CHIEF COMPLAINT: Scrotal abscess

PRESENT ILLNESS: This is a 65 M c/ pmh of hepatitis C/cirrhosis, ESRD, DM,
PVD, who presented to the [**Hospital1 1474**] ED on [**2190-8-31**] complaining of
scrotal swelling and tenderness. The patient states that the
tenderness presented last Thursday ([**8-26**]). He was seen by
hepatology on [**8-27**] with no testicular/scrotal swelling. Over the
weekend, the patient noticed increased scrotal swelling and
tenderness. At [**Hospital 1474**] Hospital, the patient was initially on
Levophed for hypotension which was weaned off with fluids.  He
as
given Vanc PO, Linezolid, Clindamycin, Cipro, and Zosyn.  CT ABD
consistent with diffuse scrotal edema with large fluid
collection
in the right wall of the scrotum. The patient was transferred to
the [**Hospital1 18**] SICU hemodynamically stable for definitive treatment.

MEDICAL HISTORY: PMH: CKD V from diabetic nephropathy (HD since [**5-/2183**]), DM2 (20
yrs, on insulin), Hepatitis C genotype 4, Cirrhosis (portal
hypertensive gastropathy, grade I varices on EGD), h/o ischemic
colitis with GIB (approx [**2180**]), small bowel AVMs, HTN, h/o TB
(age 15, Rx with PAS/INH x 2 yrs), Hep B core Ab positive
(negative viral load in [**2185**]), h/o IV drug use (heroin,
methadone
since [**2159**]), AV fistula infection , VRE and MRSA, Chronic
anemia, MSSA HD line infection, prior ESBL Klebsiella wound
infections, recent osteomyelitis of left finger, new pancreatic
head mass (CT [**2190-8-6**])

MEDICATION ON ADMISSION: CINACALCET 30 qdaily, LOMOTIL, DOXEPIN 10 mg qHS, FOLIC ACID
1 mg qdaily, GABAPENTIN 300 mg qod, INSULIN GLARGINE [LANTUS]
INSULIN LISPRO [HUMALOG], METHADONE 20 mg QID, OMEPRAZOLE,
RENAGEL 2400 mg TID, SUCRALFATE 1 gram QID, VANCOMYCIN 1 gram IV
qHD per HD protocol, VICADIN, B COMPLEX VITAMINS one Capsule(s)
by mouth daily, CYANOCOBALAMIN (VITAMIN B-12) 500 mcg daily,
FERROUS SULFATE 325 mg (65 mg iron) daily,
FERROUS SULFATE, IMODIUM A-D

ALLERGIES: Cephalosporins / Metoclopramide / Infed

PHYSICAL EXAM: VS: T 96  HR  72  BP  130/46  RR 16 96% 4L NC
GEN: NAD, AAOx3
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, R. tunnelled HD line
HEART: RRR, S1/S2
ABD: soft, ND, NT, BS present
Groin: significant scrotal swelling, diffusely tender, 5x6 cm
area of necrotic skin over right scrotum, active ? purulent
drainage from bottom, left scrotum
EXT: B/L BKA, no edema

FAMILY HISTORY: Several siblings with diabetes

SOCIAL HISTORY: Retired computer worker. Smokes [**12-26**] PPD cigarettes x 10+ years;
denies alcohol or current polysubstance use; former IVDU. Came
to [**Hospital1 18**] from [**Hospital1 1501**] the Embassy House rehab in [**Hospital1 1474**].
Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Unspecified protein-calorie malnutrition,Other inflammatory disorders of male genital organs,Sepsis,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Pressure ulcer, lower back,Below knee amputation status,Other finger(s) amputation status
Septicemia NOS,End stage renal disease,Hyp kid NOS w cr kid V,Portal hypertension,Protein-cal malnutr NOS,Male gen inflam dis NEC,Sepsis,DMII renl nt st uncntrld,Renal dialysis status,Chrnc hpt C wo hpat coma,Cirrhosis of liver NOS,Anemia NOS,Athscl extrm ntv art NOS,Pressure ulcer, low back,Status amput below knee,Status amput oth fingers
Admission Date:  [**2190-9-1**]              Discharge Date:   [**2190-9-15**]

Date of Birth:  [**2125-5-16**]             Sex:   M

Service: SURGERY

Allergies:
Cephalosporins / Metoclopramide / Infed

Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Scrotal abscess

Major Surgical or Invasive Procedure:
[**2190-9-1**] Incision and drainage of scrotal abscess, skin
debridgement
[**2190-9-2**] Further debridement of scrotal tissue

History of Present Illness:
This is a 65 M c/ pmh of hepatitis C/cirrhosis, ESRD, DM,
PVD, who presented to the [**Hospital1 1474**] ED on [**2190-8-31**] complaining of
scrotal swelling and tenderness. The patient states that the
tenderness presented last Thursday ([**8-26**]). He was seen by
hepatology on [**8-27**] with no testicular/scrotal swelling. Over the
weekend, the patient noticed increased scrotal swelling and
tenderness. At [**Hospital 1474**] Hospital, the patient was initially on
Levophed for hypotension which was weaned off with fluids.  He
as
given Vanc PO, Linezolid, Clindamycin, Cipro, and Zosyn.  CT ABD
consistent with diffuse scrotal edema with large fluid
collection
in the right wall of the scrotum. The patient was transferred to
the [**Hospital1 18**] SICU hemodynamically stable for definitive treatment.


Past Medical History:
PMH: CKD V from diabetic nephropathy (HD since [**5-/2183**]), DM2 (20
yrs, on insulin), Hepatitis C genotype 4, Cirrhosis (portal
hypertensive gastropathy, grade I varices on EGD), h/o ischemic
colitis with GIB (approx [**2180**]), small bowel AVMs, HTN, h/o TB
(age 15, Rx with PAS/INH x 2 yrs), Hep B core Ab positive
(negative viral load in [**2185**]), h/o IV drug use (heroin,
methadone
since [**2159**]), AV fistula infection , VRE and MRSA, Chronic
anemia, MSSA HD line infection, prior ESBL Klebsiella wound
infections, recent osteomyelitis of left finger, new pancreatic
head mass (CT [**2190-8-6**])

PSH: S/p bilat BKA ([**2179**], [**2183**]) for polymicrobial chronic
osteomyelitis; wears prostheses and uses walker, s/p penectomy
for necrosis [**1-26**] arterial insufficiency, past AV fistulas/grafts

Social History:
Retired computer worker. Smokes [**12-26**] PPD cigarettes x 10+ years;
denies alcohol or current polysubstance use; former IVDU. Came
to [**Hospital1 18**] from [**Hospital1 1501**] the Embassy House rehab in [**Hospital1 1474**].

Family History:
Several siblings with diabetes

Physical Exam:
VS: T 96  HR  72  BP  130/46  RR 16 96% 4L NC
GEN: NAD, AAOx3
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, R. tunnelled HD line
HEART: RRR, S1/S2
ABD: soft, ND, NT, BS present
Groin: significant scrotal swelling, diffusely tender, 5x6 cm
area of necrotic skin over right scrotum, active ? purulent
drainage from bottom, left scrotum
EXT: B/L BKA, no edema


Pertinent Results:
[**2190-9-15**] 11:15AM BLOOD WBC-7.2 RBC-3.16* Hgb-9.0* Hct-29.1*
MCV-92 MCH-28.4 MCHC-30.9* RDW-19.7* Plt Ct-183
[**2190-9-7**] 05:08AM BLOOD PT-15.8* PTT-39.5* INR(PT)-1.4*
[**2190-9-14**] 08:00AM BLOOD Glucose-144* UreaN-26* Creat-3.4* Na-132*
K-4.7 Cl-94* HCO3-33* AnGap-10
[**2190-9-7**] 05:08AM BLOOD ALT-16 AST-33 AlkPhos-101 TotBili-0.6
[**2190-9-14**] 08:00AM BLOOD Calcium-7.2* Phos-3.7 Mg-2.4
[**2190-9-14**] 08:00AM BLOOD Vanco-19.9

Brief Hospital Course:
The patient was transferred to the [**Hospital1 18**] SICU from [**Hospital 1474**]
Hospital with a significant right scrotal abscess. He was
hemondynamically stable on transfer and was taken to the OR soon
after for debridement of his scrotal abscess, which was
concerning for Fournier's gangrene. The patient had an incision
and drainage of the scrotal abscess, in addition to debridement
of necrotic skin on his right scrotum. He was transferred back
to the SICU intubated, but hemodynamically stable. On the POD1,
the patient returned to the OR for further debridement. He was
extubated on POD2/1 and continued to remain hemodynamically
stable. With regards to organ systems:

Neuro: The patient was started on IV methadone, [**12-26**] his PO dose.
He received IV morphine prn for pain. Once extubated, he was
restarted on his home PO dose of methadone with prn iv morphine.


CV: Hemodynamically stable.

Pulm: The patient remained intubated on POD0 with intention of
returning to the OR. He was extubated on POD2/1 after having his
Dobhoff tube placed by IR.

GI/FEN: While intubated, the patient was given minimal fluids
due to this ESRD and HD requirement. On POD2/1, a post-pyloric
Dobhoff was placed by IR due to coiling of the Dobhoff when
placed in SICU. He was started on Nutren 2.0 with 21g
Beneprotein. Formula was later changed to Novasource Renal at
35ml/hour. The tube was pulled out once and replaced with tip
post pyloric by xray on [**9-13**]. He experienced diarrhea. Stools
were negative for C.diff x3. Lomotil and immodium (home doses)
were resumed for chronic diarrhea. Oral vancomycin was resumed
as well for suppression of c.diff while on antibiotics. A
Flexiceal was in place most of the hospital course for diarrhea.


GU: The patient requires HD. HD was continued on
Tues-Thursday-Sat scheduled treatments. Last dialysis treatment
was [**9-14**]. IV Vanco was administered during dialysis sessions.

Heme: The patient had a coagulopathy on admission. However, he
did not experience any issues with bleeding.

ID: Due to the concern for Fournier's gangrene, infectious
diseases were immediately consulted. They recommended starting
the patient IV Vanc/Clinda/Zosyn. He was also started on PO
Vanco for C. Diff prophylaxis (prior history of C. Diff). Since
he received Vanco without HD, his levels were initially high.
Gram stain of the scrotal fluid and swab were GPC, GPR, GNR.
Culture isolated staph coag negative and enterococcus (low
numbers). Zosyn was stopped on [**9-15**]. IV Vancomycin was continued
given prior MRSA infection of hand in [**8-3**]. Vanco started [**8-1**]
with 6 week course recommended. He will continue on Vancomycin
until f/u with ID on [**9-21**].

ENDO: The patient has DM2 and is being covered initially by an
insulin drip then he was converted to glargine and humalog
sliding scale with glucoses ranging between 75-140.

Skin: Scrotal abscess was vac'd using white sponge on testes and
black sponge on the scrotum. Last vac change demonstrated
granulation on [**9-13**]. Suction was set at 75mmHg. He does have h/o
of prior penectomy for necrosis [**1-26**] arterial insufficiency.

He also had a stage 2 sacral decubitus that was treated with
Mepilex with some improvement.

PT: recommended rehab. See PT notes.

Dispo: A bed became available at [**Hospital 100**] Rehab and he was
transferred there on [**9-15**] in stable condition.



Medications on Admission:
CINACALCET 30 qdaily, LOMOTIL, DOXEPIN 10 mg qHS, FOLIC ACID
1 mg qdaily, GABAPENTIN 300 mg qod, INSULIN GLARGINE [LANTUS]
INSULIN LISPRO [HUMALOG], METHADONE 20 mg QID, OMEPRAZOLE,
RENAGEL 2400 mg TID, SUCRALFATE 1 gram QID, VANCOMYCIN 1 gram IV
qHD per HD protocol, VICADIN, B COMPLEX VITAMINS one Capsule(s)
by mouth daily, CYANOCOBALAMIN (VITAMIN B-12) 500 mcg daily,
FERROUS SULFATE 325 mg (65 mg iron) daily,
FERROUS SULFATE, IMODIUM A-D


Discharge Medications:
1. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: Three
[**Age over 90 **]y Five (325) mg PO DAILY (Daily).
7. Cyanocobalamin (Vitamin B-12) 500 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day).
12. Doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): empiric.
14. Loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times
a day) as needed for diarrhea.
15. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
17. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: Two (2)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
18. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
19. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous HD PROTOCOL (HD Protochol): administer at
hemodialysis sessions thru [**9-21**]. started [**2190-8-1**] for MRSA L hand.

20. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
21. Insulin Lispro 100 unit/mL Solution Sig: follow sliding
scale orders  Subcutaneous four times a day.
22. Tunnelled hemodialysis line care
per protocol


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
ESRD
DM
Scrotal abscess
Malnutrition
HCV cirrhosis
MRSA hand infection
Sacral decubitus

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You will be transferring to [**Hospital 100**] Rehab today
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you develop
any of the listed warning signs
Penile/scrotal wound vac dressing will continue


Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2190-9-21**] 11:10

Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2190-9-24**] 1:40

Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2191-1-31**] 11:00



Completed by:[**2190-9-15**]
{'Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Unspecified protein-calorie malnutrition,Other inflammatory disorders of male genital organs,Sepsis,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Pressure ulcer, lower back,Below knee amputation status,Other finger(s) 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: Scrotal abscess

PRESENT ILLNESS: This is a 65 M c/ pmh of hepatitis C/cirrhosis, ESRD, DM,
PVD, who presented to the [**Hospital1 1474**] ED on [**2190-8-31**] complaining of
scrotal swelling and tenderness. The patient states that the
tenderness presented last Thursday ([**8-26**]). He was seen by
hepatology on [**8-27**] with no testicular/scrotal swelling. Over the
weekend, the patient noticed increased scrotal swelling and
tenderness. At [**Hospital 1474**] Hospital, the patient was initially on
Levophed for hypotension which was weaned off with fluids.  He
as
given Vanc PO, Linezolid, Clindamycin, Cipro, and Zosyn.  CT ABD
consistent with diffuse scrotal edema with large fluid
collection
in the right wall of the scrotum. The patient was transferred to
the [**Hospital1 18**] SICU hemodynamically stable for definitive treatment.

MEDICAL HISTORY: PMH: CKD V from diabetic nephropathy (HD since [**5-/2183**]), DM2 (20
yrs, on insulin), Hepatitis C genotype 4, Cirrhosis (portal
hypertensive gastropathy, grade I varices on EGD), h/o ischemic
colitis with GIB (approx [**2180**]), small bowel AVMs, HTN, h/o TB
(age 15, Rx with PAS/INH x 2 yrs), Hep B core Ab positive
(negative viral load in [**2185**]), h/o IV drug use (heroin,
methadone
since [**2159**]), AV fistula infection , VRE and MRSA, Chronic
anemia, MSSA HD line infection, prior ESBL Klebsiella wound
infections, recent osteomyelitis of left finger, new pancreatic
head mass (CT [**2190-8-6**])

MEDICATION ON ADMISSION: CINACALCET 30 qdaily, LOMOTIL, DOXEPIN 10 mg qHS, FOLIC ACID
1 mg qdaily, GABAPENTIN 300 mg qod, INSULIN GLARGINE [LANTUS]
INSULIN LISPRO [HUMALOG], METHADONE 20 mg QID, OMEPRAZOLE,
RENAGEL 2400 mg TID, SUCRALFATE 1 gram QID, VANCOMYCIN 1 gram IV
qHD per HD protocol, VICADIN, B COMPLEX VITAMINS one Capsule(s)
by mouth daily, CYANOCOBALAMIN (VITAMIN B-12) 500 mcg daily,
FERROUS SULFATE 325 mg (65 mg iron) daily,
FERROUS SULFATE, IMODIUM A-D

ALLERGIES: Cephalosporins / Metoclopramide / Infed

PHYSICAL EXAM: VS: T 96  HR  72  BP  130/46  RR 16 96% 4L NC
GEN: NAD, AAOx3
HEENT: dry mucous membranes, no scleral icterus
CHEST: CTA B/L, R. tunnelled HD line
HEART: RRR, S1/S2
ABD: soft, ND, NT, BS present
Groin: significant scrotal swelling, diffusely tender, 5x6 cm
area of necrotic skin over right scrotum, active ? purulent
drainage from bottom, left scrotum
EXT: B/L BKA, no edema

FAMILY HISTORY: Several siblings with diabetes

SOCIAL HISTORY: Retired computer worker. Smokes [**12-26**] PPD cigarettes x 10+ years;
denies alcohol or current polysubstance use; former IVDU. Came
to [**Hospital1 18**] from [**Hospital1 1501**] the Embassy House rehab in [**Hospital1 1474**]. 

### Response:
{'Unspecified septicemia,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Portal hypertension,Unspecified protein-calorie malnutrition,Other inflammatory disorders of male genital organs,Sepsis,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Renal dialysis status,Chronic hepatitis C without mention of hepatic coma,Cirrhosis of liver without mention of alcohol,Anemia, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Pressure ulcer, lower back,Below knee amputation status,Other finger(s) amputation status'}
