CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67 year old gentleman with a past medical
history notable for hypertension, ESRD on dialysis, CHF, atrial
fibrillation on coumadin, recent MRSA bacteremia on vancomycin,
CAD s/p CABG and LAD stenting, and past CVA who presented to the
[**Hospital1 18**] on [**2168-9-12**] from his renal dialysis facility because of
change in mental status. Mr. [**Known lastname **] has been admitted
approximately once per month since [**1-/2168**] for [**Year (4 digits) **], CHF,
sepsis, and line infections. His most recent hospital admission
to the [**Hospital1 18**] was from [**2168-9-6**] to [**2168-9-8**] for CHF in the setting
of poorly controlled hypertension. The patient was discharged on
[**2168-9-8**] to his nursing home facility where, per report from
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the home, the patient returned to his baseline
state of health. Mr. [**Known lastname **] did well until the evening prior to
admission, when the staff found him to be shouting more than
normal. At baseline, the patient shouts infrequently in his
native Creole language, but the staff noted that he was shouting
more frequently last night; they also note that he seemed more
confused than normal. In addition, Mr. [**Known lastname **] did not sleep much
on the evening prior to admission. He denied any pain symptoms
when questioned by the staff. On the morning of admission, the
patient was taken to dialysis at [**Location (un) **] Dialysis where he
screamed continuously and held his groin area (the site of a
femoral line). Due to concern about the patient's change in
mental status and possible pain at the femoral line site, he did
not undergo his dialysis treatment and was taken to the [**Hospital1 18**]
emergency department for evaluation.
.
In the ED, the patient's vital signs were: T 95.5, HR 90, BP
158/98, RR 16, O2Sat 99/RA. The patient underwent a CT of the
head and chest x-ray. The CXR showed chronic LLL consolidation,
RLL consolidation that had been noted on the previous admission
and has not yet resolved, as well as small bilateral pleural
effusions. The CT of the head showed no acute intracranial
pathology. The patient was given 1 gram of ceftazidime, 1 gram
of vancomycin, epoetin, 5 mcg of paricalcitol, 62.5 mg of ferric
gluconate. Mr. [**Known lastname **] was found to be hyperkalemic and to have
an INR of 1.3. Given the persistence of the RLL consolidation,
the patient was admitted to the [**Hospital1 139**] general medical service
for work-up of his mental status change and treatment of
pneumonia.
.
Review of Systems: Per report from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the Nursing
Home, the patient has not had any recent cough, fever, nausea,
vomiting, or diarrhea. She says that his blood pressure, heart
rate, and oxygen saturation have all been normal over the last
several days.
.
MICU Txfer:
Reason for transfer: Bradyacardia and AMS
.
During his hospitalization, his mental status improved on
antibiotics. He was initially treated with Levo/Flagyl, changed
to Cefepime and Tobramycin and Flagyl when his cultures grew out
Enterobacteriae; subsequently this was changed to Meropenem as
it was felt that he may have an ESBL organism.
.
On [**2168-9-18**], patient was alert and conversing with team. On
[**2168-9-19**], patient was found to be unresponsive/lethargic and
bradycardic to the 40s. He was in Afib and did not have any
changes on his EKG. His pressure was in the 90s at this heart
rate. His finger sticks were normal. He was afebrile. His last
nodal agents was 9pm on [**2168-9-18**] (he is on metoprolol 25mg [**Hospital1 **])
and his last sedatives were olanzapine at 10am on [**2168-9-18**] and
trazodone at 9pm on [**2168-9-18**]. On the floor, he was given atropine
x 2 and his heart rate increased to 60s after 1st atropine and
his BP increased to the 110s. However, his mentation did not
improve. CT of head showed ?stroke, but Neuro consulted and felt
not c/w pt presentation.
.
On Transfer to floor from MICU:
Summary of MICU course--The episode of AMS that brought him to
the MICU was accompanied by bradycardia and hypotension. He was
started on dopamine; as his HR and BP picked up so did his
mentation. Neuro was consulted about a finding of possible
stroke on CT which they felt was not clinically consistent with
his physical exam.
.
His vitals signs were stable and mental status improved and he
was called out to floor.

MEDICAL HISTORY: 1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **],
chronic CVAs now on coumadin for likely embolic nature
2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2
sec pauses, best managed with metoprolol 75 tid per cards
3) Chronic eosinophilia unknown etiology, strongyloides sent in
[**2-22**] for w/u as well as SPEP/UPEP
4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa
post-cath--no EGD or C-scope performed in f/u yet
5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**]

MEDICATION ON ADMISSION: Docusate Sodium 100 mg Capsule One Capsule PO BID (2 times a
day)
B Complex-Vitamin C-Folic Acid 1 mg Capsule One Cap PO daily
Sevelamer 800 mg Tablet One Tablet PO TID (3 times a day).
Lactulose 10 g/15 mL Syrup Thirty ML PO DAILY PRN constipation.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 98.4 (rectal) HR: 54 BP: 124/65 RR: 18 Sat: 100/RA FS:
133
Gen: Patient is laying in bed comfortable. Wasting apparent in
temporal region and upper and lower extremities. He moans every
few minutes. Patient only understands a few words of English so
very difficult to communicate with him. [**Name2 (NI) **] in the presence of
a translator, the patient did not provide meaningful answers to
questions other than his name.
HEENT: Oropharyngeal mucosa without exudates. Pupils minimally
reactive bilaterally. Neck supple without LAD. No JVD.
CV: Irregularly irregular. Normal S1, S2. S3 appreciated. 1+
carotid, radial pulses. 2+ brachial pulse. Unable to palpate DP,
posterior tibial, and popliteal pulses.
Pul: Difficult exam because of poor cooperation. Appreciated
decreased breath sounds at bases with crackles bilaterally.
Abd: Soft, non-tender, positive bowel sounds, no HSM.
Ext: Trace edema in LE. Atrophy in upper and lower extremities.

FAMILY HISTORY: Mother with hypertension. No history of no strokes, seizures, or
heart disease

SOCIAL HISTORY: Lives in nursing home. No tobacco, etoh, illicit drug use.
Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the
relative or guardian ([**Telephone/Fax (1) 32722**].
Bacteremia,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified pleural effusion,Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Toxic encephalopathy,Anemia, unspecified,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Eosinophilia,Diarrhea,Secondary hyperparathyroidism (of renal origin),Adult failure to thrive,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins
Bacteremia,Food/vomit pneumonitis,Hyp kid NOS w cr kid V,End stage renal disease,CHF NOS,Pleural effusion NOS,Atrial fibrillation,Crbl art ocl NOS w infrc,Toxic encephalopathy,Anemia NOS,Aortocoronary bypass,Cor ath unsp vsl ntv/gft,Eosinophilia,Diarrhea,Sec hyperparathyrd-renal,Failure to thrive-adult,Mth sus Stph aur els/NOS,Inf mcrg rstn pncllins
Admission Date:  [**2168-9-12**]              Discharge Date:   [**2168-9-29**]

Date of Birth:  [**2100-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
Temporary HD catheter line placement
Tunnelled HD catheter line placement
Hemodialysis


History of Present Illness:
Mr. [**Known lastname **] is a 67 year old gentleman with a past medical
history notable for hypertension, ESRD on dialysis, CHF, atrial
fibrillation on coumadin, recent MRSA bacteremia on vancomycin,
CAD s/p CABG and LAD stenting, and past CVA who presented to the
[**Hospital1 18**] on [**2168-9-12**] from his renal dialysis facility because of
change in mental status. Mr. [**Known lastname **] has been admitted
approximately once per month since [**1-/2168**] for [**Year (4 digits) **], CHF,
sepsis, and line infections. His most recent hospital admission
to the [**Hospital1 18**] was from [**2168-9-6**] to [**2168-9-8**] for CHF in the setting
of poorly controlled hypertension. The patient was discharged on
[**2168-9-8**] to his nursing home facility where, per report from
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the home, the patient returned to his baseline
state of health. Mr. [**Known lastname **] did well until the evening prior to
admission, when the staff found him to be shouting more than
normal. At baseline, the patient shouts infrequently in his
native Creole language, but the staff noted that he was shouting
more frequently last night; they also note that he seemed more
confused than normal. In addition, Mr. [**Known lastname **] did not sleep much
on the evening prior to admission. He denied any pain symptoms
when questioned by the staff. On the morning of admission, the
patient was taken to dialysis at [**Location (un) **] Dialysis where he
screamed continuously and held his groin area (the site of a
femoral line). Due to concern about the patient's change in
mental status and possible pain at the femoral line site, he did
not undergo his dialysis treatment and was taken to the [**Hospital1 18**]
emergency department for evaluation.
.
In the ED, the patient's vital signs were: T 95.5, HR 90, BP
158/98, RR 16, O2Sat 99/RA. The patient underwent a CT of the
head and chest x-ray. The CXR showed chronic LLL consolidation,
RLL consolidation that had been noted on the previous admission
and has not yet resolved, as well as small bilateral pleural
effusions. The CT of the head showed no acute intracranial
pathology. The patient was given 1 gram of ceftazidime, 1 gram
of vancomycin, epoetin, 5 mcg of paricalcitol, 62.5 mg of ferric
gluconate. Mr. [**Known lastname **] was found to be hyperkalemic and to have
an INR of 1.3. Given the persistence of the RLL consolidation,
the patient was admitted to the [**Hospital1 139**] general medical service
for work-up of his mental status change and treatment of
pneumonia.
.
Review of Systems: Per report from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the Nursing
Home, the patient has not had any recent cough, fever, nausea,
vomiting, or diarrhea. She says that his blood pressure, heart
rate, and oxygen saturation have all been normal over the last
several days.
.
MICU Txfer:
Reason for transfer: Bradyacardia and AMS
.
During his hospitalization, his mental status improved on
antibiotics. He was initially treated with Levo/Flagyl, changed
to Cefepime and Tobramycin and Flagyl when his cultures grew out
Enterobacteriae; subsequently this was changed to Meropenem as
it was felt that he may have an ESBL organism.
.
On [**2168-9-18**], patient was alert and conversing with team. On
[**2168-9-19**], patient was found to be unresponsive/lethargic and
bradycardic to the 40s. He was in Afib and did not have any
changes on his EKG. His pressure was in the 90s at this heart
rate. His finger sticks were normal. He was afebrile. His last
nodal agents was 9pm on [**2168-9-18**] (he is on metoprolol 25mg [**Hospital1 **])
and his last sedatives were olanzapine at 10am on [**2168-9-18**] and
trazodone at 9pm on [**2168-9-18**]. On the floor, he was given atropine
x 2 and his heart rate increased to 60s after 1st atropine and
his BP increased to the 110s. However, his mentation did not
improve. CT of head showed ?stroke, but Neuro consulted and felt
not c/w pt presentation.
.
On Transfer to floor from MICU:
Summary of MICU course--The episode of AMS that brought him to
the MICU was accompanied by bradycardia and hypotension. He was
started on dopamine; as his HR and BP picked up so did his
mentation. Neuro was consulted about a finding of possible
stroke on CT which they felt was not clinically consistent with
his physical exam.
.
His vitals signs were stable and mental status improved and he
was called out to floor.


Past Medical History:
1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **],
chronic CVAs now on coumadin for likely embolic nature
2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2
sec pauses, best managed with metoprolol 75 tid per cards
3) Chronic eosinophilia unknown etiology, strongyloides sent in
[**2-22**] for w/u as well as SPEP/UPEP
4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa
post-cath--no EGD or C-scope performed in f/u yet
5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**]

6) h/o bacteremia w/ MRSA (most recently diagnosed on admission
from [**8-10**] to [**2168-8-17**]) on Vancomycin until [**2168-9-23**].
7) h/o pulling out groin lines
8) HTN, controlled
9) CAD s/p NSTEMIS, 2 LAD stents, CABG [**2164**]: last ECHO [**2167-8-27**],

EF >55%
10) Hyperlipidemia
11) Diverticulosis
12) Severe Hyperparathyroidism, presumed adenoma, not on vitamin

D for this concern
13) chronic anemia
14) chronic transudative pleural effusions
15) h/o neurocysticercosis calcified

Social History:
Lives in nursing home. No tobacco, etoh, illicit drug use.
Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the
relative or guardian ([**Telephone/Fax (1) 32722**].

Family History:
Mother with hypertension. No history of no strokes, seizures, or
heart disease


Physical Exam:
VS: T: 98.4 (rectal) HR: 54 BP: 124/65 RR: 18 Sat: 100/RA FS:
133
Gen: Patient is laying in bed comfortable. Wasting apparent in
temporal region and upper and lower extremities. He moans every
few minutes. Patient only understands a few words of English so
very difficult to communicate with him. [**Name2 (NI) **] in the presence of
a translator, the patient did not provide meaningful answers to
questions other than his name.
HEENT: Oropharyngeal mucosa without exudates. Pupils minimally
reactive bilaterally. Neck supple without LAD. No JVD.
CV: Irregularly irregular. Normal S1, S2. S3 appreciated. 1+
carotid, radial pulses. 2+ brachial pulse. Unable to palpate DP,
posterior tibial, and popliteal pulses.
Pul: Difficult exam because of poor cooperation. Appreciated
decreased breath sounds at bases with crackles bilaterally.
Abd: Soft, non-tender, positive bowel sounds, no HSM.
Ext: Trace edema in LE. Atrophy in upper and lower extremities.

Pertinent Results:
Admission Labs: [**2168-9-12**] 11:08AM
GLUCOSE-137* UREA N-31* CREAT-6.2*# SODIUM-134 POTASSIUM-6.5*
CHLORIDE-93* TOTAL CO2-28 ANION GAP-20 K+-6.0*
.
WBC-5.1 RBC-4.69 HGB-11.9* HCT-36.6* MCV-78* MCH-25.4* MCHC-32.5
RDW-21.6*
NEUTS-48.3* LYMPHS-37.5 MONOS-5.4 EOS-8.4* BASOS-0.4
.
PT-14.2* PTT-30.7 INR(PT)-1.3*
calTIBC-195* VitB12-1530* Ferritn-637* TRF-150*
TSH-2.4
.
[**2168-9-12**] 12:30 pm BLOOD CULTURE; ENTEROBACTER CLOACAE.
(SENSITIVITIES: CEFEPIME S; CEFTAZIDIME R; CEFTRIAXONE R;
CIPROFLOXACIN R; GENTAMICIN S; IMIPENEM S; LEVOFLOXACIN I;
MEROPENEM S; PIPERACILLIN R; TOBRAMYCIN S)
.
AEROBIC BOTTLE (Final [**2168-9-18**]): ENTEROBACTER CLOACAE.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 32727**]
[**2168-9-12**].
.
Final bld cultures on [**10-30**] and [**9-18**] are negative.
.


Brief Hospital Course:
Mr. [**Known lastname **] is a 67 yo w PMHx of HTN, ESRD on dialysis, CHF,
atrial fibrillation on coumadin, recently completedcourse of
vancomycin for MRSA bacteremia, CAD s/p CABG and LAD stenting,
and past CVA who was admitted and treated for mental status
changes secondary to Enterobacter bacteremia who's
hospitalization was complicated by MICU stay for acute change in
mental status and bradycardia which had resolved by discharge.
.
# Mental status change: Felt to have resolved per family.
Patient was initially admitted with change in MS on [**9-12**]. He had
an acute decompensation on [**9-19**] for which he was transfered to
the MICU. The episode of AMS that brought him to the MICU was
accompanied by bradycardia and hypotension. He was started on
dopamine; as his HR and BP picked up so did his mentation. Neuro
was consulted about a finding of possible stroke on CT which
they felt was not clinically consistent with his physical exam.
We discontinued his trazadone. Baseline he is oriented to self
and to hospital but not which one or year.
.
# Bacteremia-MRSA and Enterobacter: Positive cultures on [**9-12**]
and [**9-15**] with ENTEROBACTER CLOACAE sensitive to meropenum.
Initially was treated with Levo/Flagyl, then Cefepime and
Tobramycin, changed to Meropenum on [**9-16**]. He had a new left
tunneled hemodialysis line put in on [**2171-9-24**]. He completed a
14day course of meropenum on [**2168-9-29**]. Vanco course is complete
as on [**9-23**] per last d/c summary.
.
# CXR with bilateral consolidations/pleural effusions: CXR shows
worsening pleural effusions and he has a persistant oxygen
requirement. Likely secondary to chronic CHF. Patient will go to
NH with 1-2L oxygen.
.
# Diarrhea: Now resolved. Started while in MICU, c.diff negative
x1.
.
# End Stage Renal Disease: This patient has ESRD and is on
dialysis (MWF schedule). Continue with nephrocaps and sevelamer.
 He had IR guided permanent HD catheter placement [**9-23**].  His
INR was reversed with 10 vit K for this procedure.
.
# Bradycardia: Resolved. Unclear etiology: possibly med
effect-received metoprolol on night before MICU admission, ruled
out cardiac event with negative cardiac enzymes. Initially some
response to atropine, but not sustained. Improved with dopamine
and was slowly weaned off. He was monitored on telemetry.  His
metoprolol was discontinued.
.
# Hyperparathyroidism: This patient has baseline secondary
hyperparathyroidism. Continue with cinacalcet.
.
# Hypertension: Patient has baseline hypertension normally
treated with multiple drugs. Patient had episode of hypotension
prompting unit transfer.  Which resolved and antihypertensives
were slowly added back. At discharge patient was on admission
doses of clonidine, amlodipine and lisinopril, but his
metoprolol was discontinued.
.
# Coronary Artery Disease:  He was managed with medical
management by continuing atorvastatin 80mg and asa 81mg.
Metoprolol was discontinued.
.
# Atrial Fibrillation: Goal INR = 2.0 to 3.0. He was reversed
for tunneled line placement. Patient was restarted on coumadin
at home dose of 1mg QHS. He should have twice weekly coumadin
checks until he stabilizes.
.
# Mass in R Atrium:  We spoke with echo [**Location (un) 1131**] room who read it
as a ra "lump". He felt that it was not a myxoma, thrombus, or
cancer, but rather more likely hypertrophy. He said that it
would not likely increase risk of endocarditis over normal
anatomy. He recommended MRI of the heart to better characterize
if we felt it should be persued, and that TEE would have limited
utility.
.
# Anemia: Patient with baseline anemia, but slowly worsening
over hospital course. Laboratory studies consistent with anemia
of chronic disease.  Retic count of 2.9 (RI = 2.9*(27.2/45)/2.0
= 0.88 or less than 2% and thus hypoproliferation). Patient
received EPO and transfusions. Discontinued iron
supplementation.
.

Medications on Admission:
Docusate Sodium 100 mg Capsule One Capsule PO BID (2 times a
day)
B Complex-Vitamin C-Folic Acid 1 mg Capsule One Cap PO daily
Sevelamer 800 mg Tablet One Tablet PO TID (3 times a day).
Lactulose 10 g/15 mL Syrup Thirty ML PO DAILY PRN constipation.

Trazodone 25 mg PO HS (at bedtime) PRN insomnia
Cinacalcet 30 mg Tablet One Tablet PO Daily
Aspirin 81 mg Tablet, Chewable One Tablet PO Daily
Clonidine 0.2 mg Tablet One Tablet PO TID (3 times a day)
Amlodipine 5 mg Tablet One Tablet PO Daily
Atorvastatin 80 mg Tablet One Tablet PO Daily
Ferrous Sulfate 325 (65) mg Tablet One Tablet PO Daily
Pantoprazole 40 mg Tablet, Delayed Release (E.C.) One Tablet,
Delayed Release PO Q24H (every 24 hours)
Metoprolol Tartrate 25 mg Tablet One Tablet PO BID (2 times a
day)
Lisinopril 10 mg Tablet One Tablet PO Daily (discharge summary
says 20 mg per day, med sheet says 10 mg per day)
Vancomycin HCl 1000 mg IV TO BE DOSED AT HEMODIALYSIS (Through
[**2168-9-23**])
Coumadin 1 mg Tablet One Tablet PO QPM (discharge summary said
to take every other day, med sheet from nursing home says he is
getting it every evening)

Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous  QHD: Please have his hemodialysis unit dose the
meropenum after HD until [**2168-9-29**].
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.

5. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day): Please hold for SBP < 100. .
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): titrate to 1BM each day.
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY; PRN
() as needed for constipation.
9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO three times a
day: Please monitor phosphate. .
10. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please monitor with INRs.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
15. Warfarin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

16. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Docusate Sodium 150 mg/15 mL Liquid Sig: 10ml  PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
Roscommon

Discharge Diagnosis:
Primary
Bacteremia-enterobacter
ESRD on HD
CAD s/p CABG
A fib
h/o MRSA bacteremia
Bradycardia
Secondary
Anemia


Discharge Condition:
Stable


Discharge Instructions:
Please take your medications as prescribed.  We have
discontinued your metoprolol secondary to your bradycardia, the
trazadone secondary to change in mental status, and iron
discontinued.
.
Please seek medical attention for chest pain, palpitations,
shortness of breath, fever, chills, or if other caregivers [**Name (NI) 32728**]
a change in mental status and for any other symptoms concerning
to you.

Followup Instructions:
Please follow-up with the physician at the facility and your PCP
in the next 1-2 weeks.
{'Bacteremia,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified pleural effusion,Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Toxic encephalopathy,Anemia, unspecified,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Eosinophilia,Diarrhea,Secondary hyperparathyroidism (of renal origin),Adult failure to thrive,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins'}


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: Altered mental status

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67 year old gentleman with a past medical
history notable for hypertension, ESRD on dialysis, CHF, atrial
fibrillation on coumadin, recent MRSA bacteremia on vancomycin,
CAD s/p CABG and LAD stenting, and past CVA who presented to the
[**Hospital1 18**] on [**2168-9-12**] from his renal dialysis facility because of
change in mental status. Mr. [**Known lastname **] has been admitted
approximately once per month since [**1-/2168**] for [**Year (4 digits) **], CHF,
sepsis, and line infections. His most recent hospital admission
to the [**Hospital1 18**] was from [**2168-9-6**] to [**2168-9-8**] for CHF in the setting
of poorly controlled hypertension. The patient was discharged on
[**2168-9-8**] to his nursing home facility where, per report from
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the home, the patient returned to his baseline
state of health. Mr. [**Known lastname **] did well until the evening prior to
admission, when the staff found him to be shouting more than
normal. At baseline, the patient shouts infrequently in his
native Creole language, but the staff noted that he was shouting
more frequently last night; they also note that he seemed more
confused than normal. In addition, Mr. [**Known lastname **] did not sleep much
on the evening prior to admission. He denied any pain symptoms
when questioned by the staff. On the morning of admission, the
patient was taken to dialysis at [**Location (un) **] Dialysis where he
screamed continuously and held his groin area (the site of a
femoral line). Due to concern about the patient's change in
mental status and possible pain at the femoral line site, he did
not undergo his dialysis treatment and was taken to the [**Hospital1 18**]
emergency department for evaluation.
.
In the ED, the patient's vital signs were: T 95.5, HR 90, BP
158/98, RR 16, O2Sat 99/RA. The patient underwent a CT of the
head and chest x-ray. The CXR showed chronic LLL consolidation,
RLL consolidation that had been noted on the previous admission
and has not yet resolved, as well as small bilateral pleural
effusions. The CT of the head showed no acute intracranial
pathology. The patient was given 1 gram of ceftazidime, 1 gram
of vancomycin, epoetin, 5 mcg of paricalcitol, 62.5 mg of ferric
gluconate. Mr. [**Known lastname **] was found to be hyperkalemic and to have
an INR of 1.3. Given the persistence of the RLL consolidation,
the patient was admitted to the [**Hospital1 139**] general medical service
for work-up of his mental status change and treatment of
pneumonia.
.
Review of Systems: Per report from [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32726**] at the Nursing
Home, the patient has not had any recent cough, fever, nausea,
vomiting, or diarrhea. She says that his blood pressure, heart
rate, and oxygen saturation have all been normal over the last
several days.
.
MICU Txfer:
Reason for transfer: Bradyacardia and AMS
.
During his hospitalization, his mental status improved on
antibiotics. He was initially treated with Levo/Flagyl, changed
to Cefepime and Tobramycin and Flagyl when his cultures grew out
Enterobacteriae; subsequently this was changed to Meropenem as
it was felt that he may have an ESBL organism.
.
On [**2168-9-18**], patient was alert and conversing with team. On
[**2168-9-19**], patient was found to be unresponsive/lethargic and
bradycardic to the 40s. He was in Afib and did not have any
changes on his EKG. His pressure was in the 90s at this heart
rate. His finger sticks were normal. He was afebrile. His last
nodal agents was 9pm on [**2168-9-18**] (he is on metoprolol 25mg [**Hospital1 **])
and his last sedatives were olanzapine at 10am on [**2168-9-18**] and
trazodone at 9pm on [**2168-9-18**]. On the floor, he was given atropine
x 2 and his heart rate increased to 60s after 1st atropine and
his BP increased to the 110s. However, his mentation did not
improve. CT of head showed ?stroke, but Neuro consulted and felt
not c/w pt presentation.
.
On Transfer to floor from MICU:
Summary of MICU course--The episode of AMS that brought him to
the MICU was accompanied by bradycardia and hypotension. He was
started on dopamine; as his HR and BP picked up so did his
mentation. Neuro was consulted about a finding of possible
stroke on CT which they felt was not clinically consistent with
his physical exam.
.
His vitals signs were stable and mental status improved and he
was called out to floor.

MEDICAL HISTORY: 1) Left occipital lobe CVA [**2-22**] p/w change in MS [**First Name (Titles) **] [**Last Name (Titles) **],
chronic CVAs now on coumadin for likely embolic nature
2) Paroxysmal Afib, rate controlled with tachy/brady, occas 2
sec pauses, best managed with metoprolol 75 tid per cards
3) Chronic eosinophilia unknown etiology, strongyloides sent in
[**2-22**] for w/u as well as SPEP/UPEP
4) h/o GI Bleed in [**2167-7-20**] while on asa, plavix, IIb/IIIa
post-cath--no EGD or C-scope performed in f/u yet
5) ESRD secondary to HTN, dialysis MWF- followed by Dr. [**First Name (STitle) 805**]

MEDICATION ON ADMISSION: Docusate Sodium 100 mg Capsule One Capsule PO BID (2 times a
day)
B Complex-Vitamin C-Folic Acid 1 mg Capsule One Cap PO daily
Sevelamer 800 mg Tablet One Tablet PO TID (3 times a day).
Lactulose 10 g/15 mL Syrup Thirty ML PO DAILY PRN constipation.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T: 98.4 (rectal) HR: 54 BP: 124/65 RR: 18 Sat: 100/RA FS:
133
Gen: Patient is laying in bed comfortable. Wasting apparent in
temporal region and upper and lower extremities. He moans every
few minutes. Patient only understands a few words of English so
very difficult to communicate with him. [**Name2 (NI) **] in the presence of
a translator, the patient did not provide meaningful answers to
questions other than his name.
HEENT: Oropharyngeal mucosa without exudates. Pupils minimally
reactive bilaterally. Neck supple without LAD. No JVD.
CV: Irregularly irregular. Normal S1, S2. S3 appreciated. 1+
carotid, radial pulses. 2+ brachial pulse. Unable to palpate DP,
posterior tibial, and popliteal pulses.
Pul: Difficult exam because of poor cooperation. Appreciated
decreased breath sounds at bases with crackles bilaterally.
Abd: Soft, non-tender, positive bowel sounds, no HSM.
Ext: Trace edema in LE. Atrophy in upper and lower extremities.

FAMILY HISTORY: Mother with hypertension. No history of no strokes, seizures, or
heart disease

SOCIAL HISTORY: Lives in nursing home. No tobacco, etoh, illicit drug use.
Transfer paper work from nursing home lists [**First Name4 (NamePattern1) **] [**Known lastname **] as the
relative or guardian ([**Telephone/Fax (1) 32722**]. 

### Response:
{'Bacteremia,Pneumonitis due to inhalation of food or vomitus,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Congestive heart failure, unspecified,Unspecified pleural effusion,Atrial fibrillation,Cerebral artery occlusion, unspecified with cerebral infarction,Toxic encephalopathy,Anemia, unspecified,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Eosinophilia,Diarrhea,Secondary hyperparathyroidism (of renal origin),Adult failure to thrive,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Infection with microorganisms resistant to penicillins'}
