CHIEF COMPLAINT: Fever, Altered Mental Status

PRESENT ILLNESS: 61 y/o man with history of etoh abuse, dementia, DM, CAD, CHF,
living in extended care presenting with reports of fever, cough,
and lethargy x several days. Per reports, has had decreased
verbalization. Was febrile on AM of admission and labs drawn @
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] were notable for WBC 2.7, K+ 5.4.
.
In ED: was febrile to 101.2 and received Vanc/Levo/Flagyl/CTX.
CXR withoutu infiltrate or effusion. Blood/urine cultures sent
and LP performed with 1WBC, 1RBC. EKG with J-point elevation and
first set CE negative. LFTs within normal limits. CT head with
stable old frontal encephalomalacia, generalized atrophy, and
stigmata of chronic ischemic changes. During ER work-up patient
missed many of his daily medications and became markedly
hypertensive to 230s systolic. Multiple medications were given
including hydral 10mg IV x 1, 60mg po x 1, isosorbide 40mg po x
1, lopressor 5mg IV x 2, and lopressor 150mg po x 1 and he was
ultimately placed on labetalol gtt and transfered to the unit.

MEDICAL HISTORY: # Alcohol Abuse
# Cirrhosis
# Dementia
# CAD - Cardiac Cath [**Hospital2 **] [**Hospital3 6783**] Hosp [**2184**] w/3VD
# CHF - echo @ [**Hospital1 18**] [**2184**] w/EF 20-25% with both systolic and
diastolic dysfunction
# Right Hip Fracture s/p ORIF [**2184**] @ [**Hospital1 18**]
# PEG [**2184**] @ [**Hospital1 18**] [**2-25**] fialed s/s, pt self d/c'd [**9-/2186**]
# Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
# Diabetes, on Insulin
# Hepatitis C
# Hypertension
# Seizure disorder, on dilantin
# Prior cocaine abuse

MEDICATION ON ADMISSION: Metoprolol 150mg po BID
Hydralazine 60mg po Q6Hours
Terazosin 2mg po Qday
Isosorbide 40mg po TID
Remeron 15mg po Qhs
Donepezil 10mg po QHS
Trazadone 25mg po BID
Lorazepam 0.5mg po Qday @ 7am
Lorazepam 0.5mg po Q4h prn anxiety/agitation
Glargine 10 Units po Qday
Regular Insulin Sliding Scale [**Hospital1 **] 4-10 units
Ranitidine 150mg po BID
Albuterol 2puffs po BID prn
Keppra 500mg po Qday (but note made to hold)
Immodium prn
Senna
Dulcolax prn
Milk of Magnesia prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.8 109 193/112 97% on 2LNC
Gen: somnolent, opens eyes slowly, but does not follow other
comands. Sat up when foley placed and asked "what are you doing"

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Current resident @ [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home in [**Location (un) **].
further history per previous notes such as prior etoh and
substance abuse.
Hypertensive encephalopathy,Acute kidney failure, unspecified,Chronic combined systolic and diastolic heart failure,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of insulin
Hypertens encephalopathy,Acute kidney failure NOS,Chr syst/diastl hrt fail,Alcohol cirrhosis liver,Chrnc hpt C wo hpat coma,Mental disor NEC oth dis,Chronic kidney dis NOS,Epilep NOS w/o intr epil,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Long-term use of insulin
Admission Date:  [**2186-2-8**]              Discharge Date:   [**2186-2-17**]

Date of Birth:  [**2124-9-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Fever, Altered Mental Status

Major Surgical or Invasive Procedure:
PEG tube


History of Present Illness:
61 y/o man with history of etoh abuse, dementia, DM, CAD, CHF,
living in extended care presenting with reports of fever, cough,
and lethargy x several days. Per reports, has had decreased
verbalization. Was febrile on AM of admission and labs drawn @
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] were notable for WBC 2.7, K+ 5.4.
.
In ED: was febrile to 101.2 and received Vanc/Levo/Flagyl/CTX.
CXR withoutu infiltrate or effusion. Blood/urine cultures sent
and LP performed with 1WBC, 1RBC. EKG with J-point elevation and
first set CE negative. LFTs within normal limits. CT head with
stable old frontal encephalomalacia, generalized atrophy, and
stigmata of chronic ischemic changes. During ER work-up patient
missed many of his daily medications and became markedly
hypertensive to 230s systolic. Multiple medications were given
including hydral 10mg IV x 1, 60mg po x 1, isosorbide 40mg po x
1, lopressor 5mg IV x 2, and lopressor 150mg po x 1 and he was
ultimately placed on labetalol gtt and transfered to the unit.


Past Medical History:
# Alcohol Abuse
# Cirrhosis
# Dementia
# CAD - Cardiac Cath [**Hospital2 **] [**Hospital3 6783**] Hosp [**2184**] w/3VD
# CHF - echo @ [**Hospital1 18**] [**2184**] w/EF 20-25% with both systolic and
diastolic dysfunction
# Right Hip Fracture s/p ORIF [**2184**] @ [**Hospital1 18**]
# PEG [**2184**] @ [**Hospital1 18**] [**2-25**] fialed s/s, pt self d/c'd [**9-/2186**]
# Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
# Diabetes, on Insulin
# Hepatitis C
# Hypertension
# Seizure disorder, on dilantin
# Prior cocaine abuse


Social History:
Current resident @ [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home in [**Location (un) **].
further history per previous notes such as prior etoh and
substance abuse.

Family History:
Noncontributory

Physical Exam:
98.8 109 193/112 97% on 2LNC
Gen: somnolent, opens eyes slowly, but does not follow other
comands. Sat up when foley placed and asked "what are you doing"

HEENT: Poor Dentition, moist mucus membranes
NECK: Supple, trachea midline. Jugular vein not prominent
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: coarse breath sounds bilaterally, hoarse gurggling in
upper airway.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO EXAM: does not follow commands. Pupils are dilated but
equal bilaterally. No increased tone and moves all extremities
spontaneously.


Pertinent Results:
[**2186-2-8**] 09:45AM   PT-13.3 PTT-31.3 INR(PT)-1.1
[**2186-2-8**] 09:45AM   PLT COUNT-142*
[**2186-2-8**] 09:45AM   NEUTS-75.1* LYMPHS-17.8* MONOS-4.9 EOS-1.6
BASOS-0.5
[**2186-2-8**] 09:45AM   WBC-5.8 RBC-4.02*# HGB-12.3*# HCT-38.0*#
MCV-95# MCH-30.7 MCHC-32.5# RDW-12.9
[**2186-2-8**] 09:45AM   CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2186-2-8**] 09:45AM   CK-MB-3
[**2186-2-8**] 09:45AM   cTropnT-0.04*
[**2186-2-8**] 09:45AM   CK(CPK)-161
[**2186-2-8**] 09:45AM   estGFR-Using this
[**2186-2-8**] 09:45AM   GLUCOSE-115* UREA N-31* CREAT-1.8* SODIUM-138
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
[**2186-2-8**] 09:49AM   LACTATE-1.0
[**2186-2-8**] 12:25PM URINE  WBCCLUMP-RARE
[**2186-2-8**] 12:25PM URINE  RBC-21-50* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2186-2-8**] 12:25PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-7.0
LEUK-NEG
[**2186-2-8**] 12:25PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF)  WBC-1 RBC-1*
POLYS-10 LYMPHS-72 MONOS-18
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF)  PROTEIN-68*
GLUCOSE-74
[**2186-2-8**] 08:15PM   PLT COUNT-105*
[**2186-2-8**] 08:15PM   NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM   WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM   NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM   WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM   AMMONIA-<6
[**2186-2-8**] 08:15PM   CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2186-2-8**] 08:15PM   CK-MB-4
[**2186-2-8**] 08:15PM   cTropnT-<0.01 proBNP-[**2157**]*
[**2186-2-8**] 08:15PM   LIPASE-37
[**2186-2-8**] 08:15PM   ALT(SGPT)-21 AST(SGOT)-26 CK(CPK)-151 ALK
PHOS-73 TOT BILI-0.6
[**2186-2-8**] 08:15PM   GLUCOSE-174* UREA N-29* CREAT-1.6* SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
.
AT DISCHARGE
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2186-2-17**] 06:44AM    4.1 3.25* 10.3* 30.2* 93 31.5 34.0 12.4
111*
  DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2186-2-9**] 02:40AM    61 19* 8* 9 0 0 3* 0 0
[**2186-2-9**] 02:40AM    82.4* 0 12.0* 4.7 0.3 0.6
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2186-2-9**] 02:40AM    NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2186-2-17**] 06:44AM          111*
[**2186-2-17**] 06:44AM    13.11 40.8*     1.1

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2186-2-17**] 06:44AM    132* 15 1.2 135 3.7 107 21* 11
  ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2186-2-15**] 09:50AM    Using this1
DIL,PEP ADDED 12:15PM
1 Using this patient's age, gender, and serum creatinine value
of 1.3,
Estimated GFR = 56 if non African-American (mL/min/1.73 m2)
Estimated GFR = 68 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2186-2-17**] 06:44AM    13 20
.

[**2186-2-8**] KUB: No evidence of obstruction or free air.
..
[**2186-2-8**] CXR: No evidence of pneumonia.
.
[**2186-2-9**] CXR: Worsening opacification at the bases which may
represent atelectasis or new early pneumonia, as well as small
effusions. Recommend close attention on followup radiographs.
.
[**2186-2-10**] CXR: In comparison with the study of [**2-9**], the right
base is somewhat clearer than on the previous study and the
minimal opacification above it most likely represents merely
atelectatic change. Opacification at the left base in the
retrocardiac region is again seen consistent with atelectasis.
Probable left pleural effusion as well. The upper lung zones are
within normal limits.
.
[**2186-2-14**] RENAL ULTRASOUND
.
61 year old man with Hypertensive Urgency. Please evaluate for
renal artery stenosis
REASON FOR THIS EXAMINATION:
Renal artery stenosis
HISTORY: 61-year-old male with hypertensive urgency, concern for
renal artery stenosis.

RENAL ULTRASOUND WITH DOPPLER: Grayscale, color, and pulse
Doppler son[**Name (NI) 1417**] of both kidneys were performed. Both kidneys
are normal in grayscale appearance, with the right kidney
measuring 10.8 cm and the left kidney 11.1 cm. There is no
evidence of hydronephrosis, stones, or solid renal mass. Doppler
evaluation demonstrates patency of the bilateral main renal
arteries and veins. There are appropriate waveforms
demonstrated. Intrarenal resistive indices of the right kidney
range from 0.66 to 0.71 and on the left from 0.70 to 0.73.

IMPRESSION: Unremarkable renal ultrasound. Patent renal
vasculature. No definite evidence of renal artery stenosis.
.
[**2186-2-9**] CT ABDOMEN AND PELVIS
.
CT ABDOMEN: Visualized lung bases show patchy areas of dependent
airspace opacity that is heterogeneous. There are a few areas of
bronchiectasis in the lower lobes. There is no pleural or
pericardial effusion. Cardiomegaly is unchanged.

Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver is nodular
and shrunken, unchanged from prior exam, and consistent with
history of cirrhosis. No focal intrahepatic mass or biliary
ductal dilatation. There is no ascites. Gallbladder, pancreas,
spleen, adrenal glands, kidneys, stomach and intra-abdominal
loops of bowel demonstrate normal non-contrast appearance. There
is no free air or free intraperitoneal fluid. There is no
abnormal intra-abdominal lymphadenopathy.

CT PELVIS: Foley catheter balloon is in place within a
decompressed bladder. Pelvic loops of large and small bowel are
unremarkable. There is no free pelvic fluid or abnormal pelvic
or inguinal lymphadenopathy.

There is moderate atherosclerotic calcification of the abdominal
aorta and its branches, without focal dilatation.

OSSEOUS STRUCTURES: Old right femoral fracture fixed with
dynamic hip screw is unchanged. Old fractures of the left
inferior pubic ramus and left pubic symphysis also unchanged.
Compression deformity of the superior endplate of L3 is
unchanged.

IMPRESSION:
1. No acute process in the abdomen or pelvis.

2. Bilateral lower lobe airspace opacities raise concern for
recent aspiration or pneumonia superimposed on chronic lung
disease with areas of bronchiectasis.
3. Unchanged cirrhotic liver.
.
CT HEAD WO CONTRAST [**2186-2-8**]
.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is an unchanged area
of cystic encephalomalacia within the left frontal lobe. There
is stable prominence of the ventricles and sulci consistent with
atrophic change. Periventricular and subcortical white matter
hypodensity presumably represents chronic microvascular ischemic
change. There is no evidence for major or minor vascular
territorial infarct, acute hemorrhage, shift of normally midline
structures or hydrocephalus. No fractures are identified. There
is opacification of several anterior ethmoid air cells and mild
thickening within the frontal sinuses. The visualized mastoid
air cells and middle ear cavities are normally pneumatized and
aerated. Again seen is a 13 x 5 mm lipoma along the paramedian
right occipital subcutaneous tissues.

IMPRESSION:

1. No intracranial hemorrhage or mass effect. Stable area of
encephalomalacia in the left frontal lobe which may represent
sequela of old trauma or infarct.
2. Stable moderate atrophy and chronic changes of microvascular
ischemia.

MRI is more sensitive than CT for detection of acute ischemia.


Brief Hospital Course:
Mr. [**Known lastname 1169**] is a 61 y/o man with a history of DM, Etoh abuse,
Dementia, CAD, CHF who presented with fever, altered mental
status, and hypertension.
.
# Fever/Altered Mental status: Considered due to hypertensive
encephalopathy as well as sedation from several psychotropic
drugs. All cultures were negative including influenza DFA. Hie
mental status cleared progressively back to baseline. He
benefited from stopping Ativan and starting 50 mg Provigil
daily.
.
# Hypertension: Initially it was very poorly controlled, >200s,
requiring labetalol/nitro gtt, then transitioned to nitro paste.
He converted to topical and oral medications within 48 hours. He
persistently had somewhat elevated BP and his regimen slowly
adjusted. His ACE inhibitor has been increased, currently at 20
mg/day with improved control, this might be increased further if
necessary. Renal US negative for renal artery stenosis. He will
need to have his BP monitored and medications adjuested if
necessary.
.
# Nausea/vomiting: LFTs within normal limits. Given antiemetics
and the symptoms resolved. Hepatitis serologies have been sent,
results pending at time of discharge.
.
# Chronic Systolic and Diastolic Heart Failure: He had increased
frothy secretions initially, but CXR was without evidence of
pulmonary edema. He has a jugular vein that moves with pulse,
but is not particularly distended. He is euvolemic. He required
no diuresis. These might have been oral secretions in view of
his dysphagia. Secretions resolved prior to discharge. He will
require comfort mouth care.
.
# Chronic Renal Failure with Proteinuria: Chronic hypertensive
disease and diabetic nephropathy, with some component of
prerenal azotemia that responded to gentle hydration
.
# Cirrhosis: Secondary to etoh abuse and hepatitis C. No
coagulopathy or stigmata of decompensation. LFTs remained
normal. Some hepatitis serologies pending as stated above.
.
# History of Seizure Disorder: Unkown details, note made in med
book from [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] that keppra is discontinued, or held for
now.  He came on dilantin but his level was 0.6. He was loaded
with one gram and subsequently placed on his regimen of 100 mg
TID. He will need a level drawn within 2-3 weeks.
.
DNR DNI

Medications on Admission:
Metoprolol 150mg po BID
Hydralazine 60mg po Q6Hours
Terazosin 2mg po Qday
Isosorbide 40mg po TID
Remeron 15mg po Qhs
Donepezil 10mg po QHS
Trazadone 25mg po BID
Lorazepam 0.5mg po Qday @ 7am
Lorazepam 0.5mg po Q4h prn anxiety/agitation
Glargine 10 Units po Qday
Regular Insulin Sliding Scale [**Hospital1 **] 4-10 units
Ranitidine 150mg po BID
Albuterol 2puffs po BID prn
Keppra 500mg po Qday (but note made to hold)
Immodium prn
Senna
Dulcolax prn
Milk of Magnesia prn


Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**1-25**] inh Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
10. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO daily am ().
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): For
one month. Then switch to one tablet 40 mg daily.
16. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
17. Insulin sliding scale if needed (attached)
usually [**Hospital1 **]  4-10 units
18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
20. glargine  Sig: Ten (10) units  once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 2670**] - [**Location (un) 2716**] House - [**Hospital1 1559**]

Discharge Diagnosis:
Hypertensive urgency
Dementia
Fever


Discharge Condition:
Good. Tolerating tube feeds. Pain free. Baseline mental status


Discharge Instructions:
Admitted with hypertensive urgency with mental status changes.
This has been getting under control with medication.
.
A PEG tube was started for nutrition, goal 60 cc/hour.
Tolerating well.
.
Started on provigil for alertness and depression.
.
Please adhere to medication regimen and f/u with doctors as
written below.

Followup Instructions:
With Dr [**Last Name (STitle) 5762**] within 1-2 weeks of discharge. Phone nr [**Telephone/Fax (1) 40619**]

Please call a GI doctor if any issues with PEG , phone nr [**Numeric Identifier 68258**]
{'Hypertensive encephalopathy,Acute kidney failure, unspecified,Chronic combined systolic and diastolic heart failure,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of insulin'}


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: 61 y/o man with history of etoh abuse, dementia, DM, CAD, CHF,
living in extended care presenting with reports of fever, cough,
and lethargy x several days. Per reports, has had decreased
verbalization. Was febrile on AM of admission and labs drawn @
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] were notable for WBC 2.7, K+ 5.4.
.
In ED: was febrile to 101.2 and received Vanc/Levo/Flagyl/CTX.
CXR withoutu infiltrate or effusion. Blood/urine cultures sent
and LP performed with 1WBC, 1RBC. EKG with J-point elevation and
first set CE negative. LFTs within normal limits. CT head with
stable old frontal encephalomalacia, generalized atrophy, and
stigmata of chronic ischemic changes. During ER work-up patient
missed many of his daily medications and became markedly
hypertensive to 230s systolic. Multiple medications were given
including hydral 10mg IV x 1, 60mg po x 1, isosorbide 40mg po x
1, lopressor 5mg IV x 2, and lopressor 150mg po x 1 and he was
ultimately placed on labetalol gtt and transfered to the unit.

MEDICAL HISTORY: # Alcohol Abuse
# Cirrhosis
# Dementia
# CAD - Cardiac Cath [**Hospital2 **] [**Hospital3 6783**] Hosp [**2184**] w/3VD
# CHF - echo @ [**Hospital1 18**] [**2184**] w/EF 20-25% with both systolic and
diastolic dysfunction
# Right Hip Fracture s/p ORIF [**2184**] @ [**Hospital1 18**]
# PEG [**2184**] @ [**Hospital1 18**] [**2-25**] fialed s/s, pt self d/c'd [**9-/2186**]
# Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
# Diabetes, on Insulin
# Hepatitis C
# Hypertension
# Seizure disorder, on dilantin
# Prior cocaine abuse

MEDICATION ON ADMISSION: Metoprolol 150mg po BID
Hydralazine 60mg po Q6Hours
Terazosin 2mg po Qday
Isosorbide 40mg po TID
Remeron 15mg po Qhs
Donepezil 10mg po QHS
Trazadone 25mg po BID
Lorazepam 0.5mg po Qday @ 7am
Lorazepam 0.5mg po Q4h prn anxiety/agitation
Glargine 10 Units po Qday
Regular Insulin Sliding Scale [**Hospital1 **] 4-10 units
Ranitidine 150mg po BID
Albuterol 2puffs po BID prn
Keppra 500mg po Qday (but note made to hold)
Immodium prn
Senna
Dulcolax prn
Milk of Magnesia prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 98.8 109 193/112 97% on 2LNC
Gen: somnolent, opens eyes slowly, but does not follow other
comands. Sat up when foley placed and asked "what are you doing"

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Current resident @ [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home in [**Location (un) **].
further history per previous notes such as prior etoh and
substance abuse. 

### Response:
{'Hypertensive encephalopathy,Acute kidney failure, unspecified,Chronic combined systolic and diastolic heart failure,Alcoholic cirrhosis of liver,Chronic hepatitis C without mention of hepatic coma,Other persistent mental disorders due to conditions classified elsewhere,Chronic kidney disease, unspecified,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Long-term (current) use of insulin'}
