CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: 55yM with h/o DM2 and gastroparesis, here with abdominal
pain.  Pain is chronic and he was going to see a
Gastroenterologist this week.  However, he developed more acute
LLQ pain and N/V this past few days.  Also noted some right
buttock and scrotal pain.  Was initially admitted to the medical
service
with surgical consultation for concern of perirectal infection
vs. Fourniers Gangrene.  He had an unremarkable CT scan at
admission, but he was mildly septic with a HR in the 120s and BP
in the 90s which both responded to fluid challenge.

MEDICAL HISTORY: PMH: DM2, gastroparesis, MRSA infections, kidney stones, HTN,
Hyperchol.
.
PSH: left knee replacement

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]:Norvasc 10', Lasix 40', Neurontin 300'', Amaryl 4', Levsin
0.5''' prn, Lantus 38U'', Lisinopril 5', Reglan 10'''',
Lopressor
50'',Zocor 40'.
.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On presentation:
VS: T: 98.0 BP: 104/61 P: 96 R: 18 O2: 100% on 2L
PE:
Gen: mild distress, warm, AAOx3
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, LLQ mild TTP, no rebound or guarding, nondistended
Rectal: unable to perform rectal.  Entire right buttock very
indurated with some spreading erythema.  Posterior scrotum firm
as well and painful.  No crepitus palpated.  No spontaneous
drainage.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Unspecified septicemia,Acute respiratory failure,Necrotizing fasciitis,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Vascular disorders of male genital organs,Severe sepsis,Leukocytosis, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic kidney disease, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Gastroparesis,Pure hypercholesterolemia,Knee joint replacement
Septicemia NOS,Acute respiratry failure,Necrotizing fasciitis,Ac on chr diast hrt fail,Ac posthemorrhag anemia,Acute kidney failure NOS,Delirium d/t other cond,Urin tract infection NOS,Male gen vascul dis NEC,Severe sepsis,Leukocytosis NOS,Oth gram negatv bacteria,Chronic kidney dis NOS,Hx Methicln resist Staph,Hy kid NOS w cr kid I-IV,DMII neuro uncntrld,Gastroparesis,Pure hypercholesterolem,Joint replaced knee
Admission Date:  [**2177-12-9**]              Discharge Date:   [**2177-12-30**]

Date of Birth:  [**2121-12-28**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
[**2177-12-9**] INCISION + DRAINAGE OF PERINEUM WITH EXTENSIVE SOFT
TISSUE DEBRIDEMENT [**Doctor Last Name **]
[**2177-12-10**] WASHOUT & DEBRIDEMENT PERINEUM [**Doctor Last Name **]
[**2177-12-11**] Incision, drainage and washout of infected rectum and
perineum, laparotomy with diverting sigmoid colostomy. [**Doctor Last Name **]
[**2177-12-12**] RESETTING OF TESTICLES & PLACEMENT OF WOUND VAC [**Doctor Last Name **]
[**2177-12-18**] percutaneous tracheostomy, flexible bronchoscopy,
debridement and washout of perineal / buttock wound [**Doctor Last Name **]
[**2177-12-19**] I&D PERINEUM, WOUND VAC DRESSING PLACEMENT


History of Present Illness:
55yM with h/o DM2 and gastroparesis, here with abdominal
pain.  Pain is chronic and he was going to see a
Gastroenterologist this week.  However, he developed more acute
LLQ pain and N/V this past few days.  Also noted some right
buttock and scrotal pain.  Was initially admitted to the medical
service
with surgical consultation for concern of perirectal infection
vs. Fourniers Gangrene.  He had an unremarkable CT scan at
admission, but he was mildly septic with a HR in the 120s and BP
in the 90s which both responded to fluid challenge.


Past Medical History:
PMH: DM2, gastroparesis, MRSA infections, kidney stones, HTN,
Hyperchol.
.
PSH: left knee replacement


Family History:
Noncontributory

Physical Exam:
On presentation:
VS: T: 98.0 BP: 104/61 P: 96 R: 18 O2: 100% on 2L
PE:
Gen: mild distress, warm, AAOx3
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, LLQ mild TTP, no rebound or guarding, nondistended
Rectal: unable to perform rectal.  Entire right buttock very
indurated with some spreading erythema.  Posterior scrotum firm
as well and painful.  No crepitus palpated.  No spontaneous
drainage.


Pertinent Results:
IMAGING:
[**12-8**] CXR: No acute cardiopulmonary process. No evidence of free
air
beneath the diaphragms.
[**12-8**] KUB: pending
[**12-8**] CT ABD/PELVIS: 1. Bilateral small pleural effusions. 2. No
small-bowel obstruction. 3. Non-specific fat stranding about the
kidneys. Delayed contrast excretion. 4. Foley catheter and air
within the urinary bladder could be from placement of Foley;
correlate clinically. 5. Non obstructive 2mm stone at the lower
pole of left kidney.
[**12-9**] SCROTAL U/S: Extensive hyperechoic foci tracking to the
floor of the perineum concerning for gas w/in the scrotal cavity
and Fournier's. No fluid collection to suggest an abscess.
[**12-10**]: CXR:New right IJ catheter tip is in the upper-to-mid SVC
and there is no evidence of pneumothorax. ET tube tip is 6.6 cm
above the carina. NG tube tip is out of view below the
diaphragm, difficult to visualize. Cardiac silhouette is
unchanged. Mild pulmonary edema has worsened. Left lower lobe
retrocardiac opacity has worsened, consistent with worsening
atelectasis. Bilateral pleural effusions are small.
[**12-10**]:abd Xray:Motion artifact, unable to visualize nasogastric
tube. Recommend repeat imaging to further assess.
[**12-11**] ECHO:LA severely increased,RA is moderately dilated, mild
symm LVH with normal cavity size, moderate regional left
ventricular sys dysfunction with hypokinesis of the basal
anterior, anteroseptal and lateral walls and of the inferior
septum. increased left ventricular filling pressure
(PCWP>18mmHg). RV dilated.Aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mitral valve
leaflets are mildly thickened. Mild (1+) MR, moderate pulmonary
artery systolic hypertension, small to moderate sized
pericardial effusion
[**12-11**]: CXR: Persistent retrocardiac opacity, can't exclude
infectious process
[**12-11**]: ABD: G tube in gastric antrum
[**12-12**] CXR: Continued evidence of increased pulmonary venous
pressure with substantial enlargement of the cardiac silhouette.
There is continued opacification in the retrocardiac region
incompletely silhouetting the hemidiaphragm. Again this is
consistent with some combination of atelectasis, pneumonia, and
pleural effusion.
[**12-14**]: CXR: Mild pulmonary edema, most readily visible in the
right lung has improved. Moderate cardiomegaly and mediastinal
vascular engorgement have decreased slightly. Left lower lobe is
still collapsed.
[**12-15**]: CXR: cardiomegaly unchanged, diffuse b/l alveolar
opacities likely representing pulmonary edema worsening, LLL
atelectasis
[**12-15**]: KUB: tip of OGT in antrum of stomach
[**12-16**] CXR:e/o elevated pulmonary venous pressure. Extensive
opacification at the left base is consistent with volume loss in
the left lower lobe and pleural effusion
[**12-17**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
[**12-18**] CXR:enlarged cardiac shadow, decreased lung vol, LL
collapsed, minimal left pleural eff.
11/25CXR:As compared to the previous radiograph, the
endotracheal tube has been removed and replaced by a
tracheostomy tube. The tip of the tube is projecting 4.8 cm
above the carina. Unchanged course and position of the
nasogastric tube and of the right-sided central venous access
line. There is no evidence of complications, notably no
pneumothorax. Unchanged severe cardiomegaly with a small left
pleural effusion and left lower lobe atelectasis. No newly
appeared focal parenchymal opacities suggesting pneumonia.
[**12-20**]: CXR: No acute changes.
[**12-21**]: CXR: New large RLL consolidation consistent with
aspiration.
[**12-21**]: KUB: NG tube tip is in the proximal stomach
[**12-22**] CXR: Consolidation RML RLL, pulmonary edema periphery
right lung as well as the left has improved. Mod cardiomegaly
improved. Trach tube abuts right tracheal wall. RIJ line can be
traced junction of brachiocephalic veins. feeding tube w/ wire
stylet in place passes into stomach and out of view.

[**2177-12-29**] Chest
FINDINGS: In comparison with the study of [**12-23**], the monitoring
and support devices remain in place. There is continued
enlargement of the cardiac silhouette with elevation of
pulmonary venous pressure and bilateral pleural effusions more
prominent on the left. The more focal opacification in the right
mid zone is not appreciated at this time

[**2177-12-9**] 06:50PM   GLUCOSE-154* UREA N-59* CREAT-2.9* SODIUM-133
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
[**2177-12-9**] 06:50PM   CALCIUM-7.9* PHOSPHATE-4.4 MAGNESIUM-1.7
[**2177-12-9**] 06:50PM   WBC-18.9* RBC-2.77* HGB-8.4* HCT-25.0* MCV-90
MCH-30.2 MCHC-33.6 RDW-14.2
[**2177-12-9**] 06:50PM   NEUTS-80* BANDS-11* LYMPHS-1* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2177-12-9**] 06:50PM   PLT SMR-NORMAL PLT COUNT-249
[**2177-12-9**] 06:50PM   PT-13.1 PTT-22.5 INR(PT)-1.1
[**2177-12-9**] 04:55AM   %HbA1c-8.1* eAG-186*
[**2177-12-8**] 09:30PM   GLUCOSE-549* UREA N-57* CREAT-2.0*
SODIUM-131* POTASSIUM-4.4 CHLORIDE-94* TOTAL CO2-27 ANION GAP-14
[**2177-12-8**] 09:30PM   ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-110 TOT
BILI-0.5

Brief Hospital Course:
Patient seen by acute care surgical team and was admitted for
ICU management and aggressive debridement.
ICU Course as follows per dictation of Dr. [**First Name8 (NamePattern2) 7656**] [**Name (STitle) **]:
[**12-9**]: admission to TSICU. R IJ CVL placed. Transfused 2U
overnight.
[**12-10**]: s/p further debridement in OR, upon transfer back to ICU
pt was hypotensive- received Calcium, neo, ephedrine by
anesthesia
[**12-11**]: Went to OR for debridement and colostomy. Plan to return
to the OR tomorrow. Tissue culture is growing coag negative
staph. Echo today showed EF of 35-40%. Post op he did well, but
Hct dropped to 25 from 30 and he was started back on Neo to
maintain MAPs>65. As a result, he received 1 unit PRBCs.
[**12-12**]: went to OR for further debridement. started TFs postop.
started NPH [**8-31**] in addition to insulin gtt.
[**12-13**]:[**Last Name (un) **] consulted,erythromycin started for high TF
residuals in pt with h/o gastroparesis
[**12-14**]: Started on statin and Lopressor, ASA increased to 325.
IVF and albumin were DC'd and he was started on Lasix 20 [**Hospital1 **].
required 2 additional doses of Lasix, but still did not diurese
well. He was down 1L as of midnight. He was somewhat
uncomfortable overnight but increasing the propofol/fentanyl
resulted in respiratory depression. As a result, he was put back
on a rate with improved ABG.
[**12-15**]: Lasix held. bedside VAC changed by ASC team. Aline
replaced.
[**12-16**]: CPAP, Started on Clonidine, ACS repaired vac leakage, TF
at goal
[**12-17**]: VAC taken down at bedside by ACS.
[**12-18**]: went to OR for repeat debridement, did not reapply VAC
given plans to return to OR again [**12-19**].
[**12-19**]: hct 20.5, transfused 2units, increased clonidine to
0.3TID, went to OR for debridement, all Abx dc'ed per ACS
[**12-20**]: 1U PRBC, did have periods of hypertension and tachycardia
at first thought to be related to pain. His fentanyl drip was
maximized, but he still was uncomfortable. Per discussion with
Dr. [**Last Name (STitle) 35981**], we decided to start on methadone, continued
clonidine, and due to some abdominal distention, started
relistor. He passed gas, but not much increase in stool via
ostomy. Was more calm after the methadone. Pulled out NGT
partially, it was replaced and CXR obtained
[**12-21**]: pt had several episodes of emesis with increased
abdominal distention and minimal ostomy output. TFs were held
and meds were switched to IV. pt continued to have projectile
vomiting despite NGT sumping well. Erythro changed to Reglan.
given another dose of methylnaltrexone in the evening.
[**12-22**]: Bedside VAC change. Methadone increased. D/c Dilaudid.
Diuresis.
[**12-23**]: NGT clamped for 4 hrs;XR KUB- unchanged position of NGT;
restarted TF.
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________________________________________________________________

He was transferred to the regular nursing unit on [**2177-12-23**]:
His course as follows by systems per dictation by [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**],
NP:

Neuro-he was noted to be delirious felt to be multifactorial.
His physical exam, meds and labs were reviewed carefully. The
decision was made to stop the methadone IV that was started
while in the ICU for control of his acute pain issues. He
actually had minimal pain issues once transferred to the floor
requiring only in rare occasion oral Dilaudid. He remains on a
Clonidine patch which was also started during his ICU stay for
helping to control agitation; this should be weaned once he is
at rehab. His mental status over the course of his stay on the
floor has improved significantly. He is very alert and oriented
x2-3 and cooperative with his care.

Cardiac-his blood pressure and heart rate have been relatively
stable with SBP 140's-150's, DBP 70's-80's, he continues on his
Norvasc and Lisinopril. There are currently no acute issues at
time of this dictation.

Respiratory-he continues with a trach and receives humidified
air, his saturations have been stable ranging 95-99%. he wears a
Passy-Muir valve for speaking. He should continue on his prn
nebulizer treatments.

Gastrointestinal-patient self removed his Dobbhoff. it was
decided that he be evaluated by Speech given that his mental
status improved. He was placed on a dysphagia diet of soft
solids with thin liquids. He has required 1:1 supervision for
meals. His colostomy care was followed closely by the Wound Care
Ostomy Nurse during his stay.

Genitourinary-he is currently being treated for a UTI with a
total of 5 days of oral Cipro. His Foley catheter was replaced
on [**12-29**] and is being recommended to remain in place because of
his extensive perineal wound.

Musculoskeletal-there are no active issues. He was evaluated and
seen regularly by Physical and Occupational therapy and is being
recommended for acute rehab.

Integumentary-he has an extensive wound that has required VAC
dressing since his surgery. For transfer to rehab he has a wet
to dry, but this should be changed back to the VAC @125 once at
rehab.

Endocrine-he intermittently had elevated blood sugars requiring
adjustment of his standing and insulin sliding scales.

Heme-his hematocrits have been low but stable with a recent Hct
of 25.4 on [**12-29**] which is up from 24.9 on [**12-28**]. He is not showing
any signs of active bleeding.

Prophylaxis-he is receiving Heparin for DVT prophylaxis.


Medications on Admission:
[**Last Name (un) 1724**]:Norvasc 10', Lasix 40', Neurontin 300'', Amaryl 4', Levsin
0.5''' prn, Lantus 38U'', Lisinopril 5', Reglan 10'''',
Lopressor
50'',Zocor 40'.
.


Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
3. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. hyoscyamine sulfate 0.125 mg Tablet Sig: 2-3 Tablets PO TID
(3 times a day) as needed for GI spasm .
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30)
ML's PO twice a day as needed for constipation.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
16. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
18. NPH  Sig: Twelve (12) units Injection at breakfast.
19. NPH  Sig: Sixteen (16) units Injection at supper.
20. Humalog 100 unit/mL Solution Sig: One (1) dose Subcutaneous
four times a day as needed for per sliding scale: see attached
sliding scale.
21. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-29**]
hours as needed for pain .


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Fournier's gangrene
Respiratory failure
Urinary tract infection
Acute blood loss anemia

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

Discharge Instructions:
You were hospitalized with a severe infection in your
scrotal/perineal region requiring an operation. As a result you
have an extensive wound that requires specialized dressing
changes and care.

It is important that you not sit for long periods of time
because of the location of your wounds.

Followup Instructions:
Follow up in [**Hospital 2536**] clinic in 2 weeks for evaluation of your wound;
call [**Telephone/Fax (1) 600**] for an appointment.


Completed by:[**2178-1-7**]
{'Unspecified septicemia,Acute respiratory failure,Necrotizing fasciitis,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Vascular disorders of male genital organs,Severe sepsis,Leukocytosis, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic kidney disease, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Gastroparesis,Pure hypercholesterolemia,Knee joint replacement'}


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: 55yM with h/o DM2 and gastroparesis, here with abdominal
pain.  Pain is chronic and he was going to see a
Gastroenterologist this week.  However, he developed more acute
LLQ pain and N/V this past few days.  Also noted some right
buttock and scrotal pain.  Was initially admitted to the medical
service
with surgical consultation for concern of perirectal infection
vs. Fourniers Gangrene.  He had an unremarkable CT scan at
admission, but he was mildly septic with a HR in the 120s and BP
in the 90s which both responded to fluid challenge.

MEDICAL HISTORY: PMH: DM2, gastroparesis, MRSA infections, kidney stones, HTN,
Hyperchol.
.
PSH: left knee replacement

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]:Norvasc 10', Lasix 40', Neurontin 300'', Amaryl 4', Levsin
0.5''' prn, Lantus 38U'', Lisinopril 5', Reglan 10'''',
Lopressor
50'',Zocor 40'.
.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On presentation:
VS: T: 98.0 BP: 104/61 P: 96 R: 18 O2: 100% on 2L
PE:
Gen: mild distress, warm, AAOx3
HEENT: anicteric
CV: RRR
Pulm: CTA b/l
Abd: soft, LLQ mild TTP, no rebound or guarding, nondistended
Rectal: unable to perform rectal.  Entire right buttock very
indurated with some spreading erythema.  Posterior scrotum firm
as well and painful.  No crepitus palpated.  No spontaneous
drainage.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Unspecified septicemia,Acute respiratory failure,Necrotizing fasciitis,Acute on chronic diastolic heart failure,Acute posthemorrhagic anemia,Acute kidney failure, unspecified,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Vascular disorders of male genital organs,Severe sepsis,Leukocytosis, unspecified,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic kidney disease, unspecified,Personal history of Methicillin resistant Staphylococcus aureus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Gastroparesis,Pure hypercholesterolemia,Knee joint replacement'}
