CHIEF COMPLAINT: Scrotal and lower extremity swelling.

PRESENT ILLNESS: This is a 65 year old male with
a history of CHF, CAD status post MI, diabetes type 2,
hypertension, a-fib, who presents with a several week history
of scrotal swelling which has markedly worsened in the last
four days.  The patient also notes increased swelling of his
lower extremities.  Along with scrotal swelling the patient
notes pain which is worsened with motion and touch.  The
patient said he has been compliant with his medications,
although family members tell a different account.  The
patient denies chest pain, shortness of breath, palpitations,
nausea, vomiting, fever, chills, lightheadedness, abdominal
pain, diarrhea, constipation.  The patient has one pillow
orthopnea and dyspnea on exertion.  However, he is able to
climb four flights of stairs.  Patient with a history of
a-fib, however, not compliant with INR monitoring.  The
patient spilled grease from the stove on his right lower
extremity which resulted in an ulcer and erythema.

MEDICAL HISTORY: CHF.  CAD status post MI in the [**2141**].
Diabetes.  Hypertension.  A-fib.  Several stress tests in the
past with questionable results.  No cath.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Brother with CAD.  Mother had CAD.  Brother
with cancer.

SOCIAL HISTORY: Smoker 39 pack years, quit many years ago.
Alcohol positive, but quit 1 1/2 years ago.
Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Unspecified sleep apnea,Atrial fibrillation,Morbid obesity,Contusion of thigh,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft
CHF NOS,Cellulitis of leg,Acute respiratry failure,Sleep apnea NOS,Atrial fibrillation,Morbid obesity,Contusion of thigh,DMII wo cmp nt st uncntr,Cor ath unsp vsl ntv/gft
Admission Date:  [**2163-11-27**]       Discharge Date:  [**2163-12-12**]

Date of Birth:   [**2098-6-7**]       Sex:  M

Service:  C-MED

CHIEF COMPLAINT:  Scrotal and lower extremity swelling.

HISTORY OF PRESENT ILLNESS:  This is a 65 year old male with
a history of CHF, CAD status post MI, diabetes type 2,
hypertension, a-fib, who presents with a several week history
of scrotal swelling which has markedly worsened in the last
four days.  The patient also notes increased swelling of his
lower extremities.  Along with scrotal swelling the patient
notes pain which is worsened with motion and touch.  The
patient said he has been compliant with his medications,
although family members tell a different account.  The
patient denies chest pain, shortness of breath, palpitations,
nausea, vomiting, fever, chills, lightheadedness, abdominal
pain, diarrhea, constipation.  The patient has one pillow
orthopnea and dyspnea on exertion.  However, he is able to
climb four flights of stairs.  Patient with a history of
a-fib, however, not compliant with INR monitoring.  The
patient spilled grease from the stove on his right lower
extremity which resulted in an ulcer and erythema.

PAST MEDICAL HISTORY:  CHF.  CAD status post MI in the [**2141**].
Diabetes.  Hypertension.  A-fib.  Several stress tests in the
past with questionable results.  No cath.

ALLERGIES:  No known drug allergies.

MEDICATIONS:  Potassium 10 mEq once a day, Digitek 0.5 mg
once a day, [**Doctor First Name **], aspirin 325 once a day, Glucovance
2.5/500 twice a day, Vioxx 25 mg twice a day, ACE inhibitor.

FAMILY HISTORY:  Brother with CAD.  Mother had CAD.  Brother
with cancer.

SOCIAL HISTORY:  Smoker 39 pack years, quit many years ago.
Alcohol positive, but quit 1 1/2 years ago.

PHYSICAL EXAMINATION:  On admission temperature was 98, heart
rate 98, blood pressure 174/94, respirations 28, 91% on 2
liters.  In general, obese, white male, laying in bed, in no
acute distress, awake.  HEENT was NCAT, PERRL, EOMI, MMM,
poor dentition.  Neck soft, supple, no JVD, no LA.  Heart
distant heart sounds, positive irregularly irregular rhythm,
positive S1, S2, 2/6 SEM.  Lungs decreased breath sounds,
positive bibasilar crackles, left greater than right.
Abdomen obese, soft, positive distension, nontender,
normoactive bowel sounds, no HSM.  Scrotum diffusely
edematous, erythema, positive tenderness with palpation, no
eschar.  Extremities: right lower extremity erythema, several
discrete ulcers, positive warmth, positive drainage with
purulence, bilateral 3+ pitting edema to mid-thigh.  Neuro
alert and oriented times three.  Cranial nerves II-XII
intact.

LABORATORY DATA:  White blood cell count 7.4, hematocrit
50.8, platelets 108, neuts 74, lymphs 15, monos 9.  Sodium
143, potassium 4.3, chloride 99, bicarb 35, BUN 24,
creatinine 0.8, glucose 64.  ALT 20, AST 30, alka phos 113,
amylase 56, lipase 58.  CK 129, troponin less than 0.3, MB 4.
PT 14.8, PTT 29.4, INR 1.5.  EKG showed a-fib, rate in 110s,
right axis, old inferior MI with changes in 2, 3, aVF,
decreased ST depressions in V2, V3, decreased Ts in V2, V3.
Chest x-ray positive cardiomegaly, no CHF, questionable left
lobe infiltrate, small bilateral pleural effusion.

ASSESSMENT AND PLAN:  This is a 65 year old male, poor
historian with significant past medical history for CHF, CAD,
status post MI, diabetes, hypertension, a-fib, who presents
with a several week history of worsening scrotal and lower
extremity edema.

1.  Cardiac.  As above patient with history of CHF.  New and
total body fluid overload with marked edema, etiology likely
multifactorial, poor medicine compliance, EF question.  No
shortness of breath.  Mild crackles on physical examination,
however, O2 sat 91% on 2 liters.  History of a-fib not on
Coumadin because of lack of compliance with INR monitoring.
Currently a-fib controlled rate 110.  The patient will need
vigorous diuresis as well as optimization of medicine
regimen.  Lasix diuresis, strict Is and Os, daily weights.
Continue digoxin, Zestril, HCTZ, aspirin, beta blocker.  Will
consider echo to assess cardiac function.  Telemetry.  EKG in
a.m.  To keep O2 sats greater than 93%.  Consider adding
spironolactone.  Check lipid panel.  Heparinize, possible to
switch to Coumadin.  Followup serial enzymes for rule out MI.

2.  Endo.  History of diabetes type 2.  Will continue
outpatient regimen of glyburide and metformin with insulin
sliding scale.  Check finger sticks four times a day.  Check
hemoglobin A1C.

3.  ID.  Right lower extremity cellulitis with purulence and
ulcerations.  Started on Ancef in E.D.  Afebrile.  No
leukocytosis.  Positive scrotal edema in a diabetic.  Must
consider Fournier gangrene.  No eschar noted at this time.
Continue IV Ancef.  Blood cultures times two.  Wound care
nurse consult.

4.  Hypertension.  Blood pressure increased.  Will continue
HCTZ, Zestril, Lopressor, Lasix and adjunct as necessary.

5.  Prophylaxis with Protonix and heparin.  Code is full.

HOSPITAL COURSE:  The patient ruled out for MI.  The patient
was diuresed consistently 1 to 2 liters per day.  He was
started on heparin drip for a-fib.  The patient had an
echocardiogram which showed global right ventricular
hypokinesis and moderate pulmonary hypertension.  He was
started on Ancef for his lower extremity cellulitis.  He had
minor three to four beat nonsustained VT during his C-MED
stay.  Overnight on [**11-27**] to [**11-29**] the patient desaturated to
the 80s in room air and 70% on face mask.  Chest x-ray showed
no change later that day.  The patient was then admitted to
the MICU on [**11-29**] for hypercarbic respiratory failure and
hypoxia.  The patient required 24 hours of intubation.  The
patient's decompensation was thought to be secondary to COPD
with obstructive sleep apnea and multiple factors.  The
patient had a CT angiogram on [**2163-12-3**] which showed no evidence
of pulmonary embolus with small bilateral pleural effusions.

The patient was continued on aggressive diuresis with IV
Lasix and then subsequently switched to p.o. Lasix 80 mg
t.i.d.  Continued to diurese approximately 2 liters per day.
Heart rate controlled on diltiazem.  Dose was increased from
30 to 60 q.i.d. in the MICU.  The patient's echocardiogram on
[**2163-11-28**] showed an ejection fraction of approximately 70%
with global right ventricular hypokinesis as above.  The
patient's chest x-ray on [**2163-12-1**] showed slight improvement in
CHF with enlarged cardiac contour, increased opacity in left
retrocardiac region, question atelectasis versus effusion.

The patient was then extubated on [**2163-12-1**].  He was doing well.
Was planned for night time positive pressure noninvasive
ventilation.  The patient didn't tolerate the face mask as he
said it didn't fit well and had trouble using it while
sleeping.  Nasal BiPAP was tried with two separate masks with
no effect.  The patient was then transferred back to the MICU
and did fine through the day on 6 liters nasal cannula with
sats 90% to 92%.  The patient then had an inpatient sleep
study to assess his obstructive sleep apnea as probable cause
of desats during the night.  Sleep apnea study is pending.
The patient was on captopril 50 mg t.i.d. in the MICU.  The
patient had some poor blood pressure control with continued
diuresis.  Captopril was discontinued and has since not been
added back in until the patient's blood pressure is stable.
The patient's blood pressure on discharge here is now 120/80.
Captopril will be restarted.

The patient's right lower extremity cellulitis continued to
improve and eventually healed.  The patient's ulcer
completely healed with granulation tissue and no need for
dressing changes.  The patient was switched from cefazolin to
Levaquin 500 mg p.o. q.d.  On [**2163-12-4**] GU was consulted to rule
out Fournier gangrene due to erythema and severe scrotal
edema with some gas seen in the scrotum.  Due to the
possibility of Fournier gangrene, the patient was put on
Flagyl 500 mg IV q.eight hours, ampicillin 2 gm IV q.four
hours and levofloxacin 500 mg IV q.24 hours.  On GU followup
with clinical exam and CT of the scrotum diagnosis was made
that it was strictly scrotal edema and not Fournier gangrene.
Levaquin was continued.  Amp and Flagyl were discontinued.
The patient subsequently on [**12-5**] developed right thigh
hematoma.  Orthopaedics was consulted.  There was no evidence
compartment syndrome.  The patient's INR was elevated at 2.2.
Vitamin K was given to reverse the INR and heparin was
stopped.  The patient had serial circumference checks of his
right leg hematoma.  Hematoma improving.  Hematocrit was
stable.

On [**2163-12-6**] for the patient's a-fib, Lopressor and diltiazem
were continued.  Lopressor was changed to 50 mg t.i.d. for
better control.  Regarding CHF the patient was diuresing well
and Lasix was changed to p.o. before discharge from the MICU.
Lopressor was continued, but captopril was discontinued due
to decrease in blood pressure as above.  The patient was
doing well in terms of pulmonary with 3 liters nasal cannula,
not tolerating BiPAP well at night.  The patient's urine
output was greater than 100 cc per hour on IV Lasix as well
as on p.o. Lasix.  The patient's blood glucose was well
controlled.  Continued on insulin sliding scale.  Glyburide
was held while in the MICU, but restarted on [**12-7**] when the
patient came back to the floor as he was eating well.  The
patient's scrotal edema continued to improve.  The patient
was diuresing well.  Hematoma on leg continues to improve as
the circumference is 74 cm on discharge improved.  Patient
with minor pain to palpation of hematoma.  The patient has
right internal jugular line and peripheral access.

The patient continued to improve.  The patient is being
followed by physical therapy.  The patient is able to get out
of bed and ambulate at times during the day with help.  The
patient is utilizing a walker to walk on his own.  Chest
x-ray status post IJ placement shows no pneumothorax and
proper placement of IJ line.  The patient's lab values on
[**2163-12-3**] showed hematocrit of 39.5 which has been stable over
the past four days, slight increase in white blood cell count
to 11.  The patient's INR is stable at 1.4.  The patient's
chem-7 is stable with slightly decreased chloride and bicarb
of 39.  BUN is down to 22 with normal creatinine of 0.6.  The
patient's CK monitored down from 2144 to 847, improving.  The
patient continued to improve and diurese well.  The patient
is ambulating, eating well and is ready to return to
rehabilitation center for further improvement before going
home.

DISCHARGE MEDICATIONS:
1.  Lasix 80 mg p.o. t.i.d.
2.  Levaquin 500 mg p.o. q.d.
3.  Colace 100 mg p.o. q.d.
4.  Diltiazem 60 mg p.o. q.i.d., hold for blood pressure less
than 100.
5.  Protonix 40 mg q.d.
6.  Lopressor 50 mg p.o. t.i.d.
7.  Nystatin powder to scrotum.
8.  Lactulose p.r.n. for constipation.
9.  Bactroban cream to scrotum as needed.
10. Glyburide 1.25 mg p.o. b.i.d., to be increased once the
patient's blood sugar is under control with eating.
11. Serax 10 mg p.o. q.h.s. p.r.n. for agitation or
sleeplessness.
12. The patient's ACE inhibitor may be restarted prior to
discharge if blood pressure is stable.

DISCHARGE DIAGNOSES:
1.  Bilateral lower extremity edema and scrotal edema.
2.  CHF with right sided heart failure.
3.  CAD.
4.  Diabetes.
5.  Hypertension.
6.  A-fib.

CONDITION ON DISCHARGE:  Stable and improved.

DISPOSITION:  The patient will be discharged to rehab.

FOLLOWUP:  The patient will need followup appointments with
his primary care physician.

There will be an addendum to this for the day or two prior to
discharge that are not included in this discharge summary.






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], M.D.  [**MD Number(1) 18174**]

Dictated By:[**Last Name (NamePattern1) 4724**]
MEDQUIST36

D:  [**2163-12-10**]  16:35
T:  [**2163-12-10**]  16:37
JOB#:  [**Job Number **]


Name:  [**Known lastname **], [**Known firstname 126**]                     Unit No:  [**Numeric Identifier 17770**]

Admission Date:  [**2163-11-27**]     Discharge Date:  [**2163-12-12**]

Date of Birth:   [**2098-6-7**]     Sex:  M

Service:

ADDENDUM:  Addendum to hospital course.  The patient's actual
date of discharge was [**2163-12-12**].  The patient will be
discharged to rehabilitation in Brain Tree [**State 1145**].
Service is actually Medicine, [**Location (un) **] Firm not C-MED.

The [**Hospital 1325**] hospital course over the 1-day addendum is
improving.  The patient is diuresing well, negative 2 liters
again per day.  The patient will be continued on medications
per Discharge Summary with the addition of captopril ACE
inhibitor since the patient's blood pressure is stable.  The
patient with no new events.

The patient's condition on discharge was stable and improved.
The patient continues to improve with regard to his scrotal
and lower extremity edema.  The patient has no lower
extremity ulcers, and all former leg excoriations are healing
well.  The patient ambulating three to four times per day and
able to get out of bed using a walker.  The patient will get
rehabilitation and continue to get care for his fluid status.




                          [**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 2839**], M.D.  [**MD Number(1) 2840**]

Dictated By:[**Last Name (NamePattern1) 563**]

MEDQUIST36

D:  [**2163-12-12**]  14:42
T:  [**2163-12-14**]  13:01
JOB#:  [**Job Number 5043**]
{'Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Unspecified sleep apnea,Atrial fibrillation,Morbid obesity,Contusion of thigh,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft'}


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 and lower extremity swelling.

PRESENT ILLNESS: This is a 65 year old male with
a history of CHF, CAD status post MI, diabetes type 2,
hypertension, a-fib, who presents with a several week history
of scrotal swelling which has markedly worsened in the last
four days.  The patient also notes increased swelling of his
lower extremities.  Along with scrotal swelling the patient
notes pain which is worsened with motion and touch.  The
patient said he has been compliant with his medications,
although family members tell a different account.  The
patient denies chest pain, shortness of breath, palpitations,
nausea, vomiting, fever, chills, lightheadedness, abdominal
pain, diarrhea, constipation.  The patient has one pillow
orthopnea and dyspnea on exertion.  However, he is able to
climb four flights of stairs.  Patient with a history of
a-fib, however, not compliant with INR monitoring.  The
patient spilled grease from the stove on his right lower
extremity which resulted in an ulcer and erythema.

MEDICAL HISTORY: CHF.  CAD status post MI in the [**2141**].
Diabetes.  Hypertension.  A-fib.  Several stress tests in the
past with questionable results.  No cath.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Brother with CAD.  Mother had CAD.  Brother
with cancer.

SOCIAL HISTORY: Smoker 39 pack years, quit many years ago.
Alcohol positive, but quit 1 1/2 years ago. 

### Response:
{'Congestive heart failure, unspecified,Cellulitis and abscess of leg, except foot,Acute respiratory failure,Unspecified sleep apnea,Atrial fibrillation,Morbid obesity,Contusion of thigh,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Coronary atherosclerosis of unspecified type of vessel, native or graft'}
