CHIEF COMPLAINT: Left leg pain

PRESENT ILLNESS: Pt is a 53 year old female with history of PVD requiring bypass
procedures in both lower extremities, diabetes, and renal
failure on HD who presented with three days of pain on her lower
left leg. At rest and with no pressure, the pain was described
as "achy" [**3-8**]. However, with any pressure or movement, the pain
was described as sharp and [**9-7**]. She said it started at a level
just below her knee and radiated to the foot. Overall the pain
was worsening, and on the day of admission she could not walk.
Pain was constant and not alleviated by anything she did,
including taking "pain pills" she had from her recent procedure.
The pain interfered with falling asleep and also woke her at
night. Pt noted that her left leg swelled on the first day of
the pain. Pt recalled no recent trauma, bug bites, fevers,
chills, vomiting, nausea, or difficulty breathing. Of note, her
son was killed while at a friend's house on the first day that
she experienced the leg pain. She states the pain began before
that occurred. She notes that her appetite and sleep have been
poor. Since her bypass in [**Month (only) 116**], she has lived in a rehabilitation
facility.
.
In the last month, pt noted mood swings and a loss of memory.
She stated being forgetful of both recent and remote memories.
She mentioned it may be secondary to her medications.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

MEDICATION ON ADMISSION: 1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times

ALLERGIES: Lisinopril

PHYSICAL EXAM: ED Physical Examination
T 100.1 PO, HR 82, BP 149/43 RR 18, O2 sat 97% on 6L
.
Constitutional: Obese female laying in bed crying out in pain at
times.
.
Head/Eyes: NC/AT. PERRL, not icteric/no pallor.
.
ENT/Neck: MMM, clear oropharynx, no LAD.
.
Chest/Respiratory: Difficult to assess [**12-31**] habitus, poor effort,
but anteriorly clear.
.
CV: RRR, S1, S2, possible S4 gallop. No murmurs/rubs.
.
GI/Abdominal: Soft, Nt, ND, +BS.
.
GU: No flank pain.
.
MSK/Extremities/Back: + Left leg pain. Right thigh - wound vac
in place, draining little serosanguinous fluid. Multiple scars,
very tender to palp at left post calf. Pulses at dp Dopplerable
bilat.
.
Skin: no rashes/lesions. Dry, flaking feet. Fistula L arm, +
thrill. Left foot warm, full ROM toes, foot.
.
Neuro: A and Ox3. No focal deficits.
.
Psych: In pain, tearful.

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week.
End stage renal disease,Pain in limb,Pressure ulcer, lower back,Other postoperative infection,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Adjustment disorder with depressed mood,Obstructive sleep apnea (adult)(pediatric),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Other specified disorders of skin,Personal history of malignant neoplasm of kidney,Long-term (current) use of insulin
End stage renal disease,Pain in limb,Pressure ulcer, low back,Other postop infection,Chr airway obstruct NEC,DMII renl nt st uncntrld,Adjustmnt dis w depressn,Obstructive sleep apnea,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Skin disorders NEC,Hx of kidney malignancy,Long-term use of insulin
Admission Date:  [**2191-7-2**]              Discharge Date:   [**2191-7-12**]

Date of Birth:  [**2138-3-6**]             Sex:   F

Service: MEDICINE

Allergies:
Lisinopril

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Left leg pain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Pt is a 53 year old female with history of PVD requiring bypass
procedures in both lower extremities, diabetes, and renal
failure on HD who presented with three days of pain on her lower
left leg. At rest and with no pressure, the pain was described
as "achy" [**3-8**]. However, with any pressure or movement, the pain
was described as sharp and [**9-7**]. She said it started at a level
just below her knee and radiated to the foot. Overall the pain
was worsening, and on the day of admission she could not walk.
Pain was constant and not alleviated by anything she did,
including taking "pain pills" she had from her recent procedure.
The pain interfered with falling asleep and also woke her at
night. Pt noted that her left leg swelled on the first day of
the pain. Pt recalled no recent trauma, bug bites, fevers,
chills, vomiting, nausea, or difficulty breathing. Of note, her
son was killed while at a friend's house on the first day that
she experienced the leg pain. She states the pain began before
that occurred. She notes that her appetite and sleep have been
poor. Since her bypass in [**Month (only) 116**], she has lived in a rehabilitation
facility.
.
In the last month, pt noted mood swings and a loss of memory.
She stated being forgetful of both recent and remote memories.
She mentioned it may be secondary to her medications.

Past Medical History:
renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

Social History:
Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week.

Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

Physical Exam:
ED Physical Examination
T 100.1 PO, HR 82, BP 149/43 RR 18, O2 sat 97% on 6L
.
Constitutional: Obese female laying in bed crying out in pain at
times.
.
Head/Eyes: NC/AT. PERRL, not icteric/no pallor.
.
ENT/Neck: MMM, clear oropharynx, no LAD.
.
Chest/Respiratory: Difficult to assess [**12-31**] habitus, poor effort,
but anteriorly clear.
.
CV: RRR, S1, S2, possible S4 gallop. No murmurs/rubs.
.
GI/Abdominal: Soft, Nt, ND, +BS.
.
GU: No flank pain.
.
MSK/Extremities/Back: + Left leg pain. Right thigh - wound vac
in place, draining little serosanguinous fluid. Multiple scars,
very tender to palp at left post calf. Pulses at dp Dopplerable
bilat.
.
Skin: no rashes/lesions. Dry, flaking feet. Fistula L arm, +
thrill. Left foot warm, full ROM toes, foot.
.
Neuro: A and Ox3. No focal deficits.
.
Psych: In pain, tearful.

Pertinent Results:
Admission Labs:
[**2191-7-2**] 10:30AM BLOOD WBC-12.1*# RBC-3.38* Hgb-10.6* Hct-33.2*
MCV-98# MCH-31.4 MCHC-31.9 RDW-21.7* Plt Ct-154
[**2191-7-2**] 10:30AM BLOOD Neuts-88.0* Lymphs-7.4* Monos-4.2 Eos-0.1
Baso-0.4
[**2191-7-2**] 10:30AM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.2*
[**2191-7-2**] 10:30AM BLOOD Glucose-123* UreaN-8 Creat-5.0*# Na-143
K-4.4 Cl-100 HCO3-31 AnGap-16
[**2191-7-2**] 10:30AM BLOOD Calcium-8.7 Phos-2.4* Mg-1.8
[**2191-7-2**] 10:46AM BLOOD Lactate-1.6

[**2191-7-11**] 03:00PM BLOOD WBC-17.4* RBC-2.96* Hgb-9.4* Hct-28.9*
MCV-98 MCH-31.6 MCHC-32.3 RDW-21.0* Plt Ct-212
[**2191-7-10**] 06:30AM BLOOD Neuts-85.5* Lymphs-9.7* Monos-4.4 Eos-0
Baso-0.3
[**2191-7-11**] 03:00PM BLOOD Plt Ct-212
[**2191-7-11**] 03:00PM BLOOD Glucose-PND UreaN-PND Creat-PND K-PND
Cl-PND HCO3-PND
[**2191-7-10**] 06:30AM BLOOD Glucose-161* UreaN-22* Creat-6.9*# Na-139
K-5.6* Cl-96 HCO3-27 AnGap-22*
[**2191-7-10**] 06:30AM BLOOD Calcium-10.0 Phos-3.7 Mg-2.0
[**2191-7-7**] 05:50AM BLOOD %HbA1c-5.3#

BONE SCAN [**2191-7-8**]  Clip # [**Clip Number (Radiology) 101633**]
Reason: ? CRPS B/L LOWER EXTREMITIES

Final Report

RADIOPHARMECEUTICAL DATA:
   22.3 mCi Tc-[**Age over 90 **]m MDP ([**2191-7-8**]);
HISTORY: Left lower extremity pain and leukocytosis with concern
for possible
infection.

INTERPRETATION:
Whole body images of the skeleton were obtained in anterior and
posterior
projections.  Coned down flow and static images of both distal
lower extremities
were also obtained.  This study is somewhat limited by large
patient body
habitus.  There is no focal abnormal uptake of the left lower
extremity to
suggest infection. Increase uptake of the right ankle is likely
due to
degenerative stress changes.  The kidneys and urinary bladder
are visualized,
the normal route of tracer excretion.
IMPRESSION:
No abnormal uptake of the left lower extremity to suggest
infection.


CXR [**2191-7-6**]:  INDICATION:  End-stage renal disease with fever.
COMPARISON:  [**2191-5-7**] and [**2191-5-14**].
PORTABLE SUPINE VIEW OF THE CHEST:  Heart size at the upper
limits of normal.
There is right lateral and left lateral plate-like atelectasis.
There is
streaky left retrocardiac opacity.  No overt pulmonary edema.
There is no
pneumothorax.  The right costophrenic angle is not imaged.  Left
costophrenic
angle is sharp.
IMPRESSION:
1.  Bilateral plate-like areas of atelectasis in the lateral mid
lungs.
2.  Streaky left retrocardiac opacity, favor atelectasis over
pneumonia.

LLEG XRAY [**2191-7-6**]:
HISTORY: 53 y/o woman with peripheral vascular disease and
requiring bypass of bilateral lower extremities. Patient with
right wound infection. Evaluate for osteomyelitis or fracture.

FINDINGS: There are no signs for acute fractures or
dislocations. There is
overall demineralization. Extensive vascular calcifications are
present. There is some flattening of the calcaneus posteriorly
without discrete fracture line. Vascular calcifications are seen
throughout the medial aspect of the lower extremity soft
tissues. The ankle mortise is preserved. There is no abnormal
soft tissue gas.

IMPRESSION:
No radiographic evidence for osteomyelitis or acute fracture.

R Calf U/S [**2191-7-5**]: CLINICAL INDICATION:  Right calf abnormality
on MRI; varicosities vs. abscess.

COMPARISONS:  Calf MR dated [**2191-7-3**].

FINDINGS:  Multiple [**Doctor Last Name 352**]-scale and color Doppler images were
obtained in the
region of MR abnormality in the anteromedial calf subcutaneous
tissues. Images
revealing 1.4 x 1.2 x 1.0 cm complex cystic lesion without
definite flow
within or around it.  The lesion contains floating echogenic
debris but no
solid nodular component.

IMPRESSIONS:
1.  1.4-cm subcutaneous complex cystic lesion, likely
representing a sebaceous
cyst.  A small abscess would be considered less likely given the
absence of
associated vascularity.  This appearance is not consistent with
a varicosity.

[**2191-7-3**] U/S Venous doppler to eval for DVT:
INDICATION:  53-year-old female with three-day history of leg
pain and
swelling.  Please evaluate for popliteal DVT.

FINDINGS:  Comparison is made to duplex ultrasound from [**2191-7-2**],
which
completely assessed the left common femoral and superficial
veins, but did not
assess the popliteal vein secondary to patient discomfort.

FINDINGS:  Grayscale, color and pulse wave Doppler son[**Name (NI) 1417**]
were performed on the bilateral popliteal veins.  Normal flow,
compressibility, waveforms, and augmentation are demonstrated.
Augmentation in the left popliteal fossa could not be
demonstrated secondary to patient discomfort.  No intraluminal
thrombus is identified.

IMPRESSION:  No evidence of DVT in the bilateral popliteal
veins.


Brief Hospital Course:
Assessment and Plan: 53 year old female with history of PVD
requiring bypass procedures in both lower extremities, diabetes,
and renal failure on HD who presented with three days of pain on
her lower left leg. Differential includes DVT, complex regional
pain syndrome, compartment syndrome, necrotizing fasciitis,
cellulitis, and diabetic neuropathy. In light of the very recent
death of her son, her [**Name2 (NI) 101634**] status is concerning and
may be contributing to her pain.
.
1. Lower leg pain. Her pain appears severe. In the setting of
recent surgery, increased immobilization, and obesity, the risk
for DVT is high. Complex regional pain syndrome is also
possible, given her recent procedures and emotional stress.
However, fever and elevated white count (12.1 WBC) raise the
concern for infection, especially because necrotizing fasciitis
can present with few objective physical signs. Compartment
syndrome and cellulitis are less of a concern due to lack of
obvious swelling and erythema. Diabetic neuropathy seems less
likely due to the pain's acute and severe nature. See also
problem 3.
- Control pain with oxycodone and acetaminophen; avoid dilaudid
and morphine because they caused her to have mental status
changes and agitation per discharge note from [**2191-5-17**] and
daughter's report.
- DVT could not be ruled out because the popliteal vein was not
assessed. There was no evidence of DVT in the left common
femoral vein and superficial femoral vein. Will start empiric
heparin.
- Blood cultures pending, pt on vancomycin and zosyn for wound
infections growing ESBL Klebsiella and MRSA. Continue Vanc/Zosyn
as an outpatient for a 14 day course, which is through [**2191-7-18**].
- Vascular Surgery following, will need PVRs of distal
extremeties and follow-up with Dr. [**Last Name (STitle) **] in [**11-30**] weeks.
- Podiatric Surgery following, will need to continue splints,
debridement cream, and follow-up with Dr. [**First Name (STitle) 3209**] in 1 week.
- Physical therapy will be necessary as an outpatient.
.
2. Right thigh wound vac. s/p vascular surgery on [**2191-3-31**] c/b
wound infection.
- Vascular Surgery following
- Monitor for signs of local infection.
- Will need wound care assistance as an outpatient.
- Continue Vanc/Zosyn as above as an outpatient for a 14 day
course, which is through [**2191-7-18**].
- Wound care: Aquacell silver with dry sterile dressing qDaily
.
3. Depression/coping. She has a history of depression, and her
29 year old son was shot and died three days prior to admission.
This is clearly and understandably affecting her. If no organic
cause can be found for the leg pain, consider psychologic
exacerbation or exaggeration of pain, or somatoform (pain)
disorder. Regardless of the leg pain, addressing her mood may be
therapeutic and necessary.
- Social work and psych consults done in hospital. On Seroquel.
- Will need continued psychiatry social work consultation as an
outpatient
.
4. Self-reported recent mental status changes. Etiology could be
medications. [**Month (only) 116**] also be related to her coping and depression.
- Psych and Social work as above.
.
5. O2 requirement. History of OSA on CPAP, COPD. Pt has no
respiratory complaints, but her respiratory rate was noted to be
24. Satting 94 on 2L NC. On 2-3L NC at home, CPAP at night but
unsure of her settings.
- Adjust O2 amount based on oximetry, may need 2 liters as an
outpatient.
- continue CPAP at night
- Oxygen requirement may be related to agitation; due to
peripheral vascular disease, difficult to get accurate Sp02
[**Location (un) 1131**]. No complaints or symptoms of shortness of breath.
.
6. Hypertension/Hyoptension. On the evening of [**7-11**], the patient
was admitted briefly to the MICU reported hypertension to SBP
260.  Details: .
[**7-2**] to [**7-7**]: SBP 100-120 by automatic machine
[**7-8**] to [**7-10**]: SBP 80-90 by automatic machine
[**7-10**] 10pm: SBP 260 by doppler at wrist; SBP 130 by doppler at
brachial; SBP 80 at lower forarm by automatic machine.
Because it is unclear what the true BP is for this patient, she
is transferred to the MICU for assessment of the correct blood
pressure and for closer monitoring overnight.  Overnight the
patient was asymptomatic.  The patient is currently
asymptomatic.  She has no headache, vision changes,
lightheadedness.  She denies chest pain or shortness of breath.
Her true blood pressure is unclear, though likely approx 100s
systolic. Difficult to measure due to AV fistula in L arm and
new PICC in the R arm.

7. Diabetes. On admission, her fingerstick glucose was 152.
- Continue on home regimen and monitor FS.
.
8. End stage renal failure on hemodialysis.
- Renal to follow.  HD schedule M-W-F per patient.
- Continue Vanc/Zosyn as above as an outpatient for a 14 day
course, which is through [**2191-7-18**]. Vanc is per HD protocol, Zosyn
is 2.25g q8hrs, PLUS 0.75 grams after dialysis.
.
9. LLE Bullae. Unclear etiology, Derm consulted in hospital.
They prefer to treat symptomatically and follow rather than bx
due to pt history of poor wound healing.
- will need derm f/u as outpatient.
- Wound care: Adaptic with dry sterile dressing qDaily

10.  Right ankle wound - [**12-31**] PVD
- Wound care:  Adaptiq with dry sterile dressing qDaily

11.  Decubitus ulcer on coccyx stage 2
- Wound care:  Wound gel with allevin change q3days

F/E/N: No fluids for now. Renal to follow electrolytes and
hemodialysis. Diabetic, renal diet.
.
PPx: Heparin, bowel regimen.
.
ACCESS: PICC in right arm, AV Fistula left arm.
.
CODE: FULL CODE
.
COMM: With [**Name2 (NI) **] amd Family
.
CONTACT: [**First Name8 (NamePattern2) **] [**Known lastname 37559**] [**Telephone/Fax (1) 101635**] (cell)
.
DISPO: To [**Hospital 100**] Rehab MACU

Medications on Admission:
1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times

a day).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: 1-20 units
Subcutaneous ASDIR (AS DIRECTED).
9. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)

as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
12. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
13. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 3 days: Stop date [**5-19**].
Disp:*3 Recon Soln(s)* Refills:*0*
14. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous

QHD per protocol for 2 days: stop day [**5-19**].
Disp:*2 bags* Refills:*0*
15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by

2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.


Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
3. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
4. B-Complex with Vitamin C     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Methyl Salicylate-Menthol 15-15 % Ointment Sig: One (1) Appl
Topical QID (4 times a day).
9. Insulin Lispro 100 unit/mL Solution Sig: 1-20 units
Subcutaneous qachs: take as directed for insulin sliding scale.
Disp:*100 units* Refills:*2*
10. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous once a day: at noon.
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed: hold for loose stools.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
19. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q4H (every
4 hours) as needed for constipation.
20. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
QMOWEFR ([**Month/Year (2) 766**] -Wednesday-Friday).
21. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day).
22. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).

23. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: [**11-30**]
nebs Inhalation Q4H (every 4 hours) as needed for SOB.
24. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
25. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
26. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
27. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
28. Vancomycin 1000 mg IV HD PROTOCOL
29. Antibiotic Regimen
Please continue course of Vancomycin and Zosyn through [**2191-7-18**].
30. Zosyn 2.25 g Recon Soln Sig: 2.25 grams Intravenous every
eight (8) hours: please also give 0.75 grams after dialysis in
addition to the standing doses.
Disp:*qs * Refills:*0*
31. Outpatient Lab Work
Please check vancomycin level before each dialysis


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
1. Renal Failure
2. Peripheral Vascular Disease
3. Right lower extremity wound (thigh)
4. Right lower extremity wound (heel ulcer)


Discharge Condition:
stable


Discharge Instructions:
You were evaluated and treated for your leg pain, vascular
disease, and wound care.  Please keep your follow-up
appointments as scheduled. Please follow your wound care
instructions and take your medications as prescribed. Call your
doctor or return immediately to the emergency department for any
shortness of breath, chest pain, leg pain uncontrolled by your
pain medications, or any other concerns.
Wound care instructions:
1. Right ankle wound - Change dressing daily.  Wash wound with
sterile saline and dab dry,  apply adaptiq to wound and cover
with dry sterile dressing.
2. Right thigh wound - Change dressing daily.  Wash wound with
sterile saline and dab dry, apply aquacell silver and cover with
dry sterile dressing.
3. Decubitus ulcer over coccyx - Change dressing every 3 days.
Wash wound with sterile saline and dab dry.  Apply allevin to
wound.
4. Left posterior knee bullae - Change dressing daily.  Wash
wound with sterile saline and dab dry.  Apply adaptiq with dry
sterile dressing.

Followup Instructions:
1. Please call your primary care physician to arrange [**Name9 (PRE) 702**]
this week.
2. Please call [**Hospital1 18**] Vascular Surgery (Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 2395**] to arrange follow-up in [**11-30**] weeks for a clinic
visit and non-invasive scans of your feet/ankles
3. Please call [**Hospital1 18**] Podiatry (Dr. [**First Name (STitle) 3209**] at [**Telephone/Fax (1) 543**] to
arrange follow-up in 1 week for a clinic visit and wound
re-check.
{'End stage renal disease,Pain in limb,Pressure ulcer, lower back,Other postoperative infection,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Adjustment disorder with depressed mood,Obstructive sleep apnea (adult)(pediatric),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Other specified disorders of skin,Personal history of malignant neoplasm of kidney,Long-term (current) use of insulin'}


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 leg pain

PRESENT ILLNESS: Pt is a 53 year old female with history of PVD requiring bypass
procedures in both lower extremities, diabetes, and renal
failure on HD who presented with three days of pain on her lower
left leg. At rest and with no pressure, the pain was described
as "achy" [**3-8**]. However, with any pressure or movement, the pain
was described as sharp and [**9-7**]. She said it started at a level
just below her knee and radiated to the foot. Overall the pain
was worsening, and on the day of admission she could not walk.
Pain was constant and not alleviated by anything she did,
including taking "pain pills" she had from her recent procedure.
The pain interfered with falling asleep and also woke her at
night. Pt noted that her left leg swelled on the first day of
the pain. Pt recalled no recent trauma, bug bites, fevers,
chills, vomiting, nausea, or difficulty breathing. Of note, her
son was killed while at a friend's house on the first day that
she experienced the leg pain. She states the pain began before
that occurred. She notes that her appetite and sleep have been
poor. Since her bypass in [**Month (only) 116**], she has lived in a rehabilitation
facility.
.
In the last month, pt noted mood swings and a loss of memory.
She stated being forgetful of both recent and remote memories.
She mentioned it may be secondary to her medications.

MEDICAL HISTORY: renal failure secondary to diabetes mellitus on HD
status post R nephrectomy for renal cell cancer
depression
cholecystectomy
gastric ulcer
PVD s/p Left SFA to dorsalis pedis artery bypass for L
gangrenous heel in [**2187**]; R proximal SFA to proximal AT bypass on
[**2191-3-31**]
OSA on CPAP
Gastroparesis
Ischemic colitis
Right thigh wound
LVH, EF 55%
COPD on 3-4L NC at home

MEDICATION ON ADMISSION: 1. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
2. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times

ALLERGIES: Lisinopril

PHYSICAL EXAM: ED Physical Examination
T 100.1 PO, HR 82, BP 149/43 RR 18, O2 sat 97% on 6L
.
Constitutional: Obese female laying in bed crying out in pain at
times.
.
Head/Eyes: NC/AT. PERRL, not icteric/no pallor.
.
ENT/Neck: MMM, clear oropharynx, no LAD.
.
Chest/Respiratory: Difficult to assess [**12-31**] habitus, poor effort,
but anteriorly clear.
.
CV: RRR, S1, S2, possible S4 gallop. No murmurs/rubs.
.
GI/Abdominal: Soft, Nt, ND, +BS.
.
GU: No flank pain.
.
MSK/Extremities/Back: + Left leg pain. Right thigh - wound vac
in place, draining little serosanguinous fluid. Multiple scars,
very tender to palp at left post calf. Pulses at dp Dopplerable
bilat.
.
Skin: no rashes/lesions. Dry, flaking feet. Fistula L arm, +
thrill. Left foot warm, full ROM toes, foot.
.
Neuro: A and Ox3. No focal deficits.
.
Psych: In pain, tearful.

FAMILY HISTORY: Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.

SOCIAL HISTORY: Denies illicit drug use. Denies smoking. Denies drinking
alcohol. Lives alone.  Recent Stressor of her son fatally shot
this week. 

### Response:
{'End stage renal disease,Pain in limb,Pressure ulcer, lower back,Other postoperative infection,Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Adjustment disorder with depressed mood,Obstructive sleep apnea (adult)(pediatric),Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Other specified disorders of skin,Personal history of malignant neoplasm of kidney,Long-term (current) use of insulin'}
