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: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain, distention major surgical or invasive procedure: diagnostic paracentesis x 3 picc line placement x 2 endotracheal intubation x 3 arterial line placement x 2 left ij cvl history of present illness: 35 yo m with cerebral palsy who initially presented with abdominal pain and distention to an osh. ct scan was performed and was reported as diffuse bowel edema, gastric varices, ascites and a pancreatic cyst. he reportedly had no associated nausea, vomiting, diarrhea, hematemesis, hematochezia, jaundice, fevers or dysuria. also reported no recent weight loss, no nsaids or asa use. in ed, his initial vitals temp 98.0 hr 100 bp 83/59 rr 20. he then received unasyn at the osh. foley placed, recieved ivf and was transferred to . patient was non-verbal, in distress. per family, patient had multiple admissions prior for constipation, with a recent drainage of a pancreatic cyst this past year in . he has a bowel movement everyday except on the day of presentation to the osh. he tolerated po and was at his baseline the night of his presentation. his abdomen was distended and painful to palpation according to his mother, which is why she brought her son to the osh. upon transferred to and admitted to the sicu team given concern for an acute surgical abdomen. diagnostic paracentesis () with wbc (no growth so thought to be inflammatory state), lipase 216, amylase 141. he was started on vanco/zosyn/flagyl for suspected peritonitis and ischemic bowel with translocation. he was then intubated (in the ed) for respiratory failure. a left subclavian line was placed on . he was then given phenytoin but this was transitioned to keppra the same day. on vitamin k 1mg was infused. tpn started . he was continued on maintenance ivf with intermittent bolus but on was given lasix. on he was started on heparin gtt for smv thrombus. did have diarrhea, but improving over the course of admission. with 3l therapeutic / diagnostic paracentesis (negative culture to date, wbc 1390). concerning his respiratory status, he was extubated (s/p 4 days of mechanical ventilation) and re-intubated given increased secretions and concern that he was unable to protect his airway. on warfarin was started and flagyl was discontinued. on tobramycin was added for suspected untreated infection given lower blood pressures. upon transfer there is no positive culture data. patient has been febrile > 100.5 on and but without leukocytosis. also with persisent tachycardia > 100 bpm except for and . cta abdomen / pelvis with smv thrombus, vascular surgery consulted and thought it was likely a chronic issue given degree of collaterals and probably due to chronic pancreatic inflammation with associated vascular congestion and slowing. given no acute surgical issues, patient was transferred to the medical icu team on . upon initial evaluation, family at bedside confirms that he felt unwell for about one week prior to admission. he is nonverbal at baseline, but will push your hand away if you push his abdomen and he's in pain. otherwise, no localizing symptoms. past medical history: cerebral palsy seizure disorder chronic anemia - hct 35 gib in h/o liver cyst drainage (, ) h/o laproscopic cholecystectomy h/o pancreatic cyst drainage with chronic pancreatitis social history: lives at home with family, goes to school 5 days a week, no recent travels, no smoke/drink/ivdu. family history: nc, maternal grandmother had dm, paternal grandfather had htn, parents healthy. physical exam: upon transfer to micu 98.3, 79, 100/70, 22, 100% simv , 12, tv 300, 50% cvp 13 gen: thin, no apparent distress but slight tearing in left eye; alert heent: sclera anicteric, eyes sunken, mmm, et in place neck: supple, jvp not elevated, no lad lungs: clear to auscultation bilaterally anteriorly, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, flat, patient pushes hand away with palpation in luq/llq, bowel sounds present, no guarding, unable to assess rebound tenderness gu: foley in place ext: warm, very thin, cannot palpate radial pulses or dp b/l, no cyanosis or edema pertinent results: admission labs: 12:25pm blood wbc-8.8 rbc-3.91* hgb-10.7* hct-34.6* mcv-89 mch-27.4 mchc-31.0 rdw-20.8* plt ct-202 12:25pm blood neuts-83* bands-11* lymphs-4* monos-2 eos-0 baso-0 atyps-0 metas-0 myelos-0 12:25pm blood hypochr-2+ anisocy-2+ poiklo-normal macrocy-1+ microcy-1+ polychr-normal 12:25pm blood plt smr-normal plt ct-202 12:25pm blood glucose-92 urean-13 creat-0.5 na-142 k-4.4 cl-108 hco3-25 angap-13 12:25pm blood alt-15 ast-20 alkphos-146* totbili-0.1 12:25pm blood albumin-2.1* 07:59pm blood vanco-6.1* 10:05am blood tobra-0.7* 06:00am blood vanco-72.3* ----------------- discharge labs: ----------------- studies: cxr: 1. low lung volumes. no focal consolidation. 2. small bowel wall thickening and dilation, better evaluated on the outside hospital ct. . kub: impression: no evidence of free air. there is a relative paucity of bowel gas on this study; distended loops of fluid-containing small bowel cannot be excluded. . ctap: impression: 1. diffusely abnormal gastrointestinal tract with mucosal hyperenhancement and wall thickening. given the finding of smv occlusion, findings are highly concerning for venous congestion/ischemia. an element of shock bowel could also be a possibility. 2. hyperenhancement of the adrenal glands and narrowed distal aorta, iliac and femoral vessels, suggesting hypovolemia/shock. correlate clinically. 3. sequelae of chronic pancreatitis with a rim-enhancing fluid collection in the region of the pancreatic head, likely representing pseudocyst. this may be the etiology of smv thrombosis. 4. diffusely abnormal hepatic parenchyma, consistent with the history of hepatitis. partially occlusive right portal vein thrombus. 5. small bilateral pleural effusions, increased from the prior exam. ground- glass and nodular opacities at the lung bases suggesting infection. . tte: technically limited study; overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. at least mild to moderate aortic stenosis is present (but cannot be fully quantified). no aortic regurgitation is seen. there is no pericardial effusion. . renal us 1. small size and echogenic appearance of the kidneys consistent with chronic, diffuse parenchymal disease. no hydronephrosis. 2. ascites. . abdomen us impression: small ascites. again noted probable pseudocyst in the midline and collateral vessels related to the smv thrombosis. . : kub multiple dilated loops of large and small bowel, more prominent is colonic dilation. findings are concerning for large bowel obstruction. . : kub interval increase in gaseous distension of a segment of colon in the lower abdomen. appearance is nonspecific, but distal colonic obstruction cannot be excluded and further evaluation by ct should be considered. . : kub there has been apparent placement of a rectal tube (recommend clinical correlation with recent procedural history). there has been decrease in degree of distention of a prominent loop of bowel in the lower mid abdomen, likely representing sigmoid colon, with decrease in maximal diameter from about 10 cm to 8.6 cm in transverse width. other air- filled loops of small and large bowel appear relatively similar to the recent radiograph. by report, there is clinical concern for perforation. either an upright or left lateral decubitus abdominal radiograph would be recommended to evaluate for free intraperitoneal air. alternatively, a ct could be performed. . : ct abd/pelvis indication: 35-year-old man with known microperforation, small-bowel obstruction and colonic dilatation. increased abdominal distention. technique: ct imaging of the abdomen and pelvis was performed following the administration of oral and intravenous contrast. multiplanar reconstructions were generated. comparison: comparison is made to prior ct performed . findings: ct abdomen: small bilateral basal pleural effusions have decreased in size in comparison to the prior ct. there has also been partial resolution of atelectasis and consolidation in the basilar segments of both lower lobes. a nasogastric tube is in situ with tip in the gastric body. there is moderate gaseous distention of the stomach. there is marked distention of the sigmoid colon with gas and debris, although mural thickening is less prominent than on ct performed . a rectal catheter is in situ. the remainder of the colon is less distended than the sigmoid colon, but also contains fluid and gas throughout. no discrete transition point is identified within the large bowel. the small bowel is not significantly dilated. no free fluid or gas is seen within the abdomen or pelvis. the patient is status post cholecystectomy. no focal parenchymal abnormality is identified in the liver. the pancreas is atrophic in appearance as on prior scan. calcifications are again identified at the pancreatic head. a 1.7 cm x 1.4 cm cystic lesion at the pancreatic head seen on the prior ct is again identified, but is of higher attenuation than on the previous scan. a cortical cyst at the mid pole of the right kidney measuring 1.4 cm x 1.2 cm is unchanged from prior study. no other focal renal lesion is seen. the adrenal glands and spleen are normal in appearance. a small amount of free fluid is seen in the abdomen and pelvis, which has decreased in comparison to the prior ct scan. small bowel dilatation is less prominent than on the prior scan. there is occlusion of the superior mesenteric vein at the level of the pancreas (series 2, image 28), but the proximal portion of the vein remains patent. extensive collateral vessels are again identified in the perigastric area. the portal vein and left and right portal branches are patent. ct pelvis: no pelvic lymphadenopathy is seen. the urinary bladder appears unremarkable, but is pushed anteriorly by the distended rectum and sigmoid colon. marked degenerative changes are seen in the thoracolumbar spine with scoliosis convex to right. impression: 1. marked distention of the rectum and sigmoid colon with gas and fluid. the distention is more marked than on the prior scan , but the degree of mural thickening in the sigmoid colon has decreased in comparison to ct . a catheter is in situ within the lumen of the distatl sigmoid colon. mild distention with gas and fluid in the remainder of the colon. 2. no free intraperitoneal gas is seen. ascites has decreased in volume in comparison to the prior ct. 3. occlusive thrombus is again identified in the distal portion of the superior mesenteric vein. the portal vein remains patent. : portable abdomen history: colonic distension with rectal tube supine abdomen: there is marked dilation of large bowel, with sigmoid colon measuring up to 9.8 cm, overall unchanged when compared to prior study. there is no free intraperitoneal air or pneumatosis. surgical clips are seen in the right upper quadrant. the bladder is filled with contrast. the rectal tube is not seen on today's study. impression: unchanged marked colonic/sigmoid dilation. : portable abdomen history: vomiting. comparison: multiple priors including . supine and upright abdomen: unchanged marked dilation of large bowel with sigmoid colon measuring up to 10 cm in diameter, may represent chronic air swallowing pattern. there is no free intraperitoneal air or pneumatosis. surgical clips are seen in the right upper quadrant. nasogastric tube is seen in appropriate position. impression: unchanged marked large bowel dilation. : ct abd/pelvis clinical indication: history of smv occlusion and large bowel obstruction, with worsening abdominal distention and new hypotension. technique: mdct of the abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast and oral contrast. comparison exam is dated . findings: limited images of the lung bases demonstrate small left pleural effusion, unchanged and trace right pleural fluid. there is bibasilar atelectasis, left greater than right. a feeding tube is seen terminating in the third portion of the duodenum. compared to the prior exam, there is increased abdominal ascites, which is slightly hyperdense, measuring 30 hounsfield units in some areas. there has been interval development of marked colonic wall thickening involving the ascending colon, descending colon, sigmoid and rectum. the transverse colon appears relatively spared. there is an area of mass-like hyperdense thickening of the descending/transverse colon junction (2:63). additionally, hyperdensity is seen tracking along the descending colonic wall, likely representing hemorrhage. compared to the prior exam, there is decreased distention of the rectum and sigmoid colon. a rectal tube is now in place. there is a new hyperdense left retroperitoneal collection extending from just inferior to the left kidney into the pelvis, interposed between the rectum and bladder and displacing the bladder anteriorly and inferiorly. there are a few foci of gas in the left rectus muscle. additionally, there is a focus of gas which appears to be intraperitoneal (2:62), that was not clearly present on the prior exam. it is not clear whether this is extraluminal or not. there is no contrast extravasation. there are prominent small bowel loops with diffuse distention, but no evidence of transition point. the small bowel is non-thickened. again noted are numerous venous collaterals related to known smv occlusion. the portal vein again reconstitutes and is patent, as is the splenic vein. the pancreas is atrophic with multiple calcifications in the region of the head, consistent with chronic pancreatitis. the gallbladder is surgically absent. there is a right renal cyst. the left kidney, adrenal glands and spleen are unremarkable. pelvis: the bladder contains a foley catheter with contrast and foci of gas. there are no pathologically enlarged lymph nodes. there is diffuse mild anasarca. bone windows demonstrate scoliosis and degenerative changes of the spine. there are no focal suspicious lesions. impression: 1. interval development of marked colonic thickening involving the ascending colon, descending colon, sigmoid and rectum, concerning for colitis, possiblby on the basis of venous obstruction. there is hyperdense mass-like thickening at the junction of the descending colon and transverse colon, which is new from the prior exam and consistent with hemorrhage. hyperdensity is also seen along the descending colonic wall, also likely representing hemorrhage. there is a focus of gas which appears to be within the peritoneal cavity (2:62), not present on the prior study. this is not clearly extraluminal and no oral contrast extravasation is seen, although perforation cannot be fully excluded. 2. interval development of a large left retroperitoneal hematoma extending in the pelvis. 3. prominent small bowel distention diffusely, consistent with ileus. 4. increased abdominal ascites, slightly hyperdense, suggesting a component of hemoperitoneum. 5. numerous collateral vessels related to known smv occlusion. this appears stable from the prior exam, and the portal vein is patent and reconstituted. : picc line placement indication: iv access needed for iv access and fluids. the procedure was explained to the patient. a timeout was performed. radiologist: dr. performed the procedure. dr. , the attending radiologist who was present and supervising throughout. technique: using sterile technique and local anesthesia, the left brachial vein was punctured under direct ultrasound guidance using a micropuncture set.hard copies of ultrasound images were obtained before and immediately after establishing intravenous access. a peel-away sheath was then placed over a guidewire and a double-lumen picc line measuring 36 cm in length was then placed through the peel-away sheath with its tip positioned in the svc under fluoroscopic guidance. position of the catheter was confirmed by a fluoroscopic spot film of the chest. the peel-away sheath and guidewire were then removed. the catheter was secured to the skin, flushed, and a sterile dressing applied. the patient tolerated the procedure well. there were no immediate complications. impression: uncomplicated ultrasound and fluoroscopically guided 5 french double-lumen picc line placement via the left brachial venous approach. final internal length is 36 cm, with the tip positioned in svc. the line is ready to use. after placing the left-sided picc line, the right picc line, which is thought to be infected, was removed and the tip sent for culture and sensitivities. sterile dressings applied. : portable abdomen history: improving sbo, known dilated colon. abdominal distention. supine & upriht abdomen: slightly improvement of diameter of prominent loops of large bowel measuring up to 6.4 cm and previously measured up to 11 cm. there is no free intraperitoneal air or pneumatosis. impression: slightly improvement of mildly dilated loops of large bowel. no free intraperitoneal air. : left wrist left wrist clinical history: trauma and pain. ap and lateral films of the wrist and a somewhat motion limited ap film of the forearm were obtained. on the somewhat oblique lateral film there is a vertical lucency projected at the anterior aspect of the radius which is probably artifactual. no fracture is seen on the ap view. the carpal bones are normally aligned. impression: the study is somewhat technically limited. no definite fracture is seen. if the patient's symptoms persist, a repeat view might be of use. : left humerus clinical history: fracture. ap, oblique and scapular y views of the left humerus were obtained. there is a fracture in the region of the surgical neck of the humerus with medial displacement of the shaft relative to the humeral head. a catheter likely a picc line, is noted. impression: there is a mildly displaced fracture in the region of the surgical neck of the left humerus. : ct torso clinical indication: history of cerebral palsy with smv occlusion, partial small-bowel obstruction, colonic and retroperitoneal hemorrhage with worsening abdominal distention, tenderness, hematocrit drop and fever. technique: mdct of the chest, abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast and oral contrast. comparison exam is dated . findings: chest: there are small bilateral pleural effusions, increased from the prior exam. there are calcifications of the aortic valve, and the ascending aorta is ectatic, measuring 3.9 cm. the descending aorta is normal in caliber. a right-sided venous catheter terminates in the svc. there are no pathologically enlarged thoracic lymph nodes. lung windows demonstrate compressive atelectasis. there are no focal nodules or masses. the central airways are patent. abdomen: the liver, spleen, left kidney, adrenal glands are unremarkable. the gallbladder is surgically absent. there is a stable right renal hypodensity. again noted is atrophy of the pancreas with calcifications in the head, consistent with chronic pancreatitis. a feeding tube terminates in the duodenum. compared to the prior exam, there has been interval resolution of small bowel dilatation. colonic wall thickening has also improved, with minimal residual thickening in the descending colon in the area of prior hemorrhage. there is increased abdominal ascites. again noted is occlusion of the superior mesenteric vein, with numerous collaterals. the portal veins are patent. left retroperitoneal hemorrhage is stable. pelvis: previously seen hemorrhage interposed between the rectum and bladder is resolved. there is increased pelvic ascites with some layering high density posteriorly. there is stable rectal and sigmoid thickening. there are no pathologically enlarged lymph nodes. bone windows demonstrate degenerative changes and scoliosis, without focal suspicious lesion. impression: 1. interval resolution of small bowel dilatation, and near interval resolution of high density thickening of the descending colon. persistent sigmoid and rectal thickening. increased abdominal and pelvic ascites with some layering high density posteriorly. stable left retroperitoneal bleed and interval resolution of hemorrhage seen between the rectum and bladder. 2. small bilateral pleural effusions, increased from the prior exam. 3. stable occlusion of the smv, with numerous collaterals. 4. dilatation of the ascending aorta and marked calcification of the aortic valve for the patient's age. this finding could indicate a bicuspid valve. : cta chest and ct abdomen and pelvis with contrast indication: 35-year-old man with sudden onset of hypoxia, tachypnea and fever since yesterday. known smv clot, evaluate for pe. comparison study: ct torso from and chest x-ray from . technique: mdct of the chest, abdomen and pelvis was performed following the uneventful administration of nonionic intravenous contrast. coronal, sagittal and multiple oblique reformatted images were reviewed per pe protocol. findings: chest: the endotracheal tube is in satisfactory position. an ng tube terminates within the stomach. the ascending aorta is mildly ectatic at 3.8 cm. the descending aorta is normal in caliber. a left-sided picc line terminates in the svc. there are no enlarged axillary, mediastinal or hilar lymph nodes. there is new patchy multifocal airspace consolidation, particularly within the left upper lobe and medial segment right middle lobe consistent with pneumonia. there are increased moderate bilateral pleural effusions with compressive atelectasis. there is no pulmonary embolism within the main, lobar or segmental pulmonary arteries. abdomen: there is new ill-defined area of hypoattenuation within segment v of the liver measuring 2.8 x 3.5 cm. this may represent a developing abscess. there is stable marked ascites. the patient is status post cholecystectomy. the spleen, pancreas and adrenal glands are unremarkable. the kidneys have symmetric nephrograms. there is a 1.2 cm low attenuating lesion within the mid pole right kidney, incompletely assessed on this contrast-enhanced study. there is no evidence of small-bowel obstruction. there is stable thickening of the sigmoid colon and rectal wall. there is continued dilation of the colon. there is a stable left retroperitoneal hemorrhage which now appears more organized. bone windows show degenerative change and scoliosis without focal suspicious lesion. impression: 1. new bilateral patchy pneumonia, particularly within the left upper lobe and right middle lobe. 2. new ill-defined 2.8 x 3 cm hypoattenuating lesion in segment v of the liver. this may be secondary to a developing abscess. follow-up ultrasound is recommended in 3 days. 3. persistent sigmoid and rectal thickening with stable marked abdominal and pelvic ascites. 4. stable left retroperitoneal bleed, more organized. 5. increased moderate bilateral pleural effusions. : transthoracic echocardiogram the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. there is mild to moderate global left ventricular hypokinesis suggested(lvef = 45 %). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the number of aortic valve leaflets cannot be determined. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the patient is more tachycardic. the lv systolic function now appears depressed. the aortic valve gradient appears similar. if indicated, a tee would better clarify the basis and severity of the aortic stenosis (as well as global lv systolic function). : ruq ultrasound indication: 35-year-old man with possible liver abscess, to assess for interval change. comparison: ct torso, . findings: liver has a normal echotexture without evidence of focal liver lesions. the hypoenhancing lesion, seen in the prior ct scan, is not visualized in the ultrasound study. this likely represents an infarct of the liver, secondary to compromised blood supply through the right portal vein. there is no intrahepatic or extrahepatic biliary dilatation. patient is status post cholecystectomy. common duct measures 5 mm. a moderate amount of right pleural effusion and ascites are seen. impression: 1. no son correlate corresponding to the hypoenhancing lesion seen on prior ct of is seen. lesion seen on ct could represent an infarct secondary to compromised blood supply through the right portal vein, which appears nearly occluded. 2. right pleural effusion and ascites. : transthoracic echocardiogram right ventricular chamber size is normal. with mild global free wall hypokinesis. the number of aortic valve leaflets cannot be determined. the aortic valve leaflets are moderately thickened. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. moderate (2+) mitral regurgitation is seen. impression: moderately thickened and deformed aortic valve leaflets with moderate to severe stenosis. at least moderate mitral regurgitation. small echodensity in the left atrium adjacent to the anterior leaflet of the mitral valve (clip ) which appears consistent with artifact from mitral annular and valvular calcification; however, a small vegetation cannot be excluded. mild global biventricular hypokinesis. if clinically suggested, the absence of a vegetation by 2d echocardiography does not exclude endocarditis. compared with the prior study (images reviewed) of , the findings are similar. : video oropharyngeal swallowing study indication: 35-year-old man with pneumonia, assess for aspiration. video oropharyngeal swallowing fluoroscopy: oropharyngeal swallow fluoroscopy was performed in conjunction with the speech and swallow division. this is a limited study with nectar and thick consistencies of barium only used. no aspiration or penetration was noted for nectar or thick consistencies. impression: limited study with no aspiration or penetration for thick and nectar consistencies. for additional details, please see omr speech and swallow division note. : portable cxr ap chest, 09:48 a.m., history: shortness of breath, question interval change. impression: ap chest compared to through : pulmonary edema has cleared from the periphery of the lungs. central consolidation persists. whether this is pneumonia or pulmonary edema is radiographically indeterminate. small bilateral pleural effusions are presumed. heart size is normal. mediastinal vascular engorgement persists. no pneumothorax. nasogastric tube ends in the third portion of the duodenum. brief hospital course: # abdominal pain: the patient presented with abdominal pain. the patient was found to have a pancreatic cyst, smv thrombus, ascites and diffuse bowel thickening. the pancreatic cyst was seen on prior images and felt to be unchanged in appearance. the smv thrombus appeared chronic in nature. he was started on anticoagulation that will need to be continued for at least 6 months. this should be followed by the vascular surgeons. the ascites had a diagnostic tap which showed a leukocytosis. he was broadly covered with vancomycin and zosyn for secondary peritonitis. no bacteria grew on cultures. he had a total of 2 weeks of this course. the patient also had diffuse bowel thickening that was of unknown etiology but concerning for edema vs inschemia. he had a low lactates so edema more likely. the patient had a ctap on which showed partial small bowel obstruction vs ileus and gas in the bowel suggestive of a microperforation. surgery was contact and the patient was kept on intermittent low suction and remained npo. he received another 2 weeks of antibiotics with ciprofloxacin and metronidazole. after he finishes his course of antibiotics he will need another imaging study to evaluate for ascites. if he does have ascites he will need a paracentesis with cell count and differential. the patient passed speech and swallow and was fed with po food. his pain was controlled with iv morphine and tylenol. at the time of discharge the patient had no evidence of abdominal pain and was not requiring analgesics. . # gib: on , mr. developed coffee-ground emesis, abdominal pain, hct drop (30.8 to 24.6) and hypotension to sbps in the 60s, and was transferred to the micu. he received 3 units of prbcs in response to hct drop with appropriate response. he was seen by gi and the general surgery service, and ct scan of the abdomen was obtained showing retroperitoneal bleed. anticoagulation for smv thrombosis was held, and the patient's abdominal pain improved steadily over 48 hours, at which time his family felt that he was back to his baseline and abdominal distension (appreciated on transfer) had resolved. ngt placed to suction showed no further evidence of ugib, so endoscopy was deferred. the patient was initially placed on low-dose phenylephrine to maintain sbp > 75, but this was weaned within 48 hours. sbps remained low (upper 70s-90s) but this was consistent with patient's recent baseline and small size. he was observed in the unit for an additional 24 hours, during which time hct and bps remained stable, and he was called out to the floor. there were no more gib episodes since then. his hct has been stable during the rest of his hospital stay. . # humeral fracture: the patient was noted to have left arm pain after he got a new picc line in the micu. a x-ray of the lue was done, which showed left humeral fracture. it was unclear what caused the fracture. the suspicion is that the fracture occured when he was down in the radiology department to get picc line. patient was seen by orthopedics, who recommended a repeat shoulder film. after all the imaging was obtained, orthopedics recommende...... . # nutrition: the patient presented with a very low albumin level suggesting very poor nutrition status. the patient was started on tpn and remained npo. as his abdominal pain improved he was started on slow tube feeds which he tolerated well. the patient passed a speech and swallow evaluated and ate po food and the ngt was discontinued. he will need to continue tpn for the next month. he should also consider a peg tube as his prior nutrition was inadequate. . # acute renal failure: the patient has a baseline of 0.4-0.5. his creatinine peaked at 1.2. the most likely etiology was thought to be secondary to atn secondary to nephrotoxic . ivf failure to return cr to baseline. he had medications renally dosed and nephrotoxins were avoided. . # anemia: the patient has a baseline hct of 35. he was guaiac and ng lavage negative on admission. he required multiple transfusions for hct under 21. he showed some anemia of chronic disease/iron deficiency anemia. no evidence of hemolysis and b12, folate normal. will need iron supplementation as an outpatient. patient had gib and rp hematoma on anticoagulation on , and anticoagulation was stopped. patient was transferred to micu and required 3u prbc transfusion. his hct has been stable during the rest of his hospital stay. . # respiratory failure: the patient was intubated for respiratory failure. the patient had a lll infiltrate on cxr. he was treated with vancomycin and zosyn for hap/vap. the patient was extubated and quickly weaned to room air with normal oxygen saturation. . # smv occlusion: this appears to be chronic given the number of collaterals. he will need to be maintained on anticoagulation for 6 months per vascular surgery. he was on a lovenox bridge to warfarin with a goal inr of . . # seizure disorder: the patient was started on fosphenytoin and phenobarbital. his levels were adjusted. he had daily episodes of "absence seizures". he will need close follow up as an outpatient. outpatient neurology openheimer (). . # hypotension: the patient has a baseline systolic blood pressure in the 80s. the patient remained near his baseline as an inpatient. . micu course . # hypoxemia: the patient was transferred to micu with tachypnea and hypoxia on . he was initially started on bipap and did well for several hours, even weaning off of the bipap. unfortunately, the patient became increasingly hypoxemic and required intubation on . imaging at that time was consistent with multilobar pneumonia with sputum growing mrsa. the patient completed an 8 day course of vancomycin, cefepime, and flagyl on . . pleural effusions were also noted on imaging, likely due to fluid resuscitation for hypotension in the setting of albumin of 2.3, so the patient was aggressively diuresed with lasix boluses. . prior to extubation, the patient was made dnr/dni after long discussion with family. after optimization, the patient was extubated on to face mask and nasal cannula. oxygen requirement thought due to pulmonary edema, mucous plugging and secretions, also restrictive with low lung volumes in setting of ascites. . during the patient's last several days in the micu, he had improvement in o2 requirement with continued gentle diuresis. . the patient was started on standing lasix 40mg po bid. . # yeast bacteremia: the patient was noted to have low grade fevers. on , a urine culture regurned with > 100k yeast. on , a blood culture returned that was also growing yeast we suspected possible urogenital source with hematogenous spread. heart rate and blood pressure currently at baseline. normal wbc count, lactate. . the patient was initially started on micafungin while speciation and identification were finalized. the infectious disease service was consulted and followed the patient. the yeast was speciated as albicans that was fluconazole sensitive. on the day of discharge the patient was started on fluconazole and micafungin was discontinued. he should have lfts monitored every three days while on fluconazole for a total course of 14 days. . the patient's lines and foley catheter were replaced during this time. a new picc line was placed on . . the patient had daily surveillance blood cultures that did not show evidence of any further fungemia. . dilated fundoscopic exam on neg for apparent chororetinal lesions with signif corneal scarring. recommend repeat dfe in 2 weeks of if patient having any procedure requiring general anesthesia. on lacrilub gtts. . #fevers: the patient had daily low grade febrile episodes despite broad spectrum antibiotics. completed treatment for pulmonary infection with 8 day course of vancomycin, cefepime, flagyl. sbp possible but 3 taps have not been c/w sbp. pe considered but no evidence on cta. ct read as possible liver abscess but repeat ruq ultrasound read as more consistent with infarct. c. diff has been negative. the low grade fevers were then though to be due to positive urine and blood culture growing yeast. repeat cultures of blood, urine ngtd. . # tachycardia: the patient had persistent tachycardia into the 110s that was likely hyperdynamic in setting of fever and infection. volume status appeared grossly euvolemic; pt mentating at baseline and maintaining urine output. echo with evidence of depressed cardiac fxn, ? tachycardia induced cardiomyopathy. the patient's baseline hr has been consistently 100-115 bpm. . it should also be noted that the patient's baseline systolic blood pressure is between 80-100 mmhg. we were obtaining blood pressures via a thigh cuff as this more likely represented his true blood pressure. . # anemia/bleed: pt with retroperitoneal bleed and ct evidence of hemorrhage into bowel wall, also gastric varices c/b gib earlier in admission. he was transfused 1 unit prbcs with appropriate bump and has remained stable since. . his hematocrits were trended daily and stools were guaiac negative. . he was continued on po pantoprazole and iron supplementation. . # liver lesion. the patient had a noted on abdominal ct with concern for possible ischemia/infarction vs abscess. abdominal u/s not consistent with abscess. . # left humeral fx: likely d/t trauma sustained during radiology. patient briefly received morphine for pain control and also continued to receive lidoderm patches for comfort. no lab draws were conducted on the left arm. there was no indication for surgical intervention. . # smv thrombus: the initial plan for the smv thrombus was for anticoagulation x 6 months, but in the setting of recent gi and rp bleed all anticoagulants were discontinued. . the patient was restarted on heparin sq for dvt prophylaxis. . # seizure disorder: no recent reports of seizures. the patient was maintained on his home doses of phenobarbitol and fosphenytoin. drug levels were checked frequently and were in the therapeutic window. . # cerebral palsy: stable mental status. interactive with family but nonverbal at baseline. . fen: continue tube feeds while fully transitioning to po diet cleared for nectar thick liquids, pureed solids; needs 1:1 observation (mother may need to feed). ok to try crushed meds, but may not take reliably. . medications on admission: medications (upon admission) miralax prn phenobarbital 32.4 mg tab am, 1pm dilantin (extended caps) 75mg in am 100mg in pm ferrous fumarate 324 mg tabs daily mvi daily cyproheptadine hcl 4mg tabs 0.5 tab in am, 0.5 tabs in pm prilosec 20mg daily celexa 20mg daily zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold sore vitamine d 400 unit caps medications (upon transfer to micu service) albuterol 0.083% neb soln 1 neb ih q6h:prn low oxygen sats piperacillin-tazobactam 4.5 g iv q8h midazolam 0.5-1 mg iv q4h:prn comfort of ett fentanyl citrate 12.5-100 mcg iv q2h:prn pain pantoprazole 40 mg iv q12h magnesium sulfate iv sliding scale calcium gluconate iv sliding scale levetiracetam 1000 mg iv q12h insulin sc (per insulin flowsheet) sliding scale dextrose 50% 12.5 gm iv prn hypoglycemia protocol glucagon 1 mg im q15min:prn hypoglycemia protocol acetaminophen 325 mg po/ng q6h:prn fever, pain potassium chloride iv sliding scale chlorhexidine gluconate 0.12% oral rinse 15 ml oral tobramycin 220 mg iv q24h vancomycin 1250 mg iv q 12h heparin iv sliding scale warfarin 5 mg po/ng daily16 discharge medications: 1. miconazole nitrate 2 % cream : one (1) appl topical (2 times a day). 2. camphor-menthol 0.5-0.5 % lotion : one (1) appl topical qid (4 times a day) as needed for itching. 3. cortisone 1 % cream : one (1) appl topical qid (4 times a day) as needed for itching. 4. lidocaine 5 %(700 mg/patch) adhesive patch, medicated : one (1) adhesive patch, medicated topical daily (daily). 5. ferrous sulfate 300 mg (60 mg iron)/5 ml liquid : one (1) teaspoon po daily (daily). 6. lipase-protease-amylase 5,000-17,000 -27,000 unit capsule, delayed release(e.c.) : one (1) cap po tid (3 times a day). 7. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 2-4 puffs inhalation q4h (every 4 hours) as needed for wheeze. 8. acetaminophen 650 mg tablet : one (1) tablet po q6h (every 6 hours) as needed for pain/fever. 9. polyvinyl alcohol-povidone 1.4-0.6 % dropperette : drops ophthalmic prn (as needed) as needed for dry eyes. 10. phenobarbital 30 mg tablet : one (1) tablet po bid (2 times a day). 11. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 12. phenytoin 50 mg tablet, chewable : two (2) tablet, chewable po q 8h (every 8 hours). 13. white petrolatum-mineral oil 42.5-56.8 % ointment : one (1) appl ophthalmic qid (4 times a day) as needed for dry eyes. 14. heparin (porcine) 5,000 unit/ml solution : one (1) injection (2 times a day). 15. furosemide 40 mg tablet : one (1) tablet po bid (2 times a day). 16. morphine 2 mg/ml syringe : milligrams milligrams injection q4h (every 4 hours) as needed for pain. 17. sodium chloride 0.9% flush 10 ml iv prn line flush picc, non-heparin dependent: flush with 10 ml normal saline daily and prn per lumen. 18. sodium chloride 0.9% flush 3 ml iv q8h:prn line flush peripheral line: flush with 3 ml normal saline every 8 hours and prn. 19. fluconazole 400 mg iv q24h 20. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. discharge disposition: extended care facility: - - discharge diagnosis: primary: (1) hypoxic respiratory failure (2) health care associated pneumonia (3) fungemia (4) fungal urinary tract infection (5) retroperitoneal bleed (6) superior mesenteric vein thrombus (7) large bowel obstruction (8) acute peritonitis (9) hypotension (10) sepsis (11) left humerus fracture (12) gastric varices (13) ascites (14) ileus (15) gi bleed secondary: (1) cerebral palsy (2) seizure disorder (3) anemia discharge condition: mental status: confused - always. level of consciousness: alert and interactive (nonverbal) activity status: bedbound. discharge instructions: mr. , it was a pleasure to care for you during your hospitalization at the . during this hospitalization, you were treated for a superior mesenteric vein thrombus with blood thinning agents, but unfortunately you had bleeding in your abdomen that required the blood thinning medicines to be stopped. during this hospitalization, you also had difficulty breathing, likely due to pneumonia and fluid overload, that required intubation and ventilator assistance. you further had a pneumonia, and required medications to keep your blood pressure in a normal range. an infection was found in your blood as well as your urine (yeast) and you were treated with anti-fungal medications. unfortunately, your left arm was broken during this hospitalization. please continue to take all of your medicines as previously prescribed before this hospitalization. do not take any blood thinning (anticoagulant) medications. the following medications have been added to your regimen: (1) fluconazole 400mg iv ever 24 hours x 14 days followup instructions: you are being discharged to a rehab facility. please contact your primary care physician for follow up appointment in weeks. procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances enteral infusion of concentrated nutritional substances percutaneous abdominal drainage percutaneous abdominal drainage percutaneous abdominal drainage diagnoses: other primary cardiomyopathies thrombocytopenia, unspecified acute kidney failure with lesion of tubular necrosis unspecified pleural effusion acute posthemorrhagic anemia unspecified septicemia severe sepsis portal hypertension candidiasis of other urogenital sites perforation of intestine hypopotassemia 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 disseminated candidiasis other ascites varices of other sites ventilator associated pneumonia chronic pancreatitis other and unspecified coagulation defects chronic vascular insufficiency of intestine unspecified intestinal obstruction other specified peritonitis cyst and pseudocyst of pancreas hemoperitoneum (nontraumatic) generalized nonconvulsive epilepsy, with intractable epilepsy infantile cerebral palsy, unspecified closed fracture of surgical neck of humerus hepatic infarction methicillin resistant pneumonia due to staphylococcus aureus malnutrition of moderate degree body mass index between 19-24, adult 

Answer: The patient is high likely exposed to