CHIEF COMPLAINT: penile pain, lower extremity weakness

PRESENT ILLNESS: This is a 63 y.o. male with PMH significant for ischemic CM (EF
45%), OSA on CPAP, DM who presents with chief complaint of
bilateral leg weakness, cough, DOE, and low urine output after
surgery. He is currently POD#3 s/p penile pump implant
([**Date range (1) 34882**]/05 ) during which time the glans was persistently
dusky in color. On POD #2 his foley cath was removed, but he
failed to have significant urine output. Post void residual was
250 cc of urine, and he was discharged with a foley in place.
His wife notes that he had less that 200 cc of urine during the
day he was at home. Today he noticed that his legs were weak and
he had pain in his penis, so he decided to go the ED instead of
his scheduled follow up visit.
.
In the ED he was found to be hypotensive to 81/41 with
temperature of 99.3. He received 500 mg of levoquin IV and a
code sepsis was called. A central line was inserted and he
received 3 liters of normal saline without apprecible urine
output. Levophedrine was started for persistently low pressures.
He was transferred to the MICU for further evaluation.

MEDICAL HISTORY: 1) Cardiomyopathy, mixed LV systolic and diastolic dysfunction.

MEDICATION ON ADMISSION: Ecotrin 325 PO QD
Vit D [**Numeric Identifier 1871**] Q monday
Levofloxacin 500 mg POQD
Docusate Sodium 100 mg PO BID
Tamsulosin 0.8 mg PO QHS
Furosemide 60 mg PO QD
Ranitidine HCl 150 mg POBID
Escitalopram 5 QAM, 10 mg QHS
Losartan 50 mg POQD
Beclomethasone 1 spray PO BID
Toprol XL 100 POQD
Percocet 7.5-325 mg PRN
humalog SS: range 3-12 units in the morning for sugar 51-401,
3-12 units at lunch for 51-401, 6-14 units in the evening for
blood sugars from 51-351, 1-4 units in the evening for blood
sugars from 251-401.
lantus 8 QHS

ALLERGIES: Vicodin

PHYSICAL EXAM: Tm 99.2 Tc 99.2 BP (cuff) 84/51 P57 R20 99% 5LNC CVP 18 SVO2
65-73%
Gen: NAD, sitting comfortably in bed, alert and oritented x 3
HEENT: R pupil teardrop shaped, both reactive to light. OP
clear. MM dry. JVP 14 cm
Resp: right side with coarse breath sounds, left side bronchial
but clear
CV: RRR nl s1s2 physiologically split S2 no murmurs
Abd: obese, soft, nontender, ND +BS
Ext: trace edema, cool to touch, no cyanosis
Penis: shaft pink, tender to touch, with no purulent discharge.
Testicles ecchymotic with CDI bandaged from surgery. Foley in
place.
Neuro: CN 2-12 intact. Strength 4/5 hip flexors bilaterally.
Sensation intact bilaterally.
Skin: no rash.

FAMILY HISTORY: CVA - brother
Breast [**Name (NI) 3730**] - mother

SOCIAL HISTORY: married, retired, worked at Polaroid. He has 3 children. He
denies any history of tobacco, alcohol or drug use.
Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Subendocardial infarction, initial episode of care,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Other primary cardiomyopathies,Congestive heart failure, unspecified,Hyperpotassemia,Hypotension, unspecified,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Impotence of organic origin,Unspecified sleep apnea,Unspecified glaucoma,Old myocardial infarction,Depressive disorder, not elsewhere classified,Other postprocedural status,Long-term (current) use of insulin,Knee joint replacement
Septicemia NOS,Severe sepsis,Acute kidney failure NOS,Subendo infarct, initial,Cardiogenic shock,Hyp kid NOS w cr kid V,Chronic kidney dis NOS,Prim cardiomyopathy NEC,CHF NOS,Hyperpotassemia,Hypotension NOS,Anemia in chr kidney dis,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Crnry athrscl natve vssl,Impotence, organic orign,Sleep apnea NOS,Glaucoma NOS,Old myocardial infarct,Depressive disorder NEC,Post-proc states NEC,Long-term use of insulin,Joint replaced knee
Admission Date:  [**2141-11-10**]              Discharge Date:   [**2141-11-15**]

Date of Birth:  [**2078-1-6**]             Sex:   M

Service: MEDICINE

Allergies:
Vicodin

Attending:[**First Name3 (LF) 5368**]
Chief Complaint:
penile pain, lower extremity weakness

Major Surgical or Invasive Procedure:
Placement of central line in RIJ vein

History of Present Illness:
This is a 63 y.o. male with PMH significant for ischemic CM (EF
45%), OSA on CPAP, DM who presents with chief complaint of
bilateral leg weakness, cough, DOE, and low urine output after
surgery. He is currently POD#3 s/p penile pump implant
([**Date range (1) 34882**]/05 ) during which time the glans was persistently
dusky in color. On POD #2 his foley cath was removed, but he
failed to have significant urine output. Post void residual was
250 cc of urine, and he was discharged with a foley in place.
His wife notes that he had less that 200 cc of urine during the
day he was at home. Today he noticed that his legs were weak and
he had pain in his penis, so he decided to go the ED instead of
his scheduled follow up visit.
.
In the ED he was found to be hypotensive to 81/41 with
temperature of 99.3. He received 500 mg of levoquin IV and a
code sepsis was called. A central line was inserted and he
received 3 liters of normal saline without apprecible urine
output. Levophedrine was started for persistently low pressures.
He was transferred to the MICU for further evaluation.


Past Medical History:
1) Cardiomyopathy, mixed LV systolic and diastolic dysfunction.

EF 45%. Most recent ECHO [**6-5**].
2) CAD. Selective coronary arteriography in [**2139-6-2**]
revealed RA 5, RV 31/8, PA 33/14 with a mean of 23, pulmonary
capillary wedge pressure 6, LVEDP 9, cardiac output 5.8, CVR
235. Also revealed angiographically normal vessels with mild
coronary artery  disease of the left circumflex artery. Left
ventriculography revealed an LVEF of 63%, mitral valve was
normal. Non-ST-segment elevation myocardial infarction in [**Month (only) 547**]
of [**2139**].
3) Diabetes mellitus x 12 years, with neuropahty, nephropathy.
4) Hypertension
5) Anemia of chronic disease.
6) BPH.
7) Glaucoma; on carbonic and hydrase inhibitor
8) Chronic restrictive ventilatory disease related to a bile
duct leak with development of pulmonary fibrosis requiring
decortication
9) Depression
10) CRI with baseline creatinine of 1.7
Sleep apnea on BiPAP, currently [**10-10**]
11) Anemia of chronic disease.
12) BPH.
13) Erectile dyscunction s/p Penile implant 12/05 per HPI
..
Past surgical history is significant for:
1) History of roux-en-y reconstruction after laparoscopic
cholecystectomy in [**2139-4-2**].
2) [**2139**] status post decordication for fibrothorax complicated
respiratory failure requiring tracheostomy.
3) History of appendectomy.
4) History of left knee and hip replacement complicated by
chronic pain.


Social History:
married, retired, worked at Polaroid. He has 3 children. He
denies any history of tobacco, alcohol or drug use.


Family History:
CVA - brother
Breast [**Name (NI) 3730**] - mother

Physical Exam:
Tm 99.2 Tc 99.2 BP (cuff) 84/51 P57 R20 99% 5LNC CVP 18 SVO2
65-73%
Gen: NAD, sitting comfortably in bed, alert and oritented x 3
HEENT: R pupil teardrop shaped, both reactive to light. OP
clear. MM dry. JVP 14 cm
Resp: right side with coarse breath sounds, left side bronchial
but clear
CV: RRR nl s1s2 physiologically split S2 no murmurs
Abd: obese, soft, nontender, ND +BS
Ext: trace edema, cool to touch, no cyanosis
Penis: shaft pink, tender to touch, with no purulent discharge.
Testicles ecchymotic with CDI bandaged from surgery. Foley in
place.
Neuro: CN 2-12 intact. Strength 4/5 hip flexors bilaterally.
Sensation intact bilaterally.
Skin: no rash.


Pertinent Results:
[**2141-11-10**] 10:55AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD
[**2141-11-10**] 10:55AM URINE  RBC-21-50* WBC-[**5-12**]* BACTERIA-MANY
YEAST-NONE EPI-[**2-4**]
[**2141-11-10**] 10:55AM   WBC-12.7*# RBC-3.71* HGB-11.4* HCT-33.0*
MCV-89 MCH-30.7 MCHC-34.4 RDW-14.2
[**2141-11-10**] 10:55AM   proBNP-[**Numeric Identifier **]*
[**2141-11-10**] 10:55AM   GLUCOSE-166* UREA N-72* CREAT-4.5*#
SODIUM-134 POTASSIUM-6.6* CHLORIDE-103 TOTAL CO2-21* ANION
GAP-17
[**2141-11-10**] 10:59AM   LACTATE-2.3*
[**2141-11-10**] 02:00PM   CRP-110.8*
.
Renal US [**2141-11-11**]: No hydronephrosis.  Somewhat suboptimal
examination.
.
CXR [**2141-11-10**]: Stable left pleural thickening. Mild upper
tracheal narrowing stable compared to the prior exam.
.
LLE US [**2141-11-11**]: No DVT in the left lower extremity, no change
compared to the prior study.


Brief Hospital Course:
In the ED the pt was given 3000ml of fluids. He was continued on
Levoquine 500mg iv initially. Levophed was started to maintain
adequate blood pressure. He was transferred to the ICU where he
received a total of 2750cc of fluid in form of boluses. He was
found to be in acute on chronic renal failure with a creatinine
of 4.6. A central line and arterial line was placed. Levophed
was continued. Levaquine was stopped and the pt was started on
Vancomycin and Ceftriaxone. Urology was consulted. The acute
event was not thought to be in relation to the operative
procedure three days prior. The swelling and pain the pt
experienced in his penis and scrotum was consistent with normal
postoperative changes.
The pt was found to have elevated troponins (0.29). He never
complained of chest pain. EKGs showed T wave changes but no ST
segment changes. Echo showed no evidence of RV dysfunction c/w
PE, no change in mild TR; overall function similar to old EF
showing EF 45%. Recent stress test without evidence of ischemia.
The etiology was thought to be demand ischemia in the setting of
hypotension. The BNP was elevated to [**Numeric Identifier 6085**] although there were
no signs of Lsided heartfailure on CXR and overt signs of R
sided failure on exam. The LE edema was at baseline for the pt.
Bilateral LE US was negative for DVT. Losartan was hold during
the hsopital course adn was substituted by hydralazine and imdur
to achieve afterload reduction. Losartan should be restarted
once acute renal failure is resolved. toprol was switched to
metoprolol for better ability to titrate. The pt was given
metoprolol 12.5mg [**Hospital1 **].
The pt was found to be adrenally deficient and was started on
Hyrdocortisone and Fludrocortisone. The pt responded well to IVF
and Levophed was discontinued. The pt remained normotensive and
was restarted on metoprolol for blood pressure and heart rate
control. He was transferred to the floor for further management.

Vancomycin was stopped after three days per ID recommendations.
Ceftriaxone was continued until the day prior to discharge when
it was changed to oral Cefpodixime which should be continued for
seven days suspecting a complicated urinary tract infection as
the urine analysis was suggesting. Urine and Blood cultures
remained negative. Fludrocortisone and Hydrocortisone were
discontinued. The pt remained normotensive and afebrile. The
central line was removed. Outpatient furosemide dose was
restarted at 60mg QD on day 4 of admission. A set of urine lytes
was checked and was most consistent with prerenal azotemia. The
pt creatinine continued to trend down to 2.1 on the day of
discharge. A voiding trial was done on the day of discharge. The
pt was not able to void most likely due to obstruction. The pt
was send home with a catheter in place to follow up with
urology.
The pt's diabetes mellitus was controlled with Lantus and SSC as
[**First Name8 (NamePattern2) **] [**Last Name (un) **] Diabetes center sliding scale. The pt's hematocrit
was reduced from baseline which was attributed to dilution. The
pt has a chronic anemia chronic disease. BIPAP at night was
continued on outpatient settings ([**10-10**]). Lexapro was continued
for depression.


Medications on Admission:
Ecotrin 325 PO QD
Vit D [**Numeric Identifier 1871**] Q monday
Levofloxacin 500 mg POQD
Docusate Sodium 100 mg PO BID
Tamsulosin 0.8 mg PO QHS
Furosemide 60 mg PO QD
Ranitidine HCl 150 mg POBID
Escitalopram 5 QAM, 10 mg QHS
Losartan 50 mg POQD
Beclomethasone 1 spray PO BID
Toprol XL 100 POQD
Percocet 7.5-325 mg PRN
humalog SS: range 3-12 units in the morning for sugar 51-401,
3-12 units at lunch for 51-401, 6-14 units in the evening for
blood sugars from 51-351, 1-4 units in the evening for blood
sugars from 251-401.
lantus 8 QHS


Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
Disp:*20 Tablet(s)* Refills:*2*
2. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*20 Tablet(s)* Refills:*2*
3. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO Q MONDAY ().
Disp:*30 Capsule(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-8**]
hours: please do not take together with
oxcycodone/acetaminophen.
Please do not exceed 4g/d.
Disp:*30 Tablet(s)* Refills:*0*
12. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed): for sore throat.
Disp:*20 Lozenge(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
15. Insulin Glargine 100 unit/mL Solution Sig: One (1) 8U
Subcutaneous at bedtime.
Disp:*qs 8U* Refills:*2*
16. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous four times a day: per sliding scale.
Disp:*qs * Refills:*2*
17. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Hypotension
Possible sepsis, culture negative
Possible cardiogenic shock


Discharge Condition:
Good, hypotension resolved, ambulatory


Discharge Instructions:
Please come back to the hospital or see your primary care
physician if you develop any shortness of breath, chest pain,
lightheadedness, weakness, fevers, chills or any other concerns.
.
Please take the antibiotics for seven more days twice daily.
Please continue to take your other medications as prior to
admissions except for the Losartan (Cozaar) and the Toprol.
Please do not take the Losartan (Cozaar) until Dr. [**Last Name (STitle) **]
instructs you to do so. Please take hydralazine 25mg three times
daily and Imdur 60mg once daily until you are restarted on
Losartan. Please take metoprolol 12.5mg twice daily instead of
the toprol. Please take Pantoprazole instead of ranitidine.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the next week. Please call
for an appointment: [**Telephone/Fax (1) 1247**].
.
Please follow up with Dr. [**Last Name (STitle) **] Date/Time:[**2141-11-16**] 2:15
([**Telephone/Fax (1) 3331**]).
.
Please follow up with Dr. [**Last Name (STitle) 34883**],[**First Name3 (LF) **] A. MEN'S HEALTH
Date/Time:[**2141-11-20**] 1:30 as instructed by Dr. [**Last Name (STitle) **].
{'Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Subendocardial infarction, initial episode of care,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Other primary cardiomyopathies,Congestive heart failure, unspecified,Hyperpotassemia,Hypotension, unspecified,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Impotence of organic origin,Unspecified sleep apnea,Unspecified glaucoma,Old myocardial infarction,Depressive disorder, not elsewhere classified,Other postprocedural status,Long-term (current) use of insulin,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: penile pain, lower extremity weakness

PRESENT ILLNESS: This is a 63 y.o. male with PMH significant for ischemic CM (EF
45%), OSA on CPAP, DM who presents with chief complaint of
bilateral leg weakness, cough, DOE, and low urine output after
surgery. He is currently POD#3 s/p penile pump implant
([**Date range (1) 34882**]/05 ) during which time the glans was persistently
dusky in color. On POD #2 his foley cath was removed, but he
failed to have significant urine output. Post void residual was
250 cc of urine, and he was discharged with a foley in place.
His wife notes that he had less that 200 cc of urine during the
day he was at home. Today he noticed that his legs were weak and
he had pain in his penis, so he decided to go the ED instead of
his scheduled follow up visit.
.
In the ED he was found to be hypotensive to 81/41 with
temperature of 99.3. He received 500 mg of levoquin IV and a
code sepsis was called. A central line was inserted and he
received 3 liters of normal saline without apprecible urine
output. Levophedrine was started for persistently low pressures.
He was transferred to the MICU for further evaluation.

MEDICAL HISTORY: 1) Cardiomyopathy, mixed LV systolic and diastolic dysfunction.

MEDICATION ON ADMISSION: Ecotrin 325 PO QD
Vit D [**Numeric Identifier 1871**] Q monday
Levofloxacin 500 mg POQD
Docusate Sodium 100 mg PO BID
Tamsulosin 0.8 mg PO QHS
Furosemide 60 mg PO QD
Ranitidine HCl 150 mg POBID
Escitalopram 5 QAM, 10 mg QHS
Losartan 50 mg POQD
Beclomethasone 1 spray PO BID
Toprol XL 100 POQD
Percocet 7.5-325 mg PRN
humalog SS: range 3-12 units in the morning for sugar 51-401,
3-12 units at lunch for 51-401, 6-14 units in the evening for
blood sugars from 51-351, 1-4 units in the evening for blood
sugars from 251-401.
lantus 8 QHS

ALLERGIES: Vicodin

PHYSICAL EXAM: Tm 99.2 Tc 99.2 BP (cuff) 84/51 P57 R20 99% 5LNC CVP 18 SVO2
65-73%
Gen: NAD, sitting comfortably in bed, alert and oritented x 3
HEENT: R pupil teardrop shaped, both reactive to light. OP
clear. MM dry. JVP 14 cm
Resp: right side with coarse breath sounds, left side bronchial
but clear
CV: RRR nl s1s2 physiologically split S2 no murmurs
Abd: obese, soft, nontender, ND +BS
Ext: trace edema, cool to touch, no cyanosis
Penis: shaft pink, tender to touch, with no purulent discharge.
Testicles ecchymotic with CDI bandaged from surgery. Foley in
place.
Neuro: CN 2-12 intact. Strength 4/5 hip flexors bilaterally.
Sensation intact bilaterally.
Skin: no rash.

FAMILY HISTORY: CVA - brother
Breast [**Name (NI) 3730**] - mother

SOCIAL HISTORY: married, retired, worked at Polaroid. He has 3 children. He
denies any history of tobacco, alcohol or drug use. 

### Response:
{'Unspecified septicemia,Severe sepsis,Acute kidney failure, unspecified,Subendocardial infarction, initial episode of care,Cardiogenic shock,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, unspecified,Other primary cardiomyopathies,Congestive heart failure, unspecified,Hyperpotassemia,Hypotension, unspecified,Anemia in chronic kidney disease,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Coronary atherosclerosis of native coronary artery,Impotence of organic origin,Unspecified sleep apnea,Unspecified glaucoma,Old myocardial infarction,Depressive disorder, not elsewhere classified,Other postprocedural status,Long-term (current) use of insulin,Knee joint replacement'}
