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: heparin agents attending: chief complaint: weakness major surgical or invasive procedure: resection of c5-c6 intradural mass along with laminectomy history of present illness: 71m with a history of melanoma, s/p wide local excision and sentinel ln bx in for 0.8 mm thick, level iv melanoma located in the r-posterior auricular area admitted with new metastitic melanoma. in , sentinel ln bx showed melanoma so pt underwent a complete node dissection with no residual melanoma documented in the remaining nodes. he did well until when a second melanoma, 1.3 mm thick, level iv was found in the r-submental area. pt underwent a wide local excision and sentinel ln bx with the sentinel ln w/o evidence of melanoma. pt then did well until approximately 6 weeks ago. at that time, he noted increased neck pain and pain in his upper and lower extremities. the pt saw his pcp at that time who treated him with nsaids and muscle relaxants. however, four weeks ago, the pt noted two small moles on the right side of his scalp. he saw his dermatologist who did punch biopsies consistent with melanoma. at that time, the pt contact his oncologist and was referred to dr. at for further care. the plan was for the pt to come to this week for mri and pet scan. however, last thursday, the pt developed sudden onset weakness of his lower extremities resulting in a fall. the pt reports that the strength in his le returned and he was able to walk normally over the weekend. however, on monday, his le once again felt very weak and he had trouble walking and a repeat fall. at that time, he called dr. and was advised to come in for evaluation. pt attempted to come to but no beds were available so he went to hospital for further care. at the osh, he received a mri of the cervical spine on that showed an enhancing, likely malignant extradural lesion at the level of mid c5 to mid c6 displacing the sac and cord posteriorly. this was felt to be consistent with metastitic disease. screening sagittal views of the spine demonstrated no other abnormalities. pt also underwent a mri of the brain that showed diffuse age related changes but no evidence of malignancy. at the osh, the pt was placed on emperic decadron 10 mg iv loading dose followed by 4 mg iv q6h. this was continued following the mri findings. pt was also given morphine for pain. he is now transferred to for further oncologic and neurosurgical care. in further ros, pt denies fevers and chills. he reports that he has chronic, intermittent headaches that are unchanged. no cp or palpitations. no sob. pt has a mild cough lately that is rarely productive of a small amount of sputum. no abdominal pain, nausea, or vomiting. good appetite. pt suffers from occasional constipation but has moved his bowels in the last couple of days. no dysuria or hematuria. past medical history: 1. melanoma: as above; initial diagnosis in , 2nd lesion in , 3rd ; never had staging ct 2. cervical djd 3. htn treated with norvasc and hytrin 4. osteoporosis tx w/fosamax 5. hyperactive bladder tx w/detrol 6. bph social history: pt is married and lives with his wife in . he is a retired investment banker. no etoh, tobacco, or drug use. family history: brother who is alive and well. no history of melanoma or cancers physical exam: pe: vs: 97.9 150/80 72 20 96% ra gen: pleasant man resting in bed. nad. heent: nc at. perrl. eomi. anicteric sclera. mmm. no lesions in the oropharynx. neck- supple. scar on right from previous melenoma and lymph node disection. no cervical or supraclavicular lypmhadenopathy. lungs: ctab. no wheezes, rales, or rhonchi. cv: distant heart sounds. rrr. no m,r,g. abd: obese. soft. mildly distended (pt reports is baseline). nt. positive bowel sounds. no appreciable organomegaly. guiac negative. extr: no c/c/e. 1+ dp pulses bilaterally. neuro: alert and oriented x3. cn ii-xii intact. 4/5 strength right upper extremity. 5/5 strength left upper extremity. strength right lower extremity. 4/5 strength left lower extremity. normal rectal tone. pertinent results: labs on admission: 135 / 101 / 20 131 ------------< 131 4.2 / 28 / 0.7 ca: 8.8 mg: 2.1 p: 2.9 alt: 17 ap: 48 tbili: 0.3 alb: 4.0 ast: 13 ldh: 201 mcv= 88 wbc=15.0 hgb=14.8 plt=304 hct=43.2 pt: 13.1 ptt: 22.1 inr: 1.1 discharge labs: 06:58am blood wbc-8.2 rbc-3.97* hgb-11.6* hct-34.0* mcv-86 mch-29.3 mchc-34.2 rdw-16.4* plt ct-326 06:58am blood plt ct-326 04:53am blood glucose-93 urean-19 creat-0.4* na-139 k-3.9 cl-102 hco3-31* angap-10 cardiac enzymes: 01:30am blood ck-mb-5 ctropnt-<0.01 05:29pm blood ck-mb-5 ctropnt-<0.01 08:37am blood ck-mb-7 ctropnt-<0.01 ct chest, abd, pelvis: ct of the chest with iv contrast: small axillary lymph nodes, but none of them meet ct criteria for pathology. the largest one on the right side measures 5 mm and the largest one on the left side measures 6 mm. there are 2 enlarged mediastinal lymphnodes. the largest one is located on series 3 image 18, and measures 1.7 mm in the precarinal region. the other one is pretracheal and measures 1.4 cm.there are no significant hilar lymph nodes. the heart and great vessels are unremarkable. there is a subcutaneous soft tissue density seen on series 3 image 9 that measures 7 mm in the anterior chest wall. in the setting of melanoma, this could represent metastasis. innumerable lung nodules consistent with metastasis. the largest one in the right upper lobe measures 1.4 x 1.4 cm. there are no pleural effusions and no evidence of pneumothorax. ct of the abdomen without and with iv contrast: there is a hypodense lesion in the segment 7 of the right lobe of the liver that measures 2.7 x 2.1 cm and could represent a liver metastasis. there are also 2 possible faint lesions in the left lobe of the liver. one of them is in the segment 2 of the liver just on the left side of the falciform that is too small to characterize. there is right adrenal nodule that measures 2.0 x 1.4 cm. it measures 50 hounsfield units in the noncontrast images and could represent metastasis, but is not well characterized in this study. there is a nodule (series 3 image 48) in the paraspinal region that may represent metastasis. just above it (series 2 image 44), there is a increased density adjacent to the diaphragm. that could represent a small pleural effusion or less likely could represent metastatic disease. the kidneys and left adrenal gland are unremarkable. the pancreas is unremarkable. the ureters are unremarkable. the small and large bowel appears unremarkable. in the abdomen, there is a lymph node in the left paracolic gutter (series 4 image 46) that measures 8 mm and is of a normal significance. it could represent a small lymph node or metastatic disease. in the right lower quadrant just below the right kidney, there is another nodule that measures 7 mm (series 4 image 48). there is also a lymph node. multiple other small mesenteric lymp nodes are seen, but none of them meet ct criteria for pathology. ct of the pelvis with oral and iv contrast: the urinary bladder, distal ureters, prostate, and seminal vesicles are unremarkable. the rectum and intrapelvic bowel loops are unremarkable. there are small mid iliac lymph nodes that do not meet ct criteria for pathology. the largest one located in the right side (series 4 image 63) measures 8 mm and contains a fatty hilum. small inguinal lymph nodes do not meet ct criteria for pathology. the largest one is located on the right inguinal region and measures 8 mm. bone windows: no obvious destructive lesions seen. impression: 1) innumerable pulmonary nodules consistent with metastasis. 2) enlarged mediastinal lymph nodes could represent metastasis. 3) soft tissue subcutaneous lesion in the subcutaneous tissue of the anterior chest wall, may represent metastasis. 4) hypodense lesion in the right lobe of the liver is suspicious for metastasis. 5) paraspinal lymph node on the right side is suspicious for metastasis. 6) right adrenal nodule not well characterized in this study, may represent metastasis. 7) multiple mesenteric small abdominal lymph nodes. mri cervical spine: ct of the chest with iv contrast: small axillary lymph nodes, but none of them meet ct criteria for pathology. the largest one on the right side measures 5 mm and the largest one on the left side measures 6 mm. there are 2 enlarged mediastinal lymphnodes. the largest one is located on series 3 image 18, and measures 1.7 mm in the precarinal region. the other one is pretracheal and measures 1.4 cm.there are no significant hilar lymph nodes. the heart and great vessels are unremarkable. there is a subcutaneous soft tissue density seen on series 3 image 9 that measures 7 mm in the anterior chest wall. in the setting of melanoma, this could represent metastasis. innumerable lung nodules consistent with metastasis. the largest one in the right upper lobe measures 1.4 x 1.4 cm. there are no pleural effusions and no evidence of pneumothorax. ct of the abdomen without and with iv contrast: there is a hypodense lesion in the segment 7 of the right lobe of the liver that measures 2.7 x 2.1 cm and could represent a liver metastasis. there are also 2 possible faint lesions in the left lobe of the liver. one of them is in the segment 2 of the liver just on the left side of the falciform that is too small to characterize. there is right adrenal nodule that measures 2.0 x 1.4 cm. it measures 50 hounsfield units in the noncontrast images and could represent metastasis, but is not well characterized in this study. there is a nodule (series 3 image 48) in the paraspinal region that may represent metastasis. just above it (series 2 image 44), there is a increased density adjacent to the diaphragm. that could represent a small pleural effusion or less likely could represent metastatic disease. the kidneys and left adrenal gland are unremarkable. the pancreas is unremarkable. the ureters are unremarkable. the small and large bowel appears unremarkable. in the abdomen, there is a lymph node in the left paracolic gutter (series 4 image 46) that measures 8 mm and is of a normal significance. it could represent a small lymph node or metastatic disease. in the right lower quadrant just below the right kidney, there is another nodule that measures 7 mm (series 4 image 48). there is also a lymph node. multiple other small mesenteric lymp nodes are seen, but none of them meet ct criteria for pathology. ct of the pelvis with oral and iv contrast: the urinary bladder, distal ureters, prostate, and seminal vesicles are unremarkable. the rectum and intrapelvic bowel loops are unremarkable. there are small mid iliac lymph nodes that do not meet ct criteria for pathology. the largest one located in the right side (series 4 image 63) measures 8 mm and contains a fatty hilum. small inguinal lymph nodes do not meet ct criteria for pathology. the largest one is located on the right inguinal region and measures 8 mm. bone windows: no obvious destructive lesions seen. impression: 1) innumerable pulmonary nodules consistent with metastasis. 2) enlarged mediastinal lymph nodes could represent metastasis. 3) soft tissue subcutaneous lesion in the subcutaneous tissue of the anterior chest wall, may represent metastasis. 4) hypodense lesion in the right lobe of the liver is suspicious for metastasis. 5) paraspinal lymph node on the right side is suspicious for metastasis. 6) right adrenal nodule not well characterized in this study, may represent metastasis. 7) multiple mesenteric small abdominal lymph nodes. head mri: exam: mri of the brain. clinical information: the patient with melanoma and postoperative confusion. technique: t1 sagittal and flair, t2 susceptibility, and diffusion axial images of the brain were obtained. findings: there is no evidence of acute infarct seen on diffusion-weighted images. severe brain atrophy is identified. there is evidence of blood products in the posterior portion of both lateral ventricles with fluid-fluid levels. additionally, air is seen in both lateral ventricles and also in the frontal region, which could be secondary to recent surgery. small amount of blood is also seen in the posterior fossa involving the subarachnoid space. there is no evidence of midline shift seen. moderate ventricular prominence is visualized. there is no periventricular edema seen. impression: blood products are seen within the ventricles and subarachnoid space, which could be postoperative in nature. small amount of air is seen in the lateral ventricle and frontal subarachnoid space, which could be also postoperative in nature. no acute infarct is seen. head ct: comparison: mri performed 3 hours prior. findings: as described in the recent mri, there is a small amount of layering hemorrhage within the lateral ventricles. in addition, punctate foci of subarachnoid hemorrhage are visualized within both temporoparietal regions. small foci of gas are visualized in the frontal regions as well as lateral ventricles. there is no hydrocephalus, mass effect, or shift of the normally midline structures. visualized osseous structures and paranasal sinuses are unremarkable. impression: small amount of intraventricular and subarachnoid hemorrhage as above. additional foci of gas within the lateral ventricles and frontal regions. these findings may be postoperative in nature. these results were conveyed to the neurosurgical house staff covering for the patient. cta chest: ct chest with intravenous contrast: the pulmonary arterial vasculature is well visualized down to the segmental branches. no definite filling defects are identified. the heart, pericardium and great vessels are visualized within normal limits. there has been interval development of small bilateral pleural effusions. no pericardial effusion is identified. again identified are multiple enlarged mediastinal lymph nodes, the largest located within the pretracheal region measuring 15 mm. there has also been interval development of a large prevascular lymph node, which measures 10mm. no pathologically enlarged axillary or hilar lymph nodes are seen. there has been interval development of bibasilar collapse/consolidation. additionally seen are multiple small bilateral pulmonary nodules, which are not significantly changed since the prior examination, consistent with metastatic disease. the airways are patent to the level of the segmental bronchi bilaterally. an endotracheal tube is seen, with tip in appropriate location in the trachea. in the imaged portion of the upper abdomen, again demonstrated is a hypodense lesion within the right lobe of the liver, not significantly changed since the prior examination. the visualized spleen and stomach appear unremarkable. bone windows: no suspicious lytic or sclerotic lesions are present. ct reconstructions: coronal and sagittal reconstructions were essential in delineating the pulmonary arterial vasculature. impression: 1) no definite ct evidence for pulmonary embolism. 2) interval development of bibasilar consolidation/collapse with small bilateral pleural effusions. 3) interval increase in size and number of mesenteric lymph nodes. relatively stable appearnace of multiple small pulmonary nodules consistent with metastatic disease. 4) stable appearance of hypodensity within the right lobe of the liver suspicious for a metastasis mri c-spine: procedure: an mri of the cervical spine with and without contrast. indication: spinal canal lesion status post excision. comparison: comparison is made to previous examination of . technique: sagittal and axial t1 and t2, as well as post-gadolinium, t1 axial and sagittal images of the cervical spine were performed. mri of the cervical spine with and without contrast: there has been interval resection of the previously described intradural extramedullary lesion at the c5-c6 level. the patient is status post c4 through c6 posterior laminectomy. on the current study, central increased signal intensity is identified within the spinal cord at the site of prior resection at the c5-c6 level. this was appreciated on the prior exam, but due to severe compression on that examination, it is difficult to appreciate whether this amount of edema has increased. post-surgical changes are noted in the area of prior laminectomy. no cord compression is appreciated on the current exam. there is a small amount of linear enhancement seen along the anterior margin of the spinal cord at the resection site, which may indicate post- surgical change but residual tumor cannot be excluded at this site. vertebral body alignment and signal intensity is normal. no prevertebral soft tissue abnormality is seen. impression: 1. status post excision of intradural, extramedullary mass at the c5-c6 level with decompression of the spinal canal. 2. spinal cord edema at the level of resection, seen on previous exam but unclear whether increased as the spinal cord had been severely compressed. 3. small amount of linear enhancement along the anterior portion of the cord at the resection site. this could indicate post-surgical change but the possibility of residual tumor cannot be excluded. head ct: technique: noncontrast head ct. findings: there is a stable amount of high attenuation layering fluid in the lateral ventricles consistent with hemorrhage. the previously noted punctate foci of increased attenuation within both temporoparietal lobes has decreased, consistent with resolving subarachnoid hemorrhage. there are no new areas to indicate intra- or extra-axial hemorrhage. there is no shift of midline structures. the -white matter differentiation remains intact. the ventricles are overall stable in size. previously described pneumocephalus has resolved. new from the prior study, is opacification of the ethmoid air cells, maxillary sinuses, and sphenoid sinus. this may be related to the interval intubation. impression: stable small amount of intraventricular hemorrhage with decreased subarachnoid hemorrhage and resolution of pneumocephalus. sinus opacification likely related to intubation. head ct: indication: patient with recent removal of intradural extramedullary lesion in cervical spine, post-operative subarachnoid hemorrhage. follow up, and query hydrocephalus. comparison: head ct . findings: again, noted is small amount of layering high-density fluid within the lateral ventricles, which is slightly decreased. the ventricles and sulci remain stable in size. no regions of intracranial hemorrhage are seen. there is no shift of normally midline structures, and the / white matter differentiation is unchanged. opacification in the ethmoid, sphenoid, and maxillary sinuses is essentially unchanged. osseous structures are unremarkable. impression: no significant interval change. head ct: indication: 71-year-old man with known metastatic melanoma status post spinal surgery, now with acute mental status changes, nonverbal. technique: noncontrast enhanced ct scan. findings: the study is being compared to prior examination dated . no significant changes are seen compared to prior examination. please refer to prior report for complete detail of findings. no change in the amount of intraventricular hemorrhage is noted. impression: no significant interval change compared to prior exam dated , . mri t and l spine: indication: a 71-year-old man with metastatic melanoma, recent resection of cervical spine intradural mass, now with possible incontinence. technique: multiplanar t1, t2, inversion recovery images of the thoracic spine; multiplanar t1, t2, and inversion recovery images of the lumbar spine. comparison: none. thoracic spine mri: there is kyphosis of the midthoracic spine, however, vertebral body signal is within normal limits. no abnormal signal is detected within the spinal cord. there is no expansion of the cord or spinal stenosis. there is mild right pleural thickening. lumbar spine mri: vertebral body alignment and signal is within normal limits. the distal spinal cord, and conus medullaris also have normal signal characteristics. the cauda equina roots are aggregated and anteriorly displaced; additionally, there is a region of abnormal signal within the spinal canal at the s2-s3 level. impression: 1. thoracic spine mri: no cord compression seen. 2. lumbar spine mri: abnormal signal within the most distal portion of the spinal canal, with aggregation and displacement of the cauda equina roots. this is concerning for arachnoiditis; the focus of abnormal signal in the distal spinal cord can represent a drop metastasis. clinical correlation is requested. : lp positive for malignant cells-melanoma brief hospital course: mr. is a 71 year-old man with past medical history significant for melanoma (3 separate lesions) s/p wide local excision who presented on this admission with recurrent melanoma and a probable met from mid c5 to c6 displacing sac and cord posteriorly. the patient was initially admitted to the omed service and then transferred to the neurosurgical service for resection of intradural c5-c6 mass. after resection, patient developed respiratory distress secondary to pneumonia requiring intubation and was transferred to the micu. patient then transferred to the medical floor. this discharge summary is a reconstruction from the medical record of the hospital course during the neurosurgical and icu stays since discharge summaries were not dictated by those services. omed course dictated and included here (only first 2 days of course.) course after known first-hand to this writer. admitted to omed on , transferred to neurosurgery on . transferred to micu on for respiratory distress secondary to pneumonia, intubated. extubated on . to floor on . 1. spinal lesion at c5-6 w/cord displacement: felt to be most consistent with metastasis of the pt's recurrent melanoma. neurosurgery was contact upon admission. the decision was made not to take patient to emergent neurosurgery given his dismal prognosis and extensive metastatic disease. radiation onocology was contact to evaluate if radiation therapy would be appropriate but felt that their role was limited and that neurosurgical option was preferrable. decision with respect to treatment options was made with primary oncologist, neurosurgery, and radiation oncology. patient reported few week history of severe right-sided weakness associated with mild left-sided weakness. this progressed to the point that his right lower extremity was paretic, and the motor strength of his right upper extremity was anywherebetween 2-4/5. metastatic disease/melanoma was identified onct of the chest, abdomen and pelvis, and a lesion on the mriof his cervical spine which seemed to be extramedullary but intradural. after extensive discussion, including the prognosis, neurosurgery decided to proceed with debulking of the tumor. following that, the risks and the benefits, especially thechance of being paralyzed were discussed, and the patientwanted to proceed. posterior cervical laminectomy, c4, c5, c6, resection of extramedullary intradural spinal cord tumor was performed. surgery was successful without significant complications. patient was started on decadron on admission and it was continued throughout hospital course. pathology returned consistent with metastasis of melanoma. patient noted on subsequent head ct's to have blood in ventricles which as per neurosurgical service was to be expected post-operatively. patient was closely monitored for neuro changes and evidence of hydrocephalus. repeat head ct's did not demonstrate evidence of hydrocephalus and serial neuro exams were unchanged. post surgery, patient's admission complaint of right-sided weakness mildly improved and remained stable. some left sided weakness as well. 2. metastatic melanoma: he has had 3 separate melanoma lesions which have been excised (most recently 6 weeks ago). staging ct on admission showed extensive metastatic disease throughout chest and abdomen. resection of intradural extramedullary met as above. patient maintained on decadron throughout hospital course. on question of possible bowel/bladder incontinenece. mri of l and t spine obtained on and demonstrated drop mets in cauda equina. lp on returned positive cytology for melanoma. given leptomeningeal involvement, extensive mets, patient's prognosis poor, likely a few months. dr. , oncologist, covering for dr. , was made aware of new cns findings and treatment options were re-considered. at this time, no good treatment options available and prognosis grim. future plan is to have patient complete rehab course. at that time, if patient regains sufficient strength, radiation and potential chemotherapy will be considered. thus will need to routinely assess patient's progress at rehab and re-address treatment options as well as possible hospice if patient not improving at rehab/re-gaining strength. rad-onc and dr. of oncology aware. it is very unlikely that there are treatment options from here, but dr. should be contact to update progress. as noted above, patient followed with daily neuro exams which did not significantly change while the patient was on the medical service. he continues to have right-sided weakness which is slightly improved post surgery. steroids should be tapered by 1 gram per dose per week. 3. respiratory failure: after resection of intradural mass, patient developed respiratory distress on requiring intubation and transfer to medical icu. after extensive work-up including infecious, negative cta for pe, ultimately felt to be due to pneumonia, most likely aspiration. the patient had self-d/ced his ngtube while getting tubefeeds. the patient was extubated on . he was treated with 14 day course of vancomycin and zosyn. patient was gradually weaned from supplemental oxygen and by was satting well on room air. he was largely asymptomatic, exam was much improved and repeat chest x-rays demonstrated resolution of pneumonia. 4. htn: pt was mildly hypertensive on admission. norvasc was initially continued in-house. post operatively while on neurosurgical and micu services, patient's blood pressure became difficult to control. incrementally, medications were added. ultimately, the patient required norvasc, metoprolol, captopril and hydralazine to effectively control pressures. captopril switched to lisinopril on . patient's blood pressure becoming more labile over . some blood pressure meds have been held by parameters but continuing on current regimen. 5. mental status: patient's mental status waxed and waned throughout hospital course. post-operatively and in micu s/p extubation the patient's orientation varied. he was often confused and demonstrated varying levels of delirium. altered mental status attributed to sedating meds, pneumonia, long hospital course and metastatic melanoma. additionally, developed hyponatremia secondary to siadh. narcotics and sedating meds were limited, hyponatremia, pneumonia were treated. neurology was consulted on and followed patient until . on patient was found to be more confused, lethargic and there was concern for acute event. patient had extensive work-up at that time including repeat head ct, lp, ekg, abg, toxic-metabolic work-up which revealed no significant new cause of altered mental status. gradually over the course of and the patient's mental status returned to previous baseline. ceftazidime was given for 2 days around this period after lp returned large number of white cells with lymphocytic predominance. patien already on vanc/zosyn at that time, but ceftaz started given good bbb penetration. ultimately, however, in consultation with neurology and neurosurgery, determination was made that given patient afebrile with no new significant signs or symptoms, infectious meningitis was not likely. white cells consistent with inflammation from surgery. large number of red cells also consistent with prior surgery and blood in ventricles from surgery. gradually patient's mental status improved and by patient was less confused and more consistently oriented. he did continue to have some confusion, but his delirium was improving. narcotics continue to be limited, patient requires occasional re-orientation. demonstrates some delirium but is generally oriented, re-directable and logical in thought process. of note, hsv from lp still pending at time of discharge. 6.hyponatremia: patient developed hyponatremia secondary to siadh. resolved with fluid restriction by . as above, felt to be contributory to altered mental status. 7. hyperactive bladder-detrol was initially continued, but then stopped. pai 8. bph: hytrin was continued in-house. 9. thrombocytopenia: during the patient's micu course, noted to be thrombocytopenic. had been on heparin flushes. thought to be secondary to hit, although hit antibody negative x 2. serotonin assay sent and pending at this time. all heparin products were stopped. thrombocytopenia resolved from that time. by discharge platelets stable in 300,000's. no significant bleeding complications. no heparin products. 10. goals of care: multiple meetings with patient, wife, health care team held to determine goals of care. patient has expressed desires to minimize treatments and maximize palliative efforts. given his continued delirious state, however, wife's input as spouse and health care proxy is also determinant of future care. at this point, mutual agreement has been made to pursue rehabilitation and then re-assess goals of care and treatment option at that point. we have explained very grim prognosis, especially after cns findings/leptomeningeal involvement. likely very limited treatment options. need to consider hospice if patient not doing well, regaining strength at rehab. the medical team following including pcp will need to be involved in evaluating patient while at rehab with possible transition to hospice care if patient not regaining strenght or deteriorating. 11. code status: after extensive discussion with patient's wife, patient made dnr/dni on . medications on admission: meds on admission: 1. norvasc 5 mg daily 2. hytrin 10 mg qhs 3. fosamax 4. detrol 2 mg daily 5. advil prn 6. decadron at the osh 7. morphine at the osh . allergies: nkda. however, pt reports that he had severe difficulty urinating following general anesthesia in the past. discharge medications: 1. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed. 2. terazosin hcl 5 mg capsule sig: two (2) capsule po hs (at bedtime). 3. insulin regular human 100 unit/ml solution sig: one (1) injection asdir (as directed). 4. docusate sodium 150 mg/15 ml liquid sig: one hundred (100) mg po bid (2 times a day). 5. amlodipine besylate 5 mg tablet sig: two (2) tablet po daily (daily). 6. hydralazine hcl 25 mg tablet sig: one (1) tablet po q6h (every 6 hours). 7. albuterol sulfate 0.083 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 8. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed. 9. metoprolol tartrate 50 mg tablet sig: two (2) tablet po tid (3 times a day). 10. acetaminophen 160 mg/5 ml elixir sig: six y (650) mg po q6h (every 6 hours). 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 12. oxycodone hcl 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 13. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid w/meals (3 times a day with meals). 14. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po daily (daily). 15. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 16. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift 17. haloperidol lactate 5 mg/ml solution sig: one (1) injection hs (at bedtime) as needed for confusion/sleep. 18. protonix 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 19. dexamethasone 1 mg tablet sig: three (3) tablet po three times a day. 20. sodium chloride 0.9% flush 3 ml iv daily:prn peripheral iv - inspect site every shift discharge disposition: extended care facility: hospital of & islands - discharge diagnosis: malignant melanoma, pneumonia, hyponatremia, hypertension, delirium discharge condition: stable, residual right hemiparesis, restricted diet discharge instructions: contact md if you develop chest pain, shortness of breath or if you experience any new weakness or sensory changes or any other concerning symptoms. follow-up as below. all medications as prescribed. followup instructions: patient should be seen by pcp, . while he is at rehab. his number is . patient will be considered for further chemotherapy and radiation pending his progress at rehab. progress should be communicated to dr. . he should be called at to be updated about progress of rehabilitation. if patient progresses significantly and regains strength, treatment options would be considered for melanoma. at this point, there are no realistic treatment options. as nearing discharge, appointment with dr. will need to be made. dr. , hospitalist, or dr. , intern can be contact with questions. dr. can be contact by calling and asking operator to contact her. dr. can be reached through . procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified spinal tap incision of lung imageless computer assisted surgery excision or destruction of lesion of spinal cord or spinal meninges insertion of endotracheal tube enteral infusion of concentrated nutritional substances arteriography of pulmonary arteries diagnoses: pneumonia, organism unspecified anemia, unspecified malignant neoplasm of liver, secondary unspecified transient mental disorder in conditions classified elsewhere hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (luts) secondary malignant neoplasm of brain and spinal cord alkalosis osteoporosis, unspecified secondary malignant neoplasm of skin anticoagulants causing adverse effects in therapeutic use secondary malignant neoplasm of lung hyperosmolality and/or hypernatremia other disorders of neurohypophysis personal history of malignant melanoma of skin secondary and unspecified malignant neoplasm of intrathoracic lymph nodes secondary malignant neoplasm of bone and bone marrow secondary malignant neoplasm of other parts of nervous system other specified paralytic syndrome 

Answer: The patient is high likely exposed to