CHIEF COMPLAINT: scrotal pain

PRESENT ILLNESS: This is a 47 yo M with history of DM, MI (s/p BMS to RCA
[**12/2113**]), PE (on coumadin) who presented from [**Hospital **] Hospital
ER with with 1.5 weeks of increased left scrotal swelling and
pain at the base of the scrotum worse over the day prior to
presentation.  He has a 5-year history of 12 abscesses which
have drained spontaneously.  At [**Hospital1 **], he had a testicular
ultrasound with moderate bilateral scrotal swelling without
testicular abnormalities noted and then a CT scan that showed
scrotal cellulitis and a left scrotal abscess.  Labs were
notable for a leukocytosis to 15K and he was given Vancomycin,
Piperacillin-Tazobactam, and Clindamycin.  For INR of 12.2 he
received 5mg IV Vitamin K.  He was then transferred to [**Hospital1 18**] for
urgent urology evaluation.

MEDICAL HISTORY: -CAD complicated by myocardial infarction in [**2113-12-4**] with
placement of bare metal stent in RCA at [**Hospital3 2358**]
-Insulin dependent diabetes mellitus
-COPD
-OSA (not adherent to CPAP)
-Pulmonary Emboli X6, last 1 year ago, on coumadin with INR 1.8
X 3 months within the past several months
-Atrial flutter
-HLD
-Cerebrovascular disease (unclear history)

MEDICATION ON ADMISSION: (confirmed with patient)
glyburide 2mg [**Hospital1 **]
simvastatin 80 mg daily
lisinopril 5 mg daily
metformin 500mg [**Hospital1 **]
metoprolol succinate ER 200 mg daily
Advair Diskus 500 mcg-50 mcg/dose [**Hospital1 **]
Spiriva with HandiHaler 18 mcg daily
ProAir HFA 90 mcg/Actuation Aerosol Every 6-8 hrs, as needed
furosemide 80 mg Tab Oral daily
aspirin 81 mg Tab Oral daily
Coumadin 10 mg Tab Oral daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
Vitals: 96.3, 149/84, 112, 9, 97/4L
General: Alert, oriented, no acute distress, falling asleep
during conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present but hypoactive, no rebound tenderness or guarding, no
organomegaly
GU: no foley, large erythematous, tense tender scrotom with wick
in place in drainage site posterior to left scrotum.
Erythema/tenderness does not extend onto skin of abdomen or
buttocks
ext: clamy b/l feet with 1+ DP b/l, pitting edema [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>L
.
Discharge Exam:
Vitals: 98.3, 149/84, 89, 18, 97/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: NSR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley, slightly enlarged, erythematous scrotum that is
much improved since admission. I&D site is completely healed and
is now intact without e/o infection.
ext: wwp, no c/c/e

FAMILY HISTORY: No history of venous thromboembolic disease.  Positive for
history of diabetes mellitus and atrial fibrillation.

SOCIAL HISTORY: Former salesman, now unemployed on disability.
- Tobacco:  one pack/month
- Alcohol:  drinks every 2-3 days, denies hx of withdrawal
- Illicits:  denies
Other inflammatory disorders of male genital organs,Unspecified septicemia,Septic shock,Severe sepsis,Other and unspecified coagulation defects,Mixed acid-base balance disorder,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial flutter,Chronic airway obstruction, not elsewhere classified,Personal history of venous thrombosis and embolism,Old myocardial infarction,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Obstructive sleep apnea (adult)(pediatric)
Male gen inflam dis NEC,Septicemia NOS,Septic shock,Severe sepsis,Coagulat defect NEC/NOS,Mixed acid-base bal dis,DMII wo cmp uncntrld,Atrial flutter,Chr airway obstruct NEC,Hx-ven thrombosis/embols,Old myocardial infarct,Long-term use anticoagul,Crnry athrscl natve vssl,Status-post ptca,Obstructive sleep apnea
Admission Date:  [**2114-7-26**]              Discharge Date:   [**2114-8-1**]

Date of Birth:  [**2066-12-25**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
scrotal pain

Major Surgical or Invasive Procedure:
scrotal abscess I&D [**2114-7-26**]

History of Present Illness:
This is a 47 yo M with history of DM, MI (s/p BMS to RCA
[**12/2113**]), PE (on coumadin) who presented from [**Hospital **] Hospital
ER with with 1.5 weeks of increased left scrotal swelling and
pain at the base of the scrotum worse over the day prior to
presentation.  He has a 5-year history of 12 abscesses which
have drained spontaneously.  At [**Hospital1 **], he had a testicular
ultrasound with moderate bilateral scrotal swelling without
testicular abnormalities noted and then a CT scan that showed
scrotal cellulitis and a left scrotal abscess.  Labs were
notable for a leukocytosis to 15K and he was given Vancomycin,
Piperacillin-Tazobactam, and Clindamycin.  For INR of 12.2 he
received 5mg IV Vitamin K.  He was then transferred to [**Hospital1 18**] for
urgent urology evaluation.

Upon arrival to our ED, VS 96.5, 99, 116/81, 18, 95/4L. Labs
were significant for creatinine 1.2, calcium 7.9, lactate 1.3,
WBC 15.4 with N73.2, platelets 102. INR was 6.0. He was seem by
urology and noted to have the abscess draining through a tract
towards the left perirectal part of the left hemiscroton and I&D
done with 300 cc of "maroon,bloody, foul-smelling pus" which was
sent for culture. Urology felt this was more consistent with
abscess and not suggestive of Fournier's gangrene. There was
immediate pain relief with drainage of the abscess and the wound
was packed.  The patient's SBP's dropped to the 80s systolic on
two occasions while in the ED but improved to 100s after three
liters IVF.  Given his recent hypotension he was triaged to the
MICU for  sepsis.

On the floor, he denied recent fevers and endorsed scrotal pain.
He had mild dyspnea, which he has had previously and relates to
COPD.  No other significant complaints.

Past Medical History:
-CAD complicated by myocardial infarction in [**2113-12-4**] with
placement of bare metal stent in RCA at [**Hospital3 2358**]
-Insulin dependent diabetes mellitus
-COPD
-OSA (not adherent to CPAP)
-Pulmonary Emboli X6, last 1 year ago, on coumadin with INR 1.8
X 3 months within the past several months
-Atrial flutter
-HLD
-Cerebrovascular disease (unclear history)


Social History:
Former salesman, now unemployed on disability.
- Tobacco:  one pack/month
- Alcohol:  drinks every 2-3 days, denies hx of withdrawal
- Illicits:  denies


Family History:
No history of venous thromboembolic disease.  Positive for
history of diabetes mellitus and atrial fibrillation.


Physical Exam:
Admission Exam:
Vitals: 96.3, 149/84, 112, 9, 97/4L
General: Alert, oriented, no acute distress, falling asleep
during conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present but hypoactive, no rebound tenderness or guarding, no
organomegaly
GU: no foley, large erythematous, tense tender scrotom with wick
in place in drainage site posterior to left scrotum.
Erythema/tenderness does not extend onto skin of abdomen or
buttocks
ext: clamy b/l feet with 1+ DP b/l, pitting edema [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>L
.
Discharge Exam:
Vitals: 98.3, 149/84, 89, 18, 97/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: NSR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley, slightly enlarged, erythematous scrotum that is
much improved since admission. I&D site is completely healed and
is now intact without e/o infection.
ext: wwp, no c/c/e

Pertinent Results:
[**2114-7-25**] 10:55PM BLOOD WBC-15.4* RBC-5.01 Hgb-16.3 Hct-48.0
MCV-96 MCH-32.5* MCHC-33.9 RDW-15.5 Plt Ct-102*
[**2114-7-25**] 10:55PM BLOOD Neuts-73.2* Lymphs-18.0 Monos-5.1 Eos-3.0
Baso-0.8
[**2114-7-25**] 10:55PM BLOOD PT-55.8* PTT-40.0* INR(PT)-6.0*
[**2114-7-25**] 10:55PM BLOOD Glucose-295* UreaN-29* Creat-1.2 Na-135
K-4.7 Cl-95* HCO3-32 AnGap-13
[**2114-7-26**] 03:50AM BLOOD ALT-42* AST-36 CK(CPK)-152 AlkPhos-101
TotBili-0.8
[**2114-7-25**] 10:55PM BLOOD CK-MB-7 cTropnT-<0.01
[**2114-7-25**] 10:55PM BLOOD Calcium-7.9* Phos-4.7* Mg-1.8
[**2114-7-27**] 08:01AM BLOOD Vanco-11.5
[**2114-7-26**] 07:20AM BLOOD Type-ART pO2-69* pCO2-63* pH-7.29*
calTCO2-32* Base XS-1
.
Cultures:
MRSA SCREEN (Final [**2114-7-28**]):    No MRSA isolated.

[**2114-7-26**] 12:30 am SWAB
   GRAM STAIN (Final [**2114-7-26**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2114-7-30**]):
      Due to mixed bacterial types (>=3) an abbreviated workup
is
      performed; P.aeruginosa, S.aureus and beta strep. are
reported if
      present. Susceptibility will be performed on P.aeruginosa
and
      S.aureus if sparse growth or greater..
      DR [**First Name (STitle) **] BRUSH ([**Numeric Identifier 29614**]) REQUESTED SPECIATION OF ORGANISMS
[**7-28**].
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.
         SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
      PROBABLE MICROCOCCUS SPECIES.    SPARSE GROWTH.
      NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.    RARE GROWTH.

      CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
         SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.

   ANAEROBIC CULTURE (Final [**2114-7-30**]):    NO ANAEROBES ISOLATED.


Blood Culture, Routine (Final [**2114-8-2**]):    NO GROWTH.

.
TTE [**7-26**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF = 75%). The right ventricular free wall is
hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
.
IMPRESSION: dilated, hypocontractile right ventricle with at
least moderate pulmonary hypertension; small, hyperdynamic left
ventricle
.
[**7-26**]
BILATERAL LOWER EXTREMITY ULTRASOUND:
No deep venous thrombosis involving the right or left lower
extremity.
.
[**7-26**] CXR:
FINDINGS: An ill-defined opacity at the left lung base, likely
atelectasis, could be related to a bulge to the left mediastinal
contour just inferior to the aortic knob could be a left hilar
or mediastinal mass or, less likely aneurysm of the descending
aorta. . No pleural effusion or pneumothorax.
.
[**7-26**] CTA:
1. Mild septal thickening predominantly in the lung apices,
consistent with
mild volume overload.
2. Scattered symmetric mediastinal and hilar lymph nodes
measuring up to 11
mm. Findings may be reactive secondary to mild pulmonary
vascular congestion; however, the differential is broad and
continues to include inflammatory and neoplastic etiologies.
Therefore, follow-up chest CT in three months is recommended to
evaluate for interval resolution.
3. Mild centrilobular emphysema, predominantly at the lung
apices.
4. No pulmonary embolism or acute aortic syndrome.


Brief Hospital Course:
Primary Reason for Admission:
This is a 47 yo M with history of DM, CAD/MI, PE on coumadin,
presenting with scrotal abscess and fever admitted to the ICU
after drainage of his abscess then downgraded to floor for
discharge pending improvement in scrotal swelling.

Active Problems:

1) Sepsis from scrotal abscess: Patient presented with septic
physiology that improved in the setting of receiving broad
spectrum antibiotics (vancomycin/piperacillin-tazobactam) and
and having abscess drained by urology.  Unclear what portal of
entry was but given history of folliculitis in area possible
this evolved into cellulitis.  As of his second hospital day the
patient began to manifest considerable improvement in his septic
physiology in the context of antibiotic treatment.  Cultures
were obtained and grew out multiple bacteria as detailed in
results. His antibiotics were narrowed to Levo/Flagyl and the
patient's symptoms markedly improved prior to discharge.

2) Presumed Chronic Right Ventricular Failure: The patient had
persistent mild hypoxia in the ICU, sinus tachycardia, and echo
showing RV dilation and hypokinesis.  This raised concern of
acute PE (though he was supratherapeutic on coumadin at
presentation).  CTA without PE though did show emphysema, which
along with his OSA and recurrent previous PE's are probably the
etiology of his RV failure.  Persistent sinus tach thought due
to right ventricle being unable to augment output without
tachycardia.

3) Sinus tachycardia: Worked up as described.  Over the course
of hospitalization this improved with adequate pain control and
resolution of fever.

4)  History of pulmonary embolism: Given INR of 12 at
presentation and surgery his coumadin was held until INR hit 2.5
at which time it was restarted at half dose (5 mg per day).  At
time of discharge INR was 1.2 and the patient was bridged with
Lovenox with instructions to f/u his INR with PCP.

Chronic Problems:

5) Hypoxia: The patient remained mildly hypoxic over the first
few days in the hospital with primary etiology thought to be his
COPD and fluid shifts.  This improved over the course of his
time on the medical floor, but the patient was sent home with
supplemental O2.

6) Diabetes: [**Last Name (un) **] was consulted and recommended changing the
patient's home oral agents to long acting once daily pills due
to non-compliance with twice daily dosing. Insulin teaching was
done and the patient was also sent home with instruction to use
insulin to supplement his oral agents.

7) CAD: He had no signs or symptoms of ACS.  He had two sets of
cardiac enzymes that were negative for signs of infarction.  His
aspirin was continued throughout the hospitalization.

8) Hyperlipidemia: He was continued on his home simvastatin

9) Hypertension: His lisinopril, Metoprolol, and furosemide were
all initially held given hypotension but then restarted without
incident once the patient's hemodynamic status had stabilized.

Transitional Issues: Pt was discharged home with instructions to
follow up with his PCP, [**Name10 (NameIs) **] to follow up the results of his
chest CT that showed mediastinal LAD.  Urology and Endocrinology
follow up were also arranged.


Medications on Admission:
(confirmed with patient)
glyburide 2mg [**Hospital1 **]
simvastatin 80 mg daily
lisinopril 5 mg daily
metformin 500mg [**Hospital1 **]
metoprolol succinate ER 200 mg daily
Advair Diskus 500 mcg-50 mcg/dose [**Hospital1 **]
Spiriva with HandiHaler 18 mcg daily
ProAir HFA 90 mcg/Actuation Aerosol Every 6-8 hrs, as needed
furosemide 80 mg Tab Oral daily
aspirin 81 mg Tab Oral daily
Coumadin 10 mg Tab Oral daily


Discharge Medications:
1. nebs
nebulizer machine for COPD
2. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
every 6-8 hours.
Disp:*qs * Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB/wheeze.
Disp:*qs * Refills:*0*
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*qs Tablet(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO DAILY (Daily).
Disp:*qs Tablet Extended Rel 24 hr(s)* Refills:*2*
8. metformin 500 mg Tablet Extended Release 24 hr Sig: Two (2)
Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*qs Tablet Extended Release 24 hr(s)* Refills:*2*
9. Outpatient Lab Work
Please Have your INR Checked on [**8-3**] and [**8-7**] and faxed
to Dr. [**Last Name (STitle) 34030**] at [**Telephone/Fax (1) 89095**]
10. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

11. Lasix 80 mg Tablet Sig: One (1) Tablet PO once a day.
12. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-4**]
puffs Inhalation every 6-8 hours.
13. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation twice a day.
14. Toprol XL 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
15. Toprol XL 25 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day: take with 200mg for
a total of 225mg each daily.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
16. enoxaparin 150 mg/mL Syringe Sig: One [**Age over 90 8821**]y (140) mg
Subcutaneous Q12H (every 12 hours).
Disp:*14 syringes* Refills:*1*
17. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
18. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
19. Lantus 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
Disp:*360 units* Refills:*1*
20. One Touch Basic System     Kit Sig: One (1) kit
Miscellaneous  .
Disp:*1 kit* Refills:*0*
21. lancets misc.     Kit Sig: One (1) lancets Miscellaneous
four times a day.
Disp:*100 lancets* Refills:*2*
22. insulin syringes (disposable) 1 mL   Syringe Sig: One (1)
Miscellaneous at bedtime: to be used w lantus.
Disp:*100 syringes* Refills:*0*
23. blood glucose strip
blood glucose strip
dispense 100 strips
1 refill


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
scrotal Abscess

Secondary:
COPD
Diabetes Type 2


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Mr. [**Known lastname 89096**],

It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted to the hospital with
a scrotal abscess.  You were evaluated by Urologists, who felt
it was necessary to drain the infected fluid from your scrotum.
You were given antibiotics and your condition improved.

Of note, during your hospitalization your INR (couamdin level)
was high.  After correction your INR went too low, so you are
now on coumadin and a medication called lovenox (enoxaparin) to
keep your blood thin while your coumadin levels rise to
appropriate levels.  At discharge your INR was 1.2.  You will
need to have your INR checked on [**8-3**] and [**8-7**].

You had some shortness of breath during your hospital stay.
There were no signs of infection or blood clot.  These symptoms
are likely a result of COPD.

Your diabetes was poorly controlled.  You were evaluated by a
diabetes specialist and started on injectable insulin.  Please
check you blood sugar 4 times per day.  Call you doctor if you
sugar is less than 80.

A CT scan of your chest revealed some lymph nodes in your chest,
the significance of which is uncertain. You should follow up
with your primary care physician regarding these findings.

During your hospital stay, we made the following changes to your
medications:

DIABETES
- STOPPED Glyburide, and STARTED Glipizide XL
- STOPPED Metoformin, and STARTED Metformin XR
- STARTED injectable insulin (lantus)

INFECTION
- STARTED Flagyl and Levofloxacin, to be continued for a total
of 2 weeks

BLOOD THINNING
- STARTED Enoxaparin
- DECREASED Coumadin

BREATHING
- STARTED albuterol / ipratropium nebulizers

HEART
- INCREASED Toprol (metoprolol)

Followup Instructions:
PCP [**Name Initial (PRE) **]:Thursday, [**8-9**] at 10:45am
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD
Location: [**Hospital 17457**] MEDICAL
Address: 100 [**Doctor Last Name **] CENTER STE 126Q, [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 17458**]

Urology Appointment:Wednesday,[**8-15**] at 3pm
Name: [**Last Name (LF) **], [**First Name3 (LF) **] K. MD
Location: [**Hospital1 **]
Address: [**Location (un) **], [**Hospital Ward Name **] 3RD FL, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 921**]

Endocrinology Appointment: Tuesday, [**8-28**] at 10am
With: Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**]
Location:[**Last Name (un) **] Diabetes Center One [**Last Name (un) **] Place,
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
** You have been put on a wait list for a sooner appt. Also,
this initial appointment can take between 2 and 3 hours.
{'Other inflammatory disorders of male genital organs,Unspecified septicemia,Septic shock,Severe sepsis,Other and unspecified coagulation defects,Mixed acid-base balance disorder,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial flutter,Chronic airway obstruction, not elsewhere classified,Personal history of venous thrombosis and embolism,Old myocardial infarction,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Obstructive sleep apnea (adult)(pediatric)'}


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: scrotal pain

PRESENT ILLNESS: This is a 47 yo M with history of DM, MI (s/p BMS to RCA
[**12/2113**]), PE (on coumadin) who presented from [**Hospital **] Hospital
ER with with 1.5 weeks of increased left scrotal swelling and
pain at the base of the scrotum worse over the day prior to
presentation.  He has a 5-year history of 12 abscesses which
have drained spontaneously.  At [**Hospital1 **], he had a testicular
ultrasound with moderate bilateral scrotal swelling without
testicular abnormalities noted and then a CT scan that showed
scrotal cellulitis and a left scrotal abscess.  Labs were
notable for a leukocytosis to 15K and he was given Vancomycin,
Piperacillin-Tazobactam, and Clindamycin.  For INR of 12.2 he
received 5mg IV Vitamin K.  He was then transferred to [**Hospital1 18**] for
urgent urology evaluation.

MEDICAL HISTORY: -CAD complicated by myocardial infarction in [**2113-12-4**] with
placement of bare metal stent in RCA at [**Hospital3 2358**]
-Insulin dependent diabetes mellitus
-COPD
-OSA (not adherent to CPAP)
-Pulmonary Emboli X6, last 1 year ago, on coumadin with INR 1.8
X 3 months within the past several months
-Atrial flutter
-HLD
-Cerebrovascular disease (unclear history)

MEDICATION ON ADMISSION: (confirmed with patient)
glyburide 2mg [**Hospital1 **]
simvastatin 80 mg daily
lisinopril 5 mg daily
metformin 500mg [**Hospital1 **]
metoprolol succinate ER 200 mg daily
Advair Diskus 500 mcg-50 mcg/dose [**Hospital1 **]
Spiriva with HandiHaler 18 mcg daily
ProAir HFA 90 mcg/Actuation Aerosol Every 6-8 hrs, as needed
furosemide 80 mg Tab Oral daily
aspirin 81 mg Tab Oral daily
Coumadin 10 mg Tab Oral daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
Vitals: 96.3, 149/84, 112, 9, 97/4L
General: Alert, oriented, no acute distress, falling asleep
during conversation
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present but hypoactive, no rebound tenderness or guarding, no
organomegaly
GU: no foley, large erythematous, tense tender scrotom with wick
in place in drainage site posterior to left scrotum.
Erythema/tenderness does not extend onto skin of abdomen or
buttocks
ext: clamy b/l feet with 1+ DP b/l, pitting edema [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]>L
.
Discharge Exam:
Vitals: 98.3, 149/84, 89, 18, 97/2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP could not be assessed
Lungs: Distant heart sounds and clear to auscultation
bilaterally, no wheezes, rales, ronchi
CV: NSR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley, slightly enlarged, erythematous scrotum that is
much improved since admission. I&D site is completely healed and
is now intact without e/o infection.
ext: wwp, no c/c/e

FAMILY HISTORY: No history of venous thromboembolic disease.  Positive for
history of diabetes mellitus and atrial fibrillation.

SOCIAL HISTORY: Former salesman, now unemployed on disability.
- Tobacco:  one pack/month
- Alcohol:  drinks every 2-3 days, denies hx of withdrawal
- Illicits:  denies 

### Response:
{'Other inflammatory disorders of male genital organs,Unspecified septicemia,Septic shock,Severe sepsis,Other and unspecified coagulation defects,Mixed acid-base balance disorder,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Atrial flutter,Chronic airway obstruction, not elsewhere classified,Personal history of venous thrombosis and embolism,Old myocardial infarction,Long-term (current) use of anticoagulants,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Obstructive sleep apnea (adult)(pediatric)'}
