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: lactose attending: chief complaint: abdominal pain major surgical or invasive procedure: intubation right arterial line right ij cvc history of present illness: 50 yo woman w/ hiv on haart (last cd4 534 on ) and adult-onset stills on infliximab, chronic prednisone, and recently discontinued methotrexate presents with one-day of llq abdominal pain and fever. patient was found to have increasingly abnormal lfts, so she was taken off of methotrexate less than one week ago. pain is sharp llq, intermittent, diffuse arthralgias, no n/v/d. patient states she was brought to the ed by her son because of weakness/malaise, difficulty walking, and "rib" pain. she denies cough, fevers, chills, dyspnea at home. she denies any diarrhea, constipation, brbpr, hematochezia, or melena. she also denies any dysuria. other positive symptoms include migratory arthralgias, particularly left shoulder and left knee, difficulty ambulating fatigue, malaise, and anorexia/decreased appetite. . in the ed, initial vs were: t 100.3 -> 101.1 p 105 bp 101/66 r 16 o2 sat 100% ra. cxr was clear, ct abd/pelvis showed no acute abdominal process (wet read), but ground-glass opacities at the lung bases. patient was given 2l normal saline, acetaminophen 1 gram, ceftriaxone, azithromycin for presumed pneumonia and morphine 4mg iv. at 1:30 am, the patient's fever broke, but she began rigoring. she was given ibuprofen and cx were drawn prior to antibiotics. she also had a third culture sent after spiking to 101.1, and received a total of 2 liters ns. vitals on transfer: t 99.6, hr 111, bp 100/60, rr 18, o2 sat 100% ra. . on the floor, patient endorsed left knee pain (located in back of knee) and malaise. abdominal pain/rib pain better, sharp, now , was . no radiation. leaning on it makes it worse. nothing makes it better. she has no other complaints. past medical history: 1) hiv/aids - diagnosed in , nadir cd4 count= 3, most recent cd4 288 on arvt with atripla, vl undetectable 2) history of hypothyroidism secondary to radioactive iodine ablation for grave's disease, on levothyroxine 3) adult onset stills disease diagnosed 4) anemia 5) +ppd s/p 9 months inh in 6) shingles 7) budd-chiari type 1 malformation 8) abnormal lfts social history: from and emigrated to u.s. in . recently travelled to for approximately one week, did not take malaria prophylaxis while she was gone. no water exposures while she was there. she has 2 daughters and 2 sons. daughter is a nurse and one son is in the military. her son has recently returned from , and is planning to get married on . tobacco: denies etoh: denies illicits: denies family history: daughter with possible rheumatoid arthritis. physical exam: vitals: 101.7 95/52 hr 110 rr 18 100% ra general: alert, oriented, no acute distress, fatigued appearing heent: sclera anicteric, dry mm, oropharynx clear, no evidence of thrush neck: supple, jvp not elevated, no lad lungs: rales at left base, improve with continued respiration, otherwise clear cv: tachycardic, regular rhythm, normal s1 + s2, ii/vi early systolic murmur heard best at the lusb without radiation to the carotids, no rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly; tender to palpation over left lower lateral rib cage ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema; tenderness to palpation in left popliteal fossa; limited flexion/extention of left knee due to pain; no clear left knee effusion; synovitis in mcps skin- no erythema, rashes appreciated pertinent results: i. labs a. admission complete wbc rbc hgb hct mcv mch mchc rdw plt ct 05:45 8.7 3.09* 8.6* 26.1* 85 28.0 33.1 17.7* 252 source: line-tlcl 05:00 10.8 2.87* 7.8* 24.0* 84 27.2 32.5 17.1* 177 05:51 12.8* 2.53* 6.9* 21.0* 83 27.2 32.7 17.6* 146* source: line-ij 07:25 19.9* 2.72* 7.4* 22.8* 84 27.2 32.4 17.5* 116* added g6pd @ 1101 03:45 20.4* 2.62* 7.4* 22.3* 85 28.2 33.1 17.3* 100* source: line-aline 17:29 18.9* 2.79* 7.9* 23.7* 85 28.2 33.1 17.2* 109* source: line-aline 03:08 20.2* 2.61* 7.6* 22.2* 85 28.9 34.0 17.2* 121* source: line-aline 02:27 16.8* 2.73* 7.4* 22.7* 83 27.3 32.8 17.2* 143* source: line-aline 13:34 19.4* 2.71* 7.8* 23.2* 86 28.9 33.8 17.4* 164 source: line-aline 02:35 16.2* 2.86* 7.7* 23.5* 82 26.9* 32.7 16.8* 181 source: line-aline 13:47 19.2* 2.81* 8.0* 24.0* 85 28.6 33.5 16.6* 226 source: line-aline 02:53 12.9* 2.81* 7.9* 23.6* 84 27.9 33.3 16.6* 261 source: line-a line 12:51 13.0* 2.60* 7.4* 22.0* 85 28.6 33.7 16.5* 281 source: line-aline 02:22 17.9* 2.67* 7.7* 22.5* 84 28.8 34.3 16.5* 315 source: line-arterial 12:59 29.5* 2.94* 8.5* 24.8* 84 28.8 34.2 16.4* 330 source: line-arterial 03:01 28.2* 2.76* 7.9* 23.3* 85 28.8 34.1 16.5* 333 source: line-arterial 15:06 29.5* 2.86* 8.3* 24.2* 85 29.0 34.1 16.4* 322 source: line-aline 05:23 31.1* 2.61* 7.5* 22.7* 87 28.8 33.1 16.2* 401 source: line-aline 22:50 23.6* 2.25* 6.3* 20.1* 89 28.0 31.4 15.9* 414 source: line-arterial line 22:39 24.4* 2.28* 6.5* 20.3* 89 28.4 31.9 15.8* 434 source: line-aq line 17:17 16.4* 2.72* 7.8* 24.3* 89 28.6 32.0 15.8* 415 15:52 18.7* 2.66* 7.5* 24.2* 91 28.2 31.1 15.7* 497* 04:10 8.9 2.57* 7.3* 22.8* 89 28.5 32.2 15.8* 474* retic added on at 4:42 a.m. 16:50 11.4* 3.08* 8.6* 27.4* 89 28.0 31.5 15.7* 587* basic coagulation (fibrinogen, dd, tt, reptilase, bt) fibrino 03:08 155 source: line-aline 02:27 289 source: line-aline 13:34 308 source: line-aline 02:53 263 source: line-a line 12:59 377 source: line-arterial 03:01 402* source: line-arterial 22:50 447* miscellaneous esr qg6pd parst s 05:45 97* source: line-tlcl 05:51 110* source: line-ij 07:25 6.5 added g6pd @ 1101 17:29 68* source: line-aline 02:35 70* source: line-aline 13:47 8.6 source: line-aline 02:53 60* negative1 source: line-a line 12:51 67* source: line-aline 03:01 80* negative2 source: line-arterial 05:23 76* negative2 hemolytic workup ret aut 07:25 1.71 added g6pd @ 1101 13:47 0.8* source: line-aline 22:50 1.9 source: line-arterial line 04:10 2.2 renal & glucose glucose urean creat na k cl hco3 angap 05:45 821 6 0.6 133 3.6 106 20* 11 source: line-tlcl 05:00 67*1 8 0.5 133 3.6 106 19* 12 05:51 * 3.5 109* 18* 9 source: line-ij 07:25 60*1 14 0.6 133 3.8 109* 16* 12 t4, tsh added 9:46am 03:45 67*1 13 0.6 133 3.7 109* 17* 11 source: line-aline 17:29 144*1 13 0.6 132* 4.1 108 14*2 14 source: line-aline 03:08 105*1 15 0.7 131* 3.7 108 16* 11 source: line-aline 18:34 150*1 15 0.7 131* 4.4 110* 16* 9 j 02:27 791 14 0.6 133 4.1 110* 16* 11 source: line-aline 13:35 191*1 14 0.7 132* 3.5 110* 14*3 12 source: line-aline 02:35 761 13 0.6 134 3.0* 111* 15* 11 source: line-aline 02:53 861 15 0.8 134 3.2* 113* 13*4 11 source: line-a line 02:22 116*1 16 0.7 138 3.0* 114* 16* 11 source: line-arterial 12:59 117*1 15 0.7 134 3.7 109* 14*5 15 source: line-arterial 03:01 147*1 13 0.6 130* 3.5 107 15* 12 source: line-arterial 15:06 123*1 11 0.6 131* 3.6 108 15* 12 source: line-aline 07:22 197*1 9 0.6 131* 3.1* 106 16* 12 source: line-aline 05:23 217*1 9 0.6 133 3.3 107 15* 14 source: line-aline 22:50 165*1 8 0.6 135 2.9*6 109* 16* 13 source: line-arterial line 17:17 135*1 8 0.6 135 3.0* 111* 14*7 13 15:52 155*1 9 0.6 138 3.4 112* 16* 13 04:10 120*1 14 0.7 131* 3.2* 104 20* 10 added hap at 0658 12 03 10 16:50 4.7 100 23 17 enzymes alt ast ld(ldh) ck(cpk) alkphos amylase totbili dirbili 05:45 52* 86* 726* 691* source: line-tlcl 05:00 51* 95* 788* 0.5 05:51 60* 125* 1060* 917* 0.6 07:25 1202* t4, tsh added 9:46am 03:45 65* 167* 1271* 146 616* 1.1 03:08 1104* 273 02:27 34 99* 897* 650 172* 0.3 02:22 29 48* 349* 146* 0.4 source: line-arterial 03:01 30 51* 335* 133* 0.4 source: line-arterial 05:23 35 64* 402* 168* 1.5 17:17 30 48* 611 191* 0.8 04:10 35 41* 160* 0.4 added hap at 0658 12 03 10 16:50 48* 43* 236 18*2 207* 0.3 10:10 heparin dependent antibodies test result ---- ------ heparin dependent antibodies equivocal comment: equivocal-inhibition of a positive reaction by less than 50% is an equivocal result. this type of reaction is given by small percentage of antibodies in patients who are suspected of having type ii hit. the significance of this type of reaction is not yet established. it has not yet been determined whether it is safe to re-administer heparin to patients whose serum gives an equivocal reaction parvovirus b19 dna test result reference range/units source serum parvovirus b19 dna, ql real not detected not detected time pcr 05:23 entamoeba histolytica antibody test result reference range/units entamoeba histolytica igg <1.00 reference range: <1.00 interpretive criteria: <1.00 antibody not detected > or = 1.00 antibody detected 17:17 aspergillus galactomannan antigen test result reference range/units aspergillus antigen 0.1 <0.5 result interpretation: an index <0.5 is considered to be negative. an index >=0.5 is considered to be positive. strongyloides antibody,igg test name in range out of range reference range --------- -------- ------------ --------------- strongyloides antibody, igg () strongyloides igg <1.00 <1.00 interpretive criteria <1.00 antibody not detected > or = 1.00 antibody detected 17:17 b-glucan test ---- fungitell (tm) assay for (1,3)-b-d-glucans results reference ranges ------- ---------------- <31 pg/ml negative less than 60 pg/ml indeterminate 60 - 79 pg/ml positive greater than or equal to 80 pg/ml ii. microbiology 13:47 histoplasma antigen test result reference range/units histoplasma antigen urine <2.0 < 2.0 eia units reference range for histoplasma antigen urine: < 2.0 . . . . negative 2.0 - 4.0 . . . . weak positive > 4.0 . . . . positive 3:52 pm (malaria) **final report ** malaria antigen test (final ): negative for plasmodium antigen. (reference range-negative). performed by immunochromogenic assay. note, malaria antigen may be below the detection limit of this test in a small percentage of patients. therefore, malaria infection can not be ruled out. negative results should be confirmed by thin/thick smear with testing recommended approximately every hours for 3 consecutive days for optimal sensitivity. 2:53 am culture source: line-aline. **final report ** culture, routine (final ): no growth. 11:39 am stool consistency: not applicable **final report ** clostridium difficile toxin a & b test (final ): duplicate order-only one c. difficile is accepted per day. please resubmit a new specimen on a different date if further testing is necessary. 3:07 am stool consistency: formed source: stool 3 of 3. **final report ** ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. 10:30 am stool consistency: not applicable **final report ** cyclospora stain (final ): no cyclospora seen. microsporidia stain (final ): no microsporidium seen. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. ova + parasites (final ): no ova and parasites seen. this test does not reliably detect cryptosporidium, cyclospora or microsporidium. while most cases of giardia are detected by routine o+p, the giardia antigen test may enhance detection when organisms are rare. fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. fecal culture - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. 3:23 am sputum source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. nocardia culture (preliminary): no nocardia isolated. iii. radiology a. abdominal us indication: a 50-year-old female with still's disease and elevated lfts, ap, and ggt. comparison: liver ultrasound . findings: the liver is normal in echogenicity. there is a small region of increased echogenicity in the right lobe of the liver abutting the portal vein. the appearance of this space is consistent with focal fat. no worrisome liver lesion is identified. no biliary dilatation is seen and the common duct measures 0.4 cm. the gallbladder and pancreas are normal. the spleen is unremarkable and measures 7.7 cm. no hydronephrosis is seen. the right kidney measures 10.4 cm and the left kidney measures 11.5 cm. the aorta is of normal caliber throughout. the visualized portion of the ivc is unremarkable. impression: small region of focal fat centrally in the right lobe of the liver, but no diffuse fatty infiltration identified and no worrisome liver lesions seen. b. admission cxr history: immunosuppressed with left lower quadrant pain and fever. comparison: multiple priors, the most recent dated . findings: lung volumes are diminished. no consolidation or edema is evident. there is mild aortic tortuosity, slightly exaggerated by the low lung volumes but similar to prior studies. cardiac silhouette is top normal for size but stable. no effusion or pneumothorax is noted. the osseous structures are unremarkable. there is no free air under the diaphragm. impression: no acute pulmonary process. no free air under the diaphragm. c. ct abdomen/pelvis clinical information: hiv positive 50-year-old female with left-sided abdominal pain, fever, and leukocytosis. assess for colitis. technique: axial images were acquired of the abdomen and pelvis following the administration of oral and iv contrast. images were reformatted in the coronal and sagittal planes. findings: lung bases: there is ground-glass opacity of the bilateral visualized lung bases, no pleural effusions are seen. abdomen: the liver, spleen, pancreas, gallbladder, adrenals, and kidneys are normal in appearance. the stomach is decompressed and appears unremarkable. the small bowel and its mesentery are normal in appearance. there is no pathologic retroperitoneal lymphadenopathy. pelvis: the bladder is normal in appearance. the colon contains moderate fecal loading and is otherwise unremarkable. the appendix is normal. there is no intra-abdominal free fluid, or free air. bone windows: no concerning lytic or blastic osseous lesions. impression: 1. ground-glass opacity of the visualized bilateral lung bases is likely microatelectasis, however, in an immunocompromised patient, atypical pneumonia/infection not excluded. 2. no acute intra-abdominal process; specifically, no ct evidence of colitis. d. cxr type of examination: chest ap portable single view. indication: 50-year-old female patient with hiv and still's disease with respiratory failure. examine for interval change. findings: ap single view of the chest has been obtained with patient in sitting semi-upright position. when comparison is made with the similar portable chest examination of , no significant interval change can be identified. thus, the previously described linear atelectasis on the left base in retrocardiac position and horizontal densities on the right base represent atelectasis that are probably unchanged. no new interval changes can be identified short of the ng tube which now has been removed. when comparison is made with the portable chest examination, the corresponding single plain portable image suffers from severe diffuse artefacts throughout and additional motion blurring so that at that time made diagnosis of a right basal pneumonia or dense new density is questioned. thus, the findings on the portable examination are stable between and . iv. cardiology a. echo the left atrium is normal in size. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. no masses or vegetations are seen on the aortic valve. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. no mass or vegetation is seen on the mitral valve. the estimated pulmonary artery systolic pressure is normal. there is a trivial/physiologic pericardial effusion. brief hospital course: *micu course* hospital course: 50-year-old female with well-controlled hiv, remote hbv, positive ppd s/p inh therapy, hypothyroidism, and adult-onset still's disease on immunosuppresion with recent discontinuation of methotrexate a week before admission in setting of transaminitis that was admitted with a suspected severe still's flare with fevers, rash, polyarthritis, lymphadenopathy after recent subacute worsening arthritis in the outpatient setting. patient was initially admitted to floor. she was subsequently transferred to the micu for hypotension refractory to fluid resuscitation requiring briefly levophed and clinical decompensation requiring brief period of intubation and mechanical ventilation likely secondary to increased work of breath associated with fevers. patient has had similar episodes in past requiring icu admission. given clinical history, broad infectious work-up initiated and negative with subsequent discontinuation of broad spectrum antibiotics (cefepime/vancomycin/ciprofloxacin/flagyl/brief empiric malarial treatment consisting of quinine/doxycycline despite negative smears and low suspicion). patient was started on pulse steroids with transition to 60mg daily on transfer to wards. in addition, she was started on anakinra for treatment-resistant still's disease. hematology was consulted in setting of concern for macrophage activation syndrome with falling platelet counts and nadir of leukocytosis. mas was felt to be unlikely given lack of organomegaly, hypo-ferritinemia, etc. no bm aspirate was performed. . # respiratory failure patient had neither ventilation or oxygenation issues, but was breathing quite rapidly in setting of high fevers. patient was intubated and placed on mechanical ventilation for an approximately 1-day period as appeared patient was tiring out and would lose airway imminently. she was extubated and taken off pressors on wo difficulty. per rheumatology her sob was attributed to volume overload aggressive volume repletion in setting of hypotensive presentation. . # hypotension patient has had several admissions in past with similar presentations including hypotension without any clear infectious etiology. patient had continuing hypotension despite aggressive fluid resuscitation on floor with adequate urine output and normal lactate. patient may have had combination of vasoplegia and capillary leak from severe underlying inflammation from still's disease. sepsis like picture is not uncommon in acute stills flare. her presentation was consistent with this diagnosis. she was briefly placed on levophed with arterial line placed for hemodynamic monitoring. cortisol level was also found to be appropriate (27.4). patient subsequently did not have issues with hypotension. . # adult-onset still's disease with fevers rheumatology recently discontinued methotrexate secondary to mild transaminitis indicating drug failure. per rheumatology, the transaminitis was not felt to be methotrexate directly rather an indication of drug failure in the patient. prior to discontinuation, patient had intermittent flares and was managed with varying doses of prednisone. she continued to receive infliximab at time of presentation. patient spiked high fevers up to ~ 104 deg f during her hospitalization. patient's fever was treated with tylenol and cooling blankets. primary concern was still's flare with possible superimposed infectious process given recent travel to and in setting of immunocompromised state from hiv and immunosuppressants. fever felt less likely to be nms, hlh, or ttp. broad infectious work-up was negative. infectious disease service was consulted, and patient placed on broad spectrum antibiotics including vancomycin, cefepime, ciprofloxacin, flagyl, and brief empiric malarial treatment consisting of quinine/doxycycline despite negative smears and low suspicion. there was an initial concern about microatelectasis seen on lower lung fields on ct abdomen being atypical pneumonia. there was also concern about focal density on right of serial cxr representing pneumonia as well. however, these processes felt to atelectasis. no other apparent nidus of infection. all stool cultures negative. urine cx negative. sputum cx negative. antibiotics were discontinued prior to transfer to general wards. she was continued on bactrim for pcp and fluconazole to be continued while she is on steroids. patient was also started on methylprednisolone 500 mg iv q 12 with taper down to prednisone 60 mg po qd at time of transfer to wards. she was started on anakinra for treatment-resistant still's disease. # anemia with thrombocytopenia, leukocytosis, and coagulopathy patient had anemia on admission with retic index of 0.54 suggesting hypoproliferative bone marrow likely suppressed secondary to acute disease. her hgb dropped from her prior baseline. given recent travel to , hemolysis labs and parasite smears were obtained and were not suggestive of a hemolytic process or malaria. patient also noted to have leukocytosis with extreme neutrophilia on differential likely secondary to acute disease and pulse steroids. differential included lymphoma as well but felt to be less likely given lymph node size had not decreased. patient also noted to have decreasing platelets. given two cell lines had decreased with increased ldh and concern for macrophage activation syndrome, hematology/oncology was consulted. hlh/mas was felt to be unlikely and bone marrow biopsy was deferred given no splenomegaly or hepatomegaly with elevated ferritin and ldh being explained likely by her still's flare. her thrombocytopenia was felt to be drug induced such as with vancomycin and hit was felt less likely with a 4t score of . heparin was discontinued and hit ab pending on transfer to general wards. # steroid-induced mental disorder and altered mental status patient noted to be suspicious of hospital staff and medical team after initiation of pulse steroids. patient also felt to be somnolent during icu course at times. psychiatry consulted and recommended zyprexa for steroid-induced mental disorder, which was subsequently held after patient became febrile again given low but possible concern for nms. patient's mental status subsequently improved with steroid taper and holding of sedatives. felt to be at mental status baseline confirmed with dr. and family members on arrival to wards floor. # hiv patient has well-controlled hiv and was continued on atripla. cd4 count from was >500. she was also re-started on fluconazole along with nystatin swish/swallow given thrush causing dysphagia w plan to continue fluconazole for duration of her steroid therapy. # pcp prophylaxis in setting of chronic steroid therapy, patient was continued on bactrim. # imaging incidentals in a chest ct report on , patient noted to have lung nodule and lymphadenopathy with recommended chest ct in 6 months for follow-up. such study performed during hospitalization showing 4-mm lung nodule that was stable and needs no further follow-up. however, bilateral, pathologically enlarged axillary and anterior chest wall lymph nodes are slightly increased compared to with no mediastinal or hilar lympahdenopathy. *wards course* 50f with well-controlled hiv, remote hbv, ppd+ s/p inh, hypothyroidism, and aosd on prednisone 40, infliximab who is currently admitted with a suspected severe flare with fevers, rash, polyarthritis, lymphadenopathy after recent subacute worsening arthritis and transaminitis in the outpatient setting s/p micu stay for resp distress and severe fevers. . # aosd flare: methotrexate discontinued initially mild transaminitis however most likely pt failed mtx and developed transaminitis as part of still's flare. prior to discontinuation, patient had intermittent flares, managed with varying doses of prednisone. continues to receive infliximab. started on il-1 therapy with anakinra during micu course w improvement. mas felt to be unlikely lack of hsm, hypertg, or hypofibrinogenemia per hemonc. sepsis picture consistent with still's flare. she is currently off antibiotics w/o infectious etiology currently being treated for aosd flare. esr/crp and ferritin monitored qod. she was continued on steroids and initiated a taper on : 50mg x 3days, 40mg x 1 week, 30mg x 1 week, and 20mg continued. to be followed as an outpt. fs on steroids have been <=200, do not anticipate needing insulin coverage while at home. plan to continue anakinra 100 mg sc qd (day 1 = ), duration to be continued indefinitely as pt has failed mtx. pt received prior authorization through bc and registered for home delivery of medication through caremark. pt was discharge home with xxx doses of anakinra pending home delivery verification. physical therapy was consulted, rec dc to home w pt services. she ambulated wo difficulty and will continue home pt services after discharge. plan to f/u with rheumatology/dr. on after discharge. . # hit: hit is less likely to be the cause of thrombocytopenia however avoiding all heparin products. thrombocytopenia felt to be component of still's flare. pf4 ab equivocal (optical density is only 0.5) - hemonc confirms that pt is not hitt positive. no serotonin assay indicated. plan to continue fondaparinus ppx while in house but do no have to avoid heparin products in future. thrombocytopenia resolved at time of discharge. . # fever: primary concern is still's flare +/- possible superimposed infection given recent travel to and in setting of immunocompromised state. imaging showing likely microatelectasis but atypical pneumonia cannot be exluded. ddx includes infectious process, still's disease, or hlh. considering tissue evaluation/ln biopsy to r/o malignany if no improvement w current therapy. has been intermittently covered w abx during micu course for hap, malaria however infection seems unlikely now. she was afebrile during her wards course and did not require additional culturing or antibiotic consideration. id team signed off with plan to f/u as an outpt with dr. . . # bilateral opacities: on cxr. ddx including pulmonary edema given aggressive resuscitation, ards, or other inflammatory process. currently o2 sat 99% on ra, no pulmonary exam findings. monitor clinically. she had normal ef and systolic function on recent tte. . # anemia: retic index 0.54 suggesting hypoproliferation bone marrow likely suppressed secondary to acute disease. hemolysis labs not suggestive. hct stable at 22-24. s/p 2u prbc transfusion in micu and 1u prbc on general wards for slowly downtrending hct. her hct responded appropriately after 3rd transfusion on the floors and hct uptrended at time of discharge to baseline. . # leukocytosis resolved at time of discharge. patient with fevers and uptrending leukocytosis with 98.4 % neutrophils. ddx includes infection vs. inflammation vs. neoplasia. see fever problem for additional discussion of low suspicion for infection. wbc continues to improve. . # diarrhea: multiple day duration that started in micu. stool cultures sent prior to transfer to general wards all negative. afebrile. persistent leukocytosis but benign abd exam. multiple recent abx treatments. diet was changed to lactose free and her diarrhea resolved. . # hiv- cd4 count as above, most recent count 531 on 11/. cont atripla. cont bactrim. cont fluconazole. . # transaminitis- ruq shows focal steatosis. likely component of still's flare that resulted from failure of mtx. pt improving after discontinuation of mtx and initiation of anakinra. . # hypothyroidism- continued home dose levothyroxine . # prophylaxis: pneumoboots, ppi # access: right ij cont for access (non-heparin, flushing fluid), piv # code: full # communication: lives w daughter, phone: . medications on admission: - infliximab 7.4mg/kg (500mg) q6wks - atripla 600-200-300mg daily - vitamin d3 1,000 units daily - bactrim 80/400mg daily - alendronate 70mg qweekly - omeprazole 20mg daily - prednisone 10mg daily (tapering slowly, per pt) - hydroxyzine 10mg daily prn pruritus - levothyroxine 175 mcg daily - ensure - folic acid 1 mg daily stopped methotrexate less than one week ago discharge medications: 1. efavirenz 200 mg capsule sig: three (3) capsule po daily (daily). 2. tenofovir disoproxil fumarate 300 mg tablet sig: one (1) tablet po daily (daily). 3. emtricitabine 200 mg capsule sig: one (1) capsule po q24h (every 24 hours). 4. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 5. cholecalciferol (vitamin d3) 400 unit tablet sig: two (2) tablet po daily (daily). 6. alendronate 70 mg tablet sig: one (1) tablet po qfri (every friday). 7. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 8. hydroxyzine hcl 10 mg tablet sig: one (1) tablet po once a day as needed for itching. 9. levothyroxine 175 mcg tablet sig: one (1) tablet po daily (daily): take this medication alone w/o other meds or supplements. 10. folic acid 1 mg tablet sig: one (1) tablet po daily (daily). 11. fluconazole 100 mg tablet sig: one (1) tablet po q24h (every 24 hours). disp:*30 tablet(s)* refills:*2* 12. calcium carbonate 500 mg (1,250 mg) tablet sig: one (1) tablet po bid (2 times a day). disp:*60 tablet(s)* refills:*2* 13. prednisone 20 mg tablet sig: 2.5 tablets po daily (daily): take 2.5 tabs (50mg for one day), take 2 tabs (40mg x 7 days), take 1.5 tabs (30mg x 7 days), then continue 1 tab (20mg) until dr. tells you to stop. disp:*30 tablet(s)* refills:*2* 14. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. disp:*30 tablet(s)* refills:*0* 15. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day) as needed for constipation. disp:*60 capsule(s)* refills:*3* 16. anakinra 100 mg/0.67 ml syringe sig: one (1) injection subcutaneous once a day. disp:*30 injection* refills:*6* 17. anakinra 100 mg/0.67 ml syringe sig: one (1) syringe subcutaneous one time for 1 days: for use thursday . disp:*1 syringe* refills:*0* discharge disposition: home with service facility: homecare discharge diagnosis: adult onset still's disease flare discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital for low pressure and concern for a flare of your still's disease. you were initially admitted to the general wards however you needed to be transferred to the icu for advanced care. you had very high fevers and developed breathing difficulties necessitating a breathing tube. you were also treated with antibiotics and anti-malarial medications out of concern for your recent travel. these medications were stopped when all your cultures showed that you do not have an infection. you were started on high dose steroids to treat your still's disease flare. you will need to continue a longterm steroid taper that will be managed by dr. . . you also were started on a medication called anakinra which will replace the methotrexate and remicaide that you were on before. you will need to continued the anakinra indefinitely. your diarrhea resolved after switching to a lactose free diet. all stool studies were negative. . there was a chest nodule found on your ct chest from and repeat study during your hospitalization showed no change in size - this does not need to be followed with additional studies. . the following changes were made to your medications: started anakinra, 1 injection everyday. this medication must be administered everyday or you risk a repeat flare. this medication will be mailed to your home. **if you do not have the medication confirmed shipment by tomorrow by caremark ph 1-, call dr. ! . started prednisone, steroids will help decrease your inflammation and the symptoms of your still's disease flare. please take 50mg tomorrow. then 40mg daily for 7 days. then 30mg daily for 7 days. then continue at 20mg daily until dr. tells you to stop. started fluconazole; continue this antifungal medication while you are on steroids. started calcium supplement, continue this supplement while you are on steroids to avoid bone loss stopped remicaide and methotrexate. these medications did not work for you. . please follow up with your doctors as stated below. followup instructions: department: infectious disease when: monday at 10:00 am building: lm campus: west best parking: garage department: rheumatology when: monday at 11:30 am with: , md building: lm bldg () campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours insertion of endotracheal tube arterial catheterization central venous catheter placement with guidance diagnoses: anemia, unspecified long-term (current) use of steroids hyposmolality and/or hyponatremia candidiasis of mouth human immunodeficiency virus [hiv] disease pulmonary collapse compression of brain acute respiratory failure hypotension, unspecified alkalosis diarrhea systemic inflammatory response syndrome due to noninfectious process without acute organ dysfunction leukocytosis, unspecified physical restraints status other postablative hypothyroidism other secondary thrombocytopenia other rheumatoid arthritis with visceral or systemic involvement 

Answer: The patient is high likely exposed to