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: shellfish derived attending: chief complaint: respiratory distress, sepsis major surgical or invasive procedure: rij catheter placement () arterial line placement (, ) intubation (, , ) extubation (, ) history of present illness: 27-year-old male with a history of cll status post allogeneic transplant in early complicated by graft-versus-host disease, capillary leak syndrome, pe on lovenox who is presenting in septic shock from osh. the patient was seen on in clinic where he was noted to have a fever, wbc of 2.1 with 6% bands, hct of 24.2, cr of 1.2 (up from 0.7 on ) and was complaining of overall "not feeling well." attempts were made to send him to the ed, however the patient declined and went home instead. he was sent with augmentin. on , he was found by his vna to be lethargic, hypotensive, and febrile. he was taken to where he was hypotensive to the 70s, febrile to 103.2 and hypoxic to 91% on nrb. he got ivf boluses and started on levophed. cxr showed bilateral lower lobe opacities. labs showed wbc of 0.8, h/h and 16.2. he got vanco, cefepime, hydrocort 100mg iv, 2 units prbc, was intubated, and med flighted to . on arrival to the icu, patient is intubated and sedated. does move all 4 extremities equally. past medical history: oncologic history: * diagnosed in with cll/sll and bulky cervical lymphadenopathy *pentostatin/cytoxan x 1 with transient response and disease progression prior to 2nd cycle *r-chop x 2 cycles with decline in ejection fraction and atypical chest pain, resolved over a period of months * r-cvp x 4 * (adriamycin given as thought to be less cardiotoxic when given in an infusional way) * rituxan x 1 * r- x 2 for increasing cervical adenopathy, with modest response * bendamustine x 1 with poor response * fcr x 2 * reduced intensity allogeneic stem cell transplant with tli, atg, clofarabine as conditioning regimen. brother is donor. . post transplant complications: *cmv first noted , viral load rose on oral valcyte but resolved on iv ganciclovir. reactivated , again received iv ganciclovir *bk viruria, received ivig on . *gvhd, gi involvement requiring narcotics, tpn, and bowel rest. * acute change in mental status, ? air embolus *pe, noted currently anticoagulated with coumadin * perforation , ? related to colonoscopy * right chest wall abscess, mrsa . other medical history: asymptomatic cardiomyopathy bigeminy/trigeminy positive ppd : 12 months of therapy s/p tonsillectomy pulmonary embolism () on warfarin htn social history: former heavy drinker (20 beers/week on average) but has stopped altogether with current treatment. lives at home with his girlfriend. denies drug use. no smoking. has worked various jobs, was most recently employed as a machinist but has been laid off since 2/. he currently receives unemployment compensation, and hopefully will be eligible for disability soon. of note, his mother was his only parent he had a relationship with. she passed away when was 20 yo after sustaining a stroke which was witnessed by family. he feels as if his girlfriend is supportive. family history: mother had stroke at age 48. patient does not know his father well. has 2 brothers. physical exam: icu admission physical exam: tm 100.4??????f,tc 100.3??????f, hr128(119 - 151) bp:108/45(68)108-147/45-79(68-101) rr: 15(13 - 31) spo2: 100% general: intubated, sedated heent: sclera anicteric, perrl, no icterus neck: supple lungs: coarse breath sounds on anterior exam cv: tachycardic, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley in place ext: warm, well perfused, 3+ edema throughout lower extremities, purple striae noted across abdomen and thighs with some bullae formation, brawny induration noted of upper thighs - left thigh erythematous and warm to touch with 2 large bullae pertinent results: admission labs: 03:15pm wbc-2.1* rbc-2.96* hgb-7.8* hct-24.2* mcv-82 mch-26.5* mchc-32.4 rdw-20.4* 03:15pm neuts-78* bands-6* lymphs-7* monos-4 eos-0 basos-0 atyps-0 metas-5* myelos-0 nuc rbcs-8* 03:15pm hypochrom-3+ anisocyt-2+ poikilocy-2+ macrocyt-1+ microcyt-2+ polychrom-occasional spherocyt-occasional ovalocyt-1+ schistocy-occasional teardrop-occasional elliptocy-occasional 03:15pm calcium-9.2 phosphate-3.9 magnesium-1.7 03:15pm urea n-20 creat-1.2 sodium-139 potassium-3.8 chloride-100 total co2-24 anion gap-19 05:19pm lactate-2.6* 03:15pm alt(sgpt)-42* ast(sgot)-24 ld(ldh)-638* alk phos-94 tot bili-0.4 05:21pm fibrinoge-373# . last labs : wbc 0.8 hgb 8.7 hct 25.6 plt 27 anc 672 bun 57 cr 1.6 na 127 k 3.4cl 86 hco3 17 vbg: 7.16/61/45 : please see omr. microbiology: see omr for full listing. blood cultures up until : no growth blood culture ()- vre blood cultures (): no growth urine culture (, , ): no growth legionella urinary antigen (final ): negative for legionella serogroup 1 antigen. 1:22 am catheter tip-iv source: l ij dialysis. wound culture (final ): no significant growth. 1:45 pm stool fecal culture (final ): no salmonella or shigella found. campylobacter culture (final ): no campylobacter found. 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. clostridium difficile toxin a & b test (final ): feces negative for c.difficile toxin a & b by eia. (reference range-negative). . sputum gram stain (final ): pmns and <10 epithelial cells/100x field. no microorganisms seen. respiratory culture (final ): sparse growth commensal respiratory flora. legionella culture (preliminary): no legionella isolated. fungal culture (preliminary): no fungus isolated. . 2:24 pm tissue source: skin biopsy. staph aureus coag +. rare growth. | clindamycin----------- r erythromycin---------- =>8 r gentamicin------------ <=0.5 s levofloxacin---------- =>8 r oxacillin------------- =>4 r rifampin-------------- <=0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s vancomycin------------ 1 s . 1:38 pm blood culture source: line-left picc subclavian line. **final report ** blood culture, routine (final ): enterococcus faecium. final sensitivities. high level gentamicin screen: susceptible to 500 mcg/ml of gentamicin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details. high level streptomycin screen: susceptible to 1000mcg/ml of streptomycin. screen predicts possible synergy with selected penicillins or vancomycin. consult id for details.. daptomycin = 16 mcg/ml = non-susceptible. daptomycin sensitivity testing performed by etest. daptomycin sensitivity result being confirmed , reported to 12:00pm sent to on . daptomycin sensitivity testing confirmed by laboratories. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus faecium | ampicillin------------ =>32 r linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r anaerobic bottle gram stain (final ): gram positive cocci in pairs and chains. reported to and read back by dr. 08:00am. aerobic bottle gram stain (final ): gram positive cocci in pairs and chains. cmv viral load: 2150 copies/ml (), undetectable (), 1370 (), 3180 (), 1710 (), <600 (), 2790 (), (), 9030 (), () . pathology (skin path and immunoflouresence), 1. skin (a): fibrin thrombi in papillary and reticular dermal blood vessels with associated partial epidermal and adnexal necrosis (see microscopic description and comment). microscopic description. sections show epidermis, dermis and some superficial subcutaneous fat. there are fibrin thrombi in the papillary and reticular dermal vessels, extending into the superficial subcutaneous fat. there is sparse acute inflammation, predominantly in the deeper dermis and subcutis. acute vasculitis is not appreciated in this sample in multiple tissue levels examined. no fungal or bacterial organisms are seen on gms, pas and pas-d, or tissue gram stains, respectively. the overlying epidermis shows partial necrosis and there is also focal necrosis of associated eccrine glands. comment. the histologic features are those of an occlusive thrombotic vasculopathy. this may be seen in a variety of conditions including disseminated intravascular coagulation and warfarin necrosis, and clinical correlation is necessary to differentiate between these conditions. the negative bacterial and fungal stains argue against an acute septic vasculitis or angioinvasive fungus. correlation with culture results is necessary. 2. skin; direct immunofluorescence: no immunopathologic abnormality. no specific immunofluorescence is seen for igg, iga, igm, complement c3 and fibrin. . imaging: cxr () findings: bilateral lung volumes are low. bibasal atelectasis, left more than right, are persisting and unchanged since -3 . a concomitant left lung base consolidation cannot be ruled out. aerated parts of bilateral lungs are free of consolidation. cardiomediastinal contours are unchanged. distal end of the orogastric tube is below the level of diaphragm and is within the stomach, though the tip is beyond the view of radiograph. . tte (): the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. overall left ventricular systolic function is severely depressed (lvef= 25 %), with regional variation. the right ventricular free wall is hypertrophied. right ventricular chamber size is normal. with depressed free wall contractility. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the main pulmonary artery is dilated. there is a very small pericardial effusion. the effusion appears circumferential. the effusion is echo dense, consistent with blood, inflammation or other cellular elements. there are no echocardiographic signs of tamponade. . ct chest abd pelvis (): 1. asymmetric fat stranding along the soft tissues of the lateral left hip and thigh suggesting edema or inflammation. deep fascial infection is not excluded by this study. the extent of deep compartment involvement of infection or inflammation is not well characterized and mr could be of potential value in further assessment if needed clinically. no gas or drainable collection is visualized. 2. wall thickening and mucosal enhancement seen along the sigmoid suspicious for colitis. 3. large quantity of scrotal fluid; clinical correlation is recommended and consideration of ultrasound if needed clinically. 4. stable deep vein thrombosis. 5. increased lung opacities; although not specific, these are suggestive of atelectasis. 6. similar soft tissue defect at site of removed port. 7. suggestion of fatty liver. . ct chest (): 1. 3.5-cm area of ground-glass lesion in the right upper lobe may be resolving since it first appeared on . given the decrease in density, differential diagnosis includes atypical infection, hemorrhage or infarction. 2. interval increase since in lower lobe opacification, particularly on the left, probable atelectasis, less likely pneumonia. 3. small bilateral pleural effusions. 4. increased small pericardial effusion. . cxr (): impression: worsening left pleural effusion and complete left lower lobe atelectasis. new right focal opacities consistent with pneumonia. . ct chest (): impression: as compared to , the pre-existing right upper lobe opacity is in the course of organization. more subtle opacities in the right upper lobe have almost completely resolved. improved are areas of atelectasis at the bases of the right lower lobe. the appearance of the left hemithorax, including a small left pleural effusion, is unchanged. overall, the examination is limited by respiratory motion artifacts. no mediastinal lesions. no substantial pericardial effusion. . u/s lue (): findings: a focused ultrasound examination was performed at the site of clinical concern in the right wrist. in this region, there is fluid with internal echoes tracking tracking along the subcutaneous soft tissue planes, extending approximately 2.6 cm in length, without a discrete drainable fluid collection or hematoma identified. there is generalized subcutaneous edema and skin thickening. the underlying vein in the region of interest demonstrates normal venous flow. impression: subcutaneous edema and fluid tracking along the soft tissue planes, but no discrete abscess identified. . u/s lue (): prelim 10 x 20 x 2 mm subcutaneous fluid collection adjacent to but not involving the nearby tendon sheath. . cxr (): low lung volumes with increased right lower lobe atelectasis. . cxr (): increased left perihilar and stable right perihilar consolidations versus edema. . ct chest w/o contrast (): as compared to the previous examination, there are newly appeared right lower lobe opacities and a slightly more extensive left lower lobe opacity. both opacities have air bronchograms. the pre-existing bilateral upper lobe opacities are stable. the changes could correspond to atelectasis, aspiration, or pneumonia. no pleural effusions. no mediastinal lymph node enlargement. . ct neck without contrast (): there is no evidence of an exophytic mucosal mass. compared to the study on , there is a new 2.3 cm x 1.8 cm x 2.1 cm enlarged left level 2, without evidence of necrosis or surrounding inflammatory change. the thyroid gland is unremarkable. the sublingual and submandibular salivary glands are unremarkable. there is opacification of the right and left mastoid tip air cells. the paranasal sinuses are better assessed on the concurrent dedicated sinus ct. there are no lytic or sclerotic bone lesions. there is bilateral pulmonary opacities, described in the concurrent chest ct report. . impression: new enlarged left level 2 lymph node. no evidence of an exophytic mucosal mass. . ct sinus without contrast (): 1. moderate to severe mucosal thickening in the right sphenoid sinus. milder mucosal changes in maxillary and ethmoid sinuses. no osseous erosion or remodeling. 2. no evidence of a mass on noncontrast evaluation. . echocardiogram: impression: normal left ventricular cavity size and wall thickness with mildly depressed left ventricular systolic function. moderately dilated aortic root. no clinically significant valvular regurgitation or stenosis. borderline pulmonary artery systolic hypertension. very small percicardial effusion. compared with the prior study (images reviewed) of , the overall left ventricular systolic function appears to have minimally improved, although the previously reported ejection fraction may have been an underestimate. the absence of valvular vegetations/abscesses on transthoracic echocardiogram does not preclude its presence. if clinical suspicion for endocarditis is high, consider transesophageal echocardiogram. . cxr: findings: lung volumes remain low. bibasilar atelectasis/consolidation are not significantly changed. as compared to the prior examination, a perihilar opacities appear improved consistent with a component of edema. no pneumothorax is seen. the cardiomediastinal silhouette is unchanged. a right-sided central line is unchanged with tip reaching the right atrium. . dialysis line placement: impression: uncomplicated placement of a 20-cm, three-lumen temporary hemodialysis line with a vip port. . ruq u/s: impression: 1. limited mobile examination without cholelithiasis. 2. coarsened echotexture of the liver without fatty deposition. underlying hepatocellular disease cannot be excluded on this exam. . cxr: impression: the hd line through left internal jugular approach is new with tip terminating approximately at cavoatrial junction. bilateral lung volumes are very low. bibasilar atelectases, left side more than right side are unchanged since . pleural effusion, if any, appears minimal on the left side. wide cardiomediastinal silhouette is likely from low lung volumes. there are lung opacities concerning for pneumonia. . dialysis catheter exchange: impression: uncomplicated exchange of a temporary hemodialysis line with a vip port over the wire . line placement: impression: uncomplicated placement of a 14.4 french temporary dialysis line in the right ij. the line length is 15 cm. the tip is in the right atrium. the line is ready to use. . line placement: impression: uncomplicated successful placement of a midline venous line in the mid axillary vein. . ct abdomen and pelvis w/o contrast: impression: 1. no renal or ureteral calculi or hydronephrosis. 2. no acute vertebral compression deformity. stable multilevel compression deformities. 3. new ill-defined fat stranding in the retroperitoneum, just inferior to the aortic bifurcation with a probable 5 mm associated lymph node. lymphatic involvement of known cll is considered. . venous access procedures: procedures: 1. conversion of a temporary double-lumen hemodialysis line inserted by the right internal jugular vein approach into a tunneled double-lumen hemodialysis line, 2. de insertion of a tunneled power double-lumen central line by the left internal jugular vein approach, 3. superior vena cava venogram via the left brachiocephalic vein: . . ct chest: impression: since , bilateral multifocal pneumonia and ground glass opacification as well as bilateral lower lobes opacities representing either atelectasis, aspiration, or pneumonia have decreased. . ct head: impression: no acute intracranial process . ct chest, abdomen, and pelvis: impression: 1. no acute intra-abdominal or intrapelvic process. specifically, there is no evidence of rp bleed. 2. interval increase in patchy ground-glass opacities throughout the upper lung zones since the ct examination concerning for worsening multifocal pneumonia. ct chest: multifocal ground-glass opacities and pulmonary consolidation in the upper lobes are unchanged. mild interval progression of the dense consolidation in the right lower lobe, likely reflecting a combination of atelectasis, infection, and or aspiration. new small right pleural effusion tte: the left atrium is normal in size. the left ventricular cavity is mildly dilated. there is mild global left ventricular hypokinesis (lvef = 40%). left ventricular dysnchrony is present. right ventricular chamber size is normal. with mild global free wall hypokinesis. the aortic root is mildly dilated at the sinus level. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. the mitral valve appears structurally normal with trivial mitral regurgitation. there is no mitral valve prolapse. the estimated pulmonary artery systolic pressure is normal. there is a very small pericardial effusion. there is an anterior space which most likely represents a prominent fat pad. impression: mild global biventricular systolic dysfunction. very small pericardial effusion. compared with the prior study (images reviewed) of , the findings are similar cxr left porta catheter and dual-lumen right central line catheter end in the upper right atrium. bilateral lung volumes are low. bilateral lower lung atelectasis, left side more than right side, are unchanged. cardiomediastinal silhouette and hilar contours are stable. there are no new lung opacities of concern left foot biopsy pan-dermal hemorrhage with focal organizing thrombus formation cxr in comparison with the study of , the tip of the endotracheal tube measures approximately 5 cm above the carina. little change in the appearance of the central catheter and hemodialysis catheter. again, there are low lung volumes with stable cardiomediastinal silhouette. increasing pulmonary vascular congestion with progression of opacification in the retrocardiac region. this is consistent with volume loss in the left lower lobe, though the air bronchogram pattern raises the possibility of superimposed pneumonia in this region. there is also a more focal area of opacification in the right upper and left mid zone, worrisome for possible supervening infection ekg atrial flutter with a rapid ventricular rate of 160 beats per minute. moderate baseline artifact. non-specific st-t wave changes. compared to the previous tracing of no diagnostic interval change. rt wrist biopsy abundant intravascular and interstitial fungal hyphae with thrombosis and secondary ischemic subepidermal bulla (see note). note: the findings in the clinical context are consistent with disseminated fungal infection. the non-pigmented broad ribbon-like hyphae on h&e sections suggests mucormycosis, however aspergillus spp. can sometimes exhibit this morphology. final speciation is deferred to microbiology consultation and culture. this diagnosis was called to dr. (dermatology) by dr. , , at 12:15 pm. addendum: the fungal hyphae do not stain well with pas and gms, more characteristic of zygomycetes than aspergillus species. the presence of fungi within blood vessels and interstitially within the dermis and panniculus is concerning for, but not necessarily diagnostic of systemic infection, as this distribution may also be found in localized infection. this revises the first statement in the note above. ct sinus interval increase in degree of sinus disease, with mucosal thickening and secretions present in the ethmoid air cells and nasal cavity, along with mucosal thickening increased in the bilateral maxillary sinuses. moderate sphenoid sinus thickening as before. much of this increased secretion could be related to intubation. no bony destruction to suggest invasive mucormycosis. cxr endotracheal tube is 2.4 cm above the carina. left and right central catheters remain in satisfactory position. cardiomegaly is unchanged. the heterogeneous infiltrates in both lower lung zones are not significantly changed. the infiltrate in the axillary portion of the right lung may be slightly improved. there is no evidence of pneumothorax left groin biopsy skin and subcutaneous tissue, left thigh, biopsy: necrotic skin and panniculus with abundant gram positive bacterial cocci and thrombosed blood vessels (see note). mri rt wrist 1. marked muscular edema involving all visualized muscles as well as extensive subcutaneous edema without focal fluid collection. given the history of positive biopsy, these findings are consistent with extensive cellulitis and myositis. 2. serpiginous bone marrow signal abnormalities involving the base of the first metacarpal, distal radius and portions of the distal ulna, concerning for bone infarctions given the history of infectious vascular invasion cxr there are low lung volumes. moderate pulmonary edema with bibasilar atelectasis larger on the left side and unchanged. brief hospital course: primary reason for hospitalization: patient is a 27-year-old male with a history of cll status post allogeneic transplant in early complicated by chronic extensive moderate graft-versus-host disease involving the gi tract and capillary leak syndrome, and recent pe who presents in septic shock. 1. septic shock: the patient initially presented hypotensive to the 70s, febrile to 103.2 and hypoxic to 91% on nrb. he was transferred to the icu on intubated and sedated. he was initially covered broadly with linezolid, cefepime, cipro, and micafungin. he was noted on admission to have numerous areas of skin breakdown with erythema on the left thigh concerning for infection. on the morning of hd1, this area of erythema became bullous and the blistering extended up to his mid-abdomen/torso and down to his left knee and became the most concerning and obvious source of infection. blood, stool, and urine cultures were all sent and negative. he was given hydrocortisione 100mg iv q8 for adrenal insufficiency given his history of chronic prednisone use. he was given ivf and pressors, and a left ij line and an arterial line were placed. as his infectious sources were controlled with antibiotics, he was weaned off of pressors by hd3. on the floors, patient hemodynamically stable and weaned off hydrocortisone and restarted home dose prednisone 12.5mg daily hospital course was prolonged by repeated episodes of hypoxia requiring icu transfers. he was noted to have vre bacteremia, resistant to daptomycin, during his final icu stay. he was treated with linezolid, but due to extremely poor vascular access, hd and left picc lines were not removed, but were treated with daptomycin locks. blood cultures cleared vre by . unfortunately, during this time, a bullous right wrist lesion was noted to be expanding, and biopsy and mri were consistent with invasive mucormycosis. he was deemed a poor surgical candidate for debridement or amputation due to extensive comorbidities and attempts to treat medically with ambisome were continued. the size and extent of the right wrist mucor infection expanded, and the right hand demonstrated progressive cysnosis, pallor by . additionally, further skin biopsies showed vre growing within left groin lesion. by patient was pressor dependent, persistent sepsis, persistent bone marrow failure, with progressive renal impairment, evolving progressive lactic acidosis, and progressive systemic acidemia. following multiple discussions with health care proxy and extensive number of family members, all clearly indicated that patient would not want to be maintained on life support in the context of severe medical illness and continued decline in condition. on the unannomous decision to proceed with assuring comfort as the priority. following discontinuation of dialysis and vasopressor support, the patient peacefully expired in the presence of family members. 2. hypoxemic respiratory failure: the patient had large a-a gradient on presentation, and was therefore intubated and sedated with fentanyl and midazolam. patient was soon extubated, and by the morning of hd3, he was breathing comfortably on 2l nc. after being transferred to the floor, he remained on minimal o2 support. however, on , the patient was found to be hypoxic to the 80s on ra with increased work of breathing. he was placed on a nrb without significant improvement and was intubated for respiratory distress. this was attributed to pna seen on chest ct as well as metabolic acidosis secondary to renal failure. he remained on ventilatory support until hd 21 (), at which time he was again extubated. within four days following extubation, he was able to maintain oxygenation and ventilation on room air. following callout to the floor, however, he developed an episode of large volume epistaxis and hemoptysis, of unclear etiology, and developed respiratory distress, likely secondary to aspiration. he was transferred back to the icu and was initally placed on 100% oxygen, and following cessation of hemoptysis was eventually weaned down to 3l oxygen via nasal cannula prior to transfer back to the floor. his respiratory status waxed and waned and again required icu transfer on . he was again noted to have significant oropharyngeal bleeding, and due to repeated aspiration and hypoxia was intubated on . cxr's showed persitently low long volumes with bilateral infilatrates. additionally, as he developed anuric renal failure and hypotension, fluid balance was difficult to achieve and he became grossly fluid overloaded. by , the decision to cease supplemental o2 with ventilation was made along with his family and hcp due to insurmountable disease and medical futility. 3. cmv viremia: patient had a history of known cmv and while in the hospital he was continued on gancyclovir. surveillance cmv viral loads demonstrated a marked jump in his cmv viral load to , and patient was changed to foscarnet due to likely resistance to ganciclovir. cmv viral load on was . 4. mssa scalded skin reaction: the patient first complained of pain in l upper thigh and inguinal area on via telephone to oncology nurse. on admission, he was noted to have purpura, bullae, erythema and warmness on the left anterior thigh that progressed to the abdomen. ct torso to knees did not show evidence of necrotizing fascitis. two 4mm punch biopsies showed occlusive thrombotic vasculopathy, consistent with a scalded skin reaction, and his infection was initially treated with vancomycin, but switched to daptomycin because of vamcomycin-associated . his pain was managed with long and short acting opioid agents, as well as lidocaine gtt and pca. following intubation on , patient remained on fentanyl gtt. 5. mucormycosis: on the patient was discovered to have a small erythematous lesion on his right medial forearm. this had a small black scab/eschar in the middle and was surrounded by peeling skin. there was concern for cellulitis, investigated with ultrasound on and again on the 28th. lesion remained stable until noted to be more painful and expanding on . biopsy showed invasive mucormycosis. patient was not a surgical candidate for debridement and hand became cyanotic and cool. mri was suggestive of marrow infarction along with significant invasive diesease. he was treated with ambisome and ct of sinus showed no evidence of maxillofacial disease, and bal showed no sign of pulmonary disease. biopsy of left groin lesion showed vre but no evidence of mucor. unfortunately, wound continued to expand aggressively prior to the cessastion of pressors. 6. pna: shortly after the patient's admission, he was noted to have signs of pna on cxr and ct. he was already on empiric antibiotic coverage, so pneumonia was monitored on subsequent am cxrs. on hd13 as his respiratory status deteriorated, he was found to have increased pulmonary edema, pleural effusion, and pna. cxr showed rul infiltrate and lll collapse. he was treated with linezolid and meropenem for presumed hcap, later switched to vancomycin and meropenem as he became neutropenic. this course was continued for 8 days. subsequent bal on and showed no evidence of infection despite persistent consolidations and hypoxemia. 7. bleeding: the patient developed large volume hemoptysis and epistaxis on . ent was consulted and perrformed a scan and biopsy/ culture of sinuses. neisseria was grown, but in small volume, and thought to be insignificant. the patient was considered to be too unstable to withstand bronchoscopy. he was intitially continued on heparin gtt due to his significant history of known dvt's. hw, as his oropharyngeal bleeding continued to compromise his tenuous respiratory status, heparin gtt was discontinued on . he received numerous platelet transfusions to maintain platelet count >30. 8. nutritional: due to recurrent mucosal bleeding and clots formation in his op, patient developed significant dysphagia and odynophagis during his final icu transfer. ng and og tubes were not able to be placed, and patient was started on tpn sans lipids. of note, due to extremely poor venous access, a dedicated line was not able to be used for tpn. 9. acute renal failure: during the hospital stay, he developed a metabolic acidosis and acute renal failure. etiology of renal failure thought to be vancomycin (supratherapeutic to trough 35) as well as hypoperfusion from insensible volume loss. additionally, some element of foscarnet toxicity was thought to play a role as well. albumin 50-100g/day was given per renal recommendations, without improvement in renal fucntion. by hd13 he had a cr of 3.4 and was found to have a ph of 7.30. he was started on crrt on hd15, which was used both to normalize his acid-base status and to reduce the significant anasarca developed secondary to his skin infection and fluid resuscitation for sepsis. he was switched to hd with good results, moving to a 3x weekly schedule on . as his blood pressures became lower, he was again transitioned to crrt. 8. dvt's: patient was found to have extensive clots of his central veins involving the ivc, the subclavian veins, and an internal jugular vein on this stay. he was treated with heparin gtt and lovenox. heparin-dependent antibodies were negative. anticoagulation was discontinued on due to signficant bleeding. 9. hypertension: once the patient's sepsis resolved on hd3, the patient began to experience hypertension to the sbp 170s, particularly associated with pain. he is hypertensive at baseline, controlled with lasix and metoprolol. as an inpatient he was given metoprolol with occasional doses of hydralazine for sbp>170. his volume status was addressed with crrt/hd. 10. portacath infection: port site swab grew mrsa on hd3, one possible source of infection. patient was already on vancomycin for left leg infection, which was continued for an 8 day course sufficient to cover this skin infection. 11. anemia: the patient has a baseline anemia, worsened on presentation. he received 2 units prbc at osh and his hct remained stable on admission. initial hemolysis labs were negative and there was no evidence of dic. his hct improved initially, but declined as hospital stay continued, likely due to severe disease and recurrent bleeding. he received 26 units prbc during this admission. 12. tachycardia: patient had sinus tach throughout icu stay, thought to initially be secondary to sepsis and inflammatory response and later due to a component of pain from skin infection that the team was actively trying to control. he was given fluid boluses as needed for fluid repletion and monitored on telemetry. during his final icu admission, he was repeatedly found to convert to atrial flutter. blood pressures remained stable during these episodes, and were treated with iv nodal agents as needed. 13. hyperglycemia. patient was hyperglycemic throughout admission, likely secondary to iv hydrocortisone and stress response of illness. no known hx of diabetes. he was maintained on an iss. 14. gvhd: appears stable at this time. patient was given stress dose steroids as above and was then tapered back down according to bmt recommendations. 15. cll: patient appears to have been in remission since transplant, although his transplant course was complicated by capillary leak. during his stay he was maintained on gvhd treatment with steroids, and was given antibiotic prophylaxis with valgancyclovir (cmv), micafungin (fungal), and atovaquone (pcp). he was treated with neupogen for neutropenia for a total 5 day course. given a positive beta-glucan result he was switched to voriconazole on . 16. hyponatremia: as patient became increasingly hypervolumic due to anuric renal failure, patient developed hypervolemic hyponatremia. fluid balance was attempted to be controlled by hd/uf and crrt with poor results. na on was 127. transitional issues: deceased medications on admission: atovaquone - 750 mg/5 ml suspension - 10 ml(s) by mouth once a day budesonide - 3 mg capsule, ext release 24 hr - 1 capsule(s) by mouth three times a day citalopram - 20 mg tablet - 1 tablet(s) by mouth once a day cyclosporine modified - 25 mg capsule - 2 capsule(s) by mouth twice a day enoxaparin - (prescribed by other provider) - 80 mg/0.8 ml syringe - 1 syringe(s) every twelve (12) hours folic acid - 1 mg tablet - 2 tablet(s) by mouth once a day furosemide - (dose adjustment - no new rx) - 20 mg tablet - 1 tablet(s) by mouth once a day lactulose - 10 gram/15 ml solution - 15-30 ml by mouth once a day as needed for constipation lisinopril - (dose adjustment - no new rx) - 10 mg tablet - 1 tablet(s) by mouth daily (daily) lorazepam - 1 mg tablet - 1 tablet(s) by mouth every six (6) hours as needed for nausea, anxiety metoprolol tartrate - (dose adjustment - no new rx) - 25 mg tablet - 0.5 (one half) tablet(s) by mouth twice a day morphine - (prescribed by other provider) - 60 mg tablet extended release - 1 tablet(s) by mouth every twelve (12) hours mycophenolate mofetil - (dose adjustment - no new rx) - 250 mg capsule - 3 capsule(s) by mouth twice a day omeprazole - 20 mg capsule, delayed release(e.c.) - 1 capsule(s) by mouth once a day ondansetron - 4 mg tablet, rapid dissolve - 1 tablet(s) by mouth every eight (8) hours as needed for nausea oxycodone - 5 mg tablet - 1 tablet(s) by mouth every four (4) hours as needed for pain posaconazole - 200 mg/5 ml (40 mg/ml) suspension - 5 ml(s) by mouth three times a day potassium chloride - 20 meq tablet, er particles/crystals - 4 tablet(s) by mouth on and then 1 tablet daily prednisone - (prescribed by other provider) - 5 mg tablet - 2.5 tablet(s) by mouth once a day valganciclovir - 450 mg tablet - 2 tablet(s) by mouth once a day medications - otc cholecalciferol (vitamin d3) - (prescribed by other provider) - 2,000 unit tablet - 1 tablet(s) by mouth twice a day multivitamin - tablet - 1 tablet(s) by mouth daily (daily) sennosides - 8.6 mg tablet - 1 (one) tablet(s) by mouth twice a day as needed for constipation discharge medications: n/a discharge disposition: expired discharge diagnosis: chronic lymphocytic leukemia graft versus host disease mrsa scalded skin syndrome invasive mucormycosis vancomycin resitant enterococcus sepsis cytomegalovirus bactermia acute renal failure discharge condition: deceased discharge instructions: n/a followup instructions: n/a md procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more parenteral infusion of concentrated nutritional substances hemodialysis venous catheterization for renal dialysis arterial catheterization closed biopsy of skin and subcutaneous tissue closed biopsy of skin and subcutaneous tissue infusion of drotrecogin alfa (activated) diagnoses: pneumonia, organism unspecified other primary cardiomyopathies anemia of other chronic disease acute kidney failure with lesion of tubular necrosis unspecified pleural effusion long-term (current) use of steroids other pulmonary insufficiency, not elsewhere classified hyposmolality and/or hyponatremia severe sepsis other and unspecified alcohol dependence, in remission other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure pneumonitis due to inhalation of food or vomitus septic shock pressure ulcer, other site major depressive affective disorder, single episode, unspecified long-term (current) use of anticoagulants methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site glucocorticoid deficiency surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation other and unspecified infection due to central venous catheter streptococcal septicemia cytomegaloviral disease other pulmonary embolism and infarction delirium due to conditions classified elsewhere personal history of antineoplastic chemotherapy epistaxis pressure ulcer, stage ii acute venous embolism and thrombosis of deep vessels of distal lower extremity dysphagia, oropharyngeal phase other fluid overload other specified erythematous conditions pressure ulcer, upper back toxic shock syndrome pressure ulcer, hip chronic graft-versus-host disease secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified complications of transplanted organ, stem cell chronic lymphoid leukemia, in relapse ritter's disease 

Answer: The patient is high likely exposed to