CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: The patient is a 41 year old male with no significant past
medical history who presents with 1 day of increasing right
abdominal/flank pain. He reports it started yesterday afternoon
as a cramp in his right flank that persisted throughout the
night. In the morning, he went to work but the pain did not
subside so he presented to the emergency room. He describes the
pain as a somewhat sharp pain "like a stick" but not as sharp as
a knife. He has been able to tolerate POs although he hasn't
eaten much today because of loss of appetite. He has had normal
bowel movements and urination. He has not had nausea or vomiting
except after receiving large doses of pain medication in the ED.
He reports no subjective fever and was afebrile on arrival to
the ED but then spiked a fever to 102.4 at 6pm. He has not noted
any rashes or ecchymoses on any part of his body. He had a cold
about a week ago accompanies by some cervical lymphadenopathy
but this resolved before his abdominal pain started. He works as
a federal prosecutor in an office that is sometimes frequented
by prisoners. His only recent travel is to suburban [**State 33174**].
.
In the ED, his labs were notable for a WBC of 21.7 and INR of
1.3. Lactate was 1.9. Lytes and LFTs were normal. UA was
negative. CXR was unremarkable. Abdominal US showed a 4mm
gallbladder polyp but was otherwise unremarkable. D-dimer was
negative, but given the patient's continuing symptoms and new
fever, a CT torso was done to look for signs of infection. This
revealed an ill-defined wedge shaped area of low attenuation
within the periphery of the right hepatic lobe, which was
thought not to be of clinical significance; a neoplastic process
or infection could not be entirely excluded, however. The
patient received empiric Levaquin and Flagyl in the ED as well
as a total of 6mg IV morphine and 4mg IV Dilaudid. He was given
1g Tylenol for fever and a total of 4L IVF. He remained
tachycardic in the 100s-120s Given the patient's fever and
continuing pain, he was admitted for further workup and pain
control.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 103.3, 120, 114/60, 28, 95% 3L NC
General: uncomfortable appearing, well-developed, well-nourished
male lying in bed
HEENT: PERRL, EOMI, MMM, OP clear
Neck: no LAD, supple
Lungs: CTAB
CV: tachy, RR, nl S1S2
Abd: +BS, voluntary guarding, TTP RLQ
Ext: no c/c/e
.
ON ADMISION TO MEDICINE FLOOR
Vitals: 98.7, BP: 118/78, HR:84, RR:18, O2sat: 96-98% RA, Pain
[**4-4**].
GEN: younger than stated age, NAD, A&0*3
HEENT: PERRL, neck supple, single anterior right cervical lymph
node <1 cm, OP mild thrush on tongue, otherwise clear, EOMI,
PERRL
CHEST: CTA b/l, good excursion, no w/r/r
CARDIAC: RRR, S1, S2, no m/r/g
ABD: soft, nondistended, no hepatosplenomegaly, + BS, mild
diffuse lower abdominal tenderness, no [**Doctor Last Name **], mild CVA
tenderness
EXT: 2+ DP, 2+ radial, [**4-29**] UE biceps, triceps, deltoids. [**4-29**] LE
quads, hamstrings, plantar/dorsiflexion, no c/c/e

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Just moved into new apartment in [**Location (un) 577**], works as a
prosecuter,does not smoke, drinks 4-8 alcoholic drinks a week,
denies illicit substance use. Patient reports no recent sexual
activity in months. Mostly sexually active with women although
male sexual contact >10 years ago. HIV test 6 months ago was
negative per patient.  Recent travel to [**State 33174**], and contact
with young nipping dog. No recent exposure to Caves. Exposure to
dirt in [**State 9512**] over [**Holiday 1451**].
Other septicemia due to gram-negative organisms,Abscess of liver,Candidiasis of mouth,Severe sepsis,Iron deficiency anemia, unspecified
Gram-neg septicemia NEC,Abscess of liver,Thrush,Severe sepsis,Iron defic anemia NOS
Admission Date:  [**2114-12-20**]              Discharge Date:   [**2114-12-28**]

Date of Birth:  [**2073-5-1**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
abdominal pain


Major Surgical or Invasive Procedure:
Insertion of a central line

History of Present Illness:
The patient is a 41 year old male with no significant past
medical history who presents with 1 day of increasing right
abdominal/flank pain. He reports it started yesterday afternoon
as a cramp in his right flank that persisted throughout the
night. In the morning, he went to work but the pain did not
subside so he presented to the emergency room. He describes the
pain as a somewhat sharp pain "like a stick" but not as sharp as
a knife. He has been able to tolerate POs although he hasn't
eaten much today because of loss of appetite. He has had normal
bowel movements and urination. He has not had nausea or vomiting
except after receiving large doses of pain medication in the ED.
He reports no subjective fever and was afebrile on arrival to
the ED but then spiked a fever to 102.4 at 6pm. He has not noted
any rashes or ecchymoses on any part of his body. He had a cold
about a week ago accompanies by some cervical lymphadenopathy
but this resolved before his abdominal pain started. He works as
a federal prosecutor in an office that is sometimes frequented
by prisoners. His only recent travel is to suburban [**State 33174**].
.
In the ED, his labs were notable for a WBC of 21.7 and INR of
1.3. Lactate was 1.9. Lytes and LFTs were normal. UA was
negative. CXR was unremarkable. Abdominal US showed a 4mm
gallbladder polyp but was otherwise unremarkable. D-dimer was
negative, but given the patient's continuing symptoms and new
fever, a CT torso was done to look for signs of infection. This
revealed an ill-defined wedge shaped area of low attenuation
within the periphery of the right hepatic lobe, which was
thought not to be of clinical significance; a neoplastic process
or infection could not be entirely excluded, however. The
patient received empiric Levaquin and Flagyl in the ED as well
as a total of 6mg IV morphine and 4mg IV Dilaudid. He was given
1g Tylenol for fever and a total of 4L IVF. He remained
tachycardic in the 100s-120s Given the patient's fever and
continuing pain, he was admitted for further workup and pain
control.


Past Medical History:
none

Social History:
Just moved into new apartment in [**Location (un) 577**], works as a
prosecuter,does not smoke, drinks 4-8 alcoholic drinks a week,
denies illicit substance use. Patient reports no recent sexual
activity in months. Mostly sexually active with women although
male sexual contact >10 years ago. HIV test 6 months ago was
negative per patient.  Recent travel to [**State 33174**], and contact
with young nipping dog. No recent exposure to Caves. Exposure to
dirt in [**State 9512**] over [**Holiday 1451**].


Family History:
non-contributory

Physical Exam:
VS: 103.3, 120, 114/60, 28, 95% 3L NC
General: uncomfortable appearing, well-developed, well-nourished
male lying in bed
HEENT: PERRL, EOMI, MMM, OP clear
Neck: no LAD, supple
Lungs: CTAB
CV: tachy, RR, nl S1S2
Abd: +BS, voluntary guarding, TTP RLQ
Ext: no c/c/e
.
ON ADMISION TO MEDICINE FLOOR
Vitals: 98.7, BP: 118/78, HR:84, RR:18, O2sat: 96-98% RA, Pain
[**4-4**].
GEN: younger than stated age, NAD, A&0*3
HEENT: PERRL, neck supple, single anterior right cervical lymph
node <1 cm, OP mild thrush on tongue, otherwise clear, EOMI,
PERRL
CHEST: CTA b/l, good excursion, no w/r/r
CARDIAC: RRR, S1, S2, no m/r/g
ABD: soft, nondistended, no hepatosplenomegaly, + BS, mild
diffuse lower abdominal tenderness, no [**Doctor Last Name **], mild CVA
tenderness
EXT: 2+ DP, 2+ radial, [**4-29**] UE biceps, triceps, deltoids. [**4-29**] LE
quads, hamstrings, plantar/dorsiflexion, no c/c/e


Pertinent Results:
STUDIES:
CXR [**2114-12-26**] bilateral patchy hilar opacities, increased vascular
congestion, mild peripheral honeycombing and reticular nodular
opacities.
.
CT CHEST [**12-25**]: IMPRESSION Diffuse, multifocal ground-glass and
nodular opacities, primarily in a perihilar distribution with
associated bilateral pleural effusions, right greater than left.
 The primary differential diagnosis includes atypical infections
such as mycoplasma pneumoniae.  If the patient is
immunocompromised, other infections such as pneumocystis
jiroveci could be considered.  Although the pattern is less
compatible with gram negative rod bacterial pneumonia, it
remains a diagnostic consideration. If the findings are chronic,
other diagnostic possibilities include interstitial lung
disease. (NOT COMPARED TO CT TORSO [**12-21**]).
.
US GUIDED DRAINAGE LIVER ABSCESS [**12-25**]: IMPRESSION: 1.  Patient
status post ultrasound-guided aspiration of a hepatic abscess
without complication.
.
MRI ABDOMEN W W/O CONTRAST [**12-23**]: IMPRESSION: 1. 1.9 cm right
hepatic lobe abscess, demonstrating peripheral
enhancement/hyperemia and central necrosis. 2. Worsening
effusions and airspace disease at the bases bilaterally, likely
reactive.
.
U/S Liver [**2114-12-28**]:IMPRESSION:1. Heterogeneous area in segment
VI-VII of the liver, which is slightly smaller and corresponds
with the previously aspirated abscess. No residual fluid
collection identified. No new worrisome findings identified. 2.
Persistent right pleural effusion.
.
CT SINUSES [**2114-12-23**]: IMPRESSION: 1.  Visualized portions of the
upper lungs demonstrate patchy opacities, pleural effusions, and
septal thickening.  While these findings may all be secondary to
pulmonary edema, superimposed multifocal pneumonia is an
important consideration and chest radiographs and/or cross
sectional imaging
is recommended. 2.  Mildly prominent adenoids and tonsils
bilaterally without evidence for abscess.
.
NECK ULTRASOUND 1/2/08:1. Limited neck ultrasound demonstrating
patent internal jugular veins bilaterally without evidence of
clot.
2. No soft tissue fluid collections detected in the neck at the
level of the thyroid gland.
.
ON ADMISSION:
[**2114-12-20**] 12:15PM   GLUCOSE-101 UREA N-14 CREAT-1.1 SODIUM-141
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2114-12-20**] 12:15PM   estGFR-Using this
[**2114-12-20**] 12:15PM   ALT(SGPT)-26 AST(SGOT)-25 ALK PHOS-73
AMYLASE-75 TOT BILI-0.6
[**2114-12-20**] 12:15PM   LIPASE-43
[**2114-12-20**] 12:24PM   LACTATE-1.9
[**2114-12-20**] 12:15PM   WBC-21.7* RBC-4.95 HGB-15.4 HCT-44.7 MCV-90
MCH-31.1 MCHC-34.4 RDW-12.6
[**2114-12-20**] 12:15PM   NEUTS-74.9* LYMPHS-20.8 MONOS-3.2 EOS-0.3
BASOS-0.8
[**2114-12-20**] 12:15PM   PLT COUNT-433
[**2114-12-20**] 12:15PM   PT-14.6* PTT-30.6 INR(PT)-1.3*
[**2114-12-20**] 12:15PM   D-DIMER-123
[**2114-12-20**] 12:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2114-12-20**] 12:45PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
.
ON DISCHARGE
[**2114-12-28**] 05:25AM BLOOD WBC-9.4 RBC-4.18* Hgb-12.6* Hct-36.7*
MCV-88 MCH-30.2 MCHC-34.3 RDW-12.9 Plt Ct-417
[**2114-12-28**] 05:25AM BLOOD PT-14.8* INR(PT)-1.3*
[**2114-12-28**] 05:25AM BLOOD Glucose-80 UreaN-9 Creat-0.7 Na-144 K-3.9
Cl-109* HCO3-25 AnGap-14
[**2114-12-28**] 05:25AM BLOOD ALT-83* AST-64* AlkPhos-61 TotBili-0.4
[**2114-12-27**] 05:30AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.5 Mg-2.1
.
WORK-UP
[**2114-12-21**] 11:05AM BLOOD calTIBC-238* VitB12-648 Folate-11.1
Ferritn-287 TRF-183*
[**2114-12-21**] 11:05AM BLOOD CRP-72.0*
[**2114-12-20**] 12:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HAV-NEGATIVE
[**2114-12-21**] 11:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2114-12-21**] 12:50PM BLOOD ESR-20*
.
MICROBIOLOGY
     ABSCESS     Site: LIVER

   GRAM STAIN (Final [**2114-12-24**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Final [**2114-12-27**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2114-12-30**]):    NO GROWTH.

   ACID FAST SMEAR (Final [**2114-12-26**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Pending):

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
CMV VL not detected, CMV IgG +, CMV IgM neg
.
[**2114-12-20**] 12:15 pm BLOOD CULTURE

                            **FINAL REPORT [**2114-12-26**]**

   Blood Culture, Routine (Final [**2114-12-26**]):
      FUSOBACTERIUM SPECIES.    BETA LACTAMASE NEGATIVE.

   Anaerobic Bottle Gram Stain (Final [**2114-12-22**]):
      REPORTED BY PHONE TO [**Last Name (NamePattern4) 76662**] RN. 02:55.
      GRAM NEGATIVE ROD(S).
All other blood cultures negative.
.
[**12-25**], [**12-26**], [**2114-12-27**] sputum negative PJP.
.
[**2114-12-27**] 11:13 am STOOL     CONSISTENCY: SOFT      Source:
Stool.

                            **FINAL REPORT [**2114-12-28**]**

   MICROSPORIDIA STAIN (Final [**2114-12-28**]):    NO MICROSPORIDIUM
SEEN.

   Cryptosporidium/Giardia (DFA) (Final [**2114-12-28**]):
      NO CRYPTOSPORIDIUM OR GIARDIA SEEN.

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2114-12-27**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).
.
[**2114-12-23**] Monospot negative
.
13/20/07 Throat NO NEISSERIA GONORRHOEAE, +YEAST
.
[**12-23**], [**12-24**] Urine Cultures: negative

Brief Hospital Course:
41 year old male with no significant past medical history
presented with abdominal pain found to have gram negative rod
septicemia and increasing oxygen requirement. Upon admission to
medicine, he was treated with IV antibiotics, pain control and
overnight decompensated with increasing oxygen requirement and
SBP to 80s. He was transferred to the medicine intensive care
unit and discovered to have gram negative rod sepsis.
.
Medicine intensive care unit course:  Patient was admitted to
the medicine intensive care unit. Blood cultures were positive
for gram negative rods, later speciated as Fusobacterium, and
the patient was treated with levofloxacin/Flagyl and aggressive
rehydration. An MRI was conducted to evaluate the low
attenuation wedge lesion in the right hepatic lobe of the liver
which showed a 1.9 cm right hepatic lobe abscess, demonstrating
peripheral enhancement/hyperemia and central necrosis. The
patient continued to be febrile up to 104.5 and his antibiotics
were broadened to vancomycin/Zosyn/Flagyl. Subsequently the
abscess was aspirated under ultrasound guidance [**10-25**], although
the abscess cultures have been negative. The patient defervesced
[**2114-12-25**] and felt much improved. The patient's pain in his right
upper quadrant during this time was treated with oxycodone and
he was weaned to Tylenol and ibuprofen.
.
In the setting of this gram negative rod septicemia, the patient
developed a worsening oxygen requirement and at one point he was
maintained on a non-rebreather. Patient's chest x-ray revealed
cardiomegaly, evidence of vascular congestion and patchy
infiltrates. It was felt that the congestions was due to a
capillary leak syndrome in the setting of sepsis. The patient
was gradually weaned off oxygen and has returned to 96-98% on
room air. The pulmonary infiltrates remained a potential source
for infection and serial sputum testing for Pneumocystis
jirvovecii was initiated which was negative. He was also
evaluated with CT sinuses as possible source for pulmonary
disease or liver abscess. The CT was negative for any sinus
processes.
.
Infectious disease and hepatology were consulting services. Of
note, the patient did develop oral thrush while in the unit. He
has refused HIV testing; he reports a negative HIV test 6 months
ago. The patient was transferred to the floor for further
work-up of his pulmonary status and antibiotics management. At
the time of transfer he was afebrile *24 hours, able to tolerate
POs and had resolved his oxygen requirement.
.
Upon transfer to floor, patient states he has been doing well.
He feels weak from his illness. Denies fevers, chills, vomiting,
constipation, chest pain, shortness of breath. Patient does have
occasional nausea. Endorsed [**2-26**] loose stools per day. He
continues to experience pain which he describes as diffuse and
associates with his prolonged inactivity. Patient is eager to go
home to his new apartment. His father has traveled from [**State 33174**]
to assist.
.
The patient's antibiotics were transitioned to levofloxacin and
Flagyl. The patient remained afebrile, and his white blood cell
count continued to improve. The patient was discharged to
complete a 30 day course of levofloxacin and Flagyl for his
liver abscess. The patient's neck was re-imaged by ultrasound
given Fusobacterium can be associated with vein thrombosis, but
the imaging was negative. Follow-up imaging revealed no
drainable fluid collection and it was recommended that the
imaging be repeated in 3 months.
.
Given the improvement in the patient's status, his pulmonary
disease was felt to be  consistent with capillary leak with
underlying lung disease. His Pneumocystis jirvovecii work-up was
negative. The patient did have a dry non-productive cough worse
in the am and associate with post nasal drip which was treated
with cough suppressants for a presumed viral etiology. He was
discharged with repeat CT chest and pulmonary function tests in
6 weeks and pulmonary follow-up.
.
The patient was discovered to have an iron deficiency anemia
raising suspicious for a gastrointestinal source for his
fusobacterium sepsis. He also reports a 20 pound weight loss
which he attributed the death of his dog. The patient will  be
scheduled for an outpatient colonoscopy by his primary care
provider. [**Name10 (NameIs) **] was recommended that the patient start iron therapy
after completing his antibiotic course to prevent a decreased in
antibiotic effectiveness.
.
The patient reported loose stools after his medicine intensive
care unit stay; however stool studies were negative for
clostridium difficile, giardia, and Cryptosporidium. The
patient's loose stools resolved with a decease in his bowel
regimen. The patient also developed oral thrush which was
treated with nystatin. He will follow-up with his primary care
provider for further [**Name9 (PRE) 8019**] of his immunologic status.
.
At the time of discharge the patient was afebrile, with stable
vital signs and a good appetite. He has extensive follow-up with
primary care, infectious disease and pulmonology.

Medications on Admission:
none

Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours) for 26 days.
Disp:*78 Tablet(s)* Refills:*0*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 26 days.
Disp:*26 Tablet(s)* Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Gram Negative Rod Sepsis
Pulmonary Nodules
Liver Abscess s/p drainage
Iron Deficiency Anemia
Oral Thrush


Discharge Condition:
Stable


Discharge Instructions:
You were admitted for abdominal pain and were found to have an
infection in your blood and an abscess in your liver which was
drained. You were treated with antibiotics and improved. During
your hospitalization you had trouble breathing and were found to
have an abnormal CAT scan of your lungs. Your breathing
improved, but you will need to follow-up with a pulmonologist to
have your lung function evaluated after this hospitalization.
.
Please take all your medications as prescibed. Please keep all
your follow-up appointments.
.
If you develop fevers, chills, nausea, vomiting, increased
abdominal pain, chest pain, shortness of breath or any other
concerning symptoms please call your primary care doctor [**Telephone/Fax (1) 8693**] or go to the local emergency room.

Followup Instructions:
Please follow-up with [**Hospital3 **] to establish primary
care. You are scheduled to see Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2115-2-18**] 1:30 in the [**Hospital Ward Name 23**]
Building.
.
Please follow-up with infectious disease about your recent liver
infection. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5866**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2115-1-16**] 10:00. This appointment is in the [**Hospital Unit Name 3269**] on [**Hospital Ward Name 517**] in the Basement.
.
Please follow-up with pulmonary to evaluate your lungs. Please
arrive half an hour early at 7:30 am for your appointment with
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2115-2-8**] 8:00. This appointment is on the [**Hospital Ward Name 516**]
in [**Hospital Ward Name 23**] on the [**Location (un) 436**].
{'Other septicemia due to gram-negative organisms,Abscess of liver,Candidiasis of mouth,Severe sepsis,Iron deficiency 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: abdominal pain

PRESENT ILLNESS: The patient is a 41 year old male with no significant past
medical history who presents with 1 day of increasing right
abdominal/flank pain. He reports it started yesterday afternoon
as a cramp in his right flank that persisted throughout the
night. In the morning, he went to work but the pain did not
subside so he presented to the emergency room. He describes the
pain as a somewhat sharp pain "like a stick" but not as sharp as
a knife. He has been able to tolerate POs although he hasn't
eaten much today because of loss of appetite. He has had normal
bowel movements and urination. He has not had nausea or vomiting
except after receiving large doses of pain medication in the ED.
He reports no subjective fever and was afebrile on arrival to
the ED but then spiked a fever to 102.4 at 6pm. He has not noted
any rashes or ecchymoses on any part of his body. He had a cold
about a week ago accompanies by some cervical lymphadenopathy
but this resolved before his abdominal pain started. He works as
a federal prosecutor in an office that is sometimes frequented
by prisoners. His only recent travel is to suburban [**State 33174**].
.
In the ED, his labs were notable for a WBC of 21.7 and INR of
1.3. Lactate was 1.9. Lytes and LFTs were normal. UA was
negative. CXR was unremarkable. Abdominal US showed a 4mm
gallbladder polyp but was otherwise unremarkable. D-dimer was
negative, but given the patient's continuing symptoms and new
fever, a CT torso was done to look for signs of infection. This
revealed an ill-defined wedge shaped area of low attenuation
within the periphery of the right hepatic lobe, which was
thought not to be of clinical significance; a neoplastic process
or infection could not be entirely excluded, however. The
patient received empiric Levaquin and Flagyl in the ED as well
as a total of 6mg IV morphine and 4mg IV Dilaudid. He was given
1g Tylenol for fever and a total of 4L IVF. He remained
tachycardic in the 100s-120s Given the patient's fever and
continuing pain, he was admitted for further workup and pain
control.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 103.3, 120, 114/60, 28, 95% 3L NC
General: uncomfortable appearing, well-developed, well-nourished
male lying in bed
HEENT: PERRL, EOMI, MMM, OP clear
Neck: no LAD, supple
Lungs: CTAB
CV: tachy, RR, nl S1S2
Abd: +BS, voluntary guarding, TTP RLQ
Ext: no c/c/e
.
ON ADMISION TO MEDICINE FLOOR
Vitals: 98.7, BP: 118/78, HR:84, RR:18, O2sat: 96-98% RA, Pain
[**4-4**].
GEN: younger than stated age, NAD, A&0*3
HEENT: PERRL, neck supple, single anterior right cervical lymph
node <1 cm, OP mild thrush on tongue, otherwise clear, EOMI,
PERRL
CHEST: CTA b/l, good excursion, no w/r/r
CARDIAC: RRR, S1, S2, no m/r/g
ABD: soft, nondistended, no hepatosplenomegaly, + BS, mild
diffuse lower abdominal tenderness, no [**Doctor Last Name **], mild CVA
tenderness
EXT: 2+ DP, 2+ radial, [**4-29**] UE biceps, triceps, deltoids. [**4-29**] LE
quads, hamstrings, plantar/dorsiflexion, no c/c/e

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Just moved into new apartment in [**Location (un) 577**], works as a
prosecuter,does not smoke, drinks 4-8 alcoholic drinks a week,
denies illicit substance use. Patient reports no recent sexual
activity in months. Mostly sexually active with women although
male sexual contact >10 years ago. HIV test 6 months ago was
negative per patient.  Recent travel to [**State 33174**], and contact
with young nipping dog. No recent exposure to Caves. Exposure to
dirt in [**State 9512**] over [**Holiday 1451**]. 

### Response:
{'Other septicemia due to gram-negative organisms,Abscess of liver,Candidiasis of mouth,Severe sepsis,Iron deficiency anemia, unspecified'}
