CHIEF COMPLAINT: altered mental status
RLE pain

PRESENT ILLNESS: 68-year-old female with h/o DM2, HTN, CAD, CHF and PVD s/p left
AKA, angioplasty to R tibial artery in [**3-19**], chronic venous
stasis ulcers s/p debridement one week PTA, also with death of
son 10d PTA, who presents with several days of RLE pain and
confusion. Patient unable to give history, spoke with her
grandson at [**Telephone/Fax (1) 60469**] to gain some sense of story, though per
his report his aunt will be calling in to provide more detail.
From the grandson, the patient has had increasing RLE pain times
several days, and from the limited info provided by the patient
she ran out of the 60 tabs of Percocet also several days ago. It
is unclear if the patient has been taking more of her MS Contin
in the absence of Percocet. Per the grandson, the pt has been
"in and out of reality" for these past few days, unable to sleep
at night, poorly interactive during the day. The VNA saw the
patient on the DOA and felt that she was somnolent, called 911.

MEDICAL HISTORY: DM2,
hypertension,
coronary artery disease (h/o angina in past currently stable),
history of congestive heart failure,
severe PVD
h/o GIB
Left above-knee amputation,
left common iliac stenting,
IVC filter placement,
hysterectomy,
lumpectomy

MEDICATION ON ADMISSION: Lasix 20 mg [**Hospital1 **]
Protonix 40 mg daily
Colace 100 mg b.i.d.
Plavix 75 daily
Aspirin 325 mg
Losartan 100 mg daily
Toprol XL 150 mg daily
MS Contin 60mg [**Hospital1 **]
Oxycodone/Acetaminophen (5/325) [**1-16**] tab q4h prn
Nortriptyline 10 mg qhs
Gabapentin 300mg tid
Lipitor 10mg qd
Combivent

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals:
Gen - lying in bed, breathing comfortably, NAD except upon
manipulation of RLE wounds
Heent - PERRL, EOMI, OP wnl, MMM
Neck - supple, thick, JVP 8cm
CV - RRR, nl s1/s2, [**2-20**] holosyst murmur loudest at apex
Pulm - rhonchi throughout, likely transmitted from upper airway;

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives at home with second son, first son recently deceased 3d
Venous (peripheral) insufficiency, unspecified,Ulcer of calf,Congestive heart failure, unspecified,Hematemesis,Acute posthemorrhagic anemia,Atherosclerosis of native arteries of the extremities with gangrene,Drug-induced delirium,Hyperpotassemia,Benign neoplasm of stomach,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Poisoning by unspecified sedative or hypnotic,Accidental poisoning by unspecified sedative or hypnotic,Above knee amputation status
Venous insufficiency NOS,Ulcer of calf,CHF NOS,Hematemesis,Ac posthemorrhag anemia,Ath ext ntv art gngrene,Drug-induced delirium,Hyperpotassemia,Benign neoplasm stomach,Crnry athrscl natve vssl,Hypertension NOS,DMII neuro nt st uncntrl,Neuropathy in diabetes,Pois-sedative/hypnot NOS,Acc poison-sedatives NOS,Status amput above knee
Admission Date:  [**2163-4-21**]              Discharge Date:   [**2163-5-3**]

Date of Birth:  [**2094-8-6**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
altered mental status
RLE pain

Major Surgical or Invasive Procedure:
none

History of Present Illness:
68-year-old female with h/o DM2, HTN, CAD, CHF and PVD s/p left
AKA, angioplasty to R tibial artery in [**3-19**], chronic venous
stasis ulcers s/p debridement one week PTA, also with death of
son 10d PTA, who presents with several days of RLE pain and
confusion. Patient unable to give history, spoke with her
grandson at [**Telephone/Fax (1) 60469**] to gain some sense of story, though per
his report his aunt will be calling in to provide more detail.
From the grandson, the patient has had increasing RLE pain times
several days, and from the limited info provided by the patient
she ran out of the 60 tabs of Percocet also several days ago. It
is unclear if the patient has been taking more of her MS Contin
in the absence of Percocet. Per the grandson, the pt has been
"in and out of reality" for these past few days, unable to sleep
at night, poorly interactive during the day. The VNA saw the
patient on the DOA and felt that she was somnolent, called 911.

In the ED, the patient was confused and somnolent but in obvious
pain, wailing out but unable to give a history. She repeated
"cut it off" while holding her RLE. She received 2mg MSIR IV,
then 2 Percocets. On the floor she was still in pain, received
1mg IV dilaudid.

Past Medical History:
DM2,
hypertension,
coronary artery disease (h/o angina in past currently stable),
history of congestive heart failure,
severe PVD
h/o GIB
Left above-knee amputation,
left common iliac stenting,
IVC filter placement,
hysterectomy,
lumpectomy


Social History:
Pt lives at home with second son, first son recently deceased 3d

PTA from unclear etiology, possibly liver disease vs. HIV per
pt. Followed by VNA daily.  wheelchair bound. She is a current
smoker,
~half pack per day. Denies EtOH/IVDU.

Family History:
NC

Physical Exam:
Vitals:
Gen - lying in bed, breathing comfortably, NAD except upon
manipulation of RLE wounds
Heent - PERRL, EOMI, OP wnl, MMM
Neck - supple, thick, JVP 8cm
CV - RRR, nl s1/s2, [**2-20**] holosyst murmur loudest at apex
Pulm - rhonchi throughout, likely transmitted from upper airway;

scant bibasilar rales, L>R
Abd - obese, soft, NT, NABS
Ext - left AKA; R foot with non-pitting edema, venous stasis
changes,
4 ulcerations s/p recent debridement appearing clean with no
significant granulation yet, no evidence of cellulitis or
superimposed infection
Pulses - Rt: 1+fem/no [**Doctor Last Name **]/no DP or PT; Lt: 1+fem
Neuro - A&Ox3, slighy ptosis on right, CNs otherwise intact,
answers all questions appropriately, UE stregth intact, LE
strength 3/5 in flexors/extensors



Pertinent Results:
Chemistries
[**2163-4-21**] 11:40AM   GLUCOSE-161* UREA N-15 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-106 TOTAL CO2-24 ANION GAP-14

LFTs
[**2163-4-21**] 11:40AM   ALT(SGPT)-6 AST(SGOT)-12 LD(LDH)-155 ALK
PHOS-77 AMYLASE-70 TOT BILI-0.2
[**2163-4-21**] 11:40AM   LIPASE-42
[**2163-4-21**] 11:40AM   AMMONIA-14

CBC
[**2163-4-21**] 11:40AM   WBC-9.2 RBC-3.53* HGB-9.9* HCT-30.0* MCV-85
MCH-28.1 MCHC-33.0 RDW-17.1*
[**2163-4-21**] 11:40AM   NEUTS-68.4 LYMPHS-24.7 MONOS-3.2 EOS-3.4
BASOS-0.4
[**2163-4-21**] 11:40AM   HYPOCHROM-1+ ANISOCYT-1+ MICROCYT-1+
[**2163-4-21**] 11:40AM   PLT COUNT-339

Coags
[**2163-4-21**] 11:40AM   PT-12.9 PTT-25.8 INR(PT)-1.1

U/A
[**2163-4-21**] 11:40AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2163-4-21**] 11:40AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG

Reports:
[**2163-4-21**]   AP AND LATERAL VIEWS OF THE CHEST: Unchanged
cardiomegaly. The hilar and mediastinal contours are unchanged.
There are increased pulmonary [**Month/Day/Year 1106**] markings. The patient is
rotated but there is probable small linear atelectasis at the
left lung base. No effusions are seen. Soft tissue and osseous
structures remain unchanged.
IMPRESSION: Mild cardiac failure.

[**2163-4-21**]   CT HEAD W/O CONTRAST
FINDINGS: There is no sign for the presence of an intracranial
hemorrhage. There are cluster of small (less than 1 cm)
hypodense areas near the atrium of the left lateral ventricle.
While nonspecific in etiology, the findings are most commonly
secondary to chronic small vessel infarction. Probable
additional chronic small vessel infarction is seen in the right
corona radiata. There is no sign for hydrocephalus or shift of
normally midline structures. It is to be noted that a number of
the sections are degraded by patient motion. The surrounding
osseous and soft tissue structures show no overt pathology.
CONCLUSION: No evidence for intracranial hemorrhage. Probable
multiple small chronic infarcts, as noted above.

EGD
Findings:
Esophagus: Normal esophagus.
Stomach:
Contents: Clotted blood was seen in the fundus.
Protruding Lesions: Three polypoid structures ranging in size
from 5mm to 7mm were found in the stomach body. One of them had
stigmata had recent bleeding. Three 1 cc.Epinephrine 1/[**Numeric Identifier 961**]
injections were applied for hemostasis at the base of the polyp
with stigmata of recent bleeding. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully.
Excavated Lesions A single superficial non-bleeding 5mm ulcer
was found in the stomach body.
Duodenum: Normal duodenum.


Brief Hospital Course:
Impression: 68 yo w/ MMP now with recent GIB from likely
polypoid lesions s/p MICU stay, and severe PVD likely needing
[**Hospital1 1106**] surgery intervention.

Upper GI bleed
The patient has a history of GI bleeding and had a normal EGD in
the past several months per report.  She was on aspirin and
plavix for her common iliac stent.  During her hospitalization,
she had an episode of large volume hematemesis, requiring PRBC
support (x6 units) and a MICU transfer.  There she underwent two
EGDs which demonstrated normal esophagus and normal duodenum,
but showed three polypoid lesions in the stomach, one of which
had stigmata of bleeding; she underwent epinephrine injection
and cauterization to this area.  She also had a 5mm non bleeding
gastric ulcer.  She was started on a [**Hospital1 **] ppi.  Her HCT was
stable after this, and she had no further episodes of
hematemesis.  GI recommended a repeat EGD in [**3-20**] months, and a
colonoscopy for age appropriate screening.  These things were
conveyed in the discharge information to the patient and her
primary provider.  [**Name10 (NameIs) **] aspirin and plavix were not reinitiated
on discharge and she will follow up with her [**Name10 (NameIs) 1106**] surgeon as
below.  Given that she will likely have a surgical procedure
within the next two weeks, consideration of restarting her
plavix alone after surgery was recommended.

Chronic Pain
The patient presented with difficult to control lower extremity
pain and a change in mental status on admission.  A head CT was
negative.  Acute and chronic pain service consults were
obtained, and her mental status cleared on modification of her
pain regimen.  A regimen of a fentanyl patch (25mcg q3 days),
MSSR (60 [**Hospital1 **]), amitryptiline (10 qhs), gabapentin (900 tid), and
4-8mg oral dilaudid q6h prn for breakthrough was finally arrived
at.  She will follow up with her primary care physician
regarding pain management.

Peripheral [**Hospital1 1106**] disease and ulcerations
The patient was on [**Hospital1 **] and plavix after a common iliac stent and
angioplasty on right tibial artery.  These two medications were
held given the GI bleed, and the patient was instructed to
follow up with Dr. [**Last Name (STitle) 60470**] regarding when to reinitiate
these medications.  Dr. [**Last Name (STitle) 60470**] is planning for a STSG of
her RLE ulcerations in two to three weeks after discharge.  She
was briefly on vancomycin given her history of MRSA colonization
of her RLE lesions, but this was discontinued prior to discharge
as there was no sign of infection.

CAD
The patient was continued on a beta blocker, losartan, and a
statin; her [**Last Name (STitle) **] was held in the setting of her GI bleed.  She
was started on a small dose of lisinopril given her diabetes,
though she did not have proteinuria on this admission.  She was
continued on lasix per her outpatient dose.

DM2
The patient was started on glargine insulin, and she was
discharged with 10 units qAM.  The VNA will check fingerstick
values to ensure adequate control.


FEN:
The patient was kept on a diabetic, cardiac diet.

Ppx
The patient was discharged with a [**Hospital1 **] ppi, an aggressive bowel
regimen given her narcotics, and vitamin C, iron, phoslo, Zn.

ACCESS: right subclavian CVL, removed prior to discharge


Medications on Admission:
Lasix 20 mg [**Hospital1 **]
Protonix 40 mg daily
Colace 100 mg b.i.d.
Plavix 75 daily
Aspirin 325 mg
Losartan 100 mg daily
Toprol XL 150 mg daily
MS Contin 60mg [**Hospital1 **]
Oxycodone/Acetaminophen (5/325) [**1-16**] tab q4h prn
Nortriptyline 10 mg qhs
Gabapentin 300mg tid
Lipitor 10mg qd
Combivent

Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): HOLD UNTIL TOLD TO RESTART BY [**Month/Day (2) **] SURGEON.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): HOLD UNTIL TOLD
TO RESTART BY [**Month/Day (2) **] SURGEON.
3. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Nortriptyline HCl 10 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Morphine Sulfate 30 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO Q12H (every 12 hours).
9. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*270 Capsule(s)* Refills:*2*
13. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical  [**Hospital1 **] (2 times a day): apply after showers.
Disp:*1 month supply* Refills:*2*
14. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day).
Disp:*1 month supply* Refills:*2*
15. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
16. Ascorbic Acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
19. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*0*
20. Insulin Glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous once a day: at breakfast.
21. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
22. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
23. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
24. Senna Lax 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
25. Lactulose 10 g Packet Sig: One (1)  PO once a day as needed
for constipation.
Disp:*1 month supply* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary Diagnoses
- Upper GI bleed s/p EGD
- Right LE ulcerations

Secondary Diagnoses
- Type II Diabetes
- CAD
- HTN
- Severe peripheral [**Location (un) 1106**] disease s/p left AKA, right iliac
stenting and right tibial angioplasty
- Chronic pain


Discharge Condition:
Stable, HCT stable, tolerating an oral diet, per PT at baseline
function, pain adequately controlled, follow up in place.

Discharge Instructions:
We are discharging you today, though we strongly feel that it
would be more appropriate to fully change your pain medications
over to oral forms prior to your leaving the hospital.  You
should discuss your pain regimen with your primary care provider
[**Name Initial (PRE) 3011**].

Hold off on taking your aspirin and plavix until you talk with
Dr. [**Last Name (STitle) **] tomorrow. Take your other medications as
prescribed.  The VNA nurses should go over the changes with you
if you are confused about them.

It is very important for you to get a repeat "EGD" within [**3-20**]
months to re-evaluate your GI tract.  Please coordinate this
with your primary care physician.

Followup Instructions:
Please see your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
([**Telephone/Fax (1) 60471**]) as scheduled today. Talk with him about your pain
management, getting a repeat "EGD" within 3-6 months, and
getting a routine screening colonoscopy. You should ask about
seeing a GI specialist at [**Hospital1 2177**] so your care is all coordinated,
or you can follow up at the [**Hospital 18**] [**Hospital **] clinic. You can call
[**Telephone/Fax (1) 1983**] to arrange this.



Keep the following appointment:

Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2163-5-4**] 10:00. Ask him about when to restart
the aspirin and plavix. The [**Month/Day/Year 1106**] surgeons plan to do your
surgery in ~2 weeks time.
{'Venous (peripheral) insufficiency, unspecified,Ulcer of calf,Congestive heart failure, unspecified,Hematemesis,Acute posthemorrhagic anemia,Atherosclerosis of native arteries of the extremities with gangrene,Drug-induced delirium,Hyperpotassemia,Benign neoplasm of stomach,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Poisoning by unspecified sedative or hypnotic,Accidental poisoning by unspecified sedative or hypnotic,Above knee amputation status'}


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: altered mental status
RLE pain

PRESENT ILLNESS: 68-year-old female with h/o DM2, HTN, CAD, CHF and PVD s/p left
AKA, angioplasty to R tibial artery in [**3-19**], chronic venous
stasis ulcers s/p debridement one week PTA, also with death of
son 10d PTA, who presents with several days of RLE pain and
confusion. Patient unable to give history, spoke with her
grandson at [**Telephone/Fax (1) 60469**] to gain some sense of story, though per
his report his aunt will be calling in to provide more detail.
From the grandson, the patient has had increasing RLE pain times
several days, and from the limited info provided by the patient
she ran out of the 60 tabs of Percocet also several days ago. It
is unclear if the patient has been taking more of her MS Contin
in the absence of Percocet. Per the grandson, the pt has been
"in and out of reality" for these past few days, unable to sleep
at night, poorly interactive during the day. The VNA saw the
patient on the DOA and felt that she was somnolent, called 911.

MEDICAL HISTORY: DM2,
hypertension,
coronary artery disease (h/o angina in past currently stable),
history of congestive heart failure,
severe PVD
h/o GIB
Left above-knee amputation,
left common iliac stenting,
IVC filter placement,
hysterectomy,
lumpectomy

MEDICATION ON ADMISSION: Lasix 20 mg [**Hospital1 **]
Protonix 40 mg daily
Colace 100 mg b.i.d.
Plavix 75 daily
Aspirin 325 mg
Losartan 100 mg daily
Toprol XL 150 mg daily
MS Contin 60mg [**Hospital1 **]
Oxycodone/Acetaminophen (5/325) [**1-16**] tab q4h prn
Nortriptyline 10 mg qhs
Gabapentin 300mg tid
Lipitor 10mg qd
Combivent

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals:
Gen - lying in bed, breathing comfortably, NAD except upon
manipulation of RLE wounds
Heent - PERRL, EOMI, OP wnl, MMM
Neck - supple, thick, JVP 8cm
CV - RRR, nl s1/s2, [**2-20**] holosyst murmur loudest at apex
Pulm - rhonchi throughout, likely transmitted from upper airway;

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives at home with second son, first son recently deceased 3d 

### Response:
{'Venous (peripheral) insufficiency, unspecified,Ulcer of calf,Congestive heart failure, unspecified,Hematemesis,Acute posthemorrhagic anemia,Atherosclerosis of native arteries of the extremities with gangrene,Drug-induced delirium,Hyperpotassemia,Benign neoplasm of stomach,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Poisoning by unspecified sedative or hypnotic,Accidental poisoning by unspecified sedative or hypnotic,Above knee amputation status'}
