CHIEF COMPLAINT: Gangrene of the right foot

PRESENT ILLNESS: This 84-year-old gentleman has gangrene involving the lateral
aspect of his right foot. He had an arteriogram which showed
occlusion of his anterior tib and
posterior tibial arteries over a long distance. His peroneal
artery was opened but was diseased distally and he reconstituted
a small caliber dorsalis pedis artery. Vein mapping showed a
saphenous vein patent from the groin to the
calf. He had the distal vein harvested for CABG before.

MEDICAL HISTORY: 1. Insulin dependent-diabetes mellitus.
2. Coronary artery disease, three vessel with an ejection
fraction of 20-25%; s/p CABG [**2103**] LIMA-LAD, SVG-OM and SVG-RCA
3. Prostate cancer status post radical prostatectomy [**2096**], no
chemotherapy and no XRT
4. Paget's disease
5. Ulcerative colitis
6. Peripheral vascular disease s/p LLE bypass, left popliteal to
DP; [**3-12**] mild proximal [**Month/Year (2) **] stenosis
7. Status post left first toe amputation in [**4-4**]
8. Right inguinal hernia repair [**2099-9-3**]
9. Status post left carpal tunnel release in [**2088**]
10. Right carpal tunnel release in [**2100**]
11. Status post appendectomy in [**2053**]
12. CVA to the thalamus 6-8 years ago with no deficit.
13. Cardiomyopathy
14. s/p left 1st toe amputation [**1-6**] osteomyelitis
15. Left shoulder fracture status post fall [**2105**]
16. Mild mitral regurgitation, Echo [**2106**]
17 Mild pulmonary hypertension, Echo [**2106**]
18. Appendectomy [**2054-11-3**]
19. LE ulcerations, followed by [**Doctor Last Name **]
20. s/p ICD placement in [**2103**], revision [**2105**] - unclear reason
besides was delaying CABG for 2-3 weeks to get affairs in order

MEDICATION ON ADMISSION: SQ Heparin
Amiodarone 200 mg qd
Levothyroxine 112 mcg. qd
[**Month/Day/Year **] 81 mg po qd
Folic Acid 1 1 mg po qd
ISS
NPH 20 U QAM
Eplerenone 25 mg qd
Cipro 250 mg [**Hospital1 **]
Brimonidine 1gtt [**Hospital1 **]
Lasix 80 IV BID
Hydralazine 10 mg po tid
Isosorbide dinitrate 10 mg tid
eucerin

ALLERGIES: Penicillins / Spironolactone

PHYSICAL EXAM: VS: 98.0    P: 70      BP: 97/62    RR: 20    Spo2: 99% RA
Gen: NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
CV: RRR, normal S1, S2. No m/r/g. No S3 or S4.
Resp: unlabored, no accessory muscle use. mild bibasiler rales
Abd: Thin, soft, NT, ND. No HSM or tenderness.
Extremities/Skin:  bilateral 2 pitting edema with distal
erythema; Right leg with 1cm dorsal ulcer about 2-3 mm deep,
Left foot with lateral eschar ~5cm wide, appears necrotic, also
with dorsal 1cm ulcer. Incisions: RLE open to air with
steristrips. Minimal drainage. Incision from knee to ankle.

FAMILY HISTORY: Family history notable for brother being a 'blue baby' who died
at 26, brother died [**1-6**] MI at 47. Mothers and sisters with DM.

SOCIAL HISTORY: Widowed [**2105**], retired engineer, does not use alcohol. He quit
smoking in [**2059**] after 15 years of smoking three packs per day
while in the Navy, inaddition to cigars and pipes. There is no
history of alcohol abuse but drinks several times each week.
Atherosclerosis of native arteries of the extremities with gangrene,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Hypovolemia,Aortocoronary bypass status,Pressure ulcer, stage II,Other constipation,Other iatrogenic hypotension,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of prostate,Great toe amputation status,Osteitis deformans without mention of bone tumor
Ath ext ntv art gngrene,Systolic hrt failure NOS,DMII wo cmp nt st uncntr,Chr pulmon heart dis NEC,Hypovolemia,Aortocoronary bypass,Pressure ulcer, stage II,Constipation NEC,Iatrogenc hypotnsion NEC,Status autm crd dfbrltr,Hx-prostatic malignancy,Status amput great toe,Osteitis deformans NOS
Admission Date:  [**2110-1-21**]              Discharge Date:   [**2110-1-28**]


Service: SURGERY

Allergies:
Penicillins / Spironolactone

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Gangrene of the right foot

Major Surgical or Invasive Procedure:
[**2110-1-21**] Right popliteal to dorsalis pedis artery bypass
with non reversed right lesser saphenous vein and angioscopy.


History of Present Illness:
This 84-year-old gentleman has gangrene involving the lateral
aspect of his right foot. He had an arteriogram which showed
occlusion of his anterior tib and
posterior tibial arteries over a long distance. His peroneal
artery was opened but was diseased distally and he reconstituted
a small caliber dorsalis pedis artery. Vein mapping showed a
saphenous vein patent from the groin to the
calf. He had the distal vein harvested for CABG before.

Past Medical History:
1. Insulin dependent-diabetes mellitus.
2. Coronary artery disease, three vessel with an ejection
fraction of 20-25%; s/p CABG [**2103**] LIMA-LAD, SVG-OM and SVG-RCA
3. Prostate cancer status post radical prostatectomy [**2096**], no
chemotherapy and no XRT
4. Paget's disease
5. Ulcerative colitis
6. Peripheral vascular disease s/p LLE bypass, left popliteal to
DP; [**3-12**] mild proximal [**Month/Year (2) **] stenosis
7. Status post left first toe amputation in [**4-4**]
8. Right inguinal hernia repair [**2099-9-3**]
9. Status post left carpal tunnel release in [**2088**]
10. Right carpal tunnel release in [**2100**]
11. Status post appendectomy in [**2053**]
12. CVA to the thalamus 6-8 years ago with no deficit.
13. Cardiomyopathy
14. s/p left 1st toe amputation [**1-6**] osteomyelitis
15. Left shoulder fracture status post fall [**2105**]
16. Mild mitral regurgitation, Echo [**2106**]
17 Mild pulmonary hypertension, Echo [**2106**]
18. Appendectomy [**2054-11-3**]
19. LE ulcerations, followed by [**Doctor Last Name **]
20. s/p ICD placement in [**2103**], revision [**2105**] - unclear reason
besides was delaying CABG for 2-3 weeks to get affairs in order



Social History:
Widowed [**2105**], retired engineer, does not use alcohol. He quit
smoking in [**2059**] after 15 years of smoking three packs per day
while in the Navy, inaddition to cigars and pipes. There is no
history of alcohol abuse but drinks several times each week.


Family History:
Family history notable for brother being a 'blue baby' who died
at 26, brother died [**1-6**] MI at 47. Mothers and sisters with DM.

Physical Exam:
VS: 98.0    P: 70      BP: 97/62    RR: 20    Spo2: 99% RA
Gen: NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
CV: RRR, normal S1, S2. No m/r/g. No S3 or S4.
Resp: unlabored, no accessory muscle use. mild bibasiler rales
Abd: Thin, soft, NT, ND. No HSM or tenderness.
Extremities/Skin:  bilateral 2 pitting edema with distal
erythema; Right leg with 1cm dorsal ulcer about 2-3 mm deep,
Left foot with lateral eschar ~5cm wide, appears necrotic, also
with dorsal 1cm ulcer. Incisions: RLE open to air with
steristrips. Minimal drainage. Incision from knee to ankle.

Stage II pressue ulcer to coccyx

Pertinent Results:
[**2110-1-25**] 06:30AM BLOOD WBC-7.7 RBC-3.26* Hgb-10.6* Hct-31.6*
MCV-97 MCH-32.7* MCHC-33.7 RDW-17.0* Plt Ct-201
[**2110-1-24**] 04:07AM BLOOD Hct-29.0* Plt Ct-166
[**2110-1-23**] 04:11AM BLOOD Hct-29.8* Plt Ct-179
[**2110-1-22**] 04:50AM BLOOD WBC-11.1*# Hgb-11.2* Hct-33.6* Plt Ct-232
[**2110-1-21**] 06:15PM BLOOD Hgb-11.1* Hct-32.9* Plt Ct-222
[**2110-1-25**] 06:30AM BLOOD Plt Ct-201
[**2110-1-25**] 06:30AM BLOOD PT-15.2* PTT-33.9 INR(PT)-1.3*
[**2110-1-24**] 04:07AM BLOOD Plt Ct-166
[**2110-1-23**] 04:11AM BLOOD Plt Ct-179
[**2110-1-21**] 06:15PM BLOOD PT-14.5* PTT-91.7* INR(PT)-1.3*
[**2110-1-25**] 06:30AM BLOOD Glucose-74 UreaN-27* Creat-1.2 Na-140
K-4.6 Cl-98 HCO3-39* AnGap-8
[**2110-1-21**] 06:15PM BLOOD Glucose-132* UreaN-22* Creat-1.1 Na-144
K-3.3 Cl-103 HCO3-37* AnGap-7*
[**2110-1-21**] 06:15PM BLOOD ALT-30 AST-32 AlkPhos-140*
[**2110-1-21**] 06:15PM BLOOD CK-MB-4 cTropnT-0.04*
[**2110-1-22**] 04:57AM BLOOD Type-ART Temp-37.7 FiO2-35 O2 Flow-2
pO2-103 pCO2-58* pH-7.42 calTCO2-39* Base XS-10 Intubat-NOT
INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2110-1-25**] 06:30AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.2
[**2110-1-21**] 04:39PM BLOOD Glucose-160* Lactate-1.9 K-3.2*

Portable TEE (Complete) Done [**2110-1-21**] at 3:32:45 PM      FINAL
Conclusions:
The left atrium is markedly dilated. Moderate to severe
spontaneous echo contrast is seen in the body of the left
atrium. The right atrium is markedly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 0-10mmHg. Overall left ventricular systolic
function is severely depressed (LVEF= XX %). The estimated
cardiac index is borderline low (2.0-2.5L/min/m2). The
calculated myocardial performance index was0.9 (MPI A = 602 ms;
MPI B = 330 ms). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Transmitral
Doppler and tissue velocity imaging are consistent with Grade
III/IV (severe) LV diastolic dysfunction. with severe global
free wall hypokinesis. The descending thoracic aorta is mildly
dilated. There are three aortic valve leaflets. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen.


Brief Hospital Course:
[**2110-1-21**] Admitted direct via holding room for a scheduled LE
bypass, taken to OR and underwent Right popliteal to dorsalis
pedis artery bypass with non reversed right lesser saphenous
vein and angioscopy. Patient invasive lines (foley, a-line,
PA-line, and central line)were placed. Patient tolerated
procedure, recovered in the PACU and then transferred to [**Hospital Ward Name 121**]
5/VICU/telemetry for further observation. Overnight patient had
probelms w/ tachycardia-managed w/ IV Metoprolol. Pain managed
w/ IV Hydromorphone.

[**2110-1-22**] No acute events. On LE BP pathway. Remains on bed rest.
Clears and PO meds re-started. Given Albumin and NS for volume.
Electrolytes repleted. Remains VICU.

2/19-20/09 No acute events. Continues LEBP pathway. Diet
advanced. Art line and foley d/c'd, central line switched to
PIV. Physical therapy evaluation, touch down WB on R, FWD on L.
Remains VICU. Pain mananged. Foley replace, unable to void.

2/21-22/09 No acute events. Continues LEBP pathway. had some
problems w/ [**Name2 (NI) 34279**]-given on Bisacodyl and given fleet
enema. Became floor status. Pain management still an issue.
Having breakthrough pain requiring IV pain medications.

[**2110-1-27**] No acute events. Urine output scant, and unable to take
in large po fluids, given IV fluid bolus. Out of bed w/ assist.
Pain meds converted to PO.

[**2110-1-28**]
Stable overnight. Transferred to Rehab with indwelling foley.

Medications on Admission:
SQ Heparin
Amiodarone 200 mg qd
Levothyroxine 112 mcg. qd
[**Month/Day/Year **] 81 mg po qd
Folic Acid 1 1 mg po qd
ISS
NPH 20 U QAM
Eplerenone 25 mg qd
Cipro 250 mg [**Hospital1 **]
Brimonidine 1gtt [**Hospital1 **]
Lasix 80 IV BID
Hydralazine 10 mg po tid
Isosorbide dinitrate 10 mg tid
eucerin

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic TWICE
DAILY ().
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
[**3-10**] H () as needed for pain.
14. Humalog Sliding Scale
Insulin SC Sliding Scale
             Breakfast  Lunch Dinner Bedtime Q6H
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
Insulin Dose
0-60   mg/dL [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**] amp D50 [**12-6**]
amp D50
61-150   mg/dL 0   Units 0   Units 0   Units 0   Units 0   Units

151-200   mg/dL 2   Units 2   Units 2   Units 2   Units 2
Units
201-250   mg/dL 4   Units 4   Units 4   Units 4   Units 4
Units
251-300   mg/dL 6   Units 6   Units 6   Units 6   Units 6
Units
> 300   mg/dL 8   Units 8   Units 8   Units 8   Units 8   Units

15. NPH Insulin
24 units with breakfast


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name 3548**] [**Doctor Last Name 3549**] Nursing & Rehabilitation Center - [**Location (un) 1110**]

Discharge Diagnosis:
PVD w/ Gangrene of the right foot.
history of CAD s/p CABG [**2103**] (LIMA-LAD, SVG-RCA, SVG-OM)
history of CVA no deficits
history of insulin dependent diabetes
history of CHF (EF 20%)
history of prostate CA s/p prostatectomy,
history of VT arrest s/p ICD placement with 4 firings last year
history of hypothyroidism
Post-op constipation-treated
Post-op hypovelemia- fluid resuscitated


Discharge Condition:
stable


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions

What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
??????	You should get up out of bed every day and gradually increase
your activity each day
??????	Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
??????	Increase your activities as you can tolerate- do not do too
much right away!

2. It is normal to have swelling of the leg you were operated
on:
??????	Elevate your leg above the level of your heart (use [**1-7**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated

3. It is normal to have a decreased appetite, your appetite will
return with time
??????	You will probably lose your taste for food and lose some
weight
??????	Eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	No driving until post-op visit and you are no longer taking
pain medications
??????	Unless you were told not to bear any weight on operative foot:

??????	You should get up every day, get dressed and walk
??????	You should gradually increase your activity
??????	You may up and down stairs, go outside and/or ride in a car
??????	Increase your activities as you can tolerate- do not do too
much right away!
??????	No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
??????	You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
??????	Take all the medications you were taking before surgery,
unless otherwise directed
??????	Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
??????	Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal

What to report to office:
??????	Redness that extends away from your incision
??????	A sudden increase in pain that is not controlled with pain
medication
??????	A sudden change in the ability to move or use your leg or the
ability to feel your leg
??????	Temperature greater than 100.5F for 24 hours
??????	Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2110-2-10**] 1:20

Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3070**]
Date/Time:[**2110-4-1**] 11:15



Completed by:[**2110-1-28**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Hypovolemia,Aortocoronary bypass status,Pressure ulcer, stage II,Other constipation,Other iatrogenic hypotension,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of prostate,Great toe amputation status,Osteitis deformans without mention of bone tumor'}


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: Gangrene of the right foot

PRESENT ILLNESS: This 84-year-old gentleman has gangrene involving the lateral
aspect of his right foot. He had an arteriogram which showed
occlusion of his anterior tib and
posterior tibial arteries over a long distance. His peroneal
artery was opened but was diseased distally and he reconstituted
a small caliber dorsalis pedis artery. Vein mapping showed a
saphenous vein patent from the groin to the
calf. He had the distal vein harvested for CABG before.

MEDICAL HISTORY: 1. Insulin dependent-diabetes mellitus.
2. Coronary artery disease, three vessel with an ejection
fraction of 20-25%; s/p CABG [**2103**] LIMA-LAD, SVG-OM and SVG-RCA
3. Prostate cancer status post radical prostatectomy [**2096**], no
chemotherapy and no XRT
4. Paget's disease
5. Ulcerative colitis
6. Peripheral vascular disease s/p LLE bypass, left popliteal to
DP; [**3-12**] mild proximal [**Month/Year (2) **] stenosis
7. Status post left first toe amputation in [**4-4**]
8. Right inguinal hernia repair [**2099-9-3**]
9. Status post left carpal tunnel release in [**2088**]
10. Right carpal tunnel release in [**2100**]
11. Status post appendectomy in [**2053**]
12. CVA to the thalamus 6-8 years ago with no deficit.
13. Cardiomyopathy
14. s/p left 1st toe amputation [**1-6**] osteomyelitis
15. Left shoulder fracture status post fall [**2105**]
16. Mild mitral regurgitation, Echo [**2106**]
17 Mild pulmonary hypertension, Echo [**2106**]
18. Appendectomy [**2054-11-3**]
19. LE ulcerations, followed by [**Doctor Last Name **]
20. s/p ICD placement in [**2103**], revision [**2105**] - unclear reason
besides was delaying CABG for 2-3 weeks to get affairs in order

MEDICATION ON ADMISSION: SQ Heparin
Amiodarone 200 mg qd
Levothyroxine 112 mcg. qd
[**Month/Day/Year **] 81 mg po qd
Folic Acid 1 1 mg po qd
ISS
NPH 20 U QAM
Eplerenone 25 mg qd
Cipro 250 mg [**Hospital1 **]
Brimonidine 1gtt [**Hospital1 **]
Lasix 80 IV BID
Hydralazine 10 mg po tid
Isosorbide dinitrate 10 mg tid
eucerin

ALLERGIES: Penicillins / Spironolactone

PHYSICAL EXAM: VS: 98.0    P: 70      BP: 97/62    RR: 20    Spo2: 99% RA
Gen: NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL
CV: RRR, normal S1, S2. No m/r/g. No S3 or S4.
Resp: unlabored, no accessory muscle use. mild bibasiler rales
Abd: Thin, soft, NT, ND. No HSM or tenderness.
Extremities/Skin:  bilateral 2 pitting edema with distal
erythema; Right leg with 1cm dorsal ulcer about 2-3 mm deep,
Left foot with lateral eschar ~5cm wide, appears necrotic, also
with dorsal 1cm ulcer. Incisions: RLE open to air with
steristrips. Minimal drainage. Incision from knee to ankle.

FAMILY HISTORY: Family history notable for brother being a 'blue baby' who died
at 26, brother died [**1-6**] MI at 47. Mothers and sisters with DM.

SOCIAL HISTORY: Widowed [**2105**], retired engineer, does not use alcohol. He quit
smoking in [**2059**] after 15 years of smoking three packs per day
while in the Navy, inaddition to cigars and pipes. There is no
history of alcohol abuse but drinks several times each week. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Systolic heart failure, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other chronic pulmonary heart diseases,Hypovolemia,Aortocoronary bypass status,Pressure ulcer, stage II,Other constipation,Other iatrogenic hypotension,Automatic implantable cardiac defibrillator in situ,Personal history of malignant neoplasm of prostate,Great toe amputation status,Osteitis deformans without mention of bone tumor'}
