CHIEF COMPLAINT: Periurethral abscess, concern for Fournier's Gangrene

PRESENT ILLNESS: 67M who presented from OSH with 5 days of worsening scrotal
pain and swelling.  He states he was in his usual state of
health
when he started having worsening scrotal pain which made it
difficult to walk, prompting him to be evaluated at OSH.  He
underwent a scrotal ultrasound which showed scrotal wall
thickening with a WBC 15k, and he was transfered to [**Hospital1 18**] ED. He
received Vancomycin and Unasyn prior to transfer.  On arrival,
he
appears hemodynamically stable, and he has no SOB, CP, N/V, leg
pain.  He has had decreased appetite since yesterday evening.
His last oral intake was cabbage yesterday evening.  He denies
dysuria, hematuria, incomplete voiding, or other urinary
symptoms.

MEDICAL HISTORY: PMH: DM, HTN, ? Acute MI

MEDICATION ON ADMISSION: MEDS: Lisinopril 5 mg po qday, Metoprolol 25 mg po qday,
Glyburide 2.5 mg po qday, Simvastatin 20 mg po qday.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp: 98.1-99    HR: 61      BP: 144/75   RR: 16   Spo2: 94% RA
Gen: NAD, Alert and oriented x3
Neuro: CN II-XII
Cardiac: RRR, no mrg, + S1, S2
Lungs: CTA bilaterally, no resp distress
Abd: soft, NT, ND, no rebound/guarding
Suprapubic catheter intact and draining
L groin puncture site without bleeding or hematoma.
Extremities warm and well perfused
Dressing intact to periurital abcess

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home with wife
Aneurysm of iliac artery,Acute kidney failure, unspecified,Urethral abscess,Vascular disorders of male genital organs,Urethral stricture, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status
Iliac artery aneurysm,Acute kidney failure NOS,Urethral abscess,Male gen vascul dis NEC,Urethral stricture NOS,Abdom aortic aneurysm,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Aortic valve disorder,Crnry athrscl natve vssl,Status-post ptca
Admission Date:  [**2197-1-10**]              Discharge Date:   [**2197-1-19**]

Date of Birth:  [**2129-4-11**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Periurethral abscess, concern for Fournier's Gangrene

Major Surgical or Invasive Procedure:
Debridement of scrotal and periurethral abscess and open
placement of suprapubic urinary catheter, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**],
[**2197-1-10**].

[**2197-1-17**]
1. Ultrasound-guided puncture of the left common femoral
    artery.
2. Contralateral 3rd order catheterization of a branch of
    the right hypogastric artery.
3. Abdominal aortogram.
4. Selective arteriogram of the right hypogastric artery.
5. Coil embolization of the right hypogastric artery.
6. Closure of the left common femoral arteriotomy.

[**2197-1-17**]
Right hypogastric a. coil emobilization


History of Present Illness:
67M who presented from OSH with 5 days of worsening scrotal
pain and swelling.  He states he was in his usual state of
health
when he started having worsening scrotal pain which made it
difficult to walk, prompting him to be evaluated at OSH.  He
underwent a scrotal ultrasound which showed scrotal wall
thickening with a WBC 15k, and he was transfered to [**Hospital1 18**] ED. He
received Vancomycin and Unasyn prior to transfer.  On arrival,
he
appears hemodynamically stable, and he has no SOB, CP, N/V, leg
pain.  He has had decreased appetite since yesterday evening.
His last oral intake was cabbage yesterday evening.  He denies
dysuria, hematuria, incomplete voiding, or other urinary
symptoms.


Past Medical History:
PMH: DM, HTN, ? Acute MI

PSH: Per pt has Hx of "stenting" of vessel after left Arm pain,
but does not believe stent in heart, thinks in arm.


Social History:
Lives at home with wife

Family History:
Non-contributory

Physical Exam:
Temp: 98.1-99    HR: 61      BP: 144/75   RR: 16   Spo2: 94% RA
Gen: NAD, Alert and oriented x3
Neuro: CN II-XII
Cardiac: RRR, no mrg, + S1, S2
Lungs: CTA bilaterally, no resp distress
Abd: soft, NT, ND, no rebound/guarding
Suprapubic catheter intact and draining
L groin puncture site without bleeding or hematoma.
Extremities warm and well perfused
Dressing intact to periurital abcess

Pertinent Results:
[**2197-1-18**] 06:20AM BLOOD Hct-32.7*
[**2197-1-15**] 05:40AM BLOOD WBC-7.7 RBC-3.49* Hgb-10.7* Hct-30.8*
MCV-88 MCH-30.6 MCHC-34.7 RDW-14.2 Plt Ct-236
[**2197-1-10**] 07:54PM BLOOD Neuts-88.8* Lymphs-5.7* Monos-4.4 Eos-1.0
Baso-0.2
[**2197-1-15**] 05:40AM BLOOD Plt Ct-236
[**2197-1-11**] 01:56AM BLOOD PT-14.4* PTT-28.9 INR(PT)-1.3*
[**2197-1-18**] 06:20AM BLOOD UreaN-16 Creat-1.6* K-4.0
[**2197-1-16**] 06:15AM BLOOD Glucose-108* UreaN-20 Creat-1.6* Na-144
K-4.0 Cl-105 HCO3-31 AnGap-12
[**2197-1-11**] 08:03AM BLOOD CK(CPK)-131
[**2197-1-11**] 08:03AM BLOOD CK-MB-3 cTropnT-<0.01
[**2197-1-16**] 06:15AM BLOOD Calcium-7.9* Mg-2.0
[**2197-1-10**] 12:45PM BLOOD %HbA1c-6.3*
[**2197-1-14**] 06:05AM BLOOD Vanco-16.0
[**2197-1-12**] 01:47AM BLOOD Type-ART pO2-196* pCO2-49* pH-7.33*
calTCO2-27 Base XS-0
[**2197-1-10**] 06:00PM BLOOD Hgb-11.0* calcHCT-33
[**2197-1-12**] 01:47AM BLOOD freeCa-1.07*

Radiology Report CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND
RECONS Study Date of [**2197-1-16**] 10:23 AM


[**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] 12R [**2197-1-16**] 10:23 AM
CTA AORTA/BIFEM/ILIAC RUNOFF W   Clip # [**Clip Number (Radiology) 84126**]
Reason: pre-op eval for large iliac artery aneurysms.
Contrast: OPTIRAY



[**Hospital 93**] MEDICAL CONDITION:
   67 year old man with large bilateral iliac artery aneurysms.
Please get CTA of
   ENTIRE aorta with bilateral runoff.
REASON FOR THIS EXAMINATION:
   pre-op eval for large iliac artery aneurysms.
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Final Report
CLINICAL INDICATION: Bilateral iliac artery aneurysms.

TECHNIQUE: MDCT was performed from the upper abdomen through
bilateral feet
prior to and following the uneventful administration of nonionic
intravenous
contrast and oral contrast. Curved multiplanar reformations and
volume
rendered images were performed in the 3D imaging lab.

Comparison is made to prior CT of the pelvis performed [**1-10**], [**2196**].

FINDINGS: The liver is diffusely decreased in attenuation,
consistent with
hepatic steatosis. There are no focal lesions within the
visualized portions
of the liver and spleen. The kidneys, adrenal glands, pancreas
are
unremarkable. The gallbladder is contracted. There are no
pathologically
enlarged lymph nodes by size criteria. The abdominal bowel loops
are grossly
unremarkable and there is no free fluid.

PELVIS: There are new midline surgical staples and there is a
new suprapubic
catheter. Prostatic calcifications are noted. There has been
interval
debridement of the perineum with interval resolution of
previously seen fluid
collections. New foci of gas are noted, likely post-surgical.
There is no
pelvic free fluid. There are large bilateral inguinal lymph
nodes, likely
reactive.

Bone windows demonstrate degenerative changes of the spine.
There are no
focal suspicious lesions.

CTA: There is mild atherosclerotic change at the origins of the
celiac artery
and SMA, which remain patent. The renal arteries are patent
bilaterally.
There is a small area of focal ulcerating plaque adjacent to the
left renal
artery. There is a large infrarenal aortic aneurysm, measuring
7.3 cm in
maximum transverse dimension. AAA volume is 704 mL. Again noted
are large
bilateral common iliac artery aneurysms, right greater than
left. There are
multifocal areas of high density within the right common iliac
artery aneurysm
sac seen on pre-contrast images, consistent with calcification.
No definite
areas of contrast leak are identified on post-contrast images.
The right
common iliac artery aneurysm measures 8.4 x 8.2 cm, and the left
common iliac
artery aneurysm measures 5.4 x 5.3 cm. There is aneurysmal
dilatation of the
proximal right internal iliac artery measuring 2.0 cm. Both
external and
internal iliac arteries are patent, as are the common femoral
arteries. There
is suboptimal contrast within the superficial femoral arteries,
but these do
appear grossly patent bilaterally, with scattered areas of
atherosclerotic
calcification.

The right popliteal artery is patent, as are the anterior and
posterior tibial
and peroneal arteries. The right plantar and dorsal arches are
patent.

The left popliteal, posterior tibial and peroneal arteries are
patent
throughout. The left anterior tibial artery is patent proximally
then
occludes in its mid portion. The left plantar arch is patent and
there is a
very small left dorsal arch.

IMPRESSION:
1. Large infrarenal aortic and bilateral common iliac artery
aneurysms.
2. Three-vessel runoff on the right and two-vessel runoff on the
left.
3. Interval debridement of the perineum with interval resolution
of
previously seen fluid collections. New small foci of gas are
likely post-
surgical.
4. Hepatic steatosis.


The study and the report were reviewed by the staff radiologist.


DR. [**First Name4 (NamePattern1) 674**] [**Last Name (NamePattern1) 20058**]
DR. [**First Name (STitle) 8913**] SUN
Approved: TUE [**2197-1-17**] 8:41 AM

  Imaging Lab

[**2197-1-12**]
Echo
[**Known lastname 84127**], [**Known firstname 84128**]       [**Hospital1 18**] [**Numeric Identifier 84129**]Portable TTE
(Complete) Done [**2197-1-12**] at 2:08:18 PM      FINAL
Referring Physician     [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Hospital1 **] C
[**Location (un) 830**], [**Hospital Ward Name 452**] 440
[**Location (un) 86**], [**Numeric Identifier 718**]  Status: Inpatient DOB: [**2129-4-11**]
Age (years): 67 M  Hgt (in): 64
BP (mm Hg): 113/55  Wgt (lb): 210
HR (bpm): 100  BSA (m2): 2.00 m2
Indication: Mitral valve disease. Murmur.
ICD-9 Codes: 785.2, 424.1, 424.2
Test Information
Date/Time: [**2197-1-12**] at 14:08    Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **],
RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Adequate
Tape #: 2009W078-0:58 Machine: Vivid [**7-27**]
Echocardiographic Measurements
Results  Measurements  Normal Range
Left Atrium - Long Axis Dimension:  3.6 cm  <= 4.0 cm
Left Atrium - Four Chamber Length:  *6.4 cm  <= 5.2 cm
Left Atrium - Peak Pulm Vein S:  0.8 m/s
Left Atrium - Peak Pulm Vein D:  0.6 m/s
Right Atrium - Four Chamber Length:  *5.2 cm  <= 5.0 cm
Left Ventricle - Septal Wall Thickness:  *1.2 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  *1.2 cm  0.6 - 1.1 cm

Left Ventricle - Diastolic Dimension:  5.3 cm  <= 5.6 cm
Left Ventricle - Systolic Dimension:  3.6 cm
Left Ventricle - Fractional Shortening:  0.32  >= 0.29
Left Ventricle - Ejection Fraction:  >= 55%  >= 55%
Left Ventricle - Stroke Volume:  111 ml/beat
Left Ventricle - Cardiac Output:  11.08 L/min
Left Ventricle - Cardiac Index:  5.54  >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E':  0.09 m/s  > 0.08 m/s
Left Ventricle - Septal Peak E':  *0.06 m/s  > 0.08 m/s
Left Ventricle - Ratio E/E':  15  < 15
Aorta - Sinus Level:  3.2 cm  <= 3.6 cm
Aorta - Ascending:  3.3 cm  <= 3.4 cm
Aortic Valve - Peak Velocity:  *4.2 m/sec  <= 2.0 m/sec
Aortic Valve - Peak Gradient:  *71 mm Hg  < 20 mm Hg
Aortic Valve - Mean Gradient:  36 mm Hg
Aortic Valve - LVOT pk vel:  1.50 m/sec
Aortic Valve - LVOT VTI:  32
Aortic Valve - LVOT diam:  2.1 cm
Aortic Valve - Valve Area:  *1.2 cm2  >= 3.0 cm2
Aortic Valve - Pressure Half Time:  204 ms
Mitral Valve - E Wave:  1.1 m/sec
Mitral Valve - A Wave:  1.2 m/sec
Mitral Valve - E/A ratio:  0.92
Mitral Valve - E Wave deceleration time:  210 ms  140-250 ms
TR Gradient (+ RA = PASP):  *38 mm Hg  <= 25 mm Hg

Findings
LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.

AORTIC VALVE: ?# aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Moderate AS (area
1.0-1.2cm2) Trace AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate PA
systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.

PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.

IMPRESSION: Moderate calcific aortic stenosis. Mild symmetric
left ventricular hypertrophy with normal global biventricular
systolic function. Moderate pulmonary hypertension.
  Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2197-1-12**] 16:13

Time Taken Not Noted     Log-In Date/Time: [**2197-1-10**] 8:39 pm
      SWAB      PERINEAL FLUID SWAB TRANSPORT.

                            **FINAL REPORT [**2197-1-14**]**

   GRAM STAIN (Final [**2197-1-10**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI IN
PAIRS.

   FLUID CULTURE (Final [**2197-1-13**]):
      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..
      STAPH AUREUS COAG +.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # 287-9905S
[**2197-1-10**].

   ANAEROBIC CULTURE (Final [**2197-1-14**]):    NO ANAEROBES ISOLATED.






Time Taken Not Noted     Log-In Date/Time: [**2197-1-10**] 8:19 pm
      ABSCESS     Site: URETHRA      PERI-URETHRAL/SCROTAL
ABSCESS.

   GRAM STAIN (Final [**2197-1-10**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS, CHAINS, AND
CLUSTERS.
      3+  (5-10 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      SMEAR REVIEWED; RESULTS CONFIRMED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.

   ANAEROBIC CULTURE (Final [**2197-1-16**]):
      Mixed bacterial flora-culture screened for B. fragilis, C.
      perfringens, and C. septicum.  None isolated.

   FLUID CULTURE (Final [**2197-1-15**]):
      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..
      STAPH AUREUS COAG +.    SPARSE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
         Please contact the Microbiology Laboratory ([**7-/2493**])
immediately if
         sensitivity to clindamycin is required on this
patient's isolate.

                              SENSITIVITIES: MIC expressed in
MCG/ML

[**1-11**]
Urine cx- neg
Blood cx x2 - neg

[**2197-1-10**]
MRSA Screen negative


Brief Hospital Course:
The patient was transferred to [**Hospital1 18**] with concern for Fournier's
Gangrene.  He underwent a CT scan with IV contrast which showed
periurethral abscess with additional collection in the perineum.
 Incidental finding of large bilateral iliac artery aneurysms
was noted.  He was taken emergently to the OR for debridment of
periurethral and perineal abscess and open placement of
suprapubic urinary catheter.  The case was uncomplicated -
please see dictated operative note for full details.
Postoperatively, he was brought to the T-SICU for aggressive
dressing changes.  He continued on Vancomycin and Zosyn while he
was inpatient.  He did well and was eventually transferred to
the floor in stable condition.  He underwent twice-daily
dressing changes with wet to dry dressings in the area of
debridement.  His suprapubic catheter continued to drain well.
The Cardiology consult service saw the patient for pre-operative
clearance for future management of his bilateral iliac artery
aneurysms.  He underwent a CT angiogram of the entire Aorta with
bilateral runoff at the request of the vascular surgery service.
 He continued to do well, and after his CT scan was reviewed by
the vascular surgery team, they felt that he required an
immediate coiling procedure.  He was transferred to the vascular
surgery service with the recommendations that he continue to
have twice daily dressing changes with wet to dry dressings and
be sent out on a 2 week course of oral Bactrim.


Medications on Admission:
MEDS: Lisinopril 5 mg po qday, Metoprolol 25 mg po qday,
Glyburide 2.5 mg po qday, Simvastatin 20 mg po qday.


Discharge Medications:
1. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
bladder spasms.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Large bilateral iliac artery aneurysms on CT pelvis for
Fournier's gangrene

Acute on chronic renal failure


Past Medical History:
Diabettes
Hypertension
MI


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


Discharge Instructions:
Division of Vascular and Endovascular Surgery
Angioplasty/Stent Discharge Instructions

Medications:
??????	Take Aspirin 325mg (enteric coated) once daily
??????	If instructed, take Plavix (Clopidogrel) 75mg once daily
??????	Continue all other medications you were taking before surgery,
unless otherwise directed
??????	You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort

What to expect when you go home:
It is normal to have slight swelling of the legs:
??????	Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
??????	Avoid prolonged periods of standing or sitting without your
legs elevated
??????	It is normal to feel tired and have a decreased appetite, your
appetite will return with time
??????	Drink plenty of fluids and eat small frequent meals
??????	It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
??????	To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication

What activities you can and cannot do:
??????	When you go home, you may walk and go up and down stairs
??????	You may shower (let the soapy water run over groin incision,
rinse and pat dry)
??????	Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
??????	No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
??????	After 1 week, you may resume sexual activity
??????	After 1 week, gradually increase your activities and distance
walked as you can tolerate
??????	No driving until you are no longer taking pain medications
??????	Call and schedule an appointment to be seen in [**3-23**] weeks for
post procedure check and ultrasound

What to report to office:
??????	Numbness, coldness or pain in lower extremities
??????	Temperature greater than 101.5F for 24 hours
??????	New or increased drainage from incision or white, yellow or
green drainage from incisions
??????	Bleeding from groin puncture site

SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
??????	Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.

Twice daily dressing changes with wet to dry dressings to the
Periurethral abscess. You should take your full course of
antibiotics. You should call Dr. [**Last Name (STitle) 770**] for a follow-up
appointment appointment.


be sent out on a 2 week course of oral Bactrim.




Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-2-1**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2197-2-1**] 1:15

Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] for wound check appointment in [**1-22**]
weeks.



Completed by:[**2197-1-19**]
{'Aneurysm of iliac artery,Acute kidney failure, unspecified,Urethral abscess,Vascular disorders of male genital organs,Urethral stricture, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty 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: Periurethral abscess, concern for Fournier's Gangrene

PRESENT ILLNESS: 67M who presented from OSH with 5 days of worsening scrotal
pain and swelling.  He states he was in his usual state of
health
when he started having worsening scrotal pain which made it
difficult to walk, prompting him to be evaluated at OSH.  He
underwent a scrotal ultrasound which showed scrotal wall
thickening with a WBC 15k, and he was transfered to [**Hospital1 18**] ED. He
received Vancomycin and Unasyn prior to transfer.  On arrival,
he
appears hemodynamically stable, and he has no SOB, CP, N/V, leg
pain.  He has had decreased appetite since yesterday evening.
His last oral intake was cabbage yesterday evening.  He denies
dysuria, hematuria, incomplete voiding, or other urinary
symptoms.

MEDICAL HISTORY: PMH: DM, HTN, ? Acute MI

MEDICATION ON ADMISSION: MEDS: Lisinopril 5 mg po qday, Metoprolol 25 mg po qday,
Glyburide 2.5 mg po qday, Simvastatin 20 mg po qday.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Temp: 98.1-99    HR: 61      BP: 144/75   RR: 16   Spo2: 94% RA
Gen: NAD, Alert and oriented x3
Neuro: CN II-XII
Cardiac: RRR, no mrg, + S1, S2
Lungs: CTA bilaterally, no resp distress
Abd: soft, NT, ND, no rebound/guarding
Suprapubic catheter intact and draining
L groin puncture site without bleeding or hematoma.
Extremities warm and well perfused
Dressing intact to periurital abcess

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives at home with wife 

### Response:
{'Aneurysm of iliac artery,Acute kidney failure, unspecified,Urethral abscess,Vascular disorders of male genital organs,Urethral stricture, unspecified,Abdominal aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Aortic valve disorders,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status'}
