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 / ace inhibitors / losartan attending: chief complaint: fever, altered mental status major surgical or invasive procedure: left femoral central venous line placement () . temporary hd catheter placement on , , . tunneled hd catheter placement on . excision of left upper arm arteriovenous graft. . history of present illness: mrs. is a 76 year old female with a pmh significant for dm 2, esrd on mwf hd, dchf, cva admitted from her nursing home with 2 days of fever, altered mental status, and hyperkalemia with ecg changes. per review of records, the patient had a fever at her nh with a tmax of 102.9 today with a cxr performed at her nursing home that demonstrated increased congestion without consolidation per report. a urinalysis she was also reported to have altered mental status from her baseline. of note, the patient appears to have relatively frequent admissions for altered mental status and fever, most recently in with another admission in for bleeding avf. in the ed, vs 100.6 (tmax to 102 in ed) 142/72 88 96%ra. labs were notable for a serum potassium of 6.9 with an ecg demonstrating peaked t waves, for which the patient received calcium, insulin, and bicarbonate with a repeat serum potassium of 6.0. other notable labs at the time of initial presentation included a lactate of 4. the patient received vancomycin, cefepime, meropenem, and acyclovir prior to transfer. the patient also had a left femoral cvl after being unable to place a lij, rij, or right femoral cvl. cxr demonstrated pulmonary edema but no acute consolidation. ctap was notable for a wall thickening and pericolonic fat stranding in the left colon. the patient was also evaluated by renal, with plan for emergent hd upon admission to the micu. the patient was then transferred to the micu for further management. ros: unable to obtain secondary to ams. past medical history: 1. type 2 diabetes 2. esrd on hemodialysis 3. vascular dementia 4. hypertension 5. osteoarthritis 6. cataracts 7. hypothyroidism 8. anemia 9. pre-existing stage 3 decubitus ulcer 10. congestive heart failure, diastolic 11. s/p cva social history: home: lives in etoh: denies drugs: denies tobacco: denies family history: sister - diabetes , hypertension, hypercholesterolemia physical exam: physical exam: vs: 100 98 182/62 15 98%ra gen: minimally responsive moaning female heent: eyes possible deviated to right, although unclear secondary to patient cooperation after patient closed her eyes and would not re-open. cv: nl s1+s2, ii/vi systolic murmur throughout the precordium pulm: crackles to anterior auscultation bilaterally abd: s/nt/nd. hypoactive bs. ext: no c/c/e skin: stage 1-2 sacral decubitus ulcer neuro: unable to assess cranial nerves. exam otherwise non-focal. pertinent results: complete blood count wbc rbc hgb hct mcv mch mchc rdw plt ct 12:26pm 6.9 2.98* 9.1* 29.2* 98 30.5 31.1 16.9* 356 06:03am blood wbc-5.3 rbc-2.52* hgb-7.8* hct-24.7* mcv-98 mch-31.0 mchc-31.6 rdw-16.8* plt ct-438 05:33am blood wbc-5.9 rbc-2.67* hgb-8.3* hct-26.1* mcv-98 mch-31.0 mchc-31.8 rdw-16.6* plt ct-480* 06:51am blood wbc-8.8 rbc-2.85* hgb-9.0* hct-28.1* mcv-99* mch-31.5 mchc-32.0 rdw-16.6* plt ct-346 07:15am blood wbc-11.4* rbc-3.03* hgb-9.2* hct-28.8* mcv-95 mch-30.3 mchc-31.8 rdw-16.9* plt ct-382 06:05am blood wbc-13.2* rbc-3.21* hgb-9.9* hct-30.6* mcv-95 mch-31.0 mchc-32.5 rdw-16.8* plt ct-394 06:30am blood wbc-16.1* rbc-3.20* hgb-9.9* hct-31.2* mcv-97 mch-31.0 mchc-31.9 rdw-16.8* plt ct-365 06:30am blood wbc-10.6 rbc-3.28* hgb-10.2* hct-32.1* mcv-98 mch-31.0 mchc-31.7 rdw-16.9* plt ct-297 03:32am blood wbc-8.2 rbc-3.00* hgb-9.5* hct-28.5* mcv-95 mch-31.6 mchc-33.3 rdw-17.1* plt ct-265 06:41pm blood hct-28.7* 09:45am blood hct-28.8* 04:08am blood wbc-10.3 rbc-3.15* hgb-10.0* hct-28.5* mcv-90 mch-31.7 mchc-35.1* rdw-18.2* plt ct-264 11:39pm blood wbc-14.7*# rbc-3.46*# hgb-10.9*# hct-31.8* mcv-92# mch-31.6 mchc-34.4# rdw-18.0* plt ct-284 06:53pm blood wbc-9.6 rbc-2.65* hgb-8.1* hct-26.6*# mcv-101* mch-30.7 mchc-30.5* rdw-16.3* plt ct-213 05:57pm blood wbc-13.7* rbc-1.97*# hgb-6.0*# hct-20.9*# mcv-106* mch-30.5 mchc-28.7* rdw-14.3 plt ct-235 04:15pm blood wbc-12.6* rbc-3.38* hgb-10.8* hct-35.6* mcv-105* mch-31.9 mchc-30.3* rdw-14.2 plt ct-208 07:00am blood wbc-9.3 rbc-3.48* hgb-11.3* hct-37.2 mcv-107* mch-32.5* mchc-30.4* rdw-13.9 plt ct-235 06:25am blood wbc-6.8 rbc-3.59* hgb-11.7* hct-37.4 mcv-104* mch-32.5* mchc-31.2 rdw-14.2 plt ct-226 01:10pm blood wbc-10.0# rbc-3.75* hgb-12.2 hct-39.1 mcv-104* mch-32.5* mchc-31.1 rdw-14.4 plt ct-199 07:25am blood neuts-75.7* lymphs-17.5* monos-4.5 eos-2.0 baso-0.3 07:30am blood pt-13.6* ptt-30.9 inr(pt)-1.2* 01:10pm blood pt-13.7* ptt-28.6 inr(pt)-1.2* 03:30am blood fibrino-445* 04:08am blood fibrino-297 06:53pm blood fibrino-292 renal & glucose glucose urean creat na k cl hco3 angap 12:26pm 164*1 18 4.9*# 137 4.3 95* 32 14 06:03am blood glucose-80 urean-23* creat-5.1*# na-138 k-4.5 cl-92* hco3-33* angap-18 05:32am blood glucose-124* urean-31* creat-6.7*# na-127* k-6.4* cl-89* hco3-24 angap-20 06:51am blood glucose-126* urean-20 creat-4.3*# na-139 k-4.6 cl-96 hco3-29 angap-19 04:08am blood glucose-172* urean-58* creat-9.5* na-140 k-4.0 cl-99 hco3-25 angap-20 11:39pm blood glucose-219* urean-57* creat-9.3* na-140 k-4.1 cl-98 hco3-27 angap-19 06:53pm blood glucose-277* urean-54* creat-9.2*# na-142 k-4.3 cl-101 hco3-22 angap-23* 05:57pm blood glucose-188* urean-46* creat-8.0*# na-143 k-4.0 cl-104 hco3-21* angap-22* 04:15pm blood glucose-159* urean-58* creat-10.3*# na-135 k-5.4* cl-90* hco3-23 angap-27* 06:40am blood glucose-156* urean-22* creat-5.3*# na-142 k-4.3 cl-95* hco3-34* angap-17 06:00am blood glucose-160* urean-23* creat-4.9* na-140 k-4.9 cl-93* hco3-30 angap-22* 01:10pm blood glucose-183* urean-43* creat-7.5*# na-140 k-6.9* cl-92* hco3-31 angap-24* 04:53am blood glucose-140* urean-26* creat-5.4*# na-139 k-4.4 cl-91* hco3-36* angap-16 05:00am blood ck(cpk)-83 06:05am blood ck(cpk)-102 06:30am blood alt-21 ast-24 alkphos-97 totbili-0.3 03:32am blood alt-25 ast-34 ld(ldh)-273* alkphos-65 totbili-0.4 04:08am blood alt-44* ast-78* ld(ldh)-342* ck(cpk)-848* alkphos-61 totbili-0.8 11:39pm blood ck(cpk)-1067* 06:53pm blood alt-55* ast-93* ck(cpk)-708* alkphos-52 totbili-0.2 04:53am blood alt-26 ast-41* ld(ldh)-269* alkphos-92 totbili-0.5 09:40pm blood alt-26 ast-43* ld(ldh)-268* alkphos-94 amylase-44 totbili-0.5 06:53pm blood lipase-19 03:30am blood ctropnt-0.37* 06:08pm blood ctropnt-0.37* 11:39pm blood ck-mb-11* mb indx-1.0 ctropnt-0.39* 06:53pm blood ck-mb-4 ctropnt-0.21* 01:10pm blood ctropnt-0.23* 06:03am blood calcium-8.8 phos-5.4*# mg-2.2 05:59am blood calcium-9.3 phos-5.7* mg-1.9 04:08am blood calcium-9.0 phos-4.5 mg-2.9* 06:53pm blood albumin-2.6* calcium-8.7 phos-7.9* mg-3.2* 09:40pm blood albumin-4.4 calcium-9.1 phos-3.1 mg-2.2 04:53am blood vitb12-1436* 06:00am blood tsh-3.4 . . blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-pending inpatient tissue gram stain-final; tissue-final {staph aureus coag +}; anaerobic culture-final inpatient tissue gram stain-final; tissue-preliminary {staph aureus coag +, staph aureus coag +}; anaerobic culture-final inpatient blood culture blood culture, routine-pending inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient stool fecal culture-final; campylobacter culture-final; clostridium difficile toxin a & b test-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final {staph aureus coag +, staphylococcus, coagulase negative, staphylococcus, coagulase negative, corynebacterium species (diphtheroids)}; anaerobic bottle gram stain-final; aerobic bottle gram stain-final emergency blood culture blood culture, routine-final {staph aureus coag +, corynebacterium species (diphtheroids)}; aerobic bottle gram stain-final; anaerobic bottle gram stain-final emergency . . 4:05 pm tissue proximal graft left. gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. tissue (preliminary): reported by phone to dr 1pm. staph aureus coag +. sparse growth. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. sulfa x trimeth sensitivity testing performed by . sensitivity to daptomycin and vancomycin requested by dr. . sensitive to daptomycin at mic 0.25 mcg/ml, sensitivity testing performed by etest. sensitive to vancomycin at mic 1.5 mcg/ml, sensitivity testing performed by etest. staph aureus coag +. sparse growth. second morphology. sensitivities to daptomycin and vancomycin requested by dr. . sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | daptomycin------------ s erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- 4 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- i vancomycin------------ <=1 s anaerobic culture (final ): no anaerobes isolated. . . . **final report ** blood culture, routine (final ): staph aureus coag +. consultations with id are recommended for all blood cultures positive for staphylococcus aureus and species. final sensitivities. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. staphylococcus, coagulase negative. final sensitivities. staphylococcus species may develop resistance during prolonged therapy with quinolones. days after initiation of therapy. testing of repeat isolates may be warranted days after initiation of therapy. testing of repeat isolates may be warranted. please contact the microbiology laboratory () immediately if sensitivity to clindamycin is required on this patient's isolate. staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. corynebacterium species (diphtheroids). sensitivities performed on culture # 288-3782m. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | staphylococcus, coagulase negative | | erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- 4 r <=0.12 s oxacillin------------- =>4 r <=0.25 s rifampin-------------- <=0.5 s tetracycline---------- <=1 s <=1 s vancomycin------------ <=1 s 2 s anaerobic bottle gram stain (final ): gram positive cocci in clusters. reported by phone to # at 0855. aerobic bottle gram stain (final ): gram positive cocci in clusters. . . ct abd/pelvis final report impression: 1. finding likely suggesting mild enterocolitis, which could be infectious, inflammatory or ischemic in etiology. early obstruction can not be excluded. evaluation of colon is significantly limited particularly the transverse colon due to underdistention. close clinical follow-up and if needed further evaluation with oral contrast should be considered. the above findings were discussed with dr. from emergency radiology. 3. extensive sma and calcifications, potentially increasing risk for ischemia, although no signs specific for ischemia are identified. 4. changes of chronic pancreatitis, stable. 5. multiple abdominal wall collaterals and small collaterals along the ge junction, of uncertain etiology for which considerations might include a central venous stenosis or portal hypertension. clinical correlation is recommended. the study and the report were reviewed by the staff radiologist. dr. dr. sun approved: 10:41 am . . . cxr final report indication: fever. comparison: chest radiograph . portable ap view of the chest: mild cardiomegaly persists. the mediastinal and hilar contours are stable. there is mild perihilar haziness with mild vascular indistinctness, which appears slightly improved when compared to the prior study, suggestive of mild volume overload. mitral annular calcifications appear to be noted. no focal consolidation, pleural effusion or pneumothorax is seen. there is no acute skeletal abnormality. impression: moderate cardiomegaly with mild volume overload. dr. approved: wed 11:49 pm . . . ct head final report indication: 66-year-old woman with altered mental status and some focal signs. comparison: ct of the head without contrast from . technique: mdct images were acquired from the vertex to the 1st cervical vertebrae without contrast. findings: mild hypoattenuation of the periventricular white matter is likely secondary to chronic small vessel ischemic disease. there is calcification of the vertebral artery. no acute masses, infarct or bleed is present. no midline shift is present. no fracture is present and the visualized sinuses and mastoid air cells are well aerated. the ventricles and sulci are normal in caliber and configuration. impression: no acute bleed, infarct or mass present. the study and the report were reviewed by the staff radiologist. dr. dr. approved: 5:26 pm . . . ct abd/pelvis final report history: fever and altered mental status. question of colitis on prior ct. repeat with p.o. contrast. technique: ct through the abdomen and pelvis performed after administration of oral and iv contrast. multiplanar reformats were performed. comparison: . findings: abdomen: there is bibasilar dependent atelectasis. there is interlobular septal thickening suggestive of mild chf. there is a 5 mm nodule in the right lower lobe. the liver and gallbladder appear normal. again the pancreas is diffusely calcified with dilated pancreatic duct and pancreatic atrophy consistent with chronic pancreatitis. the spleen and adrenal glands are unremarkable. the kidneys are atrophic bilaterally. there is a small fat-containing umbilical hernia. there is extensive atherosclerotic disease of the aorta and the ostium of the mesenteric vessels. however, the sma and celiac axis appear patent. the is difficult to visualize given its small size, but does appear patent. the small bowel loops are unremarkable. again noted are numerous prominent collaterals throughout the anterior abdominal wall. pelvis: the colon is now more distended and fills with oral contrast. there is no evidence of bowel wall thickening or inflammatory process to suggest colitis. there is no evidence of bowel obstruction. a calcified uterus is noted, likely related to fibroids. a foley is seen within the decompressed bladder. there is no free fluid. there are degenerative changes in the spine including a transitional left l5-s1 vertebra. the bones are slightly dense suggestive of renal osteodystrophy. impression: 1. no evidence of colitis or other acute inflammatory process in the abdomen or pelvis. 2.stable appearance of chronic pancreatitis. 3. stable appearance of multiple abdominal wall collaterals, likely related to venous obstruction in the chest. 4. 5 mm nodule in the right lower lobe. attention on follow up imaging recommended. the study and the report were reviewed by the staff radiologist. dr. . dr. approved: 6:25 pm . . . final report history: difficulty placing jugular line. findings: duplex and color doppler demonstrate wide patency of both internal jugular veins. the patient also underwent interrogation of her left av fistula for question of a fever. the fistula is widely patent with expected areas of mild aneurysmal dilatation involving the draining vein. there is no fluid collection adjacent to the fistula. impression: 1. patent jugular veins bilaterally. 2. normal assessment of left upper extremity arteriovenous fistula. dr. approved: mon 8:40 pm . . . tte the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with infero-lateral hypokinesis. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is moderate thickening of the mitral valve chordae. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. compared with the prior study (images reviewed) of , no change (regional lv systolic dysfunction was present - but not reported- on the prior study). electronically signed by , md, interpreting physician 10:55 . . the tee probe could not be passed into the esophagus due to patient agitation/uncooperativeness. patient extracted probe from her mouth twice and communicated that she did not wish to continue with the study. impression: unsuccessful esophageal intubation. procedure aborted secondary to patient comfort/preference. dr. was notified by telephone on at 1:30 p.m. i certify that i was present for this procedure in compliance with hcfa regulations. electronically signed by , md, interpreting physician 17:59 . . . cxr final report history: 76-year-old woman with pe at rest. status post intubation. please assess for airway placement. comparison: . chest radiograph, portable ap view: interval placement of endotracheal tube ending 1.2 cm above the carina. the nasogastric tube extends into the stomach, with the tip out of view. mild patchy opacities at lower lungs are unchanged. increased right moderate pleural effusion. mild cardiomegaly is unchanged. the mediastinal and hilar contours are normal. a vascular guidewire ascends from the ivc to the stented left brachiocephalic vein. impression: 1. interval placement of endotracheal tube ending 1.2 cm above the carina. 2. increased moderate right pleural effusion and unchanged mild bibasal basal opacities. 3. retained venous guidewire. these findings were discussed with the ir team by dr. by phone on at 3:40pm. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 8:27 pm . . . cxr final report history: 75-year-old woman with pea arrest, status post intubation, evaluate for et tube placement and cardiopulmonary process. comparison: radiograph at 20:11. chest radiograph portable ap view: interval withdrawal of endotracheal tube now ending 4.7 cm above the carina. nasogastric tube extending into the stomach with the tip out of view. bibasilar mild lung patchy opacities are unchanged. right moderate pleural effusion is unchanged. there is no pnemothorax. stable mild cardiomegaly. the mediastinal and hilar contours are normal. unchanged position of the venous guidewired ending in a stent in the left brachiocephalic vein. impression: 1. interval withdrawal of endotracheal tube ending 4.7 cm above the carina. 2. stable bilateral mild lung opacities and right moderate pleural effusion. 3. guidewire retained in stented left brachiocephalic vein. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 8:27 pm . . . temp line / wire removal report: impression: 1. occlusion of the bilateral distal internal jugular veins and right subclavian vein with multiple chest wall collaterals precluding placement of a hemodialysis catheter. 2. uncomplicated placement of a 20 cm double-lumen temporary hemodialysis catheter vip via the right common femoral access with the tip terminating in the ivc. the catheter is ready to use. 3. successful removal of an indwelling vascular guidewire which was identified extending from the left common femoral central venous catheter. the study and the report were reviewed by the staff radiologist. dr. dr. approved: 8:34 am . . . tagged wbc scan final report radiopharmaceutical data: 439.0 uci in-111 wbcs (); history: 76 year-old female with persistent mrsa bacteremia and rising wbc count; recent avf ligation. interpretation: following the injection of autologous white blood cells labeled with in-111, images of the whole body were obtained at 24 and 48 hours. these images show a small focus of increased tracer uptake in the left upper arm near the elbow which may correlate with her history of a left upper extremity avf ligation and likey represents an area of inflammation versus infection. no increased tracer uptake is seen tracking up the arm; there are no other foci of increased tracer uptake. impression: 1. small focal tracer uptake in the left upper arm near the elbow, likely representing an area of inflammation versus infection. 2. no other evidence of inflammatory/infectious foci. , m.d. , m.d. approved: 2:34 pm . . . tte the left atrium and right atrium are normal in cavity size. there is mild symmetric left ventricular hypertrophy with normal cavity size. there is mild regional left ventricular systolic dysfunction with mild hypokinesis of the inferior and inferolateral hypokinesis. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. there is moderate thickening of the mitral valve chordae. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is a trivial/physiologic pericardial effusion. impression: moderate mitral regurgitation. no vegetation or abscess seen. mild inferior/inferolateral hypokinesis. mild pulmonary artery systolic hypertension. if clinically suggested, the absence of a vegetation by 2d echocardiography does not exclude endocarditis. compared with the prior study (images reviewed) of , the estimated pulmonary artery systolic pressures are lower. the other findings are similar. electronically signed by , md, interpreting physician 13:20 . . . final report two view chest, comparison: . indication: preoperative assessment for av fistula revision. findings: cardiac silhouette is mildly enlarged, but may be accentuated by ap technique. mild pulmonary vascular congestion. new airspace consolidation has developed within the right middle and right lower lobes as well as mild associated volume loss. small right pleural effusion has slightly increased in size and appears partially loculated laterally. there is no left pleural effusion. skeletal structures are unchanged. impression: 1. new right middle and right lower lobe airspace opacification concerning for pneumonia with possible parapneumonic effusion. findings discussed by phone with dr. on . 2. mild pulmonary vascular congestion. dr. approved: 5:28 pm . . ct chest/abd/pelvis impression: 1. small to moderate right pleural effusion and small left pleural effusion are simple in nature. associated bibasal compressive atelectasis is greater on the right than left lung. 2. no evidence of abscesses or infections in the chest, abdomen, and pelvis. 3. findings suggestive of chronic pancreatitis are stable. the study and the report were reviewed by the staff radiologist. dr. dr. approved: sat 10:58 am . . . final report pa and lateral chest, history: question abscess on previous chest radiograph, does not seem to have pneumonia. impression: pa and lateral chest compared to and : the right perihilar lung has cleared at least radiographically since , , probably due to decreasing moderate-sized right pleural effusion. the right hilus is still mildly enlarged, probably due to adenopathy and should be followed. left hilus is normal. heart is mildly enlarged. no left pleural effusion. no pneumothorax. there is no evidence of pneumonia. dr. approved: mon 3:44 pm . . . brief hospital course: # fevers / bacteremia / infected av fistula: 76 year old female with dmii, esrd on hd, dchf, cva, dementia who was initially admitted to the micu for fever and hyperkalemia with ecg changes. she underwent hd and was called out to the medical floor with improvment of her k. at baseline she is disoriented to person, place, mumbling speech, ambulating with walker; np altered from baseline and in setting of fever and elevated lactate strongly suggests underlying infectious etiology; initally, most likely etiology thought to be colitis apparent on ct abdomen; patient high risk for diff colitis given past history of recent antibiotic use. she was noted to be bacteremic with mrsa, coag negative staph and corynebacerium on . she was started on vancomycin on . initially there was also a concern for intra-abominal process and so she was started on cipro/flagyl. c. diff was negative and ct abd/pelvis was without infectious etiology. cipro/flagyl were d/c'd on . lung also possible but initial cxr unremarkable. urine less likely source give anuric. cns possible source given fever and ams although less likely with ct findings and absence of meningeal signs on pex. sacral decub possible source although no signs around area of infection. endocarditis possible source given murmur, but no embolic phenomena visualized and murmur is not acute; tte was unremarkable. reports of difficulty threading wire in ed through ij and concern for clot raises concern of septic thrombus. throughout hospitalization, her graft site was determined to be the likely site of infection. for the work up of her fevers/baceremia she then underwent a tte which was unrevealing and an u/s of her fistula/graft and stent in her left ij which were also unrevealing. the pt could not tolerate a tee despite attempts twice by cardiology. patient was scheduled to go to hd on but, the hd team did not feel comfortable using her fistula due to oozing. transplant sugery was contact and planned to put her on the or schedule that night. on the floor at approximately 1730 that day, she was found by nursing to be in a pool of blood and was bleeding from her fistula site. her sbp at that time was 54. a code blue was called and she was intubated while she still had a pulse. normal saline was infused and while surgery was attempting femoral access she lost her pulse and went into pea arrest. acls was started and her pulse returned after 8 minutes. during that time, transplant surgery cut down the fistula and tied the brachial artery and some veins off and packed the antecubital fossa with gauze and wrapped an ace bandage around her arm. she was transferred to the micu for further care where she had received the massive blood transfusion protocol including 5u prbc, 2u platelets, 2u ffp. arctic cooling protocol was discussed after her pea arrest but deferred given patient's improved/return to baseline mental status shortly after the event. it was also noted that a guide-wire from an emergent femoral a-line was mistakenly left in place and migrated to the abdominal aorta during the code and noticed afterwards while the patient was in ir for a hd catheter placement. this guide-wire was removed by ir without any complications. during her micu stay, her hypovolemic shock was stabilized and her hd access issues were addressed with renal, id, and transplant surgery. a temporal femoral vip line was placed and used for dialysis for two sessions. transplant surgery recommended to continue dressing changes and no or at that time. she was transferred back to the floor on daptomycin at this point but still growing positive blood cultures with staph aureus. repeat tte on was negative for vegetations. a wbc scan showed small tracer uptake at the graft site, without any other source in the body. surgical revision was re-discussed and the transplant team agreed to perform a surgical revision to remove infected graft material, which pathology/micro showed to be growing staph aureus. since that time her blood cultures have remained negative and she was able to have a tunneled hd catheter placed for long term hd access. there was minimal bleeding over 24 hrs at the catheter tunneled site which ir injected with thrombin and achieved hemostasis, the patient should not be weight bearing for 12 hours after this. she is to have 6 weeks of vancomycin (her graft mrsa was sensitive to vanc) starting from 6 weeks after removal of infected graft material, dated from , to end . # diabetes type ii. she was continued on humalog insulin sliding scale. she was placed on a diabetic diet. # diastolic chf, chronic. she has diastolic hf based on prior tte and cxr with signs of mild fluid overload, but no signs of respiratory distress. we continued hd for fluid removal. bb was held initially given concern of evolving sepsis. this was restarted prior to discharge. aspirin and statin were also restarted prior to discharge on the patient stabilized. # dementia. her baseline mental status is poor in setting of vascular dementia. per discussion with nh staff, patient receives psychotropics for agitation (trazodone, citalopram, and olanzapine), as well as prn olanzapine. the psychotropics were held this admission due to her altered mental status. citalopram, risperdone prn were continued while we held trazadone, olanzapine. # hypertension. initially her bp meds were held in the acute setting, however upon discharge she was on hydralazine, amlodipine, labetalol with good bp control. # hypothyroid. we continued her home synthroid. tsh was 3.4 during this admission. # anemia. baseline hematocrit of 30-35, likely secondary to esrd. her hematocrit returned to baseline s/p massive transfusion protocol for her hypovolemic shock/pea arrest and continued to remain stable throughout the rest of her hospital admission. # cva. aspirin was held when she was in the micu in the setting of acute bleed. # hyperlipidemia. we restarted her home statin. # code: full code (confirmed) # contact: (daughter) (c) / (h) medications on admission: hiss omeprazole 20 mg daily amlodipine 2.5 mg daily cinacalcet b complex vitamin vitamin d colace 100 mg po bid labetalol 300 mg po tid calcium hydralazine 50 mg po qid simvastatin 40 mg daily levothyroxine 75 mcg daily citalopram 5 mg daily nephrocaps daily olanzapine 5 mg qhs and prn for agitation trazodone 50 mg qhs discharge medications: 1. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous asdir (as directed). 2. levothyroxine 75 mcg tablet sig: one (1) tablet po daily (daily). 3. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 4. memantine 5 mg tablet sig: one (1) tablet po daily () as needed for dementia. 5. risperidone 1 mg/ml solution sig: 0.5 mg po hs (at bedtime) as needed for insomnia/agitation. 6. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: two (2) capsule, delayed release(e.c.) po daily (daily). 8. simvastatin 40 mg tablet sig: one (1) tablet po daily (daily). 9. acetaminophen 500 mg tablet sig: two (2) tablet po q 8h (every 8 hours) as needed for pain. 10. heparin (porcine) 1,000 unit/ml solution sig: one (1) injection prn (as needed) as needed for line flush. 11. labetalol 100 mg tablet sig: three (3) tablet po tid (3 times a day). 12. oxycodone 5 mg tablet sig: 0.5 tablet po q4h (every 4 hours) as needed for pain. 13. lidocaine 5 %(700 mg/patch) adhesive patch, medicated sig: two (2) adhesive patch, medicated topical daily (daily). 14. vancomycin in dextrose 1 gram/200 ml piggyback sig: one (1) intravenous hd protocol (hd protochol): should be stopped on . 15. amlodipine 5 mg tablet sig: two (2) tablet po daily (daily). 16. sevelamer hcl 400 mg tablet sig: four (4) tablet po tid w/meals (3 times a day with meals). 17. hydralazine 25 mg tablet sig: two (2) tablet po q8h (every 8 hours). 18. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 19. docusate sodium 50 mg/5 ml liquid sig: two (2) po bid (2 times a day) as needed for constipation. discharge disposition: extended care facility: - discharge diagnosis: primary diagnoses: hyperkalemia with ekg changes bacteremia with mrsa av fistula graft infection . secondary diagnoses end-stage renal disease on hemodialysis type ii diabetes vascular dementia hypertension osteoarthritis cataracts hypothyroidism anemia diastolic congestive heart failure s/p cerebrovascular accident discharge condition: afebrile, stable vitals, tolerating pos . mental status:confused - always level of consciousness:lethargic but arousable activity status:out of bed with assistance to chair or wheelchair discharge instructions: you were admitted to the hospital for treatment of high potassium levels in the blood and bacteria in your blood. your potassium normalized with dialysis. an extensive workup was conducted throughout your body and it was determined that the bacteria was coming from an infection in your av fistula/graft. initially, we could not perform a surgery on this site to remove the infectious nidus; however, the graft led to a serious bleed which required multiple blood products. you had a guide wire left in your aorta as well but this was succesfully found and retrieved without any complications. you continued to have positive blood cultures despite being on iv antibiotics after this time and ultimately had a graft revision by transplant surgery after which time your blood cultures remained negative. you had placement of a tunneled hd catheter for dialysis which initially had small amounts of bleeding which was ultimately controlled. . the following changes were made to your medicines: - please take vancomycin for 6 weeks after removal of infected graft material, dated from , to end . - please take amlodipine 10mg daily - please take hydralazine 50mg every 8 hrs - please stop taking aspirin 81mg due to concerns for bleeding around your hd catheter site - please stop taking olanzapine and trazodone there were no other changes to your medicines. . please attend all appointments. please do not hesitate to return to the hospital for any concerning symptoms at all. . followup instructions: please follow up with the following appointments: . transplant surgery: , md phone: date/time: 10:00 . infectious disease: provider: , md phone: date/time: 10:10 procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified insertion of endotracheal tube hemodialysis venous catheterization for renal dialysis removal of arteriovenous shunt for renal dialysis diagnoses: pneumonia, organism unspecified hyperpotassemia end stage renal disease renal dialysis status congestive heart failure, unspecified acute posthemorrhagic anemia severe sepsis hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease acute respiratory failure cardiac arrest other shock without mention of trauma peripheral vascular complications, not elsewhere classified pressure ulcer, lower back diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled encephalopathy, unspecified other and unspecified infection due to central venous catheter other complications due to renal dialysis device, implant, and graft mechanical complication of other vascular device, implant, and graft chronic diastolic heart failure vascular dementia, uncomplicated cerebral atherosclerosis methicillin resistant staphylococcus aureus septicemia pressure ulcer, stage ii 

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