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: orinal complaint - r eye vision loss major surgical or invasive procedure: a diagnostic and therapeutic 23-gauge pars plana vitrectomy with injection of vancomycin 2 mg ceftazidime 2 mg and amphotericin 5 mcg right eye. incision and drainage of right groin abscess, radical debridement of right groin and sartorius muscle flap closure of groin wound. successful ptca and stenting of the proximal left circumflex artery with a xience (3x18mm) drug eluting stent. final angiography demonstrated no angiographically apparent dissection, no residual stenosis and timi iii flow throughout the vessel (see ptca comments). debridement and drainage of groin; removal of distal end of aortobifemoral graft and replacement with rifampin-soaked 8-mm interposition dacron graft segment; complete removal of femoropopliteal graft; oversewing of popliteal artery. percutaneous endoscopic gastrostomy. history of present illness: 71yo man h/o mds, cad, pad, and dm who presents with sudden vision loss and eye pain. he was driving in when he noticed these symptoms 3 days prior to presentation. he was on a trip visiting and was feeling progressively worse with associated fevers, chills, malaise, arthralgias, and myalgias and decided to come to the ed for further evaluation. . in the ed, initial vs were: 96.4 66 102/59 18 96% ra. patient was given percocet 5/325 x 2. last set of vitals were 70 118/62 16 95%ra. opthalmology was consulted who recommended urgent vitrectomy. patient was sent to or where he underwent diagnostic and therapeutic vitrectomy and pus was expressed from the vitreous fluid. they injected tetracaine 2gtt, intraocular vancomycin 0.1ml (1mg), ceftazidime 0.1ml (2mg), amphotericine 0.1ml (5mcg), and amphotericin, and recommended work up for systemic sources of infection. they also gave 200cc of lr and patient was given remifentanil 50mcg iv once at 2245. last set of vitals were 120/55 80 16 90%ra. . on the floor, the patient complains of right shoulder and right sided chest pain. he describes it as sharp, radiating to the back and down his right arm and right chest. he says he's never had this pain before. he says the pain gets worse with movement althouth he has not been moving much. his anginal equivalent is dyspnea, and this is different that angina. he says he has no history of arthritis in his shoulder, but was given cortisol injections in his shoulder which did not help. percocets in the ed did help with the pain. he denies any associated sob, nausea, vomitting, diaphoresis, dizziness. there is no association with coughing or taking deep breaths. he did go on a long car ride on sunday (12 hours), denies calf pain, swelling, cough, hemoptysis. he denies abdominal pain, diarrhea, constipation. he does report flu-like symptoms with rhinorrhea, fevers to 104, chills, sore throat, arthralgias and myalgias. his arthralgias and myalgias seem to persist into his current r shoulder, r chest, and left arm pain. . review of systems: (+) per hpi (-) denies night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denied cough, shortness of breath. denied chest tightness, palpitations. denied nausea, vomiting, diarrhea, constipation or abdominal pain. no recent change in bowel or bladder habits. no dysuria. denied arthralgias or myalgias. past medical history: aaa with illiac artery aneurysms treated with an aortobifemoral graft . bilat carotid endarterectomies cad - coronary angioplasty and stenting cabg (lima to lad, svg to diagonal, svg to om, sequential svg to am/pda) hyperlipidemia htn aodm cerebral hemorrhage mid ??????s prior cva asbestos exposure social history: married, large family w/ many kids and grandkids. pt & wife spend most of the year living in . -occupation/hobbies: pt is a retired pipe fitter & manager. he enjoys hunting and has a new gun that he has been looking forward to using per his family -sources of support: tight-knit family -religion/spirituality: not explored -coping: family is struggling to cope w/ patient's decline -health-care /proxy: wife family history: non contributory physical exam: vitals: t: 98.1 bp: 133/87 p: 93 r: 24 sao2: 97% 3l general: lethargic, but arousable to voice. lying bed uncomfortably heent: ncat, perrl, eomi, no scleral icterus, mmm, no lesions noted in op neck: supple, no significant jvd or carotid bruits appreciated pulmonary: lungs cta in the anterior fields cardiac: rr, nl s1 s2, 2/6 sem across the sternum, no rubs or gallops appreciated abdomen: soft, nt, nd, normoactive bowel sounds, no masses or organomegaly noted extremities: right groin dressing c/d/i vac placed. underneath reveals a 5 x 5 cm wound with some granulation tissue, no puss appreciated, the rle is warm with faint distal pulses skin: no rashes or lesions noted. toes are pink on the right. left leg is tender to touch, and is covered with linear excorations which appear old neurologic: patient unable to speak or follow simple commands. lack of attention noted. withdraws all 4 extremities to pain. pertinent results: admission labs: 07:20pm lactate-1.7 02:25pm glucose-343* urea n-15 creat-1.1 sodium-129* potassium-4.5 chloride-95* total co2-25 anion gap-14 02:25pm ck(cpk)-45* 02:25pm ck-mb-2 ctropnt-<0.01 02:25pm wbc-5.3# rbc-3.90* hgb-12.0* hct-36.3* mcv-93 mch-30.7 mchc-33.0 rdw-22.7* neuts-58 bands-1 lymphs-25 monos-9 eos-0 basos-0 atyps-1* metas-3* myelos-2* promyelo-1* stool consistency: loose source: stool. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. 02:25pm hypochrom-normal anisocyt-occasional poikilocy-normal macrocyt-normal microcyt-normal polychrom-occasional 02:25pm plt count-219# 02:25pm pt-14.8* ptt-27.6 inr(pt)-1.3* recent studies: echo: the left atrium is mildly dilated. the left ventricular cavity size is normal. there is moderate to severe regional left ventricular systolic dysfunction with inferior/inferolateral/septal hypokinesis with milder hypokinesis elsewhere. right ventricular chamber size is normal. with probably mild global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is mild mitral valve prolapse. an eccentric, posteriorly directed jet of mild to moderate (+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. the pulmonary artery systolic pressure could not be determined. there is no pericardial effusion. no vegetation seen (cannot definitively exclude). compared with the prior study (images reviewed) of , left ventricular systolic function is now much worse. mitral regurgitation appears similar. . cxray : in comparison with the study of , there is continued relatively low lung volumes. enlargement of the cardiac silhouette in a patient with intact midline sternal wires. continued diffuse prominence of interstitial markings that could reflect chronic lung disease, elevated pulmonary venous pressure, or both. central catheter remains in place. there is some haziness at the bases with blunting of the costophrenic angle suggesting some pleural effusion. . ct of head w/ contrast on : findings: there is a stable area of right occipital encephalomalacia, with ex vacuo dilatation of the occipital of the right lateral ventricle. there is no evidence, for an acute major territorial infarct or acute hemorrhage. there is mild prominence of ventricles and sulci, as before. there is mild mucosal thickening in the right sphenoid sinus with a possible air-fluid level. the bones are unremarkable. there is calcification of bilateral carotid siphons. apparent hyperdensity projecting over the posterior right globe likely represents motion artifact. impression: 1. no evidence of acute intracranial abnormalities. 2. stable right occipital encephalomalacia. 3. apparent hyperdensity projecting over the posterior right globe likely represents motion artifact. please correlate with eye exam. findings: chest: an endotracheal tube terminates just beyond the thoracic inlet, 8 cm above the carina. retained mucus is noted in the proximal trachea. there is no pneumothorax. diffuse irregular bronchial wall thickening may be consistent with small airways disease, although the airways are patent to the segmental levels. there is severe, apical-predominant centriacinar and paraseptal emphysema. diffuse ground-glass opacities are present throughout the lungs, consistent with combined pulmonary edema and atelectasis, although superimposed infection cannot be excluded. moderate bilateral pleural effusions persist, with adjacent compressive atelectasis. a left internal jugular line again terminates in the distal left brachiocephalic vein. dense calcifications are noted in the aortic root, coronary arteries, and thoracic aorta. within the limits of contrast bolus timing, there is no main or lobar pulmonary embolus, and no evidence of acute aortic syndrome. the heart is normal in size, without pericardial effusion. multiple prominent mediastinal and hilar lymph nodes are present, likely reactive, and measuring up to 10 mm in the right paratracheal region. abdomen: nasogastric tube terminates in the stomach. the small bowel is normal. there is mild fatty infiltration of the liver. the gallbladder is partially collapsed. the pancreas is slightly atrophic. the spleen is normal. the adrenals are normal. the kidneys are mildly atrophic, but enhance and excrete contrast promptly and symmetrically. extensive calcifications are noted in the renal arteries. fat-containing umbilical and right parasagittal ventral hernias are present. pelvis: the appendix is normal. scattered descending colonic and sigmoid diverticula are present, without acute inflammation. note is made of a patulous, fluid-filled rectum. a foley catheter is present within the bladder. an aortobifemoral graft is present, with contrast opacifying both limbs. dense calcifications are noted in the abdominal aorta, iliac, and femoral arteries, with moderate stenosis of branch vessel origins. soft plaques are present along the posterior wall of the infrarenal aorta, resulting in mild luminal stenosis. a rim-calcified, nonenhancing 1.6 x 1.1 cm collection posterior to the proximal left iliac artery likely represents a thrombosed pseudoaneurysm. within the abdomen, there is no evidence of contrast extravasation, fat stranding, lymphadenopathy, or fluid collections to suggest endoleak, infection, or other complications. changes of debridement are again noted in the right thigh. there are two heteregeneously enhancing, lobulated soft tissue and fluid collections surrounding the proximal and distal ends of the right femoropopliteal graft. these were incompletely imaged on the most recent examination, but appear decreased in size from ct on . the collection surrounding the proximal limb is located in the right infrainguinal region (2:136) and measures 6.1 x 2.8 cm, previously 6.1 x 3.7 cm. the collection surrounding the distal limb (2:146) is located in the medial proximal thigh and measures 3 x 2.1 cm, previously 3.6 x 2.5 cm. prominent reactive inguinal lymph nodes are present, along with mild subcuatenous edema and fascial thickening. there is no evidence of intrapelvic extension. no suspicious osseous lesions are identified. moderate degenerative changes are noted in the thoracolumbar spine. impression: 1. decrease in fluid collections surrounding the ends of the right femoropopliteal graft. the appearance is nonspecific, but may reflect hematoma or phlegmon. no evidence of intra-abdominal extension; if follow-up imaging is desired, please selectively image the right thigh. 2. patent aortobifemoral graft, without evidence of complications. 3. severe emphysema with diffuse pulmonary edema, effusions, and atelectasis. superimposed infection cannot be excluded. 4. et tube just beyond thoracic inlet, please advance 3-5 cm. the study and the report were reviewed by the staff radiologist : indication: status post picc placement, assess position. comparison: chest radiograph from . findings: the left picc ends in the high svc. the right lateral lung is not included on this radiograph. there is unchanged mild cardiomegaly. the mediastinal contours are normal. there is no pneumothorax identified. the right mid-lower lung opacities are unchanged while the left mid-lower lung opacities have improved. impression: 1. unchanged right mid-lower lung opacities and improved left mid-lower lung opacities, may be secondary to pulmonary edema and/or pneumonia. recommend followup imaging to distinguish between these entities. 2. unchanged mild cardiomegaly. 3. left picc ending in high svc. echo: the left atrium is mildly dilated. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity size is normal. overall left ventricular systolic function is moderately depressed (lvef= 35 %). right ventricular chamber size and free wall motion are normal. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is borderline/mild posterior leaflet mitral valve prolapse. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. mild (1+) mitral regurgitation is seen. no masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. the pulmonary artery systolic pressure could not be determined. no masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the findings are similar. if clinically indicated, a transesophageal echocardiographic examination is recommended. impression: no definite vegetations seen (suboptimal study) 9:21 am pleural fluid gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. acid fast culture (preliminary): no mycobacteria isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. : wbc rbc hgb hct mcv mch mchc rdw plt ct 11.1* 3.21* 10.0* 30.6* 95 31.1 32.6 20.2* 130* : glucose urean creat na k cl hco3 194*1 22* 0.6 132* 3.7 99 test name value reference range units 08:45 report comment: source: catheter general urine information urine color yellow urine appearance clear specific gravity 1.016 1.001 - 1.035 dipstick urinalysis blood sm nitrite neg protein 25 mg/dl glucose neg mg/dl ketone neg mg/dl bilirubin neg mg/dl urobilinogen neg 0.2 - 1 mg/dl ph 5.0 5 - 8 units leukocytes neg microscopic urine examination rbc 0-2 0 - 2 #/hpf wbc 0-2 0 - 5 #/hpf bacteria none yeast none epithelial cells 0-2 #/hpf urine casts hyaline casts 0-2 0 - 0 #/lpf other urine findings urine mucous few 4:09 am catheter tip-iv source: central line. wound culture (final ): no significant growth. 9:12 am swab source: right groin. gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): no growth. 11:05 am blood culture blood culture, routine (final ): no growth. pertinent images: #cxray : in comparison with the study of , there is little overall change. the dobbhoff tube is uncoiled and in the upper stomach. bibasilar opacification with pleural calcification on the right is essentially unchanged. mild indistinctness of pulmonary vessels could reflect some elevated pulmonary venous pressure. . #ct pelvis on : in comparison to , fluid collections in the right groin about the bypass grafts are slightly smaller in size -- a more superior portion of the collection previously measured 2.5 x 3.2 cm is now 2.5 x 2.8 cm axially. a more inferior component previously measured 2.3 x 4.1 cm is now 1.8 x 2.7 cm axially. the craniocaudad extent is similar. while the collections about the graft are smaller, the walls appear thicker and there is increased overlying inflammatory change. this is deep to the surgical staples, and may be post- operative, though clinical correlation woudl be required to exclude infection. also noted is a new superficial collection more laterally, not present on prior study. this is of higher attenuation and may represent evolving post-operative hematoma. on the left, there is stranding consistent with recent catheterization, but no large hematoma is identified. the intrapelvic contents remain unremarkable. no deep fluid collection or abscess is identified. this study is not optimized for evaluation of the vessels, however, no new vessel occlusion is identified. partial thrombus of the right fem- graft is noted. # us of right foot on : prelim report- no abscess or fluid collection. + subcutaneous tissue edema mri: there has been little change compared to the mri. again demonstrated is encephalomalacia in the right parietal region and scattered flair/t2 hyperintensities within the cerebral white matter. there is no evidence of interval hemorrhage, infarct, or mass. the post-gadolinium images are unremarkable. abnormal appearance to the right globe is similar to prior with t2 hypointense material present within the posterior globe. the major intracranial flow voids are preserved. ventricles, cisterns, and sulci are otherwise significant for symmetric, age-related prominence. brief hospital course: mr. is a 71yo man with history of mds on dacogen (last dose 5 weeks prior to admission), cad, pad, and dm who presented with sudden vision loss and eye pain and was found to have endocarditis with endophthalmitis. # endocarditis: his endophthalmitis was felt to be secondary to endogenous source, and bacteremia was suspected. patient underwent tee on which showed a small vegetation on his aortic valve consistent with endocarditis. his blood cultures were persistently negative and either culture negative endocarditis or fungal source was suspected. he was empirically treated with vancomycin and ceftaz for bacterial coverage and ambisome and doxycycline for fungal and atypical coverage. numerous serologies including mycoplasma, brucella, bartonella, q-fever and chlamydia were sent and which are negative to date. fungal workup included beta glucan and galactomannan serologies and fungal cultures were are negative. pt was on a variety iv antibiotics per id. see below brief hosptal course out line. # id: mr. is a 71 year old man with a history of mds, disease who was admitted with 3-4 days of vision loss in the right eye, which occurred acutely at his home in . a few weeks prior to this incident, he was treatedas an outpatient with levofloxacin for an "uri" during which he had fevers to 103-104. there has been no positive culture data during this hospitalization, except for two universal pcr's done on vitreous fluid and groin pus - streptococcus agalactiae was isolated both times. he is currently on the floor and antibiotics were briefly narrowed to daptomycin only on (vancomycin was changed to daptomycin over family's concern that vancomycin may have been contributing to drug fever). he continued to have fever to 101-102 on daptomycin alone and upon the family's request on , a three drug regimen to cover other nocosomial organisms (aztreonam, ciprofloxacin, and metronidazole) was re-started. currently, the patient's last low grade fever was on . even if he continues to have higher fevers on this regimen, the antibiotic plan will be the same, unless there is new culture data to change therapy. on discharge pt is on daptomycin iv untill , then keflex 500 for life, for supression therapy. # pururic skin lesions: patient was noted to have a right medial malleolar palpable purpuric skin lesion on admission. over the next couple days, he developed scattered discrete skin lesions and one was biopsied by dermatology. the biopsy showed acute necrotizing vasculitis and dermal abscess formation and noted "although an immune-mediated vasculitis may be present, the dermal abscess formation is concerning for an infectious process." he was evaluated for possible vasculitis by rheumatology and serologies where negative. rheumatology signed off. # endophthalmitis: he was evaluated by ophthamology in the er and underwent urgent vitrectomy on which produced pus. this fluid was sent for gram stain which showed numerous polys but no microorgansims. he received intraocular vanc/ceftaz/amphotericin. as mentioned above, this was felt to be an endogenous infection. he was followed by ophthomology and treated with numerous drops. pt currently on drops as per med list. # right shoulder pain: patient complained of right shoulder pain which he had for approximately a week prior to admission. mri of the shoulder was poor quality but found supraspinatous rotator cuff tear. there was no evidence of infection. rest and anti-inflammatories were recommended by orthopedics with agreement from rheumatology. his pain was treated with oxycontin and oxycodone. this was dc'd when patient had delerium. once stable he should follow up with a orthopedist. other info r shoulder pain: r shoulder pain and new left elbow pain: mri of r shoulder poor quality but no clear signs of infection and rotator cuff tear. films of r shoulder and l elbow unremarkable. ortho feels these pains are msk related and suggested rest with pain control/anti-inflammatories and eventual pt. rheum recommends consideration of ac joint tap to rule out infection; ortho has deferred on this and does not feel exam is c/w infxn. overall symptoms are improving and feeling sl better today with some improvement in rom. # mds: he follows with dr. in . patient s/p 5 cycles of dacogen (started ) with last chemo approximately 5 weeks prior to admission. patient usually takes a week of neupogen as needed for neutropenia after the 5 days of dacogen. last bm bx in showed some blast proliferation concerning for mds conversion to leukemia. a heme onc consult was obtained, for further management and recommendations. final consult below. mr. has a history of mds and was treated in with decitabine. on presentation, he has anemia and thrombocytopenia that are less severe than previous. review of peripheral smear showed modest dysplastic changes but not blasts concerning for transformation to leukemia. mds may results in functional or absolute neutropenia and leukopenia that can result in infection and thereby fevers. in the absense of this, mds itself should not be a cause of fever. we favor ongoing infection or drug fever as the cause of mr. fever. with regard to his mds, he should receive prbc and platelet transfusions as needed. no further therapy is available or indicated for his myelodysplasia. # cad, chest pain: patient does not take aspirin at home given recent asa induced gastritis but was started on this medication when his plavix was held in the hospital per his cardiologist's recommendation. pt did have a nstemi. his was restarted on plavix he was continued on vytorin, and metoprolol. he did have a cardiac cath as outlined below. selective coronary angiography in this right dominant system demonstrated native three vessel disease. the lmca was patent. the lad was 100% occluded in the mid vessel. the lcx had a hazy area of thrombosis/in-stent restenosis. the rca was totally occluded. arterial conduit angiography revealed the lima to lad to be widely patent. venous conduit angiography revealed the svg-rca and svg-om to be widely patent and without change. limited resting hemodynamics revealed normotension 118/56 mmhg. successful ptca/stenting of proximal lcx with 3.0 x 15 mm vision bms at 20 atms. final angiogram showed 0% residual stenosis, no dissection and normal flow in the distal vessel. final diagnosis: 1. three vessel native coronary artery disease. 2. patent lima to lad. 3. patent svg to om and svg to rca. 4. successful placement of vision bare metal stent in proximal lcx. other cardiac: elevated troponins/cardiac ischemia: pt has significant hx of cad with coronary angioplasty and stenting , cabg (lima to lad, svg to diagonal, svg to om, sequential. followed by dr. . on in the setting of being hypotensive in the pacu after his i&d, he had troponins checked which were elevated. his troponins peaked at 0.88 on and his ck/mb peaked at 353/39 on . ekg remains unchanged from prior. he was tx as nstemi w/ hep gtt, asa, plavix. his repeat echo on showed significant worsening lvf with ef decreasing from 50% to 30%. he went for cardiac cath on which showed 100% mid lad occlusion, lcx hazy thrombus in stent restenosis. he had ballon angio and had bms placed on ptca, plavix was changed from qday to 75mg x 1 week, then qd on (), cont asa 325mg, cont simvastatin. # dm: his blood sugars were initially elevated but improved with sliding scale humalog and evening lantus. this was eventually switched to ssi. pt blood sugars stable on dc # brief: incision and drainage of right groin abscess, radical debridement of right groin and sartorius muscle flap closure of groin wound and debridement and drainage of groin; removal of distal end of aortobifemoral graft and replacement with rifampin-soaked 8-mm interposition dacron graft segment, complete removal of femoropopliteal graft, and oversewing of popliteal artery on . currenly patient has minimal bllod flow to foot. need future amp. does have collaterals. pt did have ischemic leg. was on iv heperin. this was dc'd because of multiple gi blled. on dc pt on asa, plavix. we are now watching leg. # vision loss: patient with most likely diagnosis of endophthalmitis. optho team concerned for endogenous source, especially given his immunocompromised status. they recommend vanc/ceftaz until cultures can confirm a pathogen. no pathogen detected. on dc current eye drops per med list. # hypoxemia: blood gas confirms hypoxemia. concominant respiratory alkalosis with hypocarbia points away from narcotic-induced hypoventilation as etiology. patient also with interstitial changes c/w interstitial fibrosis versus emphysema. pt was intubated x 2. weaned from ventalator. each time transfered to the vicu . # hyponatremia: most likely secondary to hypovolemia given patient's history of very poor po intake, dry mm, ns bolus 500cc x 1, maintanaince fluids, urine lytes. on dc na is normalized. # elevated creatinine: improving after iv fluids, back to baseline. could be related to ambisome or other medications. given iv fluids prior to iv contrast today continue to monitor lytes and creatine, thougt to be contrast induced. hydrated. on dc creatinine is stable # pain management: stopped all narcotics this am given that pt has ams likely due to delusion- with hallucinations and inattention which per family seems worse after receiving pain meds, continue to close monitor ms and pain management, cont on tylenol prn, lidocaine patch # altered mental status: pt alert and oriented x person. having hallucinations seen peopele in the room. he was previously evaluated by neuro for ams and was found to be due to metabolic causes. he does not have a neuro defecit. he had head ct on and head mri on that showed no acute process or changes when compared to prior mri done on . this was likely due to combination of medications, poor sleep, pain. this does not appear to be infectious since he has no other menigitides symptoms. on dc mental staus has cleared, still alittle confused at night. neurology was consulted neurolgoy believes his change in ms is due to metabolic delerium. there is also concern about septic emboli from ? endocarditis and arterial graft infection, so id recommended mri of head for evaluation of septic emboli. mri: there has been little change compared to the mri. again demonstrated is encephalomalacia in the right parietal region and scattered flair/t2 hyperintensities within the cerebral white matter. there is no evidence of interval hemorrhage, infarct, or mass. the post-gadolinium images are unremarkable. abnormal appearance to the right globe is similar to prior with t2 hypointense material present within the posterior globe. the major intracranial flow voids are preserved. ventricles, cisterns, and sulci are otherwise significant for symmetric, age-related prominence. impression: 1. no significant change compared to . 2. abnormal appearance of the right globe, compatible with the patient's known history of staphylococcal infection of his right globe. #thrombocytopenia/coags: pt was on hep drip which started on and had decrease in platelets which have trended down over the last several days. this could be due to bone marrow supression from the antibiotics, infection or mds. his mds initial presentation was thromcytopenia and his last chemo dose was 7 weeks ago, which he could be having bone marrow transformation of abnormal cells. doxi was stopped ; however he still on vancomycin. hit was also in the differential, but less likely given the rate of plalet decline. his calculated pre-test prob for hit is low-intermediate. so anti-hep antibody was sent, this was negative. # anemia: pt has hct trended down from low 30s->upper 20s, this is stable. he has small hematoma at site of cath that is unchanged, pt transfused multiple times, pt put on iv protonix. pt did have scope showed gi bleed. gi was consulted, ppi started, hct followed. did get a egd . grade 3 esophagitis in the gastroesophageal junction in the second part of the duodenum there was an adherent clot with blood extruding under the clot. there was fresh blood in this area. on injection of this area with 1/10,000 epi patient's heart rate and bp increased. a clip was placed one cm. proximal to the clot towards the stomach from this clot. this was to allow an angiographer to know the location. otherwise normal egd to third part of the duodenum. pt c/w drop in hct. transfused again. another egd was performed. a single bleeding spot (? visible vessel) was noted in the second part of the duodenum, at the same location as the previously noted adherent clot, just distal to the bend where the duodenal bulb meets the second part of the duodenum. the area was washed and oozing was noted from the spot. one endoclip was successfully applied for the purpose of hemostasis. there was no further oozing from the spot. it was at a location that was very difficult to identify and treat endoscopically. recommendations: the findings account for the symptoms. continue iv ppi gtt, chanfged to iv bid. hold heparin gtt, this was done. pt on iv heperin for leg ischemia. this was eventually dc'd. # fen: ivf, replete lytes prn. pt was on tube feeds given poor po intake. he pulled dobhoff tube off today while confused. will hold off in place tube back on since remains confused and was difficult to place. it was eventually decided to place peg. pt did have mutiple failed attempts at speech and swallow. on dc pt getting tf's. # prophylaxis: hep sq ppx, plavix, asa, iv protonix medications on admission: 1) glimipremide 2mg po daily 2) genuvia 100mg po daily 3) plavix 75mg po daily 4) nitro sl prn chest pain 5) lopressor 50mg po daily 6) nortryptaline 25mg po hs 7) vytorin 10-40mg po daily discharge medications: 1. bacitracin-polymyxin b 500-10,000 unit/g ointment sig: one (1) appl ophthalmic hs (at bedtime). 2. acetaminophen 650 mg tablet sig: one (1) tablet po q6h (every 6 hours) as needed for pain/fever: prn for pain. 3. fentanyl 25 mcg/hr patch 72 hr sig: one (1) patch 72 hr transdermal q72h (every 72 hours). 4. dorzolamide-timolol 2-0.5 % drops sig: one (1) drop ophthalmic (2 times a day). 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. scopolamine hbr 0.25 % drops sig: one (1) drop ophthalmic (2 times a day). 7. clopidogrel 75 mg tablet sig: one (1) tablet po daily (daily). 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 9. quetiapine 25 mg tablet sig: one (1) tablet po qhs (once a day (at bedtime)). 10. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q6h (every 6 hours) as needed for wheezes. 11. insulin sliding scale insulin sc sliding scale q6h humalog glucose insulin dose 0-70 mg/dl proceed with hypoglycemia protocol 71-119 mg/dl 0 units 120-159 mg/dl 2 units 160-199 mg/dl 4 units 200-239 mg/dl 6 units 240-279 mg/dl 8 units 280-319 mg/dl 10 units > 320 mg/dl notify m.d. 12. picc care heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 13. daptomycin 500 mg recon soln sig: one (1) recon soln intravenous q24h (every 24 hours): dc on . 14. keflex 500 mg capsule sig: one (1) capsule po twice a day: please start on after daptomycin is complete. life long ab. 15. pantoprazole 40 mg recon soln sig: one (1) recon soln intravenous q12h (every 12 hours). 16. haloperidol lactate 5 mg/ml solution sig: one (1) injection q4h (every 4 hours) as needed for aggitation. discharge disposition: extended care facility: - discharge diagnosis: infected r ptfe graft (strep agalactiae) c/b ugib persistent fevers ftt - poor nutritional status delerium endopthalmitis possible av vegetation and peri-graft abscess melena, anemia - requuiring multiple blood transfusions active oozing at juncture of duodenal bulb and 2nd part of duodenum hypotension / hypoxia requiring intubation dm cad pad htn septic emboli nstemi hyponatremia complete r supraspinatus tear arf discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: bedbound, progress to ambulation discharge instructions: please follow the course of antibiotics as scheduled for id: daptomycin to continue until . after which the patient will be placed on suppressive keflex 500mg peg care foley to gravity, dc when ambulatory pt may need flex seal in future for loose stools vac to right groin, change everry three days moniter rle for signs of ischemia, pt may need amputaton in future moniter ck weekly while on daptomycin. fax: , attn: opat moniter for fever and or chills, signs of septcemia, neurological deficits, loose stools / check for c - diff followup instructions: provider: , md phone: date/time: 1:00 provider: , md phone: date/time: 11:30 procedure: continuous invasive mechanical ventilation for 96 consecutive hours or more insertion of non-drug-eluting coronary artery stent(s) parenteral infusion of concentrated nutritional substances other revision of vascular procedure fiber-optic bronchoscopy enteral infusion of concentrated nutritional substances thoracentesis percutaneous [endoscopic] gastrostomy [peg] attachment of pedicle or flap graft to other sites endoscopic control of gastric or duodenal bleeding endoscopic control of gastric or duodenal bleeding aspiration of skin and subcutaneous tissue excision of inguinal lymph node other mechanical vitrectomy cranial or peripheral nerve graft insertion of one vascular stent excision of lingual thyroid percutaneous transluminal coronary angioplasty [ptca] procedure on single vessel diagnoses: thrombocytopenia, unspecified subendocardial infarction, initial episode of care coronary atherosclerosis of native coronary artery cellulitis and abscess of trunk toxic encephalopathy acute kidney failure, unspecified hyposmolality and/or hyponatremia severe sepsis aortocoronary bypass status hematoma complicating a procedure percutaneous transluminal coronary angioplasty status myelodysplastic syndrome, unspecified acute respiratory failure alkalosis surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure infection and inflammatory reaction due to other vascular device, implant, and graft streptococcal septicemia acute endophthalmitis arterial embolism and thrombosis of lower extremity other esophagitis duodenitis, with hemorrhage septic arterial embolism disorders of bursae and tendons in shoulder region, unspecified acute endocarditis, unspecified acute lymphadenitis 

Answer: The patient is high likely exposed to