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: vancomycin analogues / iv dye, iodine containing / ace inhibitors / benadryl attending: chief complaint: fever, respiratory distress major surgical or invasive procedure: already intubated on transfer from osh a line esophageal balloon history of present illness: 47-year old patient of with a 15-year history of hodgkin's disease, previously treated with chemotherapy complicated by bleomycin lung and two allogenic bone marrow transplants (2 and 6 years ago) complicated by heart failure and radiation fibrosis who presents as a transfer from an outside hospital after being intubated in the setting of a bleed during a bronchoscopy with subsequent development of ards. patient was in usual state of health until this past when she presented to clinic with a fever and cough. a sputum culture from was noted to have sparce growth of aspirgillus fumigatus and terreus. galactomannan and beta glucan negative. bal deferred at patient's request. treated with azithromycin and cefpodoxime. she did well and returned to work. she was given a dli on . on , she presented to medical center with worsening fevers and shakiness for 48 hours. chest imaging showed what was felt to be worsening of her infiltrate (although it is unclear what this was compared to) and pneumonitis. they performed a bronchoscopy on which was complicated by an extensive bleed leading to intubation. she later developed ards and was started on iv steroids and pressors. she was started on an antibiotic regimen which eventually included linezolid, meropenem, voriconazole and acyclovir (prophylaxis dose). she developed worsening hypercarbia on and underwent a workup for embolic disease. a cta was negative for pe but showed b/l pleural effusions r>l and a new left upper lung nodule of 1.4cm. in addition, diffuse ground glass opacities are present. a right gastrognemius thrombus and a left cephalic thrombus was found. an mri of the brain showed a new left parietal lobe infarcation. a ct also showed old infarction. given abscence of positive cultures per records at the time, antibacterials were stopped on and . voriconazole was continued. atovaquone, acyclovir ppx was continued. the patient was started on high dose methylprednisolone 60mg q8h on . a pigtail catheter drainage of r chest loculated effusion was planned for but was not done. from the vs it appears that the patient was hypotensive on . no record of a fever. wbc up to 20,000. she was transferred to for further evaluation and management given her extensive past medical care at . she arrived in the intubated, sedated and in no apparent distress. vs on arrival as below. past medical history: 1. hodgkin's lymphoma, nodular sclerosing, diagnosed in ; radiation to the mediastinum in and to the lymph nodes in 2. autologous bone marrow transplant in 3. non-myeloablative allogeneic stem cell transplant in , mud on atg conditioning c/b serum sickness; cellcept discontinued in , only on low dose prednisone recently (increased transiently to 20mg for pruritus) 4. cardiomyopathy, chemotherapy induced. 5. depression/anxiety 6. urinary incontinence 7. gvhd related to transplant with dry eyes and occasional oral involvement 8. herpes zoster, 9. pcp infection in and remains on bactrim 10. cmv viremia 11. ebv viremia mmf discontinued 12. bk viremia and viruria- 13. rsv infection in . . 46 yo female with a long history of nodular sclerosing hodgkin's disease, s/p autologous sct , s/p sibling donor allogenic transplant , and s/p unrelated allogenic sct with d 0 on . her post transplant course was notable for "serum sickness" thought related to atg with fevers, rash, and joint pains. she was started on prednisone for control of the symptoms and the steroids have subsequently been discontinued. she had a relatively uncomplicated post-transplant course until she developed cmv viremia with cmv viral load on noted at 4000. was started on iv ganciclovir. on , she was switched to valganciclovir for continued treatment. subsequent cmv viral loads on revealed a level of 9000, and repeat on was 14,500. at this point, was switched back to iv ganciclovir, and she was discharged to the local apartments on . unfortunately, her cmv viral load increased further and she was readmitted for iv foscarnet on . with improvement in her cmv viral load, she was discharged to the apartments on on iv ganciclovir. she was switched to valganciclovir 900 mg twice per day in mid . her dose was decreased to 900 mg once per day as of . she developed a macular papular rash and was seen by dermatology on . biopsy was consistent with a drug hypersensitivity reaction, possibly related to foscarnet or bactrim. she also was treated for a short period of time with keflex for possible infected sk on her hand. her bactrim was switched to atovaquone and her keflex was discontinued. she has recently been noted for slowly decreasing counts thought related to her valcyte. however, was noted for increasing ebv level of 400 and with concern for ptld, she was admitted on for evaluation and followup. subsequent ebv viral loads were < 8 and ct of the neck showed decreasing adenopathy. ct of the torso showed stable adenopathy within the abdomen. bone marrow biopsy was negative for lymphoma. was discharged on . her counts have been recovering. . - dx iie hd. treated with 6 cycles of mopp/abv hybrid followed by xrt. - recurred in with minimal disease and went to autologous transplant in 4/. - noted for recurrent disease, received gemzar as single . - s/p nonmyeloablative allogeneic stem cell transplant from a sibling donor on with evidence for recurrent disease. - s/p 3 cycles of gemcitabine and navelbine completed on followed by donor lymphocyte infusion on at a dose of 1 x10 to the 7th t cell per kilogram. - s/p 3 cycles of cepp chemotherapy with the first cycle given without procarbazine and completed on 03/. - s/p dc/dli infusion on on the dc/dli protocol with dli dose of 3 x10 to the 7th t-cell per kilogram. - evidence for disease recurrence in and status post four weeks of rituxan, last given on , supported with leukine injections. - s/p donor lymphocyte infusion at a dose of 1 x10 to 8th t-cell per kilogram on . - s/p enrollment on study involving anti-ctla-4 antibody with donor lymphocyte infusion in 05/. - evidence for recurrent disease while on protocol and status post two cycles of navelbine and gemcitabine. - s/p dli at a dose of 0.79 x10 to the 8th t-cell per kg on . - evidence for recurrent disease in and status post single velcade starting in given for two cycles, however, complicated by fevers and abdominal pain requiring admission at medical center. - began gemzar, navelbine once again on , s/p 4 cycles supported with leukine injections for the second, third and four cycles. - status post dli at a dose of 1.15 x10 to the 8th t-cell per kilogram on . - noted for progressive disease in and now s/p 2 cycles of gemzar/navelbine in / with c2d8 on . - plan to move forward with two more cycles of gemzar/naveline but developed fever, shortness of breath and increasing white count requiring admission in ny and then follow up admission at for presumed infection. - treated for pcp infection with iv bactrim and currently on bactrim prophylaxis. - persistent elevation in white blood count with increased abdominal adenopathy and began treatment with methotrexate for two doses with minimal response. - treated with three cycles of ice chemotherapy, last cycle in 1/. the 1st cycle was given at 75% dosing and 2nd and 3rd cycles were given with 50% dosing. - plan had been to move forward with possible allogeneic transplant from an unrelated donor but noted for progression of disease in cervical adenopathy and abdominal areas with increasing white count and fevers. she was given high dose steroids and then treated with three cycles of dhap starting of , with 3rd cycle on . she had initial response after two cycles with normalization of white count and resolution of cervical adenopathy but this grew again, and she received the 3rd cycle of dhap. she received a 4th cycle of dhap on for further treatment while undergoing workup for allogeneic transplant. - received dose of velban on due to increased white count and to temporize her disease prior to her admission. - admitted for 2nd allogeneic stem cell transplant from an unrelated donor with atg/tli conditioning. d 0 was . social history: worked for a state senator in , ny, no hx of etoh or tobacco, currently living in the apartments with her mother. lives in . family history: non-contributory. physical exam: vs: 97.2 118/74 88 32 92/fio2 55% gen: sedated, no acute distress heent: perrl, sclerae anicteric, neck supple, mmm cv: rrr, normal s1, s2, no r/g/m lungs: coarse, no wheeze, intubated gi: soft, non-tender, non-distended, +bs, greenish-brownish liquid stool ext: warm and well perfused, trace edema bilaterally, 2+ dp pulses palpable bilaterally skin: no erythema, rash, no jaundice neuro: moving all extremities, reacts to painful stimuli pertinent results: admission labs: 05:30pm blood wbc-9.2 rbc-2.89* hgb-9.2* hct-27.1* mcv-94 mch-31.9 mchc-34.1 rdw-16.8* plt ct-150 05:30pm blood neuts-88.1* lymphs-5.5* monos-6.3 eos-0.1 baso-0.1 05:30pm blood pt-12.5 ptt-21.8* inr(pt)-1.1 05:30pm blood glucose-137* urean-39* creat-0.6 na-142 k-4.3 cl-96 hco3-45* angap-5* 05:30pm blood alt-53* ast-31 ld(ldh)-295* alkphos-220* totbili-0.7 05:30pm blood albumin-3.1* calcium-8.7 phos-3.4 mg-2.0 . other labs: 05:38am blood fibrino-365 05:38am blood dirbili-0.4* 05:38am blood caltibc-255* hapto-280* trf-196* 04:17am blood triglyc-183* hdl-54 chol/hd-3.9 ldlcalc-120 04:48am blood triglyc-222* 04:26am blood triglyc-227* 07:53pm blood vanco-24.7* 07:03am blood vanco-16.5 05:49pm blood lactate-1.1 05:03am blood lactate-1.0 04:48am blood lactate-0.8 01:20am blood lactate-0.5 10:15am blood glucose-125* lactate-1.1 06:00pm blood lactate-0.6 04:01am blood lactate-0.6 03:31pm blood lactate-0.9 04:31am blood lactate-0.8 07:55pm blood lactate-1.3 . abgs: 05:49pm blood freeca-1.18 04:01am blood freeca-1.20 07:55pm blood freeca-1.18 05:49pm blood type-central ve temp-36.1 rates-32/ tidal v-250 peep-5 fio2-70 po2-45* pco2-88* ph-7.37 caltco2-53* base xs-20 intubat-intubated vent-controlled 08:43pm blood type-art rates-32/ peep-5 fio2-55 po2-60* pco2-59* ph-7.51* caltco2-49* base xs-19 intubat-intubated vent-controlled 03:39am blood type-art temp-36.2 rates-28/2 peep-5 fio2-55 po2-69* pco2-54* ph-7.54* caltco2-48* base xs-19 intubat-intubated vent-controlled 05:01pm blood type-art temp-36.3 rates-28/0 tidal v-270 peep-5 fio2-55 po2-83* pco2-75* ph-7.35 caltco2-43* base xs-11 -assist/con intubat-intubated 08:03pm blood type-art temp-36.3 rates-8/0 peep-10 fio2-55 po2-77* pco2-72* ph-7.33* caltco2-40* base xs-8 intubat-intubated vent-controlled comment-driving pr 12:22am blood type-art temp-36.2 rates-28/0 peep-10 fio2-55 po2-101 pco2-79* ph-7.31* caltco2-42* base xs-8 intubat-intubated vent-controlled 02:37am blood type-art temp-36.1 rates-30/0 peep-10 fio2-50 po2-94 pco2-74* ph-7.30* caltco2-38* base xs-6 intubat-intubated vent-controlled 07:12am blood type-art rates-30/0 peep-10 fio2-50 po2-68* pco2-84* ph-7.30* caltco2-43* base xs-11 intubat-intubated vent-controlled 12:51pm blood type-art rates-3/ tidal v-220 peep-3 fio2-60 po2-76* pco2-98* ph-7.26* caltco2-46* base xs-12 intubat-intubated vent-controlled 02:30pm blood type-art rates-30/ tidal v-220 fio2-55 po2-99 pco2-89* ph-7.28* caltco2-44* base xs-11 intubat-intubated vent-controlled 07:12am blood type-art rates-30/0 peep-10 fio2-50 po2-68* pco2-84* ph-7.30* caltco2-43* base xs-11 intubat-intubated vent-controlled 12:51pm blood type-art rates-3/ tidal v-220 peep-3 fio2-60 po2-76* pco2-98* ph-7.26* caltco2-46* base xs-12 intubat-intubated vent-controlled 02:30pm blood type-art rates-30/ tidal v-220 fio2-55 po2-99 pco2-89* ph-7.28* caltco2-44* base xs-11 intubat-intubated vent-controlled 04:12pm blood type-art temp-36.1 rates-32/ tidal v-220 peep-10 fio2-55 po2-71* pco2-91* ph-7.31* caltco2-48* base xs-15 intubat-intubated vent-controlled 06:34pm blood type-art temp-37.1 rates-32/ tidal v-230 peep-5 fio2-60 po2-100 pco2-73* ph-7.39 caltco2-46* base xs-14 -assist/con intubat-intubated 05:03am blood type-art temp-37.2 fio2-60 po2-120* pco2-87* ph-7.38 caltco2-54* base xs-21 intubat-intubated 09:14am blood type-art temp-36.8 rates-32/ tidal v-230 peep-5 fio2-50 po2-63* pco2-63* ph-7.44 caltco2-44* base xs-15 -assist/con intubat-intubated 05:09pm blood type-art temp-36.7 peep-5 po2-78* pco2-85* ph-7.34* caltco2-48* base xs-15 intubat-intubated 08:09pm blood type-art po2-86 pco2-91* ph-7.38 caltco2-56* base xs-23 vent-controlled 12:29am blood type-art fio2- o2 flow-50 po2-89 pco2-82* ph-7.39 caltco2-52* base xs-20 intubat-intubated vent-controlled 04:48am blood type-art temp-37.2 fio2-50 po2-71* pco2-84* ph-7.44 caltco2-59* base xs-27 intubat-intubated vent-controlled 07:44am blood type-art rates-33/ peep-5 fio2-50 po2-59* pco2-85* ph-7.43 caltco2-58* base xs-26 -assist/con intubat-intubated 11:50am blood type-art rates-32/ tidal v-270 peep-5 fio2-50 po2-69* pco2-83* ph-7.41 caltco2-55* base xs-22 -assist/con intubat-intubated 03:38pm blood type-art temp-37.9 rates-35/ tidal v-230 peep-5 fio2-50 po2-88 pco2-84* ph-7.36 caltco2-49* base xs-17 -assist/con intubat-intubated 08:45pm blood type-art temp-37.2 po2-80* pco2-82* ph-7.37 caltco2-49* base xs-17 intubat-intubated vent-controlled 12:52am blood type-art po2-242* pco2-74* ph-7.37 caltco2-44* base xs-14 intubat-intubated vent-controlled 01:20am blood type-art rates-32/ tidal v-300 fio2-50 po2-70* pco2-71* ph-7.37 caltco2-43* base xs-11 intubat-intubated vent-controlled 04:32am blood type-art temp-37.4 rates-32/ tidal v-300 peep-5 fio2-50 po2-77* pco2-77* ph-7.36 caltco2-45* base xs-13 intubat-intubated vent-controlled 10:15am blood type-art po2-69* pco2-85* ph-7.31* caltco2-45* base xs-12 10:20am blood type-central ve 04:14pm blood type-art temp-36.3 rates-32/ tidal v-200 peep-5 fio2-50 po2-114* pco2-77* ph-7.33* caltco2-42* base xs-11 -assist/con intubat-intubated 11:06pm blood type-art temp-36.8 peep-5 po2-69* pco2-70* ph-7.35 caltco2-40* base xs-9 intubat-intubated vent-controlled 05:08am blood type-art temp-36.4 peep-5 fio2-50 po2-62* pco2-66* ph-7.38 caltco2-41* base xs-10 intubat-intubated vent-controlled 01:57pm blood type-art temp-36.9 rates-32/2 peep-5 fio2-50 po2-69* pco2-83* ph-7.29* caltco2-42* base xs-10 intubat-intubated 04:40pm blood type-art temp-36.7 rates-32/ peep-5 fio2-50 po2-110* pco2-83* ph-7.27* caltco2-40* base xs-8 -assist/con intubat-intubated 07:40pm blood type-art temp-36.2 peep-5 fio2-50 po2-106* pco2-76* ph-7.30* caltco2-39* base xs-7 intubat-intubated 12:01am blood type-art temp-36.0 peep-5 fio2-50 po2-67* pco2-59* ph-7.38 caltco2-36* base xs-7 intubat-intubated 03:57am blood type-art temp-36.9 peep-5 fio2-50 po2-87 pco2-73* ph-7.35 caltco2-42* base xs-10 -assist/con intubat-intubated vent-controlled 09:41pm blood type-art po2-92 pco2-77* ph-7.38 caltco2-47* base xs-15 06:32am blood type-art po2-71* pco2-86* ph-7.34* caltco2-48* base xs-16 12:28pm blood type-art temp-36.1 rates-32/ po2-68* pco2-85* ph-7.34* caltco2-48* base xs-15 06:00pm blood type-art temp-36.8 rates-32/2 peep-2 fio2-50 po2-91 pco2-85* ph-7.35 caltco2-49* base xs-16 -assist/con intubat-intubated 04:01am blood type-art po2-64* pco2-92* ph-7.33* caltco2-51* base xs-17 11:31am blood type-art po2-66* pco2-98* ph-7.31* caltco2-52* base xs-17 02:48pm blood type-art po2-67* pco2-118* ph-7.27* caltco2-57* base xs-20 03:31pm blood type-art temp-36.6 rates-32/ peep-4 fio2-50 po2-82* pco2-93* ph-7.35 caltco2-54* base xs-20 -assist/con intubat-intubated 06:36pm blood type-art po2-89 pco2-93* ph-7.36 caltco2-55* base xs-21 10:56pm blood type-art po2-85 pco2-86* ph-7.39 caltco2-54* base xs-21 04:31am blood type-art po2-67* pco2-86* ph-7.41 caltco2-56* base xs-24 11:19am blood type-art temp-37.3 rates-32/0 peep-4 fio2-50 po2-69* pco2-87* ph-7.40 caltco2-56* base xs-23 intubat-intubated comment-ps34 07:55pm blood type-art temp-35.3 rates-32/0 fio2-50 po2-64* pco2-78* ph-7.45 caltco2-56* base xs-24 intubat-intubated vent-controlled 03:22am blood type-art temp-37.6 rates-32/ peep-4 fio2-50 po2-69* pco2-87* ph-7.43 caltco2-60* base xs-27 intubat-intubated vent-controlled 03:31pm blood type-art po2-72* pco2-88* ph-7.39 caltco2-55* base xs-22 09:00pm blood type-art po2-72* pco2-74* ph-7.44 caltco2-52* base xs-20 05:43am blood type-art po2-75* pco2-75* ph-7.43 caltco2-51* base xs-20 . . microbiology 05:38 voriconazole test concentration ---- ------------- antifungal drug level voriconazole 0.30 ug/ml comments: there are no established reference ranges for voriconazole, however, levels of <1.0 ug/ml may be sub-optimal while levels >6.0 ug/ml may be associated with toxicity, visual disturbances, and/or elevated liver function tests. . 14:17 b-glucan test ---- fungitell (tm) assay for (1,3)-b-d-glucans results reference ranges ------- ---------------- <31 pg/ml negative less than 60 pg/ml indeterminate 60 - 79 pg/ml positive greater than or equal to 80 pg/ml . 14:17 aspergillus galactomannan antigen test result reference range/units aspergillus antigen 0.1 <0.5 result interpretation: an index <0.5 is considered to be negative. an index >=0.5 is considered to be positive. . 5:30 pm blood culture **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. isolated from only one set in the previous five days. sensitivities performed on request.. anaerobic bottle gram stain (final ): gram positive cocci in clusters. . stool clostridium difficile toxin a & b test -ve blood culture blood culture, routine-final stool clostridium difficile toxin a & b -ve mrsa screen mrsa screen-final inpatient urine urine culture-final . 6:03 pm blood culture ( myco/f lytic bottle) site: a line source: line-a. blood/fungal culture (preliminary): no fungus isolated. blood/afb culture (preliminary): no mycobacteria isolated. . 6:03 pm rapid respiratory viral screen & culture source: nasopharyngeal swab. **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. respiratory viral antigen screen (final ): negative for respiratory viral antigen. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. refer to respiratory viral culture for further information. . 11:10 am sputum source: endotracheal. gram stain (final ): <10 pmns and <10 epithelial cells/100x field. no microorganisms seen. quality of specimen cannot be assessed. respiratory culture (final ): rare growth commensal respiratory flora. fungal culture (preliminary): no fungus isolated. nocardia culture (preliminary): no nocardia isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. . blood culture blood culture, routine -ve blood culture blood culture, routine -ve blood culture blood culture, routine -ve . 4:17 am immunology (cmv) source: line-aline. **final report ** cmv viral load (final ): cmv dna not detected. performed by pcr. detection range: 600 - 100,000 copies/ml. . urine urine culture -ve blood culture blood culture, routine-pending stool clostridium difficile toxin a & b test -ve stool ova + parasites -ve . 10:37 pm blood culture source: line-aline. blood culture, routine (preliminary): enterococcus faecalis. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. sensitive to daptomycin at mic 1.0 mcg/ml, sensitivity testing performed by etest. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecalis | ampicillin------------ <=2 s daptomycin------------ s penicillin g---------- 8 s vancomycin------------ 1 s aerobic bottle gram stain (final ): gram positive cocci in pairs and chains. . urine urine culture -ve . . cardiology: ecg study date of 8:07:40 pm sinus tachycardia. compared to the previous tracing of the rate is increased. tracing #1 read by: , intervals axes rate pr qrs qt/qtc p qrs t 134 128 68 282/411 56 59 34 . ecg study date of 8:42:10 pm sinus tachycardia. compared to the previous tracing there is no change. tracing #2 read by: , intervals axes rate pr qrs qt/qtc p qrs t 108 124 68 348/432 37 47 55 . portable tte (complete) done at 9:00:00 am conclusions the left atrium is normal in size. left ventricular wall thicknesses and cavity size are normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is low normal (lvef 50-55%). 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. mild (1+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. impression: very mild global left ventricular systolic dysfunction. mild mitral regurgitation. mild pulmonary hypertension. . portable tte (focused views) done at 3:55:40 pm conclusions biventricular systolic function appears grossly preserved (regional wall motion not assessed). two agitated saline injections were performed at rest. these revealed no evidence of intracardiac shunt. there was trace late contrast in the left ventricle consistent with a probable slight pulmonary arteriovenous shunt. . . radiology: xr chest (portable ap) study date of 8:03 pm impression: ap chest read in conjunction with chest ct on compared to the most recent prior chest radiograph, . moderate right pleural effusion and large areas of consolidation in both lungs are new since a year ago. whether this is multifocal pneumonia or pulmonary edema is radiographically indeterminate. et tube ends just above the upper margin of the clavicles, but only 2 cm above optimal placement due to shortening of the tracheal length because of marked pulmonary radiation fibrosis. nasogastric tube is coiled in the stomach. an infusion line ends in the svc. large calcified lymph nodes are treated lymphoma. no pneumothorax. . xr chest (portable ap) study date of 5:23 am the position of the et tube, central venous line and the ng tube is unchanged. the newly placed esophageal device tip is at the proximal stomach approximately 5 cm below the ge junction. the purpose of this device is unclear: temperature probe ? feeding tube ? there is no significant interval change in bibasal consolidations, bilateral pleural effusions, partially loculated on the left and mediastinal calcified lesion representing post-treatment changes of lymphoma. . unilat up ext veins us left study date of 11:04 am findings: suboptimal scan; patient unable to cooperate and suboptimal positioning of the left upper extremity. there is wall-to-wall flow and normal compressibility in the left jugular vein. wall-to-wall flow is seen in the left subclavian vein. there is normal compressibility of the left axillary vein. there is normal compressibility in the left brachial vein with wall-to-wall flow. there is normal compressibility in the left basilic and left cephalic vein. impression: suboptimal scan due to positioning; patient unable to cooperate. no convincing evidence of deep venous thrombosis in the left upper extremity. . xr chest (portable ap) study date of 4:37 am impression: ap chest compared to through 9: the improvement in widespread pulmonary opacification between and 9 has stabilized. while this may have been due to edema, the residual consolidation raises a possibility of multifocal pneumonia. heart size is top normal. moderate right pleural effusion is stable. et tube is in standard placement. the esophageal manometer ends in the upper stomach alongside the looped nasogastric tube. a left subclavian infusion port ends in the region of the superior cavoatrial junction and right internal jugular line in the upper svc. the large calcified central lymph nodes reflect treated lymphoma. . xr chest (portable ap) study date of 5:50 am findings: the left venous infusion catheter ends near the cavoatrial junction. the right ij catheter ends in the mid svc. the et tube ends 4 cm above the carina. the ng tube is within the stomach but coiled on itself and pointing towards the ge junction. the small left and moderate right pleural effusions are unchanged. there is unchanged right pleural thickening or loculated effusion. there is no significant overall change in the appearance of the bilateral lung opacities, consistent with edema versus multifocal pneumonia. the bulky hilar and mediastinal calcified lymphadenopathy is unchanged. impression: 1. persistent bilateral lung opacities, consistent with edema and/or multifocal pneumonia. 2. unchanged small left and moderate right pleural effusions. possible loculated component of right effusion. . dup extext bil (map/dvt) port study date of 10:12 am findings: color and -scale son was performed on the bilateral lower extremities. there is a segmental occlusive echogenic thrombus in the right posterior tibial vein, which does not extend proximally. the right common femoral, superficial femoral, popliteal veins are normal in compressibility and waveform. there is no left-sided deep vein thrombosis. the left common femoral, superficial femoral, popliteal veins are normal in compressibility, augmentation and doppler waveforms. the left-sided calf veins are patent and compressible. impression: 1. occlusive segmental deep vein thrombosis in the right posterior tibial vein, without proximal extension to other deep veins. 2. no left-sided dvt. . xr chest (portable ap) study date of 3:21 pm findings: the ng tube has been replaced with a feeding tube that ends near the ge junction. a new tracheostomy tube ends less than 1 cm from the carina. the left venous infusion catheter ends near the cavoatrial junction. the small left and moderate right pleural effusions are unchanged. possible loculated component of right effusion and/or pleural thickening is unchanged. there is no significant change in the appearance of the bilateral lung opacities, consistent with edema versus multifocal pneumonia. mediastinal and hilar calcified lymphadenopathy is unchanged. impression: 1. new feeding tube tip near the ge junction. 2. tracheostomy tube ending less than 1 cm above the carina. 3. persistent bilateral lung opacities, consistent with edema and/or multifocal pneumonia. 4. unchanged small left and moderate right pleural effusions. possible loculated component of right effusion. . xr chest (portable ap) study date of 7:58 pm findings: nasogastric tube is no longer visualized. a larger bore tube remains in place, possibly representing a feeding tube, and has been advanced further into the stomach since the prior radiograph. however, there is apparent coiling of this device more proximally in the upper thorax above the level of the thoracic inlet. at the time of this dictation, a separately dictated chest x-ray has been performed and documents subsequent removal of this device. with the exception of the change in tube positions, the appearance of the chest is relatively similar compared to the prior study of earlier the same date except for slight worsening of diffuse pulmonary opacities. . xr chest (portable ap) study date of 11:26 pm findings: feeding tube has been removed and replaced with a nasogastric tube, which terminates in the distal stomach. other indwelling devices are unchanged in position including a relatively low lying tracheostomy tube. widespread pulmonary opacities affecting the right lung to a greater degree than the left, appears slightly improved in the interval. extensive calcified lymphadenopathy and upper lobe volume loss with associated pleural and parenchymal scarring are again demonstrated as well as a moderate-sized partially loculated right pleural effusion superimposed upon pleural thickening. within the imaged portion of the upper abdomen, a single dilated loop of small bowel is present in the left upper quadrant and is of uncertain etiology. impression: newly placed nasogastric tube in standard position. . xr chest (portable ap) study date of 6:35 pm ' the current study re-demonstrates tracheostomy with its tip being relatively low, 1.3 cm above the carina, unchanged. cardiomediastinal silhouette is stable. extensive parenchymal opacities are unchanged as well. large mediastinal calcifications are re-demonstrated. the port-a-cath catheter tip is at the level of low svc. the ng tube tip is in the stomach. impression: no interval change since the prior study. . xr chest (portable ap) study date of 5:42 am portable ap chest radiograph was reviewed in comparison to prior study obtained on . the position of tubes and lines is unchanged. there is no change in multifocal opacities and loculated bilateral small-to-moderate pleural effusion, right more than left. . xr chest (portable ap) study date of 5:20 am one view. comparison with the previous study of . multifocal pulmonary opacities and bilateral pleural effusions, greater on the right, persist. mediastinal structures are unchanged. calcified mediastinal and hilar lymph nodes are redemonstrated. a right internal jugular catheter has been removed. a tracheostomy tube, left ij line and mediport catheter remain in place. impression: removal of right internal jugular catheter. no other definite change. . xr chest (portable ap) study date of 5:03 am comparison film . the position of the various lines and tubes is unchanged. multifocal opacities are again noted, probably little changed since the prior chest x-ray, allowing for differences in penetration. impression: no change. . xr chest (portable ap) study date of 5:56 am impression: ap chest compared to through 17: since , the diffuse opacification in the left lung has improved except for the apex. on the right, the multifocal consolidation is unchanged. the interval change might be remission of edema, and the large scale consolidation could be multifocal pneumonia or a non-recoverable component of edema such as ards. the moderate right pleural effusion which has been present since admission is unchanged. heart size top normal and stable. the heavily calcified mediastinal lymph nodes are treated lymphoma. an infusion port ends in the low svc, nasogastric tube passes to the distal stomach and a tracheostomy tube is in standard placement. no pneumothorax. brief hospital course: ms is a 47 year old woman with refractory hodgkin's disease s/p autologous and two allogenic transplants presenting with respiratory failure from an osh after bal and airway hemorrhage. . # respiratory failure: hypercarbic respiratory failure. etiology: ards in setting of likely infection after hemorrhagic bleed during bronchoscopy in woman with poor underlying respiratory status due to previous radiation/chemotherapy vs aggressive hodgkins recurrence. on arrival to the icu patient had already been intubated for 18days. decision made to undergo tracheostomy on . respiratory failure refractory to broad spectrum antibiotics including anti-fungals as well as stress dose steriods. patient unable to undergo repeat chest imaging due to peristent instability. decision made to transition care to comfort measures only after extensive discussion with family regarding poor prognosis. patient with terminal extubation on . family agreed to post-mortem examination. . # parietal stroke: found on head mri on at osh. neurology was consulted and imaging reviewed. per neurology and neuroradiology imaging consistent with embolic events. tte with bubble ordered which revealed no evidence of intracardiac shunt. patient anticoagulated with heparin gtt (48hrs after tracheostomy performed). heparin gtt was later transitioned to lovenox . # history of deep venous thrombosis: per outside hospital records patient with right gastrocnemius thrombus, left cephalic thrombus found on recent imaging. repeat upper and lower extremity ultrasound in house. no convincing evidence of deep venous thrombosis in the left upper extremity on repeat imaging. lower extremity study revealed occlusive segmental deep vein thrombosis in the right posterior tibial vein, without proximal extension to other deep veins. no left-sided dvt. patient was placed on heparin gtt 48hrs after placement of tracheostomy. no ivc filter was placed. medications on admission: voriconazole 200 mg po q12h acyclovir 200 mg po q8h methylprednisolone sodium succ 60 mg iv q8h midodrine 5 mg po bid atovaquone citalopram 10 mg albuterol mdis ipratropium mdis vitamin d 400 unit po/ng daily fentanyl midazolam cyclosporine *nf* 0.05 % ou discharge medications: deceased discharge disposition: expired discharge diagnosis: hypercarbic respiratory failure hodgkins disease discharge condition: deceased discharge instructions: na followup instructions: na md procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more enteral infusion of concentrated nutritional substances other permanent tracheostomy diagnoses: pneumonia, organism unspecified thrombocytopenia, unspecified anemia, unspecified long-term (current) use of steroids 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 alkalosis antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use complications of transplanted bone marrow diarrhea encounter for palliative care cerebral embolism with cerebral infarction do not resuscitate status chronic and other pulmonary manifestations due to radiation radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure critical illness polyneuropathy acute venous embolism and thrombosis of deep vessels of distal lower extremity secondary cardiomyopathy, unspecified graft-versus-host disease, unspecified hodgkin's disease, nodular sclerosis, lymph nodes of multiple sites 

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