CHIEF COMPLAINT: Right lower extremity pain and swelling

PRESENT ILLNESS: Ms [**Known lastname **] is a 80 yo female with mechanical AVR, multiple
episodes of GI
bleed and hemicolectomy [**2-9**] GIB, who recently ([**6-18**]) was started
on an unclear
dose of Lovenox to bridge her anticoagulation for colonoscopy.
Yeaterday
patient started having right lower extremity pain. Today she
went for her
hemodialyis, where she was found to have extensive right thigh
swelling.
Without undergoing dialysis she was send to ED for further
evaluation and
treatment. Currently she denies any lightheadedness, chest pain,
or SOB but
endorses significant pain and discomfort in her right lower
extremity w/o being able to ambulate or move actively. She
denies any history of recent trauma to
this site and endorses a spontaneous appearance.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%)
4. Status post tracheostomy placement after prolonged intubation
in ICU (at
time of colectomy) - removed
5. Severe AS s/p mechanical AVR
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery

MEDICATION ON ADMISSION: 1.Amiodarone-200 mg Tablet-1 Tablet(s) by mouth Daily-
(Prescribed by Other Provider)
2.Aspirin-81 mg Tablet, Delayed Release (E.C.)-1 Tablet(s) by
mouth DAILY (Daily)- (Prescribed by Other Provider)
3.B Complex-Vitamin C-Folic Acid [Nephrocaps]-1 mg Capsule-1
Capsule(s) by mouth once a day- (Prescribed by Other Provider)
4.Epoetin Alfa-4,000 unit/mL Solution-1 Solution(s) QMOWEFR
(Monday -Wednesday-Friday)- (Prescribed by Other Provider)
5.Esomeprazole Magnesium [Nexium]-40 mg Capsule, Delayed
Release(E.C.)-1 Capsule(s) by mouth Daily- (Prescribed by Other
Provider)
6.Fluticasone-Salmeterol-250 mcg-50 mcg/Dose Disk with Device-1
Disk(s) inhaled twice a day- (Prescribed by Other Provider)
7.Hydralazine-25 mg Tablet-1 Tablet(s) by mouth every six (6)
hours- (Prescribed by Other Provider)
8.Levothyroxine-75 mcg Tablet-1 Tablet(s) by mouth DAILY
(Daily)- (Prescribed by Other Provider)
9.Metoprolol Tartrate-50 mg Tablet-1 Tablet(s) by mouth twice a
day- (Prescribed by Other Provider)
10.Simvastatin-20 mg Tablet-1 Tablet(s) by mouth once a day-
(Prescribed by Other Provider)
11.Warfarin-1 mg Tablet-goal INR 2.5-3.0 Tablet(s) by mouth
DAILY (Daily) as needed for mech AVR please dose based on INR
result - goal INR 2.5-3.0 with PT/INR checked daily until off
heparin and then mon/wed/fri for continued dosing- (Prescribed
by Other Provider)

ALLERGIES: Protamine

PHYSICAL EXAM: Initial Physical Exam
VS: T 97 BP 224/110 HR 54 RR 18 O2 99RA FS 186
GEN:The patient is in obvious pain
SKIN:No rashes or skin changes noted.
HEENT: no JVD, neck supple . Oropharynx clear without lesions or
exudates.
No lymphadenopathy in cervical, posterior, or supraclavicular
chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; 3/6 SEM RUSB,no  rubs, or gallops.
ABDOMEN: non tender, not destended, colostomy bag semi filled,
no erythema or discharge
EXTREMITIES: 1+ [**Location (un) **], right thigh with bulging hematoma [**2-10**] from
iliac creast on lateral aspect
NEUROLOGIC: Alert, oriented x3 and appropriate. BUE [**5-13**],
and LLE [**5-13**] RLE [**3-13**] sensation preserved, toe strength 5/5 BL

FAMILY HISTORY: No colon CA, otherwise unremarkable

SOCIAL HISTORY: Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager
Hemorrhage, unspecified,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Precipitous drop in hematocrit,Poisoning by anticoagulants,Atrial fibrillation,Hyperpotassemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Heart valve replaced by other means,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants
Hemorrhage NOS,End stage renal disease,Comp-ren dialys dev/grft,Diastolc hrt failure NOS,Mal hyp kid w cr kid V,Drop, hematocrit, precip,Poisoning-anticoagulants,Atrial fibrillation,Hyperpotassemia,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Heart valve replac NEC,Abn react-renal dialysis,Long-term use anticoagul
Admission Date:  [**2165-6-24**]              Discharge Date:   [**2165-7-8**]

Date of Birth:  [**2084-10-17**]             Sex:   F

Service: MEDICINE

Allergies:
Protamine

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Right lower extremity pain and swelling


Major Surgical or Invasive Procedure:
PICC Line placement by IR
Fistulagram by IR


History of Present Illness:
Ms [**Known lastname **] is a 80 yo female with mechanical AVR, multiple
episodes of GI
bleed and hemicolectomy [**2-9**] GIB, who recently ([**6-18**]) was started
on an unclear
dose of Lovenox to bridge her anticoagulation for colonoscopy.
Yeaterday
patient started having right lower extremity pain. Today she
went for her
hemodialyis, where she was found to have extensive right thigh
swelling.
Without undergoing dialysis she was send to ED for further
evaluation and
treatment. Currently she denies any lightheadedness, chest pain,
or SOB but
endorses significant pain and discomfort in her right lower
extremity w/o being able to ambulate or move actively. She
denies any history of recent trauma to
this site and endorses a spontaneous appearance.


Past Medical History:
1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%)
4. Status post tracheostomy placement after prolonged intubation
in ICU (at
time of colectomy) - removed
5. Severe AS s/p mechanical AVR
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery

12. Hypothyroidism
13. Presumptive history of atrial fibrillation; on amiodarone


Social History:
Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager


Family History:
No colon CA, otherwise unremarkable

Physical Exam:
Initial Physical Exam
VS: T 97 BP 224/110 HR 54 RR 18 O2 99RA FS 186
GEN:The patient is in obvious pain
SKIN:No rashes or skin changes noted.
HEENT: no JVD, neck supple . Oropharynx clear without lesions or
exudates.
No lymphadenopathy in cervical, posterior, or supraclavicular
chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; 3/6 SEM RUSB,no  rubs, or gallops.
ABDOMEN: non tender, not destended, colostomy bag semi filled,
no erythema or discharge
EXTREMITIES: 1+ [**Location (un) **], right thigh with bulging hematoma [**2-10**] from
iliac creast on lateral aspect
NEUROLOGIC: Alert, oriented x3 and appropriate. BUE [**5-13**],
and LLE [**5-13**] RLE [**3-13**] sensation preserved, toe strength 5/5 BL

VS: 99.3 108/palp 88 16
On discharge:
Ext: Right thigh ~57cm in diameter, some tenderness on
palpation, L antecubital fossa- thrill palpable, murmur audible
on AV fistula.

Pertinent Results:
Initial CBC:
[**2165-6-24**] 02:50PM   WBC-5.2 RBC-3.49* HGB-10.8* HCT-33.7* MCV-97
MCH-31.0 MCHC-32.1 RDW-17.7*
Initial Chem 7
[**2165-6-24**] 02:50PM   GLUCOSE-165* UREA N-62* CREAT-7.7*#
SODIUM-135 POTASSIUM-5.8* CHLORIDE-95* TOTAL CO2-28 ANION GAP-18

Imaging:
1. No evidence of DVT in the right lower extremity.
2. Large presumed hematoma deep to the right thigh muscles,
extending along
the femur, medially and laterally. Recommend clinical
correlation.
3. Limited arterial interrogation revealed limited absent
diastolic flow.
* R femur Xray: Diffuse osteopenia, status post ORIF distal
femoral fracture and three-component arthroplasty, without
complication or new fracture
* Hip Xray: Diffuse osteopenia with no significant change since
[**6-15**] and no definite evidence of acute fracture.

CBC @ Lowest Point [**6-25**]
WBC 7.0 Hgb 7.6* HCT 23.5* 231

CBC @ Discharge
WBC 5.8 Hgb 9.0 HCT 27.3 Plt 375
Chem 7 @ Discharge
[**2165-7-8**] 06:32AM BLOOD Glucose-134* UreaN-53* Creat-6.5*# Na-129*
K-4.1 Cl-92* HCO3-26 AnGap-15

[**2165-7-7**] 01:03PM BLOOD %HbA1c-5.4

AVFistulagram:
Performance of PTA of central cephalic arch stenosis with
satisfactory post angioplasty result.


Brief Hospital Course:
Ms. [**Known lastname **] is an 80 yo female on enoxaparin bridge for
mechanical AVR in preparation for colonoscopy presented with
right thigh hematoma and hematocrit drop.

1. Hematoma: Believed to be secondary to overdosed enoxaparin
due to renal failure.  Patient was admitted with a Hct of 34
that dropped to 27.  Concern for a worsening bleed into her
right thigh resulted in transfusion of 4 units PRBCs total
during her stay. On hospital day 6 it stablizied at 29. Her
right thigh pain was controlled on Morphine IV and Oxycodone.
The pain subsided to a single daily dose of oxycodone for pain.
Hematocrit should be monitored daily.

2. Hypertensive urgency: SBP in the 220s on presentation to ED
as the patient had not taken BP meds on admission. She was
transferred to the MICU for closer monitoring. In the ICU, the
patient received her home regimen of hydralazine and metoprolol
which controlled her blood pressure. There were no more
incidents on this home regimen throughout the stay. She should
be continued on current regimen of Metoprolol and Hydralazine.

4. s/p Aortic Valve Replacement: Patient has mechanical valve.
Patient admitted with INR of 1.7 and 1mg of warfarin qday. Due
to acute bleed all anticoagulation was stopped. Anticoagulation
with heparin gtt and Coumadin was restarted after hematocrit
stabilized. She is currently on Warfarin 5mg PO Qday and heparin
gtt should be stopped onced INR is between 2.0-3.0.  It is 1.4
at the time of discharged today.

5. End Stage Renal Disease: The patient is anuric and has been
on hemodialysis 3 times per week for six months.  During her
stay she was kept on this regimen.

6. Diabetes (Type II) The patient has an unclear of diabetes
versus hyperglycemia.  She has not outpatient therapy for
diabetes.  She was maintained on an insulin sliding scale
requring approximately 6units throughout the day.  Her
hemoglobin A1c is 5.4, and we have put recommendations to stop
insulin and start oral therapy forward to the rehabilitation
facility.

7. Access: Patient has PICC line and tunnelled line.

Medications on Admission:
1.Amiodarone-200 mg Tablet-1 Tablet(s) by mouth Daily-
(Prescribed by Other Provider)
2.Aspirin-81 mg Tablet, Delayed Release (E.C.)-1 Tablet(s) by
mouth DAILY (Daily)- (Prescribed by Other Provider)
3.B Complex-Vitamin C-Folic Acid [Nephrocaps]-1 mg Capsule-1
Capsule(s) by mouth once a day- (Prescribed by Other Provider)
4.Epoetin Alfa-4,000 unit/mL Solution-1 Solution(s) QMOWEFR
(Monday -Wednesday-Friday)- (Prescribed by Other Provider)
5.Esomeprazole Magnesium [Nexium]-40 mg Capsule, Delayed
Release(E.C.)-1 Capsule(s) by mouth Daily- (Prescribed by Other
Provider)
6.Fluticasone-Salmeterol-250 mcg-50 mcg/Dose Disk with Device-1
Disk(s) inhaled twice a day- (Prescribed by Other Provider)
7.Hydralazine-25 mg Tablet-1 Tablet(s) by mouth every six (6)
hours- (Prescribed by Other Provider)
8.Levothyroxine-75 mcg Tablet-1 Tablet(s) by mouth DAILY
(Daily)- (Prescribed by Other Provider)
9.Metoprolol Tartrate-50 mg Tablet-1 Tablet(s) by mouth twice a
day- (Prescribed by Other Provider)
10.Simvastatin-20 mg Tablet-1 Tablet(s) by mouth once a day-
(Prescribed by Other Provider)
11.Warfarin-1 mg Tablet-goal INR 2.5-3.0 Tablet(s) by mouth
DAILY (Daily) as needed for mech AVR please dose based on INR
result - goal INR 2.5-3.0 with PT/INR checked daily until off
heparin and then mon/wed/fri for continued dosing- (Prescribed
by Other Provider)


Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO qhsprn.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Hold for loose stools.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Hold for loose stools.
14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
17. Sodium Chloride 0.9 % 0.9 % Solution Sig: One (1) ML
Injection PRN (as needed) as needed for line flush.
18. Sodium Chloride 0.9 % 0.9 % Solution Sig: Three (3) ML
Injection PRN (as needed) as needed for line flush.
19. Morphine 2 mg/mL Syringe Sig: One (1)  Injection Q2H (every
2 hours) as needed.
20. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: One (1)  Intravenous ASDIR (AS DIRECTED).
21. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
22. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
23. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
Primary Diagnosis
1. Right thigh hematoma
2. End stage kidney disease
3. Mechanical Aortic Valve Replacement requiring anticoagulation
4. Hyperglycemia

Secondary diagnosis
1. Hypertension
2. History of gastrointestinal bleed necessitating an ostomy
3. Hypothyroidism
4. Atrial fibrillation


Discharge Condition:
Stable


Discharge Instructions:
You have been admitted with a right thigh hematoma--bleeding
into the thigh itself. The bleeding has stopped, but it will
take some time before the thigh returns to normal size.

You are going to be discharged to a rehab facility while your
blood becomes thin enough to pass easily through your mechanical
valve.  They will also provide rehabilitation services to help
the leg, and dialysis for your kidney disease.

Please take all medications as listed in the discharge
instructions as below. Of note, you are on a heparin drip along
with Coumadin. Once your blood count is between [**2-10**], the heparin
drip can be stopped.

Under no circumstances should your heparin be changed Lovenox
because you have developed problems with your kidneys in the
past.

Please return to the Emergency department for chest pain,
shortness of breath, leg pain or any other medical concerns.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1266**] [**Telephone/Fax (1) 608**] within a week
of discharge from the Rehabilitation facility.
{'Hemorrhage, unspecified,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Precipitous drop in hematocrit,Poisoning by anticoagulants,Atrial fibrillation,Hyperpotassemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Heart valve replaced by other means,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants'}


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: Right lower extremity pain and swelling

PRESENT ILLNESS: Ms [**Known lastname **] is a 80 yo female with mechanical AVR, multiple
episodes of GI
bleed and hemicolectomy [**2-9**] GIB, who recently ([**6-18**]) was started
on an unclear
dose of Lovenox to bridge her anticoagulation for colonoscopy.
Yeaterday
patient started having right lower extremity pain. Today she
went for her
hemodialyis, where she was found to have extensive right thigh
swelling.
Without undergoing dialysis she was send to ED for further
evaluation and
treatment. Currently she denies any lightheadedness, chest pain,
or SOB but
endorses significant pain and discomfort in her right lower
extremity w/o being able to ambulate or move actively. She
denies any history of recent trauma to
this site and endorses a spontaneous appearance.

MEDICAL HISTORY: 1. repeated Hx of gastrointestinal bleeding (most recent
[**2165-4-24**])
2. Left hemicolectomy with transverse colostomy for GIB [**11-13**]
3. Diastolic CHF (EF 65-75%)
4. Status post tracheostomy placement after prolonged intubation
in ICU (at
time of colectomy) - removed
5. Severe AS s/p mechanical AVR
6. Hypertension
7. Elevated cholesterol
8. Diabetes type 2
9. End-stage renal disease on HD MWF
10. Bilateral total knee replacment
11. Multiple skin lesions removed by general and plastic surgery

MEDICATION ON ADMISSION: 1.Amiodarone-200 mg Tablet-1 Tablet(s) by mouth Daily-
(Prescribed by Other Provider)
2.Aspirin-81 mg Tablet, Delayed Release (E.C.)-1 Tablet(s) by
mouth DAILY (Daily)- (Prescribed by Other Provider)
3.B Complex-Vitamin C-Folic Acid [Nephrocaps]-1 mg Capsule-1
Capsule(s) by mouth once a day- (Prescribed by Other Provider)
4.Epoetin Alfa-4,000 unit/mL Solution-1 Solution(s) QMOWEFR
(Monday -Wednesday-Friday)- (Prescribed by Other Provider)
5.Esomeprazole Magnesium [Nexium]-40 mg Capsule, Delayed
Release(E.C.)-1 Capsule(s) by mouth Daily- (Prescribed by Other
Provider)
6.Fluticasone-Salmeterol-250 mcg-50 mcg/Dose Disk with Device-1
Disk(s) inhaled twice a day- (Prescribed by Other Provider)
7.Hydralazine-25 mg Tablet-1 Tablet(s) by mouth every six (6)
hours- (Prescribed by Other Provider)
8.Levothyroxine-75 mcg Tablet-1 Tablet(s) by mouth DAILY
(Daily)- (Prescribed by Other Provider)
9.Metoprolol Tartrate-50 mg Tablet-1 Tablet(s) by mouth twice a
day- (Prescribed by Other Provider)
10.Simvastatin-20 mg Tablet-1 Tablet(s) by mouth once a day-
(Prescribed by Other Provider)
11.Warfarin-1 mg Tablet-goal INR 2.5-3.0 Tablet(s) by mouth
DAILY (Daily) as needed for mech AVR please dose based on INR
result - goal INR 2.5-3.0 with PT/INR checked daily until off
heparin and then mon/wed/fri for continued dosing- (Prescribed
by Other Provider)

ALLERGIES: Protamine

PHYSICAL EXAM: Initial Physical Exam
VS: T 97 BP 224/110 HR 54 RR 18 O2 99RA FS 186
GEN:The patient is in obvious pain
SKIN:No rashes or skin changes noted.
HEENT: no JVD, neck supple . Oropharynx clear without lesions or
exudates.
No lymphadenopathy in cervical, posterior, or supraclavicular
chains noted.
CHEST:Lungs are clear without wheeze, rales, or rhonchi.
CARDIAC: Regular rhythm; 3/6 SEM RUSB,no  rubs, or gallops.
ABDOMEN: non tender, not destended, colostomy bag semi filled,
no erythema or discharge
EXTREMITIES: 1+ [**Location (un) **], right thigh with bulging hematoma [**2-10**] from
iliac creast on lateral aspect
NEUROLOGIC: Alert, oriented x3 and appropriate. BUE [**5-13**],
and LLE [**5-13**] RLE [**3-13**] sensation preserved, toe strength 5/5 BL

FAMILY HISTORY: No colon CA, otherwise unremarkable

SOCIAL HISTORY: Lives at home with husband, and son. [**Name (NI) **] children in the area.
Is a non-smoker, no alcohol use, no history of illicit drug use.
Retired, former manager 

### Response:
{'Hemorrhage, unspecified,End stage renal disease,Other complications due to renal dialysis device, implant, and graft,Diastolic heart failure, unspecified,Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease,Precipitous drop in hematocrit,Poisoning by anticoagulants,Atrial fibrillation,Hyperpotassemia,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Heart valve replaced by other means,Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Long-term (current) use of anticoagulants'}
