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: penicillins attending: chief complaint: pancytopenia (sent from ) major surgical or invasive procedure: right ij line history of present illness: 64 y/o m with history of ms presenting from with progressive lower extremity edema and new systolic murmur. patient reports subacute deterioration from his baseline. in the 2-3 weeks, he has been feeling more fatigued, weak, with one episode of severe weakness when he had trouble getting out of bed. he also has experienced increasing shortness of breath at rest. in addition, he started having bilateral lower extremity swelling 2-3 days ago (has had a remote history of this, but not as severe). ros notable for constipation, remote history of bloody stools and urine, constipation and le pinpoint rash. denies f/c, orthopnea, pnd, cough. this am, his vna visited and thought he was pale, concerned about anemia, so sent him to . office exam notable for new murmur and palpable liver edge with some jaundice, concern for valvular insufficency and hepatic congestion, and labs showing pancytopenia. in the ed inital vitals were, 98.1 92 114/53 20 98% 4l nasal cannula. exam was notable for bilateral lower extremity edema, elevated jugular venous pressure, and a systolic murmur, in addition to scleral icterus and jaundice. labs were notable for wbc 1.9, hemoglobin 3.0 and hematocrit 9.6, with platelets of 12. he had a transaminitis with elevated ldh and normal total bili. automated smear was negative for schistocytes. troponin was negative x 2 and ekg was sinus tachycardia at elevations or depressions. bnp was elevated to 3543. he was transfused 2u prbc. urinalysis was concerning for urinary tract infection, so patient was started levaquin. cxr concerning for rll infiltrate, and patient given levaquin and azithromycin. bedside echo in ed concerning for ?rv mass, vegetation? on arrival to the icu, patient comfortable, hemodynamically stable. review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies cough, shortness of breath, or wheezing. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. past medical history: multiple sclerosis - diagnosed in . multiple resolving flares. multiple lesions detected on . has been treated with alternative medications and acupuncture after having a bad experience with amantadine. osteoporosis vitamin d deficiency social history: on disability. was vp of publishing company and travelled extensively many years ago. lives alone, rarely goes outside, has groceries delivered to him and has a housekeeper. - tobacco: currently uses tobacco and marijuana - alcohol: denies - illicits: medical marijuana family history: mother: ovarian - died at age 60 father: died in accident at age 50. siblings: no siblings. denies diabetes or hypertension. physical exam: admission exam: vitals: 97.2, 70, 123/61, 23, 90% on high : alert, oriented, no acute distress heent: sclera anicteric, dry mm, oropharynx clear neck: supple, jvp elevated to angle of the jaw at 70 deg angle, no lad lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi cv: regular rate and rhythm, normal s1 + s2, holosystolic murmur at llsb, no rubs or gallops abdomen: +bs, soft, ruq tenderness, no hepatosplenomegaly, no rebound tenderness or guarding gu: foley draining red-tinged blood ext: 2+ edema in the b/l le, r>l up to mid leg. petechiae on b/l le. warm, well perfused, 2+ pulses, no clubbing, cyanosis neuro: cnii-vii intact, motor strength 5/5 in lue, in rue, in lle, in rle pertinent results: admission labs: wbc-2.4*# rbc-1.23*# hgb-3.3*# hct-9.9*# mcv-80*# mch-26.5*# mchc-31.2 rdw-30.5* plt ct-14*# neuts-43* bands-0 lymphs-39 monos-6 eos-0 baso-0 atyps-11* metas-0 myelos-0 nrbc-10* plasma-1* pt-16.9* ptt-33.4 inr(pt)-1.6* fibrino-495* esr-50* ret aut-7.5* glucose-100 urean-40* creat-1.8*# na-135 k-4.3 cl-94* hco3-29 angap-16 alt-146* ast-185* ld(ldh)-584* alkphos-106 totbili-1.0 lipase-20 probnp-3543* ctropnt-<0.01 albumin-3.4* calcium-8.2* mg-2.5 d-dimer-1223* hapto-102 ferritn-663* caltibc-244* vitb12-602 folate-15.2 ferritn-584* trf-188* triglyc-78 cortsol-17.1 hbsag-negative hbsab-negative hbcab-negative hav ab-negative igm hav-negative hiv ab-negative hcv ab-negative hsv, parvo b19, ebv, cmv negative . discharge labs 12:00am blood wbc-3.8* rbc-2.38* hgb-7.0* hct-20.8* mcv-87 mch-29.4 mchc-33.8 rdw-16.5* plt ct-39* 12:00am blood neuts-73* bands-0 lymphs-19 monos-1* eos-2 baso-2 atyps-0 metas-0 myelos-1* nrbc-1* other-2* 12:00am blood pt-16.7* ptt-36.2 inr(pt)-1.6* 12:00am blood glucose-78 urean-15 creat-0.6 na-138 k-3.8 cl-105 hco3-27 angap-10 12:00am blood alt-21 ast-16 ld(ldh)-160 alkphos-81 totbili-0.5 12:00am blood calcium-8.9 phos-4.4 mg-1.7 uricacd-2.6* . microbiology: 5:55 pm urine site: catheter urine culture (final ): citrobacter freundii complex. >100,000 organisms/ml.. this organism may develop resistance to third generation cephalosporins during prolonged therapy. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. for serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. sensitivities: mic expressed in mcg/ml _________________________________________________________ citrobacter freundii complex | citrobacter freundii complex | | cefepime-------------- <=1 s <=1 s ceftazidime----------- <=1 s <=1 s ceftriaxone----------- <=1 s <=1 s ciprofloxacin---------<=0.25 s <=0.25 s gentamicin------------ <=1 s <=1 s meropenem-------------<=0.25 s <=0.25 s nitrofurantoin-------- 64 i 32 s tobramycin------------ <=1 s <=1 s trimethoprim/sulfa---- <=1 s <=1 s pleural fluid ()- gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (preliminary): no growth. sputum endotracheal ()- contaminated, culture not performed gram stain (final ): pmns and >10 epithelial cells/100x field. sputum ()- contaminated, culture not performed, no legionella blood culture ()- ngtd, pending final blood culture ()- ngtd, pending final blood culture ()- ngtd, pending sputum ()- gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 1+ (<1 per 1000x field): yeast(s). respiratory culture (final ): rare growth commensal respiratory flora. yeast. sparse growth. legionella culture (preliminary): no legionella isolated. cmv igg positive, igm negative, no cmv dna detected - virus vca-igg ab (final ): positive by eia. - virus ebna igg ab (final ): positive by eia. - virus vca-igm ab (final ): negative <1:10 by ifa. hepatitis serologies ()- hbsag negative, hbs ab negative, hbc ab negative, hav ab negative, igm hav negative imaging: cxr : impression: subtle minimal ill-defined opacity within the right lung base may reflect an area of developing infection. no evidence for pulmonary edema. echo : the left atrium is mildly dilated. the estimated right atrial pressure is at least 15 mmhg. left ventricular wall thickness, cavity size, and global systolic function are normal (lvef>55%). due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the ascending aorta is mildly dilated. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate (2+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is mild pulmonary artery systolic hypertension. there is no pericardial effusion. ruq u/s : impression: 1. small liver hemangioma. otherwise, normal-appearing liver. 2. fullness of the bilateral renal pelvises without hydronephrosis. 3. gallbladder wall edema without significant distention of the gallbladder likely relates to third spacing. sludge within the dependent portion of the gallbladder. 4. splenomegaly. 5. bilateral pleural effusions. 6. trace ascites. 7. left renal cyst. ble u/s : impression: 1. partially occlusive thrombus within a left posterior tibial vein with possible occlusive thrombus in a second left posterior tibial vein versus superficial vein. 2. no additional deep venous thrombosis within the bilateral lower extremities. cxr : impression: 1. interval placement of an endotracheal tube which has its tip approximately 10 cm above the carina. the tube should be advanced approximately 4 cm. the patient's nurse, , was notified by phone on at 8:42 a.m. the need for repositioning. 2. both costophrenic angles are not included on this study. there is a bilateral diffuse airspace process which again appears slightly improved favoring that this represents some moderate-to-severe pulmonary edema rather than diffuse pneumonia. however, clinical correlation is advised. overall cardiac and mediastinal contours are stable. no large pneumothorax appreciated. brain, c-spine : scattered areas of high signal intensity in the subcortical and periventricular white matter, extending to the callosal septal region, consistent with demyelination and related with a history of multiple sclerosis. the plaques are more numerous since , there is no evidence of abnormal enhancement. no mass effect or shifting of the normally midline structures is present. the alignment of the cervical vertebral bodies appears maintained, disc degenerative changes are identified, consistent with disc desiccation, mild posterior disc bulge is noted at c4-c5, causing anterior thecal sac deformity and impinging the thecal sac (image 13, series 19). there is no evidence of neural foraminal narrowing or significant spinal canal stenosis. disc degenerative changes are also present at c6-c7 level with narrowing of the intervertebral disc space, schmorl's node and endplate changes are visualized at this level, consistent with bone marrow replacement for fat (image 8, series 16). the spinal cord demonstrates areas of high signal intensity on the fat suppression sequence, more evident at c2, c3 and c5 levels, likely consistent with demyelinating plaques. there is no evidence of abnormal enhancement in this area. . head ct final report indication: 64-year-old male with ms presents with coagulopathy, respiratory distress and mental status change. rule out ich. comparison: of . technique: contiguous axial images were obtained through the brain without iv contrast. ct head without iv contrast: a tiny amount of hyperdense material is seen in a right frontal sulcus (2:20) and a right temporal sulcus (2:14) concerning for subarachnoid hemorrhage. in addition, there is a small amount of hyperdense material layering in the posterior of the left lateral ventricle concerning for intraventricular hemorrhage (2:17). there is no intraparenchymal hemorrhage or extra-axial collection. there is no major vascular territory infarction, mass effect, or edema. -white matter differentiation is preserved. there is age-appropriate prominence of ventricles and sulci compatible with diffuse parenchymal volume loss. globes and lenses are intact. mucosal thickening in the left maxillary and sphenoid sinuses is noted, but the remainder of visualized paranasal sinuses and mastoid air cells are well aerated. there is no suspicious lytic or sclerotic bone lesion. impression: 1. findings concerning for subarachnoid hemorrhage in the right frontal and temporal lobes and a tiny amount of intraventricular hemorrhage in the left lateral ventricle. close interval follow up recommended to exclude progression. 2. left maxillary and sphenoid sinus inflammatory disease. comment: findings discussed by phone with dr. at 10 pm on . note added in attending review: in retrospect, the diffusely abnormal hyperintensity on the flair sequences from the mr examination of was in the subarachnoid space, rather than cortically-based (as reported). this likely represented diffuse subarachnoid hemorrhage in cortical sulci, and there was a "sedimentation layer" in the trigone and occipital of the left lateral ventricle at that time (8,12:). no pathologic leptomeningeal or dural enhancement was demonstrated on that exam. the study and the report were reviewed by the staff radiologist. dr. dr. approved: wed 10:51 am . head ct clinical information: 64-year-old male with mds and ms, found to have intracranial hemorrhage and altered mental status, for followup. comparison: ct, mr. technique: axial mdct images were acquired of the head without contrast and reformatted into coronal and sagittal planes. findings: hyperdense material is again seen layering within the occipital of the left lateral ventricle. there has been interval development of hyperdense material layering within the occipital of the right lateral ventricle, increasing the probability that this does in fact represent hemorrhage. while the ventricles are mildly prominent, there is no dilatation of the temporal horns to suggest hydrocephalus. the sulci also are prominent. the matter/white matter differentiation remains preserved. hypodensity in the frontal white matter, extending superiorly from the corpus callosum is consistent with the known demyelinating lesions seen better on . hyperdense foci are also seen within frontal sulci (image 26), which is nonspecific and could represent subarachnoid hemorrhage or calcification. there is minimal mucosal change of the left maxillary sinus, and there is partial opacification of left mastoid air cells. additionally, there is an air-fluid level seen within the left sphenoid sinus with mucosal thickening. impression: 1. redistribution of intraventricular hemorrhage, now seen within the occipital horns of the lateral ventricles, bilaterally. 2. subtle hyperdensity within multiple sulci, likely reflecting resorption and redistribution of the diffuse subarachnoid blood seen on the mr study of is unchanged from the nect obtained only 10 hours earlier. 3. there has been further ventricular dilatation since the remote mr study of , but this more likely reflects progressive global, including central atrophy, rather than developing hydrocephalus. . bone marrow biopsy cell culture was established to provide metaphase cells for chromosome analysis. no metaphases were available from this specimen, therefore the cytogenetic analysis could not be performed. -------------------interphase fish analysis, 100-300 cells------------------- nuc ish(d7z1,d7s522)x1, (egr1x1,d5s23/d5s721x2),(d8z1x2),(d20s108x2) fish evaluation for a 7q deletion was performed with the vysis lsi d7s522/cep7 dual color probe ( molecular) for d7s522 at 7q31 and cep7 (d7z1) (chromosome 7 alpha satellite dna) at 7p11.1-q11.1 and is interpreted as abnormal. a single d7s522/d7z1 hybridization signal was observed in 43/100 nuclei, which exceeds the normal range (up to 3% monosomy 7) established for this probe in the cytogenetics laboratory at . fish evaluation for a 5q deletion was performed with the vysis lsi egr1/d5s23, d5s721 dual color probe ( molecular) for egr1 at 5q31 and d5s721/d5s23 at 5p15.2 and is interpreted as abnormal. a single hybridization signal was observed in 30/100 nuclei examined, which exceeds the normal range (up to 3% egr1 deletion) established for this probe in the cytogenetics laboratory at . fish evaluation for a chromosome 8 aneuploidy was performed with the d8z2 dna probe (chromosome 8 alpha satellite dna) ( molecular) at 8p11.1- q11.1 and is interpreted as normal. two hybridization signals were detected in 94/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 6% of cells in normal samples can show apparent trisomy 8 using this probe set. a normal chromosome 8 fish finding can result from absence of trisomy for chromosome 8 or from an insufficient number of neoplastic cells in the specimen. fish evaluation for a 20q deletion was performed with the vysis lsi d20s108 probe ( molecular) at 20q12 and is interpreted as normal. two hybridization signals were observed in 97/100 nuclei examined, which is within the normal range established for this probe in the cytogenetics laboratory at . up to 8% of cells in normal samples can show apparent 20q deletion using this probe set. a normal 20q fish finding can result from absence of a 20q deletion, from a 20q deletion that does not involve the region to which this probe hybridizes, or from an insufficient number of neoplastic cells in the specimen. . specimen submitted: bon e marrow core bx iliac crest (1 jar) procedure date tissue received report date diagnosed by dr. /mn???????????? ============== diagnosis ============ specimen: bone marrow core biopsy. diagnosis: hypercellular marrow with extensive fibrosis, trilineage dysplasia, and increased myeloblasts. see note. note: the findings are highly suspicious for a myelodysplastic disorder best classified as refractory anemia with excess blasts (raeb-2) based on the number of myeloblasts in the peripheral blood (a marrow aspirate could not be obtained) and the core biopsy immunostained with cd34. however, given the clinical presentation of the patient with severe anemia and acute high output cardiac failure the findings in this marrow need to be interpreted with caution and a follow up biopsy is highly recommended, unless cytogenetic studies confirm myelodysplastic syndrome or other related myeloproloferative disorder. please correlate with cytogenetic findings and clinical evolution. microscopic description peripheral blood smear: the peripheral blood smear is adequate for evaluation. erythrocytes exhibit anisopoikilocytosis, targets, bite cells, elliptocytes, dacrocytes, and show polychromasia and basophilic stippling. the white cell count is decreased. neutrophils are decreased and exhibit dysplastic features including hyposegmentation. pseudo pelger-??????t forms are present as well as hypogranular forms. monocytes are normal in number and exhibit mild dysplasia. lymphocytes are decreased in number and include some large granular lymphocytes. platelets are decreased in number and many are hypogranular and large. multiple nucleated red blood cells are seen (50% of nucleated cells) and exhibit significant dyspoiesis including asymmetric nuclear budding, nuclear fragments and cytoplasmic nuclear dy synchrony. differential shows 54% neutrophils, 2% bands, 18% lymphocytes, 7% monocytes, 2% eosinophils, 4% basophils; 12% blasts and 1% myelocytes. aspirate smear: an aspirate smear was not submitted. biopsy and clot sections: two cores are received both measuring 9mm in length. one core consists almost entirely of fibrotic marrow with variable cellularity, which ranges from 5% to 20%. the second core is cellular with an overall cellularity of 70-80%. the m:e ratio appears decreased. erythroid precursors are increased and exhibit dyspoietic maturation. myeloid precursors are decreased in number and exhibit dysplastic maturation. megakaryocytes are increased and exhibit dysplastic maturation. special stains: a cd34 stain highlights blasts comprising 10-20% of the marrow cellularity. cd33 is immunoreactive in approximately one third of the marrow cells. e-cadherin and glycophorin-a highlight erythroblasts. there is a greater percentage of cells staining for glycophorin-a than e-cadherin which is immunoreactive in about one third of the cells, indicating that the majority of the erythroblasts are undergoing maturation. cd42 reveals numerous megakaryocytes. mpo staining is dim and stains approximately 20% or less in the cells. cd68 stains most myeloid precursors as well as increased marrow histiocytes. cd117 (ckit) has strong staining in the mast cells and reveals an increased number. dimly stained cell with cd117 correspond to increased megakaryocytes. cytogenetic studies: see separate report. flow cytometry studies: see separate report. clinical: anemia, leukopenia and thrombocytopenia. 64 year old male with progressive ms associated with pancytopenia concerning for aplastic process. . specimen submitted: immunophenotyping - pb procedure date tissue received report date diagnosed by dr. /dsj?????? previous biopsies: bon e marrow core bx iliac crest (1 jar) flow cytometry report flow cytometry immunophenotyping the following tests (antibodies) were performed: hla-dr, glycophorin a, kappa, lambda, and cd antigens 2, 3, 4, 5, 7, 8, 10, 11c, 13, 14, 15, 19, 20, 33, 34, 41, 56, 64, 71, 117. results: three color gating is performed (light scatter vs. cd45) to optimize blast yield. there are two dominant populations in the blast gate. one population is slightly dimmer than lymphocytes for cd45 and exhibits a phenotype consistent with myeloblasts (positive for cd45, cd34, cd33, cd11c, cd117 (dim), cd15, cd13 and are negative for cd14, cd41, cd56, cd64, and glycophorin. a second population which express only low levels of cd45 lacks all lymphoid and myeloid markers but is positive for cd71 and glycophorin-a and represent erythroblasts. interpretation immunophentopyic findings consistent with an increased population of myelodysplastic and erythroblasts, and suggest a myelodysplastic syndrome with increased blasts or acute leukemia. please correlate with the morphologic findings in the marrow biopsy and a blast count. please see concurrent bone marrow report s11-. note: this test was performed using analyte specific reagents (asrs). these asrs have not been cleared or approved by the us food and drug administration (fda). however, the fda has determined that such clearance or approval is not necessary . this test was developed and its performance characteristics determined by the flow cytometry laboratory at , which is licensed by clia to perform high complexity tests. this test was used for clinical purposes; it should not be regarded as for research. clinical: multiple sclerosis and new pancytopenia. gross: bone marrow for immunophenotyping. brief hospital course: 64 yo m with advanced progressive multiple sclerosis presenting with increasing fatigue/weakness, b/l le swelling, and pancytopenia, bone marrow consistent with mds, course complicated by hypoxic respiratory failure, dvt/pe, pneumonia, ich. . # hypoxic respiratory failure: patient initially presented with increasing fatigue. developed hypoxic respiratory failure requiring intubation. differential included pe (patient with dvt found on le ultrasound), transfusion associated circulatory overload to rapid multiple transfusions, and less likely pneumonia. cxr revealed a diffuse bilateral pattern. initially covered with vanc/cefepime, but then discontinued vanc/cefepime after 2 days when likelihood of pneumonia low. patient treated for dvt (potential pe) with heparin drip. extubation was performed on hd 5, however patient was extremely tachypnic and required re-intubation. antibiotics were restarted with vancomycin, cefepime, and levofloxacin and patient completed a ten day course. he was diuresed over the next several days with iv lasix (bolus and drip) for treatment of transfusion associated circulatory overload. in addition, patient had a large left sided effusion, largely related to volume overload/pulmonary edema, which was drained by thoracentesis. fluid was consistent with transudate and culture was negative. difficulty extubating was also thought to be related to underlying multiple sclerosis causing neuromuscular weakness. negative inspiratory force was low, but gradually improved and on hd 10, patient was successfully extubated. his respiratory status continued to improve and he had saturations in the mid to high 90s on room air at the time of discharge. # deep vein thrombosis: patient had bilateral swelling of lower extremities on presentation. doppler ultrasound showed a partially occlusive clot in the left lower extremity. patient was placed on heparin drip with goal ptt 60-80 given patient's high risk of bleeding given his pancytopenia. he was kept on heparin drip while intubated, and upon extubation and clearance by speech and swallow he was transitioned to lovenox and given one dose of warfarin. lovenox was however discontinued due to thrombocytopenia. the patient therefore underwent successful placement of an ivc filter by ir. a cta was deferred given patient's initial acute kidney injury. # hypotension: concern of sepsis from urinary and pulmonary sources. sedation may also have contributed to hypotension. adrenal insufficiency ruled out by normal cortisol am level and cortisol stim test. right ij placed, but patient did not require pressor support. blood pressures remained low normal throughout his hospitalization. his systolic blood pressures were in the 100-110s at the time of discharge. . # myelodysplastic syndrome: patient presented with pancytopenia. bone marrow biopsy showed mds with erythroblasts without evidence of leukemia. viral studies negative for cmv, hsv, hiv, ebv, and parvovirus. patient treated with supportive blood products, transfusion threshold hct<21 and plt<30. patient required a total of 12 units of prbc and 14 units of platelets throughout hospitalization. he was started on neupogen 480mcg daily per bmt recommendations, this was discontinued on discharge as he was no longer acutely infected. once patient's respiratory status was stabilized, he was transferred to bmt floor for further management. given the patients current deconditioned status he is not a good candidate for therapy at this time. he will follow-up with hematology/oncology as an outpatient to determine further management of his mds. for now he will be managed with transfusion support. . # multiple sclerosis: patient has progressive ms, with recent deteriorations. per conversation with outpatient neurologist, was not a necessary medication and was discontinued. oxacarbazepam was initially held as concern for cause of pancytopenia, however it was restarted once bone marrow showed mds. an was performed which showed increased numbers of plaques compared to from . patient complained of worsening right greater than left upper and lower extremity weakness, which improved following extubation, but was still quite debilitating. in addition, difficulty extubating was attributed to ms showed plaques in c3-c5 concerning for involvement of the phrenic nerve. however, as above, following extubation, patient had no signs of neuromuscular weakness effecting his ability to breath independently. the patient was evaluated by pt who felt the patient would benefit from intensive rehab. . # supraventricular tachycardia: patient was noted to have 2 episodes of tachycardia to the 150s after transfer to the bmt service. ekg showed an svt (most likely avnrt). during theses episodes his blood pressure decreased to sbp of high 80s. he also became mildly confused during the first episode. each time he was given adenosine 6 mg once with return of sinus rhythm and improvement in his blood pressure. following the second episode he was started on metoprolol tartrate which was titrated upward to 25 mg . he remained in sinus rhythm for the remainder of his hospitalization. he will need to follow-up with his . regarding need for outpatient cardiology referral. . # intracranial hemorrhage: on patient was noted to be confused. given his low platelet count there was concern for an intracranial hemorrhage. a head ct did show a small focus of intraventricular hemorrhage in the left lateral ventricle and small foci of possible sah. the patient was given vitamin k to reverse the coumadin he had received that day, ffp and platelets. repeat head ct 7 8 hours later was unchanged and the patients neuro exam was stable. neurosurgery was consulted and recommended keeping platelets > 80 for 7 days and follow up in 1 month. . # acute mental status changes: patient was noted to be confused on transfer from the icu. this was felt to be multi-factorial in nature. icu delirium was likely a factor as mental status improved with better sleep hygiene. additionally, as above the patient was noted to have a small intracranial hemorrhage. infectious work-up including blood cultures and urine cultures were negative though the patient was undergoing treatment of pneumonia. chemistry panel was unremarkable. the patients mental status continued to improve and was at baseline at the time of discharge. . # urinary retention- patient noted to be retaining urine after removal of a foly catheter. catheter was replaced. he will need repeat voiding trial in days (, ) . # elevated inr - patient noted to have inr elevated to 1.3-1.6. he was given vitamin k 5 mg x 2. he was started on po vitamin k 5 mg weekly. this medication should be continued on discharge. his inr should be monitored at rehab with discontinuation of medication when inr is within normal limits. . # urinary tract infection: urine culture was positive for pansensitive citrobacter from the urine. patient completed a 7-day course of ciprofloxacin. subsequent urine cultures were negative as were several blood cultures. . # hypernatremia: patient's sodium was high during admission. this was treated with free water flushes via og tube while patient was intubated. hypernatremia resolved and did not return. . # transaminitis: initially elevated, then trended down. ruq showed no signs of hepatic congestion or infiltrative disease. no venous thrombosis. hepatitis serologies negative, cmv negative, ebv, hiv negative. still be medication induced. this resolved prior to discharge. . # acute kidney injury: cr initially elevated, likely severe hypovolemia in the setting of severe anemia. trended back to baseline with transfusions and remained stable throughout hospitalization. . # hyperuricemia: uric acid was 11.0. potassium and phosphate were not consistent wtih tumor lysis syndrome. patient was started on allopurinol to decrease uric acid level as there was concern that high level may be contributing to acute kidney injury. his allopurinol dose was decreased to 100 mg daily prior to discharge. . # overall goals of care: established friend, , to be health care proxy. following extubation, patient expressed his wishes to be dnr/dni. paperwork for code status and health care proxy were completed with the assistance of social work. # transitional issues: - patient is dnr/dni - patient will follow-up with dr. (heme/onc), dr. (neuro ), dr. (neurology), he should also call to make an appointment with dr. () after being discharged from rehab - blood cultures were pending at the time of discharge - patient was discharged to facility in - patient will need monitoring of his inr, cbc and chem-10 medications on admission: alendronate 70mg po qweek 20mg subcutaneous daily provigil 200mg po qam, 100mg po qpm naltrexone 1.5mg po tid oxcarbazepine 150mg po bid/tid lorazepam 0.5mg po qhs prn calcium carbonate-vit d3 800mg-400u tab po bid vitamin c 1000mg po daily mvi discharge medications: 1. modafinil 100 mg tablet sig: 1-2 tablets po qam (). 2. alendronate 70 mg tablet sig: one (1) tablet po once a week. 3. oxcarbazepine 150 mg tablet sig: one (1) tablet po twice a day. 4. allopurinol 100 mg tablet sig: one (1) tablet po daily (daily). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day): hold for sbp < 90 hr < 60 . tablet(s) 6. calcium carbonate-vit d3-min 600 mg calcium- 400 unit tablet sig: one (1) tablet po twice a day. 7. ascorbic acid 500 mg/5 ml syrup sig: one (1) po daily (daily). 8. therapeutic multivitamin liquid sig: one (1) tablet po daily (daily). 9. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 10. docusate sodium 50 mg/5 ml liquid sig: ml po bid (2 times a day) as needed for constipation. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed for fever/pain. 12. lorazepam 0.5 mg tablet sig: 0.5 tablet po at bedtime as needed for anxiety/insomnia. 13. phytonadione 5 mg tablet sig: one (1) tablet po once a week. 14. ketoconazole 1 % shampoo sig: one (1) application topical every other day. 15. potassium chloride 20 meq tablet, er particles/crystals sig: tablet, er particles/crystalss po once a day as needed for hypokalemia : please administer potassium 3.8 - 3.6: 40 meq prn potassium 3.5 - 3.3: 60 meq prn potassium 3.2 - 3.0: 80 meq prn . discharge disposition: extended care facility: hospital - discharge diagnosis: primary multiple sclerosis myelodysplastic syndrome intraventricular hemorrhage deep venous thrombosis supraventricular tachycardia discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: mr it was a pleasure participating in your care while you were admitted to . as you know you were admitted because you had swelling in you legs. you were found to have a clot in your left leg. you were also found to have very low blood counts due to your bone marrow not working properly. you were given blood and platelets. since your blood counts are low we cannot give you blood thinners to treat the clot so a filter was placed in one of your blood vessels to prevent it from traveling to your lungs. you also had trouble breathing while in the hospital and required placement of a breathing tube. this was successfully taken out and you are now breathing on your own. your heart was noted to have an irregular rhythm that was very fast. we started you on medication to help control your rate. you were also noted to have a small bleed in your brain. this has been stable. there is nothing that needs to be done for this currently however you will need to follow-up with the neurosurgeons in 1 month. we made the following changes to your medications 1. stop 2. stop naltrexone 3. decrease provigil to 200 mg in the morning and stop taking it at night 4. decrease ativan to pill as needed at night 5. start metoprolol tartrate 25 mg twice a day 6. start allopurinol 100 mg daily 7. start senna, colace as needed for constipation 8. start tylenol as needed for pain 9. start vitamin k 5 mg every week 10. start ketoconazole shampoo every other day . please feel free to call if you have any questions or concerns followup instructions: department: neurology when: friday at 10:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/bmt when: tuesday at 10:00 am with: , np building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 10:00 am with: , md building: sc clinical ctr campus: east best parking: garage * the office of dr. in neurosurgey will contact you regarding a follow-up appointment in 1 month if the rehab does not hear from them they should call ( . * after discharge from rehab you will need to follow-up with dr. his number is procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of endotracheal tube insertion of endotracheal tube interruption of the vena cava enteral infusion of concentrated nutritional substances thoracentesis biopsy of bone marrow angiocardiography of venae cavae central venous catheter placement with guidance diagnoses: tobacco use disorder mitral valve disorders unspecified pleural effusion urinary tract infection, site not specified congestive heart failure, unspecified acute kidney failure, unspecified unspecified septicemia sepsis hypopotassemia constipation, unspecified myelodysplastic syndrome, unspecified acute respiratory failure other specified cardiac dysrhythmias hypotension, unspecified pneumonitis due to inhalation of food or vomitus alkalosis osteoporosis, unspecified retention of urine, unspecified acute systolic heart failure do not resuscitate status hemorrhage of gastrointestinal tract, unspecified multiple sclerosis hyperosmolality and/or hypernatremia other and unspecified coagulation defects other abnormal blood chemistry unspecified intracranial hemorrhage other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [ldh] acute venous embolism and thrombosis of deep vessels of distal lower extremity other protein-calorie malnutrition 

Answer: The patient is high likely exposed to