Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: morphine / adhesive tape attending: chief complaint: fever and tachypnea major surgical or invasive procedure: none history of present illness: 54 year old male with cad, dm, chf, and ckd was at his baseline state of health until he fell from his chair car yesterday, striking his right hip and head. according to the patient, who is a poor historian, he denies loss of consciousness, but has continued right hip pain. according to the staff at his rehab facility, he refused to go to the hospital. today, the patient reports feeling "sick" and nauseous. he also reports having chest pain while moving his wheelchair that lasted 5 minutes, radiated down his left arm, but did not make him short of breath, sweaty, or nauseous. according to the staff at his rehab facility, he was febrile to 101.6, tachypnic and diaphoretic and was convinced to go to the ed. fsbs 154. he denies shortness of breath at any point in the last few days. he denies subjective fever, chills, cough or sore throat. in the ed, initial vs were: t 98.1 hr 58 bp 95/48 rr 20 100% 4l nasal cannula. his temperature spiked at 100.4. he had good rectal tone. his labs were notable for wbc 9.5, h/h 10.2/30.1 (baseline ~), pro bnp 3622, cr 2.6 (baseline ~1.6 ), bun 72, ag 12. trop 0.14 (has been 0.1-0.2 in the past), ua 1 wbc, 0 epi, mod bact, cast 9. blood and urine cultures sent. abg 7.43/38/99 with lactate 1.7. he was given 1 l ns, vancomycin 1gm, cefepime 1gm, and lasix 40mg iv. the patient was placed on cpap. non contrast ct head, ct c-spine, ct chest, and ct abd/pelvis were prelim reads as negative except for wedge fracture of l1 without retropulsion, likely subacute on chronic. also right sided small-bowel-containing inguinal hernia. the patient arrived in the micu on cpap. after it was removed, the patient reported feeling like his normal self. he denied any shortness of breath, chest pain, or abdominal pain. past medical history: hypothyroidism insulin-dependent diabetes mellitus since peripheral neuropathy s/p r mid foot amputation retinopathy w/ hx detached r retina coronary artery disease, status post silent mi - ef >55%, cardiac cath : l circumflex 40% stenosis, proximal rca 30% stenosis peripheral vascular disease chronic left heel ulcer breast lipoma s/p removal hypertension mrsa + social history: denies smoking, alcohol and tobacco use. used to work in a mail room in but could not after an accident. now is living in nursing home v. rehab. family history: father passed away from mi, but had dm. mother also passed away from mi. physical exam: #admission physical exam: general: alert, oriented x3, no acute distress heent: scabs on scalp, sclera anicteric, mmm, oropharynx clear, pupils equal round reactive neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: breath sounds diminished bilateral lower/middle lobes, bilateral upper lobes clear, no crackles or wheezes appreciated, dull to percussion throughout. abdomen: soft, diffusely tender to palpation, distended, hypoactive bowel sounds present, no organomegaly. skin breakdown under bilateral breasts, erythematous exanthems on abdomen. gu: foley in place ext: warm, well perfused, 2+ radial pulses bilaterally, fingers contracted, no clubbing, cyanosis or edema. multiple sites of skin breakdown on right lower leg, raised weeping lesions. heel ulcer right foot. diminished leg hair. neuro: asterixis present . #discharge physical exam: vitals: t98.6, bp (143-156)/(76-79), hr 61-67, rr 18-20, o2 sat 97% ra. general: alert, oriented x3, no acute distress heent: scabs on scalp, sclera anicteric, mmm, oropharynx clear, pupils equal round reactive neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops chest: breath sounds diminished bilateral lower/middle lobes, bilateral upper lobes clear, minimal scattered crackles, no wheezes appreciated, dull to percussion throughout. abdomen: soft, nt/nd, bowel sounds present, no organomegaly. skin breakdown under bilateral breasts, erythematous exanthems on abdomen. gu: foley in place ext: warm, 2+ radial pulses bilaterally, fingers contracted, no clubbing, cyanosis or edema. lower extr: 2+ bilateral lower extremity edema. pulses not palpable edema. s/p left bka, right leg in cast (previously: 1.5cm ulcer with necrotic edges on sole of r foot. stasis dermatitis on rle, dressings c/d/i). pertinent results: #admission labs: 11:28pm pt-12.8* ptt-33.0 inr(pt)-1.2* 11:28pm plt count-249 11:28pm neuts-78.7* lymphs-15.1* monos-3.3 eos-2.5 basos-0.3 11:28pm wbc-9.5# rbc-3.90* hgb-10.2* hct-32.1* mcv-82 mch-26.3* mchc-31.9 rdw-15.0 11:28pm albumin-3.6 calcium-8.0* phosphate-3.2# magnesium-2.3 11:28pm ck-mb-2 probnp-3622* 11:28pm ctropnt-0.14* 11:28pm lipase-9 11:28pm alt(sgpt)-17 ast(sgot)-26 ck(cpk)-120 alk phos-111 tot bili-0.3 11:28pm glucose-207* urea n-72* creat-2.6* sodium-139 potassium-4.6 chloride-103 total co2-25 anion gap-16 11:37pm lactate-1.7 11:37pm po2-99 pco2-38 ph-7.43 total co2-26 base xs-0 comments-green top 12:04am urine mucous-rare 12:04am urine hyaline-9* 12:04am urine rbc-7* wbc-1 bacteria-mod yeast-none epi-0 trans epi-<1 12:04am urine rbc-7* wbc-1 bacteria-mod yeast-none epi-0 trans epi-<1 12:04am urine blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 12:04am urine color-yellow appear-clear sp -1.012 03:58am type- po2-193* pco2-39 ph-7.41 total co2-26 base xs-0 comments-green top 05:05am plt count-181 05:05am wbc-8.4 rbc-3.85* hgb-10.5* hct-31.4* mcv-81* mch-27.2 mchc-33.5 rdw-15.1 05:05am ck-mb-4 ctropnt-0.16* 05:05am ck(cpk)-110 05:05am glucose-191* urea n-70* creat-2.3* sodium-140 potassium-4.0 chloride-105 total co2-28 anion gap-11 11:19am %hba1c-7.6* eag-171* 11:19am ck-mb-3 ctropnt-0.18* 11:19am ck(cpk)-100 . #pertinent labs: 05:35am blood wbc-11.2*# rbc-3.86* hgb-10.5* hct-31.5* mcv-82 mch-27.2 mchc-33.2 rdw-15.8* plt ct-449* 01:00pm blood wbc-5.9 rbc-4.05* hgb-10.9* hct-33.2* mcv-82 mch-26.9* mchc-32.8 rdw-15.5 plt ct-454* 05:04am blood wbc-6.0 rbc-3.72* hgb-10.0* hct-30.7* mcv-83 mch-26.9* mchc-32.6 rdw-15.3 plt ct-390 09:15am blood wbc-6.1 rbc-3.87* hgb-10.3* hct-31.5* mcv-81* mch-26.7* mchc-32.8 rdw-15.0 plt ct-338 01:15pm blood wbc-5.4 rbc-3.83* hgb-10.3* hct-31.6* mcv-83 mch-27.0 mchc-32.7 rdw-14.8 plt ct-330 05:26am blood wbc-5.0 rbc-3.64* hgb-9.7* hct-29.5* mcv-81* mch-26.7* mchc-33.0 rdw-14.9 plt ct-289 07:38am blood wbc-5.0 rbc-4.01* hgb-10.9* hct-32.8* mcv-82 mch-27.2 mchc-33.3 rdw-14.7 plt ct-309 05:37am blood wbc-3.7* rbc-3.35* hgb-9.1* hct-27.3* mcv-82 mch-27.2 mchc-33.3 rdw-14.4 plt ct-211 05:25am blood wbc-5.9 rbc-3.79* hgb-10.1* hct-30.7* mcv-81* mch-26.8* mchc-33.0 rdw-14.7 plt ct-225 04:27am blood wbc-5.8 rbc-3.66* hgb-10.0* hct-29.8* mcv-82 mch-27.3 mchc-33.5 rdw-14.8 plt ct-209 05:05am blood wbc-8.4 rbc-3.85* hgb-10.5* hct-31.4* mcv-81* mch-27.2 mchc-33.5 rdw-15.1 plt ct-181 07:38am blood neuts-45* bands-0 lymphs-39 monos-10 eos-6* baso-0 atyps-0 metas-0 myelos-0 05:25am blood neuts-55.4 lymphs-32.6 monos-6.6 eos-5.0* baso-0.4 07:38am blood hypochr-normal anisocy-normal poiklo-occasional macrocy-normal microcy-normal polychr-normal tear dr 05:26am blood pt-11.1 ptt-34.3 inr(pt)-1.0 05:37am blood pt-10.8 ptt-33.5 inr(pt)-1.0 01:36pm blood esr-87* 05:30am blood glucose-211* urean-64* creat-2.1* na-137 k-4.2 cl-98 hco3-31 angap-12 05:35am blood glucose-58* urean-60* creat-1.9* na-140 k-3.9 cl-101 hco3-28 angap-15 05:35am blood glucose-91 urean-55* creat-1.9* na-143 k-4.3 cl-103 hco3-29 angap-15 09:00pm blood glucose-121* urean-55* creat-2.1* na-140 k-5.0 cl-101 hco3-28 angap-16 05:04am blood glucose-76 urean-59* creat-1.8* na-144 k-4.2 cl-105 hco3-34* angap-9 01:15pm blood glucose-367* urean-63* creat-1.9* na-142 k-4.6 cl-104 hco3-30 angap-13 07:38am blood glucose-159* urean-69* creat-2.0* na-143 k-4.7 cl-105 hco3-28 angap-15 05:37am blood glucose-244* urean-76* creat-2.1* na-136 k-4.3 cl-101 hco3-29 angap-10 05:25am blood glucose-113* urean-79* creat-2.6* na-139 k-4.5 cl-103 hco3-29 angap-12 04:27am blood glucose-206* urean-74* creat-2.4* na-138 k-4.4 cl-103 hco3-25 angap-14 05:05am blood glucose-191* urean-70* creat-2.3* na-140 k-4.0 cl-105 hco3-28 angap-11 04:27am blood alt-12 ast-20 ld(ldh)-305* alkphos-103 totbili-0.5 11:19am blood ck(cpk)-100 08:15pm blood ck-mb-3 ctropnt-0.13* 11:19am blood ck-mb-3 ctropnt-0.18* 05:05am blood ck-mb-4 ctropnt-0.16* 05:30am blood calcium-8.8 phos-4.7* mg-2.4 05:35am blood calcium-8.6 phos-5.3* mg-2.5 09:00pm blood calcium-9.0 phos-5.4* mg-2.4 09:15am blood calcium-8.2* phos-4.0 mg-2.5 05:26am blood calcium-8.3* phos-4.0 mg-2.7* 07:38am blood calcium-8.3* phos-4.1 mg-2.8* 05:37am blood calcium-8.0* phos-4.4 mg-2.6 05:25am blood calcium-8.3* phos-4.8* mg-2.5 04:27am blood albumin-3.4* calcium-7.8* phos-3.9 mg-2.5 11:19am blood %hba1c-7.6* eag-171* 03:58am blood type- po2-193* pco2-39 ph-7.41 caltco2-26 base xs-0 comment-green top 06:28pm urine color-yellow appear-clear sp -1.008 02:31pm urine color-yellow appear-hazy sp -1.009 12:04am urine color-yellow appear-clear sp -1.012 06:28pm urine blood-neg nitrite-neg protein-tr glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 02:31pm urine blood-lg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 12:04am urine blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-5.0 leuks-neg 06:28pm urine rbc-2 wbc-<1 bacteri-none yeast-none epi-0 02:31pm urine rbc-53* wbc-2 bacteri-few yeast-none epi-<1 12:04am urine rbc-7* wbc-1 bacteri-mod yeast-none epi-0 transe-<1 06:28pm urine casthy-15* 02:31pm urine casthy-35* 12:04am urine casthy-9* . #microbiology: 11:29 pm blood culture # 1. **final report ** blood culture, routine (final ): no growth. . 11:29 pm blood culture # 2. **final report ** blood culture, routine (final ): no growth . 12:04 am urine **final report ** urine culture (final ): no growth. . 4:20 pm blood culture blood culture, routine (preliminary): staphylococcus, coagulase negative. isolated from only one set in the previous five days sensitivities performed on request.. work up per dr. #. aerobic bottle gram stain (final ): reported to and read back by @ 1815 on - . gram positive cocci. in pairs and clusters. anaerobic bottle gram stain (final ): gram positive cocci in pairs and clusters. . 5:50 pm blood culture #2. **final report ** blood culture, routine (final ): no growth. . 2:31 pm urine source: catheter. **final report ** urine culture (final ): no growth. . 2:31 pm mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. . 1:00 pm blood culture **final report ** blood culture, routine (final ): no growth. . 7:38 am blood culture 1 of 2. **final report ** blood culture, routine (final ): no growth. . 5:26 am blood culture **final report ** blood culture, routine (final ): no growth. . 3:09 pm tissue site: skin gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (preliminary): reported to and read back by dr. 12:28pm. gram positive coccus(cocci). rare growth. anaerobic culture (preliminary): acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): fungal culture (preliminary): no fungus isolated. . #studies: ecg study date of 11:26:16 pm sinus rhythm with p-r interval prolongation. occasional ventricular premature contraction. poor r wave progression across the precordium. cannot exclude old anteroseptal myocardial infarction. possible left anterior fascicular block. compared to the previous tracing of ventricular premature contraction is now noted, axis is more leftward. otherwise, no significant changes. read by: das,saumya intervals axes rate pr qrs qt/qtc p qrs t 71 272 112 400/419 34 -41 81 . chest (portable ap) study date of 11:30 pm findings: the lung volumes are low with secondary widening of the cardiomediastinal silhouette. there is no pleural effusion, no pneumothorax. no lung consolidation. repeat study with deep inspiration is recommended, since assessment of edema is difficult with low lung volumes. . ct head w/o contrast study date of 11:45 pm findings: ct of the head: there is no evidence of hemorrhage, edema, mass effect, or infarction. the ventricles and sulci are normal in size and configuration. the -white matter differentiation is well preserved. there is no calvarial or skull base fracture. the paranasal sinuses and mastoid air cells are clear. there is bilateral vertebral artery and cavernous carotid artery calcification. impression: mild arterial atherosclerotic calcification. otherwise normal study. . tte conclusions the left atrium is mildly dilated. left ventricular wall thicknesses and cavity size are normal. due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. overall left ventricular systolic function is low normal (lvef 50-55%). tissue doppler imaging suggests a normal left ventricular filling pressure (pcwp<12mmhg). right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic arch is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: suboptimal image quality. normal left ventricular cavity size and wall thickness with preserved global left ventricular systolic function. mildly dilated ascending aorta and aortic arch. no clinically significant valvular regurgitation or stenosis. mild pulmonary artery systolic hypertension. compared with the prior study (images reviewed) of , it appears that the global left ventricular systolic function may have diminished slightly vs the prior study, but the image quality is markedly worse on the current study and thus a direct comparison of all previously measured parameters cannot be made. . ecg study date of 9:18:18 am normal sinus rhythm with frequent premature atrial contractions. a-v conduction delay with p-r interval equal to 0.25 seconds. left anterior fascicular block. non-specific st-t wave abnormalities. delayed r wave transition. compared to the previous tracing of no diagnostic change. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 90 /414 69 -47 90 . ct c-spine w/o contrast study date of 12:12 am findings: ct of the spine: the height of the vertebral bodies of the c-spine is preserved. no prevertebral soft tissue swelling. there is no evidence of fracture or malalignment. secretions are seen in the hypopharynx at the level of the piriform sinuses. there are no significant degenerative changes. the lung apices are clear. the thyroid gland is normal. ct has limited resolution for intraspinal soft tissue abnormalities. if there are new neurological findings after trauma, an mr may be helpful to identify abnormalities such as disk protrusions or hematoma. impression: no evidence of fracture or malalignment. secretions in hypopharynx at the level of the piriform sinuses. . ct abd & pelvis & chest w/o contrast study date of 1:02 am findings: ct of the chest: there is no pneumomediastinum, mediastinal hemorrhage, pericardial or pleural effusion. there are atherosclerotic calcifications of the coronary arteries. there is no mediastinal, hilar, or axillary lymphadenopathy. the right middle lobe bronchus is slightly narrowed. there are bibasilar atelectatic changes. there are no suspicious pulmonary nodules. the pulmonary artery is enlarged, likely due to pulmonary hypertension with prominent vascular hila. there is no evidence of pericholecystic fluid or wall thickening. there are no focal hepatic lesions, however, evaluation is limited without intravenous contrast. the pancreas is atrophic. the spleen and both kidneys are normal. there is no retroperitoneal or mesenteric lymphadenopathy. there are mild atherosclerotic calcifications at the and external iliac arteries. the stomach, and large bowel are normal. moderate amount of stool throughout colon. ct of the pelvis: there is a right small bowel-containing inguinal hernia and a left fat-containing inguinal hernia. no free fluid and no free air. the prostate gland, seminal vesicles, and urinary bladder are normal. a foley catheter is seen in the urinary bladder. diverticulosis, but no diverticulitis. there is a severe, likely chronic compression fracture of the l1 vertebral body of unknown chronicity without significant retropulsion and moderate multilevel facet degenerative changes. impression: 1. almost complete wedge compression fracture of l1 without retropulsion into the spinal canal, more likely subacute or chronic. 2. right nonobstructed small bowel containing inguinal hernia. 3. bibasilar lung opacities, likely atelectasis. 4. prominent pulmonary artery. . chest (portable ap) study date of 7:18 am findings: as compared to the previous radiograph, the lung volumes remain low. despite the low lung volumes, the findings are suggestive of mild-to-moderate pulmonary edema. newly occurred areas of atelectasis at the left lung base. . ecg study date of 8:55:58 am normal sinus rhythm with a-v conduction delay. left anterior fascicular block. delayed r wave transition. no diagnostic change from tracing #1. tracing #2 read by: , intervals axes rate pr qrs qt/qtc p qrs t 83 /424 31 -40 85 . foot 2 views right study date of 3:45 pm findings: prior exam dated demonstrates transmetatarsal amputation of all digits. in the interval there has been increased vascular calcifications and increased osteopenia. there is no periosteal reaction to suggest osteomyelitis but mr would be more sensitive. there is irregularity of the distal tibia compatible with a fracture. this is only seen on the lateral film. this finding was called to dr. at the time of discovery at 8 a.m. by dr. by phone. . chest (pa & lat) study date of 3:45 pm findings: lung volumes continue to be low but are slightly improved compared to the study from two days prior. there is improved aeration at the bases and decreased vascular plethora, however, there is still an element of pulmonary vascular redistribution and mild cardiomegaly. thus, mild fluid overload is likely. . ecg study date of 1:42:54 am baseline artifact. sinus rhythm with marked p-r interval prolongation and intraventricular conduction delay. left ventricular hypertrophy with strain type pattern. left axis deviation with left anterior fascicular block. delayed anterior r wave progression may be due to left ventricular hypertrophy, but prior anteroseptal myocardial infarction cannot be excluded. compared to the previous tracing of the rate is slower. downsloping st segment depression has given way to st segment flattening in lead i. t wave inversions are similar in lead avl. st segments are flatter in leads v3-v6 of uncertain significance. read by: , intervals axes rate pr qrs qt/qtc p qrs t 61 296 116 450/451 21 -45 95 . chest (pa & lat) study date of 6:37 pm impression: ap chest compared to through : region of scarring in the right middle lobe has been present to some degree for several years. there is also a region of chronic atelectasis in the left lower lobe. overall, there are no new focal findings to suggest pneumonia. low lung volumes are probably due in part to vascular dilatation in the lungs and top normal heart dimensions. . knee (2 views) right study date of 6:50 pm findings: no acute fracture or dislocation. cast material projects over the proximal right tibia and fibula. bone demineralization prominent atherosclerotic calcifications. lack of tangential or standing views renders evaluation of the joint spaces suboptimal. impression: 1. no acute fracture or dislocation. 2. prominent atherosclerosis. 3. bone demineralization. . tib/fib (ap & lat) right port study date of 3:26 pm findings: in comparison with the study of , there is cast about somewhat obscuring what appears to be a complex fracture of the ankle with involvement of the distal tibial shaft as well as the medial malleolus. brief hospital course: brief clinical course: 54 year old male with cad, chf, and pvd presents with fever and tachypnea, initial c/f sepsis and sent to micu, quickly stabilized and sent to floor for optimization of chf exacerbation and continuation of r/o acs. he continued to spike fevers without an identifiable source, id consulted, serial cultures negative and antibiotics held. patient defervesced over the 3 days prior to discharge and was evaluated by derm for stasis dermatitis of rle, and evaluated by ortho for distal tib/fib fracture that was placed in a cast. . active issues: . # acute on chronic diastolic chf exacerbation: new oxygen requirement previously requiring cpap. initial admission cxr consistent with pulmonary edema and crackles on exam. the patient received 20mg lasix iv on arrival to the floor and another 40mg iv at 1300 on , was started on 60mg iv lasix on . the patient was started on daily 60mg torsemide on ; got extra dose of 60mg iv lasix afternoon of . transitioned to 60mg torsemide with daily net negatives of ~2l. creatinine and electrolytes remained stable throughout his inpatient diuresis and repeat cxr showed interval improvement in lung fields, vascular congestion, and no evidence of a pneumonia. clinically, the patient had no o2 requirement in the 48 hours leading up to discharge, denies sob, dyspnea or orthopnea. . # fever/sirs likely diabetic foot ulcer: meets sirs criteria for fever, tachycardia likely diabetic foot ulcer. possible other sources included urine, cellulitis, or pna. received a dose of vancomycin and cefepime in ed. although the tachypnea could be chf exacerbation, the patient has risk factors for health care associated pneumonia. cxr suboptimal given pulmonary edema and body habitus. the patient was placed on vancomycin, ciprofloxacin, metronidazole on : covering for mrsa, gm-, pseudomonas, anaerobes given ulcer & high risk for infection, diabetes, peripheral vascular disease. this regimen was stopped on given no clear etiology for fevers. the patient was afebrile x 24 hours and recultured on and per id recs and will restart vanc and cefepime if he spikes >101. wound care consulted, recs implemented and podiatry was consulted, rec'd continuing current regimen. we ruled out chronic rle osteomyelitis with foot and leg plain films. the patient had an elevated esr 87. x-ray of rle, revealed tib-fib fracture, consulted ortho cast placed . derm consulted for large rle wound with weeping, little concern for infectious source given good wound care. repeat cxr, final read no e/o pna. f/u blood cultures, gpcs in clusters from blood cultures, speciation of s. epi likely contaminant since bottle sets; id consulted. 1st urine culture negative, repeat ua/ucx negative for growth. . #stasis dermatitis: patient with chronic (since ) large right lower extremity lesion that encompasses the entire ventral surface of the shin, with keloid formations, tense bullae and areas of weeping serosanguinous discharge; little clinical suspicion for infection given good wound care. derm consulted and saw patient; diagnosis of stasis dermatitis. patient refused biopsy on first attempt, then allowed biopsy which preliminarily came back + for gpcs, with plans to follow up in derm clinic. . # chest pain: on the day of admission he reports having 5 minutes of chest pain with radiation down his left arm without nausea, sweating or exacerbation with movement. the chest pain had resolved on admission and his ekg did not have ischemic changes. his troponin was elevated at 0.14 which is near baseline for him. troponins trended up to 0.18 but his ckmb was normal at 2-4. he did not have any other episodes of chest pain. . #hypertension: patient's bp meds stopped on arrival to the micu hypotension and c/f septic picture. sbps > 170 on arrival to the floor. switched from metoprolol to coreg 12.5 on . we continued the patient on amlodipine, hydralazine 40mg tid, isosorbide dinitrate 20mg tid. . # bradycardia: on the morning of admission to the micu he had an episode of bradycardia to the 30-40s with nausea and diaphoresis, but did not have an further episodes while in the micu. unclear , very transient, but in the setting of a troponinemia and known right coronary disease, concern for possible sa node dysfunction secondary to nstemi. also possible is vasovagal episode. troponins downtrending and known to be baseline elevated in past ckd. once on the floor, the patient's heart rate never dipped below the 70's and he had no more episodes of symptomatic bradycardia. . #distal tibia/fibula fracture: likely fall prior to admission. patient did not complain of right lower extremity pain out of proportion to his baseline pain with the stasis dermatitis. the patient received a foot x-ray out of concern for osteomyelitis after podiatry saw patient and gave wound care recs. foot x-ray negative for osteomyelitis but revealed possible distal tib/fib fracture. repeat leg x-ray of right lower extremity showed distal tib/fib fracture. orthopedics saw patient and decided not to operate, and opted for short casting instead. . # tachypnea: on admission his cxr was c/w pulmonary edema secondary to chf but could not rule out pneumonia or a pe. because of his kidney failure he was unable to get a cta to rule out a pe. because he was febrile in the ed he was given one dose of vancomycin and cefepime to cover for health care associated pneumonia but these antibiotics were discontinued in the micu because he did not have evidence of infection. repeat chest x-ray revealed no evidence of pneumonia. patient had no supplemental o2 requirement in the days leading up to discharge, with normal respiratory rates, no increased work of breathing and o2 sats >95% on room air. . # acute on chronic ckd: unclear history of ckd, cr elevated on admission to 2.6, up from recent baseline value 1.6. i/o's trended and at discharge the patient's creatinine was 1.8 and the patient's urine output was wnl. . # l1 compression fracture: possible acute exacerbation of chronic injury. we continued his home pain regimen of oxycontin and oxycodone. . # hip pain: secondary to fall. ct-abdomen/pelvis revealed no hip fracture or other pathology. pain control as above. . transitional issues: -patient will f/u with orthopedics in 2 weeks with dr. for eval of distal tib/fib fracture -patient will f/u with dermatology as an outpatient; prelim biopsy results showed gpcs on gram stain, final report pending. -patient will f/u with providers as an outpatient -patient will f/u with dr. for cardiology med management and optimization on . medications on admission: preadmission medications listed are correct and complete. information was obtained from rehab records. 1. baclofen 10 mg po tid 2. oxycodone sr (oxycontin) 10 mg po q12h hold for sedation or rr<10 3. multivitamins w/minerals 1 tab po daily 4. amlodipine 10 mg po daily 5. aspirin 325 mg po daily 6. metoclopramide 5 mg po tid:prn nausea 7. levothyroxine sodium 100 mcg po daily 8. polyethylene glycol 17 g po daily 9. docusate sodium 100 mg po tid 10. bisacodyl 10 mg po daily:prn constipation 11. quetiapine fumarate 50 mg po hs 12. quetiapine fumarate 25 mg po bid:prn agitation 13. prochlorperazine 10 mg po q6h:prn nausea 14. acetaminophen 650 mg po q4h:prn pain or fever 15. clopidogrel 75 mg po daily 16. pantoprazole 40 mg po q24h 17. atorvastatin 80 mg po daily 18. ferrous sulfate 325 mg po daily 19. gabapentin 300 mg po daily 20. tamsulosin 0.4 mg po hs 21. hydroxyzine 50 mg po q8h:prn itch 22. metformin (glucophage) 500 mg po daily 23. oxycodone-acetaminophen (5mg-325mg) 1 tab po q4h:prn pain 24. glargine 48 units breakfast insulin sc sliding scale using reg insulin 25. lactulose 15 ml po daily 26. senna 2 tab po bid 27. furosemide 20 mg po bid 28. ipratropium bromide neb 1 neb ih q4h:prn sob 29. metoprolol succinate xl 50 mg po daily 30. albuterol 0.083% neb soln 1 neb ih q4h:prn sob 31. fluocinolone acetonide 0.01% cream 1 appl tp 32. isosorbide dinitrate 5 mg po tid discharge medications: 1. albuterol 0.083% neb soln 1 neb ih q4h:prn sob 2. amlodipine 10 mg po daily 3. atorvastatin 80 mg po daily 4. baclofen 10 mg po tid 5. bisacodyl 10 mg po daily:prn constipation 6. clopidogrel 75 mg po daily 7. docusate sodium 100 mg po tid 8. ferrous sulfate 325 mg po daily 9. gabapentin 300 mg po daily 10. ipratropium bromide neb 1 neb ih q4h:prn sob 11. lactulose 15 ml po daily 12. levothyroxine sodium 100 mcg po daily 13. metoclopramide 5 mg po tid:prn nausea 14. multivitamins w/minerals 1 tab po daily 15. oxycodone sr (oxycontin) 10 mg po q12h hold for sedation or rr<10 16. pantoprazole 40 mg po q24h 17. polyethylene glycol 17 g po daily 18. prochlorperazine 10 mg po q6h:prn nausea 19. quetiapine fumarate 50 mg po hs 20. quetiapine fumarate 25 mg po bid:prn agitation 21. senna 2 tab po bid 22. tamsulosin 0.4 mg po hs 23. acetaminophen 650 mg po q4h:prn pain or fever 24. fluocinolone acetonide 0.01% cream 1 appl tp 25. hydroxyzine 50 mg po q8h:prn itch 26. metformin (glucophage) 500 mg po daily 27. oxycodone-acetaminophen (5mg-325mg) 1 tab po q4h:prn pain hold for sedation or rr < 10 28. isosorbide dinitrate 20 mg po tid hold for sbp < 100 29. hydralazine 40 mg po tid hold for sbp < 100 30. aspirin 81 mg po daily 31. glargine 50 units breakfast insulin sc sliding scale using reg insulin 32. torsemide 60 mg po daily hold for sbp < 90 33. carvedilol 12.5 mg po bid hold for sbp < 100 or hr < 60 discharge disposition: extended care facility: nursing & therapy center - ( rehabilitation and nursing center) discharge diagnosis: acute on chronic dchf exacerbation discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear mr. , it was a pleasure taking care of you. you were admitted to the for having low blood pressures and breathing rapidly. there was concern that you may have had an infection and you were placed on antibiotics and transferred to the intensive care unit. you quickly stabilized and were transferred to the cardiology unit out of concern that you may have had some fluid overload. we gave you medicine to increase your urination to get some of that fluid off. you improved significantly and were stable enough to go back to your extended care facility. we wish you the best. followup instructions: department: cardiac services when: tuesday at 2:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 3:20 pm with: ortho xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: thursday at 3:40 pm with: , np building: campus: east best parking: garage department: dermatology when: wednesday at 10:00 am with: - , md, phd building: sc clinical ctr campus: east best parking: garage procedure: closed biopsy of skin and subcutaneous tissue diagnoses: anemia, unspecified coronary atherosclerosis of native coronary artery congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia severe sepsis unspecified acquired hypothyroidism hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified acute on chronic diastolic heart failure polyneuropathy in diabetes percutaneous transluminal coronary angioplasty status chronic kidney disease, unspecified ulcer of other part of foot constipation, unspecified cellulitis and abscess of leg, except foot long-term (current) use of insulin osteoporosis, unspecified old myocardial infarction family history of ischemic heart disease pain in joint, pelvic region and thigh hypoxemia below knee amputation status background diabetic retinopathy atherosclerosis of native arteries of the extremities with ulceration ulcer of heel and midfoot diabetes with neurological manifestations, type i [juvenile type], not stated as uncontrolled diabetes with ophthalmic manifestations, type i [juvenile type], not stated as uncontrolled venous (peripheral) insufficiency, unspecified long-term (current) use of aspirin pathologic fracture of vertebrae history of fall personal history of methicillin resistant staphylococcus aureus foot amputation status wheelchair dependence 

Answer: The patient is high likely exposed to