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: patient recorded as having no known allergies to drugs attending: chief complaint: wrist pain. major surgical or invasive procedure: : left wrist incision and drainage. - upper gi endoscopy. trans-esophageal echocardiogram. : right hip hemiarthroplasty. : exploratory laparotomy, subtotal colectomy, resection of terminal ileum, temporary abdominal closure : exploratory laparoscopy, subtotal colectomy. : exploratory laparotomy, gastrostomy tube, ileocolonic anastomosis and diverting loop ileostomy : right hip revision of hemi arthroplasty due to dislocation : right hip girdlestone procedure, removal of right hip hardward, placement of spacer. history of present illness: hpi: mr. is a 59 year old man w/ a hx of esrd on hd, s/p failed transplant, and htn who presented with sudden onset left wrist pain. he noted that his wrist (distal to his native vessel fistula site) was swollen and had reduced range of motion. pain present at rest and with motion. pt also noted fevers and chills the night before, but no nausea or vomiting. he did not recall any trauma to the area or skin lesion. he is on a m/w/f dialysis schedule, but because of increased pain and swelling, presented to ed instead of usual hd. upon arrival at the ed, his vitals were t 100.5, hr 97, bp 173/71, rr 14, o2sat 100% on ra. new-onset afib was noted. his left wrist was aspirated and returned frank pus, consistent with septic arthritis. pt started empirically on vancomycin and gentamycin while awaiting wound and blood cultures, then taken to the or by plastic surgery for wash-out of pus in the joint and placement of penrose drain. following pacu recovery, the patient was transferred to the medicine service. past medical history: 1. esrd, secondary to post-streptococcal glomerulonephritis. renal transplant in failed after several years. transplant nephrectomy in . currently on hemodialysis. remains on the transplant list. 2. hyperparathyroidism due to esrd 3. hypertension 4. coronary artery disease 5. diastolic chf with remote history of systolic chf (resolved); normal lvef in 6. repeated episodes of pneumonia 7. pulmonary nodules 8. carpal tunnel release 9. left hand flexor tenosynovitis status post flexor tenosynovectomy, trigger release, and right ring finger mallet finger. 10. amyloid lesions in the wrist and metacarpals. social history: owner of a very successful vintage clothing store in downtown and travels extensively. currently lives with mother and brother in . divorced with 1 daughter. denies current tobacco and alcohol use but notes intermittent tobacco use in the past (~3 pack-years). denies illicit drug use. current orientation is homosexual; hiv test negative in , not in a relationship recently but notes that he always uses protection. family history: positive for cancer (father-prostate), (mother). father deceased. brother has fibromyalgia. daughter in good health. physical exam: on admission: vs: tm 101.6, t 99.6, bp 137/72, hr 78, rr 20, o2sat 98% on ra gen: well-nourished african american man sitting up in bed, trying to rip of ekg leads, clearly disoriented and ill, but not septic appearing. heent: ncat. eyes perrla 2->1mm. notable for injected sclera. no abnormalities of nose or ears. throat w/o exudate or erythema. neck: supple. no thyromegaly, no lad. cv: irregularly, irregular heart rate and rhythm. s1, s2, and s4 audible w/ 3/6 systolic murmer heard best at apex. pulm: ctab with exception of crackles in the bases bilaterally which largely resolve on deep cough. able to speak in full sentences w/o sob. abd: voluntary guarding w/ some tenderness diffusely. tense abd musculature on palpation. very active bowel sounds. extrem: wwp. no edema. l wrist wound w/ erythema and swelling, but no pus. exquisitely tender. margin of 1.5in btwn fistula and wound. bruit over fistula. neuro: awake. oriented only to person and year. believes he is going to . no recollection of reason for being in hospital. very inattentive. unable to complete backwards. 0/3 recall. comprehension intact to 2 step commands. strength full in lower extremities w/ exception of r ip . unclear if pain complicating strength exam. sensory intact to gross touch. proprioception intact. reflexes patellar, biceps, triceps. no asterixis. unable to cooperate w/ finger to nose testing. unable to ambulate 2* to fever and disorientation. on discharge: vs: t 97.1, bp 105/60, hr 90, rr 20, 99% on room air tm 97.4, 98-126/40-61, 76-90, 16-20, 97-100% ra gen: nad heent: op dry, but clear, no scleral icterus neck: jvp to mid-neck chest: cta anteriorly, no crackles, wheezes, or rhonchi cv: regular, normal s1 and s2, 4/6 systolic murmur loudest at llsb abd: abd wound vac in place w/minimal drainage, g-tube site c/d/i, ostomy bag on, no soilage around ostomy site; nabs, soft, nt, nd r hip: no erythema or exudate, warm to touch, pain with minimal movement, with ~100cc bloody drainage in hemovac from r-hip ext: warm, no edema. pertinent results: admission labs: 02:19pm blood wbc-5.7 rbc-3.94* hgb-13.6* hct-38.5* mcv-98 mch-34.4* mchc-35.2* rdw-15.5 plt ct-78* 02:19pm blood neuts-80.5* lymphs-8.4* monos-4.0 eos-6.9* baso-0.2 02:19pm blood pt-14.7* ptt-28.9 inr(pt)-1.3* 02:19pm blood glucose-82 urean-40* creat-10.6*# na-137 k-4.6 cl-90* hco3-29 angap-23* 02:19pm blood calcium-9.6 phos-6.3* mg-2.0 uricacd-4.6 on discharge: blood wbc-7.8 rbc-3.15* hgb-9.9* hct-28.7* mcv-91 mch-31.5* mchc-34.5* rdw-18.8 plt ct-137* blood pt-19.4* ptt-34.5 inr(pt)-1.8* blood glucose-111 urean-40* creat-5.3*# na-135 k-4.8 cl-101* hco3-26 angap-13* blood calcium-8.5 phos-4.2* mg-1.7 romi: 02:19pm blood ck(cpk)-122 07:15am blood ck(cpk)-206 02:19pm blood ck-mb-4 07:15am blood ck-mb-6 02:19pm blood ctropnt-0.17 07:15am blood ctropnt-0.18 delirium workup: 02:19pm blood digoxin-1.9 07:05am blood digoxin-2.5 07:05am blood tsh-0.16 07:05am blood vitb12-1857 infectious work-up: 02:42pm blood lactate-2.1 : l wrist cell count: 100000wbc 150000rbc 64poly 6lymp 12mono 1eo 17macro 10:49 pm l wrist swab gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. wound culture (final ): staph aureus coag +. heavy growth. oxacillin <=0.25 s 1:54 pm blood culture staph aureus coag +, oxacillin <=0.25 s 9:15 am blood culture staph aureus coag +. 7:27 pm blood culture no growth. 7:00 am rapid plasma reagin test nonreactive. 11:00 am joint fluid right hip aspiration. gram stain (final ): 4+ (>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. 6:09 am swab left wrist gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. wound culture (final ): staph aureus coag +. rare growth. oxacillin 0.5 s anaerobic culture (final ): no anaerobes isolated. 5:23 pm stool clostridium difficile toxin a & b test negative 5:23 pm stool clostridium difficile toxin a & b test negative 5:23 pm stool clostridium difficile toxin a & b test negative 5:23 pm stool clostridium difficile toxin a & b test negative cmv viral load: cmv dna not detected. hiv serology hiv ab: negative : wound culture (final ): enterococcus sp.. sparse growth. daptomycin sensitivity testing per dr (). daptomycin 1 ug/ml = sensitive by e-test. sensitivities: mic expressed in mcg/ml _________________________________________________________ enterococcus sp. | ampicillin------------ =>32 r linezolid------------- 2 s penicillin g---------- =>64 r vancomycin------------ =>32 r anaerobic culture (final ): no anaerobes isolated. cxr: in comparison with study of , there is continued enlargement of the cardiac silhouette with evidence of elevated pulmonary venous pressure. no acute focal pneumonia. on the lateral view, there appears to be some opacification in the retrocardiac area. however, some of this may be merely due to overlying soft tissues. in view of the clinical history, the possibility of a region of pneumonia cannot be excluded. left wrist x-ray: soft tissue calcifications and swelling overlying the radial aspect of the distal radius are grossly stable since . the scapholunate interval again measures 3 mm. diffuse osteopenia is unchanged. lucencies are noted within the capitate and scaphoid which are grossly stable. there is no evidence of acute fracture or malalignment. impression: stable exam without evidence of acute process right shoulder x-ray: no previous images. three views show loss of the cortical margin involving the distal clavicle with widening of the acromioclavicular joint. suggestion of an associated soft tissue prominence. in view of the clinical history, the possibility of a septic arthritis with osteomyelitis must be seriously considered. ct head (prelim report): no evidence of acute intracranial abnormality seen on non-contrast head ct, although for more sensitive evaluation for subtle intracranial infection or small acute infarct, mri would be recommended for more sensitive evaluation. diffuse small lucencies in the calvarium, particularly along the vertex, without cortical breakthrough or cortical thickening likely relates to chronic renal failure/renal osteodystrophy, less likely paget's disease or diffuse metastatic disease. tte: the left atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (lvef>55%). the estimated cardiac index is normal (>=2.5l/min/m2). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg).the estimated cardiac index is normal (>=2.5l/min/m2). the right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. there is abnormal septal motion/position consistent with right ventricular pressure/volume overload. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened with trivial mitral regurgitation. there is moderate to severe pulmonary artery systolic hypertension. there is a small to moderate sized pericardial effusion. compared with the report of the prior study (images unavailable for review) of , the right ventricular cavity dilation and moderate/severe pa systolic hypertension are new. the pericardial effusion is likely similar. portable abdomen:non-specific bowel gas pattern without evidence for obstruction or ileus. no intraperitoneal free air. mri head: there is no evidence of hemorrhage, edema, or infarction. there is no evidence of mass effect. there are no diffusion abnormalities detected, that would be suggestive of septic emboli. the ventricles and sulci are normal in caliber and configuration. there is noted to be fluid in the left petrous apex. there are a few small hyperintense foci seen in the white matter on flair images that are non specific in nature and demonstrate no restricted diffusion. the patient is noted to be status post lens replacement on the right eyeglobe. in comparison to the ct scan from the diffuse patchy and small rounded lucencies in the calvarium are not well demonstrated on this current mr study. the basilar artery is noted to be small in diameter. there is noted to be opacity within the mastoid air cells suggestive of fluid in the mastoids. this could be suggestive of mastoiditis. impression: 1. no evidence for septic emboli or abscess. no acute infarction or hemorrhage. 2. areas of rounded lucencies within the calvarium are not well demonstrated on this current mr study. please refer to ct report from for full characterization. 3. there is noted to be fluid in the left petrous apex. upper gi endoscopy: findings: esophagus: normal esophagus. stomach: mucosa: erythema and congestion of the mucosa were noted in the whole stomach. cold forceps biopsies were performed for histology at the stomach antrum. duodenum: mucosa: erythema, congestion and friability of the mucosa with no bleeding were noted in the duodenal bulb compatible with duodenitis. excavated lesions multiple non-bleeding, clean based, small ulcers were found in the duodenal bulb. impression: ulcers in the duodenal bulb. erythema, congestion and friability in the duodenal bulb compatible with duodenitis. erythema and congestion in the whole stomach (biopsy) otherwise normal egd to third part of the duodenum. pathology: gastric tissue sample: regeneration of gastric pits suggestive of chemical gastropathy. ekg: primarily atrial fibrillation although there appear to be some flutter waves in leads v1-v2. non-specific intraventricular conduction delay. left anterior fascicular block. consider left ventricular hypertrophy. consider prior lateral myocardial infarction. non specific st-t wave changes. compared to the previous tracing of the rhythm is more irregular consistent with atrial fibrillation. u/s of l av fistula: widely patent left brachial and left radial arteries with suggestion of some degree of atherosclerotic disease. widely patent radiocephalic fistula without visualized stenosis of the outflow vein which appears to be the cephalic vein. : mri of the r hip: there is small amount of joint fluid in the right hip, which is in the range for physiological quantity. there are degenerative changes in the right hip which include subchondral cystic changes in the femoral head. a subchondral cystic change is also noted in the femoral head-neck junction. given the superior joint space narrowing, the appearance favors degenerative changes. however, less likely infection may also produce this appearance. infection is considered less likely due to lack of joint fluid. there is a lobulated bright t2 signal intensity lesion adjacent to the superior labrum measuring 2.8 x 2.0 cm, which is most consistent with a paralabral cyst. the labrum is not well assessed on this non-dedicated examination. there is fluid signal intensity which spans 10 cm along the greater trochanteric bursa, and measures 5.8 x 1.6 cm in axial dimensions, with appearance consistent with right greater trochanteric bursitis. degenerative changes are also noted in the left hip. there is physiological joint fluid in the left hip. a tiny amount of fluid is also noted in the left greater trochanteric bursa, consistent with mild bursitis. there is diffuse soft tissue edema. there is edema in the right hemipelvis greater than left hemipelvis musculature, particularly in the iliacus and gluteus minimus. impression: physiological quantity of right hip joint fluid. insufficient fluid for aspiration. greater trochanteric bursitis, right side significantly greater than left. presence of a paralabral cyst suggests a superior labral tear, but the exact tear this is not optimally seen due to lack of dedicated technique. muscular edema as detailed. : ct guided biopsy: 25 cc of red serosanguineous colored fluid was aspirated with no complication fluid was sent for microbiologic examination. culture: gram stain 4+(>10 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. ekg: atrial fibrillation with controlled ventricular response. occasional ventricular premature beats. compared to the previous tracing of ectopy is new. : ct of the torso, abdomen and pelvis to r/o occult abscess: 1. mild pulmonary edema and background nodular and cystic changes, again concerning for lip (lymphocytic interstitial pneumonitis). 2. unchanged marked cardiomegaly and small-to-moderate-sized pericardial effusion. 3. small splenic infarct, age indeterminate due to lack of prior examinations. 4. no evidence of intrathoracic or intra-abdominal abscess. tee: conclusions the left atrium is dilated. no spontaneous echo contrast or thrombus is seen in the body of the left atrium or left atrial appendage. no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). there are simple atheroma in the aortic arch. there are simple atheroma in the descending thoracic aorta. the aortic valve leaflets (3) are mildly thickened. no masses or vegetations are seen on the aortic valve. there is no valvular aortic stenosis. the increased transaortic velocity is likely related to high cardiac output. mild to moderate (+) aortic regurgitation is seen. the aortic regurgitation jet is eccentric. the mitral valve leaflets are moderately thickened.there are torn, calcified mitral chordae seen. no masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. there is severe mitral annular calcification. two eccentric (anterior and posterior directed) jets of mitral regurgitation are seen with moderate to severe mitral regurgitation (3+) . a small perforation of the posterior leaflet cannot be excluded on the basis of this study. no masses or vegetations are seen on the tricuspid valve. no vegetation/mass is seen on the pulmonic valve. there is a small pericardial effusion. impression: no valvular vegetations seen. moderate to severe, eccentric mitral regurgitation. : ct of the l wrist: innumerable lucencies are seen throughout the carpus. this includes large ill-defined lucencies in the scaphoid, lunate, capitate, hamate, trapezium, triquetrum, and the bases of the metacarpals particularly the second through fourth metacarpals. numerous irregular lucencies and areas of cortical destruction are also seen in the distal ulna. there is extensive atherosclerotic vascular calcification. gas is seen within the dorsal soft tissues at the level of the wrist likely related to previous incision and drainage. the absence of intravenous contrast severely limits evaluation for an underlying fluid collection, although no discrete soft tissue density is identified. circumferential soft tissue edema is seen throughout the subcutaneous and deep fat as well as associated skin thickening. tendons are suboptimally assessed. impression: 1. innumerable lucencies throughout the carpus, distal ulna, and the bases of the metacarpals as described could reflect an erosive process such as amyloidosis. however, given the history and the destructive and ill-defined appearance of these lucencies, the possibility of superimposed osteomyelitis is difficult to exclude. 2. no discrete soft tissue collection, although evaluation is suboptimal due to the absence of intravenous contrast. 3. post-surgical changes including gas in the dorsal soft tissues of the wrist. ekg: sinus rhythm and occasional ventricular ectopy. a-v conduction delay. left atrial abnormality. right bundle-branch block. compared to the previous tracing of sinus rhythm has appeared. cxr: comparison is made to the prior chest x-ray of . the heart remains enlarged. some pulmonary plethora is present suggesting incipient failure. no areas of pneumonia are seen. impression: cardiomegaly, mild failure mri right hip: 1. interval increase in the amount of right hip joint fluid, now large in quantity. 2. more conspicuous signal changes in the right femoral head and neck and diaphysis, likely representing components of mild marrow edema and hematopoietic marrow. 3. persistent, but slightly decreased, right greater trochanteric bursitis. 4. persistent, and slightly increased, diffuse muscle edema as detailed. cxr 1) marked cardiomegaly consistent with polychamber enlargement and/or an element of pericardial fluid. 2) diffusely increased interstitial markings consistent with interstitial edema or another interstial process, (please note that the report from the ct scan also raised concern for a lymphocytic interstitial pneumonitis.) 2) compared with and allowing for technical differences, the interstitial markings are without significant interval change. no pleural effusion. left-wrist x-ray : diffuse osteoporosis is again seen, worse than on the prior occasion. soft tissue vascular calcification is again seen, and also is present on the thenar aspect of the forearm. no definite areas of bony destruction are seen; though, there is some irregularity at the distal aspect of the scaphoid on the thenar aspect. these films should be compared with the mr films by musculoskeletal radiologist. ct abd/pelvis : 1. small pelvic fluid collections noted on prior studies are less conspicuous on current study. no drainable fluid collections are identified within the pelvis, although evaluation limited given streak artifact from right hip arthroplasty. 2. little change to stranding and fluid within the region of the right gluteal musculature after hip arthroplasty. 3. bibasilar atelectasis and small right pleural effusion. smooth septal thickening within the bases again may represent pulmonary edema superimposed on previously described lymphocytic interstitial pneumonitis (lip). 4. cardiomegaly with mitral annular calcifications. significant calcifications within the sma as detailed above. 5. splenomegaly. brief hospital course: "brief" this is a 59 year old male with esrd on hd with persistent fevers despite appropriate iv abx for mssa+ bacteremia and likely endocarditis following septic arthritis of left wrist s/p wash-out. # fever: vancomycin and gentamycin started empirically for joint aspirate consistent with septic arthritis. patient taken to or by plastic reconstructive surgery for wash-out of left wrist. blood cultures and fluid cultures subsequently grew out s. aureus, and gentamycin discontinued. mssa by , vancomycin switched to nafcillin for better coverage, then to cefazolin with hemodialysis. drainage from left wrist noted to be less purulent and less erythematous per prs evaluation. however, as mr. continued to spike fevers with persistently positive cultures, id consulted and recommended restarting on nafcillin. pt continued spiking fevers although cultures cleared . gentamicin with hd started for synergy. concern for endocarditis as pt with murmur at baseline and new afib but no vegetations seen. no evidence of septic emboli on ct and mri head. x-ray to evaluate for right shoulder infection with absent cortex likely old trauma - pt later noted pain old. ultrasound of fistula with no evidence of infection. pt with pain on mobilization of r hip, concern for septic joint. mri with no evidence of hip joint involvement but showed fluid collection at tronchanteric bursa (culture negative), labral tear, muscle tear, improved with steroid injection. left wrist re-aspirated and showed rare s. aureus. wrist re-imaged with ct without significant fluid collection. tee to re-evaluate for vegetations showed increased mitral regurgitation with 2 jets concerning for valve perforation as well as new aortic regurgurgitation, both consistent with likely endocarditis. ct surgery consulted and recommended surgery. fevers continued intermittently (at least 1 every 24hrs) along w/ development of night sweats until . concern for nafcillin-related drug fever, and patient switched to vancomycin with hd. afebrile from late to , and gentamicin discontinued. however, continued to spike fevers on vancomycin and switched back to beta-lactam for better coverage of mssa but still continued to spike fevers. treated for 8 wks w/ cefazolin for ie and wrist osteomyelitis. was temporarily afebrile, then broke r hip had hemiarthroplasty, got ischemic colitis and hemicolectomy w/ ostomy. ostomy leaked into hip wound which became infected w/ enterobacter and klebsiella sensitive to cipro. initially afebrile after starting cipro and washing out hip. id recommended continuing cipro for 6 months because of concern for infected prosthesis though ortho said it was an infected hematoma. recommended switching to cefepime if he spiked a fever through the cipro. over the weekend of and , the patient continued to spike low grade fevers. out of concern for continuuing infection, the patient received a ct of the abd/pelvis on . this showed several fluid collections and possibly a larger hematoma at the right hip joint. the patient then had an ir guided drainage of fluid. the hematoma near the joint did not aspirate and 100cc of fluid collection near the staples was sampled. this fluid subsequently grew vre. it was determined the patient would need a girdlestone procedure in which the hardware of the right hip is removed and replaced with a spacer so the area could be sterilized before reinserting hardware. the patient went for this procedure on . post-op, the patient had a large amount of bloody drainage from the wound vac and did requires an additional 10 units of prbc's. after a brief stay in the micu, the patient was called out to the floor where he remained stable. # confusion: pt initially delirious in setting of persistently positive blood cultures and continuing fevers, improved back to baseline 5-6d later when no longer bacteremic and fevers running lower and more infrequent. likely also to be more sensitive to narcotics base on past response, per daughter. of note, no acute intracranial process on ct or mri head. rpr neg. b12 wnl. tsh elevated but t3 low, t4 wnl, likely euthyroid sick. uremia unlikely as lytes at baseline on hd. now resolved and remains aao x 3 on discharge. # cardiac dysarrhythmia: on admission, ekg regular with prolonged pr, unchanged from baseline. however, pt developed afib and occasional aflutter during hospital course. initially with rvr then associated with bradycardia into hr 30s-40s. evaluated by cardiology, who recommended anticoagulation with coumadin and cardioversion. however, pt was not candidate at that time as with new gi bleed, in which setting asa also discontinued. pt remained hemodynamically stable. now in afib. would consider anticoagulation in the future if bleed is no longer a concern. # cardiac/valvular disease: tte on without vegetations, trivial mr, no ai, normal ef. tee on to re-evaluate for vegetations showed increased mitral regurgitation w/ 2 jets concerning for valve perforation as well as new aortic regurgurgitation, both consistent with endocarditis. restarted on ace i to decrease afterload. evaluated by ct surgery who recommended mitral and aortic replacement. decision made by pt and medical teams to defer in setting of acute infection while aware that delay would increase risk of complications from ongoing medical issues. prior to surgery, pt will require cath and dental clearance. at the time of surgery, a bypass will likely be needed with renal transplant should follow. ct surgery will remain in contact with the patient, scheduled to follow up with dr. on . pt. remained in house complicated complications and dr. saw him again in house and recomended no valve surgery unless would go for renal transplant, also too debilitated w/ infectious processes going on . he was also given multiple blood transfusions out of concern for demand ischemia. # elevated troponin: likely baseline in setting of renal failure although with transient worsening probably to high output in setting of infection. sharp chest pain noted on several occassions throughout stay, thought to be related to anxiety and demand ischemia from mr, ai, and anemia. no ekg changes appreciated with any episode; trop at baseline. pain resolved each time within several minutes and responded well to nitroglycerin sl. # chf: pt with chronic diastolic chf and history of systolic chf (thought to be hypertensive cardiomyopathy) resolved on tte in but continued on digoxin and euvolemic on admission. as tte on this admission also showed normal ef and as digoxin levels toxic in setting of delirium, digoxin discontinued; continued on beta blocker. as pt complaining of increased angina, restarted on ace-i for afterload reduction. repeat tte after the diagnosis of endocarditis with new finding of focal inferior wall motion abnormality with ef of 45%, likely in setting of increased valvular disease v. ischemic change. the patient was restarted on digoxin. his ace-i has since been discontinued and he is being discharged on 12.5mg po bid of metoprolol. # htn: continued on metoprolol. initially held moexipril, clonidine, and minoxidil as blood pressures lower running. as these normalized, pt restarted on ace-i (lisinopril) for afterload reduction in setting of increased angina, though this is now discontinued again. he is on metoprolol for improved rate control of afib as we are currently unable to anticoagulate him. # anemia: patient was admitted w/ hct of 38.5 which slowly trended down over admission to a low of 19.4. anemia thought to be of combined etiology including gi bleed, frequent blood draws, anemia of chronic disease (as supported by fe studies), and esrd (on epogen w/ hd). patient transfused with hd as hct dropped into low 20s as developed more frequent episodes cp and sob, likely exacerbated by valvular damage endocarditis. the patient is currently guaiac negative but if hct continues to trend down, may need outpt colonoscopy. hct should be monitored on discharge, even after his hip wound ceases to drain. # guaiac positive stools: patient complained of abdominal tenderness on exam with voluntary guarding. lfts wnl and kub unremarkable, date of last bowel movement unclear. pt with one large episode melanic stool on , egd showed nonbleeding duodenol ulcers, duodenitis. pt started on ppi and home asa held. stools no longer guaiac positive except in setting of nosebleed, now again resolving. # ischemic colitis: pt complained of increasing abdominal pain during his hd session on . abdominal exam without guarding or rebound but concern as pt appeared unwell, worsened from baseline. found to have ischemic colitis on stat ct. surgery consulted and pt taken to or for left hemicolectomy and transferred to the sicu afterwards. post-op course notable for some hypotension requiring blood transfusion and pressors. however, remaining bowel appeared pink and no further bowel resection required, and pt underwent abdominal closure, ileostomy, gtube placement on . extubated without difficulty on . of note, wound vac placed on abdominal wound for caudal aspect opening on . the abdominal wound vac should be replaced every 3 days until it can be discontinued. # esrd on hd: patient s/p failed transplant, on transplant list again. between hd sessions, pt developed increased jvd and bibasilar rales but breathing comfortably and satting well. does not produce urine at baseline. continued on hd mwf, home meds, medications renally dosed. # right shoulder pain: pt complaining of right shoulder pain on movement, concern for septic involvement initially. xray showed cortical absence at distal cortex, c/w old trauma v. infection. however, as patient without point tenderness and no signs of inflammation, low suspicion for infection. on further questioning, pt reports having had pain on and off for few weeks prior to presentation; per pt, it is possible he has sustained trauma to that shoulder. # right hip fracture happened after bumping right knee on bed rail on . taken to the operating room on and underwent an right hip hemiarthroplasty. unfortunately found to have same hip dislocated on . returned to the operating room on and underwent a revision of his right hemiarthroplasty. he was found to have enterococcus growing from his wound on . he was taken back to the or for removal of the hardware on . at that time he was coagulopathic with an inr of 1.8 he was transfered to the micu following the procedure as he became hypotensive. he was found to have profound blood loss into his hip joint. he was transfused a total of 10 units of prbcs and 10 units of ffp at taht time and 2 additional units of prbcs the following day. he was stablized and monitored in the icu until when he was taken back to the or for washout. he was found to have vre in the wound and treated with daptomycin and ciprofloxacin. he was then transfered to the floor on the night of . medications on admission: nephrocaps daily clonidine 0.1 mg daily digoxin 125 mcg every other day and 250mcg every other day moexipril 15 mg in the morning and 30mg in the evening metoprolol 50 mg minoxidil 5 mg daily lorazepam or valium at night discharge medications: 1. lorazepam 0.5 mg tablet sig: 1-2 tablets po hs (at bedtime) as needed for insomnia. 2. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). 5. acetaminophen 325 mg tablet sig: one (1) tablet po q4-6h () as needed for pain, fever. 6. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 7. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed for constipation. 8. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 9. ibuprofen 400 mg tablet sig: one (1) tablet po q4-6h () as needed for pain: please use for pain prior to using opiates. 10. outpatient lab work please check hct daily until stable and transfuse with blood in hemodialysis as needed. 11. outpatient lab work please guaiac all stools. 12. insulin regular human 100 unit/ml solution sig: ssi per sliding scale injection asdir (as directed). 13. digoxin 125 mcg tablet sig: one (1) tablet po every other day (every other day). 14. lidocaine hcl 2 % solution sig: one (1) ml mucous membrane (2 times a day) as needed. 15. heparin, porcine (pf) 10 unit/ml syringe sig: one (1) ml intravenous prn (as needed) as needed for line flush. 16. sodium chloride 0.9 % 0.9 % parenteral solution sig: ten (10) ml intravenous q8h (every 8 hours) as needed for line flush. 17. ciprofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours) for 4 weeks. 18. daptomycin 500 mg recon soln sig: one (1) recon soln intravenous q48h (every 48 hours) for 4 weeks. 19. mirtazapine 7.5 mg tablet sig: one (1) tablet po hs (at bedtime). 20. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po bid (2 times a day). 21. tramadol 50 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 22. oxycodone 5 mg tablet sig: one (1) tablet po q4h (every 4 hours) as needed: please hold for sedation or rr<12. 23. outpatient lab work please have weekly cbc, chemistries and liver function tests faxed to the infectious disease clinic at . discharge disposition: extended care facility: & rehab center - discharge diagnosis: 1. methicillin-sensitive staph aureus septicemia with confirmed l septic wrist and highly probable bacterial endocarditis. 2. new mod/severe mitral regurgitation w/ perforation of the posterior leaflet and mild/moderate aortic insuffiency. 3. new onset atrial fibrillation. 4. duodenal ulcers. 5. esrd, hemodialysis dependent. 6. l hip bursitis. 7. febrile-associated delirium. 8. possible nafcillin related drug fever. 9. right femoral neck fracture, status-post girdlestone procedure 10. adrenal nodule, likely adenoma 11. non-st segment myocardial infarction 12. vancomycin resistent enterococcus infection. discharge condition: stable. afebrile. discharge instructions: you were admitted with an infected left wrist, which was surgically cleaned. the wrist and your blood cultures contained bacteria, and therefore you were started on iv antibiotics. these were changed several times during your stay here to specifically target the bacteria. despite these antibiotics, you remained febrile for several weeks and we were concerned for infection in other parts of your body. imaging of your heart showed evidence of infection, including new valve damage to your mitral and aortic valves. this makes it harder for your heart to pump blood forwards and may require replacement of your heart valves at a future date. in addition, during your stay, you were noted to have blood in your stool, found to be the result of ulcers in your duodenum. you received several blood transfusions during your hospital course. while you were here, you broke your right hip and received a hip replacement. following this, you had ischemic colitis requiring a hemicolectomy with ostomy placement. subsequently, it was found that your hip wound grew klebsiella and enterobacter. you were treated for these but continued to have low grade fevers. a ct scan showed continuing fluid collection near your hip. a girdlestone procedure was performed in which your hip hardware was removed and a spacer placed. you will receive iv antibiotics for the next several weeks for this. the bacteria which grew from this wound is called vre, which is a resistent bacteria requiring special antiobiotics. you were also noted to have had an small heart attack sometime during . you do have a history of atrial fibrillation for which you were previously taking coumadin, but this is currently being held. 1. you will be discharged to rehabilitation facility where you will have hemodialysis (hd) on your regular schedule. your antibiotics will also be continued. at a follow-up appointment with infectious disease, it will be determined the exact length of antibiotic treatment. 2. if you become very short of breath or experience a significant increase in the swelling in your legs, please let the staff at the rehab facility know. this can be a result of your heart's pumping function. 3. please follow up with dr. , dr. , and dr. as below. 4. do not take aspirin unless instructed to by a physician as this can worsen your small intestinal bleed. 5. at rehab, the following labs should be checked: - hct once every day until stable, with transfusions at hd if clinically appropriate. - guaiac stools followup instructions: please follow up with the physicians below. you will note that appointments have already been scheduled. rehab will arrange transportation. -dr. , pcp: at 8:20 am. . dr. will contact you if he would like to see you in clinic sooner. -infectious disease: you have an appointment scheduled with dr. : provider: , md phone: date/time: 9:00am. . -dr. , ct surgery: at 2:15pm. . -please see dr. , dr. , in orthopedic clinic. , np in orthopedics in 2 weeks, please call to schedule that appointment procedure: venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified other partial resection of small intestine enteral infusion of concentrated nutritional substances hemodialysis other and unspecified partial excision of large intestine partial hip replacement other incision with drainage of skin and subcutaneous tissue esophagogastroduodenoscopy [egd] with closed biopsy other small-to-large intestinal anastomosis arthrotomy for removal of prosthesis without replacement, hip other gastrostomy exteriorization of small intestine aspiration of other soft tissue aspiration of bursa other arthrotomy, wrist other incision of bone without division, other bones insertion or replacement of (cement) spacer revision of hip replacement, femoral component diagnoses: end stage renal disease subendocardial infarction, initial episode of care other postoperative infection congestive heart failure, unspecified acute posthemorrhagic anemia hyposmolality and/or hyponatremia hematoma complicating a procedure atrial flutter methicillin susceptible staphylococcus aureus septicemia hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease pressure ulcer, lower back acute and subacute bacterial endocarditis chronic vascular insufficiency of intestine chronic diastolic heart failure closed fracture of unspecified part of neck of femur pressure ulcer, stage ii infection and inflammatory reaction due to other internal orthopedic device, implant, and graft other mechanical complication of other internal orthopedic device, implant, and graft other specified disorders of intestine pyogenic arthritis, forearm enthesopathy of hip region striking against or struck accidentally by furniture without subsequent fall 

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