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: nifedipine attending: chief complaint: cough/fever major surgical or invasive procedure: : intubation, bronchoalveolar lavage, extubation history of present illness: mr. is a 61-year-old gentleman, with a past medical history of ph+ all in remission s/p chemotherapy (dva, gleevec) and s/p mud myeloablative all-bmt (today d+209) c/b gvhd of the liver, cmv viremia, r leg zygomycetes infection treated with ambisome/micafungin c/b picc line thrombus and , now day +209 post-transplant, being admitted with acute onset fever, cough and uri symptoms for the past 2-3 days. while upper respiratory symptoms began three days ago, patient first noted fever of 100.2 this morning. patient has had malaise, aches, vomiting and cough productive of white sputum sputum as well. he notes diarrhea, two bowel movements per day, for the past three days, and episodes of vomiting when he takes his pills with water. because of his vomiting and diarrhea, he has had decreased oral intake. he also notes headaches, responsive to tylenol, without any visual changes or neck stiffness. he denies any chest pain, shortness of breath, neck stiffness, changes in vision, hematuria, dysuria, hematochezia, hematemesis or new rashes. he notes that the infection on his left leg is improving. of note, his wife has been sick at home with an ear infection and cough. on , the patient visited with his five grandchildren, aged 10, 9, 7, 2 and 1. also of note, on afb grew out from bal a months ago, but is still speciating; dr. thinks this may be . . in clinic today, the paitent was febrile to 102.1. he received meropenem and micafungin. on arrival to the floor, the patient was feeling alright, but tired. . . review of systems: (+) per hpi (-) denies chills, night sweats, recent weight loss or gain. denies blurry vision, diplopia, loss of vision, photophobia. denies sinus tenderness or congestion. denies chest pain or tightness, palpitations, lower extremity edema. denies shortness of breath or wheezes. denies constipation, abdominal pain, melena, hematemesis, hematochezia. denies dysuria, stool or urine incontinence. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. all other systems negative. past medical history: oncologic history he originally presented to ed with dyspnea on exertion and lower extremity edema. labs showed him to be anemic with a hgb of 7.1 and hct of 21 and thrombocytopenic with a platelet count of 13,000. his white count was normal at 6.3 but he had 11% bands in his differential. a bone marrow biopsy was performed and per osh records pathology was consistent with acute leukemia, although no heme/path reports were sent. mr. was then transferred on to for further evaluation. . a repeat bone marrow biopsy was done on , pathology was consistent with all. cytogenetics showed the presence of bcr-abl gene rearrangement in 90/100 cells. he was started on hyper c-vad part a on , which was complicated by tumor lysis syndrome and low-grade dic. he was also started on gleevec. during his nadir on he spiked a fever and was started on cefepime and vancomycin. blood cultures from that day returned with 2/4 bottles positive for mrsa. his picc was therefore pulled on and the tip was sent for culture, which came back negative. an echo showed no signs of vegetation, and a replacement picc was placed after 48 hours of remaining afebrile. several days later he spiked fevers again and was noted to have infiltrates on ct suggestive of multi-focal pneumonia, a subsequent bronch with bal demonstrated mrsa. repeat echo again did not show any evidence of vegetations. he was discharged home on with his picc line to continue iv vancomycin for 3 weeks (end ). of note, mr. creatinine began to rise from a baseline of 0.7-0.9to a max of 2.4 on . this was felt to be secondary to an episode of relative hypotension coupled with toxic levels of vancomycin. vanco was held and then renally dosed, after which he had only a slight improvement in his creatinine. a bone marrow biopsy on day +23 of his treatment showed no evidence of leukemia and normal cytogenetics indicative of remission. . after his discharge on , he was re-admitted on with a diffuse rash and a rue dvt at his picc. the rash was thought to be due either to nifedipine, which was started during his prior admission for hypertension, or vancomycin, although this was thought to be less likely because he did not havedesquamation. instead of completing a 3 week course of vancomycin, this drug was stopped after approximately 2 weeks due to development of his rash as per id recommendations, and he was discharged on off antibiotics. an ultrasound of his right arm prior to discharge showed resolution of the previously noted dvt. . he was re-admitted on for fatigue, new cough, and a elevated white blood cell count of 14.0. he was subsequently discharged on after receiving iv fluids and starting on a course of po linezolid. during this admission his gleevec dosage was increased from 300 mg daily to 400 mg daily. an lp with prophylactic it methotrexate administration was also attempted during hospitalization but was unsuccessful. ultimately he ended up having 4 weekly doses of prophylactic it methotrexate given locally by dr. , his last dose was on . . he was admitted for his transplant on , day 0 was . his post-transplant course has been complicated by mrsa bacteremia, acute kidney injury d/t tacrolimus toxicity (was accidentally given 10 mg of tacro versus 1 mg), urinary bk virus, and cmv viremia requiring therapy with foscarnet. see dischargesummaries in omr for details regarding these admissions. . on day +98 he was re-admitted with sudden onset ruq abdominal pain and fever. an ultrasound showed gallbladder sludge without cholecystitis and an ercp was performed revealing blocked common bile duct. a sphincterotomy was performed with extraction of sludge, stone fragments, and a small amount of pus.his total bilirubin was elevated to 10.3 several days s/p ercp with stenting. a repeat ercp and mrcp showed no residual biliary obstruction. a liver biopsy was then performed which showed a mixed picture of gvhd infectious cholangitis. he was started on steroids for gvhd and his total bili had decreased to 2.5 upondischarge on . . in , pulmonary nodules noted on ct scan, and aspergillus in sputum. in , patient was readmitted with right leg mucor infection. at which point, he started treatment with ambisome and micafungin, which were continued as an outpatient, with treatment course complicated by picc line thrombus. . other past medical history: - colon cancer - s/p r hemicolectomy with anastomosis - muir- syndrome - a subset of the syndrome which stems from msh2 deletion - hemorrhoids - hypercholesteremia - lvh - hypertension - sebaceous carcinoma status post removal - right thigh malignant mass, status post surgery - ercp on and for blocked cbd, s/p sphincterotomy and stent placement - vre bacteremia on daptomycin - liver biopsy showed a mixed picture of gvhd and a neutrophil predominent proscess consistent with infectious cholangitis - gvhd of the gut, improved with steroids - cmv viremia social history: lives in with his wife, who is his healthcare proxy. 2 adult daughters and 5 . worked as saw operator cutting aluminum, not currently working d/t leukemia diagnosis. no history of alcohol intake, no smoking. denies chemical exposures. family history: multiple cancers in family including mother with uterine cancer, father who passed of lung cancer. one of his brothers passed of brain cancer at age 15, another brother also has syndrome and also has colon cancer. one of his daughters did also test positive for mutation. physical exam: admission physical exam: vs: 97.2 140/58 (by leg) 84 18 94%ra height 69 in., weight 164.8 lbs. gen: well-appearing, elderly, white male. comfortably lying in bed, nad. heent: mmm, ncat, clear oropharynx, no ulcers/thrush neck: no cerv/supraclav lad lungs: wheezes on the left. right lungfield with decreased breath sounds to halfway up lungfield. decreased breath sounds at at left lung base. bibasilar crackles. heart: tachycardic, regular rhythm, no mrg. normal s1/s2. abd: soft, non-distended, non-tender, no hsm, no masses. normoactive bowel sounds. extr: no edema, 2+ peripheral pulses skin: right anterior proximal shin with two black skin ulcers, with minimal surrounding erythema, no ttp, oozing or fluctuance. access: right upper arm picc without oozing or erythema. . discharge physical exam: afebrile gen: elderly, white male. nad in bed. very pleasant. heent: mmm, ncat, clear oropharynx, no ulcers/thrush neck: no cerv/supraclav lad lungs: ctab, good air movement bilaterally heart: rrr, no mrg. normal s1/s2. abd: soft, non-distended, non-tender, no hsm, no masses. normoactive bowel sounds. extr: no edema, 2+ peripheral pulses skin: unchanged right anterior proximal shin with two black skin ulcers, with minimal surrounding erythema, no ttp, oozing or fluctuance. access: right upper arm picc without oozing or erythema. pertinent results: admission labs: 08:05am blood wbc-1.9* rbc-2.79* hgb-9.6* hct-27.3* mcv-98 mch-34.3* mchc-35.1* rdw-17.9* plt ct-38* 08:05am blood neuts-63 bands-1 lymphs-19 monos-17* eos-0 baso-0 atyps-0 metas-0 myelos-0 nrbc-1* 08:05am blood hypochr-normal anisocy-normal poiklo-1+ macrocy-normal microcy-normal polychr-normal ovalocy-1+ 08:05am blood urean-25* creat-1.5* na-134 k-4.3 cl-104 hco3-18* angap-16 08:05am blood alt-16 ast-12 ld(ldh)-202 alkphos-169* totbili-1.4 08:05am blood calcium-8.8 phos-4.1 mg-1.6 08:05am blood igg-259* iga-8* igm-11* 08:05am blood tacrofk-less than 05:02pm urine color-yellow appear-clear sp -1.011 05:02pm urine blood-neg nitrite-neg protein-30 glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-neg 05:02pm urine rbc-1 wbc-2 bacteri-few yeast-none epi-<1 . relevant labs: 08:05am blood igg-259* iga-8* igm-11* 06:10am blood triglyc-232* 02:46am blood ret aut-3.3* 03:32pm sputum from bronchoalveolar lavage polys-58* lymphs-8* monos-33* basos-1* 03:32pm sputum from bronchoalveolar lavage polys-28* lymphs-13* monos-0 mesothe-5* macro-54* other-0 03:59pm blood ammonia-35 07:21pm cerebrospinal fluid (csf) wbc-0 rbc-4* polys-0 lymphs-9 monos-0 macroph-91 07:21pm cerebrospinal fluid (csf) totprot-69* glucose-82 . discharge labs: 06:00am blood wbc-3.8* rbc-2.77* hgb-9.1* hct-23.9* mcv-86 mch-32.8* mchc-38.1* rdw-17.5* plt ct-44* 06:00am blood neuts-62 bands-0 lymphs-30 monos-7 eos-0 baso-0 atyps-0 metas-1* myelos-0 06:00am blood pt-12.0 ptt-26.9 inr(pt)-1.1 06:00am blood glucose-98 urean-43* creat-1.4* na-137 k-3.6 cl-106 hco3-22 angap-13 06:00am blood alt-22 ast-15 ld(ldh)-205 alkphos-145* totbili-1.2 06:00am blood calcium-8.9 phos-4.8* mg-1.8 . microbiology: blood cultures x2: negative : c. diff toxin: negative : fecal culture: negative : campylobacter culture: negative : urine culture: negative : urine legionella antigen: negative : stool ova and parasites: no o+p seen : stool crypto/giardia: no cryptosporidium or giardia seen : respiratory viral antigen: positive for rsv antigen : respiratory viral culture: positive for rsv : blood culture: negative : urine viral culture: (prelim) negative : beta glucan: negative : aspergillus antigen: 0.1 (negative) : adenovirus pcr: not detected : quantiferon gold: indeterminate : sputum acid fast smear x2: negative : sputum acid fast culture x2: grown in culture (prelim) : cmv vl: not detected : sputum acid fast smear: negative : sputum acid fast culture: no mycobacteria (prelim) : stool c. diff pcr: negative : blood cultures x2: negative : urine culture: negative : stool norovirus antigen: negative : stool o+p: negative : stool viral: (prelim) negative : stool rotavirus antigen: negative : cmv vl: not detected : blood fungal culture: no fungus isolated : blood afb culture: no mycobacteria : blood culture: no growth : bronchoalveolar lavage: gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. respiratory culture (final ): ~1000/ml commensal respiratory flora. acid fast smear (final ): no acid fast bacilli seen on direct smear. no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. fungal culture (final ): no fungus isolated. potassium hydroxide preparation (final ): test cancelled, patient credited. this is a low yield procedure based on our in-house studies. if pulmonary histoplasmosis, coccidioidomycosis, blastomycosis, aspergillosis or mucormycosis is strongly suspected, contact the microbiology laboratory (7-2306). immunoflourescent test for pneumocystis jirovecii (carinii) (final ): negative for pneumocystis jirovecii (carinii).. reported to and read back by tan # @, . respiratory viral antigen screen (final ): positive for respiratory viral antigens. specimen screened for: adeno, parainfluenza 1, 2, 3, influenza a, b, and rsv by immunofluorescence. . respiratory virus identification (final ): positive for respiratory syncytial virus (rsv). viral antigen identified by immunofluorescence. csf cryptococcal antigen: not detected blood cryptococcal antigen: not detected cmv vl: not detected c. diff toxin: negative . imaging: : non-contrast ct chest large, longstanding goiter, predominantly left sided, still displaces the trachea to the right and narrows it minimally. central lymph nodes are not pathologically enlarged. right pic line ends at the superior cavoatrial junction. small pericardial and tiny right pleural effusion are unchanged. previous tiny left pleural effusion has resolved. this study is not designed for subdiaphragmatic evaluation. once again, there is air in the gallbladder and a 14-mm hypodensity in the interpolar region of the left kidney, probably a cyst, present without appreciable change since . confirmation that this is a cyst and not an abscess should be obtained with renal ultrasound, if not already performed. there is no adrenal mass. extensive bronchiolar consolidation in the posterior and apical segments of the left upper lobe, in the superior segment of the left lower lobe, and in the lateral and posterior basal segments of both lower lobes, converges into consolidation at the left base is all new since when there was only a very small region of bronchiolar nodulation in the superior segment of the right lower lobe, subsequently cleared. also improved since the previous study are a 6-mm wide fluid filled cavity in the superior segment of the right lower lobe that was 8 mm in and an 8-mm wide cavity in the right middle lobe that was at least 16 mm. the bronchial tree is normal to subsegmental levels. there are no bone findings suspicious for malignancy. schmorl's nodules and osteophytes at multiple levels in the thoracic spine are degenerative changes. impression: 1. new widespread pulmonary infection, predominantly involving small airways, with progression to bronchocentric consolidation. this is more likely viral or bacterial infection than fungal. 2. regression of two right lung cavities, consistent with slowly clearing infection, either fungal or bacterial. 3. likely left renal cyst should be confirmed by ultrasound. 4. chronic gas collection in the gallbladder has been attributed to manipulation. 5. large goiter. chronic small pericardial effusion. . lue u/s: grayscale and doppler son of the bilateral subclavian veins and the left internal jugular, left axillary, left brachial, left basilic, and left cephalic veins were performed. there is normal flow and compressibility. impression: no left upper extremity dvt. . portable cxr: the trachea is deviated rightward secondary to an enlarged thyroid. hazy opacities are seen in the right upper lobe, right lower lobe, and left lower lobe. these appears similar to the opacities seen on the recent ct scan, and likely represent an atypical infection. it does not appear to be worsening. there is no pleural effusion or pneumothorax. the cardiomediastinal silhouette is normal. impression: 1. multifocal pneumonia appears similar to recent ct scan and likely represents a viral or bacterial infection. would recommend serial chest radiographs until resolved. 2. stable rightward tracheal deviation secondary to known enlarged thyroid. . ct chest without contrast: overall, there has been little change in comparison to prior study from . again visualized are extensive bronchiolar consolidations in the right upper lobe (3:11), left upper lobe (3:24) left lower lobe (3:27, 37) and right lower lobe (3:35). these consolidations appear minimally more widespread and may be minimally worsened. however, there are no new foci of consolidations. previously visualized cavitary lesions including 8 mm fluid-filled cavitary lesion in the right middle lobe (3:27) and 6 mm fluid filled cavitary lesion in the superior segment of the left lower lobe (3:30) have remained stable. there are no new cavitary lesions. the airways are patent to the subsegmental levels. the non-opacified portions of the heart and great vessels appear stable with atherosclerotic calcifications of the aortic arch. large longstanding goiter, predominately on the left side, continues to deviate the trachea to the right and narrow it minimally. right picc tip remains in the superior cavoatrial junction. small pericardial effusion appears stable. osseous structures: there are no suspicious lytic or sclerotic osseous lesions. schmorl's nodes and osteophytes at most levels in the thoracic spine remain stable. the study is not tailored for evaluation of subdiaphragmatic structures. however, the visualized portion of the liver, gallbladder, spleen, and stomach appear normal. impression: 1. previously visualized widespread pulmonary infection appears stable to minimally worsened. this infection is likely bacterial in etiology. there is, however, no evidence of new foci of infection. 2. stable appearance of two right lung cavities. 3. large thyroid goiter appears stable. . ct head without contrast: there is no evidence of hemorrhage, edema, mass, mass effect, or infarction. the sulci and ventricles are normal in size and configuration. there is preservation of -white matter differentiation and the basal cisterns are patent. no fracture is identified. calcification of bilateral carotid siphons is noted. of note, there are air-fluid levels in both maxillary and sphenoidal sinuses with presence of secretions in the sphenoidal sinuses. there is also near-complete opacification of the ethmoidal cells as well as concentric mucosal thickening of the left frontal sinus. the mastoid air cells and middle ear cavities are clear. no gross soft tissue abnormalities are present. impression: air-fluid levels in maxillary and sphenoid sinuses with nearly complete opacification of ethmoidal cells consistent with acute sinusitis. otherwise, there is no evidence of acute intracranial process or encephalitis. . mri head with and without contrast: there are no acute changes. there is no mass effect, midline shift or hydrocephalus. a previously noted foci of t2 hyperintensity in the subcortical white matter on the mri of are much less apparent and only few remaining foci are seen, which are unchanged from the earlier mri of . no abnormal parenchymal, vascular, or meningeal enhancement seen following gadolinium administration. soft tissue changes seen in the right mastoid air cells, both maxillary sinuses and of in the frontal and ethmoid sinuses. no evidence of blood products seen. impression: since the previous mri examination, the previously noted subcortical t2 hyperintensities are considerably decreased. no new abnormalities are seen. the examination now is unchanged compared to the examination of . no enhancing brain lesions or acute infarcts are seen. soft tissue changes seen in the paranasal sinuses and mastoid air cells. . bedside eeg: the background activity showed a symmetric hz theta rhythm which briefly improved up to 7 hz at times. there were frequent bifrontally predominant or independent, right more than left, frontocentral spike and wave epileptiform discharges with phase reversals at f4-c4 and c4. at times, these bifrontally predominant spike and wave epileptiform discharges appeared to be periodic at 2.5 hz for a few seconds at a time. on video, these discharges were not accompanied by any obvious clinical change. review of the continuous eeg showed frequent frontal discharges with a prolonged run of 1 hz periodic discharges in the frontal region for 10 seconds, but no video was available for clinical correlation. spike detection programs: there were 330 automated spike detections predominantly for electrode and movement artifact but also for the epileptiform discharges in the bilateral frontal and right frontocentral regions. seizure detection programs: there were 12 automated seizure detections predominantly for muscle artifact and for 2.5 hz periodic spike and wave bifrontal discharges. pushbutton activations: there were no pushbutton activations. sleep: no normal sleep morphology is recorded. cardiac monitor: showed a generally regular rhythm with an average rate of 80 bpm. impression: this is an abnormal continuous icu monitoring study because of frequent epileptiform discharges in the bilateral frontal or right frontocentral regions which are briefly periodic, at times, for few seconds without clear clinical change seen on video. there was a prolonged run of such discharges lasting 10 seconds suggestive of a brief electrographic seizure, but no video was available for clinical correlation. these findings are indicative of epileptogenic cortex in the bilateral frontal regions and right more than left. the background showed generalized slowing in the theta frequency range indicative of mild to moderate diffuse encephalopathy which is etiologically non- specific. . eeg with video: routine sampling/continous eeg: the background activity showed a symmetric 7 hz theta rhythm. there were frequent bifrontally predominant or independent, right more than left, frontocentral spike and wave epileptiform discharges with phase reversals at f4-c4 and c4. at times, these bifrontally predominant spike and wave epileptiform discharges appeared to be periodic at 1-2 hz for several seconds but did not have any clear clinical correlate. review of the continuous eeg showed frequent such discharges during the evening and night recording with two prolonged runs of 1 hz periodic discharges for 15 seconds. there was no video recording available at these times to clinically correlate with these runs of periodic discharges. spike detection programs: there were 507 automated spike detections predominantly for electrode and movement artifact but some entries were also for the epileptiform discharges in the bifrontal and right frontocentral regions. seizure detection programs: there were six automated seizure detections predominantly for muscle artifact. pushbutton activations: there were no pushbutton activations. sleep: no normal sleep morphology is recorded. cardiac monitor: showed a generally regular rhythm with an average rate of 80 bpm. impression: this is an abnormal continuous icu monitoring study because of frequent epileptiform discharges in the bifrontal or right frontocentral region which were briefly periodic at 1-2 hz, at times, for a few seconds without clear clinical correlate. there were two more prolonged bursts lasting up to 15 seconds consistent with electrographic seizures. these findings are indicative of potentially epileptogenic cortex in the bilateral frontal regions and right more than left. the background shows generalized background slowing in the theta frequency range, indicative of mild to moderate diffuse encephalopathy, which is etiologically non-specific. compared to the prior day's recording, there appears to be a deterioration due to the more frequent bifrontal epileptiform discharges and two prolonged bursts of periodic discharges lasting 15 seconds. . portable cxr: the hazy opacifications on the right have resolved. the right lung is now clear without consolidation. at the left base, the previously seen opacification persists. there is no pleural effusion or pneumothorax. there is no pulmonary edema. the cardiomediastinal silhouette is normal. impression: 1. improvement in previously seen right-sided pneumonias. 2. stable left opacification is likely a persistent pneumonia. . bedside eeg with video: routine sampling/continuous eeg: the background activity showed a symmetric 7 hz activity with excess diffuse beta activity. there were frequent bifrontally predominant or independent right more than left frontocentral spike and wave epileptiform discharges with phase reversal at f4-c4 and c4. at times, these bifrontally predominant spike and wave epileptiform discharges appeared to be periodic at 1.5-2 hz for few seconds with no prolonged discharges on continuous eeg. spike detection programs: there were no automated spike detections. seizure detection programs: there were four automated seizure detections predominantly for bursts of bifrontal discharges or for muscle artifact. pushbutton activations: there were no pushbutton activations. sleep: no normal sleep morphology was recorded. cardiac monitor: showed a generally regular rhythm with an average rate of 90 bpm. impression: this is an abnormal continuous icu monitoring study because of frequent epileptiform discharges in the bifrontal or right frontocentral region which were briefly periodic at times for few seconds. these findings are indicative of potentially epileptogenic cortex in the bifrontal, right more than left frontocentral regions. the background showed generalized slowing in the theta frequency range indicative of mild to moderate diffuse encephalopathy which is etiologically non-specific. compared to the prior day's recording, there appeared to be fewer bifrontal epileptiform discharges which were brief lasting two seconds and there was a slight improvement in the background rhythm. brief hospital course: mr. is a 61-year-old gentleman, with a pmh ph+ all in remission s/p chemotherapy (dva, gleevec) and s/p mud myeloablative allo-bmt c/b gvhd of the liver, cmv viremia, r leg zygomycetes infection treated with ambisome/micafungin c/b picc line thrombus and , admitted with fevers, malaise and uri symptoms, found to have rsv, with course complicated by seizures, acute on chronic gut gvhd, acute on chronic anemia, and brief orthostasis. . . active issues: # febrile neutropenia secondary to rsv pneumonia: patient's presentation, with overall malaise and upper respiratory symptoms were most consistent with a viral respiratory illness (most likely grandchildren were source of infection). the patient is immunocompromised, with a complicated infectious course. he is susceptible to bacterial infectious of the lungs, as well as fungal infections; most common bacterial pathogens including strep pneumo, h. flu and atypicals. patient was therefore be treated with broad antibiotics, and continue his home iv antifungals. ct appearance was most consistent with atypical bacterial pneumonia vs. viral pneumonia. rsv grew in nasopharyngeal swab culture from admission, and wasfloridly positive on bal . following bal, patient received palivizumab on . he improved rapidly after palivizumab. additionally, he received weekly iv ig to boost immune response, on , and . he was also provided with duonebs for shortness of breath and wheezing. as the patient has a slow-growing afb at the state lab from and afb on sputa from this admission, he was kept on airborne precautions. he will follow up in clinic, and he will also have a follow-up chest ct in weeks with an appointment in pulmonary clinic afterwards. . # seizures: patient developed confusion and decreased responsiveness on . initial differential for causes of encephalopathy included progression of pneumonia, lymphoma progression to cns, other infection (including meningitis/encephalitis), seizure with prolonged post-ictal period, and pe. less likely iatrogenic, as patient was not receiving any sedating medications. non-contrast ct head did not show any evidence of hemorrhage, edema or mass effect. mri head showed decreased subcortical t2 hyperenhancements when compared to prior, and no new abnormalities. after treatment with palivizumab for rsv pneumonia, he began to have some clearing of his encephalopathy. lp on was not consistent with infection. neuro-oncology weighed in, noting frontal lobar deficits on exam that raised suspicion for seizures. eeg confirmed abnormal activity in bilateral frontal lobes. patient was started on keppra with a loading dose. cause of seizures was most likely toxic-metabolic encephalopathy vs. lowered seizure threshold from fever, exacerbated by medications (?cefepime, ?tacrolimus). patient's mental status had cleared by the time of discharge. he was instructed to make an appointment for follow up with neurology. . # acute on chronic gvhd: patient with fluctuating volume and frequency of diarrhea during this admission. this was most likely secondary to gvhd, as steroids had been reduced in the context of severe infection. work-up for infectious diarrhea was negative, and lactate was normal. stool volume and frequency lessened with increased doses of steroids. prior to discharge, patient transitioned from methylprednisolone iv to prednisone po. patient was on pantoprazole iv for gi protection while on iv steroids as an inpatient. . # acute on chronic anemia: hematocrit fluctuated during this admission, ranging mostly 23-25. baseline chronic anemia is likely multifactorial, secondary to marrow suppression along with anemia of chronic disease. reticulocyte index was indicative of continued hypoproliferation. there were no overt signs of bleeding, and labs not consistent with hemolysis. there was likely some contribution from dilution of iv fluids. patient was prophylaxed with iv ppi. . # orthostasis: patient had a brief episode of orthostasis on . this was most likely secondary to infection, with poor po intake and deconditioning. adrenal insufficiency was less likely given ongoing steroids. at the time, blood pressure and fsbs were within normal range, with a high heart rate. patient was bolused, then kept on iv fluid hydration. orthostasis resolved. . . chronic issues: # all: in remission now s/p chemotherapy and allogeneic transplant. patient has had complicated course with gvhd, cmv viremia, aspergillosis, and mucor infection. cbc with diff was monitored, and antimicrobial medications were continued. . # right leg zygomycetes infection: patient and outpatient providers note that this is stable. patient continued home amphotericin b and micafungin. general surgery consult noted no need for inpatient debridement. patient to follow up in clinic. . # hypokalemia/hypomagnesemia: history of ongoing low potassium and magnesium, thought to be secondary to iv amphotericin treatment. as inpatient, patient was repleted with sliding scales. will follow up in outpatient clinic to determine best method of home repletion. . # chronic renal insufficiency: creatinine ranged 1.0-1.6 during this admission, around recent baseline 1.3-1.7. nephrotoxins were avoided, and medications were renally-dosed. . # history of lue picc-associated dvt: no associated pain. lue u/s on this admission showed resolution of thrombus. . # history of wide-complex tachycardia: no issues during this admission. patient continued home metoprolol. electrolytes were repleted as needed. . # history of bladder spasm: patient continued home dose oxybutynin as needed for spasms. . . transitional issues: # pulmonary team recommended that the patient have a follow up ct scan in weeks, followed by re-evaluation in pulmonary clinic to ensure resolution of pneumonia. # per neuro-onocolgy, patient should have a follow-up mri in two weeks. # patient will be followed closely in clinic. id providers will help determine course of valganciclovir, and ambisome/micafungin. # code: full medications on admission: medications - prescription albuterol sulfate - (prescribed by other provider) - 90 mcg hfa aerosol inhaler - 1 hfa(s) inhaled every 4-6 hours as needed for shortness of breath or wheezing 2 (two) puffs inhaled once prior to pentamidine treatments. given in interventional pulmonary. amphotericin b liposome - (discharge med) - 50 mg suspension for reconstitution - 400 mg iv every twenty-four(24) hours budesonide - (prescribed by other provider) - 3 mg capsule, delayed & ext.release - 1 (one) capsule(s) by mouth three times a day cefpodoxime - (prescribed by other provider) - 100 mg tablet - 2 tablet(s) by mouth every twelve (12) hours enoxaparin - (prescribed by other provider) (on hold from to unknown for platelets - 60 mg/0.6 ml syringe - 0.3 syringe(s) every twelve (12) hours 0.3 ml = 30 mg finasteride - (discharge med) - 5 mg tablet - 1 tablet(s) by mouth daily (daily) loperamide - (prescribed by other provider) - 2 mg capsule - 1 capsule(s) by mouth qam (once a day (in the morning)) stop if develop constipation lorazepam - 1 mg tablet - 1 tablet(s) by mouth every eight (8) hours as needed for nausea, anxiety, insomnia magnesium sulfate - (prescribed by other provider; dose adjustment - no new rx) - 2 gram/50 ml piggyback - 2 grams intravenously once a day metoprolol tartrate - 25 mg tablet - 1 (one) tablet(s) by mouth twice a day micafungin - (prescribed by other provider) - 100 mg recon soln - 100 mg intravenously every twenty-four(24) hours ondansetron - (prescribed by other provider) - 4 mg tablet, rapid dissolve - 1 tablet(s) by mouth every eight (8) hours as needed for nausea oxybutynin chloride - (discharge med) - 5 mg tablet - 1 tablet(s) by mouth twice a day as needed for prn bladder spasm oxycodone - (prescribed by other provider) - 5 mg tablet - 1 tablet(s) by mouth every four (4) hours as needed for pain pentamidine - 300 mg recon soln - 300 mg inhaled monthly. dilute in 6 ml sterile water, administer via aerosol. potassium chloride - (prescribed by other provider) - 40 meq/100 ml piggyback - 1 piggyback(s) once a day potassium chloride - 10 meq tablet extended release - 4 tablet(s) by mouth twice a day prednisone - (prescribed by other provider; dose adjustment - no new rx) - 10 mg tablet - 1 (one) tablet(s) by mouth once a day tacrolimus - (prescribed by other provider) - 0.5 mg capsule - 1 capsule(s) by mouth every twelve (12) hours (dose to be adjusted by dr. ursodiol - (discharge med) - 300 mg capsule - 1 (one) capsule(s) by mouth twice a day valganciclovir - 450 mg tablet - 1 (one) tablet(s) by mouth daily (daily) . medications - otc docusate sodium - (otc) - 100 mg capsule - 1 capsule(s) by mouth twice a day multivitamin - (discharge med) - tablet - 1 tablet(s) by mouth daily (daily) sennosides - (prescribed by other provider) - 8.6 mg capsule - 1 capsule(s) by mouth twice a day as needed for constipation discharge medications: 1. equipment bedside/portable commode for home. 2. budesonide 3 mg capsule, delayed & ext.release sig: one (1) capsule, delayed & ext.release po tid (3 times a day). 3. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: 1-2 puffs inhalation q4 hours prn as needed for shortness of breath or wheezing: and prior to inhaled pentamidine. 4. amphotericin b liposome 50 mg suspension for reconstitution sig: four hundred (400) mg intravenous q24h (every 24 hours). disp:*30 units* refills:*2* 5. finasteride 5 mg tablet sig: one (1) tablet po daily (daily). 6. loperamide 2 mg capsule sig: one (1) capsule po qam prn as needed for diarrhea. 7. lorazepam 1 mg tablet sig: one (1) tablet po q8 hours prn as needed for anxiety. 8. magnesium sulfate 2 gram/50 ml piggyback sig: two (2) grams intravenous once a day. 9. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day). 10. ondansetron 8 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8 hours prn as needed for nausea. 11. oxybutynin chloride 5 mg tablet sig: one (1) tablet po bid prn as needed for bladder spasm. 12. oxycodone 5 mg tablet sig: one (1) tablet po q4 hours prn as needed for pain. 13. pentamidine 300 mg recon soln sig: three hundred (300) mg inhalation once a month. 14. potassium chloride 40 meq/100 ml piggyback sig: forty (40) meq intravenous once a day. 15. potassium chloride 10 meq capsule, extended release sig: one (1) capsule, extended release po once a day. 16. prednisone 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*0* 17. ursodiol 300 mg capsule sig: one (1) capsule po twice a day. 18. valganciclovir 450 mg tablet sig: one (1) tablet po once a day. 19. keppra 500 mg tablet sig: one (1) tablet po twice a day. disp:*60 tablet(s)* refills:*0* 20. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day. 21. multivitamin tablet sig: one (1) tablet po once a day. 22. senna 8.6 mg capsule sig: one (1) capsule po daily prn as needed for constipation. 23. micafungin 100 mg recon soln sig: one hundred (100) mg intravenous q24h (every 24 hours). disp:*30 doses* refills:*2* discharge disposition: home with service facility: critical care systems discharge diagnosis: primary diagnoses: rsv pneumonia bilateral frontal lobe seizures . secondary diagnoses: chromosome positive all gvhd (gi) discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure to participate in your care here at ! you were admitted with malaise and fevers, and were found to have pneumonia from respiratory syncytial virus. you had a prolonged course of pneumonia, but improved with intravenous immunoglobulin and palivizumab (a specific antibody for respiratory syncytial virus). additionally, you developed seizures during your hospital course. we believe your seizures were due to your bad pneumonia, along with medications that can predispose you to seizures. the seizures improved after you started taking keppra (levetiracetam). please note, the following changes were made to your medications: # start keppra (levetiracetam) 500 mg by mouth twice daily # increase prednisone to 20 mg by mouth daily # stop cefpodoxime # stop tacrolimus # stop enoxaparin please continue all of your other medications as you had prior to your hospitalization. additionally, in weeks, you should have a follow-up chest ct to evaluate resolution of your pneumonia. this has been ordered for you. after you have the scan, you should be seen in the pulmonary clinic. you can make an appointment by calling: . it is important that you keep your follow up appointments as listed below. wishing you all the best! followup instructions: department: hematology/bmt when: tuesday at 12:00 pm with: , rn building: sc clinical ctr campus: east best parking: garage department: bmt chairs & rooms when: tuesday at 12:00 pm department: hematology/bmt when: tuesday at 1 pm with: , md building: sc clinical ctr campus: east best parking: garage * your follow-up chest ct scan has been ordered for you. this should be done any time between and . please schedule your scan by calling: . * please call to make an appointment in the pulmonology clinic 4-6 weeks after discharge (appointment should be after your ct scan). you will be called by the clinic regarding an additional appointment on wednesday with dr. . procedure: parenteral infusion of concentrated nutritional substances closed [endoscopic] biopsy of bronchus injection or infusion of immunoglobulin diagnoses: thrombocytopenia, unspecified pure hypercholesterolemia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified other convulsions hypopotassemia chronic kidney disease, unspecified other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure long-term (current) use of anticoagulants personal history of malignant neoplasm of large intestine complications of transplanted bone marrow personal history of venous thrombosis and embolism diarrhea encephalopathy, unspecified hypovolemia cytomegaloviral disease tachycardia, unspecified disorders of magnesium metabolism aspergillosis neutropenia, unspecified anemia in neoplastic disease zygomycosis [phycomycosis or mucormycosis] fever presenting with conditions classified elsewhere antifungal antibiotics causing adverse effects in therapeutic use pneumonia due to respiratory syncytial virus acute lymphoid leukemia, in remission graft-versus-host disease, unspecified other specified disorders of bladder 

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