CHIEF COMPLAINT: Right heel ulcer

PRESENT ILLNESS: This unfortunate 70 year-old gentleman, with peripheral vascular
disease, liver cirrhosis and cancer has developed ischemic
related gangrene of his right heel.  He was transferred from
another hospital with infection.  He has
been treated with antibiotics for 48 hours and is now undergoing
debridement.

MEDICAL HISTORY: PMH:

MEDICATION ON ADMISSION: metformin 1000",
Paxil,
folate,
Lantus 32u,
spironolactone 100"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General - pale cachectic male laying in bed, good spirits,
freindly
HEENT - NCAT / PERRL / EOMI,
neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lymphandopathy, supra clavicular nodes
RESP - CTA B/L upper lobes, crackles at bases
CARDIAC - RRR 1/6 SEM at apex
ABD - tympanic, distened, NTTP, pos BS, neg CVA tenderness
BRUITS - non noted
EXT - Doppler PT/DP/AT B/L
RIGHT HEEL - excised, clean, dry. minimal erythema around
debridement site, good granulation

FAMILY HISTORY: Non contributary

SOCIAL HISTORY: Pt lives with his wife and other dtr,  in their own home in
[**Name (NI) 1474**]. Dtr, [**Name (NI) **], lives nearby and is very involved and
supportive.  Son also lives in MA and is supportive.
Atherosclerosis of native arteries of the extremities with gangrene,Unspecified intestinal obstruction,Closed fracture of base of neck of femur,Acute osteomyelitis, ankle and foot,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Fall from other slipping, tripping, or stumbling,Ulcer of esophagus with bleeding,Cellulitis and abscess of foot, except toes,Hydronephrosis,Malignant neoplasm of bronchus and lung, unspecified,Unspecified viral hepatitis C without hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Personal history of irradiation, presenting hazards to health,Dermatophytosis of nail
Ath ext ntv art gngrene,Intestinal obstruct NOS,Fx base femoral nck-clos,Ac osteomyelitis-ankle,Alcohol cirrhosis liver,Bleed esoph var oth dis,Fall from slipping NEC,Ulcer esophagus w bleed,Cellulitis of foot,Hydronephrosis,Mal neo bronch/lung NOS,Hpt C w/o hepat coma NOS,DMII wo cmp nt st uncntr,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins,Hx of irradiation,Dermatophytosis of nail
Admission Date:  [**2186-3-4**]              Discharge Date:   [**2186-4-14**]

Date of Birth:  [**2115-7-24**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Right heel ulcer

Major Surgical or Invasive Procedure:
Right heel debridement
EGD with sclerotherapy
ORIF right hip


History of Present Illness:
This unfortunate 70 year-old gentleman, with peripheral vascular
disease, liver cirrhosis and cancer has developed ischemic
related gangrene of his right heel.  He was transferred from
another hospital with infection.  He has
been treated with antibiotics for 48 hours and is now undergoing
debridement.


Past Medical History:
PMH:

glaucoma,
MI ([**2161**]),
DM1,
hepatitis NOS,
cirrhosis,
small cell lung CA s/p chemo/XRT

PSH:

A0-bifem ([**2178**], [**Last Name (un) 60919**]),
B cataract,
R hand surgery


Social History:
Pt lives with his wife and other dtr,  in their own home in
[**Name (NI) 1474**]. Dtr, [**Name (NI) **], lives nearby and is very involved and
supportive.  Son also lives in MA and is supportive.

[**Name (NI) 1094**] wife is wheel chair bound secondary to polio, but is
very independent and has essentially been caretaker for pt in
more recent years as his health/mobility has declined.

Dtr,[**Name (NI) **], is currently rennovating her home and plan is for
parents
and sister to live with her and her family by the end of the
summer.

Previous drinker

Denies tobacco


Family History:
Non contributary

Physical Exam:
General - pale cachectic male laying in bed, good spirits,
freindly
HEENT - NCAT / PERRL / EOMI,
neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lymphandopathy, supra clavicular nodes
RESP - CTA B/L upper lobes, crackles at bases
CARDIAC - RRR 1/6 SEM at apex
ABD - tympanic, distened, NTTP, pos BS, neg CVA tenderness
BRUITS - non noted
EXT - Doppler PT/DP/AT B/L
RIGHT HEEL - excised, clean, dry. minimal erythema around
debridement site, good granulation

Pertinent Results:
[**2186-3-28**]

WBC-10.2 RBC-3.17* Hgb-9.7* Hct-29.2* MCV-92 MCH-30.7 MCHC-33.3
RDW-16.7* Plt Ct-183

[**2186-3-27**]

PT-13.6* PTT-32.2 INR(PT)-1.2

[**2186-3-22**]

Fibrino-530*

[**2186-3-28**]

Glucose-42* UreaN-15 Creat-1.0 Na-133 K-3.7 Cl-107 HCO3-22
AnGap-8

[**2186-3-23**]

ALT-9 AST-25 AlkPhos-86 Amylase-23 TotBili-2.2*

[**2186-3-15**]

calTIBC-103* TRF-79*

[**2186-3-4**]

%HbA1c-7.0* [Hgb]-DONE [A1c]-DONE

[**2186-3-11**]

Triglyc-44

[**2186-3-23**]

freeCa-1.28   RADIOLOGY  Final Report

[**2186-3-23**]

CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST

INDICATION: History of lung cancer, now with ulcer in the
esophagus. Evaluate for cancer recurrence.

Soft tissue window images demonstrate abnormal esophageal wall
thickening in the distal esophagus with multiple lymph nodes
which are at the upper limits of normal in size, but given its
proximity to the abnormal esophagus, are also likely abnormal.
Additionally, there are moderate to large bilateral pleural
effusions, greater on the left. The left pleural effusion is
loculated with a moderate supbulmonic component. Additionally,
there is subtle linear enhancement of the posterior surface of
the left pleura.

There is bibasilar atelectasis, left greater than right,
associated with the bilateral pleural effusions. The entire left
lower lobe is collapsed/consolildated. In both upper lobes,
there are geographic areas of opacity with traction
bronchiectasis and scarring, likely relating to prior radiation
therapy.

An ill-defined 5mm ground glass nodule is seen in the right
middle lobe. There are diffuse emphysematous changes in both
lobes. At the base of the right lung, there is an irregular area
which likely represents atelectasis/scarring. The heart,
pericardium, and great vessels are normal.

In the visualized portion of the upper abdomen, again seen is
ascites, a hiatal hernia, and right hydronephrosis. The
visualized portions of the spleen and left kidney are normal.

BONE WINDOWS: No suspicious sclerotic lesions are seen.

IMPRESSION:
1. Abnormal thickening of the distal esophagus with adjacent
lymphadenopathy, worrysome for malignancy.

2. Geographic areas of opacity in both upper lobes, consistent
with prior radiation.

3. Subtle linear enhancement of the left posterior pleural
surface. While this could be due to radiation, given the history
of lung cancer, pleural based metastatic disease is of high
concern.

4. 5 mm ground glass nodule in right middle lobe. The nodule is
somewhat ill- defined, and is nonspecific, but given the history
of lung cancer, a 3 month follow- up chest CT is reccommended.

5. Bilateral moderate to large pleural effusions and associated
bibasilar atelectasis. The left pleural effusion appears
loculated, with a moderate subpulmonic component, and there is
associated complete collapse/consolidation of the left lower
lobe.

6. Unchanged ascites, right hydronephrosis, and a hiatal hernia.
   RADIOLOGY  Final Report

[**2186-3-21**]

ABDOMEN (SUPINE & ERECT) PORT

[**Hospital 93**] MEDICAL CONDITION:

70 year old man with +NTG, dark blood, h/o partial bowel
obstruction

INDICATION: History of partial bowel obstruction with dark blood
in the NG tube.

DECUBITUS AND SUPINE VIEW OF THE ABDOMEN: Dilated loops of small
bowel are present in the right abdomen measuring up to 5 cm in
transverse diameter. Air- fluid levels are demonstrated on the
left lateral decubitus view. The degree of dilatation of
small-bowel loops appears slightly decreased compared to the
study of [**2186-3-9**].

[**2186-3-9**]

CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST

INDICATION: 70-year-old man with history of lung cancer, now
with nausea and vomiting, and loose stools.

Small pleural effusions are seen bilaterally. There is a small
hiatal hernia. A nasogastric tube descends below the diaphragm
and terminates in the stomach. There are diffuse coronary artery
calcifications, and atherosclerotic disease within the aorta.
There is a large amount of intraperitoneal ascites. The liver is
cirrhotic, without nodules or masses. The gallbladder is not
visualized. The pancreas, spleen, both adrenals are normal.
There is mild hydronephrosis of the right kidney, with delayed
contrast excretion. The abdominal aorta is diffusely calcified
with good contrast opacification of the intraabdominal vessels.

There is diffuse dilatation of the intraabdominal loops of small
bowel, measuring 4.6 cm in cross sectional diameter with
multiple air fluid levels. There is fecalization of the small
bowel within the terminal ileum, within the right lower
quadrant. No focal masses are seen within this area. Distal
loops of small bowel and colon are decompressed with minimal
contrast opacification of the ascending colon. There is no
evidence of pneumatosis, or pneumobilia.

CT OF THE PELVIS WITH ORAL, WITH INTRAVENOUS CONTRAST: Dense
calcification of the intra-abdominal aorta increases in to
bilateral iliac arteries. A Foley catheter is seen within a
collapsed bladder. Minimal gas and stool are seen within the
sigmoid and rectum.

BONE WINDOWS: Degenerative changes are seen throughout the lower
thoracic and lumbar spine. There are no suspicious lytic or
sclerotic osseous abnormalities. There is diffuse subcutaneous
edema.

IMPRESSION:
1) Small-bowel obstruction with a possible transition point in
the distal ileum, within the right lower quadrant. No focal
masses are identified at this area.
2) Delayed right renal nephrogram with mild hydronephrosis
consistent with distal obstruction.
3) Cirrhotic liver.
4) Bilateral pleural effusions.
5) Dense diffuse atherosclerosis of the coronaries, and
intraabdominal aorta.
6) Small hiatal hernia.

[**2186-3-18**]

HIP UNILAT MIN 2 VIEWS RIGHT

REASON FOR THIS EXAMINATION:

Please assess R femur fracture

Again, demonstrated is a fracture of the right femoral neck with
angulation at the fracture site. There is also some degree of
impaction with foreshortening of the femoral neck. The
projection is slightly different than the previous study.
Allowing for this factor, the fracture is likely unchanged. No
additional fractures are identified. Extensive vascular
calcifications are present.

[**2186-3-18**]

PELVIS PORTABLE

Reason: low pelvis to view arthroplasty

The patient is status post right total hip replacement procedure
with satisfactory postoperative alignment on a single
projection. Immediate postoperative changes are noted including
soft tissue gas and superficial skin staples. Extensive vascular
calcifications are again observed.

[**2186-3-18**]

L-SPINE (AP & LAT)

REASON FOR THIS EXAMINATION:

New-onset loss of L5 motor function, please assess for
compression fx.

INDICATIONS:

Recent onset of loss of L5 motor function. Question compression
fracture.

The bones are diffusely demineralized. There is a mild
compression deformity at the L4 vertebral body level. Very
minimal loss of height is noted at L5 as well. The remaining
lumbar vertebral bodies show preservation of normal height. The
disk spaces are relatively well preserved with some mild
narrowing noted at L3-L4. Degenerative changes are noted
posteriorly in the facet joints. Extensive vascular
calcifications are seen throughout the abdominal aorta and its
branches.

Regarding the decreased height at L4, it was likely present at
the time of the recent abdominal radiograph as well, but
difficult to compare due to lack of the lateral view at that
time.

Within the abdomen, note is made of multiple air filled loops of
dilated bowel, which were also present on a recent CT of the
abdomen of [**2186-3-9**], which described a small-bowel
obstruction. There is also a suggestion of ascites.

IMPRESSION:
1) Compression deformity at L4 and very minimal compression at
L5.
2) Dilated loops of small bowel, concerning for small-bowel
obstruction. Please note that recent abdominal CT of [**2186-3-9**] described a small-bowel obstruction. Probable ascites.

[**2186-3-17**]

CT HEAD W/O CONTRAST

INDICATION: Fall. Head trauma.

NONCONTRAST HEAD CT: There is no acute intra- or extra-axial
hemorrhage, hydrocephalus, shift of normally midline structures,
or evidence of major vascular territorial infarction. There is a
generalized prominence of the sulci and ventricles consistent
with brain atrophy. Small likely lacunar infarcts are present in
the periventricular white matter bilaterally. There is no skull
fracture. Visualized paranasal sinuses are clear.
There are dense carotid siphon calcifications.

IMPRESSION: No acute intracranial hemorrhage.

[**2186-3-11**]

Cardiology Report ECG

Sinus rhythm. First degree A-V delay. Prior inferior wall
myocardial
infarction. Probable prior anteroseptal myocardial infarction.
Borderline low voltage. Since the previous tracing of [**2186-3-8**]
atrial ectopy is absent.


Intervals Axes
Rate PR  QRS QT/QTc     P  QRS T
92   250 86  378/427.71 64 34  46

[**2186-3-4**]

CHEST (PRE-OP PA & LAT)

CHEST X-RAY, PA AND LATERAL VIEWS: The study is compared to
[**2186-2-15**]. The heart size is normal. The mediastinal and hilar
contours are essentially unchanged with prominent opacity again
seen at the left hilum. The pulmonary vascularity is
unremarkable. The lungs show similar prominent interstitial
markings, but the appearance is unchanged allowing for
differences in technique. There are no pleural or pericardial
effusions. The lungs are clear. The osseous structures are
unremarkable.

IMPRESSION: No significant change since the prior study, or
acute cardiopulmonary process.

[**2186-3-21**]

SPUTUM     Site: EXPECTORATED

                            **FINAL REPORT [**2186-3-27**]**

   GRAM STAIN (Final [**2186-3-21**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2186-3-24**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------  =>16 R
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S





[**2186-3-4**]

R HEEL/SUPERFICIAL WD.

                            **FINAL REPORT [**2186-3-8**]**

   WOUND CULTURE (Final [**2186-3-8**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup is performed appropriate to the isolates recovered
from the
      site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
      aureus and beta streptococcus).
      PROBABLE ENTEROCOCCUS.    MODERATE GROWTH.
      GRAM NEGATIVE ROD(S).    RARE GROWTH.
      STAPH AUREUS COAG +.    MODERATE GROWTH.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------  =>16 R
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

[**2186-3-18**]

URINE

                            **FINAL REPORT [**2186-3-19**]**

URINE CULTURE (Final [**2186-3-19**]):    NO GROWTH.


Brief Hospital Course:
Pt had a difficult hospital course

Pt admitted on [**2186-3-4**] for heel ulcer

Pt wound is swabbed,  blood cx taken, pt is stared on IV
antiotics

[**2186-3-4**] - [**2186-3-6**]

Pt stable

[**2186-3-7**] - [**2186-3-8**]

Pt taken to the OR for debridement of the right heel, He had a
right heel block. He tolerated the procedure well. There were no
complications. Transfered to the PACU in stable condition.

There was extensive debridemnt in th OR, infection to the bone,
discussed BKA with patient.

[**11-29**] blood cx are positive for septecemia, pt followed with
surveillance cultures. IV antibiotics adjusted accordingly.

[**2186-3-9**] - [**2186-3-12**]

Pt experiences decrease U/O. Foley placed. Minimal urine output
noted. Urine lytes orderd. Pre renal. Pt treated with fluids.

Because of the pts known cirrohsis, minimal N/V, distention of
the abdomen not usual for the pt. A KUB was ordered. It was
found that the pt had a SBO. CT SCAN obtained. Pt was made
NPO/PO meds were changed to IV/NGT placed. TPN started.
Nutrition labs ordered.

General Surgery consult obtained. They recommended treating
conservativley. Diagnosis partial SBO.

[**2186-3-13**] - [**2186-3-15**]

NG tube removed, pt diet was advanced. Pt doing well.

[**2186-3-16**] - [**2185-3-18**]

Pt fell trying to got to the bathroom. A stat CT scan was
ordered. which was negative for an acute bleed.

The following day pt still c/o right hip pain. Plain films were
ordered. Showed a fracture of the right hip. A trauma consult
was obtained.

Ortho consult was obtained for the right femoral neck fracture.
Pt started on Levonox for enbolis precations. Pt taken to the OR
for ORIF of the right hip.

[**2186-3-19**] - [**2186-3-21**]

Pt undergoes right bipolar hip replacement. ( tolerated the
procedure well. There were no complications. Pt transfered to
the PACU in stable condition.

Pt transfered to VICU in stable condition.

It was noticed that the patients HCT was steadily decreasing
after the procedure. He was transfused appropriatly.

on [**2186-3-21**] Pt has an episode of coffee ground emesis. NG tube
replaced. 300 cc of coffee ground emmesis evacuated. Pt stool
was guiac Positive.

Because of the decreasing HCT and the obvious GI bleed from the
NGT and the stool. A GI consult was obtained.

Before GI saw the pt the pt became hypotensive, tachycardic. The
pt had to be emergently transfered to the ICU. Pt had to
intubated for airway protection.

The levonox was DC'd, protonix was started. Labs were ordered.

It was found that the pt had an increase of INR/PT - secondary
to Cirrohsis. FFP was given. Fluid resusitation was started.

Pt taken for emergent EGD - found to have active variceal
bleeding. Treated with scleropathy. Pt started on Octreotide
drip. Levo started for prophalaxsis.

A Heptology consult was obtained.

[**2186-3-22**]

Repeat EGD performed. Pt stabalized.

[**2186-3-23**] - [**2186-3-30**]

Pt transfered to the regular floor.

A podiatry consult was obtained to gather information on
conservative treatment given the patients difficult course. They
recommended continuation of NS W to D dsg changes. C/W MP boots.

EGD performed - Pt stable. Recommended f/u EGD in one month for
obliteration of varices and f/u in liver clinic here or with
PCP.

Because of pt poor intake of food [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult obtained. Saw
pt, recommended SSI of humulog and to decrease Lantus to 8
units.

On discharge pt is doing well. Taking PO, urinating, BM, OOB to
chair.

[**2186-3-30**] - DC


Medications on Admission:
metformin 1000",
Paxil,
folate,
Lantus 32u,
spironolactone 100"

Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).

3. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Vancomycin HCl 1000 mg IV Q24H if random level <15
already approved -- changed frequency because of vanco trough;
6. Morphine Sulfate 2 mg/mL Syringe Sig: One (1)  Injection
Q3-4H () as needed.
7. PICC LINE CARE
Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
8. INSULIN
Breakfast

Glargine      16  Units

Insulin SC Sliding Scale - Humulog

Breakfast, Lunch, Dinner and Bedtime

Glucose Insulin Dose

0-60      mg/dL 4 oz. Juice

61-120    mg/dL  Units 0

121-160   mg/dL  Units 2

161-200   mg/dL  Units 4

201-240   mg/dL  Units 6

241-280   mg/dL  Units 8

> 280     mg/dL Notify M.D.   8   Units 6   Units


Discharge Disposition:
Extended Care

Facility:
Lifecare of [**Location 15289**]

Discharge Diagnosis:
dry gangrene of right heel
partial SBO,
fracture of right hip after falling at bedside,
GIB from esophageal varices,
esophageal ulcer concerning for possible cancer - EGD [**3-27**]


Discharge Condition:
stable

Discharge Instructions:
Please do wet to dry dressing changes on the right heel.
Pt is on Vancomycin. Please adjust vanco level according to
blood draws.
PICC line care


Followup Instructions:
Please call Dr [**Last Name (STitle) **] office and schedule an appointment for
two weeks after discharge, Call him at [**Telephone/Fax (1) 3121**]. When you
call he may schedule  you for an amputation. You may not need to
see him.

Call Dr [**First Name (STitle) **] (orthopedics) and schedulae an appointment for two
weeks after discharge, Call him at [**Telephone/Fax (1) 1113**].

Please call gastroenterology and schedule an EGD for one month
after discharge, Call the gastroenterologist at [**Telephone/Fax (1) 463**].

Please call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 2422**]. He works in Heptology.
Make f/u in one month.



Completed by:[**2186-3-30**]

Name:  [**Known lastname 6232**],[**Known firstname **]                    Unit No:   [**Numeric Identifier 11124**]

Admission Date:  [**2186-3-4**]              Discharge Date:   [**2186-4-14**]

Date of Birth:  [**2115-7-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 175**]
Addendum:
Pt was transferred to the Internal Medicine service after having
esophageal varocosities treated with EGD/banding.  During this
procedure he became hypoxic O2sat=84% on 10L, and went to the
high 90s on NRB.  He was observed for two days in the MICU where
his O2sat improved to 88% on RA and high 90s on 3L NC.
.
Diuresis with lasix and aldactone was continued on the floor.
His hypoxia improved after one day with O2sat=95% on RA.  A
paracentesis was performed and 4 liters were removed with a
reduction in his abdominal discomfort.  Propanolol was added to
his regimen for varices prophylaxis.  octreotide was
discontinued on the day of discharge.  He was maintained on his
diureses regimen of lasix and aldactone.  Physical therapy
worked with the patient and he will need physical therapy as an
outpatient as he has been in bed for nearly one month due to his
illnesses.  Levofloxacin (for sbp prophylaxis) and vancomycin
(for foot ulcer) were discontinued at the time of discharge.
.
At discharge Pt was afebrile, BP 100s/60s, P 60, RR 14, O2sat
99% RA, ambulating with assistance.

Discharge Disposition:
Extended Care

Facility:
Lifecare of [**Location 2075**]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 181**] MD [**MD Number(1) 182**]

Completed by:[**2186-4-17**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Unspecified intestinal obstruction,Closed fracture of base of neck of femur,Acute osteomyelitis, ankle and foot,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Fall from other slipping, tripping, or stumbling,Ulcer of esophagus with bleeding,Cellulitis and abscess of foot, except toes,Hydronephrosis,Malignant neoplasm of bronchus and lung, unspecified,Unspecified viral hepatitis C without hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Personal history of irradiation, presenting hazards to health,Dermatophytosis of nail'}


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 heel ulcer

PRESENT ILLNESS: This unfortunate 70 year-old gentleman, with peripheral vascular
disease, liver cirrhosis and cancer has developed ischemic
related gangrene of his right heel.  He was transferred from
another hospital with infection.  He has
been treated with antibiotics for 48 hours and is now undergoing
debridement.

MEDICAL HISTORY: PMH:

MEDICATION ON ADMISSION: metformin 1000",
Paxil,
folate,
Lantus 32u,
spironolactone 100"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General - pale cachectic male laying in bed, good spirits,
freindly
HEENT - NCAT / PERRL / EOMI,
neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lymphandopathy, supra clavicular nodes
RESP - CTA B/L upper lobes, crackles at bases
CARDIAC - RRR 1/6 SEM at apex
ABD - tympanic, distened, NTTP, pos BS, neg CVA tenderness
BRUITS - non noted
EXT - Doppler PT/DP/AT B/L
RIGHT HEEL - excised, clean, dry. minimal erythema around
debridement site, good granulation

FAMILY HISTORY: Non contributary

SOCIAL HISTORY: Pt lives with his wife and other dtr,  in their own home in
[**Name (NI) 1474**]. Dtr, [**Name (NI) **], lives nearby and is very involved and
supportive.  Son also lives in MA and is supportive. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Unspecified intestinal obstruction,Closed fracture of base of neck of femur,Acute osteomyelitis, ankle and foot,Alcoholic cirrhosis of liver,Esophageal varices in diseases classified elsewhere, with bleeding,Fall from other slipping, tripping, or stumbling,Ulcer of esophagus with bleeding,Cellulitis and abscess of foot, except toes,Hydronephrosis,Malignant neoplasm of bronchus and lung, unspecified,Unspecified viral hepatitis C without hepatic coma,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins,Personal history of irradiation, presenting hazards to health,Dermatophytosis of nail'}
