CHIEF COMPLAINT: Ischemic toes of left foot, toes 1, 2 and
3.

PRESENT ILLNESS: This 76 year old male is
admitted with the history of peripheral vascular disease who
presents with a two to three week history of left foot
ischemia with mild cellulitis of the dorsal aspect of the MTP
joints of the first, second and third toes.  Denies any
constitutional symptoms.  He denies chest pain, shortness of
breath or rigors.  He has been followed by a Dr. [**Last Name (STitle) **] at
[**Hospital3 20284**] Center in [**Hospital1 189**] and was referred to Dr.
[**Last Name (STitle) **] for distal bypass of the lower extremity.  The
patient arrives with CD ROM of his left leg arteriogram and
is now admitted for further vascular care.

MEDICAL HISTORY: Hypertension, hypercholesterolemia,
history of coronary artery disease, silent myocardial
infarction, history of insulin dependent diabetes mellitus
type 2, history of peripheral vascular disease.

MEDICATION ON ADMISSION: Include Vancomycin, Levofloxacin
and Flagyl, Percocet, regular insulin sliding scale, Lipitor
40 mg daily, Digoxin 0.125 mg daily, metoprolol 100 mg
B.I.D., Folate 5 mg daily, Prazosin 1 mg B.I.D., aspirin 325
mg daily, Lantus insulin and Lasix, doses not recorded.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Is positive for mother who is diabetic,
brother with coronary artery disease and myocardial
infarction.

SOCIAL HISTORY: Occasional alcohol use.  He has not smoked
for 30 years.
Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Iron deficiency anemia secondary to blood loss (chronic),Accidental puncture or laceration during a procedure, not elsewhere classified,Retention of urine, unspecified,Accidental cut, puncture, perforation or hemorrhage during aspiration of fluid or tissue, puncture, and catheterization,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia
Ath ext ntv art gngrene,Ac osteomyelitis-ankle,Chr blood loss anemia,Accidental op laceration,Retention urine NOS,Acc cut/hem w catheteriz,DMII wo cmp nt st uncntr,Long-term use of insulin,Crnry athrscl natve vssl,Hypertension NOS,Pure hypercholesterolem
Name:  [**Known lastname 1974**],[**Known firstname 63**]                 Unit No:   [**Numeric Identifier 11111**]

Admission Date:  [**2177-3-11**]              Discharge Date:   [**2177-4-2**]

Date of Birth:  [**2100-11-7**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1546**]
Addendum:
[**2177-4-2**] d/c to rehabilitation. foley remains inplace until seen
in urology clinic with Dr. [**Last Name (STitle) **]. Please call for appointment
@ [**Telephone/Fax (1) 11112**]. Followup with Dr. [**Last Name (STitle) **] in 2 weeks. call
for appointment. [**Telephone/Fax (1) 5643**]

Discharge Disposition:
Extended Care

Facility:
Willow Manor - [**Hospital1 1612**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]

Completed by:[**2177-4-2**]

Unit No:  [**Numeric Identifier 61275**]
Admission Date: [**2177-3-11**]
Discharge Date: [**2177-4-2**]
Date of Birth:  [**2100-11-7**]
Sex:  M
Service:  VSU


CHIEF COMPLAINT:  Ischemic toes of left foot, toes 1, 2 and
3.

HISTORY OF PRESENT ILLNESS:  This 76 year old male is
admitted with the history of peripheral vascular disease who
presents with a two to three week history of left foot
ischemia with mild cellulitis of the dorsal aspect of the MTP
joints of the first, second and third toes.  Denies any
constitutional symptoms.  He denies chest pain, shortness of
breath or rigors.  He has been followed by a Dr. [**Last Name (STitle) **] at
[**Hospital3 20284**] Center in [**Hospital1 189**] and was referred to Dr.
[**Last Name (STitle) **] for distal bypass of the lower extremity.  The
patient arrives with CD ROM of his left leg arteriogram and
is now admitted for further vascular care.

PAST MEDICAL HISTORY:  Hypertension, hypercholesterolemia,
history of coronary artery disease, silent myocardial
infarction, history of insulin dependent diabetes mellitus
type 2, history of peripheral vascular disease.

PAST SURGICAL HISTORY:  Includes a right below knee
amputation in [**2168**] with common iliac stenting in [**2176-3-18**].

SOCIAL HISTORY:  Occasional alcohol use.  He has not smoked
for 30 years.

FAMILY HISTORY:  Is positive for mother who is diabetic,
brother with coronary artery disease and myocardial
infarction.

ALLERGIES:  Antibiotic allergies but patient does not
remember the [**Doctor Last Name 360**].  It was prescribed for cellulitis.

MEDICATIONS ON ADMISSION:  Include Vancomycin, Levofloxacin
and Flagyl, Percocet, regular insulin sliding scale, Lipitor
40 mg daily, Digoxin 0.125 mg daily, metoprolol 100 mg
B.I.D., Folate 5 mg daily, Prazosin 1 mg B.I.D., aspirin 325
mg daily, Lantus insulin and Lasix, doses not recorded.

PHYSICAL EXAMINATION:  Vital signs:  96.2, 134/68, 80, 20.
Oxygen saturation of 96 percent on room air.  General
appearance:  This is an alert and cooperative white male in
no acute distress.  Chest examination reveals a regular rate
and rhythm.  No murmur, gallop or rub.  Carotid pulses are 2
plus bilaterally.  Lungs are clear to auscultation
bilaterally.  Abdominal examination was soft, nontender.
Vascular examination:  Pulses - radials 2 plus, brachials 2
plus.  The right femoral and popliteal are palpable 1 plus.
On the left the femoral was 2 plus palpable and 1 plus
popliteal palpable on the left.  The dorsalis pedis and
posterior tibialis were absent by palpation and Doppler and
the dorsalis pedis on the left was triphasic and the
posterior tibialis on the left was monophasic signal.  The
peroneal on the left was a triphasic signal by Doppler.  On
the right it was absent.  The lower extremity showed left
first, second and third toes with ischemic changes.  The
second toe is with dry gangrene and cyanosis.  There is no
sensation to the toes.  There was no active purulent
drainage.  There is mild cellulitis of the dorsum of the
foot.

HOSPITAL COURSE:  The patient was a direct admit to the
hospital.  His admitting white count was 5.5, hematocrit
33.8, BUN 37, creatinine 2.2.  Urinalysis was negative.
Chest x-ray showed no infiltrates.  Electrocardiogram showed
a sinus rhythm with borderline left axis deviation, right
bundle branch block and old anteroseptal infarct.  The
inferior and lateral ST changes are nonspecific.

The patient was continued on antibiotics.  The patient was
ultrasound for graft conduit of both upper and lower
extremities.  Graft surveillance was obtained.  The patient
underwent a left femoral AP bypass graft.  He tolerated the
procedure well.  He was transferred to the Vascular Intensive
Care Unit for continued monitoring and care.  Surgery was
done on [**2177-3-18**].  Postoperatively he was extubated in the post
anesthesia care unit and transferred to the Vascular
Intensive Care Unit for continued care.  He was weaned off
his nitroglycerine which was required for systolic
hypotension.  Patient was transfused two units of red packed
cells and three units of fresh frozen plasma
intraoperatively.  His postoperative hematocrit was 29.3, BUN
19, creatinine 1.5.  The graft was palpable and the wounds
were clean, dry and intact.  Postoperative day one the
patient was no overnight events, afebrile.  His initial CK
was 138 with a troponin was .28.  His examination was
unchanged.  He had a palpable graft pulse on the left with a
palpable dorsalis pedis pulse and he is continued on his
preoperative medications.  His diet was advanced as tolerated
and his fluids were HEP-locked and serial CKs were obtained.

On postoperative day two patient had episodes of bigeminy but
he was hemodynamically stable.  He was afebrile.  His pulse
examination showed a palpable graft pulse with a triphasic
dorsalis pedis and posterior tibials.  Toes are with dry
gangrene.  He was begun on morphine PRN.  His Lopressor was
increased for rate control.  His Swan was converted to a
central line.  His Foley remained in place and he remained in
the Vascular Intensive Care Unit.  Cardiology was requested
to see the patient to make comment in regard to the elevated
troponin levels.  Dr. [**Last Name (STitle) **] saw the patient and felt that these
were not significant in the relationship of a patient with
chronic renal insufficiency.  They felt that an
echocardiogram should be obtained prior to discharge.
Otherwise continue current management.

Postoperative day three the patient remained afebrile.
Electrolytes were stable.  He required arginine dosing
adjustment at bedtime for low glucose during the night.  The
patient returned to surgery on [**2177-3-21**] and underwent an
amputation of toes 1, 2 and 3.  He tolerated the procedure
well and returned to the Vascular Intensive Care Unit for
continued monitoring and care.  He remained hemodynamically
stable.  His morphine was converted to Percocet.  His
Lopressor was adjusted to 100 mg t.i.d. with Digoxin 0.125
and aspirin.  His intravenous fluids were HEP-locked.  He
received Lasix 40 B.I.D.  His antibiotics were continued.
His Swan which initially had been planned for removal on
postoperative day two remained in place until [**2177-3-21**].  The
initial dressings at the toe amputation sites remained in
place until [**2177-3-24**].  Patient continued to be followed by the
[**Last Name (un) **] Service for glycemic control.  Ambulation was begun on
postoperative day five with nonweight bearing to the left
foot.  Initial dressings were removed on [**2177-3-24**].  Dressings
were changed B.I.D.  Foley was placed secondary to failure to
void.  Urology was consulted on [**2177-3-24**] for possible urethral
injury.  The patient failed to void on the initial catheter
removal and required replacement and it was at this time that
the urethral injury occurred.  Recommendations were that the
Foley should remain in place and patient should follow up
with urology on [**4-4**].  Flomax was started and Cipro 500 mg
B.I.D. was begun.  The patient was for follow up with Dr.
[**Last Name (STitle) **] of the urology service on [**2177-4-4**].  The patient should
make an appointment and call at [**Telephone/Fax (1) 277**].  Foley will
remain in place until seen in follow up by urology.  He will
be discharged with a leg bag.

The toe amputation site showed some wound edge necrosis.
Antibiotics were continued and adjusted according to his
cultures.  Initial wound cultures grew choanae bacterium
sparse in two colonies, probably enterococcus and staph coag
negative, rare growth.  Cultures taken [**2177-3-24**] were no growth
and finalized.  Patient was continued on his antibiotics.  He
returned to surgery on [**2177-3-28**] for transmetatarsal
amputation.  The patient tolerated the procedure well and was
placed on a Dilaudid PCA for analgesic control
postoperatively.  [**Last Name (un) **] continued to follow the patient.
His glycemic control was excellent.  Patient's pain improved
with a PCA.  Ambulation to a chair was begun on [**2177-3-29**] with
nonbearing on the left foot and a Multipodis splint at all
times.  Postoperative hematocrit at that time was 29.1.  BUN
21, creatinine 1.6.  Patient's antibiotics of Vancomycin and
Zosyn will be continued until discharge.  On [**2177-3-31**] he had
two more days of antibiotic therapy to continue.  He had a
total dose of 22 days of Vancomycin and ten days of Zosyn.
He remained afebrile.  Physical Therapy was to evaluate prior
to discharge and assess for discharge to home versus
rehabilitation and an addendum regarding their
recommendations will be made at the actual time of discharge.

DISCHARGE MEDICATIONS:  Prazosin 1 mg B.I.D., folic acid 1 mg
B.I.D., Digoxin 0.125 mcg daily, lovastatin 40 mg daily,
fludrocortisone acetate 0.1 mg daily, Oxycodone acetaminophen
5/325 mg tablets 1 to 2 q to 6 hours PRN for pain, Plavix 75
mg daily, aspirin 325 mg daily, metoprolol 100 mg t.i.d.,
Lasix 40 mg B.I.D., Colace 100 mg B.I.D., Dulcolax tablets 2
daily PRN, glargine 40 units q day, Humalog sliding scale.

DISCHARGE DIAGNOSIS:
1. Ischemic gangrenous toes left 1, 2 and 3, peripheral
   vascular disease.
2. Hypertension, controlled.
3. Type 2 diabetes insulin dependent, controlled.
4. Blood loss anemia, corrected.
5. Failure to void, urethral injury secondary to Foley
   catheter.
6. Coronary artery disease with elevated troponin levels.




                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]

Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D:  [**2177-3-31**] 14:33:41
T:  [**2177-3-31**] 16:08:57
Job#:  [**Job Number 61276**]
{'Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Iron deficiency anemia secondary to blood loss (chronic),Accidental puncture or laceration during a procedure, not elsewhere classified,Retention of urine, unspecified,Accidental cut, puncture, perforation or hemorrhage during aspiration of fluid or tissue, puncture, and catheterization,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia'}


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 toes of left foot, toes 1, 2 and
3.

PRESENT ILLNESS: This 76 year old male is
admitted with the history of peripheral vascular disease who
presents with a two to three week history of left foot
ischemia with mild cellulitis of the dorsal aspect of the MTP
joints of the first, second and third toes.  Denies any
constitutional symptoms.  He denies chest pain, shortness of
breath or rigors.  He has been followed by a Dr. [**Last Name (STitle) **] at
[**Hospital3 20284**] Center in [**Hospital1 189**] and was referred to Dr.
[**Last Name (STitle) **] for distal bypass of the lower extremity.  The
patient arrives with CD ROM of his left leg arteriogram and
is now admitted for further vascular care.

MEDICAL HISTORY: Hypertension, hypercholesterolemia,
history of coronary artery disease, silent myocardial
infarction, history of insulin dependent diabetes mellitus
type 2, history of peripheral vascular disease.

MEDICATION ON ADMISSION: Include Vancomycin, Levofloxacin
and Flagyl, Percocet, regular insulin sliding scale, Lipitor
40 mg daily, Digoxin 0.125 mg daily, metoprolol 100 mg
B.I.D., Folate 5 mg daily, Prazosin 1 mg B.I.D., aspirin 325
mg daily, Lantus insulin and Lasix, doses not recorded.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: Is positive for mother who is diabetic,
brother with coronary artery disease and myocardial
infarction.

SOCIAL HISTORY: Occasional alcohol use.  He has not smoked
for 30 years. 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,Acute osteomyelitis, ankle and foot,Iron deficiency anemia secondary to blood loss (chronic),Accidental puncture or laceration during a procedure, not elsewhere classified,Retention of urine, unspecified,Accidental cut, puncture, perforation or hemorrhage during aspiration of fluid or tissue, puncture, and catheterization,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Pure hypercholesterolemia'}
