CHIEF COMPLAINT: Abdominal and back pain

PRESENT ILLNESS: 70 yo male who initially presented to [**Hospital 1474**] Hospital with
lower
abdominal pain on [**2114-6-23**] but left hospital against medical
advice, then re-presented again at the same hospital with
similar symptoms, including back pain, fatigue, acute renal
failure, and testicular swelling on [**2114-6-25**]. He is s/p operative
scrotal debridement by urology [**2114-6-29**]. He was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: HTN
Type II DM

MEDICATION ON ADMISSION: lisinopril 40', metformin 500", glyburide 5", humulin
insulin 20 qhs, diltiazem xr 240', HCTZ 25', atenolol 50'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
Vitals- T 101, HR 67, BP 150/81, RR 33, O2sat 99% 2L
Gen- moderate distress, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, NT, ND, decreased BS
Perineum- extensive skin and subQ tissue debridement of entire
scrotum and perineal region, left testicle pallorous, no
obviously necrotic tissue, no emphysematous or erythema of
surround skin, exquisitely tender
Ext- warm, well-perfused, no edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Vascular disorders of male genital organs,Other specified types of hydrocele,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Rash and other nonspecific skin eruption
Male gen vascul dis NEC,Hydrocele NEC,DMII wo cmp uncntrld,Nonspecif skin erupt NEC
Admission Date:  [**2114-6-30**]              [**Month/Day/Year **] Date:   [**2114-7-11**]

Date of Birth:  [**2044-3-25**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal and back pain

Major Surgical or Invasive Procedure:
[**2114-6-29**] Scrotal debridment
[**2114-7-10**] Scrotal flap


History of Present Illness:
70 yo male who initially presented to [**Hospital 1474**] Hospital with
lower
abdominal pain on [**2114-6-23**] but left hospital against medical
advice, then re-presented again at the same hospital with
similar symptoms, including back pain, fatigue, acute renal
failure, and testicular swelling on [**2114-6-25**]. He is s/p operative
scrotal debridement by urology [**2114-6-29**]. He was transferred to
[**Hospital1 18**] for further management.

Past Medical History:
HTN
Type II DM

Family History:
Noncontributory

Physical Exam:
Upon admission:
Vitals- T 101, HR 67, BP 150/81, RR 33, O2sat 99% 2L
Gen- moderate distress, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, NT, ND, decreased BS
Perineum- extensive skin and subQ tissue debridement of entire
scrotum and perineal region, left testicle pallorous, no
obviously necrotic tissue, no emphysematous or erythema of
surround skin, exquisitely tender
Ext- warm, well-perfused, no edema


Pertinent Results:
[**2114-7-11**] 06:00AM BLOOD WBC-13.3* RBC-3.17* Hgb-8.5* Hct-26.2*
MCV-83 MCH-26.8* MCHC-32.5 RDW-14.9 Plt Ct-409
[**2114-7-10**] 06:15AM BLOOD WBC-13.5* RBC-3.28* Hgb-8.7* Hct-27.0*
MCV-82 MCH-26.6* MCHC-32.4 RDW-15.2 Plt Ct-528*
[**2114-7-9**] 05:40AM BLOOD WBC-11.3* RBC-3.67* Hgb-9.8* Hct-30.4*
MCV-83 MCH-26.7* MCHC-32.2 RDW-14.8 Plt Ct-510*

[**2114-7-4**] 8:53 am STOOL     CONSISTENCY: LOOSE      Source:
Stool.

                            **FINAL REPORT [**2114-7-5**]**

   CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2114-7-5**]):
      FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
           (Reference Range-Negative).


Radiology Report DUPLEX DOP ABD/PEL LIMITED Study Date of
[**2114-7-1**] 2:26 AM
SCROTAL ULTRASOUND: The right testicle measures 2.7 x 2.8 x 3.8
cm. The left
testicle measures 3.2 x 2.5 x 2.6 cm.

There is no subcutaneous gas. Within the tissues superior to the
testicles
bilaterally, heterogeneously echogenic, irregular soft tissue
swelling is
present. This is distinct from the testicles. The epididymis is
unremarkable
bilaterally.

Color and Doppler examination of the testicles reveal normal
arterial and
venous waveforms in the right testicle. However, the left
testicle shows an
overall relative decrease in blood flow, and no arterial
waveforms are
identified. Venous flow is present.

IMPRESSION:
1. No ischemic changes in the left testicle, but no arterial
flow is
visualized, though strangely venous flow is. This raises concern
for
developing ischemia of the left testicle. Normal arterial and
venous waveforms
in the right testicle.

2. Massive subcutaneous swelling superficial to the testes. No
subcutaneous
air.

Findings discussed with Dr. [**Last Name (STitle) 6955**] at 10:15 a.m.



Radiology Report SCROTAL U.S. Study Date of [**2114-7-10**] 4:06 PM
FINDINGS: Each testicle has been repositioned superiorly into
the inguinal
region of the ipsilateral side. The right testicle measures 3.1
x 2.0 x 2.7
cm. The left measures 3.3 x 1.7 x 2.8 cm. The right testicle
again shows
normal color Doppler flow, as well as spectral arterial and
venous waveforms.
Compared to the right, the left again shows less overall
vascularity than the
right on color Doppler imaging. Doppler waveforms can be
obtained in the left
testicle which shows venous flow as well as greater pulsatile
activity
suggestive of low-level arterial flow. Except for the appearance
of greater
pulsatility suggestive of arterial flow, there has been no
significant
change.

IMPRESSION: Similar appearance of reduced vascularity of the
left testicle
compared to the right, although there is greater pulsatility in
the Doppler
waveforms of the left testicle suggestive of low-level arterial
flow.







Brief Hospital Course:
He was admitted to the Surgical Service under the care of Dr.
[**Last Name (STitle) **]. He was initially taken to the Surgical ICU where he
remained for several days. Infectious Disease was consulted and
his antibiotics were changed to Vancomycin, Levofloxacin and
Flagyl. He did have blood cultures drawn on [**7-1**] and they were
negative; a stool for C-Diff was sent and was also negative.
Twice daily Dakin's dressing changes were continued. Urology was
consulted and he underwent scrotal ultrasound to assess for
residual infection and for flow. He was transferred to the
regular nursing unit. He continued to have ongoing pain control
issues; requiring IV narcotics initially, and this was changed
to PCA.

Plastic Surgery was then consulted for possible flap; he was
taken to the operating room on [**7-9**] for open wound extensive
debridement of skin, subcutaneous tissue and bilateral local
advancement flap elevation with baring of the scrotum in the
abdominal and a suprapubic cavity. His antibiotics, Levofloxacin
and Flagyl were continued and will need to continue for another
week following the surgery. His Foley catheter was removed;
there was a fecal incontinence pouch system previously in place
to keep open wound clean; this was also removed. His pain was
much less postoperatively, he no longer required IV narcotics
and was changed to an oral pain regimen using long and short
acting narcotics.

He was evaluated by Physical therapy and they have recommended
rehab after acute hospital stay.


Medications on Admission:
lisinopril 40', metformin 500", glyburide 5", humulin
insulin 20 qhs, diltiazem xr 240', HCTZ 25', atenolol 50'



[**Month/Day (4) **] Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP>110.
5. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): hold for SBP<110; HR<60.
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
8. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours)
as needed for breakthrough pain.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
10. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): hold for SBP<110.
13. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
(40) Units Subcutaneous QAM @ breakfast.
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) Units Subcutaneous HS.
17. Regular Insulin Sliding Scale  Sig: One (1) Dose
Subcutaneous four times a day as needed for per sliding scale:
See attached sliding scale.


[**Month/Day (4) **] Disposition:
Extended Care

Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]

[**Hospital1 **] Diagnosis:
Fournier's gangrene

[**Hospital1 **] Condition:
Hemodynamically stable, tolerating an oral diet, pain being
adequately controlled


[**Hospital1 **] Instructions:
AVOID any extremes of adduction/abduction of hips in order to
prevent placing pressure on the scrotum and operative site.

Followup Instructions:
Follow up this Friday [**7-13**] at 1:30 p.m. in Plastic's clinic with
Dr. [**First Name (STitle) **]. Location: [**Location (un) **], [**Hospital Ward Name 23**] Bldg, [**Location (un) 470**]
Surgical Specialities call [**Telephone/Fax (1) 4652**] if the appointment needs
to be changed.

Follow up in [**Hospital 159**] clinic in [**1-3**] weeks, call [**Telephone/Fax (1) 164**] for
an appointment.

Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.



Completed by:[**2114-7-20**]
{'Vascular disorders of male genital organs,Other specified types of hydrocele,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Rash and other nonspecific skin eruption'}


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 and back pain

PRESENT ILLNESS: 70 yo male who initially presented to [**Hospital 1474**] Hospital with
lower
abdominal pain on [**2114-6-23**] but left hospital against medical
advice, then re-presented again at the same hospital with
similar symptoms, including back pain, fatigue, acute renal
failure, and testicular swelling on [**2114-6-25**]. He is s/p operative
scrotal debridement by urology [**2114-6-29**]. He was transferred to
[**Hospital1 18**] for further management.

MEDICAL HISTORY: HTN
Type II DM

MEDICATION ON ADMISSION: lisinopril 40', metformin 500", glyburide 5", humulin
insulin 20 qhs, diltiazem xr 240', HCTZ 25', atenolol 50'

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
Vitals- T 101, HR 67, BP 150/81, RR 33, O2sat 99% 2L
Gen- moderate distress, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, NT, ND, decreased BS
Perineum- extensive skin and subQ tissue debridement of entire
scrotum and perineal region, left testicle pallorous, no
obviously necrotic tissue, no emphysematous or erythema of
surround skin, exquisitely tender
Ext- warm, well-perfused, no edema

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Vascular disorders of male genital organs,Other specified types of hydrocele,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Rash and other nonspecific skin eruption'}
