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An 83-year-old man is brought to the emergency department (ED) for treatment of fever and altered mental status. The patient resides in a skilled nursing facility (SNF) and was brought to the ED because of a one-week history of increasing agitation and urinary urgency and a one-day history of shaking chills and confusion; the caregiver reports that his urine has been foul-smelling. There is no report of head trauma. The patient has a history of mild Alzheimer's dementia, hypertension, and intermittent anxiety. Medications are donepezil (10 mg daily), paroxetine (20 mg daily), hydrochlorothiazide (25 mg daily), diphenhydramine (25 mg four times daily as needed), and oxybutynin (5 mg three times daily). On admission to the ED, his temperature is 37°C (98.6°F), pulse is 92⁄min, respirations are 18⁄min, and blood pressure is 110⁄70 mm Hg. He is lethargic and unable to answer questions. Neurologic examination shows no focal findings. Blood is drawn, and urine is collected for analysis and culture.
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