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: no known allergies / adverse drug reactions attending: chief complaint: shock major surgical or invasive procedure: thoracentesis/bronchoscopy history of present illness: 84 yo m who h/o moderate as, copd, afib on coumadin, schf who was transferred from ed to ed for further management of septic shock and respiratory failure. . per the patient's three sons, he was noted to feel sob and tired for the past few days. this morning, he called his ex-wife to drive him to the as he was feeling unwell. at , he was found to be hypotensive with sbp in the 70s-80s with hr in the 40s-60s. due to concern for pna on cxr he was given ceftriaxone. given 2 liters ns. started on dopamine and levophed with continued sbps in the 70s-80s. femoral line placed. labs notable for a wbc of 9.7 with 27% eosinophilia. due to this finding he was given 100 mg of hydrocortisone. k was elevated at 6.6 and cr elevated at 5.5 (bl ~2-2.5), bun 149, inr: 6.7. lactate 2.3. guaiac negative. given cacl, insulin with amp d50. also intubated for tachypnea and hypoxia and started on fentanyl and versed. uop was 50 cc in total. vs prior to transfer: bp: 78/39 hr: 55. . in the ed, initial vs were: 32 degrees c rectal, 68, 14, 80/37 (on dopamine and levophed) 96% on ac. he was given vancomycin and zosyn as well as 3 liters of ns. a line was placed. also 2 18 g ivs. ct torso did not show any obvious catastrophy. echo performed by cards did not show any wall motion abnormalities, did suggest severe as. renal was called for possibility of hd and felt he could be medically managed for now. labs: lactate: 1.4 k: 5.2, abg: 7.02/46/516, inr 8.5. was given cacl, 1 amp of bicarb, dopamine at 20 and levophed at 0.3 . admitted for pna as he had evidence of bilateral basilar consolidation on ct. he was treated with a course of levofloxacin and his lasix was doubled to 40 mg daily. notably ct at that time showed pleural effusion and multifocal pna. thoracentesis at that time showed a transudate. . on arrival to the micu, patient is intubated and sedated. his dopamine was weaned down, however became bradycardic to the 40s. dopamine was increased, and hr increased to the 70s. maps well above 65. . past medical history: 1. bilateral pneumonia in early treated with levofloxacin 2. systolic heart failure, ejection fraction 40% to 45%. 3. chronic kidney disease stage iv. 4. coronary artery disease status post 3 vessel coronary artery bypass in . 5. chronic atrial fibrillation on anticoagulation. 6. chronic obstructive pulmonary disease/asthma 7. gout 8. hypertension 9. peripheral vascular disease s/p left fem- bypass 10. lt cea social history: per sons, he drinks glasses of wine daily and not a current smoker, but h/o heavy smoking. was staying with his son since his hospitalization in early , prior was ambulating and living independently. family history: unknown physical exam: vitals: t: 90 f bp: 142/64 p: 67 r: 21 o2: 100% ac 500 x 22 at fio2 100% and peep 10 general: intubated and sedated heent: sclera anicteric, dry mm, oropharynx with et tube neck: supple, jvp just below ear at 30 degrees, cv: irregular, normal s1 + s2, harsh systolic murmur, no rubs, no gallops lungs: rhonchi in anterior lung fields bilaterally, decreased sounds at the bases, right>left, abdomen: soft, non-tender, mildly distended, bowel sounds hypoactive, gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: left pupil (4) and right pupil (2), very sluggish. not following commands, sedated. skin: multiple diffuse excoriations on legs/torso and old bruise on chest. . pertinent results: admission labs: 06:07pm blood wbc-8.3 rbc-2.82* hgb-8.5* hct-27.6* mcv-98 mch-30.3 mchc-31.0 rdw-16.8* plt ct-120* 11:32pm blood neuts-84.7* lymphs-11.8* monos-1.7* eos-1.7 baso-0.2 06:07pm blood pt-83.2* ptt-56.6* inr(pt)-8.5* 11:55am blood cd4%-done 11:55am blood ipt-done 11:32pm blood alt-12 ast-23 ld(ldh)-291* ck(cpk)-123 alkphos-107 totbili-0.3 06:07pm blood lipase-45 06:07pm blood ctropnt-0.03* 11:32pm blood ck-mb-9 ctropnt-0.05* 06:34pm blood ck-mb-45* mb indx-15.4* ctropnt-1.38* 10:34pm blood ck-mb-45* mb indx-16.2* ctropnt-1.66* 06:10am blood ck-mb-27* mb indx-15.6* ctropnt-1.43* 11:32pm blood albumin-3.3* calcium-8.4 phos-5.3*# mg-2.0 11:32pm blood hapto-87 02:02pm blood %hba1c-5.7 eag-117 07:16am blood tsh-2.2 03:44am blood vanco-12.3 cbc/with diff: 03:50pm blood wbc-12.9* rbc-3.46* hgb-10.6* hct-33.0* mcv-95 mch-30.6 mchc-32.1 rdw-17.1* plt ct-118* 03:59am blood wbc-11.2* rbc-3.62* hgb-11.2* hct-35.6* mcv-98 mch-31.0 mchc-31.5 rdw-16.3* plt ct-115* 07:20am blood wbc-11.2* rbc-3.23* hgb-10.0* hct-31.4* mcv-97 mch-31.0 mchc-31.9 rdw-16.1* plt ct-124* 07:05am blood wbc-9.1 rbc-3.07* hgb-9.5* hct-30.0* mcv-98 mch-30.9 mchc-31.7 rdw-15.8* plt ct-121* 09:00am blood wbc-7.7 rbc-2.66* hgb-8.0* hct-26.2* mcv-99* mch-30.2 mchc-30.6* rdw-16.1* plt ct-102* 08:21pm blood wbc-7.6 rbc-2.59* hgb-8.0* hct-25.0* mcv-96 mch-31.0 mchc-32.1 rdw-16.0* plt ct-101* 03:15am blood wbc-8.4 rbc-2.65* hgb-8.1* hct-25.3* mcv-95 mch-30.8 mchc-32.3 rdw-16.0* plt ct-105* 04:09am blood wbc-12.0* rbc-2.68* hgb-8.5* hct-25.6* mcv-95 mch-31.5 mchc-33.1 rdw-16.0* plt ct-123* 03:54am blood wbc-9.7 rbc-2.66* hgb-8.3* hct-24.7* mcv-93 mch-31.0 mchc-33.4 rdw-16.0* plt ct-133* 04:48am blood wbc-7.5 rbc-2.51* hgb-7.6* hct-23.3* mcv-93 mch-30.3 mchc-32.6 rdw-16.4* plt ct-125* 11:32pm blood neuts-84.7* lymphs-11.8* monos-1.7* eos-1.7 baso-0.2 03:59am blood neuts-79* bands-0 lymphs-9* monos-8 eos-4 baso-0 atyps-0 metas-0 myelos-0 03:25am blood neuts-77.7* lymphs-10.2* monos-3.9 eos-8.0* baso-0.3 03:50pm blood neuts-79* bands-0 lymphs-8* monos-5 eos-6* baso-1 atyps-1* metas-0 myelos-0 03:59am blood neuts-84.3* lymphs-6.4* monos-2.9 eos-5.3* baso-1.1 07:20am blood neuts-81.6* lymphs-8.7* monos-3.5 eos-5.9* baso-0.4 07:05am blood neuts-75.4* lymphs-10.2* monos-4.1 eos-9.8* baso-0.5 09:00am blood neuts-83.4* lymphs-8.8* monos-3.9 eos-3.3 baso-0.6 03:15am blood neuts-82.0* lymphs-9.3* monos-3.2 eos-5.2* baso-0.3 04:09am blood neuts-82* bands-1 lymphs-5* monos-6 eos-6* baso-0 atyps-0 metas-0 myelos-0 11:55am blood cd5-done cd23-done hla-dr 7-done kappa-done cd2-done cd7-done cd10-done cd19-done cd20-done lambda-done cd16/56-done coag labs: 07:16am blood pt-43.4* ptt-46.3* inr(pt)-4.3* 12:17pm blood pt-48.6* ptt-46.1* inr(pt)-4.8* 06:10am blood pt-35.4* ptt-40.3* inr(pt)-3.4* 03:58am blood pt-22.8* ptt-32.6 inr(pt)-2.2* 04:19pm blood pt-20.3* ptt-32.7 inr(pt)-1.9* 04:52am blood pt-23.1* ptt-33.1 inr(pt)-2.2* 02:42pm blood pt-22.9* ptt-33.2 inr(pt)-2.2* 09:00pm blood pt-19.0* ptt-31.1 inr(pt)-1.8* 03:25am blood pt-22.9* ptt-36.1 inr(pt)-2.2* 03:50pm blood pt-25.0* ptt-34.9 inr(pt)-2.4* 07:05am blood pt-44.9* ptt-42.2* inr(pt)-4.4* 09:00am blood pt-14.7* ptt-30.6 inr(pt)-1.4* 02:16pm blood pt-13.5* ptt-29.9 inr(pt)-1.3* 03:15am blood pt-12.2 ptt-27.7 inr(pt)-1.1 04:09am blood pt-16.3* ptt-31.7 inr(pt)-1.5* 04:48am blood pt-13.3* ptt-27.9 inr(pt)-1.2* 06:07pm blood fibrino-217 11:32pm blood fibrino-296 02:42pm blood fibrino-241 09:00pm blood fibrino-284 07:05am blood fibrino-595* 11:32pm blood hapto-87 02:42pm blood hapto-157 12:56pm blood hapto-174 06:07pm blood hapto-181 lytes/creatine trend: 06:07pm blood urean-120* creat-4.4* 11:32pm blood glucose-169* urean-124* creat-4.6* na-137 k-6.6* cl-114* hco3-12* angap-18 03:44am blood glucose-179* urean-119* creat-4.4* na-143 k-6.1* cl-114* hco3-19* angap-16 07:16am blood glucose-175* urean-120* creat-4.6* na-143 k-5.6* cl-115* hco3-16* angap-18 12:17pm blood glucose-316* urean-111* creat-3.9* na-142 k-5.9* cl-113* hco3-17* angap-18 04:22pm blood glucose-305* urean-104* creat-3.9* na-143 k-5.0 cl-111* hco3-20* angap-17 10:34pm blood glucose-153* urean-100* creat-3.6* na-143 k-5.1 cl-111* hco3-21* angap-16 06:10am blood glucose-163* urean-96* creat-3.4* na-141 k-4.2 cl-109* hco3-23 angap-13 04:08pm blood glucose-207* urean-92* creat-3.2* na-146* k-4.4 cl-111* hco3-23 angap-16 02:42pm blood glucose-95 urean-81* creat-2.7* na-147* k-3.6 cl-110* hco3-28 angap-13 07:20am blood glucose-111* urean-88* creat-3.0* na-148* k-3.8 cl-107 hco3-28 angap-17 09:30pm blood creat-3.1* na-144 k-4.0 cl-107 09:00am blood glucose-113* urean-81* creat-3.1* na-144 k-3.7 cl-107 hco3-24 angap-17 02:16pm blood glucose-92 urean-82* creat-3.2* na-143 k-3.4 cl-108 hco3-25 angap-13 03:17pm blood glucose-89 urean-84* creat-3.5* na-140 k-4.7 cl-107 hco3-24 angap-14 12:28am blood glucose-74 urean-85* creat-3.6* na-143 k-5.0 cl-109* hco3-22 angap-17 04:09am blood glucose-84 urean-86* creat-3.5* na-141 k-5.3* cl-107 hco3-21* angap-18 03:01pm blood glucose-109* urean-84* creat-3.4* na-142 k-4.4 cl-107 hco3-23 angap-16 03:54am blood glucose-152* urean-82* creat-3.2* na-142 k-5.9* cl-107 hco3-28 angap-13 01:08pm blood urean-80* creat-2.8* na-146* k-3.5 cl-108 hco3-28 angap-14 04:48am blood glucose-110* urean-77* creat-2.5* na-147* k-4.4 cl-110* hco3-29 angap-12 lfts/lipase: 11:32pm blood alt-12 ast-23 ld(ldh)-291* ck(cpk)-123 alkphos-107 totbili-0.3 09:00am blood alt-12 ast-17 ld(ldh)-233 ck(cpk)-34* alkphos-77 amylase-48 totbili-0.6 04:09am blood alt-15 ast-42* ld(ldh)-496* alkphos-83 totbili-0.7 03:54am blood alt-13 ast-47* ld(ldh)-561* alkphos-128 totbili-0.5 04:48am blood alt-13 ast-39 ld(ldh)-312* alkphos-111 totbili-0.7 07:16am blood lipase-402* 06:10am blood lipase-238* 03:58am blood lipase-89* 04:52am blood lipase-84* 03:59am blood lipase-82* 09:00am blood lipase-97* ce: 11:32pm blood ck-mb-9 ctropnt-0.05* 06:34pm blood ck-mb-45* mb indx-15.4* ctropnt-1.38* 10:34pm blood ck-mb-45* mb indx-16.2* ctropnt-1.66* 06:10am blood ck-mb-27* mb indx-15.6* ctropnt-1.43* 04:08pm blood ck-mb-15* mb indx-12.4* ctropnt-1.32* 02:17pm blood ck-mb-4 ctropnt-2.41* 11:27pm blood ck-mb-5 ctropnt-2.37* 03:59am blood ck-mb-4 ctropnt-2.14* 09:00am blood ck-mb-4 ctropnt-0.86* 02:16pm blood ck-mb-3 ctropnt-0.83* 08:21pm blood ck-mb-3 ctropnt-0.93* flow cytometry: the following tests (antibodies) were performed: hla-dr, fmc-7, kappa, lambda, and cd antigens 2,3,4,5,7,8,10,16,19,20,23, 45, and 56. results: three color gating is performed (light scatter vs. cd45) to optimize lymphocyte yield. lymphoid cells comprise 7% of total analyzed events. b cells comprise 23% of lymphoid-gated events, have nonspecific surface immunoglobulin staining, and do not express aberrant antigens. t cells comprise 53% of lymphoid-gated events, express mature lineage antigens (cd2, cd3, cd5, cd7) and have a normal helper-cytotoxic ratio of 1.5 (usual range in blood 0.7-3.0). cell marker analysis demonstrates an increased percentage of natural killer cells at 24 (usual range in blood 5-15%) but display an expected antigenic profile. interpretation there is an atypical pattern of immunoglobulin staining in b cells. while not diagnostic it raises the possibility of a b cell lymphoproliferative disorder. please correlate with clinical, radiologic and other laboratory findings. flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. ============= microbiology: ============= respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus. respiratory viral antigen screen (final ): less than 60 columnar epithelial cells; specimen inadequate for detecting respiratory viral infection by dfa testing. interpret all negative results from this specimen with caution. negative results should not be used to discontinue precautions. refer to respiratory viral culture results. recommend new sample be submitted for confirmation. reported to and read back by 10:12am. viral culture: r/o cytomegalovirus (preliminary): no cytomegalovirus (cmv) isolated. cytomegalovirus early antigen test (shell vial method) (final ): negative for cytomegalovirus early antigen by immunofluorescence. . =============== images/studies: =============== . ct c/a/p (): 1. large right pleural effusion with adjacent consolidation, which likely represents atelectasis, but underlying pneumonia cannot be excluded. 2. small focus of ground-glass opacity in the left upper lobe, which is nonspecific but could represent a small focus of infection. 3. trace ascites with possible peripancreatic and periduodenal stranding/fluid and trace fluid anterior to the bilateral psoas muscles. correlation with pancreatic enzymes is recommended. this could also be secondary to hydration and ongoing capillary leak. . ruq ultrasound (): 1. no gallstones or gallbladder sludge. unremarkable gallbladder. no intra-or extra-hepatic biliary dilatation. 2. sliver of perihepatic fluid along the inferior liver edge and in morison's pouch. 3. right pleural effusion. . derm biopsy l thigh (): mild spongiotic, psoriasiform, and superficial perivascular dermatitis with neutrophils and eosinophils, occasional dyskeratotic cells, and marked neutrophilic scale crust. . an eczematous dermatitis including nummular eczema is possible. due to the finding of dyskeratosis, the differential diagnosis includes a drug eruption. the scale is not that of pityriasis rosea. special stains (gram, gms, and pas) are negative for organisms. . pleural fluid (): negative for malignant cells. . bronchial washing: negative for malignant cells. . peripheral smear (): mild microcytosis with central pallor. 1 eosinophil was seen and was morphologically normal. pmns were also normal and there were no atypical lymphocytes. platelets were slightly decreased in number and had normal morphology. video swallow on : indication: suspected aspiration. technique: video oropharyngeal swallow study was performed in conjunction with the speech pathology department. varying consistencies of barium were administered in the ap and lateral projections. findings: there is severe aspiration identified with thin liquids. with nectar-thickened liquids, a single penetration event was noted, though there was no aspiration identified. moderate pharyngeal residue was noted. please consult the speech and language pathology department note in the online medical record for further details. echo on : the left atrium is mildly dilated. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. there is mild regional left ventricular systolic dysfunction with focal hypokinesis of the inferior wall and mild hypokinesis of the distal of the left ventricle. the remaining segments contract normally (lvef = 55 %). overall left ventricular systolic function is low normal (lvef 50-55%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is a mild resting left ventricular outflow tract obstruction. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are severely thickened/deformed. there is moderate aortic valve stenosis (valve area 1.0-1.2cm2). the mitral valve leaflets are mildly thickened. trivial mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , left ventricular ejection fraction is improved with improved regional function of the distal third of the left ventricle. a mild left ventricular outflow gradient is now present. there is less mitral and tricuspid regurgitation. cxray on : large right pleural effusion has increased. mild pulmonary edema persists. heart size top normal. right-sided central venous catheter ends in the upper svc. et tube in standard placement. nasogastric tube passes below the diaphragm and out of view. no pneumothorax. brief hospital course: 84 yo m h/o moderate as, copd, chf and recent admission for multifocal pna presenting with weakness and hypotension and found to be in septic shock with respiratory failure. # respiratory failure: on presentation to the osh ed, the patient was felt to be in respiratory distress and intubated. he recent underwent treatment in early for a multifocal pneumonia, and underwent a r thoracentesis at that time which showed transudative pleural fluid. imaging on this admission showed multifocal consolidations and large r sided pleural effusion, unclear as to whether these are due to residual findings from the prior pneumonia or a new hcap. he was covered with vanc/zosyn for possible hcap and repeat right sided thoracentesis during this admission showed transudative pleural fluid with negative cultures. he developed a new pneumothorax following the thoracentesis which was stable, and resolved on serial cxrs. in the setting of receiving ivf and prbc (see below), the patient became fluid overloaded in the setting of chronic heart failure. he was diuresed with bumex, as he did not respond to high doses of iv lasix (see below). he also was noted to have expiratory stridor/wheezing at his trachea and also had a hoarse, whispering voice following extubation. ent was consulted for a bedside laryngoscopy, and the patient was found to have right vocal cord paralysis. he was to be maintained on strict npo. he was called out to the medical floor and in the setting of pulling out his ng tube and having increased secretions, he developed hypercapnic respiratory failure and was reintubated. his antibiotics were broadened and treated aggressively for copd exacerbation, however it was very difficult to wean the patient from the vent due to apnea. in addition he was fluid overloaded, with a total of approximately 14l + for his length of stay. he was given bumex and metolazone and he was initially not responding to diuretics. he was also falling his multiple sbt trials due to apnea and increase secretions. this was discussed with the family with the possibility of cvvh to attempt to remove fluid and improve respiratory status, and the possibility of future tracheostomy. the family decided to change his goals of care to cmo with the plan of extubation and do not reintubate. he was then extubated on in the evening after several family members came by to see patient. he initially did well and then had increase work of breathing with increase in secretions which he was unable to clear. he was placed on morphine drip for comfort and on scopolamine patch. his oxygen saturation remained low and he then passed way on # rash: multiple excoriations and history of profound itching. dermatology was consulted for an extensive erythematous rash on his torso and extremities, and was found to have eczematous dermatitis on biopsy. he was treated with petroleum jelly for hydration of his skin as well as triamcinolone cream to be used for up to 2 weeks with some improvement of the rash. famotidine was also started, and allopurinol was stopped for question of hypersensitive reaction in the setting of his elevated creatinine. he continued to have some pruritus prior to extubation for which he was then given prednisone and low dose benadryl for comfort in addition to topical creams which seem to have helped. # bleeding: patient with significant bleeding from multiple sites including significantly increased hematuria, ?melena, and profuse bleeding from lines earlier in his hospitalization which has now improved. initially concern for dic vs ttp although lab work has been negative so far. he cont to have increase in inr at 2.2 even after having two doses of vit k. uncertain etiology. sent smear and flow cytology. he was transfused 4 units of prbc with only a minimal increase in his hematocrit. he was started on iv ppi . gi was contact with the plan of possible scope prior to discharge. # nstemi, hypotension, bradycardia: h/o chronic afib on metoprolol. was initially bradycardic on presentation, concern for decreased renal clearance of metoprolol, also likely an element of sick sinus syndrome. was found to have elevated cardiac enzymes, ekg low voltages but did not show significant st changes, consistent with nstemi. given inr was >8 on admission and >4 at the time of nstemi, started on aspirin 81 and atorvastatin 80, and held plavix or heparin gtt per cardiology recs. cardiac enzymes subsequently stabilized and started to down-trend. he was transfused with goal hct >30 for nstemi to increase coronary perfusion. he was restarted on metoprolol 5mg iv q 6hours (npo given aspiration) for tachycardia, likely rebound tachycardia given he is on nodal agents at home. he subsequently developed bleeding from multiple sites (see above) and asa 81 was discontinued. # eosinophilia: initial significant peripheral eosinophilia at , which had resolved on arrival to in the setting of stress dose hydrocortisone. hydrocortisone was discontinued several days after transfer, and several days after discontinuation, the patient was noted to have recurrence of peripheral eosinophilia which derm did not feel was secondary to his rash. he was also found to have eosinophils in his urine which was determined to be secondary to possible allergic reaction to medication , ? allopurinol or lasix. although the etiolgy was uncertain. heme was consulted for evaluation of eosinophilia as well as elevated inr. he had a peripheral smear which showed mild microcytosis with central pallor. 1 eosinophil was seen and was morphologically normal. pmns were also normal and there were no atypical lymphocytes. platelets were slightly decreased in number and had normal morphology. he also had flow cytometry which was undeterminate. heme thought that his eosinophilia could have been due to loafers syndrome or a reactive process secondary to asthma or eosinophilic pneumonia. although this is unlikely given that pt had no eos on his bronchial lavage, even though he had already been treated with steroids this should still be present. allergic reaction to antibiotics or a vasculitic process, possibly involving the lungs and skin were also a consideration. the ct scan did not show definite evidence of lymphadenopathy or tumor to suggest lymphoma or other tumors. the blood smear does not show evidence of leukemia. in addition, spep and upep were also negative. # acute on chronic ri: thought to be due to atn, but urine eos now suggest ain. the patient was previously on lasix with presumed good response but now is not responding to 80 mg iv lasix, responded to 140mg iv, but due to high doses, transitioned to bumex. after his second intubation, he was not responding to high dose of bumex and metolazone with increase in his creatine which was thought to be due to atn. we discussed possible cvvh with the family, however they decided against it. # shock: initially on two pressors for sbp in the 70's-80's, gradually weaned off with fluid resuscitation and antibiotics. likely septic shock from multifocal pna, although hypovolemic shock from overdiuresis is also a possibility given his diuretics were increased as an outpatient at the time of his prior pna in . he was also given stress dose hydrocortisone on initial presentation which was subsequently discontinued after pressors were weaned off. cultures negative to date, findings on cxr and ct chest may be residual findings from his recently treated pneumonia. he was treated with vancomycin and zosyn for 8 day course. he had a second episode of respiratory failure and hypotension post intubation requiring pressors, his cxray was consistent with ? aspiration pneumonia. he was also hypothermic and there was concern for resistant bacteria so antibiotics were broaden to vanco and meropenem. he was pan cultured with no growth in cultures as of today. # elevated inr: initial inr >8 in setting of coumadin use as an outpatient and acute renal failure. likely poor renal clearance of coumadin as well as possible nutritional deficiency, received vitamin k 5mg po x2 doses with improvement of inr. however, inr continues to remain elevated at 2.2 off coumadin and after evaluation by heme, pt had another dose of vit k which helped trend inr down, so this was likely due to nutritional deficit. # elevated lipase: ruq us was negative. be medications (lasix, abx) vs sepsis, trending down and stabilizing. his abd initially thought to be more distended on his second transfer to the icu on - he had kub which was negative for obstruction or free air. his lft were only mildly elevated w/ ast in the 40s. # aortic stenosis: moderate with valve area 1.0-1.2cm2 on echo , repeat echo showed valve are to be stable with peak gradient of 49 mm hg. as was also thought to played a significant role in his fluid status given that he had re-accumulated of pleural fluid and hypotension. he was very fluid overloaded possibly leading to over distension of ventricles and decrease co. we had a repeat echo on which showed increased left ventricular filling pressure. as noted above his renal function worse and he was only moderately responsive to diuretics. family was against cvvh given changes in goal of care. # systolic/diastolic chf: no new wall motion abnormalities noted on echo. - hold ace-i, restarted on bb and diuretics # cad s/p cabg, mi: the patient had an acute mi as described above - continue, statin, hold asa for now # gout: d/c'ed allopurinol due to concern for hypersensitive reaction # htn: hold losartan, doxazosin, continue diuresis # fen: ivfs prn, replete electrolytes, npo due to aspiration risk. pt had a ng tube while intubated. # prophylaxis: elevated inr, pneumoboots # access: peripherals, a-line, and femoral line- wich was switched to lij and removed when he was off pressors # communication: sons, hcp: # code: initially full code then changed to dnr and he was changed to comfort measures only after discussion with the 3 sons on medications on admission: vitals: t: 90 f bp: 142/64 p: 67 r: 21 o2: 100% ac 500 x 22 at fio2 100% and peep 10 general: intubated and sedated heent: sclera anicteric, dry mm, oropharynx with et tube neck: supple, jvp just below ear at 30 degrees, cv: irregular, normal s1 + s2, harsh systolic murmur, no rubs, no gallops lungs: rhonchi in anterior lung fields bilaterally, decreased sounds at the bases, right>left, abdomen: soft, non-tender, mildly distended, bowel sounds hypoactive, gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: left pupil (4) and right pupil (2), very sluggish. not following commands, sedated. skin: multiple diffuse excoriations on legs/torso and old bruise on chest discharge medications: none discharge disposition: expired discharge diagnosis: expired: respiratory failure discharge condition: expired procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more thoracentesis closed [endoscopic] biopsy of bronchus closed biopsy of skin and subcutaneous tissue diagnoses: pneumonia, organism unspecified hyperpotassemia thrombocytopenia, unspecified subendocardial infarction, initial episode of care acute kidney failure with lesion of tubular necrosis unspecified pleural effusion congestive heart failure, unspecified acquired coagulation factor deficiency unspecified septicemia severe sepsis chronic kidney disease, stage iv (severe) hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage i through stage iv, or unspecified gout, unspecified atrial fibrillation aortocoronary bypass status aortic valve disorders acute respiratory failure iatrogenic pneumothorax blood in stool septic shock long-term (current) use of anticoagulants encounter for palliative care do not resuscitate status gross hematuria delirium due to conditions classified elsewhere unilateral paralysis of vocal cords or larynx, partial acute on chronic combined systolic and diastolic heart failure contact dermatitis and other eczema, unspecified cause eosinophilia 

Answer: The patient is high likely exposed to