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: sulfa (sulfonamide antibiotics) attending: chief complaint: myelodysplastic syndrome with myeloproliferative disease with myelofibrosis major surgical or invasive procedure: sibling allogenic stem cell transplant placement of venous central lines x 2 and removal intubation x12 days for hypoxic respiratory failure placement of femoral hemodialysis line history of present illness: 51 yo f with no significant pmh, with recent diagnosis of mds/mpd with myelofibrosis admitted for sibling allogenic sct. . patient reports that five years ago, she was found to be anemic by her pcp. colonoscopy and upper gi series were done to workup the source of anemia. there were colonic polyps which were removed. she was started on iron supplementation. however, the anemia did not resolve, and she eventually developed severe thrombocytopenia (plt <40). a ct of the abdomen showed splenemegaly. patient was referred by pcp to at osh, who then referred the patient to dr. . a bone marrow biopsy was done, which was equivocal. patient had a repeat biopsy which showed mds. her sister was found to be a matched donor, and so patient is admitted to subling allogenic sct. . of note, patient has had little symptoms associated with the anemia and thrombocytopenia. denied frequent bleeding, infections, or increased fatigue. the diagnosis of mds was very much a shock, and has been a significant stressor emotionally. . review of systems: (+) per hpi (-) denies fever, chills, night sweats. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations. denies cough, shortness of breath, or wheezes. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history: oncology history: recent diagnoses of mds with myelofibrosis features from two bone marrow biopsies. result: peripheral blood with leukoerythroblastic picture. markedly hypocellular marrow (10% cellularity) with dysmegakaryocytopoiesis, bony remodeling and background myelofibrosis. . past medical history: 1. history of reactive tuberculosis skin test in 3rd grade (age 8)- does not recall any known exposures or family members with disease. was treated for 1 year with 2 drugs. 2. history of anemia, on iron social history: married and lives in with her husband and 3 sons, ages 24, 22, and 20. eldest son has quit his job and will run her business which she is in the hospital. two sisters, both healthy, one of which will be the fonor for the transplant. she owns a medical transcription service. born in ma, grew up in except for 18 months when her family lived in for 18 months. she has never lived elsewhere in the us or outside of the us. she has travelled to (sisters live in and ); , aruba, and cancun. - tobacco: smokes only when out and having a glass of wine - etoh: glasses a month - drugs: none family history: - father, deceased at 73 of lung cancer - mother, deceased at 73 of unclear causes, had history of cardiac issues - paternal aunt with breast cancer - paternal grandmother with breast cancer - 3 brothers, 1 died in card accident, 1 died of brain aneurysm resulting from an accident, 1 alive and well with hypercholesterolemia - 4 sisters, all alive and well physical exam: physical exam on discharge: from icu: general: sleeping, arousable, nad heent: eyelid rim exudative and bruised, bilateral conjunctival injection, eomi, lungs: bilateral rhonchi cv: regular rate & rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: mildly distended, bs+, nt, splenomegaly ext: 1+ edema of the feet bilaterally, pneumoboots in place, 2+ dp pulses bilaterally neuro: obeys commands gu: trace blood on pad . exam on dishcarge: gen: nad heent: mmm, no op lesions, neck is supple cv: rrr, nl s1s2 pulm: ctab abd: bs+, soft, ntnd, ? spleenemegaly limbs: no le edema, no tremors or asterixis, no clubbing skin: no rashes or skin breakdown neuro: cnii-xii nonfocal, strength 5/5 of the upper and lower extremities, reflexes 2+ of the upper and lower extremities, toes down bilaterally pertinent results: 1. labs on admission: 09:42am blood wbc-7.1 rbc-3.90* hgb-9.9* hct-30.0* mcv-77* mch-25.4* mchc-33.1 rdw-17.8* plt ct-40* 09:42am blood neuts-67 bands-4 lymphs-14* monos-6 eos-0 baso-2 atyps-1* metas-5* myelos-1* 01:30pm blood pt-14.3* ptt-30.4 inr(pt)-1.2* 12:00am blood fibrino-256 12:00am blood gran ct-5103 09:42am blood urean-13 creat-0.8 na-141 k-4.4 cl-105 hco3-28 angap-12 09:42am blood alt-20 ast-18 ld(ldh)-196 alkphos-192* totbili-0.5 09:42am blood albumin-4.7 calcium-8.9 phos-4.4 mg-2.5 . labs on dishcarge: 10:57am blood wbc-2.2* rbc-3.03* hgb-8.8* hct-25.1* mcv-83 mch-29.0 mchc-35.0 rdw-15.7* plt ct-15* 12:00am blood wbc-1.5* rbc-2.79* hgb-8.4* hct-23.8* mcv-85 mch-29.9 mchc-35.2* rdw-16.8* plt ct-13* 10:57am blood neuts-85* bands-2 lymphs-10* monos-2 eos-0 baso-0 atyps-0 metas-1* myelos-0 12:00am blood neuts-83* bands-2 lymphs-8* monos-5 eos-1 baso-0 atyps-0 metas-1* myelos-0 10:57am blood hypochr-normal anisocy-1+ poiklo-1+ macrocy-1+ microcy-1+ polychr-1+ tear dr1+ 04:18pm blood hypochr-1+ anisocy-1+ poiklo-1+ macrocy-normal microcy-1+ polychr-occasional ovalocy-1+ tear dr1+ 10:57am blood plt smr-rare plt ct-15* 12:00am blood plt ct-13* 12:00am blood glucose-85 urean-86* creat-1.4* na-139 k-3.7 cl-107 hco3-20* angap-16 12:00am blood glucose-123* urean-99* creat-1.7* na-138 k-4.7 cl-107 hco3-22 angap-14 12:00am blood alt-13 ast-14 ld(ldh)-195 alkphos-143* totbili-3.2* 12:00am blood alt-9 ast-15 ld(ldh)-193 alkphos-164* totbili-3.1* 12:00am blood calcium-8.7 phos-4.2 mg-1.8 12:00am blood albumin-3.6 calcium-8.6 phos-4.5 mg-2.1 12:00am blood hapto-69 09:52am blood cyclspr-152 12:00pm blood anti-platelet antibody-test 11:24am blood anti-platelet antibody-test 11:30am blood herpes 6 dna pcr, quantitative-test name . 3. imaging/diagnostics: -abdomen u.s. (complete study) study date of 3:07 pm impression: 1. no evidence of biliary duct obstruction, as questioned. 2. gallbladder sludge, with no son features of acute cholecystitis. 3. stable splenomegaly. 4. stable 2.6 cm echogenic splenic lesion, benign. -ct chest w/o contrast study date of 9:26 am impression: 1. interval development of diffuse and symmetric perihilar ground glass opacities and septal thickening, most suggestive of diffuse pulmonary edema. pulmonary hemorrhage and diffuse infection are considered less likely given the symmetric findings. 2. increase in size of a right pleural effusion, which is now large in size. 3. minimal decrease in size of a left pleural effusion. 4. ascites and massive splenomegaly, partially imaged. 5. diffuse osseous sclerosis, compatible with changes relating to myelodysplastic syndrome. -tte (complete) done at 2:19:06 pm final conclusions the left atrium is normal in size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. 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. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the degrees of mitral and tricuspid regurgitation along with pulmonary hypertension have all increased. -ct torsow/o contrast study date of 1:41 pm impression: 1. increasing ascites and pelvic free fluid. no evidence of intraperitoneal abscess, hematoma, colitis, or renal abnormality. 2. stable splenomegaly and unchanged appearance of the hypodense inferior pole lesion. 3. increasing right pleural effusion, interstitial thickening within the lung parenchyma. 4. stable appearance of the calcified uterine fibroid. 5. diffusely dense bones, unchanged compared to prior. -ct chest w/o contrast study date of 3:32 pm impression: 1. bilateral effusions, right greater than left, are slightly increased from prior studies. there is associated relaxation atelectasis. 2. subtle peribronchovascular scattered ground-glass opacities in the right upper lobe, nonspecific, compatible with either infectious or inflammatory etiologies. the lungs are otherwise clear without consolidative opacities to suggest pneumonia. 3. splenomegaly. 4. increased ascites. 5. diffusely sclerotic bones, reflects underlying mds. - ct head w/o contrast study date of 4:58 pm impression: 1. unchanged small amount of bifrontal subarachnoid hemorrhage. no new foci of hemorrhage identified, however portions of the brain are incompletely evaluated in the presence of motion artifact despite second attempt. 2. no evidence of parenchymal hemorrhage or intra- or extra-axial hematoma within limitation of motion degraded study. 3. persistent opacification of mastoid air cells without osseous erosion. persistent mucosal thickening within paranasal sinuses. recommend clinical correlation to exclude the possibility of infection. -head ct w/o contrast 1. small amount of bifrontal subarachnoid hemorrhage. 2. 5 mm hyperdensity projecting over the right anterolateral temporal lobe likely represents a bone-related artifact 3. opacification of the mastoid air cells without osseous erosion, and possible fluid in the paranasal sinuses, new since the prior study. clinical correlation is advised regarding the possibility of an infection. -transvaginal u/s 1. heterogeneous uterus with thickening of the endometrial stripe measuring up to 1 cm, concerning in a postmenopausal patient. consider hysteroscopy/direct visualization for further evaluation. 2. normal appearance of both ovaries, without adnexal masses. 3. moderate-to-large amount of free fluid is seen within the pelvis, similar to recent prior ct exam. 4. although an exophytic partially calcified fibroid is suggested extending from the left lateral aspect of the fundus on recent prior ct, this is not visualized on ultrasound. - ct chest//pelvis w/o contrast () 1. bilateral pleural effusions consisting of simple or chylous fluid, with compressive atelectasis. 2. trace intraperitoneal free fluid, but no retroperitoneal or flank hematomas. 3. splenomegaly with incompletely-characterized but nonspecific inferior pole hypodensity. 4. prominent paratracheal lymph node. - liver or gallbladder u/s w/ doppler of portal system () 1. hepatic artery, hepatic veins, and portal veins are patent. 2. unchanged severe splenomegaly and small right pleural effusion. - renal u/s () no evidence of vasoocclusive disease at both kidneys. echogenic lesion in the spleen, suggestive of a hemangioma. although the echogenic appearance would be somewhat atypical, a focal lesion associated with the patient's underlying disease process cannot be excluded. - echocardiogram () the left atrium and right atrium are normal in cavity size. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). diastolic function could not be assessed. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. physiologic mitral regurgitation is seen (within normal limits). there is borderline pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. there are no echocardiographic signs of tamponade. - brief hospital course: 52 yo f with recent diagnosis of mds/mpd, day d+59 sibling allogenic sct with ablative busulfan/cyclophosphamide therapy. noted anemic 5 years ago with polyps on colonoscopy but persisted and eventually deveoped severe pancytopenic and ct showed splenomegaly - 1 bmbx equivocal second showed mds. cough and febrile neutropenia post transplant d2 treated with iv cefepime, vanc, micafungin and cipro w acyclovir and had progressive resp decompensation requiring micu admission and intubation - intubated for 12 days and successfully extubated on . developed arf felt likely atn in the setting of hypotension and is on dialysis. was bronched on and was normal. persistent confusion since icu likely multifactorial in nature which resolved by . had deranged lfts max bili 11 in icu which have trended down ? drug effect ? gvhd and was treated with steroids. u/s was normal. she was still overloaded re volume status but urine output improved and fluid status improved with boluses of furosemide on advice of renal. her diet was advanced and was latterly able to eat normally and take oral meds by . she had no further fevers and antimicrobials rationalised . iv mp stopped on but restarted on cefepime stopped . and iv cefepime/ started due to new onset pain although scan negative ? gvhd. all antibiotics were stopped on . respiratory decompensation and ct showed pulmonary edema and responded to aggressive diuresis with considerable improvement in fluid status. she was found to have hlaii antibodies which do not necessitate hla matched platelets. due to deteriorating bili with tapering iv steroids, ivmp increased back to 30mg . symptomatically much improved so decreased steriods to 20mg on . although she was still requiring frequent transfusions of platelets and blood and needed to continue micafungin, it was felt that the pt was stable enough to be discharged to the apartments with daily monitoring at the clinic. . . # myelodysplastic syndrome/myeloproliferative disorder: allo sct . on acyclovir, and mica. patient underwnet pre-conditioning treatment with busulfan/cytoxan. she tolerated busulfan well, but started to experience nausea and abdominal discomfort with cytoxan. she was treated for nausea. she received stem cells from her sister without incident. required prbc and platelet transfusions during times. total bilirubin was elevated (direct bilirubin elevated) at one point, but abdominal ultasound was negative. she was started on tpn. she was transferred to the icu for febrile neutropenia and hypoxic respiratory failure. solumedrol was continued, but bactrim (for pcp ) was held secondary to profound neutropenia. acyclovir was also held as per bmt recommendations. in he icu, the patient had a baseline anemia bm suppression s/p transplant, but developed a falling hct and a small amount of vaginal bleeding in the context of low platelets (plts 7). ct chest/abdomen/pelvis did not identify any other source of bleed. no evidence of rp or thigh bleed was found on physical exam. therefore, the patient was tranfused prbc to a goal hct >21. platelets remained low in spite of platelet transfusions, presumably secondary to the patient's splenomegaly. gynecology recommended vaginal u/s that was done on . in the icu, the patient's neutropenia persisted throughout her icu stay, but her anc rose to 494 before she left the icu. she was put on neutropenic precautions and treated with filgrastim. she was treated with broad spectrum abx as discussed above under respiratory failure. abx will be continued until anc>500 as per id. the patient was thrombocytopenic throughout her icu course and has been refractory to platelet transfusions. after transfusion, her platelets briefly rise by points, but quickly drop back to her baseline of 7. this is presumed to be because of her significant splenomegaly. it was decided that she would be transfused plts only before procedures or in setting of active bleeding and transfusion goal was latterly set to aim for a hct>20 and plt>10 to reduce the transfusion burden due to high requirement of transfusions and lack of symptoms at this level. on transfer back to bmt floor from the micu, counts were increasing on gcsf. she remained on meropenem, vancomycin, ciprofloxacin, and micafungin until she was no longer neutropenic. thrombocytopenia was noted to be refractory to platelets, which were then only given when pt was showing signs of bleeding. pra was negative, so refractoriness was thought to be splenomegaly. after transfer to bmt floor from micu, patient was more responsive to platelets although this was again an issue by with little increase in her counts despite transfusions and having difficulty even attaining a platelet count of 20. due to absence of fevers, stopped mica, cefepime and vanc on . afebrile, no longer neutropenic. had ih pentamidine for prophylaxis. changed cipro to cefepime due to possible drug effect causing pancytopenia. started atovaquone for pcp and stopped cefepime . stopped atovaquone and started dapsone for pcp . bone marrow from was hypocellular but otherwise trilineage hematopoesis. cmv 1070 copies - started treatment dose iv gancyclovir . . #febrile neutropenia: patient was neutropenic during admission, and became febrile. initially was started on vancomycin, cefepime and micafungin, but she continued to have fevers and developed a cough that continued to worsen. ct scan on and showed no evidence of infiltrate. micafungin was changed to voriconazole on for coverage of aspergillus. pt triggered several times for tachycardia and tachypnea related to fever and was transferred to the icu for closer monitoring. the patient's neutropenia persisted throughout her icu stay, but her anc rose to 494 before she left the icu. she was put on neutropenic precautions and treated with filgrastim. she was treated with broad spectrum abx as discussed above under respiratory failure. abx were continued. on return to bmt floor from icu, patient remained on meropenem, vancomycin, ciprofloxacin, and micafungin while still neutropenic. she was planned to continued micafungin as an outpt at the clinic . #hypoxemic respiratory failure requiring icu transfer: in the icu the patient developed hypoxemic respiratory failure, initially secondary to volume overload with flash pulmonary edema in the context of a prbc transfusion. this was all likely complicated by a probable pneumonia (viral, bacterial or fungal). the patient was intubated for hypoxemic resp failure and ventilated for 12 days. the patient's pneumonia was treated w/ meropenem, cipro, vanc, micafungin as per id recs and her respiratory status improved. she was extubated successfully on . id recommended that micafungin/meropenem be continued until anc>500. her most recent granulocyte count is 494 on . the patient was given mucinex prn for cough. after starting hd, the patient's fluid balance became positive and she continues to respond poorly to lasix. her resp status nevertheless continues to be good and she remained clinically stable in this regard on ra until her episode of decompensated pulmonary edema on (see note on pulmonary edema for details). . #arf: no longer dialysis dependent. pt developed acutely worsening renal function after intubation and the cause was felt to be atn secondary to hypoperfusion during an episode of hypotension during intubation. she developed worsening hypervolemia, hyperkalemia up to 6.3 and a creatinine level of 4.1 in spite of intravenous fluids and treatment for hyperkalemia. the pt was treated w/ cvvh and volume was successfully removed over 8 days. however the pt's renal function continued to be poor and the patient was switched to intermittent hd when the patient was off pressors and relatively stable. she was transferred back to the floor once stable. while on the floor, she was dialysed with hd as needed for fluid removal and for uremia when renal function did not significantly improve. patient was noted to have altered mental status likely uremia as this improved after dialysis sessions. medications were renally dosed. she had a temporary dialysis line inserted on and it was felt that her uremia may be contributing to altered mental status although this was multi-factorial and resolved by early 11/. she had bilateral effusions and r effusion worse on ct . effusions improved with aggressive diuresis although by right effusion still present and small-moderate. she passed progressively higher volumes of urine and by passed 1000ml urine over 24 hrs as end of and this trended upwards. fluid status improved but she still had gross pitting edema to knees bilaterally. on advice of renal she was slowly started on iv furosemide boluses to help her fluid status. rby she no longer required dialysis. after an episode of acute pulmonary edema, she as aggressively diuresed from onwards with 80-100mg iv furosemide and her fluid status greatly improved. with diuresis, she was clinically improving and renal function was stable. dialysis line removed with platelet cover . kidney function has been stable and slowly improving. . # confusion: this was considered likely multifactorial given a high bili which improved, a high bun on dialysis and the possibility of infection. she was treated for infectious etiologies and /mica/vanc stopped . her lfts improved but did not resolve to the normal range and she was dialysed until her renal function recovered whereupon she no longer required dialysis. following discontinuation of antibiotics, she greatly improved in the matter of a few days to the extent that by she was gcs 15/15. . # subarachnoid hemorrhage: traumatic sah following fall out of bed on in the context of considerable thrombocytopenia and ct-head showed small bifrtontal sah with no itraparenchymal element. stable on rpt head ct. she was seen by the neurosurgery service who recommended rescanning only if she had a change in neuro exam and recommended transfusing platelets. she was rescanned on for concern for worsening altered mental status and bleed was unchanged. since she had been refractory to platelet transfusions, she was given doses of amicar and ddavp to avoid further bleed. her blood pressure was controlled initially with iv hydralazine and ;latterly has been transitioned to oral labetalol. neurologic status improved (she had been confused post-icu) and she had no sequelae clinically of her sah. a mild anisocoria was noted with the left pupil very marginally larger than the right. she otherwise had an unremarkable neuro exam other than mild jerky saccades. on overnight, fell out of bed and head ct showed bifrontal subarachnoid hemorrhage. she will need f/u with neurosurgery in 2 weeks. . # pancytopenia: ? cause ? viral ? drug effect ? failure of graft. stopped potential incriminating meds. d/w renal changed hydralazine to labetalol 100mg tid, stopped famotidine, stopped fluconazole and changed to mica iv, stopped metoclopramide and olanzapine prn. had bmbx - results awaited. transfused 2 units rcc hb 6.7/18.6 to 8.2/22.8. investigated dat -ve , hit ab pending, hapto normal, ldh normal smear -ve for schistocytes. started gcsf 300mcg qd. counts static. still requiring regular transfusions. bmbx . platelet count not increasing as of and labs sent for hla ab. ivig 0.4g/kg 25g one dose . gcsf was stopped on . . #gvhd: rash was present on back resolved. bili was high and decreased and remained stable. she initially had diarrhea initially which resolved. in the icu, cyclosporin levels were checked qam and cyclosporin was redosed if level <100 as per bmt recs. ivmp was continued in the icu. in the icu, the patient's t. bili and ap were initially elevated, but trended down during the patient's icu stay. likely the elevation was secondary to a medication effect vs gvhd. abdominal u/s found no biliary/gallbladder pathology. on her arrival in the icu, the patient was treated with voriconazole in the context of neutropenia and a possible pneumonia. this was stopped because of possible hepatotoxicity and micafungin was used instead. in the course post return rom the icu, we tapered iv methylpred and stopped on cyclosporin levels were taken daily and dose was adjusted accordingly. cyclosporin level aim was <100 in icu on renal advice and on transfer to the floor 100-150 but when renal function improved, this was increased to 150-200. restarted iv mp at 30mg qd. rash improving. changed to oral cyclosporin 11/4nd increased dose to 100mg and to 125mg on . level 263 on and reduced to 75mg . due to nausea, changed to cyclosporin iv 75mg . changed ivmp to oral prednisone 40mg qd and pred decreased to 20mg . changed tto cyclosporin 75/100 on . increased cyclopsorin to 100mg iv on and restarted ivmp 30mg . cyclosporin changed to 150mg and good level . increased to cyclosporin 175/150 on . . # pulmonary edema: respiratory decompensation dropped sats to 88% ra and now 94% on 2l o2 with initially high rr36 which also settled. bp maintained. but gradual over last 3 days - ct showed pulmonary edema and aggressively diuresed total 100mg iv furosemide . echo showed good lv function, mod mr/tr and pulmonary htn. further 100mg iv furosemide and to good effect and symptomatic improvement. isosorbide dinitrate 10mg tid started for decreasing afterload. if decompensates for further furosemide and trial of cpap +/- nitro iv infusion. her volume status improved and on , lasix was discontinued. . #cough and changing ggos on ct: persistent since admission ? cause ? reactive (asthma) ? secondary to fluid overload ? infectious started on regular albuterol nebs and incentive spirometer. pertussis -ve and ct-chest showed some change in ggos which have migrated. pulm consulteda dn felt wide differential. repeat ct chest 1 week and started cough suppressants with guaifensain/dextro qid regularly and added codeine prn which improved matters. f/u ct-chest - centrilobular ggo in lul suspicious for opportunistic infection - pulmonolary unimpressed and no current need for bronch. started oral levofloxacin and antibiotics changed to iv cefepime and given bowel concern. id reviewed and concerned re increased sob although not diuresed in past 2 days and found to have florid pulmonary edema by . she was initially continued on levofloxacin and then switched to cipro at discharge. diuresed sucessfully. . # acute pain: ? gvhd ? constipation. tender lower and voluntary guarding in rlq and r flank - eased by oxycodone. ct- /pelvis without contrast showed showed worsening ascites since prev film, no free air, fluid collection or abscess, no thickened bowel to suggest colitis (although no oral contrast) and no renal abnormalities or evidence of hematoma. antibiotics chaged to iv cefepime and metronidazoel (possible concern for c difficile given increased stool output) and negative. id recommended stopping iv cefepime and adding iv levofloxacin and keep iv metronidazole. generally resolved by with single episode . constipation was felt somewhat responsible. . # cmv reactivation: cmv vl 1070. started iv gancyclovir and increased to 2.5mg/kg on . no peripheral signs of cmv. given concerns for cmv with no other organ focus, seen by ophthalmology and evidence of retinal hemorrhage in supero-temporal field close to disc no evidence of cmv retinitis. will need repeat cmv levels on (one week from ). . # vaginal bleeding: noted to passing blood with clots through vagina while in icu stay in the setting of low platelets. she was evaluated by the gyn service who recommended vaginal u/s that showed thickened endometrial stripe concerning for endometrial neoplasm or other pathology. in the setting of her recent transplant and low platelets, no intervention at this time, but they recommended that she followup with a gynecologist after discharge. . #htn: given sah strict bp control was required. iv hydralazine to control. changed iv hydralazine 20mg to oral 50mg on . changed to oral labetalol and bp thus far controlled. medications on admission: 1. alprazolam 0.5 mg po qhs 2. butalbital-acetaminophen-caffein 50 mg-325 mg-40 mg tablet - 1 tablet po q4hr prn for headache (hasn't been using) 3. lorazepam 1-2 mg po qhs prn for insomnia 4. ferrous sulfate dose uncertain 5. folic acid dose uncertain discharge medications: 1. polyvinyl alcohol-povidone 1.4-0.6 % dropperette sig: drops ophthalmic qid (4 times a day). disp:*qs tube/bottle* refills:*2* 2. folic acid 1 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 3. labetalol 100 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 4. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 5. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 6. oxycodone 5 mg tablet sig: one (1) tablet po q8h (every 8 hours) as needed for pain for 10 days. disp:*10 tablet(s)* refills:*0* 7. dapsone 25 mg tablet sig: two (2) tablet po bid (2 times a day). disp:*120 tablet(s)* refills:*2* 8. trazodone 50 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*30 tablet(s)* refills:*0* 9. cyclosporine modified 25 mg capsule sig: seven (7) capsule po qam: non-substitutable! please take 175mg (seven 25mg tablets) in the morning . disp:*210 capsule(s)* refills:*2* 10. isosorbide dinitrate 10 mg tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 11. lorazepam 0.5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. disp:*10 tablet(s)* refills:*0* 12. ganciclovir 160 mg iv q12h 13. micafungin 100 mg recon soln sig: one (1) intravenous once a day. disp:*qs * refills:*2* 14. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. disp:*30 ml(s)* refills:*2* 15. cyclosporine modified 25 mg capsule sig: six (6) capsule po qpm: do not substitute. please take 150mg (six 25mg tablets) in the evening. disp:*180 capsule(s)* refills:*2* 16. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation prn as needed for shortness of breath or wheezing. disp:*1 * refills:*0* 17. multivitamin tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 18. ursodiol 300 mg capsule sig: one (1) capsule po bid (2 times a day). disp:*60 capsule(s)* refills:*2* 19. omeprazole 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). disp:*30 capsule, delayed release(e.c.)(s)* refills:*2* 20. prednisone 20 mg tablet sig: two (2) tablet po once a day for 4 days. disp:*8 tablet(s)* refills:*0* 21. ciprofloxacin 500 mg tablet sig: one (1) tablet po q12h (every 12 hours) for 7 days. disp:*14 tablet(s)* refills:*0* discharge disposition: extended care facility: - discharge diagnosis: primary: mds sibling allogenic stem cell transplant . secondary: pulmonary edema pneumonia respiratory failure require intubation acute renal failure requiring dialysis rash, granft versus host disease cmv infection treated with gancycolvir discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for sibling allogenic stem cell transplant. you received busulfan/cytoxan pre-conditioning therapy and your sister came in for collection of stem cells. . over the course of your transplant stay, you experienced some fevers and cough for which you received antiobiotics given that your white blood cell count was very low. you also received blood and platelets given your low red blood cell and low platelet counts. your course was complicated pulmonary edema and acute kidney injury for which you required transfer to the icu. you required intubated for respiratory failure in the setting of pulmonary edema (fluid in the lungs) and possible pneumonia. you also had fluid removed with dialysis given your acute kidney injury. you received supportive care and medications were given to help remove the excess fluid from your body in addition to dialysis. you symptoms improved, dialysis was able to be stopped and you were able to be transferred out of the icu and back to the regular bone marrow transplant floor. initially after coming out of the icu you experienced disorientation but this improved. you also had a fall out of your bed; ct scan was performed at that time which should a small amount of bleeding in your head. you were monitored and your symptoms improved. you also had a rash and abdominal pain concerning for rejection which improved with immunosuppressive medicatin. you received steriods and cyclosporin to prevent rejection of your transplant and will need to continue on these medications although they will likely need to be adjusted as you continue your recovery. you also received neupogen to help stimulate your bone marrow. . you also had post-menopausal vaginal bleeding. you were seen by gynecology and ultra sound showed thickened endometrial stripe that will need further gynecologic follow-up as an outpatient in the future. . the following changes were made to your medications: - please start taking prednisone 40 mg po daily - please start taking cyclosporine (neoral) 175 mg in the morning and 150mg in the evening. (ok for pharmacy to substitute with a generic form. - please start taking ganciclovir 160 mg iv every 12 hours. - please start taking dapsone 50 mg po/ng twice daily. - please start taking micafungin 100 mg iv daily. - please start taking ursodiol 300 mg twice a day. - please start taking omeprazole 40 mg daily. - please start taking multivitamins 1 tab daily. - please start taking cipro 500mg every 12 hrs for a total of 7 days (starting , last day ) - please continue to take all of your other home medications as prescribed please be sure to take all medication as prescribed. . please be sure to keep all follow-up appointments with your primary care phyisician, hematologist/oncologist and other healthcare providers. . it was a pleasure taking care of you and we wish you a speedy recovery. followup instructions: please be sure to keep all follow-up appointments with your primary care phyisician, hematologist/oncologist and other healthcare providers. . department: bmt/oncology unit when: sunday at 8:30 am building: fd building (/ complex) campus: east best parking: main garage . department: bmt chairs & rooms when: monday at 8:30 am . department: hematology/oncology when: monday at 8:30 am with: , rn building: sc clinical ctr campus: east best parking: garage md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis venous catheterization for renal dialysis closed [endoscopic] biopsy of bronchus injection or infusion of cancer chemotherapeutic substance allogeneic hematopoietic stem cell transpant without purging injection or infusion of biological response modifier [brm] as an antineoplastic agent transplant from live related donor central venous catheter placement with guidance diagnoses: pneumonia, organism unspecified acute kidney failure with lesion of tubular necrosis unspecified septicemia severe sepsis other specified forms of chronic ischemic heart disease myelodysplastic syndrome, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure acute respiratory failure other shock without mention of trauma antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use paralytic ileus other specified disorders of biliary tract complications of transplanted bone marrow surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation drug induced neutropenia other and unspecified coagulation defects myelofibrosis splenomegaly other specified noninflammatory disorders of vagina retinal hemorrhage other specified erythematous conditions acute graft-versus-host disease fever presenting with conditions classified elsewhere cough other specified aplastic anemias transfusion associated circulatory overload 

Answer: The patient is high likely exposed to