CHIEF COMPLAINT: gangrenous scrotum

PRESENT ILLNESS: 67yo M h/o ESRD, ESLD, CAD who presents with scrotal rash.
Initially presented to pcp who prescribed lamisil. The next day
he re-presented to [**Hospital3 **] where he was diagnosed with
fourniers gangrene. Patient was given Clindamycin and Zosyn. A
CT abdomen reportedly showed no free air and the patient was
lethargic but they spoke to his neice who wanted a further
workup and he was sent here for urology.
.
In the ED, initial vs were: T 97.4 52 100/46 14 99. He was A+OX1
and unable to give a history. He was noted to have crepitus and
a gangrenous scrotum on exam. The OSH CT scan was read here as
having evidence of free air by our radiologists but then they
decided there was not free air actually it was just the
decompressed bladder with foley balloon tenting it up. Urology
consult and Surgery consult both thought that he was too sick to
be a surgical candidate and recommended admit to MICU for
unclear reasons. Blood and urine cultures were sent and he was
given vanc/gent here per urology recs. He was also given
thiamine for alcoholism and encephalopathy and 3L NS. While he
was in the ED his neice was [**Name (NI) 653**]. She said he would not
want surgery but would want antibiotics and other treatment. She
also faxed over DNR paperwork, however the patient reportedly
said he would be willing to be intubated. Family was called in
and will be here around 9pm from out of town. Ground work laid
to be CMO later tonight. Renal aware that he's here but since
DNR/DNI but may need HD at some point. (Normally does not get HD
as an outpatient). Two PIVs in for access.
.
Vital signs prior to transfer: HR: 45-50 sinus bradycardia, BP:
111/60 RR 14 98% RA.
.
On the floor, patient had no pain. Said the rash had been there
for a year. No other complaints except that he has "Flat lined"
and sick of medical care.

MEDICAL HISTORY: ESLD
Afib
Diabetes
Bypass surgery
HTN
ESRD not on HD yet
Gastric bypass
ETOH abuse

MEDICATION ON ADMISSION: Paxil 30mg daily
lactulose 30mL QID
Os-cal with vit D daily
Folate 1mg daily
Levothyroxine 150mcg daily
MVI
FeSo4 325mg daily
Nadolol 20mg daily
PRN APAP QD
Ativan 0.5 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97 BP:102/59 P:55 R:16 O2: 100% RA
General: Alert, oriented to person only, no acute distress
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, non-tender, bowel sounds present, no
rebound tenderness or guarding,
GU: foley in place with crepitus in scrotum and left side of
groin along inguinal ligament. Two patches of necrotic tissue
(about 2cm in diameter) on scrotum with candidal rash overlying
it in groin
Ext: warm, well perfused, anasarca

FAMILY HISTORY: unknown

SOCIAL HISTORY: Lives in [**Hospital3 **] and is a former accountant. Heavy ETOH abuse
for 7 years per niece and wife after gastric bypass he started
drinking instead of eating. Stopped smoking several years ago.
Other inflammatory disorders of male genital organs,End stage renal disease,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other ascites,Other sequelae of chronic liver disease,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Bariatric surgery status,Other and unspecified alcohol dependence, continuous
Male gen inflam dis NEC,End stage renal disease,Encephalopathy NOS,Hyp kid NOS w cr kid V,Acidosis,Ascites NEC,Oth sequela, chr liv dis,Atrial fibrillation,Crnry athrscl natve vssl,Bariatric surgery status,Alcoh dep NEC/NOS-contin
Admission Date:  [**2159-6-2**]              Discharge Date:   [**2159-6-6**]

Date of Birth:  [**2091-8-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
gangrenous scrotum

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
67yo M h/o ESRD, ESLD, CAD who presents with scrotal rash.
Initially presented to pcp who prescribed lamisil. The next day
he re-presented to [**Hospital3 **] where he was diagnosed with
fourniers gangrene. Patient was given Clindamycin and Zosyn. A
CT abdomen reportedly showed no free air and the patient was
lethargic but they spoke to his neice who wanted a further
workup and he was sent here for urology.
.
In the ED, initial vs were: T 97.4 52 100/46 14 99. He was A+OX1
and unable to give a history. He was noted to have crepitus and
a gangrenous scrotum on exam. The OSH CT scan was read here as
having evidence of free air by our radiologists but then they
decided there was not free air actually it was just the
decompressed bladder with foley balloon tenting it up. Urology
consult and Surgery consult both thought that he was too sick to
be a surgical candidate and recommended admit to MICU for
unclear reasons. Blood and urine cultures were sent and he was
given vanc/gent here per urology recs. He was also given
thiamine for alcoholism and encephalopathy and 3L NS. While he
was in the ED his neice was [**Name (NI) 653**]. She said he would not
want surgery but would want antibiotics and other treatment. She
also faxed over DNR paperwork, however the patient reportedly
said he would be willing to be intubated. Family was called in
and will be here around 9pm from out of town. Ground work laid
to be CMO later tonight. Renal aware that he's here but since
DNR/DNI but may need HD at some point. (Normally does not get HD
as an outpatient). Two PIVs in for access.
.
Vital signs prior to transfer: HR: 45-50 sinus bradycardia, BP:
111/60 RR 14 98% RA.
.
On the floor, patient had no pain. Said the rash had been there
for a year. No other complaints except that he has "Flat lined"
and sick of medical care.


Past Medical History:
ESLD
Afib
Diabetes
Bypass surgery
HTN
ESRD not on HD yet
Gastric bypass
ETOH abuse

Social History:
Lives in [**Hospital3 **] and is a former accountant. Heavy ETOH abuse
for 7 years per niece and wife after gastric bypass he started
drinking instead of eating. Stopped smoking several years ago.


Family History:
unknown

Physical Exam:
Vitals: T:97 BP:102/59 P:55 R:16 O2: 100% RA
General: Alert, oriented to person only, no acute distress
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, non-tender, bowel sounds present, no
rebound tenderness or guarding,
GU: foley in place with crepitus in scrotum and left side of
groin along inguinal ligament. Two patches of necrotic tissue
(about 2cm in diameter) on scrotum with candidal rash overlying
it in groin
Ext: warm, well perfused, anasarca


Pertinent Results:
[**2159-6-2**] 05:20PM BLOOD WBC-11.4* RBC-3.03* Hgb-9.1* Hct-27.4*
MCV-90 MCH-30.1 MCHC-33.3 RDW-15.0 Plt Ct-198
[**2159-6-2**] 05:20PM BLOOD Neuts-83.8* Lymphs-11.5* Monos-3.8
Eos-0.7 Baso-0.2
[**2159-6-2**] 05:20PM BLOOD PT-15.6* PTT-37.2* INR(PT)-1.4*
[**2159-6-2**] 05:20PM BLOOD Glucose-98 UreaN-73* Creat-5.7* Na-143
K-4.0 Cl-116* HCO3-11* AnGap-20
[**2159-6-2**] 05:20PM BLOOD ALT-6 AST-10 CK(CPK)-16* AlkPhos-79
TotBili-0.5
[**2159-6-2**] 05:20PM BLOOD Albumin-2.1* Calcium-8.2* Phos-6.1*
Mg-3.0*
[**2159-6-2**] 05:29PM BLOOD Lactate-2.2*

[**2159-6-5**] 07:35AM BLOOD WBC-9.6 RBC-2.89* Hgb-8.8* Hct-25.2*
MCV-87 MCH-30.5 MCHC-35.0 RDW-15.0 Plt Ct-163
[**2159-6-5**] 07:35AM BLOOD PT-16.1* INR(PT)-1.4*
[**2159-6-5**] 07:35AM BLOOD Glucose-40* UreaN-70* Creat-5.7* Na-145
K-3.2* Cl-115* HCO3-13* AnGap-20
[**2159-6-5**] 07:35AM BLOOD Calcium-7.3* Phos-5.1* Mg-2.5

[**2159-6-3**]   Radiology SCROTAL U.S.
1. No evidence of abscess.
2. Massive scrotal edema consistent with stated diagnosis of
cellulitis.
3. Small right hydrocele otherwise normal testes and
epididymides
bilaterally.

[**2159-6-3**]   Radiology CHEST (PORTABLE AP)
Lungs are well aerated, without consolidation or effusion. Heart
size,
mediastinal contours, and pulmonary vascular markings are within
normal
limits.

[**2159-6-3**]   Radiology CT ABDOMEN/PELVIS W/O CONTRAST
1. No evidence of air within the scrotum or subcutaneous
tissues.
2. Large amount of ascites. Small nodular liver consistent with
history of
chronic liver disease.
3. Diffuse anasarca and bilateral hydroceles.



Brief Hospital Course:
67yo M with h/o ESLD, ESRD, CAD admitted with scrotal cellulitis
and worsening hepatic and renal failure.

Patient evaluated by urology and surgery in the ED who felt pts
scrotum not true fournier's, just a scrotal cellulitis.  Scrotal
ultrasound was obtained and did not show evidence of deep tissue
fluid collections or gas.  Broad abx coverage initiated with
vanc/zosyn.  Discussed with family and pt who agreed that he
would not want surgical management even if indicated.
Similarly, despite worsening renal failure (creatinine to 5.7
from ?baseline 1.7) and poor urine output, patient and family
declined dialysis despite electrolyte abnormalities and
metabolic acidosis attributed to anuria.  He was managed
medically with pain control, antibiotics, and IV bicarbonate.
His renal function did not improve.  Lactulose was continued for
his liver disease.  Palliative care was very involved regarding
goals of care with patient and his family.  Patient had been ill
for a very long time and did not want aggressive care.  On the
day prior to discharge patient was made CMO with treatment with
oral antibiotics, symptom control, lactulose, and comfort
feeding.  He was discharged [**Last Name (un) **] with hospice.


Medications on Admission:
Paxil 30mg daily
lactulose 30mL QID
Os-cal with vit D daily
Folate 1mg daily
Levothyroxine 150mcg daily
MVI
FeSo4 325mg daily
Nadolol 20mg daily
PRN APAP QD
Ativan 0.5 mg daily

Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q24H (every 24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Disp:*2700 ML(s)* Refills:*2*
3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Dilaudid-5 1 mg/mL Liquid Sig: [**2-22**] mL PO every four (4) hours
as needed for pain.
Disp:*250 mL* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Hospice of [**Hospital3 **]

Discharge Diagnosis:
Health Care Proxy has been invoked.

Primary Diagnosis:
1. Scrotum Cellulitis
2. End Stage Renal Disease
3. End Stage Kidney Disease


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted with infection of your scrotum. You were
initially in the ICU and treated with IV antibiotics. You have
end state kidney and liver disease, and your health care proxy
decided to focus on comfort care only. You are going home with
hospice services.

Please continue all medications as prescribed.
You will complete Augmentin for another 9 days for your scrotal
infection.

Please contact your hospice services for any questions or
concerns.


Followup Instructions:
Please follow up all concerns with hospice and your new PCP.



Completed by:[**2159-6-7**]
{'Other inflammatory disorders of male genital organs,End stage renal disease,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other ascites,Other sequelae of chronic liver disease,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Bariatric surgery status,Other and unspecified alcohol dependence, continuous'}


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: gangrenous scrotum

PRESENT ILLNESS: 67yo M h/o ESRD, ESLD, CAD who presents with scrotal rash.
Initially presented to pcp who prescribed lamisil. The next day
he re-presented to [**Hospital3 **] where he was diagnosed with
fourniers gangrene. Patient was given Clindamycin and Zosyn. A
CT abdomen reportedly showed no free air and the patient was
lethargic but they spoke to his neice who wanted a further
workup and he was sent here for urology.
.
In the ED, initial vs were: T 97.4 52 100/46 14 99. He was A+OX1
and unable to give a history. He was noted to have crepitus and
a gangrenous scrotum on exam. The OSH CT scan was read here as
having evidence of free air by our radiologists but then they
decided there was not free air actually it was just the
decompressed bladder with foley balloon tenting it up. Urology
consult and Surgery consult both thought that he was too sick to
be a surgical candidate and recommended admit to MICU for
unclear reasons. Blood and urine cultures were sent and he was
given vanc/gent here per urology recs. He was also given
thiamine for alcoholism and encephalopathy and 3L NS. While he
was in the ED his neice was [**Name (NI) 653**]. She said he would not
want surgery but would want antibiotics and other treatment. She
also faxed over DNR paperwork, however the patient reportedly
said he would be willing to be intubated. Family was called in
and will be here around 9pm from out of town. Ground work laid
to be CMO later tonight. Renal aware that he's here but since
DNR/DNI but may need HD at some point. (Normally does not get HD
as an outpatient). Two PIVs in for access.
.
Vital signs prior to transfer: HR: 45-50 sinus bradycardia, BP:
111/60 RR 14 98% RA.
.
On the floor, patient had no pain. Said the rash had been there
for a year. No other complaints except that he has "Flat lined"
and sick of medical care.

MEDICAL HISTORY: ESLD
Afib
Diabetes
Bypass surgery
HTN
ESRD not on HD yet
Gastric bypass
ETOH abuse

MEDICATION ON ADMISSION: Paxil 30mg daily
lactulose 30mL QID
Os-cal with vit D daily
Folate 1mg daily
Levothyroxine 150mcg daily
MVI
FeSo4 325mg daily
Nadolol 20mg daily
PRN APAP QD
Ativan 0.5 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T:97 BP:102/59 P:55 R:16 O2: 100% RA
General: Alert, oriented to person only, no acute distress
HEENT: Sclera anicteric, very dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  distended, non-tender, bowel sounds present, no
rebound tenderness or guarding,
GU: foley in place with crepitus in scrotum and left side of
groin along inguinal ligament. Two patches of necrotic tissue
(about 2cm in diameter) on scrotum with candidal rash overlying
it in groin
Ext: warm, well perfused, anasarca

FAMILY HISTORY: unknown

SOCIAL HISTORY: Lives in [**Hospital3 **] and is a former accountant. Heavy ETOH abuse
for 7 years per niece and wife after gastric bypass he started
drinking instead of eating. Stopped smoking several years ago. 

### Response:
{'Other inflammatory disorders of male genital organs,End stage renal disease,Encephalopathy, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Acidosis,Other ascites,Other sequelae of chronic liver disease,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Bariatric surgery status,Other and unspecified alcohol dependence, continuous'}
