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 / zestril attending: chief complaint: fever, ams, rectal bleeding major surgical or invasive procedure: 1. paracentesis, x2 2. intubation, extubation 3. lumbar puncture history of present illness: pt is a 72 yo female with h/o htn, hl, dm, herpes zoster, anemia, hyperparathyroidism, and renal cell carcinoma s/p bilateral nephrectomy resulting in esrd on hd. she also has h/o a fib and as with porcine avr done in which was uncomplicated and she was discharged to rehab. at rehab she contracted c diff and was readmitted for abd pain, distension, and severe c diff colitis. during this admission in she ultimately required a subtotal colectomy and diverting ileostomy and pouch. at the time of this admission she had been on peritoneal dialysis and was switched and she was started on hd. . since this admission her mental status has never been the same. prior to her subtotal colectomy in she was alert and oriented x3 and doing her adls. since her surgery she has been more confused and alert and oriented x1 or 2 on some days and not talking on other days. . on she returned with fever up to 101.3 and rectal bleeding from pouch. in the ed she had ct abd done which only showed contrast thickening in rectum. her cxr was notable for atelectasis. her ct head was negative. cardiac surgery and transplant surgery are following as pt is on renal tp list. . differential of her fevers at admission included c diff of rectal stump (on vanco enemas and iv flagyl), sbp (had prev h/o) given pt had ascities (paracentesis negative for sbp), endocarditis (tte showed no vegetation), and pna. she has been convered with meropenem and daptomycin since admission given h/o sbp and tp said ok to stop daptomycin today and to continue meropenem for possible pna. she has also been on acyclovir for possible herpetic stomatitis. she has had a respiratory alkalosis with occasional rr in the 20s to 30s. she is on 2 l and was never hypoxic. . her pouch has stopped bleeding and inr 1.4 down from 2.1 on admission. hct have been stable at 24-26. . neuro was consulted for her ams. at rehab she had been noted to have ue jerking. an eeg was done there which was non diagnostic but keppra was started at rehab in case she was having subclinical seizures. neuro recommended to get eeg and to consider lp. tsh was elevated. rpr and b12 were both normal. . in the tsicu, she was sleepy but arousable. . review of systems: unable to obtain ros secondary to mental status. past medical history: toxic colitis with full-thickness colonic ischemia on the sigmoid colon s/p exploratory laparotomy with subtotal colectomy and ileostomy pmh: - aortic valve stenosis - hypertension - dyslipidemia - diabetes mellitus type ii - history of renal cell carcinoma status post nephrectomy resulting in esrd, requires peritoneal dialysis since - history of peritonitis over five years ago - history of herpes zoster several years ago - history of c. difficile colitis - anemia - arthritis, history of gout - hyperparathyroidism social history: lived alone before operation, residing at rehab prior to admission; no etoh, distant smoking history family history: non contributory physical exam: admission: vitals: t:98.4 bp:105/51 p:86 rr:24 o2: 100% 2l general: sleepy but arousable elderly caucasian woman, unable to answer questions heent: ncat, op clear, dry mm cardiac: rrr load s2, healed sternotomy scar pulmonary: ctab anteriorly abdomen: +bs, soft, non tender, large mid abdomen surgical wound healing by secondary intention with pink granulation tissue. no exudate, no odor. unable to view rectum in pt's current condition. extremities: 2+ pitting edema in hands bilaterally and 2+ pitting edema in lower legs neurologic: opens eyes. does not follow any commands other than wiggling toes on command. perrl. generally moving eyes but unable to test cn ii, iv, vi. tongue in midline but pt did not stick out completely. no facial droop. ue tone increased and mildly rigid in ue. pt able to squeeze both hand with much prompting. does not move arms spontaneously. resists mildly in ue when moving her. . discharge: vs - 98.7 98.7 126/66 107-126/51-70 84 70-86 16 96% ra bg 98 24h not recorded/-- +250 ostomy general - lying down in bed, appropriate, less agitated this morning, nad heent - nc/at, sclerae anicteric, dry mm neck - supple, jvp mildly elevated, difficult to assess lungs - clear bilaterally though decreased bs at left>right base, no crackles, good air movement, resp unlabored, no accessory muscle use heart - rrr, sem heard throughout precordium, nl s1-s2 chest: hd catheter in place, clean, no erythema, non-tender abdomen - +bs, ostomy in place with brown-green stool, soft, no rebound/guarding extremities - warm, dry, trace dp pulses, no ; r picc in place, no erythema skin: ~3cm sacral decubitus ulcer with clean base, granulation tissue, no drainage neuro - awake, a&ox2, states "i'm at the hospital," though unable to name which one, states that she does not know the year. cns ii-xii grossly intact, moving extremities pertinent results: admission labs: : wbc 9.7 hct 26.5 plt 257 wbc range: 2.9-15.8 hct range: 20.3-29.7 . : na 145 k 4.5 cl 109 co2 28 bun 29 cr 3.7 . discharge labs: : 12.6 hct 25.7 plt 320 na 135 k 4.0 cl 99 co2 25 bun 12 cr 2.2 . iron studies : iron binding capacity, total 75* 260 - 470 ug/dl ferritin 2290* 13 - 150 ng/ml transferrin 58* 200 - 360 mg/dl . micro: cx , , , , , , , , , , : negative cx : pending . c diff , , , , : negative . c. diff pcr sent : pending at time of discharge . rpr negative . 11:06 am fluid,other pericardial fluid.. **final report ** gram stain (final ): no polymorphonuclear leukocytes seen. no microorganisms seen. fluid culture (final ): no growth. anaerobic culture (final ): no growth. . 5:33 pm peritoneal fluid peritoneal fluid. gram stain (final ): 2+ (1-5 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. this is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white cell count.. fluid culture (final ): no growth. anaerobic culture (final ): no growth. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on direct smear. acid fast culture (preliminary): no mycobacteria isolated. . 11:42 am sputum site: endotracheal source: endotracheal. **final report ** gram stain (final ): pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram positive cocci. in pairs and clusters. respiratory culture (final ): commensal respiratory flora absent. staph aureus coag +. moderate growth. of two colonial morphologies. oxacillin resistant staphylococci must be reported as also resistant to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations rifampin should not be used alone for therapy. vancomycin susceptibility testing confirmed by sensititre. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin----------- =>8 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------------ 2 s . cytology: peritoneal fluid : negative for malignant cells csf fluid : negative for malignant cells . cardiology: echo : the left atrium is mildly dilated. the right atrium is moderately dilated. there is mild symmetric left ventricular hypertrophy with normal cavity size. left ventricular systolic function is hyperdynamic (ef>75%). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). there is a mild resting left ventricular outflow tract obstruction. right ventricular chamber size and free wall motion are normal. a bioprosthetic aortic valve prosthesis is present. the aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. no masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. the mitral valve leaflets are mildly thickened. 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. there is moderate functional mitral stenosis (mean gradient 8 mmhg) due to mitral annular calcification. 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. there is an anterior space which most likely represents a prominent fat pad. compared with the prior study (images reviewed) of , a bioprosthetic valve has replaced the stenotic native aortic valve. there is no echocardiographic evidence of endocarditis. if clinically indicated, a tee may better assess the prosthetic aortic valve. . tte : conclusions left ventricular systolic function is hyperdynamic (ef>75%). right ventricular chamber size and free wall motion are normal. a bioprosthetic aortic valve prosthesis is present. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. there is severe mitral annular calcification. there is mild functional mitral stenosis (mean gradient 6 mmhg) due to mitral annular calcification. trivial mitral regurgitation is seen. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the findings of the prior study (images reviewed) of , the findings are similar. . tee : conclusions no spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. there are simple atheroma in the descending thoracic aorta. a bioprosthetic aortic valve prosthesis is present. the aortic valve prosthesis leaflets appear to move normally. no masses or vegetations are seen on the aortic valve. no aortic valve abscess is seen. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. tricuspid valve is normal. no tricuspid regurgitation. pulmonic valve is normal. no pulmonic regurgitation. there is no pericardial effusion. impression: no valvular vegetations demonstrated. well-seated bioprosthetic aortic valve with normal function. mild to moderate mitral regurgitation. preserved left ventricular systolic function. . radiology: cxr: supine upright chest x-ray, at 1206 hours. history: altered mental with indwelling right picc line. assess for location of line. comparison: . impression: the picc line has migrated with the distal tip at the junction of the subclavian and axillary arteries. lung volumes are markedly diminished with resultant bronchovascular crowding. it is difficult to entirely exclude a mild element of volume overload. additionally, hazy opacity at the left lung base and to a lesser severity on the right likely reflect atelectasis, although concurrent infectious infiltrate cannot be entirely excluded on the basis of this examination alone. ct head () indication: 72-year-old woman with altered mental status. question bleed or ischemia. comparison: none available. technique: mdct images were acquired through the head without contrast. multiplanar reformations were obtained and reviewed. findings: no acute hemorrhage, large vascular territory infarct, shift of midline structure or mass effect is present. prominence of the ventricles and sulci are compatible with mild age appropriate atrophy. the visible paranasal sinuses show mild mucosal thickening within the left sphenoid sinus. both mastoid air cells are opacified, without evidence of osseous destruction. impression: no acute intracranial process. bilateral mastoid air cell opacification suggestive of ongoing inflammation. . mri head : impression: 1. generalized cerebral volume loss. 2. mild small vessel ischemic change. 3. no evidence of an acute infarction or mass. 4. bilateral fluid-filled petromastoid air cells without evidence of a nasopharyngeal mass. 5. contrast was not administered due to poor renal function and egfr less than 20. . ct torso : impression: 1. no focal fluid collections identified. 2. right adrenal mass is unchanged and not completely characterized on this study, but its heterogeneity is concerning for metastasis. further evaluation with an mri is suggested. 3. moderate ascites increased since the prior examination with layering material within the ascitic fluid concerning for hemorrhagic ascites. adherent hyperdense material along the left abdominal wall (2, 74) is noted; please correlate with history of recent paracentesis. 4. bilateral pleural effusions, left greater than right with adjacent atelectasis versus infection. 5. ground glass opacity in bilateral upper lobes, left greater than right, may represent aspiration versus pneumonia. 6. increased anasarca. 7. right picc tip likely within left brachiocephalic vein in the midline. . cxr : findings: in comparison with study of , there is little overall change. monitoring and support devices remain in place. continued enlargement of the cardiac silhouette with mild-to-moderate pulmonary vascular congestion. increasing opacification at the left base is consistent with worsening atelectasis and effusion. in the appropriate clinical setting, supervening pneumonia would have to be considered. . cxr : impression: 1. unchanged left basilar opacification is some combination of atelectasis and pleural effusion. 2. resolved mild pulmonary edema. 3. improved right basilar opacities. 4. low lung volumes. brief hospital course: hospital course: pt is a 72f recent s/p valvuloplasty (avr on ), esrd on pd post-op course complicated by readmission for c.diff colitis with toxic megacolon requiring exploratory laparotomy and subtotal collectomy with ileostomy intubated for 6 days and converted to hd from pd, discharged on with 2 week course of flagyl to rehab, who re-presented with reported fever to 101.3, altered mental status and bloody discharge from her pouch. pt had prolonged hospitalization. fevers with unclear source with negative cultures, c. diff, and stool cultures. pt had paracentesis on with negative gram stain. initially treated with broad spectrum antitbiotics. tte demonstrated no vegetations. pt's course also complicated by delirium. pt was evaluated by neurology and lp was done, and negative for meningitis. thought to be toxic metabolic encephalopathy. mri was negative for mass or acute ischemia (however, non-contrast given esrd). pt had anemia during her hospitalization, thought to be from slow gi bleed vs. slow bleed from initial peritoneal dialysis. she was transfused (total of 8 units prbc's, last ) during this admission and started on epo with hd. pt also with anemia of chronic disease with high ferritin. course also complicated by acute respiratory failure, attributed to volume overload and possible central tachypnea. she required stay in micu and intubation. she developed a mrsa ventilator-associated pneumonia and was treated with vancomycin. she was continued on dialysis during this hospitalization. her respiratory status improved and she had o2 sats high 90s to 100% on ra on day of discharge. she was discharged to acute for continued management of her multiple medical problems. . # altered mental status: before operation a few months ago, she was aaox3 and verbal. she has had cognitive decline since operation but overall is significantly worse from her true baseline. neurology was consulted with impression of non-focal exam consistent with toxic metabolic encephalopathy with contributors including renal failure, colitis, and sedatin medication. she was also noted to have tremors at rehab with concern for seizures. eeg showed no seizure activity. neuro-imaging included normal head ct. lp showed elevated protein with no cells - differential included resolved bacterial meningitis, seizure, isolated cns vasculitis. neurology felt this continued to be c/w toxic metabolic. in the icu, famotidine was discontinued due to 1% incidence of coma as side effect. she continued dialysis. acyclovir continued until csf hsv negative. mri showed generalized cerebral volume loss, mild small vessel ischemic change, no evidence of an acute infarction or mass, bilateral fluid-filled petromastoid air cells without evidence of a nasopharyngeal mass. phenytoin level was found to be high and this was held. continuous eeg tracing continued to show signs of encephalopathy and , but no seizure activity so all anti-epileptics were held. during her icu course, she continued to have delirium, which was attributed to multiple etiologies including esrd, intermittent fevers, hypoxic respiratory failure requiring intubation. on the medical floors, her mental status improved. she was oriented to place and person but not date on discharge. she was answering questions appropriately. she was quite tearful as her mental status improved and would benefit from social work, and continued reassessment of goals of care with her family while at . . # hypoxic respiratory failure: pt had tachypnea throughout the admission, which was initially attributed to possible central tachypnea. however, on the evening of , pt became increasingly tachypneic with severely elevated a-a gradient on top of chronic respiratory alkalosis. pt was admitted to the micu for closer monitoring, respiratory distress progressed requiring intubation. etiology unclear, but ddx include given transfusion in the afternoon, flash pulmonary edema, or pe. thought to be unlikely; transfusion workup was sent. pe thought to be less likely given on sc heparin, though given prolonged immobility and recent surgery, definitely with several risk factors for pe, though she was not tachycardic and denied chest pain. worsening infection such as hcap considered, but no clear evidence of pna intially and without cough or clear infiltrate on cxr. thought that pulmonary edema contributing. pt was monitored closely in the micu, and abx were discontinued given no clear source. renal continued to follow and pt had crrt in evening of , which she tolerated well. pt found to be growing gpc's from sputum, and was started on vanc/cefepime for vap. sputum cx grew out mrsa, and she was continued on vancomycin. sbt was attempted, and pt was extubated on with plans to not reintubate. she tolerated extubation well and was continued to improve her respiratory status such that she was only on nasal cannula. she was transferred to the medicine floors and we were able to wean her oxygen down to 2l. she had o2 sats in high 90s to 100% on ra on the day of discharge. . # fever: patient transferred from nsg home with reported fevers that were felt presumably to be due to c. diff (which she had in the previous hospitization). on on admission to the trauma sicu and continued on flagyl (since ), started on vancomycin enema, acyclovir (for report of herpes sore on lip), meropenem, and daptomycin. cultures were negative, stool ostomy - negative for campylobacter, shigella, salmonella , stool rectum - negative for c.diff and peritoneal fluid - no pmns, no micro-orgs, no growth. tte showed no vegetation. ct abdomen showed mild wall thickening of the hartmann's pouch such that colitis could not be completely ruled out. she spiked fever again on with negative cultures again. daptomycin was stopped on and meropenem stopped on . vanco was stopped on . as above, meningitis was considered, but ruled-out with negative lp. patient had a low grade fever on and was pan-cultured which didn't show any infection. the patient remained afebrile until when she had low grade fever and this continued on the evening of . she had an episode of hypotension and leukopenia so infection was suspected and she was started on vanco/cefepime/flagyl to cover hap and c. diff. this was discontinued during her micu stay as no clear source. as above, sputum culture showed gpc's. cultures and c. diff were negative. as above, she was treated for mrsa vap, and she defervesced. she remained afebrile on the medicine floors. though she remained afebrile, c. diff pcr was sent given mild leukocytosis (as discussed below), and pending at the time of discharge. she remained afebrile for >7 days prior to discharge. . # leukocytosis: pt had a mild leukocytosis on the medicine floors, wbc ranging from . pt remained afebrile with repeat cxr without clear infiltrate, and no cough. differential showed no bands, with mild neutrophilic predominance. repeat cxr again showed no infiltrate. cultures from continued to be pending at the time of discharge. given history of c. diff, despite multiple negative c. diff ag's during this hospitalization, c. diff pcr was sent and pending at the time of discharge. her wbc count was 12.6 at the time of discharge, trended down, and as above, she remained afebrile without localizing symptoms. . # ascites: pt had paracentesis initially on presentation given fevers, without growth from cultures. pt had large volume ascites on ct later in hospitalization and given continued fevers, and had therapeutic and diagnostic tap in the micu. approximately 4l serosanguinous fluid tapped, with saag<1.1. cytology & cultures sent, which showed no growth and no evidence of malignancy. her abdominal distention improved with dialysis. . # hypotension: intermitently hypotensive in the icu with sbp's in 80's. she was pan-cultured and this was negative and given patient didn't have fever this was felt unlikely to be due sepsis. her mental status was so poor that it was not possible to detect a change. did not bolus ivf given total body volume. started midodrine for pressure with improvement. on transfer to the floor the patient's pressure was initially >100 so midodrine was held. on the night of her sbp was again found to be 80 and she had a low grade fever. she received a 500cc bolus and sbp improved. random cortisol was added on that showed 28.9. pt likely had developing sepsis given vap while in the icu. she required pressor support with levophed. during her micu stay, she was started on midrodrine, and was able to be weaned off levophed. on the medicine floors, her bp improved, and she was discharged on midrodrine. all anti-hypertensives on admission were held. . # tachypnea/alkalosis: throughout her admission the patient has been intermittently tachypneic to 40s and her abg continued to show respiratory alkalosis. etiology was unclear but was presumed to be central tachypnea or autonomic dysregulation (though no other signs of icp). lenis were negative for clot. it was clear these ongoing symptoms were not from a pe as her respiratory status was stable for >2 weeks, so cta was not pursued. again, as above, pt was intubated, extubated, and respiratory status improved. . # anemia: admission hct 26. on admission patient having was small amount of pouch and mucus. she was on coumadin for atrial fibrillation and her inr was 4 on arrival to the hospital. she was transferred to the icu for further management. coumadin was held in the icu. the surgical team was concerned for colitis and ordered a ct scan, which revealed no bowel perforation, or dilation. stool cultures and c. diff were negative. she had no signs of brisk bleeding but her hct dropped <22 on 3 occasions. each time she responded to prbcs given in dialysis. hemolysis labs were normal. it was felt that the ongoing anemia was multifactorial given her poor nutritional status, esrd, chronic disease, phlebotomy, and guaiac positive ostomy output. she was transfused a total of 8 units of prbc's during this admission, with last transfusion , in the micu, prior to transfer to the medicine floors. on the medicine floors, pt's hct was stable, and was 25.7 on the day of discharge. again, she had no signs of active bleeding. she was started on lansoprazole given guaiac positive output. as above, c. diff pcr was sent and pending at the time of discharge. pt was planned to continue with epo with hd. . #. recent avr for aortic stenosis: transplant surgery discussed with cardiac surgery who indicated anticoagulation could be held given patient has porcine valve. warfarin was held during admission and discontinued on discharge. . #. esrd on hd: history of renal cell carcinoma s/p bilateral nephrectomy resulting in esrd, requiring peritoneal dialysis since . pt continued on dialysis during this admission. she required crrt during her micu course. on the medicine floors she had hd, which she tolerated well. she will continue hd on discharge. continue on nephrocaps, cinacalcet, and epo & zemplar with hd. last received hd , plan for mwf schedule at . . # atrial fibrillation with rvr, paroxysmal: on post-op, the patient went into afib with rvr while she was not taking po meds (metoprolol and amiodarone) due to poor mental status and inability to place ng tube due to concern for seizures. patient was given metoprolol and diltiazem but became hypotensive and was transferred back to the micu and loaded with amiodarone. she was transitioned to po amiodarone and patient was sinus soon afterwards. in the micu, her amiodarone was discontinued as afib was paroxysmal s/p procedure. she remained in sinus rhythm with no need for rate-control or anti-coagulation. . # nutrition: pt required tube feeds while intubated during her micu stay. her albumin was low at 2.8. she had a speech & swallow evaluation on , and was advanced to a dysphagia diet. plan for repeat s&s evaluation on ; however, given time constraints, this was not able to be done prior to discharge to the ltac. pt should have re-evaluation with speech & swallow today or tomorrow to advance diet as able. pt had a diet of regular; cardiac/heart healthy , diabetic/consistent carbohydrate consistency: ground (dysphagia); thin liquids please have 1:1 supervision with all meals, maintain aspiration precautions at time of discharge/ . # sacral decubitus ulcer, pressure heel ulcers: wound followed the patient and helped with skin care. on discharge, the sacral ulcer had a clean base with pink granulation tissue without evidence of infection. pt should have wound care continued at - current recs: recommendations: continue pressure relief measures per pressure ulcer guidelines. sacrum: cleanse with wound cleanser, pat dry apply duoderm gel to the wound bed cover with mepilex sacral border dressing change dressing every 3 days or prn. . # ostomy: followed by wound during her hospitalization. recommend continuing recs at ltac: treatments/equipment/intervention: cleanse stoma/peristomal skin with warm water. filled in wound at junction separation with stomahesive powder. dab no-sting barrier wipe peristomal skin. apply seal around stoma to cover and protect junctional wound. apply pouch dist # # cut to template size . #. dyslipidemia: continued home atorvastatin while patient taking po meds but otherwise held. . #. dm ii: glucose well controlled on insulin. . # right adrenal mass: noted as stable on ct abdomen. this should be followed-up as outpatient. . transitional care: 1. code: dnr/dni, confirmed with son, 2. contact: (cell) 2. follow-up: - renal/hd at - doctors at rehab 3. medical management: - several changes to medications made as noted in paperwork - speech & swallow re-evaluation or to advance diet as able - continue discussion of goals of care with patient and family. pt quite tearful on medicine floors, and pt may not want to be readmitted if issues arise. should address with family if develops illness whether or not she and they would want icu level care. 4. outstanding studies/labs: - cultures 4/30 - c. diff pcr - pt should have follow-up for continued right adrenal mass 5. risks to re-hospitalization: - pt with continued delirium - multiple medical problems with previous readmissions medications on admission: 1. acetaminophen 325 mg tablet : 1-2 tablets po q6h prn 2. allopurinol 100 mg tablet : 1.5 tablets po every other day 3. atorvastatin 10 mg tablet qd. 4. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler : 6-10 puffs inhalation q4h (every 4 hours) as needed for wheezing 5. amiodarone 200 mg tablet : two (2) tablet po once a day: 400mg daily x 1 week, then 200mg daily until further instructed. 6. metoprolol tartrate 25 mg tablet : 0.5 tablet po tid. 7. ipratropium-albuterol 18-103 mcg/actuation aerosol : puffs inhalation q6h (every 6 hours) prn 8. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) inhalation q4h (every 4 hours). 9. cepacol sore throat + coating 15-5 mg lozenge : one (1) 10. lidocaine hcl 2 % solution : one (1) ml mucous membrane tid (3 times a day) as needed for mouth sores. 11. acyclovir 400 mg tablet : one (1) tablet po q12h 12. tramadol 50 mg tablet : one (1) tablet po q6h pain 13. metronidazole in nacl (iso-os) 500 mg/100 ml piggyback : one (1) intravenous q8h (every 8 hours) for 11 days: through . 14. nystatin 100,000 unit/ml suspension : five (5) ml po qid (4 times a day). 15. ondansetron 2 mg iv q8h:prn nausea 16. heparin (porcine) in d5w 25,000 unit/250 ml parenteral solution : one (1) intravenous asdir (as directed): 700 units/hr for goal ptt 50-70 17. warfarin 1 mg tablet : one (1) tablet po wd goal inr 2-2.5 18 insulin lispro 100 unit/ml solution . iss discharge medications: 1. atorvastatin 10 mg tablet : one (1) tablet po once a day. 2. allopurinol 100 mg tablet : 1.5 tablets po once a day. 3. acetaminophen 325 mg tablet : 1-2 tablets po every six (6) hours as needed for pain. 4. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization : one (1) treatment inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. ipratropium bromide 0.02 % solution : one (1) treament inhalation every six (6) hours as needed for shortness of breath or wheezing. 6. lidocaine viscous 2 % solution : one (1) solution mucous membrane three times a day as needed for mouth sores. 7. tramadol 50 mg tablet : one (1) tablet po every six (6) hours as needed for pain. 8. midodrine 5 mg tablet : three (3) tablet po tid (3 times a day). 9. cinacalcet 30 mg tablet : 0.5 tablet po daily (daily). 10. b complex-vitamin c-folic acid 1 mg capsule : one (1) cap po daily (daily). 11. miconazole nitrate 2 % powder : one (1) appl topical qid (4 times a day) as needed for rash. 12. lansoprazole 30 mg tablet,rapid dissolve, dr : one (1) tablet,rapid dissolve, dr daily (daily). 13. aspirin 81 mg tablet, chewable : one (1) tablet, chewable po daily (daily). 14. ondansetron hcl (pf) 4 mg/2 ml solution : four (4) mg injection q8h (every 8 hours) as needed for nausea. 15. gabapentin 100 mg capsule : one (1) capsule po hs (at bedtime). 16. heparin (porcine) 5,000 unit/ml solution : 5000 (5000) units injection tid (3 times a day). 17. hydromorphone (pf) 1 mg/ml syringe : 0.25 mg injection q4h (every 4 hours) as needed for pain. 18. oxycodone 5 mg tablet : 0.5-1 tablet po q4h (every 4 hours) as needed for pain . 19. insulin regular human 100 unit/ml solution : as directed units injection qachs: for bg <150, no insulin, 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10. 20. heparin, porcine (pf) 10 unit/ml syringe : two (2) ml intravenous prn (as needed) as needed for line flush. discharge disposition: extended care facility: discharge diagnosis: primary diagnoses: 1. fever 2. delirium 3. ventilator associated pneumonia 4. esrd on hd 5. anemia 6. hypotension secondary: 1. aortic stenosis s/p avr 2. renal cell carcinoma s/p nephrectomy 3. c. difficile colitis c/b by toxic megacolon s/p ex lap with subtotal colectomy and diverting ileostomy 4. gout 5. hyperparathyroidism discharge condition: mental status: confused - sometimes. level of consciousness: lethargic but arousable. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: dear ms. , it was a pleasure taking care of you during this admission. you had a very prolonged course. you were re-admitted to the hospital from with continued fevers. you were treated with broad-spectrum antibiotics. you were also more confused during this hospitalization. you were evaluated by neurology and had an mri of the brain with no new abnormalities. you had sampling of your spinal fluid, which revealed no infection. during your stay, your breathing became fast, and you required intubation. you were taken care of in the icu, and required close monitoring. you were found to have a pneumonia for which you were treated with antibiotics. during your stay your pressure was intermittently low, requiring medication for pressure support. your pressure then improved. you also had dialysis during this admission which you will continue. the following medications were changed during this admission: - stop amiodarone - stop metoprolol tartrate - stop acyclovir - stop metronidazole - stop nystatin - stop warfarin - start midrodrine 15mg by mouth three times daily - start nephrocaps 1 tablet by mouth daily - start cinacalcet 15mg by mouth daily - start miconazole powder as needed for rash - start aspirin 81mg by mouth daily - start lansoprazole 30mg by mouth daily - start gabapentin 100mg by mouth at night for neuropathic pain (burning sensation). **your doctors to increase or decrease this dose based on your dialysis sessions. this medication may make you tired or sleepy. - start hydromorphone 0.25mg intravenously every 4hrs as needed for pain - start oxycodone 2.5-5mg every 4hrs as needed for pain. **both the hydromorphone and oxycodone medication may also make you very tired or sleepy. - start heparin 5000units subcutaneously three times daily while you are at rehab (this is to help prevent clots) - start epoeitin with dialysis - start zemplar with dialysis - change the dose of ondansetron 2mg intraveneously to 4mg every 8 hours as needed for nausea please continue the other medications were on prior to this admission. followup instructions: please follow-up with the doctors . procedure: venous catheterization, not elsewhere classified continuous invasive mechanical ventilation for 96 consecutive hours or more spinal tap incision of lung parenteral infusion of concentrated nutritional substances diagnostic ultrasound of heart insertion of endotracheal tube enteral infusion of concentrated nutritional substances hemodialysis percutaneous abdominal drainage arterial catheterization diagnoses: end stage renal disease renal dialysis status toxic encephalopathy diabetes mellitus without mention of complication, type ii or unspecified type, not stated as uncontrolled iron deficiency anemia secondary to blood loss (chronic) atrial fibrillation hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage v or end stage renal disease hemorrhage complicating a procedure acute respiratory failure alkalosis pressure ulcer, lower back fever, unspecified other ascites hyperparathyroidism, unspecified methicillin resistant staphylococcus aureus in conditions classified elsewhere and of unspecified site heart valve replaced by transplant ventilator associated pneumonia personal history of malignant neoplasm of kidney pressure ulcer, stage iii malnutrition of moderate degree 

Answer: The patient is high likely exposed to