CHIEF COMPLAINT: elective toe amputation and ulcer debridement

PRESENT ILLNESS: 66 yo M with ESRD on HD, CHF, COPD and severe PVD originally
admitted for right 1st and 2nd toe amputation with pre-op
pneumonia, and post-op loculated pleural effusions and a fib
with RVR.
.
The patient initially was admitted to the [**First Name3 (LF) 1106**] surgery
service for right 1st and 2nd toe amputations as well as right
lower leg ulcer debridement with VAC dressing placement on
[**2136-4-11**] On pre-op testing the patient was found to have a right
middle lobe pneumonia. Subsequent CT chest on [**2136-4-11**] revealed
bilateral loculated pleural effusions and pneumonia. He received
multiple antibiotics including nafcillin, clindamycin,
vancomycin and levofloxacin. The patient had a CT guided
thoracentesis with pigtail catheter placement on [**2136-4-13**].
Cultures on this fluid to date are without growth. Sputum
culture has growth only from [**2136-4-11**] with moraxella. The
patient was transitioned to vancomycin and zosyn and is now on
approximately day 6 of an expected 10 day course of zosyn
monotherapy.
.
On post-op day #2 the patient developed a fib with RVR with a
rate to the 130-150's. He developed hypotension to the systolic
70-80's and required transfer for the medical ICU. The patient
transiently required pressors. He was started on an amiodarone
load on [**2136-3-18**].
.
On the day of transfer from the ICU to the floor, the patient
underwent PICC line placement which failed and ended in midline
placement. He is scheduled to undergo revision by IR tomorrow.
In addition, he made his code status DNR/DNI by ICU team report.

MEDICAL HISTORY: ESRD on HD (on Tue-Thurs-Sat schedule)
PVD
HTN
CHF sys/diastolic(EF 55%)
COPD
Crohn's
chronic anemia
hyperlipidemia
CAD/MI/PCI in [**2097**]'s
Paroxysmal AFib
.
PSH: left axillary-bifem bpg [**7-/2128**] (rest pain), L BKA [**12-24**] trauma,

MEDICATION ON ADMISSION: Oxygen 2L/min
Carvedilol 25 [**Hospital1 **]
Omeprazole 20 [**Hospital1 **]
Asacol 1200 tid
Phoslo 3 caps tid
Alprazolam [**Hospital1 **]
Buspar [**Hospital1 **]
Zoloft qhs
EC-ASA 325 qd
Nitro 0.4 sl prn
Fe pills
.

ALLERGIES: Methadone / Dilaudid

PHYSICAL EXAM: In ICU:
Vitals: 95.8 84/50 68 20 95% 2L NC
GEN: NAD, appearing older than stated age
HEENT: EOMI, PERRL. MM dry.
Lungs: Diffuse rhonchi with bronchial breath sounds in the R
middle lung field.
Heart: RRR S1, S2, no MRG
Abdomen: soft NT, ND, L-sided axillary-fem bypass palpable
[**Month/Year (2) **] AKA
[**Month/Year (2) **] 2+ edema at ankle, necrotic [**11-23**] toes, open wound of dorsal
foot, open wound with moderate purulence of anterior shin
.
On transfer from the ICU:
PE 95.6-96.2 68-104 84-110/40-60 13 99% 2L NC I/O: +315 in 24
hrs, 6.5L length of stay
Gen: NAD, comfortable.
HEENT: PERRL.
CV: Systolic ejection murmur loudest at the right sternal
border. Regular rate and rhythm.
Pulm: Coarse crackles in bilateral lung fields.
Abd: Soft, nontender, no organomegaly.
Ext: S/p Left BKA, VAC dressing in place in right shin. Surgical
wound dressing in place over right 1st and 2nd toes. Large [**Month/Day (2) **]
bullae.
.

FAMILY HISTORY: Mother died of gastric cancer in her 80's. Father died at
85 from ESRD. # siblings, one died of liver disease. Married
with
4 children.

SOCIAL HISTORY: see previous d/c summeries
Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Ulcer of ankle,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Pneumonia, organism unspecified,Chronic combined systolic and diastolic heart failure,Regional enteritis of unspecified site,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Above knee amputation status
Ath ext ntv art gngrene,End stage renal disease,Ulcer of ankle,Septicemia NOS,Severe sepsis,Septic shock,Pleural effusion NOS,Pneumonia, organism NOS,Chr syst/diastl hrt fail,Regional enteritis NOS,Chr airway obstruct NEC,Atrial fibrillation,Anemia in chr kidney dis,Hyperlipidemia NEC/NOS,Status amput above knee
Admission Date:  [**2136-4-10**]              Discharge Date:   [**2136-4-21**]

Date of Birth:  [**2069-9-8**]             Sex:   M

Service: MEDICINE

Allergies:
Methadone / Dilaudid

Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
elective toe amputation and ulcer debridement

Major Surgical or Invasive Procedure:
PROCEDURE PERFORMED:
1. Amputation of the first and second digits of the right
    foot.
2. Debridement of right lower extremity anterior ulcer.
.
PICC line Placement


History of Present Illness:
66 yo M with ESRD on HD, CHF, COPD and severe PVD originally
admitted for right 1st and 2nd toe amputation with pre-op
pneumonia, and post-op loculated pleural effusions and a fib
with RVR.
.
The patient initially was admitted to the [**First Name3 (LF) 1106**] surgery
service for right 1st and 2nd toe amputations as well as right
lower leg ulcer debridement with VAC dressing placement on
[**2136-4-11**] On pre-op testing the patient was found to have a right
middle lobe pneumonia. Subsequent CT chest on [**2136-4-11**] revealed
bilateral loculated pleural effusions and pneumonia. He received
multiple antibiotics including nafcillin, clindamycin,
vancomycin and levofloxacin. The patient had a CT guided
thoracentesis with pigtail catheter placement on [**2136-4-13**].
Cultures on this fluid to date are without growth. Sputum
culture has growth only from [**2136-4-11**] with moraxella. The
patient was transitioned to vancomycin and zosyn and is now on
approximately day 6 of an expected 10 day course of zosyn
monotherapy.
.
On post-op day #2 the patient developed a fib with RVR with a
rate to the 130-150's. He developed hypotension to the systolic
70-80's and required transfer for the medical ICU. The patient
transiently required pressors. He was started on an amiodarone
load on [**2136-3-18**].
.
On the day of transfer from the ICU to the floor, the patient
underwent PICC line placement which failed and ended in midline
placement. He is scheduled to undergo revision by IR tomorrow.
In addition, he made his code status DNR/DNI by ICU team report.

.
Currently the patient complains of persistent shortness of
breath and lower extremity pain.


Past Medical History:
ESRD on HD (on Tue-Thurs-Sat schedule)
PVD
HTN
CHF sys/diastolic(EF 55%)
COPD
Crohn's
chronic anemia
hyperlipidemia
CAD/MI/PCI in [**2097**]'s
Paroxysmal AFib
.
PSH: left axillary-bifem bpg [**7-/2128**] (rest pain), L BKA [**12-24**] trauma,

L AKA for ischemia gangrene, right AVF with revision, right
CFA-BK [**Doctor Last Name **] with NRSVG in [**7-29**] with 4 compartment fasciotomy in
[**7-29**], appendix, rotator cuff repair, bladder surgery


Social History:
see previous d/c summeries


Family History:
Mother died of gastric cancer in her 80's. Father died at
85 from ESRD. # siblings, one died of liver disease. Married
with
4 children.


Physical Exam:
In ICU:
Vitals: 95.8 84/50 68 20 95% 2L NC
GEN: NAD, appearing older than stated age
HEENT: EOMI, PERRL. MM dry.
Lungs: Diffuse rhonchi with bronchial breath sounds in the R
middle lung field.
Heart: RRR S1, S2, no MRG
Abdomen: soft NT, ND, L-sided axillary-fem bypass palpable
[**Month/Year (2) **] AKA
[**Month/Year (2) **] 2+ edema at ankle, necrotic [**11-23**] toes, open wound of dorsal
foot, open wound with moderate purulence of anterior shin
.
On transfer from the ICU:
PE 95.6-96.2 68-104 84-110/40-60 13 99% 2L NC I/O: +315 in 24
hrs, 6.5L length of stay
Gen: NAD, comfortable.
HEENT: PERRL.
CV: Systolic ejection murmur loudest at the right sternal
border. Regular rate and rhythm.
Pulm: Coarse crackles in bilateral lung fields.
Abd: Soft, nontender, no organomegaly.
Ext: S/p Left BKA, VAC dressing in place in right shin. Surgical
wound dressing in place over right 1st and 2nd toes. Large [**Month/Day (2) **]
bullae.
.


Pertinent Results:
[**2136-4-10**] 05:45PM BLOOD WBC-12.2* RBC-3.54* Hgb-8.9* Hct-29.0*
MCV-82 MCH-25.1* MCHC-30.6* RDW-17.8* Plt Ct-300
[**2136-4-12**] 12:04AM BLOOD WBC-10.6 RBC-3.32* Hgb-8.4* Hct-27.8*
MCV-84 MCH-25.2* MCHC-30.1* RDW-16.5* Plt Ct-226
[**2136-4-13**] 03:52AM BLOOD WBC-23.6*# RBC-4.30* Hgb-10.4*#
Hct-38.5*# MCV-89 MCH-24.1* MCHC-26.9* RDW-16.1* Plt Ct-388#
[**2136-4-14**] 04:20AM BLOOD WBC-39.5*# RBC-3.86* Hgb-9.2* Hct-33.0*
MCV-86 MCH-24.0* MCHC-28.0* RDW-16.6* Plt Ct-296
[**2136-4-15**] 04:52AM BLOOD WBC-23.5* RBC-3.78* Hgb-9.2* Hct-32.4*
MCV-86 MCH-24.3* MCHC-28.4* RDW-16.8* Plt Ct-302
[**2136-4-17**] 04:09AM BLOOD WBC-9.3 RBC-3.52* Hgb-8.6* Hct-30.8*
MCV-88 MCH-24.4* MCHC-27.8* RDW-17.0* Plt Ct-222
[**2136-4-18**] 06:50AM BLOOD WBC-10.4 RBC-3.63* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.1* MCHC-29.7* RDW-18.9* Plt Ct-250
[**2136-4-19**] 06:00AM BLOOD WBC-9.7 RBC-3.75* Hgb-9.3* Hct-32.3*
MCV-86 MCH-24.7* MCHC-28.7* RDW-17.9* Plt Ct-254
[**2136-4-20**] 06:30AM BLOOD WBC-10.3 RBC-3.69* Hgb-9.3* Hct-31.2*
MCV-85 MCH-25.2* MCHC-29.8* RDW-19.8* Plt Ct-281
[**2136-4-21**] 04:07AM BLOOD WBC-14.3* RBC-3.61* Hgb-9.1* Hct-30.7*
MCV-85 MCH-25.3* MCHC-29.8* RDW-19.7* Plt Ct-347
[**2136-4-10**] 05:45PM BLOOD Neuts-84.9* Lymphs-7.6* Monos-5.8 Eos-1.6
Baso-0.2
[**2136-4-13**] 03:52AM BLOOD Neuts-83* Bands-0 Lymphs-13* Monos-2
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2136-4-19**] 06:00AM BLOOD Neuts-70 Bands-0 Lymphs-13* Monos-9 Eos-2
Baso-1 Atyps-0 Metas-2* Myelos-3*
[**2136-4-12**] 08:33PM BLOOD PT-16.4* PTT-45.2* INR(PT)-1.5*
[**2136-4-20**] 06:30AM BLOOD PT-18.6* PTT-34.5 INR(PT)-1.7*
[**2136-4-21**] 04:07AM BLOOD PT-15.2* PTT-32.3 INR(PT)-1.3*
[**2136-4-10**] 05:45PM BLOOD Glucose-142* UreaN-26* Creat-4.7* Na-141
K-3.7 Cl-98 HCO3-28 AnGap-19
[**2136-4-12**] 07:01PM BLOOD Glucose-108* UreaN-19 Creat-3.6*# Na-141
K-4.0 Cl-105 HCO3-22 AnGap-18
[**2136-4-21**] 04:07AM BLOOD Glucose-88 UreaN-21* Creat-4.9*# Na-140
K-4.3 Cl-100 HCO3-29 AnGap-15
[**2136-4-21**] 04:07AM BLOOD ALT-31 AST-17 LD(LDH)-172 AlkPhos-277*
TotBili-0.7
[**2136-4-14**] 04:20AM BLOOD Lipase-58
[**2136-4-19**] 06:00AM BLOOD GGT-238*
[**2136-4-11**] 01:10AM BLOOD CK-MB-NotDone cTropnT-0.79*
[**2136-4-11**] 09:10AM BLOOD CK-MB-NotDone cTropnT-0.74*
[**2136-4-18**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.38*
[**2136-4-18**] 11:40PM BLOOD CK-MB-NotDone cTropnT-0.40*
[**2136-4-19**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.45*
[**2136-4-12**] 09:48AM BLOOD TotProt-6.1* Albumin-3.0* Globuln-3.1
[**2136-4-14**] 04:20AM BLOOD TotProt-6.1* Albumin-2.9* Globuln-3.2
Calcium-9.4 Phos-7.5* Mg-2.0
[**2136-4-19**] 06:00AM BLOOD Albumin-2.9* Calcium-10.1 Phos-4.6*
Mg-1.7
[**2136-4-21**] 04:07AM BLOOD Calcium-10.0 Phos-4.6* Mg-1.6
[**2136-4-20**] 07:00AM BLOOD ANCA-PND
[**2136-4-17**] 04:09AM BLOOD Vanco-13.8
[**2136-4-14**] 04:20AM BLOOD Vanco-5.2*
[**2136-4-12**] 07:01PM BLOOD HoldBLu-HOLD
[**2136-4-14**] 10:37PM BLOOD Lactate-1.4
Imaging:
PREOP PA AND LATERAL CHEST, [**2136-4-10**]
IMPRESSION:
1. Dense right middle lobe consolidation, new since [**8-28**],
likely pneumonic.
2. CHF with interstitial edema; new small right pleural effusion
may relate to either process.
.
CT CHEST W/O CONTRAST  [**2136-4-11**] 4:23 AM
IMPRESSION: Bilateral loculated pleural effusions, right more
than left. Right lower lobe and middle lobe _____ pneumonia.
Moderate apical emphysema. Moderate mediastinal adenopathy.
.
IMPRESSION:
CT THORACENTESIS W/TUBE PLACMENT  [**2136-4-13**] 2:49 PM
1. Successful CT-guided subcutaneous catheter drainage
placement.
2. Incidental 6 mm right middle lobe pulmonary nodule and
emphysema.
_____ catheter care and findings of this _____ pulmonary nodule
discussed with Dr. [**Last Name (STitle) **] at 4:30 p.m. on [**2136-4-13**].
.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT  [**2136-4-14**] 8:20 PM
IMPRESSION:
1. Ascites and pulsatile flow within the portal vein which may
relate to congestive heart failure.
2. Extensive sludge within the gallbladder (which may relate to
the patient's overall clinical status), but no evidence of acute
cholecystitis.
.
CHEST (PORTABLE AP)  [**2136-4-14**] 7:03 AM
IMPRESSION: New right-sided chest tube. No evidence of
pneumothorax. Interval improvement in right pleural effusion
with residual small amount of fluid remaining in the right major
fissure.
.
CHEST (PORTABLE AP)  [**2136-4-16**] 3:22 AM
Portable AP chest radiograph was compared to [**2136-4-14**],
obtained at 2:18 p.m.
The pigtail catheter inserted in the upper pleural space in the
right upper lobe is unchanged. There is no interval change in
small amount of intrafissural pleural fluid on the right as well
as there is no change in the right basal areas of atelectasis.
There is interval progression of the [**Year (4 digits) 1106**] engorgement in the
left perihilar area which may represent mild volume overload
with asymmetric distribution due to patient's position.
Bibasilar retrocardiac atelectasis are unchanged. No
pneumothorax or left effusion is demonstrated.
.
ECG: Study Date of [**2136-4-10**]  9:28:38 PM
Sinus rhythm. Left ventricular hypertrophy with secondary ST-T
wave changes although myocardial ischemia cannot be ruled out.
Compared to the previous tracing of [**2135-9-15**] left ventricular
hypertrophy is more prominent and ST segment depressions in the
lateral leads are also more prominent. TRACING #1
.
ECG: Study Date of [**2136-4-12**]  9:45:50 AM
Atrial fibrillation with rapid ventricular response. Left
ventricular
hypertrophy. ST segment depression in leads V4-V6 which may be
related
to ischemia in the setting of left ventricular hypertrophy.
Clinical
correlation is suggested. Compared to the previous tracing of
[**2136-4-11**]
atrial fibrillation persists with a slightly slower ventricular
response.
.
ECG:Study Date of [**2136-4-18**]  1:06:08 PM
Atrial fibrillation with rapid ventricular response
Slight nonspecific intraventricular conduction delay
Nonspecific ST-T abnormalities
Since previous tracing of [**2136-4-12**], precordial QRS voltage less
prominent and ST-T wave changes decreased


Brief Hospital Course:
.
#Pneumonia: Patient found to have consolidation on admission,
with CT scan demonstrating loculated pleural effuions.  Sputum
cultures grew moraxella.  Patient was started on zosyn in house.
 Pig-tail catheter was placed to drain pleural effusion, and
cultures sent, but were without growth.  Moraxella felt to be an
unlikely pathogen, and patient was clinically improving on
zosyn, so was continued on this regimen for plan of full 14 day
course.  Pig-tail catheter was pulled on the floor after several
days and consultation with thoracics.  CXR following removal
demonstrated no pneumothorax, or significant reaccumulation of
fluid.  Plan to complete course of zosyn via picc as directed
below for full 14 days.
- Patient should have repeat CXR in [**1-24**] weeks time to document
resolution of his infiltrate.
- Please remove PICC upon completion of antibiotics.
.
#Atrial Fibrillation: Patient with A. Fib with RVR.  During
initial presentation did not tolerate this rhythm well and was
hypotensive requiring ICU stay.  As a result, patient was loaded
with amiodarone with goal of maintaining sinus rhythm.  Patient
tolerated amio load well and converted to sinus rhythm prior to
call-out from the ICU.  Did have [**11-23**] recurrence of A. Fib with
RVR on the floor that second of which required IV diltiazem to
break.  Patient was then started on low dose oral diltiazem for
rate control and remained in sinus rhythm for the remainder of
his hospital stay and 48 hours prior to discharge.  Plan to
continue amiodarone and diltiazem and f/u with outpatient [**Month/Day (2) 3390**]
for further management.  [**Month (only) 116**] not require long term amiodraone
for rhythm control and would consider discontinuation once his
pneumonia resolved.  Patient was not anticoagulated given he his
only indication was history of CHF.
.
#Hypotension: In setting of A. Fib with RVR and pneumonia.
Consistent with sepsis and unstable tachycardia.  Improved with
IVF's and rhythm control of his A. Fib.  Recommend monitoring
blood pressures by mentation, and L-forearm given AV fistula on
R-arm and picc proximal on the left.
.
#Amputation: Patient had successful 1st/2nd toe amputation with
debridement of his arterial ulcer.  Patient followed closely by
[**Month (only) 1106**] surgery in house who recommended outpatient follow-up
on discharge.  continue current wound-care and wound vac with
changes as directed.
.
#ESRD: Continued on HD in house.  Last session on day of
discharge - Saturday.  Continue T/H/Sat dialysis.
.
#Sacral Wound: Seen by wound care nurse in-house.  continue
dressing changes as directed.
.
#Coagulopathy: Mild coagulopathy in house on antibiotics.
Thought [**12-24**] to abx and nutriotional status.  Given PO vitamin K
with subsequent improvement.
.
#Transaminitis/Liver: Developed in-house.  Thought [**12-24**] to
hypotension/shock liver.  Normalized prior to discharge.  If
recurs would consider amiodarone toxicity.  Patient with
persistent Alk Phos elevation and GGT confirming it to be
hepatic and not from recent amputation.  Liver USD with biliary
sludge but no e/o cholecystitis/ductal dilation or other acute
pathology.  Would consider outpatient ERCP/MRCP in future given
h/o Crohn's disease and elevated alk phos - concern for PSC.
Sent P-ANCA in house - pending at time of discharge.
.
#Crohn's Disease: Continued on outpatient regimen.  No diarrhea.
#Leukocytosis: Mild new leukocytosis on day prior to discharge.
Vitals stable, afebrile, and without e/o infection.  If develops
diarrhea would have concern for C. Diff in this hospitalized, HD
patient on zosyn.
.
#Lung nodule: Patient had several CT scans in house.  On one
occasion a scan found a 6 mm right middle lobe pulmonary nodule.
 Recommend repeat evaluation w/ CT scan of this nodule as an
outpatient once acute pneumonia has resolved to better ascertain
size of nodule and assess for interval change.
# Chronic anemia. Stable, likely anemia of chronic disease.
# CAD s/p MI with PCI in the [**2097**]'s. No signs of active
ischemia.  ST depressions on EKG correlated with A. Fib w/ RVR
and enzymes stable.  Troponin mildly elevated but [**12-24**] to ESRD
and demand from rapid rate.
- Continue aspirin, nitroglycerin PRN.
.
# Psych. Continue buspirone and sertraline.  Stable.
# Prophylaxis. Heparin subcutaneously, PPI. Antiemetics PRN.
# Access: Tunnelled line, midline.  Please remove midline after
completion of antibiotics.
# Code: DNR/DNI
.


Medications on Admission:
Oxygen 2L/min
Carvedilol 25 [**Hospital1 **]
Omeprazole 20 [**Hospital1 **]
Asacol 1200 tid
Phoslo 3 caps tid
Alprazolam [**Hospital1 **]
Buspar [**Hospital1 **]
Zoloft qhs
EC-ASA 325 qd
Nitro 0.4 sl prn
Fe pills
.

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
6. Buspirone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.

9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
11. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 days: through [**4-23**], and then begin reduced dose
prescription.
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
to start on [**4-24**] after completion of loading phase.
15. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours): hold for SBP < 100.
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
17. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q12 () for 5 days: through [**2136-4-26**]
for total of 2 weeks.
18. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
19. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 1293**] - [**Location (un) **]

Discharge Diagnosis:
1st and second toe amputation
arterial ulcer
atrial fibrillation with rapid ventricular response
Pneumonia
Sepsis
End stage renal disease
Transaminitis
Sacral Ulcer


Discharge Condition:
Stable, non-weight bearing.


Discharge Instructions:
You were admitted to the hospital for a toe amputation.  On
admission it was found that you had a pneumonia. Your amputation
was performed successfully and your leg ulcer was surgically
debrided.  You were then treated for your pneumonia.
.
You also developed an irregular heart rate known as atrial
fibrillation and required the intensive care unit for monitoring
and control of your heart rate.  You were started on 2 new
medications for control of this heart rate - Amiodarone and
diltiazem.  You should discuss these with your doctor as you may
not need to take them long term.  In the short term however,
please take all new medications as directed upon leaving the
hospital.
.
Please call your physician should you develop any new lower
extremity pain, chest pain, palpitations, shortness of breath,
fever > 101 or any other symptom concerning to you.
.
You must take the following medications:
1.  Piperacillin/tazobactam - for total of 2 weeks through [**4-26**] [**2135**]
2.  Amiodarone - 400mg twice daily and then 200mg daily
thereafter.  Please do not discontinue this medication without
discussing it with your doctor.
3. Diltiazem 15mg by mouth every 6 hours.  Please do not
discontinue this medication without discussing it with your
doctor.
4.  Please continue all other medications as directed.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2389**] [**Last Name (NamePattern1) 2390**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2136-5-1**] 12:30 on the [**Location 74518**] [**Hospital Ward Name 121**] building,
Chest Disease Center, [**Location (un) 453**], [**Hospital1 **] building.  You will
see the NP [**Location (un) 1439**] or [**Female First Name (un) **]
Report to the [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **] Radiology
for a Chest X-Ray 45 minutes before your appointment.
..
Provider: [**Name10 (NameIs) **] Surgery -> [**2136-5-2**] at 11:45AM, with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**], [**Hospital Unit Name **] 110 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 5c,
([**Telephone/Fax (1) 14585**]
.
Provider: [**Name10 (NameIs) 3390**], [**Name11 (NameIs) 4392**],[**Name12 (NameIs) **] [**Name Initial (NameIs) **] [**Telephone/Fax (1) 74519**], please call for an
appointment in the next 1 month.
{'Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Ulcer of ankle,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Pneumonia, organism unspecified,Chronic combined systolic and diastolic heart failure,Regional enteritis of unspecified site,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,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: elective toe amputation and ulcer debridement

PRESENT ILLNESS: 66 yo M with ESRD on HD, CHF, COPD and severe PVD originally
admitted for right 1st and 2nd toe amputation with pre-op
pneumonia, and post-op loculated pleural effusions and a fib
with RVR.
.
The patient initially was admitted to the [**First Name3 (LF) 1106**] surgery
service for right 1st and 2nd toe amputations as well as right
lower leg ulcer debridement with VAC dressing placement on
[**2136-4-11**] On pre-op testing the patient was found to have a right
middle lobe pneumonia. Subsequent CT chest on [**2136-4-11**] revealed
bilateral loculated pleural effusions and pneumonia. He received
multiple antibiotics including nafcillin, clindamycin,
vancomycin and levofloxacin. The patient had a CT guided
thoracentesis with pigtail catheter placement on [**2136-4-13**].
Cultures on this fluid to date are without growth. Sputum
culture has growth only from [**2136-4-11**] with moraxella. The
patient was transitioned to vancomycin and zosyn and is now on
approximately day 6 of an expected 10 day course of zosyn
monotherapy.
.
On post-op day #2 the patient developed a fib with RVR with a
rate to the 130-150's. He developed hypotension to the systolic
70-80's and required transfer for the medical ICU. The patient
transiently required pressors. He was started on an amiodarone
load on [**2136-3-18**].
.
On the day of transfer from the ICU to the floor, the patient
underwent PICC line placement which failed and ended in midline
placement. He is scheduled to undergo revision by IR tomorrow.
In addition, he made his code status DNR/DNI by ICU team report.

MEDICAL HISTORY: ESRD on HD (on Tue-Thurs-Sat schedule)
PVD
HTN
CHF sys/diastolic(EF 55%)
COPD
Crohn's
chronic anemia
hyperlipidemia
CAD/MI/PCI in [**2097**]'s
Paroxysmal AFib
.
PSH: left axillary-bifem bpg [**7-/2128**] (rest pain), L BKA [**12-24**] trauma,

MEDICATION ON ADMISSION: Oxygen 2L/min
Carvedilol 25 [**Hospital1 **]
Omeprazole 20 [**Hospital1 **]
Asacol 1200 tid
Phoslo 3 caps tid
Alprazolam [**Hospital1 **]
Buspar [**Hospital1 **]
Zoloft qhs
EC-ASA 325 qd
Nitro 0.4 sl prn
Fe pills
.

ALLERGIES: Methadone / Dilaudid

PHYSICAL EXAM: In ICU:
Vitals: 95.8 84/50 68 20 95% 2L NC
GEN: NAD, appearing older than stated age
HEENT: EOMI, PERRL. MM dry.
Lungs: Diffuse rhonchi with bronchial breath sounds in the R
middle lung field.
Heart: RRR S1, S2, no MRG
Abdomen: soft NT, ND, L-sided axillary-fem bypass palpable
[**Month/Year (2) **] AKA
[**Month/Year (2) **] 2+ edema at ankle, necrotic [**11-23**] toes, open wound of dorsal
foot, open wound with moderate purulence of anterior shin
.
On transfer from the ICU:
PE 95.6-96.2 68-104 84-110/40-60 13 99% 2L NC I/O: +315 in 24
hrs, 6.5L length of stay
Gen: NAD, comfortable.
HEENT: PERRL.
CV: Systolic ejection murmur loudest at the right sternal
border. Regular rate and rhythm.
Pulm: Coarse crackles in bilateral lung fields.
Abd: Soft, nontender, no organomegaly.
Ext: S/p Left BKA, VAC dressing in place in right shin. Surgical
wound dressing in place over right 1st and 2nd toes. Large [**Month/Day (2) **]
bullae.
.

FAMILY HISTORY: Mother died of gastric cancer in her 80's. Father died at
85 from ESRD. # siblings, one died of liver disease. Married
with
4 children.

SOCIAL HISTORY: see previous d/c summeries 

### Response:
{'Atherosclerosis of native arteries of the extremities with gangrene,End stage renal disease,Ulcer of ankle,Unspecified septicemia,Severe sepsis,Septic shock,Unspecified pleural effusion,Pneumonia, organism unspecified,Chronic combined systolic and diastolic heart failure,Regional enteritis of unspecified site,Chronic airway obstruction, not elsewhere classified,Atrial fibrillation,Anemia in chronic kidney disease,Other and unspecified hyperlipidemia,Above knee amputation status'}
