolus herself should her sugars be elevated.
She has been seen by the Department of Physical Therapy and
she has been cleared for discharge to home.  It is felt that
rehabilitation is not necessary at this time.  Visiting
Nursing Association will be set up for wound care, as well as
to monitor for infections or recurrent congestive heart
failure.

Physical examination at the time of discharge revealed the
patient to be in no apparent distress.  She is afebrile.
Vital signs were stable.  Neck was supple without evidence of
carotid bruits.  Heart revealed regular rate and rhythm.
Lungs are clear to auscultation bilaterally without wheezes,
rubs, or rhonchi.  Abdomen was soft, nontender, and
nondistended with palpable kidney transplant.  Extremities
revealed a well healed left arm incision, as well as slowly
healing incisions of the right lower extremity.  The foot is
warm and there is good Dopplerable signals in her foot.  At
this point there was no change in her wound.  However, we
expect to see a change in the next several weeks.

LABORATORY DATA:  Studies at the time of discharge are as
follows:  white blood cell count of 10.7, hemoglobin 10.2,
hematocrit 30.8, platelet count 240,000, glucose 89, BUN 21,
creatinine 0.8, sodium 139, potassium 4.3, chloride 97,
bicarbonate 35, calcium 8.6, phosphorus 2.7, magnesium 1.5.
Wound cultures from the foot revealed coagulase negative
Staphylococcus aureus in sparse growth.  The chest x-ray from
[**12-12**], revealed persistent pattern of interstitial
and alveolar opacities representing mild congestive heart
failure.

DISPOSITION:  Stable, progressing well.  She will go home
with VNA Services.  The staples in the left groin are to be
removed by Dr. [**Last Name (STitle) **] in the followup visit in [**7-26**] days.
Dry sterile dressing is to be placed to the right heel, as
well as to the right plantar wound.  She is to be followed by
the podiatry department in approximately 7-10 days.  She will
be discharged.  She is advised to followup closely with the
[**Hospital **] Clinic for further management of her diabetes, as well
as the renal transplant service on a routine basis for
continued evaluation, as well as monitoring of her
immunosuppressive medications.


DISCHARGE MEDICATIONS:
1.  Prograf 2 mg p.o.b.i.d.
2.  CellCept [**Pager number **] mg p.o.b.i.d.
3.  Bactrim single strength, p.o.q.d.
4.  Neurontin 300 mg p.o.t.i.d.
5.  Sliding scale of regular insulin.
6.  Lasix 40 mg p.o.b.i.d.
7.  Lopressor 25 mg p.o.b.i.d.
8.  Zantac 150 mg p.o.q.d.
9.  Prednisone 7.5 mg p.o.q.d.
10. Insulin pump with a basal rate of 1.8 cc per hour.
11. Dilaudid 2-4 mg p.o.q.[**4-22**] h.p.r.n.

DISCHARGE DIAGNOSES:
1.  Nonhealing ulceration of the right lower extremity status
post right femoral to popliteal bypass graft with left arm
vein.
2.  Brittle diabetic female with insulin dependent diabetes
mellitus for the last 24 years, currently controlled at this
time with an insulin pump.
3.  Congestive heart failure currently resolved on oral
diuretics.
4.  End-stage renal disease status post kidney transplant
with no active issues at this time.
5.  Hypertension, managed on oral beta blockers.




                            [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 19472**]

Dictated By:[**Doctor First Name 22875**]
MEDQUIST36

D:  [**2118-12-13**]  12:19
T:  [**2118-12-13**]  12:16
JOB#:  [**Job Number 26633**]
{'Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled,Peripheral angiopathy in diseases classified elsewhere,Ulcer of heel and midfoot,Polyneuropathy in diabetes,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Kidney replaced by transplant,Unspecified essential hypertension'}


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: Nonhealing ulceration of the right lower
extremity for approximately six months.

PRESENT ILLNESS: 

MEDICAL HISTORY: 1.  Insulin dependent diabetes mellitus for the last 34 years
with triopathy and gastroparesis.
2.  Coronary artery disease status post myocardial infarction
in [**2114**].
3.  Hypertension.
4.  70 pack per year history of nicotine use, which continues
today.  She admits to 2?????? pack per day for the last 34 years.
5.  Hyperlipidemia.
6.  The patient admits to having two cerebrovascular
accidents with residual defect on the left, both occurring in
[**2116**], as well as anemia, and end-stage renal disease status
post kidney transplant in 9/[**2117**].

MEDICATION ON ADMISSION: 1.  Insulin pump with a basal rate of 0.7 units, 12 midnight
to 12 noon, 0.9 units 12 noon to 6 p.m. and 0.7 units 6 p.m.
to 12 midnight.
2.  Aspirin 325 mg p.o.q.d.
3.  Lasix 80 mg p.o.q.d.
4.  Neurontin 200 mg p.o.q.d.
5.  Lopressor 25 mg p.o.b.i.d.
6.  Prograf 2 mg b.i.d.
7.  CellCept [**Pager number **] mg p.o.b.i.d.
8.  Prednisone 7.5 mg p.o.q.d.
9.  Bactrim single strength p.o.b.i.d. for PCP [**Name Initial (PRE) 1102**].
10. MS Contin 60 mg p.o.q.d.
11. Dilaudid 2 mg p.o.t.i.d.
12. Moban 50 mg p.o.q.h.s.
13. Dulcolax.

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient has a 70 pack per year history
of nicotine use, which continues today.  She admits to 2??????
pack per day for the last 34 years.  She denies any history
of alcohol abuse. 

### Response:
{'Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled,Peripheral angiopathy in diseases classified elsewhere,Ulcer of heel and midfoot,Polyneuropathy in diabetes,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Kidney replaced by transplant,Unspecified essential hypertension'}
