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: nafcillin attending: chief complaint: altered mental status major surgical or invasive procedure: transesophageal echocardiogram x2 intubation and mechanical ventilation right ij cvl placement picc line placement left iliopsoas abscess drain placement with removal history of present illness: this is a 29-year-old woman who is an active iv drug user, s/p tricuspid valve replacement(29mm mosaic), mitral valve repair (p2 resection,26mm cg future ring) for mssa endocarditis on (course complicated by septic emboli to the brain and lungs) who presents with relapse of drug abuse and septic shock. . the patient was reportedly last heard normal on when talking to her mother on the phone. she lives with her boyfriend and on he noticed "odd behavior" described as combative and aggressive thus called the paramedics. it is unclear when she restarted using iv drugs after admission this , likely since . per micu note, she had been using cocaine and heroin on . when ems arrived, the patient's hr was 150 and sbp 100, and she was given ativan x2 without effect. . upon arrivival at ed, her bp was 89/73 with hr 118 (lowest recorded bp was 54/40). labs were remarkable for creatinine of 5.2. wbc 2.4, hct 38.2, plt 32. troponin i was 0.135, inr 3.9. she was given 1mg narcan, 750mg levaquin, 1g vancomycin, geodon 20mg and 25mg diphenhydramine and 100mg hydrocortisone. she was started on a levophed drip. prior to transfer to , a right femoral central line was placed. she had a beside tte that showed no pericardial effusion, intact tvr, no mr. ecg shows ventricular pacing at 104. . on arrival to the micu, the patient was reported to be quite agitated. vitals were hr 122, bp 104/89, t 97.6, satting 99% ra on 0.12mcg/kg/min of norepinephrine. she was confused and thought that every person who entered the room was her boyfriend and was unable to answer any other questions. . during her stay in the micu, she was continued on norepinephrine drip, bolused with fluids, and treated with vanc/cefepime initially then switched to gent/nafcillin for septic shock (blood cultures from osh grew staph aureus, suspecitble to oxacillin, resistant to penicillin g.) tee showed vegetation on tricuspid valve, normal valve otherwise, no vegetations on pacemaker, no abnormalities on mitral valve. she was seen by cardiothoracic surgery who did not think there was indication for surgical intervention. given low urine output at osh concerning for septic emboli (vs. pre-renal --> atn), renal ultrasound was obtained (without doppler) which was normal. renal was consulted and thought etiology was likely atn and recommended prn lasix for volume overload. she had a stat head ct given ams which showed possible new hypodensities in r parietal and l cerebellar areas (patient can't get mri due to pacemaker). inr was 5 on admission thus was stopped and patient was given po vitamin k 2.5 mg to reverse inr to try to prevent septic emboli bleeding in brain. she was intubated on , extubated on without complications. following extubation, she had full-body pain and was put on scale with librium. speech and swallow cleared her for regular diet. prior to transfer, mental status was near baseline and patient was hemodynamically stable (bps 90s/60s). past medical history: 1. ivda, s/p tvr and mvr for endocarditis: a. tricuspid valve replacement with a size #29-mm mosaic tissue valve. b. mitral valve repair with resection of p2 and repair with size #26 cg future band. -completed 6wk course of nafcillin on at , post-op course c/b septic emboli to lungs and brain for which she was anticoagulated. 2. 3rd degree heart block: s/p pacemaker placement on with altrua model s606 dual-chamber pacemaker 3. anxiety 4. asthma social history: patient lives with fiance (arrested on outstanding warrant after calling ems) in . not working, use to be nanny. active ivda, last time was ? . current smoker, does not report using etoh. family history: unable to obtain physical exam: admission exam: general: confused, incoherent, perseverating on a drug deal gone bad. heent: sclera anicteric, dry mucus membranes, eomi, perrl, approximately 5mm, down to 3mm. neck: supple, jvp at approximately 10, with diastolic flickering, no lad cv: regular rate and rhythm, normal s1 + s2, diastolic murmur, heard best over right sternal border, no radiation to axilla. chest: well healed midline scar. lungs: clear anteriorly, although patient not cooperating with exam abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly gu: foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: confused, mumbling, asking for "please" over and over again. patient did not cooperate with exam, although able to track eyes and attend to either side of room. reflexes 2+ bilaterally patellar, downgoing babinski. no clonus skin: numerous excoriations on upper forearms. finger tips with violaceous flat petechiae. lower extremities with 7mm escars scattered along legs. discharge exam: general: aaox3, pleasant and cooperative heent: op clear, mmm cv: 3/6 systolic murmur, normal s1 and s2 abdomen: ntnd, active bs x$ extremities: wwp, pulses 2+ and eqaul neuro: ms wnl, strength and sensation wnl derm: no signs of embolic phenomenon pertinent results: 06:20am blood wbc-5.4 rbc-4.20# hgb-10.9* hct-34.6* mcv-83# mch-25.8*# mchc-31.3 rdw-15.7* plt ct-35*# 12:52pm blood wbc-10.7# rbc-4.27 hgb-11.1* hct-35.5* mcv-83 mch-25.9* mchc-31.2 rdw-15.7* plt ct-56*# 04:40am blood wbc-8.4 rbc-4.11* hgb-10.7* hct-33.2* mcv-81* mch-26.0* mchc-32.2 rdw-15.8* plt ct-54* 02:37pm blood wbc-8.1 rbc-4.13* hgb-10.9* hct-32.9* mcv-80* mch-26.3* mchc-33.1 rdw-15.9* plt ct-53* 02:11am blood wbc-12.8*# rbc-4.25 hgb-10.9* hct-33.5* mcv-79* mch-25.6* mchc-32.5 rdw-15.8* plt ct-48* 02:37pm blood wbc-8.1 rbc-4.13* hgb-10.9* hct-32.9* mcv-80* mch-26.3* mchc-33.1 rdw-15.9* plt ct-53* 02:11am blood wbc-12.8*# rbc-4.25 hgb-10.9* hct-33.5* mcv-79* mch-25.6* mchc-32.5 rdw-15.8* plt ct-48* 09:00pm blood wbc-12.2* rbc-3.94* hgb-10.2* hct-31.2* mcv-79* mch-25.9* mchc-32.7 rdw-16.1* plt ct-44* 02:26am blood wbc-10.8 rbc-4.10* hgb-10.7* hct-32.4* mcv-79* mch-26.1* mchc-33.0 rdw-16.2* plt ct-49* 05:05am blood wbc-11.6* rbc-3.89* hgb-10.1* hct-31.1* mcv-80* mch-26.0* mchc-32.5 rdw-16.3* plt ct-66* 05:32am blood wbc-13.0* rbc-3.87* hgb-9.9* hct-30.7* mcv-79* mch-25.6* mchc-32.3 rdw-16.4* plt ct-109*# 05:52am blood wbc-17.2* rbc-3.88* hgb-9.8* hct-31.1* mcv-80* mch-25.2* mchc-31.5 rdw-16.8* plt ct-133* 04:50am blood wbc-16.6* rbc-3.77* hgb-9.6* hct-30.2* mcv-80* mch-25.6* mchc-31.9 rdw-16.7* plt ct-139* 06:34am blood wbc-17.2* rbc-3.60* hgb-9.1* hct-29.4* mcv-82 mch-25.3* mchc-31.0 rdw-17.7* plt ct-139* 05:13am blood wbc-13.9* rbc-3.31* hgb-8.6* hct-26.8* mcv-81* mch-26.0* mchc-32.0 rdw-17.6* plt ct-174 07:46am blood wbc-9.5 rbc-3.10* hgb-8.1* hct-25.3* mcv-82 mch-26.1* mchc-32.0 rdw-17.8* plt ct-210 07:50am blood wbc-7.4 rbc-3.10* hgb-8.0* hct-25.2* mcv-81* mch-25.8* mchc-31.7 rdw-18.1* plt ct-196 07:10am blood wbc-4.7 rbc-2.81* hgb-7.3* hct-22.9* mcv-82 mch-25.9* mchc-31.7 rdw-18.0* plt ct-182 12:23pm blood wbc-4.5 rbc-2.81* hgb-7.2* hct-22.9* mcv-82 mch-25.7* mchc-31.4 rdw-18.0* plt ct-196 05:21am blood wbc-4.1 rbc-2.63* hgb-6.8* hct-21.6* mcv-82 mch-25.9* mchc-31.5 rdw-18.2* plt ct-180 04:25am blood wbc-3.6* rbc-2.57* hgb-6.6* hct-21.0* mcv-82 mch-25.7* mchc-31.5 rdw-18.1* plt ct-188 02:39pm blood wbc-3.5* rbc-2.77* hgb-7.2* hct-22.6* mcv-82 mch-25.9* mchc-31.8 rdw-18.1* plt ct-208 05:30am blood wbc-2.9* rbc-2.65* hgb-7.0* hct-21.8* mcv-82 mch-26.5* mchc-32.3 rdw-18.3* plt ct-174 04:59am blood wbc-3.3* rbc-2.88* hgb-7.6* hct-23.7* mcv-82 mch-26.3* mchc-32.0 rdw-18.1* plt ct-195 05:30am blood wbc-3.3* rbc-2.67* hgb-6.9* hct-21.9* mcv-82 mch-25.9* mchc-31.6 rdw-18.7* plt ct-181 04:50am blood wbc-3.2* rbc-2.84* hgb-7.4* hct-23.3* mcv-82 mch-25.9* mchc-31.6 rdw-19.0* plt ct-205 05:32am blood neuts-86.4* lymphs-10.5* monos-1.8* eos-1.0 baso-0.2 05:52am blood neuts-81.8* lymphs-14.1* monos-2.9 eos-0.8 baso-0.5 04:50am blood neuts-80.9* lymphs-16.1* monos-2.2 eos-0.4 baso-0.4 06:34am blood neuts-80.9* lymphs-16.5* monos-1.7* eos-0.3 baso-0.6 05:13am blood neuts-81.3* lymphs-16.0* monos-2.1 eos-0.4 baso-0.2 07:46am blood neuts-78.0* lymphs-18.1 monos-3.1 eos-0.7 baso-0.2 07:50am blood neuts-79.7* lymphs-16.8* monos-2.6 eos-0.6 baso-0.3 07:10am blood neuts-73.3* lymphs-23.0 monos-3.0 eos-0.5 baso-0.2 05:21am blood neuts-63.5 lymphs-32.4 monos-2.8 eos-0.9 baso-0.4 04:25am blood neuts-59.6 lymphs-34.9 monos-3.1 eos-1.7 baso-0.7 04:59am blood neuts-63.3 lymphs-31.6 monos-2.0 eos-2.9 baso-0.2 05:30am blood neuts-62.0 lymphs-34.1 monos-1.6* eos-2.2 baso-0.3 04:50am blood neuts-59.2 lymphs-35.2 monos-2.7 eos-2.6 baso-0.4 06:20am blood pt-49.3* ptt-32.7 inr(pt)-4.9* 12:52pm blood pt-58.7* ptt-33.5 inr(pt)-5.9* 10:36pm blood pt-42.3* ptt-33.7 inr(pt)-4.2* 04:40am blood pt-37.3* ptt-33.3 inr(pt)-3.6* 02:11am blood pt-66.6* ptt-39.7* inr(pt)-6.7* 09:00pm blood pt-21.7* ptt-34.6 inr(pt)-2.1* 02:26am blood pt-18.4* ptt-31.0 inr(pt)-1.7* 05:05am blood pt-17.1* ptt-27.9 inr(pt)-1.6* 05:32am blood pt-14.6* ptt-28.0 inr(pt)-1.4* 05:52am blood pt-13.5* ptt-28.4 inr(pt)-1.3* 04:50am blood pt-12.5 ptt-28.2 inr(pt)-1.2* 06:34am blood pt-14.2* ptt-28.7 inr(pt)-1.3* 05:13am blood pt-14.5* ptt-30.7 inr(pt)-1.4* 07:46am blood pt-14.9* ptt-30.1 inr(pt)-1.4* 07:10am blood pt-14.5* ptt-30.2 inr(pt)-1.4* 05:21am blood pt-14.4* ptt-32.1 inr(pt)-1.3* 05:30am blood pt-13.6* ptt-30.8 inr(pt)-1.3* 04:50am blood pt-13.5* ptt-31.8 inr(pt)-1.3* 05:52am blood esr-30* 05:30am blood gran ct-1480* 12:52pm blood fibrino-295 02:26am blood fibrino-301 06:20am blood glucose-90 urean-59* creat-4.6*# na-135 k-4.8 cl-104 hco3-13* angap-23* 12:52pm blood glucose-102* urean-64* creat-4.8* na-137 k-4.7 cl-106 hco3-15* angap-21* 06:30pm blood glucose-122* urean-69* creat-4.7* na-138 k-4.4 cl-107 hco3-16* angap-19 10:36pm blood glucose-123* urean-68* creat-4.7* na-136 k-3.8 cl-104 hco3-19* angap-17 04:40am blood glucose-123* urean-68* creat-4.7* na-138 k-3.4 cl-103 hco3-21* angap-17 02:37pm blood glucose-135* urean-69* creat-4.4* na-137 k-3.6 cl-102 hco3-23 angap-16 02:11am blood glucose-111* urean-65* creat-4.1* na-138 k-3.7 cl-102 hco3-21* angap-19 09:00pm blood glucose-96 urean-62* creat-3.6* na-138 k-3.4 cl-102 hco3-24 angap-15 02:26am blood glucose-92 urean-59* creat-3.4* na-139 k-4.0 cl-103 hco3-24 angap-16 05:05am blood glucose-118* urean-58* creat-2.8* na-139 k-3.9 cl-103 hco3-25 angap-15 05:32am blood glucose-88 urean-46* creat-2.3* na-141 k-3.4 cl-106 hco3-24 angap-14 05:52am blood glucose-92 urean-35* creat-1.6* na-140 k-3.6 cl-107 hco3-25 angap-12 04:50am blood glucose-113* urean-28* creat-1.3* na-143 k-3.9 cl-110* hco3-26 angap-11 06:34am blood glucose-90 urean-22* creat-1.3* na-140 k-4.0 cl-109* hco3-25 angap-10 05:13am blood glucose-78 urean-20 creat-1.2* na-138 k-3.7 cl-104 hco3-27 angap-11 07:46am blood glucose-89 urean-19 creat-1.1 na-139 k-3.6 cl-105 hco3-28 angap-10 07:50am blood glucose-162* urean-18 creat-1.1 na-138 k-3.4 cl-103 hco3-26 angap-12 07:10am blood glucose-93 urean-15 creat-1.0 na-137 k-3.8 cl-105 hco3-26 angap-10 05:21am blood urean-16 creat-1.0 na-139 k-3.8 cl-106 hco3-27 angap-10 04:25am blood glucose-91 creat-1.0 na-139 k-3.9 cl-107 hco3-27 angap-9 05:30am blood glucose-83 urean-15 creat-1.0 na-140 k-3.9 cl-107 hco3-27 angap-10 05:30am blood glucose-88 urean-15 creat-1.0 na-138 k-4.0 cl-103 hco3-27 angap-12 04:50am blood glucose-116* urean-18 creat-1.0 na-140 k-4.1 cl-106 hco3-26 angap-12 06:20am blood alt-45* ast-62* ck(cpk)-105 alkphos-206* totbili-1.6* 12:52pm blood ck(cpk)-115 02:11am blood alt-40 ast-39 alkphos-161* totbili-2.3* 09:00pm blood alt-33 ast-24 ld(ldh)-250 alkphos-234* totbili-3.8* 02:26am blood alt-29 ast-22 ld(ldh)-226 alkphos-249* amylase-19 totbili-4.3* dirbili-3.5* indbili-0.8 05:05am blood alt-20 ast-14 alkphos-221* totbili-3.4* 05:32am blood alt-13 ast-14 ld(ldh)-226 alkphos-169* totbili-2.2* 05:52am blood alt-14 ast-15 alkphos-149* totbili-1.3 04:50am blood alt-12 ast-17 alkphos-129* totbili-2.1* 06:34am blood alt-11 ast-15 alkphos-110* totbili-1.9* 05:13am blood alt-9 ast-15 alkphos-96 totbili-1.6* 07:46am blood alt-9 ast-14 ld(ldh)-266* alkphos-90 totbili-1.1 07:50am blood alt-9 ast-16 ld(ldh)-279* alkphos-89 totbili-0.9 07:10am blood alt-7 ast-14 ld(ldh)-256* alkphos-79 totbili-0.7 05:21am blood alt-7 ast-11 ld(ldh)-209 alkphos-72 totbili-0.7 04:25am blood alt-7 ast-15 ld(ldh)-204 alkphos-68 totbili-0.7 05:30am blood alt-7 ast-15 alkphos-71 totbili-0.6 05:30am blood alt-7 ast-15 alkphos-70 totbili-0.6 04:50am blood alt-8 ast-16 alkphos-78 totbili-0.7 12:52pm blood d-dimer-* 04:25am blood hapto-124 12:52pm blood hbsag-negative hbsab-positive 05:52am blood crp-50.2* 09:00pm blood hiv ab-negative 10:07am blood genta-1.2* 11:06am blood genta-1.5* 01:00pm blood genta-5.4 10:44am blood genta-1.5* 05:31am blood genta-0.8* 07:46am blood genta-<0.3* 01:30pm blood genta-1.5* 07:37am blood genta-1.4* 10:00am blood genta-3.1* 07:45am blood genta-1.7* 07:46am blood genta-4.2* 07:46am blood genta-4.1* 07:50am blood genta-1.6* 08:00pm blood genta-0.4* 09:57pm blood genta-2.7* 05:33pm blood genta-0.3* 06:20am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 06:47am urine blood-mod nitrite-neg protein-300 glucose-tr ketone-tr bilirub-neg urobiln-2* ph-5.5 leuks-lg 01:24pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.5 leuks-neg 06:47am urine rbc-16* wbc->182* bacteri-many yeast-none epi-0 urine culture: urine culture (final ): staph aureus coag +. >100,000 organisms/ml.. of two colonial morphologies. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s nitrofurantoin-------- 32 s oxacillin------------- 0.5 s tetracycline---------- <=1 s trimethoprim/sulfa---- <=0.5 s outside hospital blood cultures, re-grown in house: time taken not noted log-in date/time: 10:12 am isolate isolate sent from for re-identification and susceptibility testing. **final report ** isolate for mic (final ): staph aureus coag +. final sensitivities. staphylococcus species may develop resistance during prolonged therapy with quinolones. therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. testing of repeat isolates may be warranted. sensitivities: mic expressed in mcg/ml _________________________________________________________ staph aureus coag + | clindamycin-----------<=0.25 s erythromycin----------<=0.25 s gentamicin------------ <=0.5 s levofloxacin----------<=0.12 s oxacillin-------------<=0.25 s trimethoprim/sulfa---- <=0.5 s all blood cultures while hospitalized from to present are negative. 11:30 am joint fluid right hip joint . **final report ** gram stain (final ): 1+ (<1 per 1000x field): polymorphonuclear leukocytes. no microorganisms seen. fluid culture (final ): no growth. 11:30am joint fluid wbc-2900* rbc-1250* polys-78* lymphs-18 monos-4 tee : no atrial septal defect is seen by 2d or color doppler. overall left ventricular systolic function is normal (lvef>55%). right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. 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 moderately thickened. a mitral valve annuloplasty ring is present. no mass or vegetation is seen on the mitral valve. trivial mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. there is a small (0.7x0.3), linear, mobile echodensity attached to the septal tricuspid leaflet consistent with a vegetation. the body of the antero-lateral and septal leaflets of the bioprosthesis appear thickened (clips 122, 126) suggesting more extensive leaflet involvement by the infectious process. the mean transtricuspid mean gradient and peak velocity are slightly higher than expected for the type of valve. there are two pacer wires noted, one in the coronary sinus, and one in the right atrium. no mass or vegetation seen on the pacer wires. impression: small vegetation on the septal leaflet of the bioprosthetic tricuspid valve with thickening of the anterolateral and septal leaflets and slightly higher than expected transvalvular gradients. these findings are new compared with the prior study dated (images reviewed). ct head : impression: focal hypodensities in right parietal and left cerebellar hemispheres are new since exam, and may represent areas of infarction or infectious focus. correlate with mri head without and with contrast if not ci. ct chest and abdomen : impression: 1. interval development of small to moderate-sized intramuscular fluid collections involving both iliacus and psoas muscles, with the largest in the left iliacus with apparent connection to the underlying iliopsoas bursas. suggestion of surrounding edema and hyperdense rim is concerning for underlying inflammation/infection. differential considerations include abscess formation versus iliopsoas bursitis with developing infection. 2. significant overall improvement of the intrapulmonary sequela of septic emboli with a few areas of nodularity and linear fibrosis. previously seen peripheral nodules with intrinsic cavitation have mostly resolved. moderate bilateral pleural effusions and basilar atelectasis persist. 3. findings most consistent with subacute to chronic infarcts in the periphery of the spleen as detailed above. vasculature is however grossly patent. tee : no masss/veg seen on pacer wires.the left atrium is normal in size. overall left ventricular systolic function is normal (lvef>55%). the aortic valve leaflets (3) appear structurally normal with good leaflet excursion. no masses or vegetations are seen on the aortic valve. no aortic regurgitation is seen. a mitral valve annuloplasty ring is present. there is a moderate to large sized vegetation on the mitral valve. mild (1+) mitral regurgitation is seen. a bioprosthetic tricuspid valve is present. there is a large vegetation on the tricuspid valve. moderate tricuspid regurgitation is seen. no vegetation/mass is seen on the pulmonic valve. impression: bioprosthetic tricuspid valve endocarditis. mitral valve/annuloplasty ring endocarditis. moderate tricuspid regurgitation. ct chest and abdomen : impression: 1. near resolution of left psoas muscle fluid collection after drain placement. the drain could be removed if the output is less than 15 ml/day for a consecutive 48 hours. 2. ill-defined fluid collections within the iliacus muscles have decreased in size from prior. 3. significant volume overload marked by anasarca, gallbladder wall edema, mild ascites, bilateral moderate pleural effusions and intralobular septal thickening. 4. unchanged intrapulmonary sequela of septic emboli with a few areas of nodularity and fibrosis. 5. unchanged splenic infarctions without evidence of abscess formation. discharge labs 05:21am blood wbc-3.5* rbc-2.94* hgb-8.1* hct-26.0* mcv-89 mch-27.8 mchc-31.3 rdw-22.6* plt ct-205 04:58am blood pt-13.1* ptt-31.0 inr(pt)-1.2* 07:00am blood glucose-83 urean-18 creat-0.9 na-144 k-4.0 cl-109* hco3-29 angap-10 07:54am blood alt-6 ast-17 alkphos-91 totbili-0.6 08:38pm blood calcium-9.0 phos-3.6 mg-1.9 brief hospital course: 29-year-old woman, active iv drug user, s/p tricuspid valve replacement, mitral valve repair, mssa endocarditis on transferred from osh to micu for septic shock, continued drug abuse, altered mental status, atn found with recurrent mssa endocarditis. # septic shock, bacteremia, and endocarditis: in the micu, patient met sirs criteria by hr and rr. she was placed on a norepinephrine drip in order to maintain adequate maps. the patient was initially treated with vancomycin and cefepime, but when osh blood cultures grew out staph aureus, susceptible to oxacillin, resistant to penicillin g., patient was switched to nafcillin and gentamicin, rifampin later added given has prostetic valve. tee showed a vegetation on the bioprosthetic tricuspid valve, c/w endocarditis. the patient was extubated on and was transferred to the medical floor after she had been hemodynamically stabilized. she remained stable on the floor, sbps ranging from 90s to 110. we obtained blood cultures daily which were all negative. she had several issues with access including pulling picc out, contaminating ij, and picc fragmenting inside right arm during repeat placement (not retrieved by surgery as unable to see on ultrasound). imaging showed multiple septic emboli sequela, including bilateral psoas abscesses (see below). due to the continuing burden of septic left sided emboli repeat tee was performed after approximately 2 weeks of naf/gent/rif which showed interval progression of the tricuspid vegetation and a new large mitral vegetation. due to the progression of her endocarditis in spite of appropriate antibiotic therapy, ct surgery was consulted who refused surgery due to her ongoing iv drug abuse issues (she was informed prior to her original surgery in that if she used iv drugs again, that she would not be a surgical candidate at this institution). she was rejected for consultation at and due to her ongoing ivdu. as her hospital course progressed she defervesced and her wbc count normalized and further cultures were negative of her blood; she complained of recurrent joint pain but ct scanning repeatedly showed no further abscess formation. a few days prior to discharge she developed a pruritic rash felt secondary to nafcillin so she was changed to cefazolin. she was discharged on cefazolin and rifampin to be continued until at least , which is when her id followup appointment is and they may be continued for longer; gentamicin was dc'ed prior to discharge per id recommendations. she has an id followup appointment after discharge at which it will be determined whether her course should be continued. she will be seen in infectious disease clinic on and will have tee prior to the appointment as well to assess her vegetations. tee is not yet scheduled, facility will be contact after scheduling. # acute renal failure: the patient was given 8l fluid at osh and only made 60ccs urine. there was concern for septic emboli causing arf versus hypotension and prerenal etiology. creatinine was initially 4.6, down from 5.2 at osh. renal was consulted who recommended continuing ivf and obtaining a renal u/s, which was unremarkable. most likely etiology was septic shock --> pre-renal failure --> atn. her cr continued to trend down and by discharge was normal. by this point, her foley was out and she was making adequate urine. we trended her cr daily and renally dosed all medications. # pulmonary edema: patient became tachypneic on floor after being called out of micu to 40s, cxr showed pulmonary edema. ther was concern for ards vs. volume overload vs. valvular regurg in setting of endocarditis. bedside tte did not show any valvular abnormalities, ef was 55%. cardiology was consulted who recommended diuresis, which was attemped until she became febrile and concern for repeat sepsis occured (see below). at time of discharge she was on room air without further diuresis needed. # left hip pain: as her course progressed she began spiking high temperatures (~7d into hospital course) with rigors and an elevated wbc count; she refused ct torso for multiple days. eventually when she allowed scanning bilateral psoas abscesses were discovered, left greater than right. per id's recommendation, ir placed a ct guided drain in the left iliopsoas abscess, which ultimately grew nothing but which resulted in normalization of her wbc count and defervescence. repeat scan prior to drain removal showed near resolution of the left abscess and resolution of the right abscess. # right hip pain: etiology unclear, joint was tapped without growth of any organisms but does have evidence of osteoarthritis on ct scan. patient was maintained on a regimen of dilaudid which was slowly downtitrated given her history of drug abuse. she will be discharged on po dilaudid 2-4 mg q6h prn and should be downtitrated as tolerated. she should not be discharged with narcotics given history of drug abuse after rehab completed. if continues to have hip pain in weeks, would consider re-evaluation and possibly further imaging. # altered mental status with features of wernickie's aphasia: on arrival to the micu, patient was confused and incoherent. of note, urine tox positive for cocaine and opiates, serum tox negative. there was a concern about resurfacing of prior neurological defecits from previous embolic stroke vs. new stroke. as per mother, patient did not have aphasia after her prior embolic stroke. ct scan showed new hypodensities in l cerebellum and r parietal lobe that were suspicious for ischemia, perhaps from septic emboli. mri could not be performed due to the patient's pacemaker. given her inr near 5 and her thrombocytopenia, she was given platelets and ffp to prevent hemorrhagic conversion. haldol 1mg prn was given for agitation. her mental status was improved on and and on the medical floor, was a+o x 3, speaking coherently and fluently though she showed concerning behavior such as pulling out picc line, defecating in cereal bowl. ultimately this was attributed to delerium which resolved over the hospital course. # pacemaker s/p 3rd degree block: pocket did not appear to be tender, echo did not show any lead infection, but patient had several episodes of no v-pacing seen on tele and what appeared to be asystole. ep was consulted and this was thought was intermittent capture likely caused by high capture thresholds of v lead, related to patient's position. they increased the voltage ventricular pace output to maximum and she had no further episodes. she will need follow-up with her electrophysiologist ( ) 2 weeks after discharge from rehab. # thrombocytopenia: platelets were within normal range at 235,000 on . thrombocytopenia likely from marrow suppression secondary to septic shock. dic was ruled out in micu given normal ptt, normal fibrinogen (although inr was elevated). we obtained daily cbcs. platelets continued to rise and on discharge, were normal. # anion gap: patient presented with elevated anion gap of 18. vbg with ph 7.23. serum osms of 303 and calculated osms of 296 making other ingestion unlikely. her anion gap was though likely secondary to renal failure as described above. her anion gap closed as she was repleted with fluids. # pulmonary emboli: has history of septic emboli but also presented in with a large pulmonary emboli burden and discharged on warfarin. it is unclear from the ct chest with contrast whether this was septic emboli vs clot, warfarin was started empirically. as she was supratherapeutic, warfarin was held. her inr trended to normal range during admission. continued to be held throughout the admission with a normal inr due to completion of 6 month course after first pe and concern for septic emboli given her history. it was held on discharge as well but could consider restarting after followup tee if vegetation is decreasing in size and there are no signs of embolic disease. heparin tid was continued throughout for dvt ppx. # ivdua: patient continues to use cocaine and heroin. social work followed her throughout her admission. will require extensive services for substance abuse post discharge from rehab. transitional issues: - requires appointment to be set up with dr of ep at ( for 2 weeks post discharge - can restart lopressor during her rehab stay if she becomes hypertensive, otherwise would continue to hold until her outpatient cardiologist evaluates in . - needs referral to substance abuse counselors after discharge - iron studies to work up anemia pending on discharge - antibiotics course for endocarditis to continue until at least , course to be determined by infectious disease team - tee will be scheduled prior to id appointment and facility will be contact with the date and time when scheduled medications on admission: preadmission medications listed are correct and complete. information was obtained from patient. 1. warfarin 5 mg po daily16 2. metoprolol tartrate 50 mg po bid 3. clonazepam 0.5 mg po qhs 4. quetiapine fumarate 50 mg po qhs discharge medications: 1. acetaminophen 650 mg po q6h:prn fever 2. benzonatate 100 mg po tid 3. cefazolin 2 g iv q8h 4. docusate sodium 100 mg po bid hold if pt has bm 5. heparin 5000 unit sc tid 6. heparin flush (10 units/ml) 2 ml iv prn line flush picc, heparin dependent: flush with 10ml normal saline followed by heparin as above daily and prn per lumen. 7. ibuprofen 400 mg po q8h:prn pain 8. multivitamins 1 tab po daily 9. polyethylene glycol 17 g po daily constipation 10. rifampin 300 mg po q8h 11. senna 1 tab po bid:prn constipation 12. tramadol (ultram) 50 mg po q4h:prn pain 13. trazodone 50 mg po hs:prn insomnia 14. hydromorphone (dilaudid) 2-4 mg po q6h:prn pain hold for sedation, rr<10 rx *dilaudid 2 mg tablet(s) by mouth every six (6) hours disp #*30 tablet refills:*0 discharge disposition: extended care facility: - discharge diagnosis: endocarditis septic shock acute renal failure left iliopsoas abscesses s/p drainage discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear ms. , it was a pleasure taking care of you during your recent admission at . you were transferred here from for treatment of your endocarditis leading to septic shock. you were stabilized in the micu for several days prior to transfer to the floor. we treated your endocarditis with several antibiotics (gentamicin, nafcillin, rifampin) and obtained daily blood cultures. your antibiotics were changed to cefazolin and rifampin on discharge since you may have had an allergic reaction to rifampin. you will be receiving these antibiotics until at least , which is when you have your infectious disease appointment. you had pain in your hips which was due to an abscess in the muscles of your legs which we drained. social work saw you to discuss strategies for stopping intravenous drug use. do not ever use injection drugs again. changes to your medications: start taking cefazolin 2 gm iv every 8 hours for your endocarditis start taking rifampin 300 mg by mouth every 8 hours for your endocarditis start taking dilaudid 2-4 mg by mouth every six hours as needed for pain start taking ibuprofen 400 mg every 8 hours as needed for pain start taking acetaminophen as needed for pain start taking benzonatate three times a day for cough start taking colace twice a day for constipation start taking heparin 5000 units subcutaneously three times a day to prevent blood clots start taking multivitamins daily start taking miralax daily for constipation start taking senna as needed for constipation start taking tramadol as needed for pain start taking trazodone as needed for insomnia stop taking warfarin followup instructions: department: cardiac services when: tuesday at 2:30 pm with: , np building: sc clinical ctr campus: east best parking: garage department: infectious disease when: friday at 10:30 am with: , md building: lm bldg () campus: west best parking: garage procedure: continuous invasive mechanical ventilation for less than 96 consecutive hours venous catheterization, not elsewhere classified venous catheterization, not elsewhere classified diagnostic ultrasound of heart diagnostic ultrasound of heart insertion of endotracheal tube percutaneous abdominal drainage arterial catheterization artificial pacemaker rate check central venous catheter placement with guidance central venous catheter placement with guidance diagnoses: acidosis thrombocytopenia, unspecified tobacco use disorder acute kidney failure, unspecified severe sepsis asthma, unspecified type, unspecified methicillin susceptible staphylococcus aureus septicemia atrioventricular block, complete septic shock long-term (current) use of anticoagulants cardiac pacemaker in situ dermatitis due to drugs and medicines taken internally pain in joint, pelvic region and thigh acute and subacute bacterial endocarditis personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits heart valve replaced by transplant pulmonary congestion and hypostasis aphasia cocaine abuse, continuous opioid abuse, continuous delirium due to conditions classified elsewhere personal history of pulmonary embolism psoas muscle abscess penicillins causing adverse effects in therapeutic use septic pulmonary embolism 

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