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: penicillins attending: chief complaint: abd pain major surgical or invasive procedure: paracentesis history of present illness: 45m with a history of non-alcoholic steatohepatitis with a recent transplant eval for end-stage liver disease presenting with question of worsening mental status as well as abdominal pain. . per patient he has experienced acute onset right upper quadrant abdominal pain since 2:30 this morning as well as a few episodes of non-bloody loose stool. he denies any chest pain or shortness of breath. no fever or chills. he also had decreased oral intake. per there was also concern for mild confusion (though it is unclear what the confusion was) . in the ed, 97.6 58 113/58 16 100%. exam notable for jaundiced appearance, ms: alert and oriented; abdomen soft with mild tenderness in the right upper quadrant without signs or rebound or guarding, guaiac-negative brown stool with external hemorrhoids. cbc showed wbc 10.3, hct 32.0, and plt 65, all similar to values during his recent admission. chem panel showed worsening hyponatremia with na 122, and with cr 1.9 from baseline 1.1 to 1.2 during recent admission. lfts were abnormal with alt 157, ast 327, alk 274, and tbili 23.1, albumin 2.3, inr 3.3 similar to recent prior values. . he was given normal saline 1000 ml for presumed volume depletion, morphine 2 mg iv for pain and po lactulose for reported confusion though patient without signs of encepathopathy. he was admitted to medicine for further management of and abdominal pain in the setting of esld. vitals prior to floor transfer were t 97.9, hr 58, bp 97/57, rr 13, and spo2 100% on ra. . on arrival to the floor is without complaint. . review of systems: denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, , constipation, melena, hematochezia, dysuria, hematuria. past medical history: --metabolic syndrome t2dm, obesity, gout --presumably nash cirrhosis, decompensated with ascites, jaundice social history: from republic, worked in construction and environmental cleanup (oil spills, asbestos), divorced with children, family in area, lives with two roomates. no smoking or drugs. last drink (socially) 3 years ago. has been taking "diclofenac" without prescription for years for knee pain and "fluid." took brazillian diet pills of unknown formulation. family history: liver cancer physical exam: discharge exam: vs -99.0, 84, 120/76, 18, 100 ra 137.4kg admission weight 120.1 kg discharge weight general - well-appearing in nad, comfortable, appropriate heent - nc/at, perrla, eomi, sclerae icteric, mmm, op clear neck - supple, no jvd, no carotid bruits lungs - cta bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use heart - pmi non-displaced, soft heart sounds rrr, no mrg, nl s1-s2 abdomen - + bs, soft, nt, nd, horizontal suprapubic incision partially dehisced in midline with 4x5cm opening covered in wet to dry dressing on discharge, otherwise c/d/i, staples removed, 3 old drain sites sutured, no ecchymosis, no swelling extremities - nonpitting bilateral le edema, 2+ peripheral pulses (radials, dps) pertinent results: admission labs: 04:35pm blood wbc-10.3 rbc-3.65* hgb-11.6* hct-32.0* mcv-88 mch-31.9 mchc-36.4* rdw-17.2* plt ct-65* 04:35pm blood neuts-66 bands-0 lymphs-22 monos-6 eos-6* baso-0 04:55pm blood pt-33.4* inr(pt)-3.2* 04:55pm blood totbili-23.4* 04:35pm blood lipase-79* 04:55pm blood albumin-2.6* 11:17pm blood osmolal-277 04:55pm blood ethanol-neg 04:48pm blood glucose-86 na-123* k-5.1 cl-95* calhco3-23 05:25am blood wbc-4.1 rbc-3.01* hgb-9.7* hct-26.6* mcv-88 mch-32.2* mchc-36.5* rdw-17.9* plt ct-58* 01:00pm blood hgb-10.0* hct-27.5* plt ct-51* 02:00pm blood hgb-8.9* hct-25.1* plt ct-58* 03:00pm blood hgb-9.7* hct-26.8* plt ct-75* 03:55pm blood hgb-9.1* hct-26.0* plt ct-64* 11:30pm blood wbc-3.4* rbc-3.54* hgb-10.7* hct-29.6* mcv-84 mch-30.4 mchc-36.3* rdw-16.1* plt ct-85* 06:12am blood wbc-4.7 rbc-3.19* hgb-10.0* hct-26.4* mcv-83 mch-31.3 mchc-37.8* rdw-16.5* plt ct-87* 11:31am blood wbc-5.8 rbc-3.47* hgb-10.7* hct-29.7* mcv-86 mch-30.8 mchc-36.1* rdw-16.1* plt ct-81* 07:32pm blood wbc-5.9 rbc-3.54* hgb-10.7* hct-30.4* mcv-86 mch-30.2 mchc-35.3* rdw-16.3* plt ct-89* 03:58am blood wbc-6.6 rbc-3.57* hgb-11.0* hct-30.5* mcv-85 mch-30.9 mchc-36.2* rdw-16.2* plt ct-76* 07:25pm blood wbc-5.4 rbc-3.70* hgb-11.0* hct-31.8* mcv-86 mch-29.7 mchc-34.5 rdw-16.1* plt ct-76* 02:01am blood wbc-14.6* rbc-4.21* hgb-12.7* hct-37.0* mcv-88 mch-30.2 mchc-34.4 rdw-15.8* plt ct-87* 01:08pm blood wbc-13.7* rbc-4.33* hgb-13.0* hct-38.0* mcv-88 mch-30.0 mchc-34.2 rdw-15.7* plt ct-72* 01:56am blood wbc-18.9* rbc-4.36* hgb-13.9* hct-37.5* mcv-86 mch-31.8 mchc-36.9* rdw-16.2* plt ct-57* 01:53pm blood wbc-34.1*# rbc-4.31* hgb-13.1* hct-37.7* mcv-87 mch-30.5 mchc-34.9 rdw-16.6* plt ct-81* 03:33pm blood wbc-46.5* rbc-4.32* hgb-12.8* hct-37.7* mcv-87 mch-29.7 mchc-34.0 rdw-17.4* plt ct-129* 03:17am blood wbc-44.8* rbc-4.25* hgb-13.0* hct-37.4* mcv-88 mch-30.7 mchc-34.9 rdw-17.5* plt ct-134* 02:57am blood wbc-16.1* rbc-3.13* hgb-9.7* hct-28.1* mcv-90 mch-31.0 mchc-34.4 rdw-17.7* plt ct-89* 01:54am blood wbc-18.7* rbc-3.38* hgb-10.4* hct-29.8* mcv-88 mch-30.8 mchc-34.9 rdw-17.0* plt ct-107* 06:15am blood wbc-7.9 rbc-3.07* hgb-9.2* hct-27.4* mcv-89 mch-30.0 mchc-33.6 rdw-16.7* plt ct-165 06:00am blood wbc-9.8 rbc-3.01* hgb-9.2* hct-26.8* mcv-89 mch-30.5 mchc-34.4 rdw-17.2* plt ct-167 07:30am blood wbc-14.2* rbc-2.77* hgb-8.4* hct-25.3* mcv-91 mch-30.2 mchc-33.0 rdw-15.6* plt ct-108* 06:52am blood wbc-17.9* rbc-2.67* hgb-8.2* hct-24.8* mcv-93 mch-30.8 mchc-33.1 rdw-15.8* plt ct-111* 05:45am blood plt ct-49* 06:30am blood pt-35.8* ptt-44.2* inr(pt)-3.5* 05:25am blood plt ct-58* 03:55pm blood plt ct-64* 07:45pm blood plt ct-99* 06:12am blood pt-19.2* ptt-29.5 inr(pt)-1.8* 09:02pm blood pt-20.7* ptt-28.0 inr(pt)-2.0* 11:31am blood pt-22.3* ptt-27.4 inr(pt)-2.1* 11:59am blood pt-23.6* ptt-29.8 inr(pt)-2.3* 01:54am blood pt-23.7* ptt-31.1 inr(pt)-2.3* 02:01am blood pt-20.6* ptt-31.3 inr(pt)-2.0* 01:53pm blood pt-24.4* ptt-51.4* inr(pt)-2.3* 03:08am blood pt-18.5* ptt-35.4 inr(pt)-1.7* 03:17am blood pt-17.6* ptt-33.5 inr(pt)-1.7* 03:08am blood pt-16.8* ptt-31.3 inr(pt)-1.6* 02:25pm blood pt-14.6* ptt-33.2 inr(pt)-1.4* 06:00am blood pt-13.3* ptt-27.3 inr(pt)-1.2* 05:58am blood pt-11.9 ptt-28.3 inr(pt)-1.1 03:25pm blood na-132* k-5.1 cl-96 06:30am blood glucose-76 urean-42* creat-1.9* na-131* k-4.8 cl-95* hco3-25 angap-16 07:30pm blood glucose-99 urean-45* creat-1.9* na-132* k-5.2* cl-98 hco3-25 angap-14 01:52pm blood glucose-137* urean-45* creat-2.4* na-143 k-5.5* cl-101 hco3-31 angap-17 07:32pm blood glucose-141* urean-67* creat-5.1*# na-141 k-5.2* cl-95* hco3-26 angap-25 01:54am blood glucose-235* urean-71* creat-3.9* na-136 k-4.3 cl-93* hco3-24 angap-23* 02:01am blood glucose-277* urean-73* creat-4.3* na-136 k-4.2 cl-94* hco3-25 angap-21 03:42pm blood urean-81* creat-3.1* na-135 k-3.8 cl-98 hco3-25 angap-16 01:53pm blood glucose-183* urean-85* creat-2.7* na-139 k-4.4 cl-101 hco3-22 angap-20 03:07am blood glucose-97 urean-100* creat-3.3* na-137 k-3.6 cl-100 hco3-23 angap-18 07:59pm blood glucose-165* urean-113* creat-3.6* na-140 k-4.1 cl-101 hco3-24 angap-19 10:05pm blood glucose-209* na-140 k-4.2 cl-100 hco3-23 angap-21* 03:17am blood glucose-94 urean-98* creat-3.3* na-142 k-3.9 cl-101 hco3-24 angap-21* 07:55pm blood glucose-162* urean-35* creat-2.1* na-138 k-4.3 cl-102 hco3-24 angap-16 03:08am blood glucose-172* urean-32* creat-1.8* na-138 k-4.5 cl-101 hco3-24 angap-18 02:57am blood glucose-205* urean-45* creat-3.3*# na-133 k-4.8 cl-99 hco3-21* angap-18 02:05am blood glucose-106* urean-38* creat-2.7* na-134 k-4.7 cl-101 hco3-21* angap-17 06:15am blood glucose-152* urean-39* creat-3.6* na-138 k-4.2 cl-98 hco3-28 angap-16 05:51am blood glucose-80 urean-50* creat-6.0*# na-131* k-5.1 cl-92* hco3-27 angap-17 06:15am blood glucose-65* urean-60* creat-7.0* na-129* k-5.8* cl-91* hco3-27 angap-17 05:35am blood glucose-62* urean-41* creat-6.2*# na-133 k-3.9 cl-94* hco3-32 angap-11 05:58am blood glucose-81 urean-25* creat-4.1*# na-132* k-4.5 cl-95* hco3-31 angap-11 07:30am blood glucose-115* urean-43* creat-5.6*# na-131* k-4.5 cl-92* hco3-33* angap-11 06:30am blood alt-76* ast-124* alkphos-138* totbili-32.4* 05:35am blood alt-69* ast-113* alkphos-126 totbili-31.3* 05:25am blood alt-69* ast-112* alkphos-123 totbili-33.4* 05:25am blood alt-63* ast-107* alkphos-113 totbili-33.2* 01:52pm blood alt-1387* ast-6610* ck(cpk)-2096* alkphos-59 totbili-19.4* dirbili-15.7* indbili-3.7 04:00am blood alt-1141* ast-3063* ck(cpk)-1776* alkphos-69 totbili-20.8* dirbili-19.0* indbili-1.8 11:31am blood alt-1083* ast-2558* alkphos-68 amylase-265* totbili-22.1* dirbili-15.6* indbili-6.5 01:08pm blood alt-445* ast-262* alkphos-125 totbili-17.7* 01:54am blood alt-355* ast-200* alkphos-129 totbili-16.0* 01:56am blood alt-223* ast-138* alkphos-132* totbili-21.1* 03:31am blood alt-222* ast-118* alkphos-159* totbili-26.5* 03:42am blood alt-151* ast-83* ld(ldh)-409* alkphos-193* totbili-27.0* 02:57am blood alt-117* ast-79* ld(ldh)-365* alkphos-245* totbili-26.1* 01:54am blood alt-114* ast-89* ld(ldh)-405* alkphos-331* totbili-26.4* 05:35am blood alt-158* ast-179* ld(ldh)-406* alkphos-484* totbili-27.8* 04:45am blood alt-160* ast-188* ld(ldh)-359* alkphos-478* totbili-26.2* 06:00am blood alt-205* ast-218* ld(ldh)-465* alkphos-413* totbili-16.6* 05:05am blood alt-164* ast-175* alkphos-388* totbili-10.1* 07:38am blood alt-152* ast-148* alkphos-355* totbili-9.8* 05:58am blood alt-143* ast-135* alkphos-392* totbili-8.3* 01:52pm blood albumin-3.4* calcium-12.0* phos-9.1*# mg-2.0 09:02pm blood albumin-3.4* calcium-12.0* phos-9.6* mg-2.0 04:00am blood albumin-3.6 calcium-11.2* phos-9.5* mg-2.1 01:53pm blood albumin-2.8* calcium-8.8 phos-4.7*# mg-1.8 03:07am blood albumin-2.6* calcium-8.2* phos-4.1 mg-2.0 03:17am blood albumin-2.9* calcium-8.3* phos-4.2 mg-2.1 03:33pm blood albumin-2.7* calcium-8.3* phos-5.3* mg-2.2 03:42am blood albumin-3.4* calcium-9.2 phos-1.9* mg-1.9 02:57am blood albumin-2.9* calcium-8.5 phos-2.1* mg-1.9 09:21am blood calcium-8.8 phos-1.8* mg-1.9 02:07am blood albumin-2.7* calcium-8.4 phos-2.1* mg-1.8 05:02am blood albumin-2.6* calcium-8.5 phos-4.4 mg-2.2 05:51am blood albumin-2.7* calcium-8.6 phos-6.6*# mg-2.3 06:15am blood albumin-2.6* calcium-8.5 phos-6.9* mg-2.3 06:00am blood albumin-2.6* calcium-8.3* phos-4.4# mg-2.1 05:58am blood albumin-2.8* calcium-8.7 phos-2.4* mg-2.1 05:55am blood tacrofk-7.0 06:05am blood tacrofk-11.2 04:51am blood tacrofk-21.1* 04:54am blood tacrofk-21.9* 05:47am blood tacrofk-8.7 05:54am blood tacrofk-15.7 05:54am blood tacrofk-15.7 06:06am blood tacrofk-15.1 05:50am blood tacrofk-9.9 04:19am blood tacrofk-6.7 06:00am blood tacrofk-6.5 06:03am blood tacrofk-6.2 06:10am blood tacrofk-6.9 04:45am blood tacrofk-11.3 06:15am blood tacrofk-12.9 05:35am blood tacrofk-11.5 06:15am blood tacrofk-10.6 06:00am blood tacrofk-9.5 07:16am blood tacrofk-8.8 05:20am blood tacrofk-7.8 05:35am blood tacrofk-7.1 05:05am blood tacrofk-8.6 05:05am blood tacrofk-8.6 05:58am blood tacrofk-6.7 imaging: ruq us 1. cirrhosis with splenomegaly and small volume of ascites. no pocket of ascites was deemed large enough to mark for bedside paracentesis. 2. persistently sludge-filled gallbladder with gallbladder wall thickening likely due to underlying cirrhosis. 3. patent hepatic vasculature. . renal us : the right kidney measures 11.9 cm. the left kidney measures 9.9 cm. no stones, masses, or hydronephrosis are identified in either kidney. partially imaged is known splenomegaly and a small amount of ascites in the pelvis. urinary bladder appears unremarkable . ct abdomen w/contrast 1. cirrhosis, splenomegaly, and varices. liver volumes will be generated separately by the advanced imaging lab. 2. pancreatic stent, with surrounding extraluminal air concerning for perforation. no biliary dilation or large fluid collections. . portable abdomen one of the two projections is seriously limited by respiratory motion artifact. at least two of the clips appear to remain at the post-operative site. however, one linear metallic particle, located approximately 2 to 3 cm caudal from the clips on yesterday's ct examination now projects over the right iliac bone. if the clinical symptoms persist, a repeat radiograph should be performed. there also is slightly increasing dilatation of small bowel loops in the mid abdomen. . colonoscopy friable and erythematous with superficial ulcerations in the splenic flexure, proximal transverse colon and distal ascending colon (biopsy) mosaic appearence in the cecum compatible with portal colopathy ulcers in the distal rectum grade 1 internal hemorrhoids diverticulosis of the sigmoid colon and descending colon no evidence of masses or polyps one (1) cord of non bleeding rectal varices was identified otherwise normal colonoscopy to cecum 1. follow up pathology results 2. resume diet as tolerated 3. follow up hepatology recs 4. repeat colonoscopy in 10 years . egd : varices at the lower third of the esophagus medium hiatal hernia no evidence of active bleeding, ulcers or masses mosaic appearance in the fundus and stomach body compatible with severe non bleeding portal gastropathy normal mucosa in the first part of the duodenum and second part of the duodenum no evidence of active bleeding, ulcers or varices otherwise normal egd to third part of the duodenum receipient liver biopsy: liver, native hepatectomy: 1. established cirrhosis with sinusoidal fibrosis, trichrome stain evaluated (stage 4 fibrosis). 2. mild steatosis with balloon cell degeneration and intracytoplasmic hyaline. 3. moderate septal and mild lobular mononuclear inflammation, see note. 4. rare foci of up to 1 mm of hepatocellular necrosis seen. 5. severe canalicular and hepatocellular cholestasis. 6. iron stain shows moderate iron deposition in hepatocytes and kupffer cells. 7. negative biliary and vascular margins. 8. gallbladder with marked autolytic changes. note: these findings are consistent with toxic/metabolic injury. in addition, the septal and lobular inflammation is prominent and shows a component of plasma cells. correlation to rule out a concomitant autoimmune or drug-induced injury is recommended. ruq us : impression: status post liver transplant. no focal fluid collections or ascites. patent hepatic artery, and portal and hepatic veins, demonstrating appropriate waveforms and flow directions. ruq us : impression: 1. patent hepatic vasculature. 2. coarsened heterogeneous hepatic architecture. 3. splenomegaly 4. mild ascites which is increased since the prior ultrasound of .. ruq us impression: 1. no biliary dilatation. 2. echogenic coarsened hepatic architecture again noted. 3. scant trace of ascites. 4. patent hepatic vasculature. 5. splenomegaly. ct torso: impression: 1. right lower lobe atelectasis. a component of consolidation cannot be ruled out. 2. narrowing of the inferior vena cava proximal to the anastomosis as described. 3. the hepatic artery is minimally narrowed at the anastomotic site. distal to the anastomosis, the hepatic arteries are diminutive. note is made of the fact that the phase of acquistion of the arterial images is suboptimal, which might contribute to these findings. if further evaluation is required, ultrasound can be considered. 4. multiloculated fluid collection posterior to the liver and to the inferior vena cava as described. note is made of the or report that stated surgicel was placed within this region, however, an abscess cannot be excluded. 5. small hematoma in pouch. no active extravasation. 6. splenomegaly and portosystemic shunts as described. 7. edematous pancreas with stranding of the peripancreatic fat may represent pancreatitis. viseral sel/supersel a-gram impression: successful uncomplicated celiac and hepatic angiograms in a transplant liver was performed, which did not show hepatic artery stenosis. liver biopsy: liver, allograft, needle core biopsy: 1. prominent parenchymal necrosis involving approximately 40% of the biopsy (confirmed with reticulin stain) with associated bile ductular proliferation with abundant mixed inflammation with prominent neutrophils. 2. moderate canalicular and hepatocellular cholestasis. 3. no features of acute cellular rejection are seen. 4. trichrome stain demonstrates no definite increase in fibrosis (stage 0). 5. iron stain shows mild, patchy iron deposition within kupffer cells and portal macrophages. 6. gms stain is negative for microorganisms. 7. immunoperoxidase stains for herpes simplex viruses 1 and 2 and cytomegalovirus are negative with satisfactory controls. 8. immunostain for - virus (to be completed at an outside laboratory) will be reported in an addendum. liver biopsy liver, allograft, needle core biopsy: 1.marked ballooning and focal feathery degeneration of hepatocytes with moderate to severe intrahepatocytic and canalicular cholestasis with focal bile plug formation. 2.aggregates of lobular lipofuscin-laden macrophages and hepatocyte regeneration, consistent with a component of ongoing injury and repair; see note. scattered lobular neutrophilic aggregates are identified. 3.prominent bile ductular proliferation with numerous associated neutrophils; see note. 4.no diagnostic involvement by acute cellular rejection identified; focal, mild portal lymphocytic inflammation with eosinophils present. 5.mild small and large droplet steatosis, involving less than 20% of the parenchyma. 6.cmv and hsv immunostains are in progress, along with iron and trichrome special stains; results will be reported in an addendum. ruq us impression: limited study due to patients body habitus and limited acoustic window due to overlying dressings. 1. echogenic coarsened hepatic echotexture consistent with patients history of cirrhosis. 2. patent hepatic vasculature. 3. moderate splenomegaly. renal us no hydronephrosis. cta abd improvement in diffuse narrowing of the hepatic arteries with mild residual narrowing extending from the anastomotic site to the branching of the right and left hepatic arteries. patent portal vein. 3d reformats are pending. kub mild ileus. no obstruction or large gastric air. . urinalysis: 04:55pm urine bnzodzp-neg barbitr-neg opiates-neg cocaine-neg amphetm-neg mthdone-neg marijua-negative 10:32pm urine osmolal-321 10:32pm urine hours-random urean-310 creat-68 na-59 k-37 cl-69 . paracentesis: 02:21pm ascites totpro-1.1 albumin-less than 02:21pm ascites wbc-110* rbc-50* polys-6* lymphs-42* monos-36* macroph-16* brief hospital course: hospital course pre-transplant: mr is a 45 year old male with a history of decompensated nash cirrhosis with ascites and jaundice. he was recently admitted to from to for evaluation of his end-stage liver disease presenting with ruq abdominal pain and . # abdominal pain: patient admitted with complaints of ruq pain x1 day. s/p ercp with pancreatic stent placement on last admission for similar symptoms but unable to cannulate cbd at that time. no fever or leukocytosis this admission to suggest infection. elevated lfts and t bili on admission were concerning for possible obstruction; ruq u/s neg for gallstone or thrombosis. pt was pain free upon transfer to the floor the morning of admission and lfts trending down at that time as well. considered possiblity of passed gallstone to explain transient pain and lft/bili elevation. also obtained u/s guided paracentesis to r/o sbp, ascites was negative for sbp. # ams: reported in ed but resolved upon transfer to floor overnight. no details provided on the way in which patient appeared confused, so unsure the extent of his symptoms at that time. etiology could have been mild encephalopathy hypovolemia, gastrointestinal bleeding, hypoglycemia ( to glipizide) or infection. ruq u/s neg for thrombosis. obtained para as above. adjusted ssi down; and continued lactulose and esld meds. # : baseline previously 1.1. 1.5 on admission, and labs c/w prerenal state. initially worsened after 1l ns in ed. received albumin, but continued to trend up to new baseline of 2.0. started octreotide, midodrine, and albumin for type ii hrs. # end stage liver disease: he was evaluated at for esld presumably from nash cirrhosis. biopsy results from at were consistent with this diagnosis. he was listed for transplant. his cirrhosis was decompensated with meld 39, up from 32 on discharge earlier in . continued nadolol 20 mg po daily, rifaximin 550 mg po bid, and omeprazole 20 mg po daily. lactulose was temporarily held due to lgib and . mental status remained clear. # diabetes: blood sugars were running low in house (<100). decreased ssi. holding glipizide, which patient said he has stopped taking at home due to low blood sugars at home as well. hospital course post transplant: the patient underwent an olt on . overall there were few complications and he ended up tolerating the procedure well. he did have intraop hypotension on phenylehrine with massive blood product transfusion (25 unit prbcs, 40 ffp and 11 platelets) with multiple ca chloride boluses. post-op, he went to the unit intubated. he was extubated on pod 6 sucessfuly. however, starting from pod 4 , he was intermittently spiking fevers to 102, tachypneic and tachycardic. he was taken back to the or on pod 10 for an ex-lap and was found to have an infected hematoma which was washed out. he tolerated the procedure well and was extubated the next day. he was transferred to the floor on pod 18/8. he was discharged on pod 34/24 after his insurance was activated and was accepted at a rehabiliation facility. neuro: post-operatively, the patient received iv morphine. when tolerating oral intake on pod 16/6, the patient was transitioned to oral pain medications. his mental status at first was very altered, not alert, not following commands but began to improve on pod . he slowly began to become more aware and oriented x3. cv: the patient was mostly stable from a cardiovascular standpoint; all instances of hypotension were resoloved with units of prbc's prn low hct and hypotension. vital signs were routinely monitored and he was on telemetry for most of his stay. pulmonary: the patient was mostly stable from a pulmonary standpoint; it took 6 days for him to be extubated after the transplant due to poor mental status but after that his pulmonary function was stable. he received albuterol nebs prn weezing. vital signs were routinely monitored and he was on telemetry for most of his stay. gi/gu: on pod 2, the patient was started on tpn. tube feeding was first started on pod 5 and finally advanced to goal on pod 15/5. tpn was discontinued on pod 6. he was first advanced to a regular diet on pod and slowly began tolerating them. his tube feeds were being cycled from pod 13/3 to allow for more eating during the day which was well tolerated. he was also started on a bowel regimen to encourage bowel movement. foley was removed on pod 20/10. he received intermitted dialysis prn as per the nephrology team. on he underwent an ercp for persisitently elevated alk phos levels and had a sphincerotomy and stent placement for cbd dliatation and obstruction. ursodiol was started the next day. he had several days of ileus around pod 26/16 which was resolved with an agressive bowel regimen. later on in his post operative course he began complaining of nausea and decreased appetite he felt was related to the tube feeds and the feelings resolved after the tube feeds were temporarily stopped. his tube feeds were then adjusted to be continous at a slower rate. all jp drains were removed prior to discharge. intake and output were closely monitored. id: before the second procedure, he was placed on prophylactic daptomycin, cefepime and flagyl. these were stopped on pod 17/7. he was also placed on the usual post transplant antibiotics: valcyte, micafungin and bactrim. the micafungin was switched to fluconazole on pod 18/8. the patient's temperature was closely watched for signs of infection and after his ex lap/washout procedure he remained afebrile for the rest of his hospital course. the middle portion of his wound did dehisce around pod 18/8 and a wound vac was placed and changed every 3 days. on discharge it was granulating in nicely and there was no purulent drainage or cellulitis. heme: he was transfused as necessary based on hematocrit and hemodynamic stability. overall, the pt received 40 u prbcs, 62 u ffps, 21 u plts, 16 u cryo and 15 vials of albumin. he will be getting epogen with every dialysis treatment. : he received routine immunosuppression at time of transplant to include solumedrol with taper to prednisone and mycophenylate. prograf was started on the evening of pod 1, levels were followed throughout the hospitalization, and dose adjusted accordingly. prophylaxis: the patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. at the time of discharge on pod#34/24, the patient was doing well, a+o x3, afebrile with stable vital signs, tolerating a regular diet and tube feeds, ambulating, having bowel movements, and pain was well controlled. he is to be discharged to rehab for further strengthening,nutrition management, vac management, and medication teaching. medications on admission: nadolol 20 mg po daily rifaximin 550 mg po bid lactulose (10 gram/15 ml) 30 ml po bid prilosec otc 20 mg po daily multivitamin 1 tab po daily discharge medications: 1. multivitamin tablet sig: one (1) tablet po daily (daily). 2. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 3. heparin (porcine) 5,000 unit/ml solution sig: 5000 (5000) units injection tid (3 times a day). 4. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) as needed for rash. 5. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: neb inhalation q6h (every 6 hours) as needed for wheeze. 6. morphine 15 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain: pls hold for sedation and/or rr<12. 7. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po bid (2 times a day). 9. valganciclovir 450 mg tablet sig: one (1) tablet po 2x/week (,th). 10. ursodiol 300 mg capsule sig: two (2) capsule po tid (3 times a day). 11. insulin glargine 100 unit/ml cartridge sig: twenty (20) units subcutaneous once a day: at lunch. 12. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po qid (4 times a day). 13. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day). 15. prednisone 5 mg tablet sig: three (3) tablet po daily (daily) for 7 days: today is pod 34. decrease prednisone by 2.5 mg on pod 40 and then decrease by 2.5 mg every 10 days until pod 90. 16. polyethylene glycol 3350 17 gram/dose powder sig: one (1) po daily (daily). 17. zofran 4 mg tablet sig: one (1) tablet po every 6-8 hours as needed for nausea. 18. tacrolimus 1 mg capsule sig: three (3) capsule po q12h (every 12 hours): titrate to level of . 19. outpatient lab work please check the following every monday and thursday and fax to : cbc, chem 10, ast, alt, alk phos, albumin, t.bili, profraf level discharge disposition: extended care facility: - - discharge diagnosis: - acute renal failure - nash cirrhosis complicated by ascites and jaundice- esld discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to for abdominal pain, liver failure and worsening renal function. you were diagnosed with end stage liver disease and underwent a liver transplant on . 10 days later you went back to the operating room to clean out an infected hematoma. after a lengthy hospital stay you are well enough to continue your recovery in a rehabilitation facility with the following instructions: -you will continue dialysis every monday, wednesday and friday -labs will be drawn every monday and thursday for transplant monitoring -abdominal wound vac should be changed every 3 days -continue tube feeds -no heavy lifting -please do not adjust medications without consulting with the transplant clinic please call your doctor or go to the emergency department if: *you experience new chest pain, pressure, squeezing or tightness. *you develop new or worsening cough, shortness of breath, or wheeze. *you are and cannot keep down fluids or your medications. *you are getting dehydrated due to continued , , or other reasons. signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *you see blood or dark/black material when you vomit or have a bowel movement. *you experience burning when you urinate, have blood in your urine, or experience an unusual discharge. *your pain is not improving within 12 hours or is not under control within 24 hours. *your pain worsens or changes location. *you have shaking chills, or fever greater than 101.5 degrees fahrenheit or 38 degrees celsius. *you develop any concerning symptoms. general discharge instructions: please resume all regular home medications, unless specifically advised not to take a particular medication. please take any new medications as prescribed. please take the prescribed analgesic medications as needed. you may not drive or heavy machinery while taking narcotic analgesic medications. you may also take acetaminophen (tylenol) as directed, but do not exceed mg in one day. please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. please also follow-up with your primary care physician. incision care: *please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *avoid swimming and baths until cleared by your surgeon. *you may shower and wash incisions with a mild soap and warm water. gently pat the area dry. *you have steri-strips and they will fall off on their own. please remove any remaining strips 7-10 days from today. what to watch out for when you have a dobhoff feeding tube: 1. blocked tube: if the tube won't flush, try using 15 ml carbonated cola or warm water. if it still will not flush, call your nurse or doctor. always be sure to flush the tube with at least 60 ml water after giving medicine or feedings. 2.: *call your doctor persists. causes the loss of body fluids, salts and nutrients. *give the feeding in an upright position. *try smaller, more frequent feedings. be sure the total amount for the day is the same though. *infection may cause . clean and rinse equipment well between feedings. *do not let formula in the feeding bag hang longer than 6 hours unrefrigerated. after the formula can is opened, it should be stored in refrigerator until used. 3. : *this is frequent loose, watery stools. *can be caused by: giving too much feeding at once or running it too quickly, decreased fiber in diet, impacted stool or infection. some medicines also cause . *avoid hanging formula for longer than 6 hours. *give more water after each feeding to replace water lost in . *call doctor does not stop after 2-3 days. 4. dehydration: *due to , , fever, sweating. (loss of water and fluids.) *signs include: decreased or concentrated (dark) urine, crying with no tears, dry skin, fatigue, irritability, dizziness, dry mouth, weight loss, or headache. *give more water after each feeding to replace the water lost. *call your doctor. 5. constipation: * be caused by too little fiber in diet, not enough water or side effects of some medicines. *take extra fruit juice or water between feedings. *if constipation becomes chronic, call the doctor. 6. gas, bloating or cramping: be sure there is no air in the tubing before attaching the feeding tube. 7.tube is out of place: if the tube is no longer in your stomach, tape it down and call your doctor or home health nurse. do not use the tube. you will need to have a new tube placed. followup instructions: provider: , md, phd: date/time: 2:20 provider: , phone: date/time: 2:30 provider: , md, phd: date/time: 3:20 md, procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances other endoscopy of small intestine insertion of endotracheal tube hemodialysis closed (percutaneous) [needle] biopsy of liver closed (percutaneous) [needle] biopsy of liver venous catheterization for renal dialysis percutaneous abdominal drainage endoscopic sphincterotomy and papillotomy endoscopic insertion of stent (tube) into bile duct other transplant of liver arteriography of other intra-abdominal arteries reopening of recent laparotomy site closed [endoscopic] biopsy of large intestine peritoneal lavage open biopsy of liver other operations on lacrimal gland transplant from cadaver diagnostic ultrasound of abdomen and retroperitoneum transjugular liver biopsy diagnoses: pneumonia, organism unspecified other iatrogenic hypotension acute kidney failure with lesion of tubular necrosis other postoperative infection cirrhosis of liver without mention of alcohol acute posthemorrhagic anemia diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled acute and subacute necrosis of liver hepatorenal syndrome hyposmolality and/or hyponatremia portal hypertension hematoma complicating a procedure sepsis long-term (current) use of insulin other complications due to other vascular device, implant, and graft morbid obesity paralytic ileus other sequelae of chronic liver disease other septicemia due to gram-negative organisms other ascites awaiting organ transplant status hypovolemia esophageal varices in diseases classified elsewhere, without mention of bleeding other specified disorders of stomach and duodenum internal hemorrhoids with other complication obstruction of bile duct other and unspecified coagulation defects hepatitis, unspecified diverticulosis of colon (without mention of hemorrhage) other chronic nonalcoholic liver disease disruption of external operation (surgical) wound jaundice, unspecified, not of newborn dysmetabolic syndrome x body mass index 50.0-59.9, adult acute venous embolism and thrombosis of internal jugular veins chronic congestive splenomegaly personal history of allergy to penicillin disorders of copper metabolism other digestive system complications 

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