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: motrin / compazine / haldol / nitrofurantoin / iodine / vancomycin hcl attending: chief complaint: sepsis mostly likely caused by uti major surgical or invasive procedure: intubated and extubated history of present illness: 53 yo f with pmh hiv last cd4 1068, on haart, hepatitis b, hepatitis c, h/o ?pe on coumadin, morbid obesity, h/o recurrent uti last one with esbl e. coli, osa and h/o ovarian ca in s/p oophrectomy, present with sob, cp, cough, n/v diarrhea over the past 4-5 days. per ed report, she also had chest pain, abdomenial pain, had diarrhea x8. denies any melena, brbpr. . in the ed: initial vs: temp 102, tachy 134, bp 159/74, rr 40 89% on? nc. then became hypotensive to 70/40 for unclear reason and started on levo/neo. an aline was placed. after initiation of pressors, bp increased to 110/67. ij was placed. blood culture were sent. ct chest done showing patchy opacity at the bases. initial labs remarkable for lavtate of 5.8--->4.5. ua grossly positive. initial gas: 7.21/49/76--->7.18/57/67--->7.17/58/95 . received a total of 5l ns and cefepime and flagyl. anesthesia believe the patient to be a difficult to intubate. . on the floor, patient was somulent, not able to answer any of the questions appropriately. she was able to be weaned off to 1 pressor. past medical history: 1. hiv, sexually transmitted, diagnosed on haart. 2. hepatitis b and hepatitis c virus also sexually transmitted, diagnosed , s/p ifn x6 months with failure to suppress vl. 3. asthma. 4. ovarian cancer diagnosed , status post oophorectomy and chemotherapy. 5. morbid obesity. 6. s/p mva with l4-l5 laminectomy in , operation c/b infection, including vre requiring re-exploration and drainage. 7. chronic back pain 8. chronic l leg pain 9. cholecystectomy . 10. osteoarthritis involving bilateral knees 11. recurrent utis last on 12 recurrent cystitis consistent with urethral syndrome or chronic cystitis 13. qt prolongation -? assocation with abilify 14. s/p tibial fracture on , medically managed social history: lives alone in apartment in , limited contact with family. only support per patient is a few friends, especially her hcp, #. tobacco: 120 pack-year. currently smokes half a pack per day, used to smoke up to 3ppd. no current etoh, but distant use in past. denies history of illicit drug use. . family history: father is deceased and had htn, cad. mother is recently deceased after long course with esrd, htn, multiple strokes and chf. aunt with neuroblastoma, otherwise no other cancers per patient. . physical exam: vitals: t: 99 bp:99/64 p:104 r: 25 o2: 98% nrb general: in moderate distress, somulent but responsive to commands, obese, flushed heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp/lad unable to appreciate due to body habitus lungs: ronchus throughout, unable to appreciate posteriorly due to body habitus cv: tachy, sinus, normal s1 + s2, no murmurs, rubs, gallops abdomen: obese, non-tender, non-distended, bowel sounds present, gu: foley present, urine appears concentrated, yellow ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . physical exam on day of discharge: vitals: t: 97 bp:1199/72 p: 69 r: 18-20 o2: 95-96% ra general: obese nad. oriented x3., awake, approprately responsive to questions. heent: ncat. sclera anicteric. per, eomi. conjunctiva were pink, no pallor or cyanosis of the oral mucosa. no xanthalesma. no lad appreciated neck: supple, jvp could not be appreciated due to body habitus. no cartid bruits appreciated cardiac: distant heart sounds due to body habitus, rr, normal s1, s2. no m/r/g appreciated. no thrills, lifts. no s3 or s4. lungs: no chest wall deformities, scoliosis or kyphosis. resp were unlabored, no accessory muscle use. ctab no rhonchi, rales or wheezes abdomen: +bs soft, nt obese. surgical scars. no hsm or tenderness could be appreciated but exam limited by body habitus. extremities: +1 le edema. wwp. +2 pulses skin: no stasis dermatitis, ulcers, scars, or xanthomas. pertinent results: labs day of admission: 08:05pm pt-21.9* ptt-38.1* inr(pt)-2.0* 08:05pm plt smr-low plt count-88*# 08:05pm hypochrom-normal anisocyt-normal poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 08:05pm neuts-70 bands-12* lymphs-12* monos-2 eos-0 basos-0 atyps-0 metas-4* myelos-0 08:05pm wbc-5.9 rbc-5.47*# hgb-17.4*# hct-53.5* mcv-98 mch-31.7 mchc-32.5 rdw-15.2 08:05pm estgfr-using this 08:05pm glucose-56* urea n-23* creat-1.3* sodium-132* potassium-3.7 chloride-93* total co2-19* anion gap-24* 11:30pm calcium-7.8* phosphate-1.8*# magnesium-1.3* 11:30pm alt(sgpt)-32 ast(sgot)-43* alk phos-255* tot bili-1.5 11:30pm glucose-45* urea n-27* creat-1.6* sodium-134 potassium-3.1* chloride-100 total co2-16* anion gap-21* 11:43pm lactate-5.8* 11:43pm comments-green top 01:43am glucose-78 lactate-4.5* 01:43am type-art po2-76* pco2-49* ph-7.21* total co2-21 base xs--8 intubated-not intuba 01:43am urine gr hold-hold 01:43am urine uhold-hold 01:43am urine hours-random 01:43am urine hours-random 02:52am po2-67* pco2-57* ph-7.18* total co2-22 base xs--7 04:13am po2-95 pco2-58* ph-7.17* total co2-22 base xs--7 04:30am urine rbc-0-2 wbc-* bacteria-many yeast-none epi- 04:30am urine blood-lg nitrite-neg protein-75 glucose-neg ketone-tr bilirubin-neg urobilngn-neg ph-6.5 leuk-mod 04:30am urine color-yellow appear-hazy sp -1.012 04:30am urine gr hold-hold 04:30am urine ucg-negative 04:30am urine hours-random 04:30am urine hours-random 08:33am freeca-1.08* 08:33am glucose-98 lactate-2.3* na+-136 k+-3.6 cl--104 08:33am type-art po2-164* pco2-59* ph-7.16* total co2-22 base xs--8 09:39am wbc-33.4* lymph-5* abs lymph-1670 cd3-42 abs cd3-700 cd4-22 abs cd4-373 cd8-19 abs cd8-317 cd4/cd8-1.2 09:39am fibrinoge-534* 09:39am fdp-10-40* 09:39am pt-23.8* ptt-39.2* inr(pt)-2.3* 09:39am plt count-69* 09:39am wbc-33.4*# rbc-4.10*# hgb-13.3# hct-41.1# mcv-100* mch-32.6* mchc-32.5 rdw-15.1 09:39am calcium-7.2* phosphate-4.4# magnesium-1.4* 09:39am alt(sgpt)-84* ast(sgot)-159* alk phos-149* tot bili-1.3 09:39am glucose-130* urea n-29* creat-1.6* sodium-135 potassium-3.7 chloride-103 total co2-20* anion gap-16 10:05am glucose-139* lactate-2.4* 10:05am type-art po2-93 pco2-80* ph-7.11* total co2-27 base xs-- 12:27pm urine eos-positive 12:27pm urine granular-* 12:27pm urine rbc-0-2 wbc-* bacteria-mod yeast-none epi- 12:27pm urine blood-lg nitrite-neg protein-75 glucose-neg ketone-tr bilirubin-sm urobilngn-1 ph-5.0 leuk-mod 12:27pm urine hours-random urea n-325 creat-99 sodium-43 potassium-23 chloride-33 03:31pm wbc-26.6* rbc-4.01* hgb-13.0 hct-39.8 mcv-99* mch-32.3* mchc-32.5 rdw-15.1 03:31pm calcium-7.4* phosphate-4.3 magnesium-1.4* . labs day of discharge: 06:56 wbc rbc hgb hct mcv mch mchc rdw plt ct 6.7 3.73* 11.9* 36.9 99* 31.8 32.1 16.3* 284 neuts lymphs monos eos baso 72.6* 21.8 2.4 2.5 0.8 . **final report ** blood culture, routine (final ): escherichia coli. final sensitivities. warning! this isolate is an extended-spectrum beta-lactamase (esbl) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. consider infectious disease consultation for serious infections caused by esbl-producing species. sensitivities: mic expressed in mcg/ml _________________________________________________________ escherichia coli | ampicillin------------ =>32 r ampicillin/sulbactam-- =>32 r cefazolin------------- =>64 r cefepime-------------- =>64 r ceftazidime----------- =>64 r ceftriaxone----------- =>64 r ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem-------------<=0.25 s piperacillin/tazo----- 32 i tobramycin------------ 8 i trimethoprim/sulfa---- <=1 s anaerobic bottle gram stain (final ): gram negative rod(s). reported by phone to dr. . 8:40am. aerobic bottle gram stain (final ): gram negative rod(s). . 8:15 pm blood culture #2. **final report ** blood culture, routine (final ): escherichia coli. identification and sensitivities performed on culture # 302-9848b . anaerobic bottle gram stain (final ): gram negative rod(s). reported by phone to dr. . 8:40am. aerobic bottle gram stain (final ): gram negative rod(s). . 9:39 am blood culture source: line-a. **final report ** blood culture, routine (final ): escherichia coli. identification and sensitivities performed on culture # 302-9848b . anaerobic bottle gram stain (final ): gram negative rod(s). . 9:38 am mrsa screen source: nasal swab. **final report ** mrsa screen (final ): no mrsa isolated. .time taken not noted log-in date/time: 11:11 am sputum source: endotracheal. gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): rare growth commensal respiratory flora. yeast. rare growth. legionella culture (final ): no legionella isolated. fungal culture (preliminary): yeast. . 9:43 am stool consistency: not applicable source: stool. microsporidia stain (final ): no microsporidium seen. cyclospora stain (final ): no cyclospora seen. fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. 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 - r/o vibrio (final ): no vibrio found. fecal culture - r/o yersinia (final ): no yersinia found. fecal culture - r/o e.coli 0157:h7 (final ): no e.coli 0157:h7 found. cryptosporidium/giardia (dfa) (final ): no cryptosporidium or giardia seen. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). viral culture (preliminary): no virus isolated so far. ' 9:43 am stool consistency: not applicable source: stool. **final report ** clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). . 11:55 am blood culture source: line-a-line #1. **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. final sensitivities. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. staphylococcus, coagulase negative. second morphology. final sensitivities. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | clindamycin----------- r r erythromycin---------- =>8 r =>8 r gentamicin------------ 4 s 8 i levofloxacin---------- 4 r 4 r oxacillin------------- =>4 r =>4 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- <=1 s <=1 s vancomycin------------ 2 s 2 s aerobic bottle gram stain (final ): gram positive cocci in clusters. reported by phone to # 01:40pm. . 7:00 pm blood culture source: line-rue a-line radial. **final report ** blood culture, routine (final ): staphylococcus, coagulase negative. final sensitivities. coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. staphylococcus, coagulase negative. second morphology. final sensitivities. this isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . coag neg staph does not require contact precautions, regardless of resistance. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. rifampin should not be used alone for therapy. sensitivities: mic expressed in mcg/ml _________________________________________________________ staphylococcus, coagulase negative | staphylococcus, coagulase negative | | clindamycin-----------<=0.25 s r erythromycin---------- =>8 r =>8 r gentamicin------------ <=0.5 s <=0.5 s levofloxacin---------- =>8 r =>8 r oxacillin------------- =>4 r =>4 r rifampin-------------- <=0.5 s <=0.5 s tetracycline---------- =>16 r =>16 r vancomycin------------ 1 s 1 s aerobic bottle gram stain (final ): gram positive cocci in clusters. reported by phone to , on at 1814. . 7:00 pm sputum source: endotracheal. 3:51 am serology/blood source: line-aline. **final report ** rapid plasma reagin test (final ): nonreactive. reference range: non-reactive. . blood cultures form , , , still pending. . chest (portable ap) study date of 11:43 pm portable ap view of the chest: right internal jugular central venous catheter terminates at the cavoatrial junction. no pneumothorax. there is increased interstitial opacity and engorgement of the pulmonary vasculature in the setting of cardiomegaly, compatible with edema. lung volumes are low. retrocardiac opacity is likely atelectasis. mediastinal silhouette is notable only for tortuosity of the thoracic aorta. . ct abdomen and pelvis w/o contrast study date of 2:48 am ct chest without iv contrast: there is patchy opacity at the bilateral lung bases which is slightly more consolidative appearing at the left base and could represent atelectasis, but underlying infection should be considered. trace left pleural effusion. heart and great vessels are unremarkable. right internal jugular central venous catheter terminates in the distal svc. no pericardial effusion. no pneumothorax. no axillary or hilar lymphadenopathy is noted. multiple small mediastinal nodes do not meet ct criteria for pathologic enlargement. airways are patent to the segmental level. ct abdomen with iv contrast: evaluation of the abdominal organs is limited without iv contrast. within this limitation, there is fatty infiltration of the liver. the gall bladder is surgically absent. there is fatty atrophy of the pancreas. splenomegaly measuring up to 15 cm is noted. bilateral adrenal glands are unremarkable. a 5 mm stone is noted in the left proximal ureter with associated mild hydronephrosis. tiny nonobstructing stone in the right renal pelvis. non- opacified stomach and intra-abdominal loops of small and large bowel are unremarkable. no free air or fluid in the abdomen. no mesenteric or retroperitoneal lymphadenopathy meeting ct criteria for pathologic enlargement. ct pelvis without iv contrast: the urinary bladder is collapsed around a foley catheter. uterus, adnexa, sigmoid colon and rectum are unremarkable. no free fluid in the pelvis. no pelvic or inguinal lymphadenopathy meeting criteria for pathologic enlargement. bone windows: bones are diffusely demineralized. no suspicious lytic or sclerotic osseous lesion is present. there are six non-rib-bearing lumbar vertebral bodies with partial fusion of the l5 and l6 vertebral bodies. there has been slightly increased anterior wedging of the l2 vertebral body compared to . compression fractures of t6 and t8 are similar to prior. impression: 1. patchy opacity at the bilateral lung bases which is more consolidative appearing at the left base. although findings may represent atelectasis, infection is possible. trace left pleural effusion. 2. 5 mm left ureteral stone with mild hydronephrosis. tiny nonobstructing right renal stone. 3. slight progression of l2 compression deformity compared to . . ct abdomen and pelvis w/o contrast study date of 3:28 pm findings: there has been an increase in the small bilateral pleural effusions but more marked progression of the bilateral lower lobe atelectasis. superimposed consolidation cannot be excluded. no suspicious pulmonary nodule is seen. the visualized heart, great vessels and pericardium are unremarkable in appearance on this non-contrast study. non-contrast examination of the liver, adrenal glands and pancreas is unremarkable. the gallbladder is surgically absent. the spleen is enlarged measuring approximately 15 cm. this is unchanged compared with previous imaging as far back as . the right kidney is normal in size measuring approximately 6.4 x 7.2 x 10 cm. there is a tiny 0.2cm calcific density seen in the lower pole of the right kidney. this is not causing any apparent obstruction and is unchanged in position compared with the previous study. no hydronephrosis. no perinephric fat stranding evident. there is a small hypoattenuating lesion in the lower pole of the right kidney which is incompletely characterized on ct but could represent a small aml. the left kidney is swollen, measuring 9 x 6.5 x 11.2 cm with mild perinephric fat stranding. the renal collecting system and ureter are not dilated on this side, so this appearance could be related to urosepsis rather than ureteric obstruction. the previously identified calculus in the proximal left ureter is now seen to lie within the pelvis at the approximate location of the left vesicoureteric junction. this calculus measures approximately 0.3 cm and is not causing any proximal hydronephrosis, although it has not yet passed into the bladder. ct of the pelvis without iv contrast: the urinary bladder is collapsed around the foley catheter. the uterus, adnexal regions, sigmoid colon and rectum are unremarkable. no free fluid is seen. no pelvic lymphadenopathy. osseous structures: stable compression fractures at l2. impression: 1. 0.3cm calculus at the left vesicoureteric junction not causing proximal hydronephrosis. swelling of the left kidney, likely secondary to pyelonephritis. 2. 0.2-mm calculus in the lower pole of the right kidney, non-obstructing. 3. stable compression fractures at t6, t8 and l2. . chest (portable ap) study date of 11:26 am one view. comparison with . there is interval improvement in pulmonary vascular congestion. well defined increased density at the left lung base persists. the heart and mediastinal structures are unchanged. an endotracheal tube, nasogastric tube, and right internal jugular catheter remain in place. impression: interval improvement in pulmonary vascular congestion. . chest (portable ap) study date of 3:35 pm ap upright radiograph of the chest: the lung volumes are low. there are bilateral patchy airspace opacities, minimally improved since the prior study particularly in the retrocardiac region where there is better parenchymal aeration. otherwise there are no significant interval changes. the et tube, ng tube are in standard location. there has been interval removal of the right ij catheter. impression: slight improvement in parenchymal aeration otherwise unchanged with multifocal patchy opacities predominantly at the lung bases. . ct low ext w/o c right study date of 3:11 pm findings: the study is slightly limited by patient motion. there is a partially healed fracture of the proximal fibula, with evidence of bony bridging about the lateral aspect of the fracture and well-corticated fracture lines through the medial aspect of the fracture. there is a lateral fixation plate and screws transfixing a partially healed fracture of the proximal tibia. the superior most screw extends approximately 2.8 cm beyond the tibial cortex into the soft tissues with small amount of soft tissue density adjacent to the screw tip. there is no lucency about the hardware and no evidence of hardware fracture. the distal tibial diaphyseal fracture is incompletely healed. there is partial healing of the fracture at its proximal aspect, with sclerotic corticated fracture margins superiorly and posteriorly. however, there is an abnormal diastasis of the bone fragments, with irregularity and non-healing of the bone at the anterior aspect of the fracture (best seen on the sagittal images - 1000a:37 and on the axial images (8:129). there is an abnormal lucency within the medullary cavity, surrounded by faint sclerosis, somewhat fuzzy margins, as well as soft tissue density extending beyond the cortex. these findings are concerning for osteomyelitis and intramedullary fluid. evaluation of the knee joint demonstrates tricompartmental osteoarthritis with tricompartmental osteophytes, sharpening of the tibial spines, osteophytes projecting into the trochlear notch, as well as osteophytes in the patellofemoral compartment. there is subchondral cyst formation. there is a small knee joint effusion. degenerative changes are seen at the proximal tibiofibular joint with osteophyte formation and sclerosis. the osseous structures are diffusely demineralized. impression: 1. partially united proximal tibial diaphyseal fracture with findings concerning for osteomyelitis as described above. 2. partially united proximal fibular fracture. 3. moderate tricompartmental knee joint djd. 4. small knee joint effusion. . tee (complete) done at 2:37:58 pm final referring physician information , pulmonary, critical care & , 8 , status: inpatient dob: age (years): 53 f hgt (in): 67 bp (mm hg): 120/62 wgt (lb): 289 hr (bpm): 78 bsa (m2): 2.37 m2 indication: endocarditis. icd-9 codes: 424.90, 424.0 test information date/time: at 14:37 interpret md: , md test type: tee (complete) son: cardiology fellow doppler: full doppler and color doppler test location: west echo lab contrast: none tech quality: adequate tape #: 2010w004-0:00 machine: vivid q-2 sedation: versed: 2 mg fentanyl: 100 mcg patient was monitored by a nurse throughout the procedure echocardiographic measurements results measurements normal range findings left atrium: no spontaneous echo contrast or thrombus in the la/laa or the ra/raa. good (>20 cm/s) laa ejection velocity. right atrium/interatrial septum: lipomatous hypertrophy of the interatrial septum. no asd by 2d or color doppler. left ventricle: overall normal lvef (>55%). right ventricle: normal rv chamber size and free wall motion. aorta: no atheroma in aortic arch. no atheroma in descending aorta. aortic valve: normal aortic valve leaflets (3). no masses or vegetations on aortic valve. no ar. mitral valve: normal mitral valve leaflets with trivial mr. no mvp. no mass or vegetation on mitral valve. tricuspid valve: normal tricuspid valve leaflets with trivial tr. no mass or vegetation on tricuspid valve. pulmonic valve/pulmonary artery: normal pulmonic valve leaflets. no vegetation/mass on pulmonic valve. no pr. pericardium: no pericardial effusion. general comments: a tee was performed in the location listed above. i certify i was present in compliance with hcfa regulations. the patient was monitored by a nurse throughout the procedure. local anesthesia was provided by benzocaine topical spray. the patient was sedated for the tee. medications and dosages are listed above (see test information section). 0.2 mg of iv glycopyrrolate was given as an antisialogogue prior to tee probe insertion. no tee related complications. image quality was suboptimald - poor esophageal contact. conclusions spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. the mitral valve appears structurally normal with trivial mitral regurgitation. no mass or vegetation is seen on the mitral valve. no vegetation/mass is seen on the pulmonic valve. there is no pericardial effusion. impression: no mass or vegetation seen on mitral valve, aortic valve, tricuspid valve, or pulmonic valve. no pathologic valvular regurgitation. normal biventricular systolic function. . venous dup upper ext bilateral study date of 2:24 pm bilateral upper extremity ultrasound: grayscale and color doppler son was performed of the right and left subclavian, axillary, brachial, radial, cephalic, and basilic veins and the internal jugular veins. normal flow, augmentation, compressibility, and waveforms are demonstrated. no intraluminal thrombus is seen. impression: no evidence of an upper extremity dvt. brief hospital course: micu course: 53 yo f with pmh hiv last cd4 1068, on haart, hepatitis b, hepatitis c, h/o ?pe on coumadin, morbid obesity, h/o recurrent uti last one with esbl e. coli, osa and h/o ovarian ca in s/p oophrectomy, present with sob, cp, cough, n/v diarrhea over the past few days. . # hypotension: the patient was hypotensive on admission and required pressors. likely multifactorial including dehydration from vomiting and diarrhea as well as sepsis with urine as likely source, though evidence is not clear cut as urne culture only grew out ~1000 cfu's of gnr's, though urinalysis was c/w infection and blood cultures grew out esbl e. coli which she has had in previous uti's/. she was initially treated with ivf and meropenem and continued on meropenem at time of transfer to the floor on . . # respiratory distress: the patient presented in respiratory distress and was intubated likely due to acute insult of sepsis on underlying copd/asthma. she developed ards and was placed on ardsnet protocol. cta showed atelectasis vs. pna; it was negative for pe. pt was covered for infectious process with meropenem as above. sputum cultures were consistently negative. she was given nebulizer treatments for symptomatic improvement. she was eventually weaned off the ventilator and successfully extubated. she was then transferred from icu to the floor for further care. . # coag negative staph bacteremia: the patient developed coag negative staph bacteremia and spiked fevers. her a-line was pulled and she was started on linezolid. she had positive cultures the following day off a resited a-line. it too was pulled. she was continued on linezolid and remained afebrile, with greater than 48 hours of negative cultures at the time of discharge. a tee was negative for endocarditis and a ct of her r knee was negative for infected hardware / osteomyelitis. was consulted and agreed that there was no evidence of osteomyelitis or infected hardware. outpatient follow-up is planned with . . # arf: the patient presented in acute renal failure likely from poor perfusion. she also had a stone in the l ureter with mild hydronephrosis. both urology and interventional radiology deferred procedural intervention given that her cr normalized and the difficulty of procedure given her body habitus and comorbidities. at the time of transfer out of icu her cr had normalized. . # diarrhea: the patient had a large amount of diarrhea. c.diff and stool cultures were sent and eventually returned negative. she was initially started empirically on cipro and flagyl which were dc'd with negative work-up. diarrhea was most likely secondary to lactulose administration. on transfer out of icu to the floor diarrhea had resolved. . # altered mental status: the patient alternated between somnolence and agitation during much of her micu stay. her home methadone dose was decreased to 10 mg tid with good response. tsh, b12, and ammonia levels were normal. lactulose was given. at time of transfer to medicine floor, pt mental status had not cleared but was improving. . # hiv: she was continued on home meds and a viral load was nearly undetectable. . # hepatitis b/c: continued on home meds ....... once out of the iceu and on the medicine floor, pt intial was delerius but had continued improvement over several days. methadone and other sedating medications were initially held as there was concern that these may be contributing to pt delerium. vs remained stable. pt continued course of meropenem and linezolid which were complete on and respectively. pt had a bought of several loose stools; c diff was repeated and was negative. pt also noted increased buring with urination; ua and culture was repeated; these cultures were pending at time transfer to rehab. pt was afebrile, vs remained stable and delerium cleared prior to day of discharge to rehab. pt was restarted on coumadin with lovenox bridge with goal of therapeutic inr of to be monitored in rehab and in outpatient setting. medications on admission: - albuterol sulfate 90 mcg/q4h prn asthma. - atazanavir 300 mg po daily. - bisacodyl 10 mg (e.c.) by mouth daily prn constipation. - calcium carbonate 500 mg tid - camphor-menthol .5-0.5 % lotion qid prn itching - cholecalciferol (vitamin d3) 400 unit po daily - clonazepam 0.5 mg tablet po tid. - cyclobenzaprine 10 mg po tid prn for spasms - diphenhydramine hcl 50 mg po q6h prn itching - docusate sodium 100 mg capsule po bid - duloxetine 20 mg (e.c.) po daily - emtricitabine-tenofovir 200-300 mg tablet po daily - fluticasone 50 mcg/actuation spay 2 spray nasal daily - furosemide 40 mg tablet po bid - gabapentin 800 mg capsule po qam, qpm, 2 at bedtime - hydromorphone 4-8 mg po q3h prn pain. - methadone 40 mg po tid prn - multivitamin po daily. - ritonavir 100 mg po daily. - sennosides 8.6 mg tablet 1-2 tablets po bid. - spironolactone 25 mg po daily - sumatriptan succinate 100 mg po daily prn migraine - tiotropium bromide 18 mcg inhalation daily (daily). - zolpidem 10 mg po qhs - warfarin 5mg po daily discharge medications: 1. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: one (1) inhalation every four (4) hours as needed for shortness of breath or wheezing. 2. atazanavir 300 mg capsule sig: one (1) capsule po once a day. 3. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po once a day as needed for constipation. 4. calcium carbonate 500 mg (1,250 mg) tablet, chewable sig: one (1) tablet, chewable po three times a day. 5. camphor-menthol 0.5-0.5 % lotion sig: one (1) topical four times a day as needed for itching. 6. cholecalciferol (vitamin d3) 400 unit tablet sig: one (1) tablet po once a day. 7. cyclobenzaprine 10 mg tablet sig: one (1) tablet po three times a day as needed for spasm. 8. diphenhydramine hcl 50 mg tablet sig: one (1) tablet po every six (6) hours as needed for itching. 9. docusate sodium 100 mg capsule sig: one (1) capsule po twice a day as needed for constipation: hold for loose stool. 10. duloxetine 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. 11. emtricitabine-tenofovir 200-300 mg tablet sig: one (1) tablet po daily (daily). 12. fluticasone 50 mcg/actuation spray, suspension sig: two (2) nasal once a day. 13. gabapentin 800 mg tablet sig: one (1) tablet po once a day: qam. 14. gabapentin 800 mg tablet sig: two (2) tablet po at bedtime. 15. hydromorphone 4 mg tablet sig: 1-2 tablets po q3h:prn as needed for pain: hold for sedation. 16. methadone 10 mg tablet sig: two (2) tablet po three times a day as needed for pain: hold for sedation. 17. multivitamin tablet sig: one (1) tablet po daily (daily). 18. ritonavir 100 mg capsule sig: one (1) capsule po daily (daily). 19. sennosides 8.6 mg tablet sig: 1-2 tablets po twice a day as needed for constipation. 20. sumatriptan succinate 100 mg tablet sig: one (1) tablet po once a day. 21. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) inhalation once a day. 22. coumadin 10 mg tablet sig: one (1) tablet po once a day. 23. spironolactone 25 mg tablet sig: one (1) tablet po once a day. 24. furosemide 40 mg tablet sig: two (2) tablet po twice a day. 25. lovenox 100 mg/ml syringe sig: one (1) subcutaneous twice a day: lovenox bridge to coumadin total dose of lovenox 130mg , inr goal of . 26. lovenox 30 mg/0.3 ml syringe sig: one (1) subcutaneous twice a day: lovenox bridge to coumadin total dose of lovenox 130mg , inr goal of . discharge disposition: extended care facility: center for rehab & sub-acute care - discharge diagnosis: primary: bacteremia uti sepsis - most likely a concequence of uti . secondary: delerium ards pneumonia asthma discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: you were admitted to the hospital because of shortness of breath, chest pain, fever, nausea and vomitting for several days without improvement. you're symptoms worsened when you initially arrived and you had to be admitted to the icu. because you vital signs were very unstable you were intubated to help you breath while the cause of your illness was determined and treated. it was found that you had an infection of your bladder and your blood. you received antibiotics and you're condition improved. you were able to be extubated but remained confused. eventually your condition improved to the point where you no longer required icu level care and you were transferred to the main medicine floor. after you completed you coures of antibiotics, you were then discharged to an extended care facility to complete your recovery and rehabilitation. . the following changes were made to your medications: - please decrease your dose of methadone to methadone 20 mg three times a day; this will be titrated at the rehabilitation facility as necessary to your original dose based on your pain needs. - please stop taking zolpidem 10 mg at night. please discuss the need for this medication with your doctor. - please stop taking clonazepam 0.5mg three times a day; this was stopped given our concern over your confusion and sedation. please discuss the need for this medication with your doctor. - please restart taking warfarin 10mg daily. please be sure to have your inr checked per protocol at the rehabilitation facility and then as per your doctors orders once return home at you regular . goal inr of - please start taking lovenox 130mg while we are waiting for your coumadin to reach the appropriate level. goal inr of - please continue to take all of your other home medications as prescribed. please be sure to take all medication as prescribed. . please check inr twice a week until inr level is stable. continue lovenox until reaching inr goal of . please be sure to have your inr checked at the rehabilitation clinic per anticoagulation monitoring protocol; once discharged please be sure to have your inr checked at your regular per your doctors . . please be sure to keep all follow-up appointments with your pcp and other health care providers. . it was a pleasure taking care of you and we wish you a speedy recovery. followup instructions: please be sure to keep all follow-up appointments with your pcp and other health care providers. . please be sure to have your inr checked at your regular . please check inr twice a week until inr level is stable. continue lovenox until reaching inr goal of . . department: orthopedics name: , pa (works with , ) location: center address: , , phone: appt: at 10:30am when: tuesday at 12:10 pm with: xray (scc 2) building: sc clinical ctr campus: east best parking: garage department: orthopedics when: tuesday at 12:30 pm with: , md building: campus: east best parking: garage md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances arterial catheterization arterial catheterization injection or infusion of oxazolidinone class of antibiotics diagnoses: pneumonia, organism unspecified obstructive sleep apnea (adult)(pediatric) other chronic pain tobacco use disorder urinary tract infection, site not specified acute kidney failure, unspecified severe sepsis unspecified viral hepatitis c without hepatic coma hypopotassemia acute respiratory failure bacteremia septic shock morbid obesity diarrhea chronic obstructive asthma, unspecified septicemia due to escherichia coli [e. coli] hydronephrosis calculus of ureter other candidiasis of other specified sites delirium due to conditions classified elsewhere personal history of antineoplastic chemotherapy asymptomatic human immunodeficiency virus [hiv] infection status viral hepatitis b without mention of hepatic coma, acute or unspecified, without mention of hepatitis delta staphylococcus infection in conditions classified elsewhere and of unspecified site, staphylococcus, unspecified mixed acid-base balance disorder infection with drug-resistant microorganisms, unspecified, with multiple drug resistance personal history of malignant neoplasm of ovary 

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