CHIEF COMPLAINT: RLE pain x1 day and difficulty ambulating bilaterally

PRESENT ILLNESS: 72M presenting with 1-2 day h/o sudden onset of pain in RLE that
has progressed over past day to point where he has had
difficulty ambulating. Patient states initially he felt like he
'pulled a muscle' in his hamstring.  Pain also in calf. He was
having difficulty moving legs and had numbness of his right foot
causing difficulty ambulating and causing him to fall. Also
states difficulty
moving left leg, feels like he has to pull his leg forward.
Patient also claims he syncopized today.

MEDICAL HISTORY: PMH:
-coronary artery disease
-EF 20%
-complete heart block, pacer dependent
-diabetes mellitus type 2
-obstructive sleep apnea on CPAP
-history of syncope
-hypertension
-benign prostatic hypertrophy
-peripheral vascular disease
-hiatal hernia
-Meniere's disease
-psoriasis
-cervical and lumbar spinal stenosis
-GERD
-right eye blindness

MEDICATION ON ADMISSION: Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5", Flomax 0.4',
Actos 15', Advair 250/50', Gemfibrozil 600", Omeprazole 20",
Ranitidine 150', Glyburide 10", Nasonex 1", Albuterol, Metformin
500 QID, Lasix 20'

ALLERGIES: Procardia / Benadryl

PHYSICAL EXAM: PE:
97.5  96  138/96  96RA
A&Ox3
Obese male in no acute distress
Regular rate/rhythm
CTA b/l
Abd obese, +bs, non-distended, non-tender, unable to palpate
abdominal aorta.
RLE minimal  lower leg.  Motor diminished in LE
Able to move toes b/l but diminished in Rt
VAC dressing in place. Fasciotomy site is c/d/i
B/l popliteal aneurysms.
Pulses:
    F   [**Doctor Last Name **]   PT  DP
R   2+   3+   1+  Trip
L   2+   3+   1+  1+

FAMILY HISTORY: No family history of cardiac disease

SOCIAL HISTORY: Lives alone, widowed, Tobacco - quit cigars 30 yrs ago, No eTOH,
no illicits
Aneurysm of artery of lower extremity,Acute on chronic systolic heart failure,Arterial embolism and thrombosis of lower extremity,Traumatic compartment syndrome of lower extremity,Acute posthemorrhagic anemia,Hemorrhage complicating a procedure,Atrioventricular block, complete,Atherosclerosis of native arteries of the extremities with intermittent claudication,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Cardiac pacemaker in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Legal blindness, as defined in U.S.A.,Esophageal reflux,Unspecified fall,Personal history of tobacco use
Lower extremity aneurysm,Ac on chr syst hrt fail,Lower extremity embolism,Trauma comp synd low ext,Ac posthemorrhag anemia,Hemorrhage complic proc,Atriovent block complete,Ath ext ntv at w claudct,Crnry athrscl natve vssl,Aortocoronary bypass,Status cardiac pacemaker,DMII wo cmp nt st uncntr,Obstructive sleep apnea,Hypertension NOS,BPH w/o urinary obs/LUTS,Legal blindness-usa def,Esophageal reflux,Fall NOS,History of tobacco use
Admission Date:  [**2161-6-5**]              Discharge Date:   [**2161-6-10**]

Date of Birth:  [**2088-11-10**]             Sex:   M

Service: SURGERY

Allergies:
Procardia / Benadryl

Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
RLE pain x1 day and difficulty ambulating bilaterally


Major Surgical or Invasive Procedure:
Right leg 3-compartment fasciotomy ([**2161-6-6**])
Wound vac placement ([**2161-6-8**])


History of Present Illness:
72M presenting with 1-2 day h/o sudden onset of pain in RLE that
has progressed over past day to point where he has had
difficulty ambulating. Patient states initially he felt like he
'pulled a muscle' in his hamstring.  Pain also in calf. He was
having difficulty moving legs and had numbness of his right foot
causing difficulty ambulating and causing him to fall. Also
states difficulty
moving left leg, feels like he has to pull his leg forward.
Patient also claims he syncopized today.


Past Medical History:
PMH:
-coronary artery disease
-EF 20%
-complete heart block, pacer dependent
-diabetes mellitus type 2
-obstructive sleep apnea on CPAP
-history of syncope
-hypertension
-benign prostatic hypertrophy
-peripheral vascular disease
-hiatal hernia
-Meniere's disease
-psoriasis
-cervical and lumbar spinal stenosis
-GERD
-right eye blindness

PSH:
-CABGx3 '[**44**] (LGSV)
-pacemaker and ICD '[**54**]
-laminectomy of the cervical and lumbar spine


Social History:
Lives alone, widowed, Tobacco - quit cigars 30 yrs ago, No eTOH,
no illicits


Family History:
No family history of cardiac disease

Physical Exam:
PE:
97.5  96  138/96  96RA
A&Ox3
Obese male in no acute distress
Regular rate/rhythm
CTA b/l
Abd obese, +bs, non-distended, non-tender, unable to palpate
abdominal aorta.
RLE minimal  lower leg.  Motor diminished in LE
Able to move toes b/l but diminished in Rt
VAC dressing in place. Fasciotomy site is c/d/i
B/l popliteal aneurysms.
Pulses:
    F   [**Doctor Last Name **]   PT  DP
R   2+   3+   1+  Trip
L   2+   3+   1+  1+


Pertinent Results:
[**2161-6-10**] 05:59AM BLOOD

WBC-11.3* RBC-3.11* Hgb-9.1* Hct-27.4* MCV-88 MCH-29.3 MCHC-33.3
RDW-13.8 Plt Ct-388

[**2161-6-10**] 05:59AM BLOOD

PT-17.4* PTT-56.5* INR(PT)-1.6*

[**2161-6-10**] 05:59AM BLOOD

Glucose-59* UreaN-12 Creat-0.8 Na-141 K-4.1 Cl-106 HCO3-24
AnGap-15

[**2161-6-7**] 09:09PM BLOOD

CK(CPK)-5571*

[**2161-6-9**] 03:51AM BLOOD

CK(CPK)-2291*

[**2161-6-10**] 05:59AM BLOOD

Calcium-8.8 Phos-3.7 Mg-2.2

[**2161-6-6**] 1:10 am MRSA SCREEN      NASAL.

MRSA SCREEN (Final [**2161-6-8**]):    No MRSA isolated.

HISTORY: 72-year-old male with mottled right foot, concern for
vascular
disease.

FINDINGS:

CT OF ABDOMEN AND PELVIS: Imaged lung parenchyma reveals 5-mm
pulmonary
nodule in the lingula and a calcified 2-mm nodule in right
middle lobe that are stable since [**2157**]. Previously described
nodule in the anterior right middle lobe appears to be of
ground- glass density on today's study and is unchanged in size.
There is no pericardial or pleural effusion.

Gallstones in otherwise unremarkable gallbladder. A 9-mm nodule
with
indeterminate features in the left adrenal gland seems to be
present in [**2159**] study, but it is difficult to compare due to
different techniques. The liver, spleen, right adrenal gland,
and kidneys are unremarkable. The pancreas is atrophic without
focal lesions. Bowel loops are normal in caliber. There are no
pathologically enlarged mesenteric or retroperitoneal lymph
nodes.

CT OF THE PELVIS: Urinary bladder appears unremarkable. Prostate
gland is
enlarged and heterogenous, with gross calcifications, measuring
up to 72 mm in laterolateral diameter. Seminal vesicles are
unremarkable. There are no pathologically enlarged pelvic lymph
nodes. There is no free fluid or free air in pelvic cavity.

CT ANGIOGRAM: Abdominal aorta is normal in size without evidence
of
dissection. Atherosclerotic changes with calcifications and
mural plaques,
some of them ulcerated, are noted along the arterial tree. A
focal ectasia of proximal celiac artery is identified, although
the origin is not narrowed. The origins of the superior
mesenteric, single renals and inferior mesenteric arteries are
patent.

On the right side, the common and external iliac arteries are
patent. There is a tight stenosis (60%) with post-stenotic
dilatation of the right internal iliac artery (3A:135). The
common, deep and superficial femoral arteries are unremarkable.
There is a 41 x 32 mm mostly thrombosed aneurysm of the
popliteal artery that extends for approximately 60 mm. There is
no opacification of AT. PT is patent, giving off branches to the
plantar arch. The DP opacifies from the collaterals coming from
the plantar arch. Peroneal artery has a narrowed origin, and
presents with multilevel disease.

On the left side, the origin of the common iliac artery is
narrowed, and then becomes aneurysmal, measuring up to 20 mm and
with large irregular areas of contrast pooling about the
periphery and separated from the vessel lumen by curvilinear
density, an appearance that may represent extensive ulcerated
plaque but could also represent chronic focal dissection. The
internal iliac artery presents a focal 12- mm aneurysm. The
external iliac artery and femoral arteries are unremarkable.
There is a 42 x 41 x 42-mm mostly thrombosed aneurysm in the
popliteal artery. There is no opacification of AT. The flow in
PT and peroneal arteries is delayed compared to the
contralateral side (could be due to proximal disease). The
peroneal artery has a narrowed origin, opacifies well only until
the mid- calf, and then shows faint opacification, but could be
due to a very slow flow. The patent PT gives off dorsalis pedis.

DP is filled by collaterals from the plantar arch.

OSSEOUS STRUCTURES: Bilateral spondylolysis and grade 1
anterolisthesis are noted at L5- S1. Degenerative changes in
spine.

IMPRESSION:
1. Bilateral mostly thrombosed popliteal artery aneurysm,
measuring up to 42 mm.
2. Aneurysm of the left common iliac artery that presents with
complicated
probable ulcerated plaques vs focal dissection with multiple
areas of saccular foci of contrast, measuring up to 20 mm.
3. Focal aneurysm of the left internal iliac artery.
4. No opacification of anterior tibialis arteries bilaterally.
5. Delayed flow in the left PT and peroneal arteries.
6. Narrowing at the origin of the left common iliac, the right
internal iliac and both peroneal arteries.
7. Gallstones.
8. Left adrenal gland nodule, indeterminate but possibly
previously present.
9. Stable lingular and right middle lobe nodules stable since
[**2157**] consistent with benignity. Ground- glass opacity in right
middle lobe is stable.  Continued attention may be paid at next
follow up.


Brief Hospital Course:
Admitted through ED.  Currently coming in with 1-2 day h/o
sudden onset of pain in RLE that has progressed over pastday to
point where he has had difficulty ambulating.  Patientstates
initially he felt like he 'pulled a muscle' in his
hamstring.  Pain also in calf.  He was having difficulty moving
legs and had numbness of his right foot causing difficulty
ambulating and causing him to fall.  Also states difficulty
moving left leg. feels like he has to pull his leg forward.

Diagnosis of Compartment syndrome. He agreed to have an elective
surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained,  all other preperations were
made.

Pt started on IV heparin drip. Moniter of PTT. To be DC'd on
Lovenox untill surgery.
Bicarb drip started.

He underwent a:

Right leg 3-compartment fasciotomy.
VAC dressing placed.

He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.

Post-operatively, he was extubated and transferred to the CVICU
for further stabilization and monitoring.

His CK's were followed:

[**Numeric Identifier 35553**]*, [**Numeric Identifier **]*, [**Numeric Identifier 97371**]*, 9357*, 7560*, 5571*, 2291*. All in a
downtrend. On Dc his leg has less pan, improved movement and
sensation.

It was noticed that he had significant hematuria in the post op
period. A urology consult was obtained. Pt currently in  being
worked up. Has out patient cystoscopy planned on the 14th. Most
labs are outptient. He currently has a CBI. This has been in
place since urology has seen the patient. Can remove at rehab.
If so clamp CBI. Hand irrigate if needed. If clears can pull
foley. If cannot urinate replace.

Pt also had an acute episode on chronic systolic dysfuntion.
Recieved lasix IV. responded appropriatly. Cardiology on board.
managed care. Resolved with lasix.

He was then transferred to the VICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status.

On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.


Medications on Admission:
Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5", Flomax 0.4',
Actos 15', Advair 250/50', Gemfibrozil 600", Omeprazole 20",
Ranitidine 150', Glyburide 10", Nasonex 1", Albuterol, Metformin
500 QID, Lasix 20'

Discharge Medications:
1. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) puffs Inhalation [**Hospital1 **] (2 times a day) as needed for
shortness of breath or wheezing.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. CPAP 13
50 cc EERS, 2 liters oxygen
For severe mixed sleep disordered breathing
6. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation PRN as needed for shortness of breath
or wheezing.
9. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.

10. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. Nasonex 50 mcg/Actuation Spray, Non-Aerosol Sig: One (1)
spray Nasal twice a day.
12. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
17. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
19. Lovenox 100 mg/mL Syringe Sig: One (1)  Subcutaneous twice a
day: STOP THE MORNING DOSE THE DAY OF YOUR SURGERY WITH DR
[**Last Name (STitle) 1111**].
20. Metformin 500 mg Tablet Sig: One (1) Tablet PO qid: 8 AM,
NOON, 4 PM AND [**2152**].
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Bilateral popliteal aneurysms
Right lower extremity distal ischemia
Anemia secondary to blood loss requiring PRBC's.
hematuria
Acute CHF on chronic CHF systolic dysfunction


Discharge Condition:
Good


Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from your incision site, chest pain, shortness of
breath, or anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.

YOU ARE ON LOVENOX. THE DAY BEFORE YOUR SCHEDULED SURGERY YOU
MUST STOP THE MORNING DOSE.


Followup Instructions:
1. Follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] [**Name (STitle) **] on [**2161-6-15**] at 4:00 p.m.
for your outpatient cystoscopy. Call the office at [**Telephone/Fax (1) 921**]
to confirm your appointment.

2. Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2161-6-15**] 4:00

3. Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2161-7-2**] 2:00

4. Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2161-7-15**] 10:10

5. You are scheduled for b/l popiteal stents. Call Dr [**Last Name (STitle) **]
office to get the exact date. His number is [**Telephone/Fax (1) 3121**]. It
should be scheduled [**7-1**]. This is not affirmed as of yet.



Completed by:[**2161-6-10**]
{'Aneurysm of artery of lower extremity,Acute on chronic systolic heart failure,Arterial embolism and thrombosis of lower extremity,Traumatic compartment syndrome of lower extremity,Acute posthemorrhagic anemia,Hemorrhage complicating a procedure,Atrioventricular block, complete,Atherosclerosis of native arteries of the extremities with intermittent claudication,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Cardiac pacemaker in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Legal blindness, as defined in U.S.A.,Esophageal reflux,Unspecified fall,Personal history of tobacco use'}


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: RLE pain x1 day and difficulty ambulating bilaterally

PRESENT ILLNESS: 72M presenting with 1-2 day h/o sudden onset of pain in RLE that
has progressed over past day to point where he has had
difficulty ambulating. Patient states initially he felt like he
'pulled a muscle' in his hamstring.  Pain also in calf. He was
having difficulty moving legs and had numbness of his right foot
causing difficulty ambulating and causing him to fall. Also
states difficulty
moving left leg, feels like he has to pull his leg forward.
Patient also claims he syncopized today.

MEDICAL HISTORY: PMH:
-coronary artery disease
-EF 20%
-complete heart block, pacer dependent
-diabetes mellitus type 2
-obstructive sleep apnea on CPAP
-history of syncope
-hypertension
-benign prostatic hypertrophy
-peripheral vascular disease
-hiatal hernia
-Meniere's disease
-psoriasis
-cervical and lumbar spinal stenosis
-GERD
-right eye blindness

MEDICATION ON ADMISSION: Aspirin 81, Lipitor 40', Diovan 40', Coreg 12.5", Flomax 0.4',
Actos 15', Advair 250/50', Gemfibrozil 600", Omeprazole 20",
Ranitidine 150', Glyburide 10", Nasonex 1", Albuterol, Metformin
500 QID, Lasix 20'

ALLERGIES: Procardia / Benadryl

PHYSICAL EXAM: PE:
97.5  96  138/96  96RA
A&Ox3
Obese male in no acute distress
Regular rate/rhythm
CTA b/l
Abd obese, +bs, non-distended, non-tender, unable to palpate
abdominal aorta.
RLE minimal  lower leg.  Motor diminished in LE
Able to move toes b/l but diminished in Rt
VAC dressing in place. Fasciotomy site is c/d/i
B/l popliteal aneurysms.
Pulses:
    F   [**Doctor Last Name **]   PT  DP
R   2+   3+   1+  Trip
L   2+   3+   1+  1+

FAMILY HISTORY: No family history of cardiac disease

SOCIAL HISTORY: Lives alone, widowed, Tobacco - quit cigars 30 yrs ago, No eTOH,
no illicits 

### Response:
{'Aneurysm of artery of lower extremity,Acute on chronic systolic heart failure,Arterial embolism and thrombosis of lower extremity,Traumatic compartment syndrome of lower extremity,Acute posthemorrhagic anemia,Hemorrhage complicating a procedure,Atrioventricular block, complete,Atherosclerosis of native arteries of the extremities with intermittent claudication,Coronary atherosclerosis of native coronary artery,Aortocoronary bypass status,Cardiac pacemaker in situ,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Legal blindness, as defined in U.S.A.,Esophageal reflux,Unspecified fall,Personal history of tobacco use'}
