CHIEF COMPLAINT: FEVER, Altered mental Status

PRESENT ILLNESS: 87 year old male with history of [**Last Name (un) 309**] Body Dementia, Complex
partial seizure, stroke, Barrett's,  Arrives with increased
confusion, responing only to sternal rub. Reportedly, patient
was just diagnosed with PNA the other day by Old Soldiers [**Name8 (MD) **]
MD. Daughter also reports loss of alertness and mobility, and
that he also had a fever of 101, and was given tylenol. Daughter
( of note HCP, as well as [**Name8 (MD) **] [**MD Number(3) 108111**] nursing facility),
reports altered MS, not taking keppra for partial tonic clonic.
Treated for PNA w/ azitha and levo.
Family also noted that he gets severe hyponatremia on any other
anti-seizure medication, but Keppra is ok.
.
In the ED, initial vs were: 98.3 108 118/66 18 98% RA. Patient
had had a CXR, showing possible right middle lobe PNA, and was
started on Vanc/Zosyn combination.
.
He had an ABG, showing pH 7.48 pCO2-36 pO2-72 HCO3-28.
He had a CT scan of the head, with Wet read negative for
pathology
He had a CXR done showing possible PNA.
He had an EKG - unchanged to prior, with old infarct, and some
pvcs.
He was seen by neurology, who felt that the patient is likely
delirious in setting of history of LBD, now with pneumonia.
Cannot rule out ongoing seizure activity and also myoclonic
jerks noted on exam. Please change Keppra to IV if not taking PO
meds. Please get EEG. Will follow on consult service.
.
Prior to transfer, his vitals were temp 99.8 HR 80, BP 120/68 RR
22 Satting 100% on Room air.
.
On the floor, the patient only responded to voice, but was
oriented to family members and names.
.
Review of sytems: unable to ascertain, as patient is not
answering questions.

MEDICAL HISTORY: 1. Complex partial seizure.
2. DVT and PE.
3. History of GI bleeding.
4. Barrett's esophagus.
5. Stroke.
6. Left inguinal hernia status post herniorrhaphy.
7. Status post partial amputation of left fourth finger.
8. Asbestos exposure.
9. Mild obstructive lung disease on PFTs.
10. Seasonal allergies.
11. Asthma.
12. Hypertension.
13. Sleep apnea.
14. Basal cell carcinoma.
15. Venous stasis.
16. Autonomic dysfunction and orthostatic hypotension.
17. Dementia of [**Last Name (un) 309**] body.
18. Cervical spondylosis
19. Shingles.
20. Elevated PSA of 13 (family decided not to pursue it)

MEDICATION ON ADMISSION: 1. Donepezil 15mg daily
2. fludrocortisone 0.1mg (2tabs) daily
3. Levetiracetam - 750 mg [**Hospital1 **] (per daughter- had been recorded
as 1000 mg po BID)
4. Omeprazole 20 ER
5. Seroquel 25mg ([**12-25**] tablet PRN agitation)
6. Zoloft 100mg daily
7. Aspirin 325 daily
8. Calcium/VitD3 500-400 Chewable
9. Vit B12 - 100mcg ER

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T: 97.3, P: 87, BP: 149/65, RR: 14, 98% on 4L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, mild erythema
around eyes.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:Nonfocal exam. Moving all extremities. Gets very agitated
when apply nailbed pressure. Left four finger partially missing.
mild myoclonus.

FAMILY HISTORY: -Father: colon cancer
-Mother: died of "old age"
-Sisters: [**Name2 (NI) **] CA

SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **] does not have any
services.  His daughter [**Name (NI) 108112**] is a nurse practitioner [**First Name (Titles) 1023**] [**Last Name (Titles) 108113**]s his medical care and also is a healthcare proxy. [**Name (NI) **]
does not drink alcohol and he is a former smoker. He is able to
perform feeding, ambulating with a walker, toileting, but needs
help with dressing and bathing, and other instrumental
activities of daily living.
Unspecified septicemia,Toxic encephalopathy,Pneumonia, organism unspecified,Alkalosis,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Personal history of venous thrombosis and embolism,Barrett's esophagus,Chronic obstructive asthma, unspecified,Unspecified disorder of autonomic nervous system,Other and unspecified hyperlipidemia,Do not resuscitate status
Septicemia NOS,Toxic encephalopathy,Pneumonia, organism NOS,Alkalosis,Part epil w/o intr epil,Sepsis,Dementia w Lewy bodies,Dementia w/o behav dist,Hx-ven thrombosis/embols,Barrett's esophagus,Chronic obst asthma NOS,Autonomic nerve dis NEC,Hyperlipidemia NEC/NOS,Do not resusctate status
Admission Date:  [**2197-12-3**]              Discharge Date:   [**2197-12-11**]


Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
FEVER, Altered mental Status


Major Surgical or Invasive Procedure:
none

History of Present Illness:
87 year old male with history of [**Last Name (un) 309**] Body Dementia, Complex
partial seizure, stroke, Barrett's,  Arrives with increased
confusion, responing only to sternal rub. Reportedly, patient
was just diagnosed with PNA the other day by Old Soldiers [**Name8 (MD) **]
MD. Daughter also reports loss of alertness and mobility, and
that he also had a fever of 101, and was given tylenol. Daughter
( of note HCP, as well as [**Name8 (MD) **] [**MD Number(3) 108111**] nursing facility),
reports altered MS, not taking keppra for partial tonic clonic.
Treated for PNA w/ azitha and levo.
Family also noted that he gets severe hyponatremia on any other
anti-seizure medication, but Keppra is ok.
.
In the ED, initial vs were: 98.3 108 118/66 18 98% RA. Patient
had had a CXR, showing possible right middle lobe PNA, and was
started on Vanc/Zosyn combination.
.
He had an ABG, showing pH 7.48 pCO2-36 pO2-72 HCO3-28.
He had a CT scan of the head, with Wet read negative for
pathology
He had a CXR done showing possible PNA.
He had an EKG - unchanged to prior, with old infarct, and some
pvcs.
He was seen by neurology, who felt that the patient is likely
delirious in setting of history of LBD, now with pneumonia.
Cannot rule out ongoing seizure activity and also myoclonic
jerks noted on exam. Please change Keppra to IV if not taking PO
meds. Please get EEG. Will follow on consult service.
.
Prior to transfer, his vitals were temp 99.8 HR 80, BP 120/68 RR
22 Satting 100% on Room air.
.
On the floor, the patient only responded to voice, but was
oriented to family members and names.
.
Review of sytems: unable to ascertain, as patient is not
answering questions.

Past Medical History:
1. Complex partial seizure.
2. DVT and PE.
3. History of GI bleeding.
4. Barrett's esophagus.
5. Stroke.
6. Left inguinal hernia status post herniorrhaphy.
7. Status post partial amputation of left fourth finger.
8. Asbestos exposure.
9. Mild obstructive lung disease on PFTs.
10. Seasonal allergies.
11. Asthma.
12. Hypertension.
13. Sleep apnea.
14. Basal cell carcinoma.
15. Venous stasis.
16. Autonomic dysfunction and orthostatic hypotension.
17. Dementia of [**Last Name (un) 309**] body.
18. Cervical spondylosis
19. Shingles.
20. Elevated PSA of 13 (family decided not to pursue it)

Social History:
The patient lives at home with his wife. [**Name (NI) **] does not have any
services.  His daughter [**Name (NI) 108112**] is a nurse practitioner [**First Name (Titles) 1023**] [**Last Name (Titles) 108113**]s his medical care and also is a healthcare proxy. [**Name (NI) **]
does not drink alcohol and he is a former smoker. He is able to
perform feeding, ambulating with a walker, toileting, but needs
help with dressing and bathing, and other instrumental
activities of daily living.

Family History:
-Father: colon cancer
-Mother: died of "old age"
-Sisters: [**Name2 (NI) **] CA

Physical Exam:
VS: T: 97.3, P: 87, BP: 149/65, RR: 14, 98% on 4L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, mild erythema
around eyes.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:Nonfocal exam. Moving all extremities. Gets very agitated
when apply nailbed pressure. Left four finger partially missing.
mild myoclonus.

Pertinent Results:
Admission labs:
[**2197-12-3**] 01:20PM BLOOD WBC-11.7*# RBC-3.64* Hgb-11.1* Hct-33.4*
MCV-92 MCH-30.4 MCHC-33.2# RDW-12.7 Plt Ct-367#
[**2197-12-3**] 01:20PM BLOOD PT-16.1* PTT-27.0 INR(PT)-1.5*
[**2197-12-3**] 01:20PM BLOOD Glucose-118* UreaN-29* Creat-1.0 Na-138
K-4.9 Cl-100 HCO3-24 AnGap-19
[**2197-12-3**] 01:20PM BLOOD ALT-39 AST-45* CK(CPK)-104 AlkPhos-103
TotBili-0.6
[**2197-12-3**] 01:20PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
[**2197-12-5**] 06:00AM BLOOD Vanco-21.6*
[**2197-12-3**] 01:06PM BLOOD pO2-72* pCO2-36 pH-7.48* calTCO2-28 Base
XS-3
[**2197-12-3**] 01:25PM BLOOD Lactate-1.7
.
Imaging:
.
CT HEAD without contrast:
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
Correlate clinically to decide on the need for further workup.
.
CXR
IMPRESSION: Increased density in the right lung base may reflect
aspiration or pneumonia in appropriate clinical circumstance
.
ECG
Sinus rhythm. Atrial premature beats and ventricular premature
beats. Compared
to the previous tracing of [**2197-9-27**] the atrial and ventricular
premature
depolarizations are new. Otherwise, no other interval change.


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 120 98 344/417 61 -6 17
.
EEG
FINDINGS:
ABNORMALITY #1: The background was slow and disorganized
throughout the
recording reaching a maximum 5.5-6 Hz frequency at times.
BACKGROUND: As described above in Abnormality #1.
HYPERVENTILATION: Was not performed.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
[**1-22**]
flashes per second (fps) produced no activation of the record.
SLEEP: No clear state changes were seen.
CARDIAC MONITOR: A single EKG channel showed an irregular rhythm

throughout the recording.
IMPRESSION: Abnormal routine EEG due to the presence of a slow,
disorganized background, reaching a maximum frequency in the
theta
frequency range. This finding suggests the presence of a
moderate
encephalopathy which is non-specific in etiology but indicates
diffuse
cerebral dysfunction. No epileptiform features were seen.
.
Discharge labs:

[**2197-12-11**] 07:00AM BLOOD WBC-10.5 RBC-3.51* Hgb-10.4* Hct-31.5*
MCV-90 MCH-29.8 MCHC-33.1 RDW-12.5 Plt Ct-550*
[**2197-12-11**] 07:00AM BLOOD Plt Ct-550*
[**2197-12-11**] 07:00AM BLOOD Glucose-92 UreaN-9 Creat-1.2 Na-143 K-3.5
Cl-106 HCO3-31 AnGap-10
[**2197-12-3**] 01:20PM BLOOD ALT-39 AST-45* CK(CPK)-104 AlkPhos-103
TotBili-0.6
[**2197-12-11**] 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2
.

Transitional issues:
Please call the hospital for a pending keppra level from
[**2197-12-10**]

Brief Hospital Course:
Mr. [**Known lastname 60272**] is an 87 yo M with a history of possible [**Last Name (un) 309**] Body
dementia, autonomic dysfunction, HTN, previous CVA, who was
admitted to the ICU with altered mental status, and leukocytosis
and fevers, and evidence of pneumonia on Xray.

#Acute mental status change:  Likely secondary from infection
and hospital acquired pneumonia. Given history of seizures,
post-ictal state was considered as well but there were no
evidence of seizures on EEG.  Neurology evaluated the patient
but was confident that seizure was not occurring and that it was
not contributing to the altered mental status. We concluded that
acute delirium superimposed on chronic dementia was the most
likely cause of the altered mental status. The patient remained
somewhat somnolent throughout his stay until the last day, when
he became alert and was able to sit in a chair and eat his meal.
The patient was discharged at his baseline mental status, able
to eat and get out of bed.

#HCAP: patient admitted with leukocytosis, fever and CXR
findings consistent with pneumonia. He was treated with
Vanco/Zosyn for HCAP for 8 days. He completed his course 1 day
before discharge and remained asymptomatic.

#. HISTORY OF SEIZURES: on levitiracetam 750 mm po BID at home,
increased to 1000 mg po BID with the supervision of neurology.
EEG showed that the patient was not having any active seizures,
and patient's mental status was at baseline on discharge.

# Nutrition: During [**Hospital 228**] hospital stay, his waxing and
[**Doctor Last Name 688**] mental status made it difficult for him to consistently
eat.  His nutrition was supplanted by ensure when the patient
was awake enough to be fed safely.  By discharge, patient was
awake and able to feed himself.

#HISTORY OF STROKE:  continued on aspirin.

#. GERD/BARRETTS: continued on omeprazole.

#. HYPERLIPIDEMIA: continued on zocor

Medications on Admission:
1. Donepezil 15mg daily
2. fludrocortisone 0.1mg (2tabs) daily
3. Levetiracetam - 750 mg [**Hospital1 **] (per daughter- had been recorded
as 1000 mg po BID)
4. Omeprazole 20 ER
5. Seroquel 25mg ([**12-25**] tablet PRN agitation)
6. Zoloft 100mg daily
7. Aspirin 325 daily
8. Calcium/VitD3 500-400 Chewable
9. Vit B12 - 100mcg ER


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. donepezil 5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for agitation.
9. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 500 + D (D3) 500-125 mg-unit Tablet Oral
12. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO once a
day.


Discharge Disposition:
Extended Care

Facility:
Soldiers Home in [**State 350**] - [**Location (un) **]

Discharge Diagnosis:
Acute delirium
Chronic dementia
Pneumonia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Mr. [**Known lastname 60272**], you presented to us with altered mental status and
a pneumonia was found to be in your lungs. We started you on
appropriate antibiotics and watched you carefully in the ICU for
a few days. Once we determined that you were medically stable,
we transferred you to the general floor for further monitoring.
While with us, we had the neurologists see you to evaluate for
possible seizure activity in the brain. Electroencephalograph
found no evidence of altered brain waves. The neurologists
determined that you were not having seizures.  We also had the
geriatricians see you, to evaluate for other causes of altered
mental status. Our conclusion was that the pneumonia had caused
an acute delirium which superimposed on your baseline dementia.
Once your antibiotic therapy had completed, we discharged you
back to your extended care facility and you were in stable
condition.
The following changes have been made to your medications:
Increase keppra to 1000mg by mouth twice a day.


Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2198-1-11**] at 1 PM
With: [**Last Name (un) 3895**] [**First Name8 (NamePattern2) 3896**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2197-12-11**]
{"Unspecified septicemia,Toxic encephalopathy,Pneumonia, organism unspecified,Alkalosis,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Personal history of venous thrombosis and embolism,Barrett's esophagus,Chronic obstructive asthma, unspecified,Unspecified disorder of autonomic nervous system,Other and unspecified hyperlipidemia,Do not resuscitate 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: FEVER, Altered mental Status

PRESENT ILLNESS: 87 year old male with history of [**Last Name (un) 309**] Body Dementia, Complex
partial seizure, stroke, Barrett's,  Arrives with increased
confusion, responing only to sternal rub. Reportedly, patient
was just diagnosed with PNA the other day by Old Soldiers [**Name8 (MD) **]
MD. Daughter also reports loss of alertness and mobility, and
that he also had a fever of 101, and was given tylenol. Daughter
( of note HCP, as well as [**Name8 (MD) **] [**MD Number(3) 108111**] nursing facility),
reports altered MS, not taking keppra for partial tonic clonic.
Treated for PNA w/ azitha and levo.
Family also noted that he gets severe hyponatremia on any other
anti-seizure medication, but Keppra is ok.
.
In the ED, initial vs were: 98.3 108 118/66 18 98% RA. Patient
had had a CXR, showing possible right middle lobe PNA, and was
started on Vanc/Zosyn combination.
.
He had an ABG, showing pH 7.48 pCO2-36 pO2-72 HCO3-28.
He had a CT scan of the head, with Wet read negative for
pathology
He had a CXR done showing possible PNA.
He had an EKG - unchanged to prior, with old infarct, and some
pvcs.
He was seen by neurology, who felt that the patient is likely
delirious in setting of history of LBD, now with pneumonia.
Cannot rule out ongoing seizure activity and also myoclonic
jerks noted on exam. Please change Keppra to IV if not taking PO
meds. Please get EEG. Will follow on consult service.
.
Prior to transfer, his vitals were temp 99.8 HR 80, BP 120/68 RR
22 Satting 100% on Room air.
.
On the floor, the patient only responded to voice, but was
oriented to family members and names.
.
Review of sytems: unable to ascertain, as patient is not
answering questions.

MEDICAL HISTORY: 1. Complex partial seizure.
2. DVT and PE.
3. History of GI bleeding.
4. Barrett's esophagus.
5. Stroke.
6. Left inguinal hernia status post herniorrhaphy.
7. Status post partial amputation of left fourth finger.
8. Asbestos exposure.
9. Mild obstructive lung disease on PFTs.
10. Seasonal allergies.
11. Asthma.
12. Hypertension.
13. Sleep apnea.
14. Basal cell carcinoma.
15. Venous stasis.
16. Autonomic dysfunction and orthostatic hypotension.
17. Dementia of [**Last Name (un) 309**] body.
18. Cervical spondylosis
19. Shingles.
20. Elevated PSA of 13 (family decided not to pursue it)

MEDICATION ON ADMISSION: 1. Donepezil 15mg daily
2. fludrocortisone 0.1mg (2tabs) daily
3. Levetiracetam - 750 mg [**Hospital1 **] (per daughter- had been recorded
as 1000 mg po BID)
4. Omeprazole 20 ER
5. Seroquel 25mg ([**12-25**] tablet PRN agitation)
6. Zoloft 100mg daily
7. Aspirin 325 daily
8. Calcium/VitD3 500-400 Chewable
9. Vit B12 - 100mcg ER

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T: 97.3, P: 87, BP: 149/65, RR: 14, 98% on 4L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, mild erythema
around eyes.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:Nonfocal exam. Moving all extremities. Gets very agitated
when apply nailbed pressure. Left four finger partially missing.
mild myoclonus.

FAMILY HISTORY: -Father: colon cancer
-Mother: died of "old age"
-Sisters: [**Name2 (NI) **] CA

SOCIAL HISTORY: The patient lives at home with his wife. [**Name (NI) **] does not have any
services.  His daughter [**Name (NI) 108112**] is a nurse practitioner [**First Name (Titles) 1023**] [**Last Name (Titles) 108113**]s his medical care and also is a healthcare proxy. [**Name (NI) **]
does not drink alcohol and he is a former smoker. He is able to
perform feeding, ambulating with a walker, toileting, but needs
help with dressing and bathing, and other instrumental
activities of daily living. 

### Response:
{"Unspecified septicemia,Toxic encephalopathy,Pneumonia, organism unspecified,Alkalosis,Localization-related (focal) (partial) epilepsy and epileptic syndromes with simple partial seizures, without mention of intractable epilepsy,Sepsis,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Personal history of venous thrombosis and embolism,Barrett's esophagus,Chronic obstructive asthma, unspecified,Unspecified disorder of autonomic nervous system,Other and unspecified hyperlipidemia,Do not resuscitate status"}
