CHIEF COMPLAINT: Chief Complaint: Lethargy and abnormal labs

PRESENT ILLNESS: 84 year old male with history of senile/vascular dementia
(baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE
in [**2134**]), and prior MRSA pneumonia, referred to [**Hospital1 18**] ED from
her nursing home ([**Hospital **] Rehab [**Telephone/Fax (1) 41602**]) with a 1-week
history of lethargy and "abnormal labs", with only BUN slightly
elevated. He was managed with IV hydration for a few days and
initially improved, but then noted to have decreased O2 sats
(rehab unsure how low they went on room air). He is on
aspiration precautions and given nectar-thickened liquids at his
nursing home. He was placed on O2 and noted to be 88% on 2L NC
with increased RR to 24 and noted decreased PO intake.  He is
normally oriented to himself, but generally confused and
tolerates PO intake well. He has a CBI catheter with irrigation
in place since last year for frequent UTI with recent change
after a malfunction last week. He is completely dependent with
ADLs.

MEDICAL HISTORY: - senile dementia
- seizure disorder likely secondary to his vascular events
(hasn't had seizure for quite awhile per nursing home reports;
witnessed tonic-clonic seizure in [**4-/2135**] and then in [**7-/2135**])
- hypertension
- abdominal aortic aneurysm
- status post pacemaker placement ([**2134-10-18**]) for sick
sinus/syncope
----[**Company 1543**] Enpulse DR E2DR31, last interrogation [**2140-7-31**]
with atrial fibrillation with vent rate of 50-80, > 90% and has
been since his clinic visit in [**Month (only) 958**]. He had no ventricular high
rates. He has been paced < 1%. DDI mode, lower rate 55 bpm, AV
delay 300 milliseconds.
- Last ECHO ([**2135-5-9**]), LVEF 60 %, moderate AS
- history of vertebral body fracture
- BPH
- history of MRSA pneumonia
- C. difficile colitis

MEDICATION ON ADMISSION: Medications (from nursing home records):
- ASA 81 mg Po qD
- citalopram 20 mg Po qD
- MVI
- seroquel 12.5 mg PO qD
- colace/senna
- trazodone 25 mg PO BID
- calcium with Vit D
- [**Month/Year (2) **] 500 mg PO BID
- metoprolol 100 mg Po BID
- APAP 1000 mg PO q 8 hr
- lamotrigine 50 mg PO BID - being tapered up this month

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals:  HR 70 BP 106/45 RR 22 SpO2 97%/RA
General: Lethargic, arousable to voice
HEENT: Dry MMM
Neck: JVP difficult to assess, appears to be 6-7cm
CV: Irregular rhythm (demand paced), [**1-24**] crescendoo-descrescndo
murmur heard through the precordium and the back
Lungs: Quiet breath sounds but otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: FH: Non-contributory to this presentation with sepsis.

SOCIAL HISTORY: Unable to obtain from the patient. Currently living in a nursing
home (Stonehedge).  Dependent for ADLs and IADLs.
From previous d/c summary: Former 4 pack/day smoker, quit about
50 years ago. Drinks 1 beer daily, but unclear if this is
current.
Pneumonitis due to inhalation of food or vomitus,Metabolic encephalopathy,Other nonspecific findings on examination of urine,Hypotension, unspecified,Dysphagia, oropharyngeal phase,Senile dementia, uncomplicated,Cerebral atherosclerosis,Cardiac pacemaker in situ,Aortic valve disorders,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Epilepsy, unspecified, without mention of intractable epilepsy,Leukocytopenia, unspecified,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Hypoxemia,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Personal history of pathologic fracture,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Urinary obstruction, not elsewhere classified,Personal history of tobacco use,Pressure ulcer, lower back,Long-term (current) use of antibiotics,Atrial fibrillation
Food/vomit pneumonitis,Metabolic encephalopathy,Abn urine findings NEC,Hypotension NOS,Dysphagia, oropharyngeal,Senile dementia uncomp,Cerebral atherosclerosis,Status cardiac pacemaker,Aortic valve disorder,Meth resis Staph carrier,Epilep NOS w/o intr epil,Leukocytopenia NOS,Adv eff antconvl NEC/NOS,Hypoxemia,Hypertension NOS,Abdom aortic aneurysm,Hx pathological fracture,BPH w urinary obs/LUTS,Urinary obstruction NEC,History of tobacco use,Pressure ulcer, low back,Long-term use antibiotic,Atrial fibrillation
Admission Date:  [**2141-4-1**]              Discharge Date:   [**2141-4-6**]

Date of Birth:  [**2056-4-25**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Chief Complaint: Lethargy and abnormal labs

Reason for MICU transfer: Sepsis and acute encephalopathy


Major Surgical or Invasive Procedure:
None

History of Present Illness:
84 year old male with history of senile/vascular dementia
(baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE
in [**2134**]), and prior MRSA pneumonia, referred to [**Hospital1 18**] ED from
her nursing home ([**Hospital **] Rehab [**Telephone/Fax (1) 41602**]) with a 1-week
history of lethargy and "abnormal labs", with only BUN slightly
elevated. He was managed with IV hydration for a few days and
initially improved, but then noted to have decreased O2 sats
(rehab unsure how low they went on room air). He is on
aspiration precautions and given nectar-thickened liquids at his
nursing home. He was placed on O2 and noted to be 88% on 2L NC
with increased RR to 24 and noted decreased PO intake.  He is
normally oriented to himself, but generally confused and
tolerates PO intake well. He has a CBI catheter with irrigation
in place since last year for frequent UTI with recent change
after a malfunction last week. He is completely dependent with
ADLs.

Vital signs on transfer from nursing home were: T 98.8 BP
118/76, HR 112, RR 24, O2 sat 88% on 2L.  EMS was called and
provided additional IVF given hypotension as well as
supplemental O2 en route.  FSBG measured at 135.

He was recently seen by Neurology ([**2141-2-19**]) for his seizure
disorder, not having seen him for 2 years.  They noted his
significant decline in mental status compared to that time and
felt his leukopenia might be attributable to the [**Last Name (LF) 13401**], [**First Name3 (LF) **] this
is being transitioned to lamotrigine.  Cardiology saw him in
[**2141-1-19**] and confirmed appropriate function of his PPM.

In the ED, initial VS were: 98 70 81/52 22 96% 4L NC. Exam was
notable for complete disorientation (AAOx0), diaphoretic, opens
eyes and responds to voice and name, guiaic negative brown
stool, III-IV SEM heard throughout precordium, and a CBI
catheter.  Urinalysis showed many WBCs, large leuk esterase with
significant amount of bacteriuria and CXR showed concern for a
RML/RLL infiltrate.  He was subsequently covered with cefepime,
vancomycin, and Flagyl. IVFs 1.5L.  BP improved to 100-120s/60s
and mental status very slightly improved.  Urine output hard to
quantify given CBI.  HCP was [**Name (NI) 653**] in the [**Name (NI) **] and he is a
confirmed full code.

On arrival to the MICU, patient's VS: HR 70 BP 106/45 RR 22 SpO2
97%/RA.  He is lethargic and unable to answer many questions but
states that his breathing feels ok and and he denies any pain.
From speaking with his nursing home, he is normally verbal but
consused, A&Ox1. Over the past week, they  note that he has been
more lethargic and eating less.  Today was the first day they
noted him to be hypoxic.  No fevers per their report.

Review of systems: (+) per HPI, otherwise unable to complete
given patient disorientation

After stqbilization of the patient's sepsis in the medical ICU,
the patient was transitioned to the hospital medicine service
for ongoing care.


Past Medical History:
- senile dementia
- seizure disorder likely secondary to his vascular events
(hasn't had seizure for quite awhile per nursing home reports;
witnessed tonic-clonic seizure in [**4-/2135**] and then in [**7-/2135**])
- hypertension
- abdominal aortic aneurysm
- status post pacemaker placement ([**2134-10-18**]) for sick
sinus/syncope
----[**Company 1543**] Enpulse DR E2DR31, last interrogation [**2140-7-31**]
with atrial fibrillation with vent rate of 50-80, > 90% and has
been since his clinic visit in [**Month (only) 958**]. He had no ventricular high
rates. He has been paced < 1%. DDI mode, lower rate 55 bpm, AV
delay 300 milliseconds.
- Last ECHO ([**2135-5-9**]), LVEF 60 %, moderate AS
- history of vertebral body fracture
- BPH
- history of MRSA pneumonia
- C. difficile colitis


Social History:
Unable to obtain from the patient. Currently living in a nursing
home (Stonehedge).  Dependent for ADLs and IADLs.
From previous d/c summary: Former 4 pack/day smoker, quit about
50 years ago. Drinks 1 beer daily, but unclear if this is
current.


Family History:
FH: Non-contributory to this presentation with sepsis.


Physical Exam:
Admission Physical Exam:
Vitals:  HR 70 BP 106/45 RR 22 SpO2 97%/RA
General: Lethargic, arousable to voice
HEENT: Dry MMM
Neck: JVP difficult to assess, appears to be 6-7cm
CV: Irregular rhythm (demand paced), [**1-24**] crescendoo-descrescndo
murmur heard through the precordium and the back
Lungs: Quiet breath sounds but otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: 3-way Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Patient not cooperative with full exam.  Moving all 4
extremities on command.

Discharge physical exam:
Physical exam
Vital signs:  Tmax afeb BP 109-127/70-85 HR 91 94% RA O2 sat
BM X 4.  I/O 1120/2050.
General: lying in bed, somnolent, arousable.
HEENT:  OP moist, no LAD appreciated, jvp not elevated.
Lungs no rales appreciated anteriorly, but coarse bilaterally.
CV: irregular with 3/6 systolic harsh murmur heard throughout
precordium.
Abdomen soft, NT, ND, NABS
Ext:  no edema
Neuro:  alert/oriented to self, in Valley forge, in hospital,
not
to date.  moves all extremities, follows simple commands, eomi.

GU: foley catheter in place, yellow urine
Skin:  small stage II ulcer on coccyx.


Pertinent Results:
ADMISSION LABS:
[**2141-4-1**] 10:50AM BLOOD WBC-2.5* RBC-3.86* Hgb-10.6* Hct-34.0*
MCV-88 MCH-27.5 MCHC-31.2 RDW-15.1 Plt Ct-235
[**2141-4-1**] 10:50AM BLOOD Neuts-52.8 Lymphs-35.8 Monos-5.8 Eos-4.4*
Baso-1.3
[**2141-4-1**] 11:30AM BLOOD PT-12.9* PTT-27.9 INR(PT)-1.2*
[**2141-4-1**] 10:50AM BLOOD Glucose-124* UreaN-21* Creat-0.8 Na-143
K-4.5 Cl-109* HCO3-25 AnGap-14
[**2141-4-1**] 10:50AM BLOOD ALT-19 AST-31 AlkPhos-74 TotBili-0.3
[**2141-4-1**] 10:50AM BLOOD Lipase-34
[**2141-4-1**] 10:50AM BLOOD cTropnT-<0.01
[**2141-4-1**] 10:50AM BLOOD Albumin-2.6* Calcium-8.5 Phos-2.7 Mg-2.1
[**2141-4-1**] 11:08AM BLOOD Lactate-2.8*
[**2141-4-1**] 09:15PM BLOOD Lactate-1.6
[**2141-4-1**] 10:50AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.009
[**2141-4-1**] 10:50AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2141-4-1**] 10:50AM URINE RBC-72* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
[**2141-4-1**] 10:50AM URINE WBC Clm-MANY Mucous-OCC
.
MICROBIOLOGY:

Micro - c diff negative, urine culture from admission
contaminated, blood cultures from admission no growth to date.

ECHO [**4-3**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). There is no ventricular
septal defect. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is a
rhematic deformity of the tricuspid valve. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.

Compared with the prior study (images reviewed) of [**2135-5-9**],
the degree of AS is now slightly more severe (mean gradient now
61 mmHg vs 38 mmHg on prior) with more hyperdynamic LV systolic
function.

IMAGING:
-[**4-1**] CXR:
FINDINGS:  Lung volumes are low.  There is a right pleural
effusion and right basilar consolidation.  No pneumothorax is
detected on this view.  Heart and mediastinal contours are
similar to [**2134**], but difficult to evaluate in the setting of low
lung volumes.  Pacing hardware appears similarly position.
IMPRESSION:  Small right pleural effusion with right lower lung
opacity, which could represent atelectasis, aspiration, or
pneumonia.

Discharge labs:
[**2141-4-6**] 08:45AM BLOOD WBC-1.9* RBC-3.67* Hgb-10.1* Hct-31.5*
MCV-86 MCH-27.6 MCHC-32.1 RDW-15.3 Plt Ct-231
[**2141-4-6**] 08:45AM BLOOD Glucose-89 UreaN-6 Creat-1.0 Na-139 K-3.7
Cl-105 HCO3-27 AnGap-11

Brief Hospital Course:
Impression: The patient is an 84 year old man with history of
dementia, sick sinus syd s/p PPM, moderate AS, prior MRSA
pneumonia and C. diff colitis, with indwelling catheter, and a
seizure disorder, presenting with sepsis secondary to likely
pulmonary sources. He was initially admitted to the ICU for
early goal-directed therapy for the sepsis, and was later
transitioned to the hospital medicine service once the sepsis
had been stabilized, and continuosly improved until discharge
back to his long term nursing home.

Acute Issues

# Sepsis: Upon admission, the most likely source was the urinary
tract given his chronic 3-way urinary catheter at rehab and his
UA with >182 WBCs.  Aspiration PNA may also have played a role
given his RML/RLL infiltrates on CXR and his poor mental status
with high risk for aspiration. There was no report of fevers or
diarrhea at rehab. He was mildly hypotensive on arrival to the
[**Hospital Unit Name 153**] with SBP in the 80s on no pressors. His BP's improved to
the 100-120s after about 1L total of fluids, and he received
empiric vanc/Zosyn for presumed urosepsis as well as MRSA
covereage given the concern for aspiration PNA. Urine culture
was negative, and therefore cause of symptoms presumed due to
aspiration pneumonia. He will complete a course of augmentin at
his facility for pneumonia.

# Acute encephalopathy on admission Patient was reportedly more
lethargic than usual, per direct discussion with the [**Hospital1 1501**] staff.
His baseline MS is A&Ox1 to self, thought to be from vascular
dementia.  The most likely cause for his AMS was sepsis from
UTI, but may also have been [**12-22**] to starting lamotrigine
recently, although it would not have been expected to resolve as
quickly as was noted if due to medications.  We held his
seroquel and trazodone initially, but continued Celexa. He was
resumed on home trazodone and seroquel at discharge.

# Leukopenia:  Unclear etiology, may be related to [**Month/Day (2) 13401**].  He
is currently being transitioned from [**Month/Day (2) 13401**] to lamotrigine in an
attempt to improve his leukopenia.  His underlying
infection/sepsis may be acutely lowering his WBC, although he
has evidence of leukopenia prior to his presentation for sepsis.
 ANC at admission is 1300 and he is very mildly neutropenic, so
concern for atypical infections was low. The transition off
[**Month/Day (2) **] was continued, after discussion with his neurologist, and
the [**Month/Day (2) 13401**] was decreased from 500 mg twice daily to 250/500.

The recommended plan was to continue to decrease the [**Month/Day (2) **] by
250 mg a week (ie: next dose would be 250/250) as the
lamotrigine was increased by 25/25mg each week until goal of 150
mg po bid. At this time, we increased his lamotrigine to 75/75mg
doses.

# Aortic stenosis: Valve area 0.8cm2 in [**2134**].  He appears
somewhat volume depleted on exam, he has no edema or crackles on
exam. His cardiac exam is consistent with a decreased S2,
suggestive of critical AS. Repeat TTE showed progression of his
aortic stenosis, to severe.  As a result, he is likely to be
very sensitive to low blood pressures.

# Hematuria and CBI: Patient presented from rehab with a 3-way
Foley and CBI.  His rehab states that he has been on this for at
least a year and plan to continue it indefinitely.  He had not
been seen by urology at [**Hospital1 18**] for 2 years.  Has had negative
cystoscopy and CT urogram with no clear cause for his hematuria.
We stopped the CBI, with no hematuria, and changed his foley to
a regular foley prior to discharge.  CBI SHOULD NOT BE
RESTARTED.  If he develops hematuria after a foley catheter
change, this should be monitored for evidence of obstruction.
If he continues to have hematuria or obstruction, CBI can be
started for 24-72 hours as needed until his urine clears again,
at which point it should be stopped.  He should follow up with
urology as needed if this persists.

# Goals of care: Upon admission, the [**Hospital Unit Name 153**] team spoke with the
patient's brother, [**Name (NI) **] [**Name (NI) 23203**], who states that he is the
health care proxy and makes decisions for the patient.  He
stated that the patient has expressed that he would like
everything done for him, including resuscitation, intubation,
pressors and invasive procedures.   This should be re-addressed
with the brother again given severe aortic stenosis, and his
degree of cognitive dysfunction.

Chronic issues:
# Atrial fibrillation.  He was rate controlled, not
anticoagulated.
# Chronic dementia.  Stable.

TRANSITIONS OF CARE:
1.  Antiseizure medications:  continue to titrate up to goal
lamotrigine dose of 150 mg po bid, and taper off of
levatericetam over next 3 weeks.
2.  Pneumonia:  Complete course of augmentin on [**4-9**].
3.  Blood cultures pending at discharge.

Medications on Admission:
Medications (from nursing home records):
- ASA 81 mg Po qD
- citalopram 20 mg Po qD
- MVI
- seroquel 12.5 mg PO qD
- colace/senna
- trazodone 25 mg PO BID
- calcium with Vit D
- [**Month/Year (2) **] 500 mg PO BID
- metoprolol 100 mg Po BID
- APAP 1000 mg PO q 8 hr
- lamotrigine 50 mg PO BID - being tapered up this month


Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 5 days: through [**4-10**], then increase by 25 mg
[**Hospital1 **] per week.
5. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO once a day.
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO twice a day.
8. Calcium with Vitamin D 600 mg(1,500mg) -400 unit Tablet Sig:
One (1) Tablet PO twice a day.
9. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 3 days.
10. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for HR < 55, SBP < 100.
11. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every eight (8) hours.
12. levetiracetam 100 mg/mL Solution Sig: Two [**Age over 90 1230**]y
(250) ML PO once a day: IN AM.
13. levetiracetam 100 mg/mL Solution Sig: 5 ML ML PO HS (at
bedtime): AND TAPER AS PER DR. [**First Name (STitle) **], 250 MG/WEEK TAPER UNTIL
OFF.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]

Discharge Diagnosis:
Aspiration pneumonia
Dementia
Seizure disorder
Leukopenia, possibly related to anti-seizure medication

Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound or out of bed with significant
assistance.

Discharge Instructions:
It was a pleasure to care for you during this admission. You
were treated for pneumonia.  Your blood pressure was low when
you were admitted, and you were sleepy. These things improved
with intravenous fluids and antibiotics.  We stopped the bladder
irrigation and this should not be restarted.

Medication changes:
Augmentin 875 mg po bid for 4 more days
Lamictal increased to 75 mg po bid
[**Location 13401**] decreased to 250 mg/500 mg po bid

Followup Instructions:
Department: NEUROLOGY
When: THURSDAY [**2141-6-15**] at 10:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) 8222**], MD [**Telephone/Fax (1) 2928**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2141-7-25**] at 9:30 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumonitis due to inhalation of food or vomitus,Metabolic encephalopathy,Other nonspecific findings on examination of urine,Hypotension, unspecified,Dysphagia, oropharyngeal phase,Senile dementia, uncomplicated,Cerebral atherosclerosis,Cardiac pacemaker in situ,Aortic valve disorders,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Epilepsy, unspecified, without mention of intractable epilepsy,Leukocytopenia, unspecified,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Hypoxemia,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Personal history of pathologic fracture,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Urinary obstruction, not elsewhere classified,Personal history of tobacco use,Pressure ulcer, lower back,Long-term (current) use of antibiotics,Atrial fibrillation'}


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: Chief Complaint: Lethargy and abnormal labs

PRESENT ILLNESS: 84 year old male with history of senile/vascular dementia
(baseline AAOx1), sick sinus/syncope s/p PPM, moderate AS (TTE
in [**2134**]), and prior MRSA pneumonia, referred to [**Hospital1 18**] ED from
her nursing home ([**Hospital **] Rehab [**Telephone/Fax (1) 41602**]) with a 1-week
history of lethargy and "abnormal labs", with only BUN slightly
elevated. He was managed with IV hydration for a few days and
initially improved, but then noted to have decreased O2 sats
(rehab unsure how low they went on room air). He is on
aspiration precautions and given nectar-thickened liquids at his
nursing home. He was placed on O2 and noted to be 88% on 2L NC
with increased RR to 24 and noted decreased PO intake.  He is
normally oriented to himself, but generally confused and
tolerates PO intake well. He has a CBI catheter with irrigation
in place since last year for frequent UTI with recent change
after a malfunction last week. He is completely dependent with
ADLs.

MEDICAL HISTORY: - senile dementia
- seizure disorder likely secondary to his vascular events
(hasn't had seizure for quite awhile per nursing home reports;
witnessed tonic-clonic seizure in [**4-/2135**] and then in [**7-/2135**])
- hypertension
- abdominal aortic aneurysm
- status post pacemaker placement ([**2134-10-18**]) for sick
sinus/syncope
----[**Company 1543**] Enpulse DR E2DR31, last interrogation [**2140-7-31**]
with atrial fibrillation with vent rate of 50-80, > 90% and has
been since his clinic visit in [**Month (only) 958**]. He had no ventricular high
rates. He has been paced < 1%. DDI mode, lower rate 55 bpm, AV
delay 300 milliseconds.
- Last ECHO ([**2135-5-9**]), LVEF 60 %, moderate AS
- history of vertebral body fracture
- BPH
- history of MRSA pneumonia
- C. difficile colitis

MEDICATION ON ADMISSION: Medications (from nursing home records):
- ASA 81 mg Po qD
- citalopram 20 mg Po qD
- MVI
- seroquel 12.5 mg PO qD
- colace/senna
- trazodone 25 mg PO BID
- calcium with Vit D
- [**Month/Year (2) **] 500 mg PO BID
- metoprolol 100 mg Po BID
- APAP 1000 mg PO q 8 hr
- lamotrigine 50 mg PO BID - being tapered up this month

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals:  HR 70 BP 106/45 RR 22 SpO2 97%/RA
General: Lethargic, arousable to voice
HEENT: Dry MMM
Neck: JVP difficult to assess, appears to be 6-7cm
CV: Irregular rhythm (demand paced), [**1-24**] crescendoo-descrescndo
murmur heard through the precordium and the back
Lungs: Quiet breath sounds but otherwise clear
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: FH: Non-contributory to this presentation with sepsis.

SOCIAL HISTORY: Unable to obtain from the patient. Currently living in a nursing
home (Stonehedge).  Dependent for ADLs and IADLs.
From previous d/c summary: Former 4 pack/day smoker, quit about
50 years ago. Drinks 1 beer daily, but unclear if this is
current. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Metabolic encephalopathy,Other nonspecific findings on examination of urine,Hypotension, unspecified,Dysphagia, oropharyngeal phase,Senile dementia, uncomplicated,Cerebral atherosclerosis,Cardiac pacemaker in situ,Aortic valve disorders,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Epilepsy, unspecified, without mention of intractable epilepsy,Leukocytopenia, unspecified,Other and unspecified anticonvulsants causing adverse effects in therapeutic use,Hypoxemia,Unspecified essential hypertension,Abdominal aneurysm without mention of rupture,Personal history of pathologic fracture,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Urinary obstruction, not elsewhere classified,Personal history of tobacco use,Pressure ulcer, lower back,Long-term (current) use of antibiotics,Atrial fibrillation'}
