CHIEF COMPLAINT: Infected right ileo femoral graft

PRESENT ILLNESS: 54y/o female well known to Vascular Surgery service, recently
hospitalized from [**Date range (1) 63758**] for rt. groin pain. Evaluated
with tagged WBC which showed uptake at ileo-fem graft site.
Patient treated in hsopital with Vancomycin, flagyl, cipro
started [**11-7**], cipro d/c'd [**11-8**] aztreoman added [**11-8**]. ID
recommended [**3-10**] week course. Leg amputation was recommended,
patient defered surgery until after the holidays. She was
discharged home [**2198-11-16**] VNA services and IV vanco/aztreoman and
po flagyl to finish the 4-6 weeks as recommended by ID. Returns
now for amputation.

MEDICAL HISTORY: history of PVD, s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
histroy of chronic pancretieis s/p Pestow,J-tube,ccy1998,Expl
lap [**2189**]
history of ETOH cirrhosis/chronic pancreatitis
history of left breast cyst s/p excision
history of GERD,pud
histroy of esophgitis with stricure
history of small bowel obstruction
history of PV,SMV thrombosis
histroy of asthma
history of cervical ca s/p multiple d/c's
history of DM2 insulin dependant
history of entero-colonic fistula

MEDICATION ON ADMISSION: Albuterol inh q6
Amylase-Lipase-Protease iii TID
Aspirin 325mg qd
Clopidogrel 75mg qd
Duloxetine 30mg qd
Ergocalciferol (Vitamin D2)50,000u i qd
Hexavitamin i qd
Insulin Glargine 12u qhs, HISS
Nicotine 14mg/24 hr Patch qd
Oxycodone 5mg prn
Pantoprazole 40mg qd
Spironolactone 25mg qd
Tiotropium Bromide 18mcg qd
Warfarin 4mg qd

ALLERGIES: Penicillins

PHYSICAL EXAM: vital signs:97.5-96-18 B/P 124/69 )2 sat 94% room air
cachectic female who Ox3 but nods off during interview
HEENT: nonicteric, no LAD, no carotid bruits or JVD
Lungs: clear to ausculation bilaterally
Heart: RRR
ABd: BS present , soft c/w ascities with mild distention
EXT: rt. foot cool with 3+edema, hyperemic, firm, tense rt. leg
     rt. groin with open wound with purulent drainage and warm
to touch to above the rt. knee. Pain with passive plantar
flection
Pulses: dopperable femoral and [**Doctor Last Name **] pulses with absent pedal
pulses rt.
        palpable femoral and [**Doctor Last Name **] pulses and dopperable pedal
pulses on left.
Neuro: grossly intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: former ETOH use
tobacco use , current
married and lives with spouse
Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute vascular insufficiency of intestine,Portal vein thrombosis,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Alcoholic cirrhosis of liver,Urinary complications, not elsewhere classified,Anemia, unspecified
React-oth vasc dev/graft,Ac vasc insuff intestine,Portal vein thrombosis,Alveol pneumonopathy NEC,Acute kidney failure NOS,Int inf clstrdium dfcile,Hyperosmolality,Ath ext ntv art ulcrtion,Ulcer other part of foot,DMII neuro nt st uncntrl,Neuropathy in diabetes,Alcohol cirrhosis liver,Surg compl-urinary tract,Anemia NOS
Name:  [**Known lastname 10645**],[**Known firstname **] M                  Unit No:   [**Numeric Identifier 11351**]

Admission Date:  [**2198-11-17**]              Discharge Date:   [**2198-12-14**]

Date of Birth:  [**2144-10-24**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1472**]
Addendum:
The patient must not be further diuresed, as she has been in
renal failure and no longer has pulmonary edema. In addition,
she has marked hypoalbuminemia which is contributing to her
peripheral edema.
.
She is scheduled to see a new PCP here at [**Hospital1 8**], per her
request. See discharge instructions.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 41**] - [**Location (un) 42**]

                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]

Completed by:[**2198-12-14**]

Admission Date:  [**2198-11-17**]              Discharge Date:   [**2198-12-14**]

Date of Birth:  [**2144-10-24**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Infected right ileo femoral graft

Major Surgical or Invasive Procedure:
right AKA [**2198-11-19**]
flex bronchoscopy x 2
intubation x 2
VATS


History of Present Illness:
54y/o female well known to Vascular Surgery service, recently
hospitalized from [**Date range (1) 63758**] for rt. groin pain. Evaluated
with tagged WBC which showed uptake at ileo-fem graft site.
Patient treated in hsopital with Vancomycin, flagyl, cipro
started [**11-7**], cipro d/c'd [**11-8**] aztreoman added [**11-8**]. ID
recommended [**3-10**] week course. Leg amputation was recommended,
patient defered surgery until after the holidays. She was
discharged home [**2198-11-16**] VNA services and IV vanco/aztreoman and
po flagyl to finish the 4-6 weeks as recommended by ID. Returns
now for amputation.

Past Medical History:
history of PVD, s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
histroy of chronic pancretieis s/p Pestow,J-tube,ccy1998,Expl
lap [**2189**]
history of ETOH cirrhosis/chronic pancreatitis
history of left breast cyst s/p excision
history of GERD,pud
histroy of esophgitis with stricure
history of small bowel obstruction
history of PV,SMV thrombosis
histroy of asthma
history of cervical ca s/p multiple d/c's
history of DM2 insulin dependant
history of entero-colonic fistula

Social History:
former ETOH use
tobacco use , current
married and lives with spouse

Family History:
noncontributory

Physical Exam:
vital signs:97.5-96-18 B/P 124/69 )2 sat 94% room air
cachectic female who Ox3 but nods off during interview
HEENT: nonicteric, no LAD, no carotid bruits or JVD
Lungs: clear to ausculation bilaterally
Heart: RRR
ABd: BS present , soft c/w ascities with mild distention
EXT: rt. foot cool with 3+edema, hyperemic, firm, tense rt. leg
     rt. groin with open wound with purulent drainage and warm
to touch to above the rt. knee. Pain with passive plantar
flection
Pulses: dopperable femoral and [**Doctor Last Name **] pulses with absent pedal
pulses rt.
        palpable femoral and [**Doctor Last Name **] pulses and dopperable pedal
pulses on left.
Neuro: grossly intact


Pertinent Results:
[**2198-11-17**] 04:39PM   GLUCOSE-187* UREA N-20 CREAT-0.6 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-113* TOTAL CO2-28 ANION GAP-9
[**2198-11-17**] 04:39PM   WBC-8.0 RBC-2.30* HGB-7.2* HCT-23.5* MCV-102*
MCH-31.3 MCHC-30.7* RDW-17.4*
[**2198-11-17**] 04:39PM   NEUTS-72.4* LYMPHS-21.9 MONOS-4.8 EOS-0.6
BASOS-0.3
[**2198-11-17**] 04:39PM   PLT COUNT-544*
[**2198-11-17**] 04:39PM   PT-14.5* PTT-23.7 INR(PT)-1.3*
.
at discharge
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2198-12-14**] 06:19AM    8.3 2.67* 8.5* 26.6* 100* 31.8 31.9 17.7*
868*
Source: Line-PICC
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos NRBC
[**2198-12-10**] 04:45PM    77.9*   15.9* 4.2 1.7 0.3
.

RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2198-12-14**] 06:19AM    88 24* 0.6 149* 4.0 113* 30
.

[**2198-12-13**] ECHO
.
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60-70%) There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Abnormal flow consistent
with a patent ductus arteriosus is identified. There is no
pericardial effusion.
.
[**2198-12-10**] LUNG PATHOLOGY
.
Lung wedge, right lower lobe (A-B):

a.  Organizing pneumonitis, see note.

b.  Mild subpleural fibrosis.

II.  Lung wedge, right middle lobe (C-D):

a.  Marked accumulation of hemosiderin-laden macrophages, see
note.

b.  Septal fibrosis.

III.  Lung wedge, right lower lobe (E-G):

a.  Organizing pneumonitis, see note.

b.  Accumulation of hemosiderin-laden macrophages.

c.  Subpleural fibrosis.

d.  Rare giant cells seen.

Note:  The changes are patchy and not well-developed.  The
morphology of the organizing pneumonitis is suggestive of
bronchiolitis obliterans / organizing pneumonia (BOOP/COP).  The
accumulation of macrophages in alveolar spaces in a smoker are
consistent with respiratory  bronchiolitis - interstitial lung
disease (RBILD).  Clinical correlation is recommended.

.
[**12-3**] CTA CHEST
.
On the current examination, there is increasing interstitial
prominence, predominantly at the upper lobes bilaterally.
Additionally, increasing confluence is identified within the
right upper lobe as well as at the left base. Differential
considerations for the increase in interstitial markings include
pulmonary edema superimposed on a background of chronic lung
disease. Worsening of the patient's interstitial lung disease is
also a differential consideration. However, on the current
examination, there is increase in multifocal patchy airspace
disease, predominantly identified within the right lung. Several
of these areas do appear somewhat peripheral. Therefore, the
differential considerations do include septic embolism. Other
considerations do include a diffuse infectious process. Findings
are discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] at the time of dictation.
There is no evidence of main, central, or segmental pulmonary
embolism. There is increasing mediastinal and right hilar
lymphadenopathy, which appears most prominent in a subcarinal
location on the current study.

On the current exam, new small bilateral pleural effusions are
noted.

IMPRESSION:
1. Increasing interstitial prominence as noted above, which may
represent congestive failure and/or worsening of the patient's
interstitial lung disease.
2. No evidence of pulmonary embolism.
3. Patchy airspace opacities as noted. The differential
considerations are as discussed above and include septic
embolism and diffuse infection. The imaging findings are fairly
nonspecific.
4. Increasing mediastinal and right hilar lymphadenopathy.
.

[**11-29**] CT ABDOMEN PELVIS
.
FINDINGS: Direct comparison is made to prior examination dated
[**2198-11-21**]. As on a prior examination, there is evidence of
diffuse interstitial abnormality with interlobular septal
thickening and areas of honeycombing. Overall, the degree of
superimposed pulmonary edema as evidenced by areas of
ground-glass opacity, appear improved since the prior exam.
Also, there has been resolution of previously described pleural
effusions. There is a somewhat more confluent opacity within the
right upper lobe which likely also represents similar disease
process of pulmonary edema superimposed on interstitial lung
disease, however, infectious etiology cannot be definitively
excluded based on these imaging appearances.

There is evidence of intra- and extra-hepatic biliary dilatation
as previously described on CT dated [**2198-4-25**]. There is
narrowing of the distal common bile duct, suggesting possibility
of a stricture, possibly related to the patient's history of
chronic pancreatitis which is evidenced by the scattered
pancreatic parenchymal calcifications. The spleen and adrenal
glands are unremarkable. Remaining liver parenchyma is otherwise
grossly unremarkable. The kidneys are grossly unremarkable.

Diffusely stool filled colon is noted. Small bowel loops are
fluid filled throughout with areas of fecalization more
distally.

The pelvic structures are grossly unremarkable with Foley
catheter in place.

Significant diffuse atherosclerotic calcification is noted.
Again, there is evidence of thrombosis of the right-sided iliac
arteries. Bilateral common iliac artery stents are noted. The
left-sided stent does appear to be patent.

There is evidence of thrombosis of right-sided iliac and femoral
veins as previously described.

There is no evidence of intravenous contrast extending into the
right superficial femoral artery. Evidence of recent above the
knee amputation is noted with atrophy of the musculature of the
anterior compartment of the thigh.

No suspicious lytic or blastic bony lesions are identified.

Evaluation of the mediastinum again reveals mediastinal
lymphadenopathy in the subcarinal, pretracheal and prevascular
distributions with lymph nodes measuring up to 12 mm in short
axis dimension.

IMPRESSION:
1. Findings of pulmonary edema superimposed on interstitial lung
disease. Pulmonary edema appears improved since the
aforementioned prior examination. More confluent opacity is
noted and infection within the right upper lobe cannot be
definitively excluded.
2. Interval resolution of bilateral pleural effusions.
3. Intra- and extra-hepatic biliary dilatation is again
identified as detailed above. There is suggestion of a possible
stricture within the distal common bile duct.
4. Significant vascular pathology as noted.
5. Mediastinal lymphadenopathy as noted above.


Brief Hospital Course:
The patient was admitted [**11-18**] with pain RLE with nonhealing
ulcer and osteo requiring AKA on 12/17th [**2197**] by vascular
surgery. This was complicated with hypoxia requiring two
intubations and MICU stay, a fiberoptic visualization of pharynx
for extravasation of contrast in neck (resolved on its own), c
difficile colitis, bronchoscopy by pulmonary and VATs by
thoracics for persistent hypoxia after extubation, and renal
failure secondary to diuresis. At the time of discharge, all
these issues are resolved and creatinine is 0.6 (baseline
0.4)and trending down after diuresis stopped. She has had and
still has persistent asymptomatic hypernatremia wich is likely
to resolve in a few days as the patient's PO intake continues to
be stable.
.
Hypoxia: this was the main post op complication, with the
patient requiring 3 liters n/c for most of her stay, and
re-intubation in the MICU after her PACU stay post AKA. She is
comfortable on room air at discharge. CTA was negative for PE.
CTA and CXRs revealed an interstitial disease that was
attributed partially to noncardiogenic pulmonary edema, as her
echo showed normal EF. Pulmonary consult was obtained and PFT
revealed a restrictive disease. She was diuresed numerous times
with subjective relief of dyspnea but minimal change in oxygen
requirement. She underwent bronchoscopy with BAL and cultures
were negative for atypical infections, also galactomanan and B
glucan were negative (equivocal b glucan). Eventually Thoracic
Surgery was consulted for VATS, and biopsy revealed underlying
RB-ILD (Respiratory Bronchiolitis- Interstitial Lung Disease).
She was counseled to stop smoking. She will be followed up at
pulmonary clinic for serial PFTs and DLCO. Steroids were
discussed and ultimately decided against, as they have not been
shown to significantly improve outcomes. In addition, in her
case, prednisone would further complicate her glycemic control.
.
C difficile: she has 3 more days of Flagyl to complete 14 days
plus one additional week beyond discontinuation of other abx.
She has had intermittent diarrhea the past few days and she was
started on imodium prn yesterday.
.
AKA: she had no complications from the stump. She was on a 3
week course of aztreonam and vancomycin which she completed and
she remained afebrile. The staples need to be d/c in 3 days. She
developed intermittent erythema on the LLE and this was treated
with topical mupirocin with resolution of sx. Doppler for DVT
were negative.
.
ARF: With daily diuresis, her creatinine rose to 0.9 from 0.3,
from pre-renal causes, and she also had hyperphosphatemia >7.
Diuresis was discontinued and she received gentle hydration;
creatinine is trending down at discharge. She is taking adequate
PO food and liquids. Today creatinine is 0.6. The patient
appears to not need any diuresis and did very well off diuretics
for the past 3 days. She was on sevelamer for 2 days and
hyperphosphatemia resolved. She also received calcium
supplementation for 2 days.
.
Hypernatremia: The patient has been intermittently
hypernatremic. This has been treated with D5W with resolution,
however she quickly reverted to hyperNa. This will likely
resolve once her PO intake normalizes completely. She has stated
that at times she was very thirsty but did not drink due to pain
(either at the AKA stump or at the VATs site).
.
Diabetes Mellitus: Her sugars seem to have stabilized on 30
units glargine for breakfast (HS was tried with worse results)
and the attached sliding scale. During her stay she was at times
hyper and at times hypo (lowest recorded sugar in the 40s). This
quickly resolved with half an amp of D50. She is very non
compliant with the diabetic diet and needed constant reassurance
and teaching that she needed to eat regularly and adhere to a
diabetic diet. She has improved on this at discharge.
.
SMV thrombosis, with presumed hypercoagulable state. She was on
coumadin 2.5-5 mg with therapeutic INR. This was discontinued
and a heparin drip bridge was started for procedures. At
discharge, she remained on heparin bridge to coumadin and there
will need to be an overlap of 2 days before heparin can be d/c.
She had no clotting events during her stay.
.
Depression: she was briefly on celexa and is discharged on
duloxetine 60 mg daily. Her mood improved during her stay on
medication. SW also visited and worked with the patient.
.
The patient was evaluated by and worked with PT during her stay.
She is very weak and deconditioned and will need aggressive
rehab.
.
Anemia: this was worked up and was consistent with chronic
disease. She received one unit of blood 1/10 to help her
oxygenation and her Hct bumped 4 points to>26 at discharge.
.
The patient remained FULL CODE. She is discharged stable from
all her medical issues and ready to begin aggressive rehab.


Medications on Admission:
Albuterol inh q6
Amylase-Lipase-Protease iii TID
Aspirin 325mg qd
Clopidogrel 75mg qd
Duloxetine 30mg qd
Ergocalciferol (Vitamin D2)50,000u i qd
Hexavitamin i qd
Insulin Glargine 12u qhs, HISS
Nicotine 14mg/24 hr Patch qd
Oxycodone 5mg prn
Pantoprazole 40mg qd
Spironolactone 25mg qd
Tiotropium Bromide 18mcg qd
Warfarin 4mg qd


Discharge Medications:
1. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
4. Medium Chain Triglycerides     Oil Sig: Fifteen (15) ML PO
TID (3 times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q6H (every 6 hours).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
10. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
13. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
14. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

16. Multivitamins     Tablet, Chewable Sig: One (1) Cap PO DAILY
(Daily).
17. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
18. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q6H (every 6 hours) as needed.
19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
20. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
21. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
22. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

23. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
25. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
26. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

27. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
28. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
29. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
30. glargine 30 units at breakfast
And sliding scale insulin attached
31. heparin drip IV
For goal PTT 60-80.
After INR therapeutic for 2 days, d/c the heparin drip
32. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Infected right. Ileo femoral graft( enterobacter cloacae )
S/p right Above the Knee Amputation
Respiratory Bronchiolitis-Interstitial Lung Disease
chronic obstructive pulmonary disease
Diabetes Type II, uncontrolled with complications
SMV thrombosis
cirrhosis


Discharge Condition:
Stable. Afebrile. Breathing on room air. Ambulatory


Discharge Instructions:
Admitted for severe infection in leg that needed amputation
above the knee. You received antibiotics and the infection
resolved. The staples need to come out in 3 days.
.
Shortness of breath developed which was due to a disease called
Respiratory Bronchiolitis-Interstitial Lung Disease. We could
diagnose this because a bit of tissue and fluid was taken from
your lung during an operation. It is essential that you stop
smoking.
.
You need to be on coumadin for an INR [**1-6**] due to clots. Please
make sure your INR is checked frequently. Follow your rehab
doctor's instructions.
.
Take your medications as prescribed and return if you have any
worrisome concerns.
.
You have appointments with your vascular doctor and your lung
doctor. They are below. Please keep these appointments.

Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**] , call for an appointment [**Telephone/Fax (1) 1393**]
Call your primary care [**First Name8 (NamePattern2) **] [**Doctor Last Name 5448**] as needed.
See a pulmonologist (lung doctor) regularly:


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute vascular insufficiency of intestine,Portal vein thrombosis,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Alcoholic cirrhosis of liver,Urinary complications, not elsewhere classified,Anemia, unspecified'}


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: Infected right ileo femoral graft

PRESENT ILLNESS: 54y/o female well known to Vascular Surgery service, recently
hospitalized from [**Date range (1) 63758**] for rt. groin pain. Evaluated
with tagged WBC which showed uptake at ileo-fem graft site.
Patient treated in hsopital with Vancomycin, flagyl, cipro
started [**11-7**], cipro d/c'd [**11-8**] aztreoman added [**11-8**]. ID
recommended [**3-10**] week course. Leg amputation was recommended,
patient defered surgery until after the holidays. She was
discharged home [**2198-11-16**] VNA services and IV vanco/aztreoman and
po flagyl to finish the 4-6 weeks as recommended by ID. Returns
now for amputation.

MEDICAL HISTORY: history of PVD, s/p rt. ileo-fem bpg [**12-10**] complicated by
lymphocele s/p drainage [**2198-1-11**],rt. ililac/femoral thrombectomy
[**4-10**],rt. ileo-fem graft thrombectomy with bovine
patchangioplasty [**2196**],rt. ileofem bpg with PTFE [**2195**],
histroy of chronic pancretieis s/p Pestow,J-tube,ccy1998,Expl
lap [**2189**]
history of ETOH cirrhosis/chronic pancreatitis
history of left breast cyst s/p excision
history of GERD,pud
histroy of esophgitis with stricure
history of small bowel obstruction
history of PV,SMV thrombosis
histroy of asthma
history of cervical ca s/p multiple d/c's
history of DM2 insulin dependant
history of entero-colonic fistula

MEDICATION ON ADMISSION: Albuterol inh q6
Amylase-Lipase-Protease iii TID
Aspirin 325mg qd
Clopidogrel 75mg qd
Duloxetine 30mg qd
Ergocalciferol (Vitamin D2)50,000u i qd
Hexavitamin i qd
Insulin Glargine 12u qhs, HISS
Nicotine 14mg/24 hr Patch qd
Oxycodone 5mg prn
Pantoprazole 40mg qd
Spironolactone 25mg qd
Tiotropium Bromide 18mcg qd
Warfarin 4mg qd

ALLERGIES: Penicillins

PHYSICAL EXAM: vital signs:97.5-96-18 B/P 124/69 )2 sat 94% room air
cachectic female who Ox3 but nods off during interview
HEENT: nonicteric, no LAD, no carotid bruits or JVD
Lungs: clear to ausculation bilaterally
Heart: RRR
ABd: BS present , soft c/w ascities with mild distention
EXT: rt. foot cool with 3+edema, hyperemic, firm, tense rt. leg
     rt. groin with open wound with purulent drainage and warm
to touch to above the rt. knee. Pain with passive plantar
flection
Pulses: dopperable femoral and [**Doctor Last Name **] pulses with absent pedal
pulses rt.
        palpable femoral and [**Doctor Last Name **] pulses and dopperable pedal
pulses on left.
Neuro: grossly intact

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: former ETOH use
tobacco use , current
married and lives with spouse 

### Response:
{'Infection and inflammatory reaction due to other vascular device, implant, and graft,Acute vascular insufficiency of intestine,Portal vein thrombosis,Other specified alveolar and parietoalveolar pneumonopathies,Acute kidney failure, unspecified,Intestinal infection due to Clostridium difficile,Hyperosmolality and/or hypernatremia,Atherosclerosis of native arteries of the extremities with ulceration,Ulcer of other part of foot,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Alcoholic cirrhosis of liver,Urinary complications, not elsewhere classified,Anemia, unspecified'}
