CHIEF COMPLAINT: Ischemic right lower extremity

PRESENT ILLNESS: 76 yo female s/p emergency CABG x2 is referred from [**Hospital1 **] due to abdominal pain and mental status changes.  Early
on [**2144-7-31**] the patient was noted to develop right leg pain; worse
with movement.  She had previously not had a history of
claudication.

MEDICAL HISTORY: 1.  Hypertension.
2.  Polymyalgia rheumatica on prednisone.
3.  Cerebrovascular accident in [**2144**], [**2-26**].  Coronary artery disease status post coronary artery bypass
grafting of two vessels on [**2144-7-16**] with limit to the RCA and
her
vein graft to be LAD.
5.  Hyperlipidemia.

MEDICATION ON ADMISSION: 1.   Lasix 20 mg b.i.d.
2.  Aspirin 325 mg daily.
3.  Captopril 25 mg t.i.d.
4.  Prednisone 20 mg daily.
5.  Lopressor 25 mg daily.
6.  KCL 40 mg daily.
7.  Protonix daily 40 mg.

ALLERGIES: Iodine / Heparinoids

PHYSICAL EXAM: Awake, alert. GCS 15
Pulm: frequent rhonchi; moderate work of breathing
Chest: RRR, distant. 2 left chest tubes have been cut and left
open to drain.
Abd: Obese, well healing midline laparotomy incision.
Gastrostomy tube    f
     functioning well.
     Well healing bilateral groin incisions from thrombectomies.
Ext: Warm, edematous.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Mrs. [**Known lastname 55840**] has a large and dedicated family.
Embolism and thrombosis of iliac artery,Unspecified pleural effusion,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Empyema without mention of fistula,Subdural hemorrhage,Acute posthemorrhagic anemia
Iliac artery embolism,Pleural effusion NOS,Ac duodenal ulcer w hem,Empyema w/o fistula,Subdural hemorrhage,Ac posthemorrhag anemia
Admission Date:  [**2144-7-31**]              Discharge Date:   [**2144-9-17**]

Date of Birth:  [**2067-6-25**]             Sex:   F

Service: VSURG

Allergies:
Iodine / Heparinoids

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Ischemic right lower extremity

Major Surgical or Invasive Procedure:
[**2144-7-31**]  Thrombectomy of right iliofemoral artery.
[**2144-8-4**]  Superficial femoral artery thrombectomy.
            Intraoperative arteriography.
            Bilateral lower extremity arteriography,
            Rheolytic thrombectomy left common and external
iliac
            artery,left external iliac stent placement.
[**2144-8-14**]  Left thoracoscopy
[**2144-8-20**]  Tracheostomy
[**2144-9-3**]  Gastroscopy.
            Attempted laparoscopy.
            Open gastrostomy tube placement.
            Lysis of adhesions.
[**2144-9-9**]  Left thoracoscopy with removal of pleural fibrin
            and evacuation of empyema cavity with placement of
            chest tubes.


History of Present Illness:
76 yo female s/p emergency CABG x2 is referred from [**Hospital1 **] due to abdominal pain and mental status changes.  Early
on [**2144-7-31**] the patient was noted to develop right leg pain; worse
with movement.  She had previously not had a history of
claudication.

Past Medical History:
1.  Hypertension.
2.  Polymyalgia rheumatica on prednisone.
3.  Cerebrovascular accident in [**2144**], [**2-26**].  Coronary artery disease status post coronary artery bypass
grafting of two vessels on [**2144-7-16**] with limit to the RCA and
her
vein graft to be LAD.
5.  Hyperlipidemia.


Social History:
Mrs. [**Known lastname 55840**] has a large and dedicated family.


Family History:
Noncontributory

Physical Exam:
Awake, alert. GCS 15
Pulm: frequent rhonchi; moderate work of breathing
Chest: RRR, distant. 2 left chest tubes have been cut and left
open to drain.
Abd: Obese, well healing midline laparotomy incision.
Gastrostomy tube    f
     functioning well.
     Well healing bilateral groin incisions from thrombectomies.
Ext: Warm, edematous.

Pertinent Results:
[**2144-9-17**] 03:56AM BLOOD WBC-12.7* RBC-3.46* Hgb-10.4* Hct-30.8*
MCV-89 MCH-30.1 MCHC-33.9 RDW-15.1 Plt Ct-190
[**2144-9-16**] 03:25AM BLOOD WBC-10.3 RBC-3.54* Hgb-10.3* Hct-32.2*
MCV-91 MCH-29.1 MCHC-32.0 RDW-15.0 Plt Ct-192
[**2144-9-15**] 03:59AM BLOOD WBC-11.9* RBC-3.60* Hgb-10.7* Hct-32.3*
MCV-90 MCH-29.6 MCHC-33.1 RDW-14.6 Plt Ct-160
[**2144-8-28**] 06:34AM BLOOD Neuts-87.5* Bands-0 Lymphs-7.7*
Monos-1.7* Eos-2.7 Baso-0.3
[**2144-9-17**] 03:56AM BLOOD Plt Ct-190
[**2144-9-17**] 03:56AM BLOOD PT-13.2 PTT-26.1 INR(PT)-1.1
[**2144-9-16**] 03:25AM BLOOD Plt Ct-192
[**2144-9-16**] 03:25AM BLOOD PT-13.1 PTT-26.1 INR(PT)-1.1
[**2144-9-15**] 03:59AM BLOOD Plt Ct-160
[**2144-9-15**] 03:59AM BLOOD PT-13.0 PTT-25.0 INR(PT)-1.1
[**2144-8-7**] 02:05AM BLOOD Plt Ct-66*
[**2144-8-7**] 02:05AM BLOOD PT-17.9* PTT-61.2* INR(PT)-2.1
[**2144-8-4**] 03:35AM BLOOD Plt Ct-49*
[**2144-8-4**] 03:35AM BLOOD PT-15.9* PTT-59.2* INR(PT)-1.7
[**2144-9-17**] 03:56AM BLOOD Glucose-115* UreaN-26* Creat-0.8 Na-139
K-4.9 Cl-101 HCO3-29 AnGap-14
[**2144-9-16**] 02:59PM BLOOD K-4.4
[**2144-9-16**] 03:25AM BLOOD Glucose-108* UreaN-24* Creat-0.8 Na-138
K-3.2* Cl-97 HCO3-31* AnGap-13
[**2144-9-15**] 03:59AM BLOOD Glucose-92 UreaN-22* Creat-0.8 Na-138
K-4.1 Cl-98 HCO3-32* AnGap-12
[**2144-9-14**] 02:30PM BLOOD Glucose-118* K-3.8
[**2144-9-14**] 03:27AM BLOOD Glucose-94 UreaN-20 Creat-0.7 Na-137
K-4.2 Cl-96 HCO3-32* AnGap-13
[**2144-9-8**] 04:07AM BLOOD CK-MB-2 cTropnT-0.04*
[**2144-9-7**] 10:24PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2144-9-7**] 02:30PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2144-9-17**] 03:56AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.0
[**2144-9-16**] 03:25AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.1
[**2144-9-15**] 03:59AM BLOOD Calcium-7.9* Phos-4.5 Mg-1.9
[**2144-8-4**] 12:10AM BLOOD Vanco-18.9*
[**2144-9-14**] 10:13AM BLOOD Type-ART pO2-89 pCO2-42 pH-7.46*
calHCO3-31* Base XS-5
[**2144-9-10**] 05:13PM BLOOD Type-ART Temp-37.2 Tidal V-400 PEEP-5
pO2-PND pCO2-PND pH-PND calHCO3-PND Base XS-PND
Intubat-INTUBATED
[**2144-9-10**] 11:47AM BLOOD Type-ART Rates-/28 Tidal V-500 PEEP-5
O2-40 pO2-83* pCO2-33* pH-7.48* calHCO3-25 Base XS-1
[**2144-9-10**] 02:14AM BLOOD Type-ART Temp-37.1 Rates-14/6 Tidal V-55
PEEP-5 O2-50 pO2-124* pCO2-35 pH-7.48* calHCO3-27 Base XS-3
-ASSIST/CON Intubat-INTUBATED
Time Taken Not Noted     Log-In Date/Time: [**2144-9-9**] 4:06 pm
      SWAB     Site: PLEURAL      L. PLEURAL EFFUSION.

   GRAM STAIN (Final [**2144-9-9**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2144-9-11**]):
      A swab is not the optimal specimen collection to evaluate
body
      fluids.
      ESCHERICHIA COLI.    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
174-8037M
         ([**2144-9-8**]).

   ACID FAST SMEAR (Final [**2144-9-10**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Pending):

   FUNGAL CULTURE (Preliminary):
      NO FUNGUS ISOLATED.
      A swab is not the optimal specimen for recovery of
mycobacteria or
      filamentous fungi.  A negative result should be
interpreted with
      caution.  Whenever possible tissue biopsy or aspirated
fluid should
      be submitted.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2144-9-10**]):
      Test cancelled by laboratory.
      PATIENT CREDITED.
      Inappropriate specimen for Fungal Smear (KOH).

   ANAEROBIC CULTURE (Final [**2144-9-10**]):
      SPECIMEN NOT TRANSPORTED ANAEROBICALLY.
      TEST CANCELLED, PATIENT CREDITED.

[**2144-9-9**] 2:00 pm TISSUE      PLEURAL FIBRIN.

   GRAM STAIN (Final [**2144-9-9**]):
      THIS IS A CORRECTED REPORT ([**2144-9-10**]).
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      PREVIOUSLY REPORTED AS.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2144-9-12**]):
      ESCHERICHIA COLI.    MODERATE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
174-8037M
         ([**2144-9-8**]).

   ANAEROBIC CULTURE (Final [**2144-9-11**]):
      DUE TO LABORATORY ERROR, UNABLE TO PROCESS.
      ANAEROBES ARE SCREENED FOR IN THE TISSUE CULTURE.
      TEST CANCELLED, PATIENT CREDITED.

   ACID FAST CULTURE (Pending):

   ACID FAST SMEAR (Final [**2144-9-10**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   POTASSIUM HYDROXIDE PREPARATION (Final [**2144-9-10**]):
      NO FUNGAL ELEMENTS SEEN.
[**2144-9-4**] 4:45 pm SPUTUM

                            **FINAL REPORT [**2144-9-7**]**

   GRAM STAIN (Final [**2144-9-4**]):
      <10 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
      QUALITY OF SPECIMEN CANNOT BE ASSESSED.

   RESPIRATORY CULTURE (Final [**2144-9-7**]):
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      OROPHARYNGEAL FLORA ABSENT.
      ESCHERICHIA COLI.    SPARSE GROWTH.  OF TWO COLONIAL
MORPHOLOGIES.
      YEAST.    SPARSE GROWTH.
      STAPH AUREUS COAG +.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 55841**]
([**2144-8-28**]).

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2144-9-3**] 4:16 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2144-9-5**]**

   GRAM STAIN (Final [**2144-9-3**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Final [**2144-9-5**]):
      RARE GROWTH OROPHARYNGEAL FLORA.
      GRAM NEGATIVE ROD(S).    SPARSE GROWTH.
         IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 55841**]
         [**2144-8-28**].
      YEAST.    SPARSE GROWTH.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 55841**] [**2144-8-28**].

[**2144-8-28**] 12:38 am SPUTUM      Source: Endotracheal.

                            **FINAL REPORT [**2144-9-2**]**

   GRAM STAIN (Final [**2144-8-28**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.

   RESPIRATORY CULTURE (Final [**2144-9-2**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.    HEAVY 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.
         Please contact the Microbiology Laboratory ([**7-/2446**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.
      ESCHERICHIA COLI.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          ESCHERICHIA COLI
                             |          |
AMPICILLIN------------              <=2 S
AMPICILLIN/SULBACTAM--              <=2 S
CEFAZOLIN-------------              <=4 S
CEFEPIME--------------              <=1 S
CEFTAZIDIME-----------              <=1 S
CEFTRIAXONE-----------              <=1 S
CEFUROXIME------------                4 S
CIPROFLOXACIN---------              =>4 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S      <=1 S
LEVOFLOXACIN----------   =>8 R      =>8 R
MEROPENEM-------------           <=0.25 S
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN----------              <=4 S
PIPERACILLIN/TAZO-----              <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA----              <=1 S
VANCOMYCIN------------   <=1 S

[**2144-8-18**] 6:34 pm SPUTUM     Site: ENDOTRACHEAL
      Source: Endotracheal.

                            **FINAL REPORT [**2144-8-24**]**

   GRAM STAIN (Final [**2144-8-19**]):
      >25 PMNs and <10 epithelial cells/100X field.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   RESPIRATORY CULTURE (Final [**2144-8-22**]):
      OROPHARYNGEAL FLORA ABSENT.
      ESCHERICHIA COLI.    MODERATE 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.
         Please contact the Microbiology Laboratory ([**7-/2446**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |          STAPH AUREUS COAG +
                             |          |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
ERYTHROMYCIN----------              =>8 R
GENTAMICIN------------   <=1 S    <=0.5 S
LEVOFLOXACIN----------   =>8 R      =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN-------------              =>4 R
PENICILLIN------------            =>0.5 R
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
RIFAMPIN--------------            <=0.5 S
TETRACYCLINE----------              <=1 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
VANCOMYCIN------------              <=1 S

[**2144-8-2**] 10:00A
     TEST                           RESULT
HEPARIN DEPENDENT ANTIBODIES        POSITIVE
COMMENT:    POSITIVE FOR HEPARIN PF4 ANTIBODY [**Doctor First Name **]
            REPORTED TO  [**Name8 (MD) **], RN [**2144-8-3**] 2 PM.
Complete report on file in the laboratory.


Brief Hospital Course:
A brief summary of the patient's course is summarized below by
problem:

1. Heparin induced thrombocytopenia
Invasive procedures relating to the problem:
[**2144-7-31**] Thrombectomy of right iliofemoral artery.
[**2144-8-4**] Superficial femoral artery thrombectomy.
           Intraoperative arteriography.
           Bilateral lower extremity arteriography,
           Rheolytic thrombectomy left common and external iliac
           artery,left external iliac stent placement.

Heparin induced thrombocytopenia was recognized as the etiology
of the patient's presenting problem of bilateral lower extremity
ischemia.  She underwent the above listed interventions and was
anticoagulated with Lepirudin, Plavix, and Aspirin.  This was
continued until a recalcitrant bleeding duodenal ulcer developed
after which she was maintained on aspirin only for the majority
of her remaining hospital stay.  After the initial treatment of
the HIT, there were no recurrent clinical sequels of her HIT.

2. Duodenal ulcer, bleeding s/p endoscopic treatment with
cautery and epinephrine injection x 3
After anticoagulation for the patient's HIT and bilateral lower
extremity arterial thromboses, she developed significant UGI
bleeding.  It was ultimately controlled with a combination of
multiple upper endoscopies, and cessation of her lepirudin and
plavix. Endoscopic evaluation revealed a duodenal ulcer and a
gastric ulcer as the source of her bleeding.  The duodenal ulcer
was the primary contributor.  Prior to discharge, she was
restarted on Coumadin 5 mg nightly and has tolerated resumption
of the coumadin without evidence of recurrence of her bleeding.


3. Supraventricular tachycardia
Throughout her hospital stay, the patient has had SVT on
occasion but this has improved significantly with beta blockade,
amiodarone, and diuresis.  She is being discharged with
amiodarone but it may be possible to discontinue this after
further resolution of her current illness.

4. Subacute subdural hematoma
The patient developed a diminished level of consciousness and
increased agitation several weeks into her admission.  This was
evaluated with a CT scan of the head.  Bilateral subacute
subdural hematomas were demonstrated.  A neurosurgical consult
was obtained.  No neurosurgical intervention was recommended.
With time her sensorium has improved dramatically.  This is
considered an inactive issue.

6. Acute blood loss anemia requiring transfusion
The patient's blood loss was secondary to her upper GI bleeding.
 She is currently hemostatic.

7. Left pleural effusion requiring thoracentesis, ultimately
requiring video assisted thoracoscopy with partial decortication
and chest tube placement:
[**2144-8-14**] Left thoracoscopy
[**2144-9-9**] Left thoracoscopy with removal of pleural fibrin and
evacuation of empyema cavity with placement of chest tubes

The patient had developed a chronic left thoracic pleural
effusion following her CABG.  Ultimately this became an infected
collection and was found, following VATS, to contain E. Coli.
Chest tubes were left in place following the VATS procedure.
These have had diminishing output since the day of the
procedure.  The thoracic surgery team has taken the tubes off of
waterseal as the collections do not communicate significantly
with the patient's airway.  These will be removed, an inch per
week, until the chest tubes are completely removed.

Summation:
The patient has undergone a series of insults following her
emergency CABG on [**2144-7-16**] beginning with bilateral lower
extremity ischemia due to heparin induced thrombocytopenia,
bleeding duodenal ulcer and bilateral subdural hematomas
probably secondary to anticoagulation, and multiple foci of
infection with the Left empyema representing the largest one.
Taken together these injuries have required a prolonged course
accelerated to some extent by tracheostomy and gastrostomy.  Ms.
[**Known lastname 55840**] has made major progress from a serious illness and is
being transferred to [**Hospital3 7**] in fair, stable, but
improving condition.


Medications on Admission:
1.   Lasix 20 mg b.i.d.
2.  Aspirin 325 mg daily.
3.  Captopril 25 mg t.i.d.
4.  Prednisone 20 mg daily.
5.  Lopressor 25 mg daily.
6.  KCL 40 mg daily.
7.  Protonix daily 40 mg.


Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  PRN
(as needed).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day) as needed.
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): D/C after [**2144-9-23**]. Tablet(s)
9. Metoclopramide HCl 5 mg/5 mL Solution Sig: One (1)  PO QID (4
times a day).
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): discontinue after [**2144-9-19**].
11. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Ondansetron HCl 2 mg/mL Solution Sig: One (1)  Intravenous
Q6H (every 6 hours) as needed for nausea.
15. Furosemide 10 mg/mL Solution Sig: One (1)  Injection TID (3
times a day).
16. Potassium Chloride 20 mEq Packet Sig: One (1)  PO twice a
day: titrate as needed based on diuretic usage; potassium
levels.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
1.  Duodenal ulcer, bleeding status post endoscopic treatment
with cautery and epinephrine injection x 3
2.  Heparin induced thrombocytopenia, (HIT type 2), white clot
syndrome
3.  supraventricular tachycardia
4.  acute bilateral lower extremity ischemia s/p bilateral groin
cutdown and thrombectomy
5.  subacute subdural hematoma
6.  acute blood loss anemia requiring transfusion
7.  Left pleural effusion requiring thoracentesis, ultimately
requiring video assisted thoracoscopy with partial decortication
and chest tube placement
8.  Left chest empyema


Discharge Condition:
Fair

Discharge Instructions:
1.  Routine Trach care
2.  Anticoagulate with coumadin to goal INR 2.0-3.0
3.  Activity as tolerated
4.  Routine Gastrostomy care
5.  Tube feeds at goal rate
6.  [**Month (only) 116**] remove abdominal staples after [**2144-10-13**]

Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2819**], M.D, General Surgery ([**Telephone/Fax (1) 6347**]
[**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**], M.D., Thoracic Surgery 2A ([**Telephone/Fax (1) 1504**]
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D., Hematology ([**Telephone/Fax (1) 15328**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D., Vascular Surgery ([**Telephone/Fax (1) 9393**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], MD, Cardiothoracic Surgery ([**Telephone/Fax (1) 1504**]
{'Embolism and thrombosis of iliac artery,Unspecified pleural effusion,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Empyema without mention of fistula,Subdural hemorrhage,Acute posthemorrhagic anemia'}


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: Ischemic right lower extremity

PRESENT ILLNESS: 76 yo female s/p emergency CABG x2 is referred from [**Hospital1 **] due to abdominal pain and mental status changes.  Early
on [**2144-7-31**] the patient was noted to develop right leg pain; worse
with movement.  She had previously not had a history of
claudication.

MEDICAL HISTORY: 1.  Hypertension.
2.  Polymyalgia rheumatica on prednisone.
3.  Cerebrovascular accident in [**2144**], [**2-26**].  Coronary artery disease status post coronary artery bypass
grafting of two vessels on [**2144-7-16**] with limit to the RCA and
her
vein graft to be LAD.
5.  Hyperlipidemia.

MEDICATION ON ADMISSION: 1.   Lasix 20 mg b.i.d.
2.  Aspirin 325 mg daily.
3.  Captopril 25 mg t.i.d.
4.  Prednisone 20 mg daily.
5.  Lopressor 25 mg daily.
6.  KCL 40 mg daily.
7.  Protonix daily 40 mg.

ALLERGIES: Iodine / Heparinoids

PHYSICAL EXAM: Awake, alert. GCS 15
Pulm: frequent rhonchi; moderate work of breathing
Chest: RRR, distant. 2 left chest tubes have been cut and left
open to drain.
Abd: Obese, well healing midline laparotomy incision.
Gastrostomy tube    f
     functioning well.
     Well healing bilateral groin incisions from thrombectomies.
Ext: Warm, edematous.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Mrs. [**Known lastname 55840**] has a large and dedicated family. 

### Response:
{'Embolism and thrombosis of iliac artery,Unspecified pleural effusion,Acute duodenal ulcer with hemorrhage, without mention of obstruction,Empyema without mention of fistula,Subdural hemorrhage,Acute posthemorrhagic anemia'}
