CHIEF COMPLAINT: change in mental status

PRESENT ILLNESS: 46 year old man with a hx of DM2, HTN, hypercholesterolemia, and
schizophrenia presented from his group home with a change in
mental status noted by staff at his group home on [**8-14**]. On
admission, pt was alert and oriented x2 however is unable to
provide a history of present illness. Information was obtained
from the director of his group home.
.
Patient was in his USOH until evening of [**2111-8-13**] when he did not
take his PM medications. Staff found him to be asleep in bed,
difficult to arouse. He refused his medications. He was NOT
noted to have a facial droop, loss of conciousness or witnessed
seizure activity. EMS was called and foud patient
sitting in chair, leaning to the left. He answered some
questions but was "occasionally aphasic". He was able to
ambulate to the ambulance independently. He was then transported
to the [**Hospital1 18**] ED.
.
Initial vital signs in ED on [**8-14**]:  104.8 P 113 BP 135/86 R 28
97% on 3L. He had LP which was unrevealing. HE recieved 3.5 L NS
and also vanco/ceftriaxone/ampicillin, acyclovir and multiple
ativan.
.
Pt was admitted to the MICU for sepsis workup.  Was intubated on
the evening of admission due to worsening respiratory status.
.

MEDICAL HISTORY: 1. DM2
2. Paranoid Schizophrenia w/ auditory hallucination- well
controlled on Clozaril and history of violence
3. GERD
4. High Cholesterol
5. HTN

MEDICATION ON ADMISSION: Clozaril 400mg [**Hospital1 **]
Depakote 750mg qam and 1000mg qpm
Protonix 40mg QD
Seroquel
Ativan 1mg QD and 0.5mg PRN
Zoloft 25mg QD
ASA 81mg QD
Lisinopril 5mg QD
Avandia 4mg qam
Gemfibrozil 600mg [**Hospital1 **]
glucophage 1000mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on Admission: T104.8 BP135/86 HR113 RR28 O2 Sat 93%
Gen: A+O x2
HEENT: NC/AT, sclera anichteric, no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no Kernig's or Brudzinski signs, no bruit
CV: Tachy, Nl S1 and S2,
Lung: +basilar crackles bilaterally, occasional expiratory
wheeze
Abd: +BS soft, non-distended
Ext: no edema
Neurologic examination:
Mental status: Awake, lethargy, cranial nerve normal, minimally
responsive to external stimuli and nearly non-verbal, His muscle
tone is normal and reflexes are decreased throughout
.
Exam on Day of Transfer [**2111-8-29**]:
T 98.6 144/80 76 18 94%RA
Gen: Lying in bed, pill rolling tremor at baseline A+O x3
HEENT: PERRLA (3mm--> 2mm bilat), no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no LAD, no bruit, thyroid smooth and not enlarged
CV: Nl S1 and S2, [**1-18**] holosystolic murmur at LLSB no radiations
Lung: decreased breath sounds at bases, otherwise CTA
bialterally
Abd: NABS soft,obese non-distended, NT
Ext: no edema, no clubbing
Neurologic examination:
Mental status: pill rolling tremor; CN 3-12 indivisually tested
and intact; strength 5/5 upper and lower extremities

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives in a group home ([**Location (un) **]) since [**3-16**]. Phone # of
home: [**Telephone/Fax (1) 96990**]. Usually spends days in day program or pan
handling at Downtown Crossing. Known to use marijuana, but no
other drugs. [**Month (only) 116**] have a remote EtOH history. No close family.
Unspecified septicemia,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Pressure ulcer, lower back,Infection and inflammatory reaction due to other vascular device, implant, and graft,Schizoaffective disorder, unspecified,Severe sepsis,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia
Septicemia NOS,Acute respiratry failure,Legionnaires' disease,Acute kidney failure NOS,Pressure ulcer, low back,React-oth vasc dev/graft,Schizoaffective dis NOS,Severe sepsis,DMII keto nt st uncntrld,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2111-8-14**]              Discharge Date:   [**2111-9-7**]

Date of Birth:  [**2064-9-9**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
change in mental status

Major Surgical or Invasive Procedure:
Endotracheal intubation
Subclavian central venous line placement X 2
Radial arterial line placement
Peripheral intravenous central catheter placement
Sacral decubitus wound debridement

History of Present Illness:
46 year old man with a hx of DM2, HTN, hypercholesterolemia, and
schizophrenia presented from his group home with a change in
mental status noted by staff at his group home on [**8-14**]. On
admission, pt was alert and oriented x2 however is unable to
provide a history of present illness. Information was obtained
from the director of his group home.
.
Patient was in his USOH until evening of [**2111-8-13**] when he did not
take his PM medications. Staff found him to be asleep in bed,
difficult to arouse. He refused his medications. He was NOT
noted to have a facial droop, loss of conciousness or witnessed
seizure activity. EMS was called and foud patient
sitting in chair, leaning to the left. He answered some
questions but was "occasionally aphasic". He was able to
ambulate to the ambulance independently. He was then transported
to the [**Hospital1 18**] ED.
.
Initial vital signs in ED on [**8-14**]:  104.8 P 113 BP 135/86 R 28
97% on 3L. He had LP which was unrevealing. HE recieved 3.5 L NS
and also vanco/ceftriaxone/ampicillin, acyclovir and multiple
ativan.
.
Pt was admitted to the MICU for sepsis workup.  Was intubated on
the evening of admission due to worsening respiratory status.
.


Past Medical History:
1. DM2
2. Paranoid Schizophrenia w/ auditory hallucination- well
controlled on Clozaril and history of violence
3. GERD
4. High Cholesterol
5. HTN

Social History:
Lives in a group home ([**Location (un) **]) since [**3-16**]. Phone # of
home: [**Telephone/Fax (1) 96990**]. Usually spends days in day program or pan
handling at Downtown Crossing. Known to use marijuana, but no
other drugs. [**Month (only) 116**] have a remote EtOH history. No close family.

Family History:
Unknown

Physical Exam:
Exam on Admission: T104.8 BP135/86 HR113 RR28 O2 Sat 93%
Gen: A+O x2
HEENT: NC/AT, sclera anichteric, no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no Kernig's or Brudzinski signs, no bruit
CV: Tachy, Nl S1 and S2,
Lung: +basilar crackles bilaterally, occasional expiratory
wheeze
Abd: +BS soft, non-distended
Ext: no edema
Neurologic examination:
Mental status: Awake, lethargy, cranial nerve normal, minimally
responsive to external stimuli and nearly non-verbal, His muscle
tone is normal and reflexes are decreased throughout
.
Exam on Day of Transfer [**2111-8-29**]:
T 98.6 144/80 76 18 94%RA
Gen: Lying in bed, pill rolling tremor at baseline A+O x3
HEENT: PERRLA (3mm--> 2mm bilat), no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no LAD, no bruit, thyroid smooth and not enlarged
CV: Nl S1 and S2, [**1-18**] holosystolic murmur at LLSB no radiations
Lung: decreased breath sounds at bases, otherwise CTA
bialterally
Abd: NABS soft,obese non-distended, NT
Ext: no edema, no clubbing
Neurologic examination:
Mental status: pill rolling tremor; CN 3-12 indivisually tested
and intact; strength 5/5 upper and lower extremities

Pertinent Results:
Labs on admission:
[**2111-8-13**] 02:25PM BLOOD WBC-16.3* RBC-4.07* Hgb-12.8* Hct-36.1*
MCV-89 MCH-31.4 MCHC-35.4* RDW-14.8 Plt Ct-150
[**2111-8-13**] 02:25PM BLOOD PT-12.8 PTT-30.7 INR(PT)-1.1
[**2111-8-15**] 12:05AM BLOOD Fibrino-1031*
[**2111-8-13**] 02:25PM BLOOD Glucose-360* UreaN-34* Creat-1.7* Na-136
K-3.4 Cl-99 HCO3-19* AnGap-21*
[**2111-8-13**] 02:25PM BLOOD ALT-9 AST-18 CK(CPK)-475* AlkPhos-61
Amylase-36 TotBili-0.5
[**2111-8-14**] 07:38AM BLOOD Lipase-34
[**2111-8-13**] 02:25PM BLOOD Albumin-4.1 Calcium-9.2 Phos-2.9 Mg-1.7
[**2111-8-14**] 07:41PM BLOOD Hapto-339*
[**2111-8-14**] 07:38AM BLOOD Cortsol-44.4*
[**2111-8-14**] 07:38AM BLOOD CRP->30
[**2111-8-25**] 03:58AM BLOOD Vanco-3.5*
[**2111-8-13**] 02:25PM BLOOD Valproa-24*
[**2111-8-13**] 02:32PM BLOOD Lactate-2.4*
[**2111-8-14**] 01:53PM BLOOD O2 Sat-81
.
[**8-29**] am labs (on transfer to floor):
Valproate 51
.
Na 137
K 3.5
Cl 101
HCo3 26
BUN 12
Cr 0.5
Glu 153
.
WBC 5.6
hct 28.0 (up from 26.2 yesterday)
Plt 612
MCV 91
.
Vancomycin Trough 15.9
.
Labs on discharge:
*********

MICRO:
[**8-31**] Blood Cx: negative
[**8-30**] Blood Cx: negative
[**8-29**] Blood Cx: NGTD
[**8-28**] Blood Cx: negative
[**8-28**] Right Subclavian Cath tip: 3 species staph, including MRSA
[**8-27**] Blood Cx: [**12-16**] bottle: Coag Neg Staph (Anaerobic) -
contaminant
[**8-26**] Blood cx: negative
[**8-25**] Blood cx: [**12-16**] bottle: Coag Neg  Staph (Aerobic) -
contaminant
[**8-25**] C DIFF AG: NEG
[**8-23**] sputum: <10PMNs, <10 epi: 3+ MRSA
[**8-24**] Blood cx: [**2-13**] bottle MRSA
[**8-22**] Ucx: NEG
[**8-22**] Myco/Lytic Blood Cx: NGTD
[**8-22**] Blood Cx: [**12-15**] coynebacterium diptheroids (aerobic)
[**8-20**] Blood cx: NGTD x 2
[**8-15**] Sputum: Legionella Pneumophilia
[**8-14**] CSF cx: NEGATIVE
[**8-13**] Blood cx x 2: NEGATIVE
.
Imaging:
[**9-3**] ECHO:
1. Left ventricular wall thickness, cavity size, and systolic
function are  normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. The aortic root is moderately dilated. The ascending aorta is
mildly
dilated.
3. No evidence of endocarditis seen.
4. Compared with the findings of the prior study of [**2111-8-14**],
there has been no significant change.
.
[**8-28**] RUE U/S: No DVT
.
[**8-28**] CXR: RLL Pneumonia improving, small right sided pleural
effusion (new or newly seen), left lung clear.
.
[**8-20**] Abdominal U/S: Nl liver, gallbladder, splenomegaly at 15.7
cm
.
[**8-13**] CT HEAD: No bleed, tiny calcification within posterior right
eye, retention cyst within right maxillary sinus and possible
acute sinusitis


Brief Hospital Course:
1. Pneumonia - Legionella: Patient presented initially with high
fevers (>104F) requiring cooling maneuvers and was initially
broadly covered for pneumonia with levofloxacin, vancomycin, and
metronidazole.  Urine legionella was noted to be positive with
sputum culture presumptive legionella positive on hospital day
3.  Course was complicated by ARDS (see below).  Antibiotics
were tapered to levofloxacin 750mg single [**Doctor Last Name 360**] with good effect
targeted against legionella as cultures were identified with
assistance by infectious disease consultants.  By hospital day
9, patient began to defervesce, and levofloxacin was
discontinued after completing a 14 day course.
.
2. ARDS: Patient had severe hypoxia and oxygen requirements
despite high PEEP and FIO2 as well as paralysis with
cisatracurium.  Esophageal balloon measurements were used to
guide PEEP levels with target >0 transpulmonary pressures to
prevent atelectrauma to max level of 28 (FIO2 70%).
Nonetheless, patient required ventilation at Tv 570 (ARDSNET 6cm
= 507) in order to maintain oxygenation.  Ultimately, however,
compliance improved from 21 on hospital day 3 to 40s on hospital
day 10, and PEEP was successfully downtitrated.
.
By hospital day 13, patient was weaned to minimal vent settings
with RSBI <100, and patient was extubated on hospital day 14 and
transferred to floor on hospital day 16.
.
3. Pneumonia - MRSA: However, course was further complicated by
development of new fevers.  Sputum culture and gram stain
revealed gram positive infection which ultimately speciated MRSA
along with 3/4 bottles of blood cultures positive for MRSA on
[**2111-8-24**] [SEE below].  Patient was reinitiated on vancomycin,
however, increasing doses were required to achieve effective
trough level (1650mg q8h for target level of 15-20).  Patient
completely defervesced by day 6 of vancomycin, and completed a
14 day course of Vancomycin.
.
4. MRSA bacteremia:  Blood cxs on [**2111-8-24**] 3/4 bottles MRSA +,
source = MRSA VAP.  On Vancomycin titrated to appropriate
troughs.  With initial + blood cultures, central line was
removed, which demonstrated 3 staph species, including MRSA.
Surveillance cultures drawn after initial positive blood culture
demonstrated no growth x 8 blood cultures (2 cultures
demonstrate 1/4 bottles coag negative staph - 1 in aerobic
bottle, 1 in anaerobic bottle - determined to be contaminant,
and remainder of surveillance blood cultures were negative).
Trans-thoracic ECHO was obtained on day #11 of Vancomycin
therapy that demonstrated no evidence of endocarditis.  Patient
remained afebrile since day 6 of Vancomycin throughout remainder
of hospital course and completed a 14 day course of Vancomycin.
.
5. Sacral Decubitus Ulcer:  Cooling blanket was placed under
patient in emergency department at 37F due to the fact that
patient was >104F core temperature.  Patient was transferred to
MICU on this.  As patient became unstable secondary to
respiratory status, it became impossible to move blanket.
Blanket temp was adjusted to 70s, however, patient ultimately
developed an ulcer on sacral area thought to be secondary to
frostbite from a total time on blanket of 5 hours.  As patient's
respiratory status stabilized, plastic surgery was consulted,
and patient was debrided at bedside.  Plastic surgery and wound
care nursing followed patient throughout hospital course, and
patient remained on [**Hospital1 **] wet-to-dry dressing changes at time of
discharge.  Was discharged to acute rehab where wound care would
continue with plans to follow up with plastic surgery in clinic
for further management of the ulcer.
.
5. DM2:  Given severe legionella PNA, patient was started on
[**Location (un) 24402**] protocol insulin infusion.  Following extubation,
patient was initiated on NPH and sliding scale regular insulin.
As his medical issues stabilized, patient was re-started on his
outpatient hypoglycemics (Avandia 4mg qam and glucophage 1000mg
[**Hospital1 **] and ASA 81mg qam) with good blood sugar control throughout
remainder of hospitalization.
.
6. Schizophrenia:  Patient with history of severe schizophrenia
controlled as an outpt with Clozaril 400mg [**Hospital1 **], Depakote 750mg
qam and 1000mg qhs, Seroquel, Ativan 1mg [**Hospital1 **] and 0.5mg PRN,
Zoloft 25mg Qam.  Since admission, Clozaril discontinued (as
initially patient was intubated in ICU, and as he approached
extubation, did not want to cloud clinical picture, as clozaril
can cause fevers), other psych meds listed above also
discontinued except kept on Depakote.  As approached extubation,
patient was started on standing Haldol dose complicated by
akithesia which was treated with Propanolol (Benztropine was not
used secondary to ?encephalopathy from underlying medical
conditions).  As patient was transferred from the MICU to the
floor and his medical issues stabilized, patient was started on
low dose Clozaril, initially 25mg [**Hospital1 **] (also remained on Depakote
750mg qam and 1000mg qpm).  This was slowly titrated up by
25mg/day per psychiatry recommendations, and orthostatics and
WBC were followed, with improvement of mental
status/responsiveness as Clozaril was titrated up.  Patient
remained on Haldol with plans to discontinue once patient
reached outpatient dose of Clozaril (400mg [**Hospital1 **]).  Patient was
discharged to rehab with instructions to continue titrating up
Clozaril until reached outpatient dose of 400mg [**Hospital1 **], at which
time, both Haldol and propanolol (patient on this for akithesia
side effects of propanolol) could be discontinued.  Pychiatry
monitored patient throughout hospital course.
.
7. HTN: On Lisinopril 5mg qhs as an outpatient.  Held on
admission due to sepsis. Patient's blood pressure remained
stable (averaging around 130/70) during hospitalization.  As
sepsis resolved, patient's schizophrenia was treated as
described above, including being placed on Propanolol to address
the akithesia side effects of Haldol.  As was on propanolol,
lisinopril was held.  Due to patient's DM, lisinopril is the
ideal anti-hypertensive for this patient.  Therefore, patient
was discharged with instruction to:  When Haldol is discontinued
(upon titration of Clozaril to reach goal of outpatient dose of
400mg [**Hospital1 **]), then may also discontinue propanolo and restart
patient on outpatient dose of Lisinopril of 5mg.
.
8. Anemia:  Pt with Hct of 36 on admission (likely
hemoconcentrated).  Has ranged between 30-36 since admission.
MCV = 91.  Guiac of stool was negative.  Iron studies
demonstrated consistent with anemia of chronic disease.  HCT
remained stable throughout hospital course.
.
9. Hypercholesterolemia: Patient on Gemfibrozil as an
outpatient.  This was initially held during MICU course, but was
subsequently restarted along with his oral hypoglycemics upon
transfer to the floor and stabilization of his medical
conditions.
.
10. GERD: On protonix 40mg qd as an outpt.  Continued during
hospital course.
.
11. FEN: Upon extubation, patient maintained on Cardiac and
diabetic diet.
.
12. PPX: Patient kept on Protonix, Bowel regimen, SC heparin.
.
13. Code Status:  Full
.
14. Dispo:  Back to group home facility after rehabilitation at
acute rehab.
.
15. Contact: father [**Name (NI) 382**] [**Telephone/Fax (1) 96991**]


Medications on Admission:
Clozaril 400mg [**Hospital1 **]
Depakote 750mg qam and 1000mg qpm
Protonix 40mg QD
Seroquel
Ativan 1mg QD and 0.5mg PRN
Zoloft 25mg QD
ASA 81mg QD
Lisinopril 5mg QD
Avandia 4mg qam
Gemfibrozil 600mg [**Hospital1 **]
glucophage 1000mg [**Hospital1 **]


Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Continue while
bed-bound.  Once becomes more active, can discontinue.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-14**]
Puffs Inhalation Q4H (every 4 hours) as needed.
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Valproic Acid 250 mg Capsule Sig: Four (4) Capsule PO QPM
(once a day (in the evening)).
10. Valproic Acid 250 mg Capsule Sig: Three (3) Capsule PO QAM
(once a day (in the morning)).
11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 14 days: Through [**9-12**].
16. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).

17. Propranolol 20 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for restlessness: [**Month (only) 116**] discontinue once reach
400mg [**Hospital1 **] of Clozaril.  Then may START Lisinopril 5mg PO QD.
18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Rosiglitazone 4 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
21. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
23. Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): [**Month (only) 116**] discontine once reach 400mg PO BID of Clozaril.
24. Papain-Urea 830,000-10 unit-% Spray, Non-Aerosol Sig: One
(1) Appl Topical  DAILY (Daily).
25. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
26. Clozapine 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day): Please titrate up Clozaril dose:
Currently taking 75mg Clozaril PO BID ([**9-6**]).  Titrate up by
25mg daily:
[**9-7**] 75mg qam, 100mg qpm
[**9-8**] 100mg [**Hospital1 **]
[**9-9**] 100mg qam, 125mg qpm
[**9-10**] 125mg [**Hospital1 **]
[**9-11**] 125mg qam, 150mg qpm
[**9-12**] 150mg [**Hospital1 **]
etc. until reach 400mg [**Hospital1 **]
ONCE have reached 400mg [**Hospital1 **], may discontinue Haldol and
Propanolol and restart Lisinopril 5mg PO QD
.
27. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection
Injection TID (3 times a day) as needed.
28. PICC LIne care
PICC line care per protocol
29. Vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous  Q 8H (Every 8 Hours): until [**9-7**] (last dose 9/26
pm).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 672**] Hospital

Discharge Diagnosis:
1.) Legionella pneumonia -> ARDS
2.) Ventilator associated pneumonia with MRSA
3.) MRSA bacteremia
4.) Sacral ulcer


Discharge Condition:
Stable.  Patient status-post treatment of legionella pneumonia
(including intubation and successful extubation) and on current
treatment for MRSA pneumonia/MRSA bacteremia.  Oxygenating well
off of supplemental oxygen.


Discharge Instructions:
1.) Please notify physician if fever > 100.4, worsening cough,
Shortness of breath, chest pain/pressure, any other
questions/concerns
2.) Please take medications as directed
3.) Please follow up with appointments as directed

INSTRUCTIONS FOR REHAB:
1.) Please complete 14 day course of vancomycin antibiotics -
through [**9-7**]
2.) Please titrate up Clozaril dose:
-Currently taking 75mg Clozaril PO BID
-Titrate up by 25mg daily:
[**9-7**] 75mg qam, 100mg qpm
[**9-8**] 100mg [**Hospital1 **]
[**9-9**] 100mg qam, 125mg qpm
[**9-10**] 125mg [**Hospital1 **]
[**9-11**] 125mg qam, 150mg qpm
[**9-12**] 150mg [**Hospital1 **]
etc. until reach 400mg [**Hospital1 **]
ONCE have reached 400mg [**Hospital1 **], may discontinue Haldol and
Propanolol and restart Lisinopril 5mg PO QD


Followup Instructions:
1.) Follow up with physician at rehab
2.) Follow up with Plastic Surgery for sacral ulcer managment -
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Where: LM [**Hospital Unit Name 96992**] SURGERY Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2111-9-11**] 2:30
{"Unspecified septicemia,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Pressure ulcer, lower back,Infection and inflammatory reaction due to other vascular device, implant, and graft,Schizoaffective disorder, unspecified,Severe sepsis,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia"}


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: change in mental status

PRESENT ILLNESS: 46 year old man with a hx of DM2, HTN, hypercholesterolemia, and
schizophrenia presented from his group home with a change in
mental status noted by staff at his group home on [**8-14**]. On
admission, pt was alert and oriented x2 however is unable to
provide a history of present illness. Information was obtained
from the director of his group home.
.
Patient was in his USOH until evening of [**2111-8-13**] when he did not
take his PM medications. Staff found him to be asleep in bed,
difficult to arouse. He refused his medications. He was NOT
noted to have a facial droop, loss of conciousness or witnessed
seizure activity. EMS was called and foud patient
sitting in chair, leaning to the left. He answered some
questions but was "occasionally aphasic". He was able to
ambulate to the ambulance independently. He was then transported
to the [**Hospital1 18**] ED.
.
Initial vital signs in ED on [**8-14**]:  104.8 P 113 BP 135/86 R 28
97% on 3L. He had LP which was unrevealing. HE recieved 3.5 L NS
and also vanco/ceftriaxone/ampicillin, acyclovir and multiple
ativan.
.
Pt was admitted to the MICU for sepsis workup.  Was intubated on
the evening of admission due to worsening respiratory status.
.

MEDICAL HISTORY: 1. DM2
2. Paranoid Schizophrenia w/ auditory hallucination- well
controlled on Clozaril and history of violence
3. GERD
4. High Cholesterol
5. HTN

MEDICATION ON ADMISSION: Clozaril 400mg [**Hospital1 **]
Depakote 750mg qam and 1000mg qpm
Protonix 40mg QD
Seroquel
Ativan 1mg QD and 0.5mg PRN
Zoloft 25mg QD
ASA 81mg QD
Lisinopril 5mg QD
Avandia 4mg qam
Gemfibrozil 600mg [**Hospital1 **]
glucophage 1000mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam on Admission: T104.8 BP135/86 HR113 RR28 O2 Sat 93%
Gen: A+O x2
HEENT: NC/AT, sclera anichteric, no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no Kernig's or Brudzinski signs, no bruit
CV: Tachy, Nl S1 and S2,
Lung: +basilar crackles bilaterally, occasional expiratory
wheeze
Abd: +BS soft, non-distended
Ext: no edema
Neurologic examination:
Mental status: Awake, lethargy, cranial nerve normal, minimally
responsive to external stimuli and nearly non-verbal, His muscle
tone is normal and reflexes are decreased throughout
.
Exam on Day of Transfer [**2111-8-29**]:
T 98.6 144/80 76 18 94%RA
Gen: Lying in bed, pill rolling tremor at baseline A+O x3
HEENT: PERRLA (3mm--> 2mm bilat), no conjunctival injection, dry
oral mucosa, face appears flushed
Neck: supple, no LAD, no bruit, thyroid smooth and not enlarged
CV: Nl S1 and S2, [**1-18**] holosystolic murmur at LLSB no radiations
Lung: decreased breath sounds at bases, otherwise CTA
bialterally
Abd: NABS soft,obese non-distended, NT
Ext: no edema, no clubbing
Neurologic examination:
Mental status: pill rolling tremor; CN 3-12 indivisually tested
and intact; strength 5/5 upper and lower extremities

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives in a group home ([**Location (un) **]) since [**3-16**]. Phone # of
home: [**Telephone/Fax (1) 96990**]. Usually spends days in day program or pan
handling at Downtown Crossing. Known to use marijuana, but no
other drugs. [**Month (only) 116**] have a remote EtOH history. No close family. 

### Response:
{"Unspecified septicemia,Acute respiratory failure,Pneumonia due to Legionnaires' disease,Acute kidney failure, unspecified,Pressure ulcer, lower back,Infection and inflammatory reaction due to other vascular device, implant, and graft,Schizoaffective disorder, unspecified,Severe sepsis,Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia"}
